?i oC C; c^iP:' nj)« ^v>hJ?J THE GIFT OF 9ji.,..M...eiiL.^tfa!!d: .ilaHo.S. tolmjjg. 7583 Cornetl University Library arV19391 A practical guide to the study of the di 3 1924 031 293 560 olin,anx Cornell University Library The original of tliis book is in tine Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924031293560 A PRACTICAL GUIDE TO THE STUDY OF THE DISEASES OF THE EYE: THEIE MEDICAL AND SUEGICAL TEEATMENT. HENRY W. WILLIAMS, M. D., FELLOW OF TUB MASSACHUSETTS MEDICAL SOCIETY, HONOEAKY FELLOW OF THE BHODE ISLAND MEDICAL SOCIETY, MEMBER OF THE AMERICAIT MEDICAL ASSOCIATION, ETC., ETC., ETC. BOSTON: TIOKNOR AND FIELDS. NEW YORK: SHELDON & CO., AND WILLIAM WOOD. PHILADELPHIA: J. B. LIPPINCOTT & CO., AND LINDSAY & BLAKISTON. 1862. Entered according to Act of Congress, in the year 1862, by Henry W. Williams, in the Olerk's Office of the District Court of the District of Massachusetts. UNirHRSITV PRESS: WXLCB, BlOELOW, AND COUFAHTi CAMBItlVeB. PREFACE. We are not unprovided with works on the diseases of the eye ; but they are either so elaborately complete as to require a high de- gree of education, and large experience in ophthalmic practice, to enable the reader to appreciate the nice distinctions laid down ; or they attempt too much within narrow limits, and, from want of space and confused arrange- ment, sacrifice that clearness of description which should be regarded as all-important in a work intended for instruction. In offering this treatise to the profession, and to those who are about to enter it, the author does not assume to set forth aU which is known in respect to diseases of the eye. He has endeavored to supply a want which his relations with junior practitioners and students have shown him to exist, and to prepare a work which shall afford, in a form iv PREFACE. as simple and concise as possible, a practical and serviceable knowledge of these diseases, and of their treatment, to those whose op- portunities for special study have been less extensive than they could have desired. It is only in a few cities, in Apaerica, that stu- dents find even limited facilities for clinical observation of these affections; and a very large number yearly begin their career as practitioners, without having enjoyed the privilege of any instruction whatever in this important branch of medical education. It has been the aim of the author to avoid encumbering his work, and confusing the reader, by the introduction of merely ex- ceptional details, — by an account of every proposed but exploded mode of treatment, or by more than the most sparing use of the too learned technical designations which abound in ophthalmic literature ; but he has endeavored to give clear and explicit descrip- tions of the usual forms of disease, so that the physician may be able to recognize, at once, their distinctive features, — and to de- fine the course of treatment best adapted, in a majority of cases, to remove the morbid con- PREFACE. dition. Some affections, and certain phases of disease, of rare occurrence and trivial im- portance, will be merely alluded to ; enough being said, however, to enable the reader to detect their character, as exceptional cases, and to allow him to consult other works, at his leisure, should he wish for complete infor- mation regarding them. It is impossible for the author of a medical work to avoid availing himself of the rich treasures accumulated as the result of the labors of his predecessors. To all of them the writer acknowledges his indebtedness. But he would not have assumed his task, except from a desire to fulfil the duty which he believes to be incumbent on every phy- sician, of adding something, if possible, to the stock of knowledge which it is the glory of our profession to regard as the common property of all its members. He has hoped to do this, by promulgating new and origi- nal views, which he deems highly important, upon certain of the subjects considered in this treatise, — and by facilitating, by simpli- fied classification, the study of what at first eight seem to be the intricate and compli- VI PREFACE. cated phenomena of diseases of the organ of vision. The descriptions given, the conclusions an- nounced, and the treatment recommended, are such as the author's own observation and experience have led him to consider accurate and useful. 15 Arlington Street, Boston, 1st June, 1862. TABLE OP CONTENTS. CHAPTEE I. METHOD OF EXAMINING THE EYE. The Physician's own Observation to be chiefly relied on, 3. — Exam- ination of the Appendages of the Eye, 4; of the Surface of the Globe, 5 ; of internal Surface of Lids, B ; of internal Parts of the Eye, 6. — Mode of everting the Upper Lid, 8. — Examination in Chil- dren, 8. — Varieties of Injection as a Means of Diagnosis, 10. — Differences in the Secretions, 10. — Differences in Pain, 11. — Impor- tance of these Symptoms in the Classification of Diseases, 11. CHAPTER II. THE OPHTHALMOSCOPE. Description of, 12. — Manner of using, 14. CHAPTER III. REMEDIES AND THBIE APPLICATION. Some Affections require only local Applications, IB. — Others demand Constitutional Treatment, 15. — Solutions preferable as CoUyria, IS. — Ointments should never be used, 16. — Danger of employing Preparations containing Lead, 16. — Too free Use of Nitrate of Sil- ver, 17. — The Sulphate of Copper in Form of Crayon, 18. — Mode of using Crayon, 19. — Manner of introducing Collyria, 20. — Deple- tion by -Leeches, 20. — Scarification seldom useful, 21. — Inutility of Division of Vessels running upon Cornea, 21. — Tonic Treatment com- patible with local Depletion, 21. — Poultices often hurtful, 22. — Collyria have little Effect on Inflammations of internal Parts, 22 — Sedatives, 22. CHAPTER IV. APFECTIONS OP THE CONJUNCTIVA. Simple Conjunctivitis, 24; caused by Foreign Particles, 24; by Draughts of Air, 26. — Eemoval of Foreign Bodies, 2B. — Ekuptive VUl TABLE OF CONTENTS. ConjuNCTiviTis, 27. — Papulas on Conjunctiva and Cornea, 27. — Flattened Papula, 27. — Change of Air useful, 28. — Moco-puru- LENT Conjunctivitis, 28. — Catarrhal Conjunctivitis, 29. — Frequently sudden in Access, 29. — Lids first implicated, 29. — Disease extends to Globe, 30. — Granulations, 30. — Upper Half of Cornea often cloudy from Friction of Granulations, 31. — Kind of Pain, 32. — Form of Injection, 32. — Inoculation a frequent Cause, 33. — Importance of effecting a complete Cure, 34. — Blow Eecovery of In Cases of very long standing, 35. — Results of Ulceration of Cornea, 36. — Tonic Treatment essential in many Cases, 37. — Cleanliness essential, 39. — Perseverance in Treatment, 41. — Purulent Con- junctivitis, 43. — Contagiousness of, 43. — Chemosis, 44. — Gentle Treatment better than Heroic Measures, 47. — Common in Armies, 47. — GoNOKRHcEAL CONJUNCTIVITIS, 47. — Extreme Violence of, 48. — Most common in Males, 48. — Eapid Fatality of, 48. — Con- junctivitis OF NEW-BORN Infants, 50. — Generally supervenes u, few Days after Birth, 51. — Enormous Amount of Discharge, 61. — Danger of Perforation of Cornea requires Vigilance, 51. — Use of an Elevator to raise Lids, 53. — Harsh Remedies to be avoided, 54. — Atropia to be used if Cornea becomes implicated, 5?. — Pterygium. 56. — Not a merely temporary Enlargement of Vessels, 57. — Removal of, 58. — EccHYMOsis, 58. — (Edema, 59. — Warty Growths, Ctsticerci, 60. CHAPTER V. AEFECTI9NS OF THE LACHKYMAL ORGANS. Eversion of Puncta Lachrymalia, 61. — Thickening of Lining of Pas- sages, 62. — Obstruction of Duct, 62. — Abscess of Sac, 63. — Fistula Lachrymalis, 63. — Canute and Styles to be rarely inserted, 66. — Introduction of a large-sized Probe through the previously enlarged Punctum, 67. — Means of relieving Abscess without the Lancet, 69. — Treatment of Actual Fistula, 70. CHAPTER VI. TRAUMATIC INJURIES OF THE EYE. Over Activity in Treatment too common, 72. — Injuries of Cornea and Conjunctiva, 78. — From Beard of Grain, 73. — Chemical Injuries, 74. — Burns, 74. — When complicated with Hernia of Iris, 76. — Wounds of Eyelids, 76. — Wounds of Sclerotica, 78. — Wounds of Crystalline Lens, 78. — Dislocation of Lens, 80. — Injuries of the Iris, 81. — Injuries from Percussion-Caps, 81; from penetrating Bits of Steel, 81. — Foreign Bodies in interior of Eye, 82. — Sympathetic Inflammation of other Eye, 85. TABLE OF CONTENTS. ix CHAPTER Vn. AFFECTIONS OP THE COENBA. Ulceration of the Cornea, 88. — Generally met with in Children of strumous Diathesis, 88. — Child fretful and feverish, 88. — Photo- phobia, 88. — Tact requured in examining the Patient, 89. — Ulcers most often central, 93 ; accompanied by Disease of Meibomian Glands, 98. — Dotted OpApiTT, 100. — Comeitis, 102; often a Symptom of inherited Syphilis, 103; frequently conjoined with Iritis, 104. — Opacities, 107 ; sometimes accompanying actual Dis- ease, at other Times the Result of former Ulceration, 107. — Deposits of Lead, 108. — Aitcus Senilis, 109. — Conical Cornea, 110. — Foreign Bodies in Cornea, 113. — Stapyhyloma, 114. CHAPTER VIII. affections of the sclerotica. Wounds of the Sclerotica, 117 ; Incised, 117. — Rupture, 117. — Protrusion of Lens through, 117, — Thinning, 118. — Staphyloma. CHAPTER IX. affections of the iris. Tolerance of Injuries, 121. — Rheumatic Iritis, 122. — Characteristic Pain, 122. — Peculiar Injection, 123. — Copious Lachrymal Secre- tion, 123. — Intolerance of Light, 123. — Puffy Appearance of Iris, 124. — Contraction of Pupil, 124. — Slow Recovery of Vision, 125. — Self-limited in some Cases, 126. — Liable to Continuance and Com- plication if the Symptoms are neglected or exceed a certain Degree, 126. — Great Importance of preventing Adhesions by maintaining Dilatation of the Pupil, 126.^ — Examination of the Value of Mercury in Treatment of Iritis, 127. — Anatomical Reasons for Value of Bella- donna, 129. — Detachment of Adhesions when formed, 136. — Syphi- litic Iritis, 137. — Congenital Syphilitic Iritis, 139. CHAPTER X. affections op the crystalline lens. Dislocation, 140. — Spontaneous Dislocation, 140. — Cataract, 143. — Congenital Cataract, 143. — Oscillation of Globe, 144. — Hereditary Predisposition, 144. — Numerous Cases in one Family, 144. — Time required for Absorption after Operation, 148. — Trau- matic Cataract, 149. — Lenticular Cataract, 152. — Most com- X TABLE OF CONTENTS. mon in advanced Age, 152. —Hard Cataract, 153. — Nuclear Cata- ract, 153. — Soft Cataract, 153. — Cortical Cataract, 153. — Hereditary Tendency to at about a certain Age, 153. — Belladonna employed by Charlatans for a pretended Cure, 155. — Cloudiness may commence in the Nucleus or in the Cortical Portion of Lens, 156. — No Treatment except by Operation of any Avail, 158. — Time for Operating, 159.— Operation on one or both Eyes, 169. — Preparation for Operation, 160. — Modes of Operating, 160. — Catabact-Glasses, 176. — Second- AKY Operations foe Catakact, ■ 177. — Glaucomatous Cata- KAGT, 179. CHAPTER XI. AFFECTIONS OF THE TITKEOUS HUMOB. Softening of the Vitreous, 160. — Sparkling Synchisis, ISO,— Crystals of Cholesterine, 180. CHAPTER Xn. OPERATIONS FOR ABTIFIOIAL PUPIL. When called for, 182. — Conditions Eequisite to Success, 182. CHAPTER xm. affections involving the entikb globe. Glaucoma, 188. — Operations for Glaucoma, 189. — Hydrophthalmia, 192 — Paracentesis, 193. — Cancer, 193. — Encephaloid, 193. — Melanosis, 195. — Scirbhus, 196. — Ophthalmitis 196; sometimes one of the Sequelae of Fever, Phlebitis, or the Puerperal Condition, 197. — Pus developed behind the Globe, within the Ocular Capsule, may simulate Phlegmon of the Globe, 198. — Syjipathetic Oph- thalmia ; may come on a long Time after the oOier Eye has recovered from Traumatic Injury, 200. — Sluggish Changes in deep-seated Parts of the Eye, 201. — Operation for removing the Eyeball, 202. CHAPTER XIV. artificial eyes. Should correspond with other Eye, and be suitable Size for the Cavity in which they are to be worn, 206. — To be removed at Night, 207. — Mode of inserting and removing, 208. — Adhesions between Lids and Globe not to be rashly divided, 209. — Eye not to be worn if it loses its Polish, 208. TABLE OF CONTEXTS. XI CHAPTER XV. AFFECTIOirS Oy THE CHOROID. IMFI.AMMATION, 211. — Hkmokrhage, 212. — Serous Effusioh, 213. — Absence of Pigment-Cells, 213. CHAPTER XVI. affections op the ketina. Inflammation, 215. — Apoplexy, 215. — Anh^emia, 216. — Fatty Disease. Sepabatios from Choboid, 216. — Encefhaloid, 217. CHAPTER XVn. AMAUKOTIC affections. Vagueness of Term " Amaurosis," 219. — Dilatation of Pupil may exist without Loss of Vision, 220. — Disposition of Patients to deceive themselves into a Belief that they are gaining, when such is not the Case, 225. CHAPTER XVIII. TEMPOKABT AFFECTIONS OF VISION. Night Blindness, 227. — Loss of Vision during Pbegnancy ob Lactation, 228, CHAPTER XIX. pec0liaeities of vision. Inability to distinguish Colobs, 230. — Increased Sensibility TO Light and Acuteness of Vision. Sometimes simulated, 234. — Musca; VoLiTANTES, 234; often observed by healthy Eyes, 235; seldom entirely got rid of, but do not lead to Blindness, 236. — Dou- ble Vision, 237. — Sometimes a Result of Paralysis of Muscles of Eye, 237. — Sometimes merely an Effect of Debility, 237. — Spec- teal Illusions, 237. CHAPTER XX. affections of THE ADAPTIVE POWEE OF THE BYE. Mechanism of the Changes of Refraction, 239. — Short-sightedness, 240; sometimes a Symptom of other Disease in the Eye, 240; not often congenital, 241. — Rules in regard to Eye-Glasses or Specta- cles, 243. — Glasses should not be stronger than absolutely needed, Xll TABLE OF CONTENTS. 246. — Long-sightedness, 247 ; increased by improper Use of Eye.s, or by wearing Glasses when not required, 248. — Glasses should not be assumed too soon nor avoided too long, 249. CHAPTER XXI. CHOICE OF SPECTACLES OR ETE-GLASSES, 253. CHAPTER XXn. ASTHENOPIA. Weariness and Pain after too long continued use, 260. — Measles and other Diseases a frequent Cause, 261. — Use of the Eyes not to be absolutely forbidden, 264. — Glasses sometimes of apparent Assist- ance, but should not be hastily advised, 267. CHAPTER XXni. AFFECTIONS OE THE MUSCLES OF THE EYEBALL. Strabismus, 269. — Most often convergent, 269. — Vision often less good in the Eye most affected, 270. — Operations, fok Strabismus 273. — Paralysis of the Muscles of the Eye, 281. — Paralysis OF the Third Pair of Nerves, 281. — Various Branches may be implicated, 282. — Mydriasis, 283. — Vision good if the Size of the Pupil be lessened, 283. — Paralysis of the Sixth Paie, 285. — Paralysis of the Fourth Pair, 285. CHAPTER XXIV. affections op the eyelids. Falling of the upper Lid, 287. — (Edema, 288. — Inflammation, 289. — Wounds and Injuries, 290. — Ecchymosis, 291. — Furuncle, 292. — Cancer, 293. — Excrescences, 294. — Adhesions of Lids, 294. — Encysted Tumors, 295. — Liable to refill if merely punc- tured, 297. — Albuminous Tumor, 298. — Fibrous Cysts, 298. — Vitiligo, 299. — Diseases of the Meibomian Glands and Cili- ary Bulbs, 301. — Hordeolum, 299. — Stye, 299. — Trichiasis, 306. — Inversion of Eyelashes, 306. — Lice on Borders of Lid, 307. — Enteopiumj or Inversion of Lid, 307. — Ectropium; or Eveesion of Lid, 309. DISEASES OF THE EYE. We shall derive the greatest advantage, in our study of the pathology of the eye, from such a classi- fication of its diseases as may not only aid us in forming a prompt diagnosis, but assist in deter- mining, at once, the general plan of treatment to be adopted. The most simple and rational arrange- ment, and one which includes a very large propor- tion of the numerous diseases of the eye, is that which ranks them, as far as may be, according to the structure which they primarily affect. A fiirther subdivision is required, to designate those peculiar phases of disease denoting the existence of any con- stitutional condition or other circumstance capable of modifying the course of the malady or its results. Many of the inflammatory as well as other affec- tions of the eye are disjtinctly limited, at the outset, to certain of its tissues, — as the iris or the con- junctiva, — and may disappear without involving contiguous parts ; but even these, if left to them- selves, tend to produce new conditions, affecting 1 2 DISEASES OF THE EYE Other structures, and complicating or even masking the original disease. As an instance of this latter tendency, we may refer to the effect produced upon the cornea by long-continued friction of granulated lids upon its surface. For a considerable time, especially if the granulations are flabby rather than hard, the cornea continues clear ; but at length ves- sels become developed upon its surface, it loses its transparency, and, if the original disease remain un- checked, it .becomes ulcerated, and perforation very probably ensues. When these changes have occurred, attended, perhaps, with much circum-orbital pain, serving still further to disguise the case, it is difficult for an inexperienced observer to recognize, as the cause of all this mischief, a condition of the mucous membrane lining the upper lid, towards which, if he hope for success, his remedial measures must be primarily and almost solely directed. In order to unmask these complications, and dis- cover the true features they conceal, — or, when they have themselves become, de facto, new diseases, to determine where and how to direct his treatment, — it is essential that the observer should accustom himself to close and careful examination of the eye, overlooking no morbid change, however apparently, trivial. This being of so much consequence, I shall endeavor to point out the mode of making an accu- rate and methodical examination, that the student may have a guide as to what he should look for and how he is to find it. METHOD OF EXAMKING TfiE EYE. CHAPTER I. METHOD OF EXAMHSflNG THE EYE. So far as it goes, information obtained by the physician's own senses is of more value than that derived from the patient. As a general rule, there- fore, a personal inspection should precede any in- quiries as to the history or symptoms of the case. Thus relying on his own observation, the physician learns to note every deviation from a normal con- dition, — he avoids, in a measure, the chance of being misled by preconceived theory in the mind of his patient, — and he may often gain, at once, the patient's confidence, by showing, in his first question or remark, that he thoroughly comprehends the disease. The examination of the patient may commence from the moment he enters the room. The skilfal observer will distinguish, in his very bearing, the patient with cataract, who, with shaded eyes, ap- pears as if searching his way, from him who has the bold gait and wandering eyeballs marking the loss of all perception of light. The half-closed lids of the short-sighted, the spasmodic contraction at- tendant on intolerance of light, the deviation from 4 DISEASES OF THE EYE. harmonious action in the eyes of those affected with strabismus, may all be observed at a glance. The patient should be seated near a window, with the light falling obliquely on his eye. For exami- nations requiring much delicacy, a window having a north aspect is best. The appendages of the eye, the brow and lids, should receive an instant's attention before we turn to the globe itself. Recent wounds or contusions of the eyebrows, or the cicatrices resulting from former injury, are worthy of note, as such accidents now and then, through the supra-orbital branch of the fifth pair, seriously affect the power of vision. In the lids, we should observe if there is any loss of the natural freedom of motion, whether from mus- cular paralysis, or from thickening of their structure, or from photophobia. We should note any inversion or aversion of their edges, or the existence of wounds, ecchymosis, cedema or tumors. The tarsal borders may be thickened ; or covered more or less with crusts, indicating disease of the Meibomian glands ; or infested with pediculi. The absence of a portion of the eyelashes, or their misdirection, constitutes another important change. In cases where the cilia are thus misdirected, growing towards the eyeball, they are often so pale, from constant immersion in the secretions of the eye, that it is difficult to detect them, and they may be best discovered by the fact that the tears are drawn slightly around them by simple attraction. METHOD OF EXAMINING THE EYE. 5 Any alteration of the position of the globe, or other evidence of tumors in the orbit, should be at once noted. All the appendages of the eye having been scru- tinized at a rapid glance, we turn our attention to the globe itself. Its anterior surface should be carefully passed in review, to detect the presence of any foreign body, ulceration of the cornea,- vas- cularity or cloudiness resulting from friction of gran- ulated lids, or lingering traces of former disease of the cornea ; or any abnormal conditions of the con- junctiva, such as the ohve stain produced by long- continued applications of solutions of the nitrate of silver, chemosis, small papulae, pterygium, or any increase of vascularity. If abnormal vascularity of the eye exists, we are to observe its character and seat, whether it affects the superficial and inoscu- lating conjunctival vessels, or the radiating zone of those of- the sclerotica, and whether accompanied or not by augmented secretion. We should also detect any alteration of the form of the globe, from conicity of the cornea, staphyloma, hydrophthalmia, or atrophy. If there is reason to suppose that an extraneous substance has become lodged under the lids, or to suspect the existence of granulations, the lids should next be everted. In nine cases in ten, a foreign body which may have intruded is found at the centre and near the edge of the upper lid. b DISEASES OF THE E\-E. As we proceed to explore the internal parts of the eye, the clearness or haziness of the field of the pupil, its size, irregularities in its outline, or any unusual appearances in the iris, are to be noted. The con- tractility of the pupils must be tested in each eye separately. To do this the fingers of one hand are placed upon the brow and tlie thumb upon the upper lid of one eye, the other hand being similarly placed as regards the other; and the lid of one eye is to be raised by the thumb, without pressure, while the other is kept closed. Unless tliis is done, we may be deceived, as the light falhng on one eye causes sympathetic contraction of the other pupil, though that eye may have lost all sensibility to light. This alternate closing and opening of the eyes also aids us in detecting cataract or other changes behind tlie iris ; as, by covering the eye for a moment, we obtain such dilatation of the pupil as permits of a quick glance over a larger field. By pressure of the thumb upon the globe, we ai'e also enabled to judge as to any Increase or lessening of the normal degree of hardness, indicating tension on the one hand or on the other commencing atrophy of the eye. Should it be desired to dilate the pupil for the purpose of obtaining a better view of tlie deep- seated parts, this may best be done by touchino- the inner surface of the lower lid with a small camel's-hair pencil dipped in a solution of the sul- METHOD OF EXAMINING THE EYE. 7 phate of atropia, of about five grains to the ounce. This apphcation will be painless, and produces con- siderable dilatation in fifteen or twenty minutes. The lens, the vitreous mass, and the whole of the posterior portion of the interior of the globe, may now be examined to great advantage. Should the physician be unprovided with atropia, the object may be accomplished by using the fresh juice, or a solution of the extract of belladonna or stramo- nium, which may be smeared upon the eyebrows and lids. Various pathological changes may be discerned in the deeper parts of the eye, especially after hav- ing dilated the pupil, without the aid of the oph- thalmoscope, — as, for instance, opacities of the lens, constituting cataract; or those more profoundly sit- uated, in the vitreous body ; or the formation of purulent collections or commencement of cancerous disease at the posterior part of the globe. With the ophthalmoscope, we may detect the minutest difier- ences of vascularity or exceedingly delicate changes of structure in the retina itself, as well as the incip- ient stages of the above-named affections. If we are satisfied that .the lining of the lids is in a healthy condition, the upper lid need not be everted. But in very many cases, including a large share of those where the conjunctiva is affected, the source of mischief, is to be found in this very situation. Almost invariably the upper is much more diseased than the 8 DISEASES OF THE EYE. lower lid. This is principally due to its anatomical f onfiguration, — the upper lid being broader than the lower, — and to its position, rendering its vessels more liable to become and remain engorged, from the influence of gravitation ; whereas - the circulation in the lower lid more readily recovers from any tempo- rary congestion. As in these cases eversion of the lid must be performed, perhaps daily, for a considera- ble time, for the purpose of applying remedies directly to the affected parts, it is of great consequence to the patient's comfort and the surgeon's success that adroit- ness and delicacy in executing this little manoeuvre should be acquired. The eyelashes and edge of the lid are to be taken hold of with the thumb and finger of the left hand, and drawn gently forward and then upward, while at the same moment pressure is made against the lid, at about the upper edge of the tarsal cartilage, with a probe, a small pencil, or some similar object, held in the other hand, — the upper edge of the cartilage being thus tilted backward while the lower edge is brought forward. The patient is to look down, thus making the reversal of the lid more easy. METHOD OF EXAMINATION IN CHILDREN. "With small children, especially those suflFering from photophobia, or who have been long diseased, we must use a diflFerent method in our examination. It is important to avoid terrifying them, as any future METHOD OF EXAMINING THE EYE. 9 i inspections, or even the application of necessary rem- edies, are thus rendered more difficult ; and, more- over, we can often obtain a better view by patience and stratagem than we can by force. By calling the child's attention to something else, and not appearing to care for the eye, we may often see it to good ad- vantage ; and, if we can gain but a momentary glance in cases of photophobia, this may suffice to assure us that the cornea is not seriously threatened, which, for the moment, is all we need to know. But if the child is unwilling or unable to allow us this assuring glance, — or where, in other cases, the swollen state of the lids prevents their being easily raised, — we must often feel compelled, at least at a first exami- nation, to ascertain the exact condition of things by the employment of gentle force. The child should be held on the knees of another person, his feet turned from the surgeon, who sits at right angles to the individual holding the child. His head should then be lowered between the surgeon's knees and firmly grasped by them, and, his hands being held by the attendant, he can make no resistance. Both hands of the surgeon are free, and he can depress the lower lid with one hand, while with the other he raises the upper lid. Should the resistance offered by the orbicularis muscle be too strong, or the lid be greatly swollen, it may be necessary to use an eleva- tor to raise the upper lid, so as to obtain the requisite view of the cornea. 1* 10 DEBASES OF THE EYE. Any remedial measures may be applied, if neces- sary, while the child is in this position. VARIETIES OF INJECTION AS A MEANS OF DIAGNOSIS. I have alluded to the distinct characters of the in- jection of the external vessels, and those more inti- mately connected with the internal parts. The ves- sels of the conjunctiva run tortuously upon its surface, inosculating in all directions, and may be readily moved over the surface of tlie sclerotica by friction exercised through the eyelid. They have a bright scarlet color, and are largest at the point where the conjunctiva is reflected irora the lid upon the globe. Even though the injection should be sufBcient almost to hide the sclerotica, it may still be distinguished by these features. Injection of the sclerotica is charac- tferized by the presence of minute vessels, largest next to the margin of the cornea, and tapering to an invis- ible fineness as they radiate upon the globe. They form a distinct circum-corneal zone, of a purplish or lake tint, and cannot be displaced by friction. They are evidently deeper seated than the conjunctival vessels. DIPFEEENCES IN THE SECRETIONS. A similar marked difference is exhibited in the na- ture of the secretions. Those poured out by an in- flamed conjunctiva have a more or less viscid mucous or purulent consistence ; while those which flow when the internal parts are implicated, or when ulceration METHOD OF EXAMINING THE EYE. 11 of the cornea exists, seem to be derived, to a large extent, from the lachrymal gland, and have the char- acter of acrid tears. DIFFEKENCES IN PAIN COMPLAINED OF. The kind of pain complained of by the patient is also very characteristic of the diseases it accompanies. In conjunctivitis, the sensation is one of smarting, or as if sand or sticks were in the eye, and is generally evidently superficial ; while in inflammations of in- ternal parts of the eye, and sometimes in cases of ulceration of the cornea, the pain has an aching character, extends deeply through the organ, and frequently affects also the circum-orbital branches of the fifth pair. The difference in the characteristics of affections as indicated by these three symptoms — the injection, the secretion, and the pain — should never be forgot- ten, as a due appreciation of these is of the greatest assistance in making a diagnosis, and of the greatest value as regards treatment. We may feel little anx- iety and give a favorable prognosis in a case of severe conjunctivitis, where the amount of redness renders the disease formidable to the eyes of the patient's friends ; whilst we watch with far more solicitude an eye which seems to others only slightly affected, but where we find deep-seated pain and development of radiating vessels, denoting, to our experienced esti- mation of their value, implication of important inter- nal parts. 12 DISEASES OF THE EYE. CHAPTER II. USE OF THE OPHTHAIiMOSCOPE. The ophthalmoscope is now so well known that it seems scarcely to require description in these pages. Yet, as its invention is still recent, a few words as to its principles of construction and application may not be misplaced. Previous to the success of Helmholz in devising means for a satisfactory illumination of the deeper parts of the eye, nearly the whole of that por- tion lying behind the crystalline lens was veiled to our observation; it being difficult to place our own eyes in a position to receive rays which are reflected from another retina in the direction in which they reach it, — any attempt to do so intercepting the lu- minous rays themselves. His invention has made a large addition to our means of diagnosis of the deep- seated diseases of the eye. I shall describe two only of the numberless modi- fications proposed in the construction of tliis instru- ment. Essentially the same arrangement originally pro- posed by Helmholz — in which several plates of thin, unsilvered glass placed obliquely in a darkened tube rSE OF THE OPHTHALMOSCOPE. 13 constitute the reflecting surface, — is still in favor, and, from the mild light thrown into the eye, it is well adapted for the investigation of cases requiring cau- tion as to the amount of light admitted. Behind the reflecting mirror a perforated diaphragm protects the eye of the observer from the influx of too much light. By placing in a ring, provided at the back of this dia- phragm, a suitable concave glass, an enlarged upright image of the retinal surface is distinctly seen. The concave glass should in most cases have a power of from eight to twelve inches. The instrument thus made up requires to be held near the eye of the pa- tient, as its illuminating power is not sufficient at a longer distance. A practitioner who has frequent occasion to examine the interior of the globe should be provided with an ophthalmoscope constructed in this manner. A simple instrument, available for most purposes, consists of a concave silvered mirror, having a small hole at its centre. Nachet and others have also add- ed a ring behind the mirror for receiving concave or convex glasses. This instrument has a strong illu- minating power, even when held at the ordinary dis- tance of the observer's distinct vision, and we should be careful not to have the light too brilliant. The reversed image of the retina is indistinctly seen by the aid of the mirror alone. But if a convex lens of two inches radius is held by the other hand of the observer near the eye of the patient, a smaller but more distinct reversed image in all its details can be perceived. 14 DISEASES OF THE EYE. For a thorough mvestigation of the eye, it is desira- ble that the pupil should be previously dilated by atropia. Examinations can be made with most fa- cility in a darkened room, and by artificial light from a gas-burner or a carcel or student's or solar lamp. The patient is to be seated beside a table, with the light nearly on a level with his eye and not far from his ear. A pamphlet or some other screen should be placed, or held by the patient, between his head and the light, — so that the orbital region may be shaded from all rays except thos& from the mirror. The eye of the observer should be on a level with or a httle above the eye he explores. The mirror is to be so directed that its reflected rays may pass tlirough the pupil, and the instrument with the lenses employed, if any, should be held slightly nearer or farther from the patient's eye till the exact focus is ascertained. The difference of ac- commodative power in vaiious eyes renders it impos- sible to fix any exact distance or any precise focus of lens to be employed. With the instrument thus properly adapted, the minutest details of structure or patliological change can be seen with almost as much clearness and pre- cision as if situated on the external surface of the globe. Having obtained the exact focus of one point, we are able, by moving the instrument, or by direct- ing the patient to turn his eye, slowly, to explore in tui-n every part of the interior. EEMEDIES, AND THEIR APPLICATION. 15 CHAPTER III. EEMEDIES, AND THEEB APFLICATION. Before proceeding to a description of particular affections, we may properly devote a little space to a few of the principles which should guide us in the treatment of ophthalmic diseases. A certain share of them, among which are most of those of the conjunc- tiva, may he regarded as almost wholly local, and amenable to local remedies, little attention to the gen- eral condition being required. In others, no local treatment is called for, but certain conditions of the system demand our exclusive attention ; as, for in- stance, in the loss of vision which sometimes accom- panies excessive lactation. In another large class, as in the rheumatic and syphilitic forms of iritis, and in strumous affections of the cornea, it is important to combine the judicious administration of remedies with a proper application of local means. Of the various methods of local treatment, the use of coUyria, more or less astringent, stimulant, or sed- ative, is of most extensive application. Solutions are preferable to any other vehicle for our remedies, as we are able to graduate them to a uniform strength, and no mechanical violence is requisite to their intro- 16 DISEASES OF THE EYE. duction. No ointments, of any description, should ever be used inside the eyelids. They are liable to vary in strengtli, to become rancid or decomposed, and their fatty substance forms, at best, a vehicle far inferior to water for distributing the medicinal agent over the whole of the affected surface. Under no cir- cumstances do they offer any advantages which are not afforded by judiciously adapted aqueous solutions. I have seen most serious results from incautious use of nitrate of silver ointment, in the hands of physi- cians themselves, as well as when employed by pa- tients at the suggestion of well-meaning friends. Solutions of the acetate of lead, sugar of lead as it is popularly called, formerly had a prominent place among collyria, and are even now extensively em- ployed by some physicians, and especially by the com- mon people. They should be banished from the list of ophthalmic remedies. In cases where they seem to be of service, the object can be better accomplished by other means which are not dangerous to the eye, as are all the preparattons containing lead. Where ulceration of the cornea exists, the solution of lead is liable to be decomposed and deposited in the texture of the cornea, forming an indelible opacity. I have several times removed crusts from the anterior sur- face of the cornea which have been proved by anal- ysis to contain lead. While, therefore, we have excellent substitutes in other astringents, it is not justifiable to make use of lead as an ingredient in a REMEDIES, AND THEIK APPLICATION. 17 coUyrium; as we can seldom be certain that the cornea may not become implicated in the inflammations for which it is ordinarily prescribed, or that the same collyrium may not be employed at a future time for another member of the family who may happen to be attacked with ophthalmic disease. But, aside from the danger of employing it, lead does not deserve the reputation it has enjoyed, and is certainly inferior in value to other mineral astringents, for ophthalmic purposes. The abuse of strong solutions of the nitrate of sil- ver is another evil to which I feel bound to call atten- tion. It is apparently considered, by some, a specific for all the ills which eyes are heir to, — and is so lavishly employed that we not only observe, as results, a disagreeable olive stain of the conjunctiva, but, in some instances, destruction of the folds of this mem- brane and adhesions between the Hd and the globe, where solutions approaching to saturation have been incautiously applied. It frequently aggravates the symptoms, and I can assert, as the result of many comparative trials, where the nitrate, in solutions of dilFerent strength, has been used for one eye, and solutions of the sulphate of zinc, with perhaps the crayon of sulphate of copper for the other equally diseased eye of the same individual, that I have al- ways found recovery slower in the eye to wMch the nitrate of silver was applied, and have often been compelled to abandon its use and substitute the treat- 18 DISEASES OF THE EYE. ment under which the other eye had already recov- ered. I do not say that the use of the nitrate of silver should be abandoned. It may be resorted to with good effect in certain cases ; but entire absti- nence from its use, as an application inside the lidsj for a long period in my own practice, has proved that it may be dispensed with without its want being felt, and I am glad to find the more recent authorities restricting its use within far narrower bounds than formerly. My desire is, only, to caution the young practitioner against too frequent use of this powerful stimulant, in cases where a mild astringent would bet- ter serve his purpose. It would be a gain for ophthal- mic therapeutics if its use should become far less gen- eral ; as, even in cases where its application may be followed by recovery, the same result would equally have been attained had milder means been employed. The crayon of sulphate of copper is capable of re- placing, with great advantage, the nitrate of silver, in most of the cases where this has been in favor; espe- cially m the treatment of conjunctival inflammation and granulated lids. It does not, like the nitrate in substance or in strong solutions, act as a caustic, de- stroying the surface of the conjunctiva, but as a pow- erful astringent. To obtain good crayons, which is exceedingly important, it is almost essential to pro- cure crystals from a laboratory or to recrystallize a quantity of the sulphate ; as, when sent to market, the crystals are so much broken that it is difficult to REMEDIES, AND THEIE APPLICATION. 19 find suitable pieces. The part to be sdected is the hard portion, free from water of crystaUization, near the apex of the crystal. This is to be carefully cut with a pocket-knife, or sawn, into the desired shape, which should be that of an ordinary crayon of large diameter. It may then be rendered as smooth as a piece of glass by rubbing with a wet rag, and fitted in a porte caustique. If the selection has been well made, th6 crayon will wear perfectly smooth, and, if carefully wiped after each application, may be used a great number of times, and for various pa- tients, without danger ; though, of course, as a precau- tion, the physician should be provided with several if he has to employ them upon those whose diseases are highly contagious. It should usually be very lightly applied, over the whole surface of the conjunctiva of the everted upper Hd. Too heavy a touch should be avoided, as, if clumsOy used, it causes much more pain, and acts as an over-stimulus. Where the in- flammation is intense, the pain from the first appli- cations is sometimes considerable, but it is less than that produced by an equivalent strength of the solu- tion of nitrate of silver ; and as the patient becomes habituated to the remedy and the symptoms diminish in severity, the pain becomes trivial, even children disregarding it after the first few moments from its application, though they may have seemed to suffer very much when it is used for the first few times. Collyria may be dropped into the eye from a tea- 20 DISEASES OF THE EYE. spoon, or a quill, — or a bit of rag or fine sponge may- be moistened with the fluid, which is then to be squeezed into the eye ; or any other means most con- venient to the patient may be employed in their inti'o- duction ; it being desirable to instil a few di'ops at each application, tliat the whole of the affected sm-face may be reached by the remedy. This is not the place to introduce a full list of rem- edies which are useful for external applications to the eye. Suffice it to say, that among them the mineral astringents hold a prominent and deserved place. Theoretically, the vegetable astringents would seem adapted to do good service ; but practically I have been disappointed in their effects. As to the strength of the solution to be employed, the best general rule is, that it should not cause smarting for more than a few minutes. As a rule, a coUyrium should be so mild as to allow of its frequent use, that its influence on the eye may be kept up. If more active remedies are required, other means should generally be resorted to, rather than to increase the strength of the collyrium. If its effects continue a long time, I usually direct the patient to reduce a portion of the collyrium till it causes pain for not more than five minutes, and to continue to use it thus diluted till the eye becomes able to bear the full strength. Local depletion by means of leeches is often of signal service in the acute stages of inflammation, but EEMEDIES, AND THEIR APPLICATION. 21 their influence is scarcely felt in affections wMch have become chronic. When prescribed, they should gen-, erally be applied on the temple, at some distance be- hind the eye and on a level with it. If applied on or above or too near the lids, much swelling is liable to ensue, from infiltration of the loose sub-cutane- ous cellular tissue. Depletion by scarification of the conjunctiva, or division of vessels on the surface of the globe, has been much recommended by some au- thorities ; but, though scarification is often followed by a sense of relief, the effect is but transitory, — the reparative process for the healing of the small incisions renewing the vascular congestion to fully its original degree, — so that on the second day the con- dition is usually the same as before the operation was performed. Vessels should not be divided with the hope of cutting off a supply from a diseased cornea ; such an expedient could only have been devised by a superficial observer ; as in this case their development is the effect and not the cause of the disease, and, if certain branches are obliterated after incision, others are immediately developed in their place ; whereas they all 'disappear after, but not before, the state of the cornea is improved by proper treatment. Local depletion, to a moderate extent, is by no means incompatible with a general tonic treatment. Unloading the neighboring vessels may relieve a pas- sive congestion, the return of which may best be prevented by giving vigor to the general circulation. 22 DISEASES OF THE EYE. Poultices, whether made secundum artem, or com- posed of the disgusting ingredients so much in favor with the vulgar, are very rarely allowable in disease of the eye itself. If applied in conjunctivitis, or dis- ease of the cornea, they tend to augment the dis- charge and to soften the corneal tissue, favoring the formation of ulcers and perforation by the relaxation produced by the constant application of heat and moisture. When deep-seated, aching pain, with injection of the zone of vessels radiating outwards from the mar- gin of the cornea, indicates inflammation of the iris or other internal part of the eye, — the collyria and other outward applications, of so much service in affections of the external tissues, become valueless. They cannot reach the diseased portion of the organ, and, far from being able to control any secondary injection of tlie conjunctiva which arises from conti- guity to the inflamed parts, they tend to aggravate it. This injection will subside with the diminution of the primary disease, — and our use of local remedies must often be restricted to such sedatives as may con- trol the pain, and to agents capable of effecting en- largement of the pupil. In traumatic injuries of the globe, we should be very sparing of our resort to active treatment. Non- interference should be the rule, except where positive indications are manifest. This point cannot be too strongly insisted on. EEMEDIES, AND THEIK APPLICATION. 23 In specifying the treatment of the various affec- tions, I shall not attempt to mention all the remedies which may be of service. My design is rather to mark out a safe, and, as far as possible, the best course to be followed, without confusing the reader by a multiplicity of details. General principles being thus established, the practitioner will have no difficulty in selecting other remedies of similar action to those recommended as a first choice, whenever in his judg- ment they may seem to be indicated. 24 DISEASES OF THE EYE. CHAPTER IV. AFFECTIONS OF THE CONJUNCTIVA. SIMPLE CONJUNCTITITIS. The slight and transient irritation of the conjunc- tiva, caused by the presence of a foreign body, scarcely deserves to be regarded as one of its dis- eases ; yet it is a source of annoyance often requiring relief, and if improperly treated may lead to more serious symptoms. It is characterized by slight injection, increased lachrymation, and a sensation of having something in the eye, with more or less sensitiveness to light. If a foreign body is still present, its removal is to be at once effected. A large proportion of such bodies are particles of sand, cinders, or other similar objects, which have been blown into the eye, or minute par- ticles of iron, &c., which have been projected into it from lathes in machine-shops, or in the use of various tools in stone-cutting and other occupations. Nearly all the former which are not readily washed out by the increased flow of tears, become lodged beneath the upper hd and near its edge, at the centre of the tarsal cartilage. The adroit eversion of the lid and removal of the offending substance with a SIMPLE CONJUNCTIVITIS. 25 probe, a small brush, the point of a pencil, or any- thing at hand, is but the work of an instant. Usually the patient is at once relieved from the sensation of scratching caused by the sharp particle ; but at times the feeKng of having something in the eye is not immediately removed, owing to the vessels having become injected. This sensation will soon subside, if the eye is left to itself or bathed a few times with tepid or cold water or milk and water. Where a particle of iron, cinder, or other hard substance has become imbedded in the cornea, it is usually detected with little difficulty ; but, if it happen to be near the centre, in front of the black field of the pupil, it may escape notice unless carefully looked for. If only slightly imbedded, it may be removed by a brush or small stick, such as are used for toothpicks. When it has been driven with force into the cornea, and is firmly held in its elastic tissue as a nail is fastened in a board, a small instrument having a round, slightly-blunted extremity, or an instrument shaped like a cataract-needle, but having a shorter shaft that it may have less spring, is very service- able. When the particle has been but a short time in the eye it may usually be readily removed; but, where unsuccessful attempts have been made by fel- low-workmen and others, the sensitiveness becomes extreme, and it is difiicult for the patient to control his eye long enough for the surgeon to efi^ect the object. The use of ether to induce anaesthesia may 2 26 DISEASES OF THE EYE. be required in a few cases under such .circumstances. The patient may stand near a window, his head resting against the frame of the window and the wall, or may be seated in a high-backed chair, and the surgeon, separating the lids with the fingers of his left hand, endeavors, by quick manoeuvres with his instrument, to lift the foreign body from its po- sition ; keeping on his guard against sudden move- ments of the globe, that the instrument may neither scratch the cornea nor be thrust through it. A similar form of conjunctivitis to that caused by a foreign body, is often occasioned by exposure to draughts of air or sudden changes of temperature, not sufficiently prolonged or violent in their action to bring on the catarrhal form of inflammation. If treated by strong stimulants or astringents the symptoms are aggravated, but they are easily removed by the fre- quent use of mild applications. Lotions with tepid water, milk and water, rose-water, or infiision of tea, are often all which is needed. When these have proved insufficient, I have found great advantage from the use of a collyrium containing from eight to twelve grains of borax to an ounce of the aqua camphorte of the U. S. Pharmacopoeia. A little of this solution, dropped into the eye three or four times a day, appears to have a gently stimulant and at the same time sedative effect, and answers the purpose far better than the strong solutions so often indiscreetly recommended. AFFECTIONS OF THE CONJUXCTIVA. 27 EEUPTIVE CONJUNCTIVITIS. Another variety of disease of tlie conjunctiva is characterized by the appearance of one or several small papular elevations upon its surface ; each papule being surrounded by a slight injection. Sometimes their summits are white, but they have no true pustu- lar character. Their most frequent seat is at or near the margin of the cornea. Children near the age of puberty, and young females whose menstruation is irregular, are the subjects in whom we oftenest observe thLs form of disease. The treatment should consist in the use of mild means only, as any severe applications tend to aggravate symptoms which would generally spontaneously disappear in a few days. A very weak astringent, dropped into the eye three or four times a day, seems not only to favor the reso- lution of the papulae, but to fortify the conjunctiva against their recurrence. Nothing more active than very weak solutions of borax, alum, or sulphate of zinc is to be advised. This tendency to recur is one of the features of the disease ; to obviate which, the general health should be maintained by tonics and nutritious food. Another form of this eruptive affection is more chronic in its tendency. It exhibits a flattened ele- vation of much larger size than the papules just spoken of, sometimes having a diameter of two lines or more. Save in its tendency to persist, it resem- 28 DISEASES OF THE EYE. bles tlie disease already described, — its causes, prog- nosis, and treatment being similar. A solution of borax, ten grains to tbe ounce, may be dropped into the eye, and lotions of an emollient nature (as in- fusions of sassafras pith, althea root, or quince seeds), may sometimes be advantageously used. If other collyria are required, solutions of alum, one or two grains to the ounce, or wine of opium largely diluted with water, are sufficiently active. A nearly ex- pectant treatment is better than too much inter- ference. INIore attention to the general condition seems to be required in this chronic form of the disease, most of its subjects being in a state of health below the normal standard ; otherwise the morbid changes may remain for weeks notwithstanding ju- dicious local treatment. Occasionally a change of air seems to be very beneficial, the symptoms quickly subsiding after a sojourn at the seaside, if the patient has resided in the country, or vice versa. MUCO-PURULENT CONJUNCTIVITIS. By far the most important class of affections 6f the conjunctiva is made up of several diseases of which a common and peculiar feature is the occur- rence of a muco-purulent discharge from this mem- brane. Their importance claims for each a separate description. AFFECTIONS OF THE COXJUXCTIVA. 29 CATAKEHAL CONJUNCTIVITIS. The sensations experienced at the outset are scarcely more severe than those complained of in simple conjunctivitis. The patient has a sensation of itching, smarting, or dryness of the lid, usually, though not invariably, increased towards evening, sometimes most felt on awaking in the morning. Frequently the access is so sudden, that he feels sure that some foreign body is beneath the lids, and I have often found it difficult to convince my friends of the ' profession who have consulted me, that such was not the case with them when seen in the early stages of this disease. But the appearance of the conjunctiva, on everting the upper lid, shows a marked difference in the two cases. Where a foreign body is or has been lodged beneath the lid, there is simply injection of the palpebral conjunctiva, usually over a limited extent, — while in commencing ca- tarrhal inflammation the conjunctival surface is more universally injected, and shows a velvety thickening of the mucous membrane, quite different from the smooth though congested surface which has been merely irritated by some intruding substance. At this stage it is easily arrested, in healthy and cleanly subjects, by the use of a mild astringent collyrium. A solution of sulphate of zinc, from one to three grains to the ounce, has seemed to me most certain to insure prompt recovery. Sometimes, a 80 DISEASES OF THE EYE. collyrium of borax, ten grains to the ounce, will serve the purpose, — and now and then, frequent lotions with tepid water, milk and water, infusion of rose-leaves carefully strained, or strong tea, are all which is needed. Tepid are better than cold lotions in these affections ; as, though the latter sometimes seem more grateful at the moment of application, they appear to cause a reaction which is unfavor- able to recovery. The majority of patients also find more relief from the use of lotions at a warm tem- perature. But it is seldom that the disease is brought to our notice till it has made further advances. The sen- sation of sand or sticks in the eye becomes more marked, and the edges of the lids are often agglu- tinated in the morning by the abundant secretion which has accumulated during the night. Exami- nation shows a great increase of the injection and thickness of the membrane, and a more or less vil- lous, or, as it is termed, granular condition of its surface. The enlarged vessels, which before were confined to the palpebral, now extend to the ocular portion of the conjunctiva. Instead of a disposition to spontaneous recovery, or a ready yielding to mild remedies, we now find a tendency in the disease to persist indefinitely, and to occasion yet fiirther morbid structural change. As the affection becomes confirmed, the granula- tions are more and more prominent, the conjunctiva CATAPvEHAL CONJUNCTIVITIS. 31 of the upper lid having a surface as irregular as that of a raspberry. Now and then the enlarged foUicles become pedunculated and seem almost detached from the surface. According to the condition assumed by these gran- ulations, we may expect more or less serious changes in the globe itself. If they remain soft and flabby the disease may be almost limited to the lids, and may continue for years without affecting the cornea ; but, even in these more favorable cases, the cornea at length yields, and, though the symptoms have long pursued a mild course, they are liable to sudden aggravation. Where, on the contrary, the granula- tions become hard and almost homy, the constant friction of the rough lid over the surface of the trans- parent cornea brings on vascularity, cloudiness, and at length ulceration, ending, if allowed to take its course, in perforation of the cornea, and perhaps de- struction of the eye. The lining of the upper is almost invariably more affected than that of the lower lid. Consequently the upper part of the cornea, which is most of the time covered by this lid, is usually the first to become cloudy, every movement of the eye or lid bringing the roughened surface in contact with the delicate transparent structure. So marked is the effect thus produced, that the upper half of the cornea is some- times deeply ulcerated while the lower part remains clear, and a glance at the eyeball is sufficient to show what must be the condition of the upper lid. 82 DISEASES OF THE EYE. The character of the pain, and form of injec- tion proper to all the varieties of conjunctivitis, are of themselves, as I have elsewhere shown, siifScient to establish the diagnosis between the affections of this tissue and tliose of the internal parts of the globe. The pain is a" smarting or itching, with a sensation of having some substance inside the lids, — and is wholly different from tlie severe aching, deep-seated pain, often extending along the supra- orbital or other branches of the fifth pair of nerves, which accompanies inflammation of the internal parts. There is no pain, of consequence, when the eye is moved or gently pressed upon. The injection of the globe commences at the line of reflection of the con- junctiva from the lids upon the eyeball, and the ves- sels diminish in size as they approach the cornea. They are tortuous and irregular, crossing and inoscu- lating in all directions, and have a bright scarlet or vermilion color. They may also be moved fi-eely over the surface of the sclerotica by rubbing the hd to and fro upon the globe. In internal inflammations, as for example in iritis, the pain, as I have said, is deeper-seated and often circura-orbital. The injection is evidently in the sclerotica, radiating from the margin of the cornea, the vessels growing less and disappearing at a dis- tance of a few lines from its edge. They do not cross each other, and have a straight, instead of a tortuous course. They cannot be made to glide, by CATARRHAL CONJUNCTIVITIS. 33 movements of the lid. The color is a pink or pur- plish hue, quite different from the florid tint of the congested conjunctival vessels. "When, however, conjunctivitis has involved the cornea, the character of the pain changes, — and it has a nature and severity resembling that attendant on inflammation of deeper-seated parts. CoMses. — The causes of catarrhal conjunctivitis are, principally, exposure to cold and to atmospheric changes, and the irritation occasioned by fine parti- cles of dust, especially if the patient is afterwards exposed to cold, damp winds, or night air. In Cali- fornia, and upon our western prairies, these influ- ences are largely felt, and affect great numbers of persons. Inoculation of a healthy eye with the secretion from one affected with the disease, is liable to induce a similar condition, and is in fact one of its most fre- quent causes. It is not uncommon for whole fami- lies to be attacked, from the indiscriminate use of towels which have served for individuals suffering from the affection. In these instances, the symptoms are not unfrequently more severe in the cases sec- ondarily affected, than in that from which they were derived. Prognosis. — Scarcely any disease is more amena- ble to treatment, — and we may be almost certain of perfect restoration of the normal condition, if the disease has not already produced irreparable changes. 2» c 34 DISEASES OF THE EYE. But to secure this result, constant and patient care is requisite in all but the mildest cases. The disease must be driven from its last hiding-place beneath the upper lid, as, if allowed to linger there^ it is liable to be re-extended to the eyeball, upon any imprudent exposure. The patient often requires to be detained, when he thinks himself almost entirely recovered, till the normal condition of the conjunctiva is fully restored in all its parts ; otherwise he is liable to relapse, and may have to submit to even more te- diously prolonged treatment before he can recover lost ground. Even where the cornea has become obscured, by the development of vessels and the cloudiness which results from their presence, or where considerable ulceration has taken place, we may yet obtain com- plete restoration of its transparency, notwithstanding the disease may have been in progress for years. In one instance in which I was consulted, the patient had been known as a blind man for sixteen yeara, but was restored to vision by assiduous treatment contin- ued for months. It was amusing to witness his sur- prise that his friends had grown so much older since he last saw them. But, when ulceration is followed by perforation of the cornea, closure of the pupil is likely to occur, the iris becoming cemented to the cornea by the lymph effused to close the perforation. "Where the aperture is but small, adhesions of the iris to the cornea may sometimes be prevented, and the CATAEKHAL CONJXISCTIVITIS. 35 pupil preserved, by the prompt use of atropia ; large dilatation of the pupil keeping its edge at a distance from the point where reparation of the cornea is going on. But, unless the original disease is at the same time arrested, the ulceration is likely to extend, and the entire cornea becomes softened and gives way, allowing the iris to protrude, and forming with it a staphylomatous projection. When no deep ulceration of the cornea has oc- curred, we may promise, as I have said, complete restoration, notwithstanding the great amount or long duration of obscurity resulting from thickening and vascularity of the epithelial layer of the cornea. We are not to allow the patient to be discouraged because he perceives very little improvement even after treat- ment has been continued for a considerable period. The fact is, the cornea has become so altered from its normal state, that even a small amount of friction from the lid suffices to keep up its morbid condition, and it is only after the roughness of the hds has been very much reduced that a gain in the transparency of the cornea, and improvement in vision, may be ex- pected. The patient must be satisfied, at first, with our assurances, — and with a diminution of the secre- tion and increased power of opening the lids, — with- out obtaining the pleasing evidence of progress which is afforded by returning sight. After the prominence of the granulations has been considerably reduced, and the condition of the whole conjunctival surface at 36 DISEASES OF THE EYE. the same time improved, the patient gains more rap- idly, and soon observes an amendment from one week to another, if not from day to day. When the patho- logical changes have existed a long time, or when the epithelial layer of the cornea, in common with the rest of the conjunctiva, has been stained by the excessive use of solutions of the nitrate of silver, recovery of perfect vision for small objects is often tediously slow. A slightly hazy look of the cornea, as if the anterior chamber were filled with smoke, continues for some time after large objects can be distinctly perceived. Time, however, with or without the aid of mild stimu- lating or astringent coUyria, will gradually dissipate all obstacles to pei'fect vision. Where ulceration of the cornea has occurred, the cicatrix, even if very extensive, may disappear after a time, if the ulcer has not penetrated too far. If very deep, the cicatrix persists ; and when it occupies the centre of the cornea, interferes more or less with per- fect sight ; but it frequently diminishes to a small fraction of its original size, and allows of much more vision than was at first expected. Where only a por- tion of the edge of the pupil has been involved, in cases of perforation, this diminution of the cicatrix often affords happy results. But when the pupil is entirely closed, an operation for artificial pupil is the sole resource for recovery of vision. This means should not be resorted to while good vision remains in the other eye, as the want of harmony in the two CATAEEHAL COXJUXCTIVITIS. 37 eyes would probably cause the result to be more annoying than useful to the patient. Treatment. — Our first care should be, to guard against contagion. If but one eye is affected, precau- tions should be taken against contact of the secretion with the other eye. The patient's friends should also be warned against making use of towels, wash-basins, or handkerchiefs which may have become contami- nated. As regards general treatment, I must protest against a course which is exceedingly common, — the placing a patient upon strict diet, subjecting him to active general or local depletion, and administering remedies which reduce the general health below the previously existing standard. A large proportion of the worst cases are conjoined with a strumous dia- thesis, or occur in those who are already enfeebled by the privations which poverty brings in its train, and which are only too quickly increased when disability to labor cuts off the usual resources. In these condi- tions, a resort to depressing measures only aggravates the symptoms. The disease, in the stage at which we generally see it, is essentially chronic in its char- acter, and is not to be thrown off by any heroic treat- ment ; but it is far more readily subdued when we can give tone to the circulation and vigor to the general system. In acute cases, advantage may now and then be derived from a purgative, which has a derivative 38 DISEASES OF THE EYE. effect on the circulation, and sometimes from two or three leeches applied to the temple, unloading the vessels in the vicinity of the eye, and giving the conjunctiva an opportunity to recover itself. But when the affection has become chronic, little if any good results from these remedies of transient influ- ence, and no general treatment is required, except to keep the patient as nearly as may be at the standard of health. We should allow the usual diet if the food is well digested, even making it more substantial ■where the state of the system is below par. Gruel and frequent laxatives are by no means adapted to keep up the health or spirits of a patient who is already sufficiently depressed by the prospect of blindness, — and their use could only be justified by the results of experience, which, far from favoring, forbid them. On the other hand, abstinence from stimulants should be insisted on, unless when pre- scribed to obviate some low condition of the system. Exposure to cold and damp, to high winds, or sudden variations of temperature, should be guarded against. In cases where the granulation is of long standing and the cornea much involved, it is desirable that the patient should be rather quiet than otherwise, taking only so much exercise as is necessary to his health, and keeping the eyes much of the time in repose, that there may be less of the friction upon the globe which must always take place while the patient is looking about as he walks. CATARRHAL CONJUNCTIVITIS. 39 But the disease is so eminently a local affection, that the principal treatment must consist- in local remedies. If these are judiciously employed, we have the satisfaction of an almost invariable suc- cess, — if they are ill chosen or unskilfully applied, ■we shall often fail, for the languid efforts of nature are of slight avail to arrest the destructive tendency-. Cleanliness should be insisted on, — as the frequent removal of the secretion takes away one source of irritation. The eyes may be bathed several times a day, if necessary, with tepid water or milk and water, and a httle of some simple ointment should be ap- plied along the edge of the Hds at bedtime, to pre- vent their becoming agglutinated, and to allow of a free escape of the secretion during the night. The choice of a collyrium is one of the most im- portant points of treatment, in this affection of the eye. By this means, which should be so mild that it may be frequently introduced by the patient with- out exciting excessive irritation, we keep up an in- fluence on the disease which can be exerted in no other way. The occasional and even daily appli- cation of remedies by the physician himself, even when most judiciously made, wUl often fail of success because nothing has been given to the patient to act as an auxiliary to the means used, and keep up a constant mild action on the diseased tissues. In both the acute and chronic stages of this affection, a solution of sulphate of zinc in the proportion of 40 DISEASES OF THE EYE. from two to four grains to the ounce of water or rose-water, answers admirably in a large proportion of cases. This should be employed from two to four times a day, the lower lid being drawn down, and a few drops poured from a spoon, or squeezed from a bit of rag or fine sponge into the eye. It is carried to all parts of the conjunctiva by the movements of the lids. Unless a child, the patient can apply this without assistance. The best rule in regard to the collyrium, is to have it of such strength as will cause smarting for a few minutes only, after which the eye should have a sense of more or less relief. Should the patient complain of pain pro- longed beyond this time, he should reduce the strength of the solution. In the acute stage, many cases require nothing more than the use of tepid lotions, with such a collyrium as I have described. Solutions of alum, acetate of zinc, or sulphate of copper may also be employed in this affection, if a change is considered desirable, the alum being used stronger and the sulphate of copper weaker than the solution of sulphate or acetate of zinc. Probably many more remedies than we have been in the habit of employing might be added to the list ; but our present ophthalmic pharmacopoeia needs to be cur- tailed of certain of its preparations, and it should be enlarged only after sufficient experimental trial. In more obstinate or chronic cases, the same plan is to be pursued by the patient, but other additional local CATAERHAL CONJUNCTIVITIS. 41 applications should be made by the physician himself. Of these, by far the best is the crayon of sulphate of copper, prepared as I have described in the chap- ter on " Remedies, and their Mode of Application," and lightly passed over the inner surface of the upper lid ; which, as I have explained, is the original seat of the disease. This touch with the crayon should be repeated every day or once in two or three days, according to circumstances. The more frequently the better, as a rule, in chronic cases ; yet, if the patient is unable to attend so often, once in two or three days may answer the purpose, especially after the symptoms are considerably ameliorated. The crayon should be gently passed, once only, over the surface of the lid ; repeating it several times gives too strong a stimulus, and what should have been a remedy becomes an irritant. When the physician, especially if young or of Kmited experience in these diseases, has charge of one of the sluggish cases I have described, — where the disease has existed for years, and must continue for months, even under the most skilful management, his position is a difficult one. It is hard to satisfy himself or his patient that he is doing the best which can be done, in following an almost unvarying treatment week after week, whilst little progress seems to be made towards the wished for end. It is still more difficult to persist when the patient appears to lose ground, as will now and then be the case after some imprudent exposure, 42 DISEASES OF THE EYE. which causes a relapse from which recoA'ery is even more slow than before. The temptation to try other remedies is nearly irresistible ; some other course seems imperatively called for. But I am satisfied, from careful and long observation, that it is better in these instances to persevere in a course which experience has justified, as, we may say, invariably successful ; particularly if, in some respects, its effects have seemed beneficial, and the patient has for a time improved; rather than to try one remedy after another, in a hopeless attempt to effect a rapid recovery. This need not prevent our substituting, temporarily, other collyria, or the use of lotions or other applications of little potency, with a view to keep the attention of the patient occupied, and lead him to feel that the physician is using every means he thinks likely to be of service. In preferring the crayon of the sulphate of copper to solutions of nitrate of silver, I am fer from wishing to undervalue the latter, or to advocate any mere- ly routine treatment. But comparative experiments have proved, for me, that the sulphate of copper will accomplish everything which can be effected with the stronger remedy ; and as it does not destroy the tis- sues, as is sometimes done by the nitrate to such an ex- tent as to cause adhesion of the entire lid to the globe ; or produce indelible stains, which often ensue when lunar-caustic is employed for a considerable time ; it certainly seems advisable to prefer a reliable and less CATAKEHAL CONJUNCTIVITIS. 43 dangerous agent than the nitrate must be admitted to be. Having charge, at one time, of a large number of ophthalmic patients in one of our public institu- tions^ comprising many cases of chronic granulation of the lids, — I repeatedly experimented, comparatively, with the two remedies, applying the crayon of sulph. cupri to one eye, and solutions of argent, nit. of vari- ous strength, to the other eye of the same patient. Of course no differences of constitution or habits could influence the result ; but I believe in every instance recovery was more rapid in the eye to which the crayon had been applied, and in some instances it was necessary to substitute the crayon of copper for the nitrate of silver before any improvement could be effected. PTJEITLENT CONJUNCTIVITIS. This variety of the same class of inflammations of the conjunctiva, known also under the name of Egyp- tian Ophthalmia, Ophthalmia of Armies, &c., differs from the catarrhal form rather in the virulence of its contagion and the extreme rapidity of its course, than in any radical dissimilarity of nature. Causes. — It is caused by direct contagion, by ex- posure to glare of light, to winds charged with fine sand, and especially by theinfluence of cold at night after such exposure and great fatigue during the day. Perhaps, also, the crowding together of large num- bers of men in ill-ventilated barracks, or of children 44 DISEASES OF THE EYE. in foundling or other hospitals, may induce the dis- ease, where others who are affected occupy the same apartments, even without direct contact. This last supposition finds some support in recent experi- ments which are said to have detected the presence of pus in the air of such localities where the disease existed. Some military authorities, especially in Belgium, where the disease is endemic in certain garrisons, have denied the virulent properties of the secretion, even going so far as to introduce it into their own eyes ; but the evidence in support of the doctrine of its contagiousness is too strong to be set aside by a few negative facts. Symptoms. — In a very short time, even a few hours after its invasion, the lids become enormously swollen, and often livid, the disease not only causing great thickening of the conjunctiva, but implicating other tissues of the lid. The upper lid is sometimes so much enlarged as to cover the lower lid and rest upon the cheek. Chemosis, or infiltration of the sub-conjunctival cellular tissue covering the globe, is usually present, — at first serous in its character, but afterward becoming phlegmonous, as the cellular tis- sue becomes itself inflamed. The secretion is very copious, and has more of a purulent character than in the catarrhal form of conjunctivitis. Being con- fined by the swollen lid, it gushes out in large quan- tity when this is raised. The sensation of having PURULENT CONJUXCTIVITIS. 45 sand in the eye is intensely acute, and is often accom'- panied with circum-orbital pain, from the extreme distension of the tissues, and, perhaps, from com- mencement of disease of the cornea. Prognosis. — The disease requires prompt interfer- ence ; otherwise there is danger that sloughing of the cornea may occur from strangulation, its proper nutrient supply heing cut off; or that more or less extensive ulceration, with its consequences, may take place. Treatment. — Cleanliness is a cardinal point in all the muco-purulent affections of the conjunctiva. The se- cretion should not be allowed to accumulate within the lids, — as it is highly irritating in its character, and appears to macerate and soften the cornea. If it does not freely escape upon opening the lids, the nozzle of a syringe should he introduced beneath the swollen lid, and the orbital cavity cleansed, alternately with pure water and with a suitable collyrium. In doing this, the operator should take care that no drop of liquid is thrown into his own eye. Collyria, of somewhat greater strength than those required in catarrhal in- flammation, should be frequently used, and, if neces- sary, as is generally the case, should be injected by means of a syringe, that they may come in contact with the whole of the diseased surface ; but they should not be so strong as to cause smarting for more than a few minutes after their application. The other eye should be carefully protected, if only one is at-. tacked. ■i6 DISEASES OF THE EYE. The crayon of sulphate of copper may be applied twice in twenty-four hours, introducing it beneath tlie swollen upper lid, which it is almost impossible to evert. If perforation of the cornea is threatened, the iris should be put under the influence of atropia, except when the ulceration is near tlie edge of the cornea. Local depletion, by leeches applied to the temple, or, in patients who cannot afford the cost of leeches, by cupping, and derivation by means of an active cathartic and hot pediluvia, are proper ; but these measures should be pursued to only a moderate extent. The application of the crayon of nitrate of silver, or of a strong solution of the same, has been recom- mended by authors, with a view to change the char- acter of the inflammation, and substitute a simply traumatic for a virulent form. But I have not seen the expected advantages follow this plan of treatment, nor do the published results speak very strongly in its favor. The same is true as resards extensive scarifications or excisions of the chemosed conjunctiva. If absolutely required, to I'elieve the cornea from commencing strangulation, the scarifications should radiate from the cornea outward, and should not be so numerous as to involve excessive subsequent con- gestion of the conjunctiva for the accomplishment of their own repair. Observations of the course of catarrhal conjunc- tivitis, and of that form which affects new-born in- PUKULENT CONJUNCTIVITIS. 47 fatits, do not encourage the use of extreme measures in the disease we are now considering ; and I have obtained better results from the plan recommended for the catarrhal form, more closely followed up, — combined with the greatest precautions as to clean- liness, — than I ever saw from treatment intended to exterminate the disease by substituting another train of symptoms of an assumed traumatic form. The subsidence of the more active phenomena often leaves behind an extremely granular condition of the lids. This, as also any other pathological change which may have ensued, is to be treated according to the rules given for similar conditions following catarrhal inflammation. The granulations should be actively followed up with the crayon of sulphate of copper and a mild collyrium, that they may be removed before they have time to injure the transparent cornea. This form of disease has fortunately been of very rare occurrence with us ; but I am informed that it is now prevailing with violence at certain garrisons of the army of the United States, and it may be ex- pected to do so, should extensive military operations be protracted until the arrival of the more unfavor- able warm season which is now at hand. GONORRHCEAL CONJUNCTIVITIS. The affection resulting from inoculation with gon- orrhoeal matter is even more violent than idiopathic 48 DISEASES OF THE EYE. purulent conjunctivitis. It comes upon the eye witli terrible suddenness, a few hours after infection, and the cornea may be totally destroyed and vision hope- lessly lost in a few hours more. I have myself seen a patient who had lost both eyes, from sloughing of the cornea, within less than forty-eight hours from the time of inoculation, which was distinctly traced ; and instances are recorded where even a less time has been sufficient for this irreparable mischief. It is more frequent in males than in females, the pestilent secretion being much more likely in them to be conveyed from the genitals to the fingers and thence to tlie eyes. It is usually confined to one eye, at the outset ; and subsequently, unless the dis- charge from this is carelessly allowed to enter the other eye. The swelling of the conjunctiva, sub-conjunctival tissue, and all the textures of the lids, proceeds with great rapidity, the skin of the lids becoming livid from distension. This is accompanied by a copious thin secretion, of a straw color, or sometimes a slightly greenish tint. The chemosis is phlegmo- nous, and its effect on the vessels supplying the cornea, with the retention in contact with it of the morbid secretion, causes a loss of vitality in that tis- sue, showing itself in ulceration or in the formation of a slough, involving a part or the whole of its extent, and penetrating more or less deeply. In some instances, this process of disorganization occurs GONOEEHCEAL CONJUNCTIVITIS. 49 in the whole circumference of the cornea, and it is thrown off in one mass. When ulceration or slough- ing is taking place, we observe a dirty, sanious dis- charge mingled with the purulent conjunctival secre- tion. Prognosis. — Notwithstanding the formidable nature of the disease, there is still hope of recovery so long as extensive perforation of the cornea has not taken place. Even hernia of the iris, through a perforation of Umited extent, is not necessarily fatal to vision, or even to the good appearance of the globe. The cloudi- ness attending a partial loss of vitality may be re- solved,' and the scar resulting from ulceration is after a time nearly or quite absorbed. But where the whole cornea has perished, there can be no hope of vision ; and, as a general rule, protrusion of the iris and lens ensues, forming staphyloma. Treatment. — The means to be adopted are, first, to keep the other eye from danger of receiving any of the poisonous secretion ; next, to insure absolute cleanliness in the diseased eye by frequent removal of the accumulated discharge. To effect this, water may be injected from a small syringe, its nozzle being passed well up beneath the overlapping lid. These injections may be alternated with others containing mild astringents ; of which borax, sulphate of zinc, or alum are to be preferred. The application of a crayon of sulphate of copper may be combined with the use of these means, if the symptoms are violent. Should 3 D 50 DISEASES OF THE EYE. haziness of the cornea be observed, it will be well to maintain dilatation of the pupil by the use of a solu- tion of atropia or of extract of belladonna, that hernia of the iris may, if possible, be prevented from occur- ring, should perforation take place. Leeches may sometimes be of service, as also the use of cathartics ; but we have seldom time for ob- taining the effect of other internal remedies, even were they indicated, during the acute stage of the disease. After the extuiction of the severer symptoms, a col- lyrium of borax may sometimes be usefully alternated with the more astringent solutions. The granulations, always exuberant in and subsequent to this disease, should be removed by a continued use of some of these coUyria, especially a solution of sulphate of zinc ; aided by daily touches witli the crayon of sulphate of copper. Should hernia of the iris occur through an aperture in the cornea, while the disease is yet at its height, or during the decline of the symptoms, it is often good practice to snip off the small protruding portion, close to the cornea, with curved scissors ; in order to pre- vent an increase of the ulceration and hernia from constant traction of the lid upon tlie portion of iris already projecting. CONJONCTIVITIS OF NEW-BOEN CHILDEBN. The symptoms are usually observed within four or five days after birth, though they may declare them- CONJUNCTIVITIS OF NEW-BORN CHILDREN. 51 selves at a later period. A slight red line along the centre of the upper lid is often the first indication of disease. This is followed by the discharge of a little mucous secretion, and if the inside of the lids is then examined, their conjunctival lining is seen to be red and swollen. If the disease is allowed to go on, the tumefaction rapidly gains ground, the upper lid swelling to such an extent as to cover the lower and rest upon the malar prominence. The amount of secretion is astonishing, — and as it is retained by the occlusion of the lids, it gushes out in large quantity whenever these are opened, even if at short intervals. Half a teaspoonfiil or more accumulates within a few minutes in some aggravated cases. In these young and delicate subjects there is great danger of partial or total destruction of the cornea, and constant vigilance is required to avert this misfor- tune. It should also be borne in mind, that haziness and even perforation of the cornea may come on at a late period of the disease, and even after great im- provement has taken place in the other symptoms, — the cornea having resisted to a certain point the pernicious influences which threatened it, but at last having given way. Causes. — The presence of a leucorrhoeal, still more of a gonorrhoeal, discharge in the mother, seems to be one of the causes of this affection ; some of the secretion finding its way into the eyes during the transit of the child through the vagina, or upon its 52 DISEASES OF THE EYE. , first opening them after birth. Other irritants, such as soap or alcohol, used in cleansing the child, may also perhaps excite the disease if they come in con- tact with the eye. Cold is apparently a frequent cause, especially if acting conjointly with those first mentioned. Exposure to bright light has been sup- posed to induce the disease, but this is doubtful. Prognosis. — Scarcely any disease has a greater tendency to an unfortunate termination, if neglected, or even if over-treated. When left to itself, the accu- mulating secretion seems to soften the cornea and hasten its destruction, and if harsh means are used there is equally danger of an unhappy result, the inflammation of the lids being kept up by the exces- sive irritation thus created, till the cornea gives way. But a mild treatment, especially if commenced early and pursued with vigilance, is almost certain to be effectual. Even if haziness of the cornea has begun to show itself, we need feel no uneasiness, if the other symptoms are assuming a favorable aspect, as the transparency will be restored within a short time. If perforation, with hernia of the iris, has actually happened, our prognosis must be guarded ; but cases occur where even this condition is recovered from, — the only remaining traces of disease being adhesion of a portion of the edge of the pupil to a small cica- trix of the cornea, — the rest of the margin of the pupil remaining free. Treatment. — The most watchful and constant at- CONJUNCTIVITIS OF NEW-BORN CHILDREN. 53 tention is required, from the outset, in this disease. If attacked early, it may be extinguished with httle difficulty, and the physician himself, as well as the friends of the patient, escape the anxiety attendant upon the progress of so grave a malady. No appar- ent mildness of the symptoms should throw the physi- cian off his guard and lead him to neglect such an examination of the eyes as may satisfy him of the integrity of the cornea. Practitioners of experience, particularly those who had never met with other than mild cases of this affection, have been deceived by a certain amount of decrease of the severer symptoms, — to discover, too late, that insidious mischief had destroyed the cornea whilst they flattered themselves that all danger was past. The swollen state of the lids renders it difficult to obtain a view of the cornea without the assistance of an elevator. This may be employed without risk of injury. If the physician is not provided with this instrument, he may make one by bending half an inch of the handle of an old-fashioned thin teaspoon to a suitable curve, or a common probe may be doubled to the shape of a hair-pin and the rounded end then bent flatwise, to form an elevator. Either of these will generally raise the lid to a sufHcient extent to permit a view of the cornea, but the first is the bettpr of the two, as the bent probe allows the tumefied conjunctiva to prolapse between the sides of the impromptu elevator, whereas the other draws all the tissues before it. 54 DISEASES OF THE EYE. As before remarked, many cases are ruined by undue activity in treatment. Strong irritants, of whatever kind, are almost invariably hurtfiil. On the other hand, the consequences of ignorance or neglect on the part of parents and nurses present themselves with melancholy frequency. Reliance on inefficient remedies, such as breast-milk, or the application of poultices ; or want of proper attention to cleanliness, have brought a pang to many a moth- er's heai-t, who finds her child doomed to hopeless blindness. The eyes should be kept clean. However often attention may be called for, it must be rendered. As a general rule, a syringe is requisite, in severe cases, to insure thorough removal of the discharge. Its noz- zle is to be carefully insinuated beneath the lid, and the injection may then be made with gentle force. Care must be used by the operator, that the ejected fluid, mixed with the virulent secretion, does not touch his own eye, as instances are known where the accidental spirting of a drop into the eye of the physician or nurse has given rise to purulent con- junctivitis and occasioned the loss of vision. We may employ conjointly, as injections, luke- warm water, and a solution of alum of five grains to the ounce. They should be used, alternately, as often as required to keep the eyes free from any accu- mulated discharge ; once in two hours, hourly, or even every half-hour dui-ing the daytime, — according to tlie CONJUNCTIVITIS OF NEW-BORN CHILDREN. 55 severity of the case. Two or three times during the night will generally suffice. A little simple ointment or rose-water ointment may be applied along the edges of the lids, to prevent adhesion during the night and allow the discharges to come away more freely. The injections may be replaced by the dropping of a little of the collyrium into the eyes, whenever the lids are, or become, so little swollen as to permit this to be done. Its use should still be frequently repeated, that a constant effect may be kept up on the conjunctiva, and it should not be entirely given up till the lids have for some time had a healthy appearance, and the discharge has ceased. Other mild astringents may be substituted for the alum solution, if the physician sees indications for so doing ; but this should not be hastily or inconsid- erately done because immediate amelioration of the symptoms is not observed under the treatment al- ready advised. Improvement must take place grad- ually, and is not to be hastened by frequent changes of remedies. If the physician decides that a differ- ent collyrium is desirable, he may employ the sul- phate or acetate of zinc, the solution being of the strength of from one to three grains to the ounce. In sluggish cases, a gentle application of the crayon of sulphate of copper to the inner surface of the upper lid may be very serviceable ; but this is to he regarded as only exceptional, and very rarely called for. 66 DISEASES OF THE ^YE. The nitrate of silver, whether in substance, solu- tion, or ointment, should be avoided, as being less safe and less frequently useful than the means I have described. It and otlier very stimulating applications have done vast mischief in cases of this affection. The use of lead, in any form, is not to be thought of. Solutions containing bi-chloride of mercury, for- merly recommended by good authority, but not now- approved of, and all the mercurial ointments, should not be made use of, as they are likely to prove too irritating. When the cornea is implicated, even to the extent of only a slight haziness, it is best, as a precaution, to instil into the eye, once a day, a drop of a solution of sulphate of atropia, one or two grains to the ounce, as we thus diminish the risk of extensive ad- hesion of the iris and closure of the pupil, in case perforation of the cornea should unfortunately occur. Should the child be feeble when the disease declares itself, it is important to inquire as to the quantity and quality of its nutrition ; as, if its nurse is unable to give it a proper supply, another should be obtained without delay. PTERYGIUM. This disease consists in a morbid growth, situated in the conjunctiva and the subjacent cellular tissue, having its origin most frequently at the inner angle of the eye, and gradually extending itself towards and PTEEYGroM. 57 upon the cornea. Sometimes a second pterygium extends from the outer canthus ; and in a few cases other growths have been met with over the situation of the superior and inferior recti muscles. Both eyes are frequently, but by no means invariably, affected. The disease is very rare in landsmen, but is ex- tremely common in mariners who have been much in hot latitudes. At first it seems scarcely more than a fasciculus of vessels, but finally becomes a broad wing or wedge- shaped band, of fleshy or even fibrous appearance. Its progress is usually very slow, and, having reached the edge of the cornea, it is usually arrested for a period more or less long, before beginning its march upon the closely investing epithelial layer of the cornea. After advancing a little distance upon this tissue, however, it goes on more rapidly, and I have seen it (though very seldom) extend so far as to par- tially cover the pupil and interfere with vision. In some patients the disease causes scarcely any inconvenience ; others are liable, when exposed to cold or wind, to inflammation of the morbid growth and the surrounding portion of the conjunctiva. Mere fasciculi of vessels, terminating in a small aphthous papule, — or an unusual development of the vessels of the inner canthus in some persons, — or small, round, yellowish deposits termed Pinguecula, often seen beneath the conjunctiva, near the inner 3* 58 DISEASES OF THE EYE. margin of the cornea, must not be mistaken for pterygium, as these are harmless, or at most require but the mildest local remedies. Treatment. — The morbid growth is to be divided, and the half next the cornea carefully removed ; taking care that every connecting fibre, throughout the whole breadth of the band, is cut off. The sur- face of the sclerotica should be exposed, clear of diseased tissiie. It is not necessary to remove that portion of the growth M-hich is towards the car- uncule, as this seems to disappear after a part has been excised. If the disease has invaded the cornea, it is to be carefully dissected off with fine instru- ments ; removing all trace of the pterygium, but im- pinging as little as possible upon the corneal substance. Cauterization does not accomplish the extii-pation of pterygia, unless a more active caustic is employed than can be used without endangering the eye. Weaker applications of this nature are more likely to stimulate than to arrest the morbid growth, and their repeated use, from which alone any success could be expected, would prove far more painful and troublesome than the operation as above advised, which effects a radical cure. The disease scarcely ever returns after having been thoroughly excised. ECOHTMOSIS OF THE CONJUNCTIVA. ' Extravasation of blood, from a ruptured conjunc- tival vessel, is a not infi-equent consequence of slight ECCHYMOSIS OF THE CONJtmCTIVA. 59 blows, exposure to high wind, or such trifling ex- ertions as coughing, sneezing, &c. The efiiision may be small in amount, or may be sufiBcient to extend completely around the cornea, spreading itself be-- tween the conjunctiva and sclerotica. The accident is unimportant, except from the disagreeable aspect it gives to the patient ; as it spontaneously disappears in a short time. But as the person is naturally anx- ious for a prompt recovery, we may endeavor to aid the absorption of the blood by a mild astringent col- lyrium, or by lotions with infusion or diluted tincture of arnica. If the hemorrhage is still going on, we should check it by laying cold wet compresses over the eye. As the effusion is removed, the color be- comes lighter, and a yellowish appearance takes the place of the bright red hue in the ecchymosed patches, to be exchanged for the natural white of the sclerotica as absorption is completed. CEDEIIA OF THE CONJUNCTIVA. Watery effusion beneath the conjunctiva often occurs where the lids are the seat of erysipelatous inflammation, small abscesses, or boils. In these cir- cumstances it is unimportant, but subsides with the decrease of the primary disease. It is also observed in a marked degree, often very early, in cases of phleg- monous inflammation of the eyeball, and is a symptom of very unfavorable import when thus occurring ac- companied by severe pain. The same phenomenon. 60 DISEASES OF THE EYE. under the name of serous chemosis, is also attendant on some cases of conjunctivitis, tliough it is not to be mistaken for the gi-aver symptom termed phleg- monous chemosis which supervenes in purulent forms of that disease. But it seldom requires attention, per se ; om* efforts being directed to tlie removal of tlie disease on which it depends, with full confidence that the oedema will vanish as the otlier s3Tnptoms subside. MORBID GROWTHS FROM THE CONJUNCTIVA, CTSTICERCI. Small warty or fungous growths are now and then developed from the conjunctiva, and cysticerci have, very rarely, been seen lodged beneath it. Excision may in all these cases be safely and readily per- formed. AFFECTIONS OF THE LACHRYMAL ORGANS. 61 CHAPTER V. AITECTIONS OF THE LACHEYMAL ORGANS. These diseases are assigned a place next to those of the conjunctiva, because the parts affected have an intimate connection with it, as well as a similar anatomical structure and analogous diseases to those of this membrane. Obstruction to the free conveyance from the eye of the tears and other secretions may occur at vari- ous points of the lachrymal passages. I commence the' description of these affections with those depart- ures from the normal condition which have their seat nearest the eye. The puncta lachrymalia, or minute openings of the canals by which the secretions are conveyed to the lachrymal sac, are sometimes everted, in consequence of a thickened or of a relaxed state of the conjunc- tiva. In this position the tears can no longer be taken up by capillary action, and, if the eversion continues for any length of time, the orifices are liable to become closed. In some instances we may keep these open by occasional dilatation with a probe having a fine point but slightly increasing in size at a short distance from the extremity, for such time 62 DISEASES OF THE EYE. as will enable us to correct the abnormal condition of the conjunctiva and bring the edge of the lid and the lachrymal orifice once more into a proper position in regard to the globe. If permanent elongation of the lid, or ectropium, has caused the eversion, the lachrymal punctum and canal may be slit up to such a distance as will allow of the absorption of the tears ; this little operation causing only slight pain, and giving rise to no inconvenience ; or, if required by the extremely relaxed state of the parts, a V- shaped portion of the centre of the lid, including its whole thickness, may be excised. The same causes which induce catarrhal inflamma- tion of the conjunctiva, similarly affect the lining of the lachrymal sac and of the duct leading from it to the nostril. Even a slight degree of thickening of the lining of these passages diminishes their calibre, to such a degree that the patient cannot walk or ride in a cold wind without being annoyed by the trickling of tears upon the cheek. Fm'ther progress of these changes causes the secretions to accumulate in the sac, giving rise to discomfort from distension ; but tlie contents may still be pressed downwards into the nose by placing a finger upon the tumor and using some force. If the morbid process advances a step further, the duct becomes yet more obstructed, and the sac begins to pour forth a thickened secretion which offers another obstacle to free evacuation downward throush the duct. This condition of things may remain AFFECTIONS OF THE LACHRYMAL ORGAXS. 63 chronic, the patient heing still able to discharge the contents of the sac upwards through the puncta, by- pressure with the finger, even when he can no longer cause it to pass downwards. Rehef of the sac in this maimer may require to be repeated several times a day, yet the patient may have no great discomfort from the existence of his infirmity. But acuter symptoms are liable to supervene upon slight exposure, and the case is transformed suddenly into one of active inflammation of the sac. The dis- tention becomes excessive, accompained by intense pain arising fi-om the unyielding fibrous structure of the sac. The swelling extends to the neighboring parts, causing so much tumefaction of the lids and cheek, with chemosis or oedema of the conjunctiva, that the case is often mistaken, by the inexperienced, for an erysipelatous attack. The history of the com- mencement of the swelling, and its great prominence and hardness in the region of the sac, are sufiicient guides to a right diagnosis. The eye is often closed from infiltration of the lids, and the patient cannot obtain an instant's repose on account of the agoniz- ing pain. If the inflammation is allowed to take its course, the sac gives way, the accumulated pus is difiiised beneath the skin, and finally makes its. way to the surface, forming true fistula lachrymalis. The severe symptoms subside when the abscess has been opened, either spontaneously or by the lancet, 64 DISEASES OF THE EYE. and in some instances tlie fistula spontaneously diminishes to a minute orifice, through which, now and then, a drop of secretion is discharged ; the sac returning in other respects to its healthy condition. In other cases the opening closes, and the sac contin- uing in a morbid state, renewed acute attacks occur, followed by the same train of symptoms. Treatment. — The treatment of afiections of the lachrymal passages must be as varied as their difierent degrees. In the outset, little diiSculty is experienced in their management, if gentle measures are perse- veringly employed. When we .are uncertain as to the perviousness of the duct, or wish to ascertain the probable amount of thickening of its lining, it is desi- rable to make an exploratory injection, by throwing a little warm water from Anel's syringe through the lower punctum into the sac, whence, if there be no obstruction, it will pass readily through the duct and be felt in the nostril or throat. If we find little im- pediment to the free passage of this injection we may hope to remove the symptoms, even when they have become quite annoying to the patient, by the use of remedies adapted to improve the condition of the conjunctiva and the lachrymal passages. The con- junctiva is most frequently afiected to a certain extent, and it is important to restore its healthy char- acter simultaneously with that of the lachrymal organs themselves. A mild collyrium should be dropped into the eye three or four times a day, and AFFECTIONS OF THE LACHRYMAL ORGANS. 65 the inside of tlie upper lid may be touched, if thought desirable, with a crayon of alum every day or two. If the edges of the lids are thickened, and the Mei- bomian glands diseased, about the size of the head of a pin of an ointment composed of one part of the citrine ointment and five' parts of simple or sperma- ceti ointment may be melted on the end of the finger and apphed along the edge of the closed lids at bed- time. Such a coUyrium and ointment, thus used, are often sufiicient to effect a cure, the remedies being carried by the tears into contact with the hning of the sac, thus acting directly upon it, while the fact that the internal membrane of the sac and duct is contin- uous, as we may say, with the conjunctiva, causes it to participate indirectly in any improvement which is brought about in the condition of that tissue. Of course the patient should be careful to avoid exposure to vicissitudes of weather, and shoxild be prudent even as to long-continued use of the eyes. If the morbid process has advanced so far that a tumor is formed from accumulations within the sac, it should be reduced by emptying the sac by gentle pressure ; especially previous to the application of remedies. The pressure should be made downward, that the passage of the collected tears and mucus may assist in maintaining the perviousness of the duct. If an occasional stoppage should occur it may often be overcome after the parts have been relaxed by the ap- pHcation of warm fomentations for two or three hours. 66 DISEASES OF THE EYE. When the sac can no longer be emptied down- wards, our chance of restoring the natural condition of the duct by gentle measures is materially lessened. But, if we are able to bring the conjunctiva and the lining of the sac into such a state that no unhealthy secretion shall be formed, the patient is rendered comfortable, and may go on with his pursuits for years, if he chooses so to do, with no worse infirmity than the being compelled to press upward the fluid contents of the sac, perhaps two or three times a day. But if it is considered expedient or desirable to at- tempt a radical cure, it can only be accomplished, in this stage of the disease, by mechanical means. We are able, however, to resort to measures much more efiectual, and less barbarous, than those formerly in vogue. No excuse now exists for the insertion of canulse or styles, nor for a resort to the introduction of Gensoul's sound from the nostril into the lower extremity of the duct. The tubes and styles were occasionally a temporary relief, seldom a lasting bene- fit. If the canula was inserted and the skin allowed to close over it, it frequently caused abscess and cai'ies of the bone, after having been worn for some time in comfort, and I have repeatedly had occasion to re- move them on this account. If the style was worn with its head exposed, it was disagreeably conspic- uous, — the relief while worn was often very slight, — and if taken out at the end of a year or two, there was no certainty that fresh attacks of inflamma- AFFECTIONS OF THE LACHRYMAL ORGANS. 67 tion might not declare themselves. The passage of a sound from the nose involved the necessity of sub- mitting to its presence for a considerable time at each repetition, in the hope of elBPecting dilatation ; it was quite painful, and has long since been condemned by the authorities of most experience, as practically inef- fectual, though theoretically it seemed to promise good results. Formerly, the only other means employed for re- moving obstructions of the duct, were the fine probes of Anel, which were often too delicate to effect a pas- sage ; or, if successful in this, made an opening so small that it became speedily reclosed. The plan proposed by Mr. Bowman of London, of enlarging the punctum, so as to admit of the use of even a common-sized surgical dressing-probe, has superseded all other methods in the majoritjf of cases. He ob- served that the lachrymal canals were of sufficient size to admit of the passage of a large instrument, provided this could be passed through the punctum. Experiment proved that the punctum might be divid- ed and the canal sht open, even as far as the sac, if required, without subsequent inconvenience. Gener- ally, the orifice only, needs to be enlarged, and this may best be done by inserting the point of a fine pair of scissors to the distance of about a line, and divid- ing the ring surrounding the opening by a quick stroke. The surgeon should be provided with va- rious-sized probes, and if he finds difficulty in intro- 68 DISEASES OF THE EYE. ducing one of large diameter he may begin with a smaller, gradually increasing the size till he arrives at the dimensions he desires. The only point at which he is like to encounter difficulty is at the junction of the canal with the sac, and, if he finds it impossible to overcome tliis stricture, it may be divided by a mi- nute knife intended for the purpose, or may even be laid open, with the entire length of the canal. Hav- ing entered the sac, the extremity of the probe is to be directed downwards, and pushed, with gentle force, through the duct into the nose. It is well that the probe should not be too inflexible, and it should be slightly curved from a straight line, near the point, that the orifice of the duct may be readily found and its direction conformed to. Some hemorrhage may occur at the time the probe is first passed, and even at subsequent repetitions ; but it is only of impor- tance as enforcing the necessity of gentleness in man- ipulation, as it does not seem materially to retard the cure, if not too copious. It probably arises froni slight laceration of the mucous membrane lining the sac or duct, by the extremity of the probe. It is well to repeat the introduction of the probe, after two or three days' interval, that the' passage may not have time to close. The same manoeuvre will need to be several times performed, in order to insure permanent good results ; perviousness of the duct being maintained by these artificial means, until we judge that its lining has had time to regain a AFFECTIONS OF THE LACHRYMAL ORGANS. 69 healthy 'condition. The probe is passed with more and more faciUty each time it is introduced. When an acute attack declares itself, either in those who have long been subjects of chronic inflam- mation of the sac, or in others, we are to lose no time, if we hope to obtain resolution of the symp- toms without the formation of abscess. Formerly, if the application of a leech and warm fomentations did not afford relief, no' other resource was believed to be left but to puncture the abscess, and end the patient's sufferings by giving exit to the distending fluids. I have pursued another course with great advantage. If the application of warm fomentations does not soon diminish the sensitiveness, and relax the parts sufficiently to allow of evacuation of the sac by pressure, I introduce a fine probe through the punctum into the sac, which, by bringing the canal into one straight line, generally allows the pus to escape along the side of the probe, or immediately upon its withdrawal, especially if gentle pressure is at the same time made. The discharge of even a small portion of the accumulated matter gives im- mense relief, by taking off the tension of the parieties of the sac, and the probe may often be inserted a sec- ond time, and the evacuation completed with little pain. Where the parts have become so exquisitely tender that the slightest touch cannot be borne, it is desira- ble to produce insensibility by the administration of ether by inhalation, before proceeding to the intro- 70 DISEASES OF THE EYE. duction of the probe. It is but rarely, however, that ether is required. Should it be impossible to find the opening and introduce the probe, the punctum and canal may be laid open, or the sac itself entered from tliis direction, with a very narrow knife, rather than to allow the abscess to take its own course, or to relieve it by puncture through the skin. Having afforded relief to the urgent symptoms, we may wait for the subsidence of the exalted sensibility of the parts before attempting measures looking to a radical cure. We should then pursue the plan al- ready indicaied for restoring the pervious condition of the duct. When fistula lachrymalis has already formed, pre- vious to our seeing the patient, it is well to take ad- vantage of the abnormal opening through the skin for the dilatation of the duct. A large probe may generally be passed into the sac, though in some cases only after patient endeavors to find the internal fistu- lous aperture. It is then to be carried through the duct. The fistula should be kept open, while required for the purpose of dilatation, by inserting a tent formed of a strip of muslin or fine cotton, not more than a Kne in width ; which is to be moistened, pushed through the whole extent of the fistula upon the point of a probe, and left in place until the next day, when the duct is to be again explored, and another tent introduced. After a few days the tent may be dis- continued, and the fistula left to itself. Should it AFFECTIOXS OF THE LACHEYMAL ORGANS. 71 close entirely, we may treat the case as if it had not existed ; passing the prohe, if required, through the ^unctum ; but not renewing operative proceedings till the sac has had a short time to recover itself from the inflammation it has undergone. Should a minute fistulous opening persist, it is better to leave it, for a while at least, as a sort of safety-valve ; as, if the duct is in a normal state, the tears will seldom escape through the fistula, and, in case of any ten- dency to a fresh attack, it affords a vent for the secretions, and obviates the dangers which arise from distention. But its almost capillary orifice may at any time be closed by refreshing its edges with an actual cautery in the shape of a hot needle, when the proper moment for its obliteration appears to have arrived. 72 DISEASES OF THE EYE. CHAPTER VI. TRATBIATIC INJURIES OF THE EYE. The management of tlie various accidents of which the eye may be the subject is of great importance to tlie general practitioner, especially if established in the country, as cases will come under his notice in which the responsibility of treatment must rest with him, — the patient being unable to go else- where for advice. The preservation or loss of vision will depend, in numerous instances, on tlie course pursued immediately subsequent to the injury. The error of over activity in treatment is far more common and fatal than its opposite. For instance, in case of an extensive wound of the cornea, — repeated examinations, frequent application of a collyrlum, or anything which disturbs the absolute repose in which the cut edges should be left, will tend to prevent union, excite inflammation, and cause loss of the eye, when, if intrusted to Nature, immediate adhe- sion might have taken place, and all unfortunate results have been averted. It is only in the rarest cases that any other than local treatment can be employed with benefit. There is in fact, until inflammation and pain shall TEAUMATIC INJUBIES. 73 have ensued, no more disturbance of the general system than would follow a cut finger, for the cure of which there would be no propriety in employing active measures. INJDEIES OF THE CORNEA AND CONJUNCTIVA. In treating of simple conjunctivitis, I have already described the mode of disposing of those small par- ticles of iron, cinders, husks of seeds, &c., which so often become impacted in the cornea. Another and far more dangerous injury frequently occurs among reapers, who, in cutting handfuls of grain with the sickle, sometimes brush the heads against the eye, lodging in the cornea a minute particle of the beard of the grain. The serrated edge of this particle of beard rankles in the wound, and induces, if the offending substance is not removed, rapidly destructive ulceration and sloughing of the cornea ; so that many eyes are annually lost from this cause. The treatment consists in removal of the source of ir- ritation, and the use of soothing lotions of tepid water or milk and water. Local depletion, by leeches to the temple, and the administration of a purgative, together with stimulating pediluvia, may also be resorted to if the symptoms assume a grave aspect from the lateness of the period at which the patient applies for advice. It is extraordinary how much suffering may result from the slightest abrasions of the cornea by a scratch 4 74 DISEASES OF THE EYE. from an infant's finger-nail, the comer of a sheet of paper, or any such trivial cause. This often continues for two or three days, and sometimes, during preg- nancy or nursing, for weeks and months. The pain is circum-orbital, as if from connection of the injured part with branches of the fifth pair of nerves, but is attended with, at most, slight injection of the eye. In the acute stage, mucilaginous lotions, as infii- sions of sassafras-pith or althea-root, or a collyrium of. borax, seem to sheath over the abraded surface and give relief, while the healing process goes on. Long persistence of pain after such accidents is often- est met with in women who are nursing, and whose system is in a low condition. No trace of disease is visible in the cornea, the slight abrasion of its sm-face having long since healed. The treatment must here be general rather than local. Tonics, antispasmod- ics, and good diet are required, and it is sometimes necessary that the child should be removed from the breast if the mother does not find relief after they have been administered for a sufficient period. Chemical injuries, or burns, are serious in propor- tion to the extent of their action on the parts. Lime, potash, or strong acids may so far decompose the cornea, that sloughing or an indelible opacity may result ; or destroy the mucous surfaces of the con- junctiva of the lids and the globe to such an extent that unmanageable cicatrices are formed, with cohe- sion of the apposed surfaces. mjUBIES OF THE CORNEA AND CONJUKCTIVA. 75 It is seldom that the case is seen in time for the advantageous employment of any antidote ; the mischief is instantaneously accomplished. The eye should be bathed with tepid water, to remove any irritating particles which may remain, and such lotions should be subsequently continued. Should unhealthy ulceration threaten to perforate the cornea, atropia should be used, to prevent hernia of the iris. Where this has actually occurred, but is of small size, and is acted on as a foreign body at each move- ment of the lids, it should be excised by a quick stroke of fine scissors, on a level with the cornea, thus getting rid of the mechanical irritation caused by friction against it. It is surprising how quickly perforation of the cornea will often heal, when re- lieved of the constant irritation caused by the pres- ence of hernia iridis. If the lesion of the cornea is not too extensive, vision is often preserved, the iris adhering at some point only to the cicatrix of the ulcer, and the pupil remaining unobstructed. Even where the ulceration resulting from the injury is very extensive, our prognosis must not be too unfavorable if the loss of substance is superficial, and no perfora- tion has occurred ; as the cornea has great power of regaining its transparency. When the mucous surfaces of the lid and the globe nave both been destroyed to any considerable extent, it is important to prevent adhesion, if possible, by bringing together some portions of the wound by 76 DISEASES OF THE EYE. suture, so that two surfaces denuded of their mucous membrane may not be in contact and become united, as they are almost sure to do unless prevented by suitable precautions. Wounds of the eyelids should also be brought care- fully together by suture, that we may not only avoid deformity but prevent any displacement of the eye- lashes or the formation of ridges to irritate the sur- face of the globe. The cornea is not unfrequently cleanly cut, more or less largely, by explosion of glass bottles or retorts, or the sudden slipping of a knife ; or lacerated by a blow from some jagged object ; or burst by coming forcibly in collision with some hard body. If the wound is merely an incision, it may be very exten- sive without of necessity involving any danger to vision ; as, for instance, in the operation for extrac- tion of cataract, where one half of the circumference of the cornea is divided. But where an accidental wound involves a lai'ge extent of the cornea, it is accompanied by a loss of the aqueous humor, and frequently with hernia of the iris. When no hernia is present, the treatment required is absolute rest of the organ, the patient being placed on his back and directed to keep both eyes closed and as quiet as possible. The eyes may be lightly covered with a bandage, as an additional precaution, and if there is reason to fear that the patient will not follow our injunction to keep his eyes closed, tlie lids may be INJmtlES OF THE COENEA AKD CONJUNCTIVA. 77 kept shut by confining them with narrow strips of isinglass or court-plaster. The aqueous humor is thus retained in the eye, as a fresh secretion takes place, and the wound rapidly unites. If hernia has formed, efforts should be made to reduce it by gentle friction of the lid upon the globe, or by carelul at- tempts with a probe, and, if the hernia be central, by the use of atropia. If the iris still continue to pro- trude, like a small sac, between the hps of the wound, it may be punctured with a cataract needle, and, if this does not lead to permanent collapse, a small portion of iris should be excised at the centre of the prominence, with fine curved scissors. This allows the edges of the wound to come into contact and unite. Among my notes of such cases of accident, I find two where the incision (caused in one instance by a broken carriage window, in the other by a frag- ment of glass bottle) extended across the cornea at its lower third, and some distance into the sclerotica, more than half an inch in all; yet only the lower portion of the iris was involved in the hernia which occurred, and, upon the excision of a small bit of iris, the wound promptly healed, and vision was perfectly restored. When the wound has more of a contused or lace- rated character the prognosis is less favorable ; but where the internal parts of the eye have not been too much injured by the accident, we often obtain a good result, or at least preserve the eye in such a con- 78 DISEASES OF THE EYE. dition as would admit of an operation for artificial pupil in case loss of vision should befall the other eye. When the entire globe is involved in the injury, and suppuration ensues, its progress should be favored by fomentations or poultices. Wounds of the sclerotica are to be treated on simi- lar principles of non-interference. Even if a small portion of the vitreous body protrude, it may be left to itself. But if the protruding miiss is so large as to give rise to much friction against the lid, it is better to excise it with sharp scissors than to incur the risk of the dragging out of a still larger portion of the vitreous and retard the union of the sclerotic wound. Punctured wounds of the cornea and sclerotica are more serious than small incisions ; but we often ob- serve great tolerance of these injuries. I have seen a case where the point of scissors, thrown at a young lady, entered the globe at the junction of the cornea and sclerotica, and nearly passed again through the sclerotica at a point half an inch distant, near the inner canthus, pushing the tunics of the globe before it so as to form a small projection instead of a counter puncture ; yet the iris and lens escaped serious injury and vision was preserved. Wounds of the crystalline lens or capsule result in opacity of the lens. If the capsule has been largely divided or ruptured there may be much swelling of the lenticular substance, making it necessary to put INJUEIES OF THE CEYSTALLINE LENS. 79 the pupil under the influence of atropia to prevent inflammation of the iris. Where the capsule is thus extensively lacerated, complete absorption of the crys- talline may take place, and the opacity disappear from the field of the pupil, without operation. But where only a small opening has been made in the capsule, the wound often closes without giving opportunity for absorption, and the resulting cataract can only be removed by surgical means. The question of opera- tion will be considered under the head of traumatic cataract. Opacity of the lens may also be occasioned by blows upon the eye, producing no obvious external ■injury, but probably rupturing more or less of the suspensory ligament or preventing in some way the proper nutrition of the lens. I have seen two cases from the same small town, where this result followed a blow from the knot at the end of a whip-lash, received on cracking the whip. Generally, opacity of the crystalline is to be observed within a few weeks from the reception of the blow, and in cases of such injury, the prognosis given should be guarded, the patient being notified of the possibility of such a consequence. In one instance, however, I have seen the appearance of cloudiness delayed for eight years . from the time the eye was injured by a stone playfully thrown. The girl was under my care at the time the blow was received, and the chance of the formation of cataract was explained to her parents ; but she soon recovered from the immediate effects of the in- 80 DISEASES OF THE EYK jury, and after many montlis I considered the danger past. Eight years after, however, cataract made its appeai-aiico, and interfered so seriously with her good loolis that I removed it by operation, and restored vision as well as comeliness. Dislocation of the lens may also occur, when the eye is struck by a stick of wood or other heavy body. In these circumstances, tlie capsule and lens may remain transparent, or opacity may ensue. Instances are now within my observation where this displace- ment has occurred, and the crystalline, still trans- parent, changes its place with the position of the head. The patients are able to see on stooping for- ward, witli tolerable clearness ; but as the head is brought to an erect position, I can observe the falling back of the crystalline, at the same moment that the patient finds his sight obscured, and vision only becomes good by the aid of a cataract-glass. I shall describe elsewhere a very remarkable case of span- taneous dislocation of the lens in both eyes. When the dislocated lens is thrown into the ante- rior chamber, lodged in the pupil, or situated so as to press upon the iris, it often creates so much irri- tation that its extraction becomes imperative. The general rules for the operation of extraction should be followed, so far as practicable ; but the relations of the parts are so altered by the violence which has been suffered, that tlie surgeon must use his judgment in deciding on the method of executing it. The INJUEIES OF THE lEIS. 81 results of extraction in such circumstances must, of course, be less favorable than in ordinary cases of cataract. Injuries of the iris, when uncomplicated by the presence of any foreign body, rarely give rise to inflammation. We areTible, in our operations for artificial pupil, to lacerate the iris, and even to draw from the eye and excise large portions of its tissue, almost with impunity. But wounds of the iris sel- dom reunite, and the effect upon vision wiU depend on their situation and extent ; a large fissure in cer- tain parts causing much less visual disturbance than a smaller one in other situations. Among the most dangerous injuries of the eye are those caused by the penetration of fragments of per- cussion caps or other projectiles. So very common is the loss of an eye from the entrance of a bit of cop- per cap, that children should never be allowed to amuse themselves by placing them upon a post or window-sUl and striking them with a hammer or stone, or by exploding them in any other way. Small fragments of a cold chisel or other tool are sometimes struck ofi^, and projected with great force into the eye, by a blow from another tool in the hands of stone-cutters or machinists. The mischief in these cases results from the fact, that whatever is propelled with sufficient force to pass'through the cornea, has almost always sufficient momentum to carry it onward to the iris or lens, 82 DISEASES OF THE EYE. and, too frequently, to the very posterior part of the globe ; where it excites suppuration and destroys the organ. Intense pain is often felt at the instant the injury is received ; but this soon subsides, and for a day or two — sometimes for several days — the patient has no uneasiness, or next to none. But the practised observer is not deceived by this tranquillity. On ex- amining the eye, he can generally detect the wound of die cornea, already cicatrized ; — but beyond this he traces the course of the fatal missile, in perhaps another perforation of the iris beliind the slight opacity of tlie cornea, or in commencing haziness of the lens. Should tlie foreign body be arrested by the iris, and remain lodged in its tissue, it usually excites so much irritation as to require its removal ; but this may generally be accomplished, if undertaken in due season, without material injury to vision. If lodged in the lens, the immediate effect is loss of vision, from the formation of traumatic cataract ; but if the wound of the capsule is sufficiently large to permit the aqueous humor to come freely in contact with the lenticular substance, this is frequently dis- solved, leaving only the capsule, in which the bit of extraneous substance has become enveloped by a deposit of lymph. The foreign body may enter through the sclerotica, thus depriving us of the opportunity of ti-acin| its course. But, in the absence of otlier indications, the PROJECTILES ENTERING THE GLOBE. 83 loss of vision is an important sign, in these circum- stances, of its presence within the globe. The course of events varies where projectiles have become thus deeply lodged; — sometimes injection of the circum-comeal zone of vessels, with much • deep- seated orbital and frontal pain, will manifest itself within a few days ; — in other cases months elapse before these symptoms declare themselves. Now and then these phenomena subside, and the foreign body ceases to be an offending substance, — probably be- coming surrounded by an efiusion of lymph. Such a favorable termination is, however, exceedingly rare. In most instances, the observer sooner or later per- ceives an opacity behind the pupil, far back in the eye, — which he recognizes as a deep-seated purulent collection. This has sometimes been mistaken for cat- aract. It generally comes slowly forward, in accord- ance with the tendency of matter to make its way to the surface, and at -length points, usually at some part of the cornea, bringing with it the foreign body, the cause of all the disturbance. In most cases we can employ only palliative means ; as, however certain the surgeon may be that a metal- lic fragment is deposited in the eye, he will scarcely feel justified in operating for its removal till sure that it is within easy reach, unless sympathetic inflamma- tion of the other eye is threatened. The patient and his friends cling to hope till the last moment, and can scarcely believe that an eye, which still looks but 84 DISEASES OF THE EYE. slightly aiFected, can be hopelessly diseased and re- quire an operation by which it must be disfigured. Furthermore, the expulsive process, as accompHshed by the efforts of nature, results in less subsequent deformity than is often occasioned by an operation to remove a fragment, the precise situation of which is not known. The use of the ophthalmoscope may, perhaps, place it in our power, in a few instances, to discover the foreign body soon after its entrance, and, after etherization of the patient, remove it by delicate canula instruments, and thus spare Mm the long pe- riod of suspense and uneasiness preceding its spontan- eous expulsion, even if we are unable to preserve his vision. Whilst the deposit of pus is slowly coming forward we may reheve pain by fomentations and lotions, and, if necessary, by the internal administration of ano- dynes. Whenever the foreign body can be per- ceived, it is well to operate for its removal, and hasten the final result. The globe is generally somewhat diminished in size, and tlie cornea may be more or less changed in aspect, after the tlirowing off or removal of the intruding substance. If the deformity is slight, no concealment should be attempted ; but should it be considerable, it may be masked by wearing an arti- ficial eye. Among traumatic injuries of the eye we also rank the consequences of a blow in tlie supra-orbital re- DANGER OF SYMPATHETIC OPHTHALMIA. 85 gion, wMch is sometimes followed by blindness when the eyeball does not appear to have sustained any harm. Formerly it was supposed that the result was due to injury of the fifth pair ; but in many instances examination with the ophthalmoscope, after the acci- dent, reveals some deep-seated lesion of the retina or choroid. A melancholy consequence often following grave traumatic injury of one eye is the subsequent devel- opment of a peculiar form of inflammation of the other globe, which we term sympathetic ophthalmia. Of this I shall treat elsewhere in this work, and will only say here, that this liability forms an urgent reason for watching cases of traumatic injury with scrupulous care, in order that, if mischief cannot be prevented in the injured organ, the symptoms may be palliated, and morbid irritability lessened as much as possible, in the hope of averting the danger of fature destruction of the other and healthy eye. 86 DISEASES OF THE EYE. CHAPTER VII. AFFECTIONS OF THE CORNEA. The affections of the cornea are some of them less distmctly limited to tliis single tissue than ai"e those of the conjunctiva. But I shall endeavor to describe several conditions in which, however much it may be complicated with symptoms extending to contiguous structures, the state of the cornea con- stitutes the primary and essential morbid affection. The cornea is a tissue of low organization, and its diseases proper have a tendency to slow recovery ; much time being requisite for the repair of any loss of substance or of transparency. On the other hand, this same low vitality fiivors rapid disorganization when acted on by destructive agencies arising from disease of other parts, — as, for example, the virulent secretion poured out in some forms of conjunctivitis, or the continual friction of granulated lids. Several of the diseases of the cornea depend intimately, more- over, on conditions of the general system, and can only be removed by attention to the morbid diatlieses which give rise to them. Nearly all these conditions of the system have an asthenic type, — an important fact to be remembered in connection with the struc- UICEEATION OF THE COENEA. 87 ture of the tissue itself. All of these circumstances require to be taken into account, in determining the question of treatment. If the physician expect to be able to afford the same speedy relief he has often been able to confer in other affections of the eye, — where, perhaps, the symptoms were seemingly much more formidable, — he will often be disappointed ; — if he act as a mere specialist, and attempt to gain his object by local remedies alone, his best endeavors will be baffled and the symptoms will persist or in- crease ; — if he resort too readily and fi-eely to an- tiphlogistics and alteratives, which might be appropri- ate for subduing an active inflammation, he wiU often hasten the disorganization already favored by an im- poverished state of the circulating fluid and a gener- ally depressed mental and physical condition. ULCERATION OF THE CORNEA. Under this head I do not propose to include those ulcerations which are sequelse of other disease, as, for example, the sloughing ulcer so frequently a result of purulent conjunctivitis, or the destructive ulceration consequent on neglected granulation of the lids. Two series of phenomena occur, where the ulceration de- serves to be regarded as the characteristic and only important local feature of disease. These are, the simple ulceration mostly observed in children, and the dotted ulceration now and then met with in children or adults. 88 DISEASES OF THE EVE. SIMPLE TJLCEKATION OF THE CORNEA. This disease, with its concomitant symptoms, which form an ensemble frequently described under the name of scrofulous ophthalmia, is exceedingly common in children aged fi-om two to twelve years, especially in those of a strumous diathesis, and who are ill nourished, scantily clothed, and exposed to vicissi- tudes of temperature. Other and more healthy chil- dren, not habitually subject to these unfavorable influences, may be attacked, if exposed to cold and damp weather with insufficient protection, — espe- cially during the period of teething. Ulceration may occur after a small papule on the epithelial covering of the cornea ; but it often er makes its appearance without any such precursory alteration, no other phenomena being observed than very slight injection and lachrymation. No sooner, however, is the ulcerative process established, than we have, in most cases, an accession of more marked symptoms. The cliild becomes peevish and fretful, refuses food, declines play, exhibits more or less of febrile disturbance, and, if old enough, often complains of severe pain in and around the eye. The intoler- ance of light frequently becomes so intense that the patient will remain for days and even weeks in a darkened room, covering his eyes closely by day and burying his face in the pillow at night. Even his physiognomy is peculiar, — every muscle on tliat SmPLK ULCERATION OF THE CORNEA. 89 side of his face seeming to concur in a strong effort to keep the hds closed, so as to exclude every ray of light. Both eyes are rarely simultaneously affected, but morbid symptoms often alternate, first in one, then in the other. Much tact and patience are frequently necessary to enable the physician to examine the eye. The child's attention should be engaged, if possible, without his being allowed to suspect that any effort is made to inspect the eye. So doing, after a few minutes we may usually, in a moderate light, obtain a glimpse of the cornea. In mild cases, and when the phy- sician does not intend to make any application to the eye with his own hand, it is a great advantage to accomplish this inspection thus quietly and without a struggle ; as, if the child's confidence be thus gained, he will allow any future exploration or treatment with much more willingness, whereas he will be con- stantly on his defence if violence is used at the first interview. A mere glance is sufficient to allow us to determine whether or not serious changes are going on in the cornea, and this, in connection with the other obvious symptoms, will guide us in adapting our treatment. If the photophobia prevents the child from opening his eyes, the physician may often, by playing with the child and touching other parts of. his face, succeed at last in raising the lid, by a quick movement, sufficiently to assure himself as to the state of the cornea. But if the child, from peevish- 90 DISEASES OF THE EYE. ness, previous harah treatment, or extreme photo- phobia, resist every attempt to examine his eyes, it is best at once to employ gentle force, if we deem it important to ascertain the exact pathological condi- tion. Where we are confident that the cornea cannot have become profoundly affected, this forcible exami- nation need not be insisted on ; at least at the first visit. No danger would be incurred by delay, and we sometimes gain in the good opinion of the child and its parents by not appearing too ready to resort to extreme measures. The mode of proceeding, as I have .already explained, is, to have the child lield upon the lap of another person, its back towards tlie surgeon. Its head is then to be lowered between his knees and firmly grasped by them, and the hands of the child being held by the other person, the surgeon has his own at liberty, for raising and depressing the lids. If the cornea is rolled so far upwai-ds tliat it cannot be seen, the upper lid may be raised still more by means of an elevator. When the resistance of the child has been from wilfulness, he often submits readily enough to future examinations, without a resort to force, after having once experienced the futility of opposition. But, when the intolerance of light is excessive, he cannot exercise sufficient conti'ol to permit an inspection of his eyes, however well dis- posed, — and we are sometimes compelled to repeat the forcible exploration, which, though disagreeable, is not otherwise painful. The amount of pathologi- SIMPLE ULCERATION OF THE CORNEA. 91 cal lesion is often very small compared with the severity of the symptoms. Examination shows, perhaps, merely a small spot of cloudy effusion in the cornea ; or, if the symptoms have advanced a degree further, a smaller or larger excavation of the corneal surface, surrounded or not by effiision gradually shading off in density as the distance from the ulcer increases. There is injection of the circum-corneal zone of vessels ; but those of the conjunctiva proper may be only slightly con- gested. The pupil is often contracted ; but the iris exhibits no trace of morbid alteration, and the disease is not to be confounded with iritis, as it often is, on account of the pain, photophobia, or circum-corneal injection, or of the contraction of the pupil. The intolerance of light does not depend on any alteration affecting the integrity of the retina; for the child sees well at evening or in a darkened room, pro- vided the ulceration has not become so extensive as to hinder the free transmission of the rays of light. The photophobia is subject to exacerbations and remissions, and is generally greatest in the morning. In many cases the child is able to open his eyes in the afternoon or evening, but suffers a return of all his symptoms the next morning, to be again relieved as before. The flow of tears is greatly increased, and their abnormal acridity not only irritates the lining of the nose, but causes disease of the Meibomian glands, and 92 DISEASES OF THE EYE. produces excoriation of the skin of the lids and cheek, often leading to the formation of thick crusts, and constituting one of the pathognomonic features of the disease. No increased mucous secretion, such as accompanies conjunctivitis, is observed. Inter-laminar effusions of lymph or pus are some- times formed in the cornea, and these may either be reabsorbed, or may open outwards, forming new ulcerating cavities, or inward, giving rise to hypopion or a collection of matter in the anterior chamber. After the excavated ulcer has for some time had a perfectly transparent appearance, it is not an un- favorable sign to see its surface become covered with a slight cloudiness, as this is evidence of an attempt of nature to fill and heal the ulcer by an exudation of lymph. This deposit, if it occur, should not be meddled with. But the process of healing may take place without this exudation, — the cornea after- wards exhibiting a slight transparent depression upon its surface at the point where the ulcer had existed. These small saucer-like excavations or facettes are not to be mistaken for actual ulcerations ; as they may exist long after all injection or other symptom of ulceration has passed away. When simple ulcer occurs in adults, its characters are nearly the same as in children. Sloughing ulcer may occur in patients of any age, as a result of chemical decomposition, purulent conjunctivitis, ex- treme debiUty, or tension of the globe from inflam- SIMPLE ULCERATION OF THE COENEA. 93 mation of the entire eyeball. The cornea then takes on an appearance resembling a tough, leathery mem- brane, and the gangrenous part shrivels and separates from the surrounding tissue. In two cases, in adults, I have seen the central part of the cornea isolated from the sclerotica by a ring of ulceration, the middle portion continuing al- most clear until its nutrition had been entirely cut off, but finally yielding to the morbid, process and breaking down into a disorganized mass. The cause, in these cases, was the introduction beneath the lids of an ointment sold by an itinerant vender of quack medicines as a specific for sore eyes. The cases when first seen were beyond the reach of remedial measures. Prognosis. — Ulcers of the cornea have an unfor- tunate proclivity towards its central portion ; yet, even if of formidable size, they may leave no trace of their having existed, if they do not penetrate too deeply ; any temporary opacity disappearing, and in- tegrity of the structure being fully restored. But if neglected, they are likely to affect the laminje more profoundly, and a cicatrix results which may never be wholly removed by absorption. Even in these cases, however, the opacity diminishes, both in density and extent, as the child becomes older, and, though occupying the centre of the cornea, may in- terfere but very slightly with vision. Perforation rarely occurs in these cases of simple ulceration, 94 DISEASES OF THE EYE. unless the disease is wholly neglected ; and if it take place, the pupil, under skilful management, may be implicated to only a small extent, or all adhesion of the edge of the pupil to the cornea may even be prevented. Treatment. — Constitutional remedies are of quite as much importance as any local applications. Prepara- tions of iron, of which the solution of tlie iodide is one of the best, iodide of potassium, cod-liver oil, quinia, and other medicines of similar tonic properties, may be administered, whilst at tlie same time we enforce the necessity of good, nuti-itious diet and wai-m clotliing. A laxative may be given with benefit at the outset ; but the popular plan of giving frequent purgatives " to cleanse the blood " is often a source of serious mischief; as is also the keeping a child on low diet, or on the unsuitable food which is often the sole nutriment provided for their chil- dren by the poorer class of our foreign population. Fresh meat, once a day at least, and bread and milk, are to be substituted if possible for such indigestible articles. Sea-bathing is often of great service, espe- cially to childi*en from the countiy, and a change to the interior appears to be sometimes advantageous to a child residing near the coast. In fine weatlier the child should go or be taken out, if the photo- phobia will allow of this. His eyes should not be covered with thick bandages, but kept cool by ex- posure to tlie ail" ; but a large shade may be worn SIMPLE ULCEEATION OF THE COKNEA. 95 with advantage, to protect his eyes from bright light. When photophobia exists, the room should be dark- ened- to a considerable extent, and the child en- couraged tp open his eyes in this subdued, light. He must not be allowed to bury his face in the pillow at night, but if asleep in this position he should be carefully turned over, and if his sleep be disturbed by this action, recourse must be had to local or even general anodyne treatment for the relief of the photo- phobic symptoms, and the increased nervous sensi- bility, so that he may be able to endure sleeping in a proper position. As local means, if the child is manageable, we may direct the use of a mild coUyrium, of two grains sulphate of zinc, or six grains of borax to an ounce of water, three times a day. But, if a straggle takes place every time an attempt is made to instil this, its introduction becomes so difficult, and its benefits are so far counteracted by the resistance and tears of the child, that its utility is doubtful, and it is better to dispense with any and all coUyria. Its place may be supplied by a light touch, once a day, or once in two days, with a smooth crayon of sulphate of copper. This can be introduced beneath the upper lid with little difficulty, notwithstanding the spas- modic contraction of the orbicularis, — the head of the child being held between the knees of the sur- geon in the same manner as when making an exami- nation. As one application of this crayon is more 96 DISEASES OF THE EYE. tlian equivalent in efficiency to several of any col- lyrium which might be employed, — and as a few days generally suffice for tlie removal of tlie extreme intolerance, and for placing the eye out of danger, its application is in reality tlie mildest course which can be pursued. A light touch of the crayon over the inside of the lid is all that is necessary, the remedy reaching the ulcer as the lid returns to its contact with the globe.. After two or three repe- titions, the child usually makes less complaint, espe- cially after the urgent symptoms have yielded, and if resistance is still made to tlie introduction of col- lyria, and sometimes in any event, the application of the crayon should be continued till convalescence is assured. It is to be considered, in estimating the amount of pain occasioned by the crayon, that the child is in a condition of heightened nervous irrita- bility, — querulous and fretful, and will make great complaint at even a small degree of suffering. That the application is much milder than would appear from the child's behavior will be evident as the disease subsides, as he at length complains for only a few moments after the crayon has been employed, instead of perhaps for several hours as at first. The earlier applications ai'e doubtless more painful tlian those subsequently made ; but at that time, when the disease is at its height, every remedy, even the mildest, causes severe symptoms. When the photophobia is excessive, a solution of SIMPLE ULCERATION OF THE COENEA. 97 atropia (gr. i. to the ounce), or of ext. of belladonna, is of great service in mitigating this symptom, and seems to have a happy influence on the general course of the disease. A drop may be put into the eye by means of a camel'.s-hair pencil, after the crayon has been appHed ; or once a day where this has not been required. Its introduction after the crayon has been applied evidently relieves the pain caused by its use, or shortens its duration. Collyria composed of watery infiisions of opium or other anodynes, soothing lotions, or holding the eyes over hot water into which a portion of some prepara- ' tion of opium has been put, are among the means to which we may look for relief. In certain sluggish cases, collyria of a more stimulating nature, as vinum opii diluted with water or rose-water to one sixth or less of its ftdl strength, are very serviceable. Should the ulcer show no disposition to cicatrize, it may be carefiilly touched with the crayon of sulphate of copper. All preparations of lead should be most scrupu- lously avoided, for the reason, as I have before ex- plained, that they are almost certain to be decom- posed, and the lead incorporated with the corneal tissue, forming an opaque deposit. Counter-irritation, by means of blisters and issues, has formerly been much in vogue, both among the profession and the people. But more recently, the best authorities unite in regarding their value as having 5 a 98 DISEASES OF THE EYE. been over-estimated. They are certainly ill adapted to the strumous diathesis belonging to most of the sub- jects of this affection, and are a great annoyance to children, increasing the irritability already present in a large degree. I regret that it should be necessary to refer with condemnation to the practice of blowing powders of finely ground sugar, calomel, glass, or even more objectionable substances into the eye, for the cure of strumous ophthalmia. This is still kept up ; but can only be regarded as a mode of treatment worthy of veterinary surgery, — to be banished beyond the pale of toleration as regards human therapeutics. The injection of the conjunctiva does not require special attention. It disappears with tlie severer affection of the cornea which gave rise to it. The Hds and cheek should be protected from the action of the augmented flow of scalding tears, by smearing a little simple ointment or spermaceti ointment upon the exposed surfaces. Ointment or cerate is better than liquid oily substances, or glyce- rine, as it is not so readily absorbed into, but retains its place upon, the skin, thus protecting it for a longer time. Disease of the Meibomian glands often coexists with tliis affection of the cornea. If much crusting occurs along their orifices, the crusts should be soft- ened with warm water and carefully removed, every morning. The spots most affected along the edge SIMPLE ULCERATION OF THE CORNEA. 99 of the lid, especially if ulcers have formed beneath the crusts, may be touched, at intervals of a day or tvi^o, with a pointed crayon of nitrate of silver. About the size of the head of a pin of a suitable ointment is to be carefully appUed, with a feather or small brush, along the edge of the lid, after the «hild is asleep, the ointment being first melted near the flame of a lamp. An excellent prescription for this purpose is the ung. hydrar. nitratis one part, simple or rose-water ointment five or six parts. Two grains of the red oxide of mercury to a drachm of simple ointment or lard is another excellent combi- nation. Only a very small quantity is to be used ; as it is better that it should not find its way into the eye. If the crusts are not troublesome, this treatment may be postponed till the more serious symptoms have been disposed of; but the afiection of these glands and the roots of the cilia should receive attention at a proper moment ; as it is im- portant that all morbid conditions of the eye or its appendages should be removed, as a security against relapses. As the lining of the nose is frequently made very sore by the constant flow of tears, it may be neces- sary to soften and remove the hardened crusts which obstruct it, and to apply either simple ointment or a preparation composed by adding to almond-oil enough of a saturated solution of borax to form an emulsion. In some instances, the medicated oint- 100 DISEASES OF THE EYE. ments recommended for the ciliary edges of the lids may be used a few times in the nose with ad- vantage. Should perforation of the cornea be threatened, the pupil must be placed and kept under the influ- ence of atropia, — that, if this event should occur, hernia of the iris may be prevented. Even a small hernia is not incompatible with a fair recovery. If efforts to reduce it should not be successful, it may be left to itself, if not too prominent ; but in case it project so far as to be irritated by every move- ment of the lid, it should be snipped off close to the cornea with fine curved scissors, as I have already advised. When perforation of tlie cornea has resulted from ulceration caused by granular hds or purulent oph- thalmia, atropia may be used if the aperture is near the centre of the cornea ; but if near the margin, it should generally be omitted, lest it cause further protrusion of tlie iris. DOTTED OPACITY OF THE CORNEA. Another, but rare form of disease of the cornea exhibits itself in the development of numerous mi- nute ulcerations, which give to the surface an appear- ance like tliat of ice on which saltJias been sprinkled. There is also a resemblance to ground glass ; but the variety of disease now spoken of is to be distinguished, I think, from syphilitic disease of the cornea, as it DOTTED OPACITY OF THE COENEA. 101 occurs in children and young adults, where a similar appearance is presented, which will be described in another chapter. If examined with a lens of mod- erate power, a great number of distinct dots of ulcer- ation are observed. These most often occupy the central portion, but they may increase in number till a large part of the cornea becomes nebulous. They do not penetrate deeply. Sometimes the mi- nute excavations seem to be filled with accumula- tions of foreign matter, giving them a black appear- ance. This affection is most frequently met with in per- sons who are strumous or anhtemic, or who are suf- fering from exhaustion or from disordered menstrua- tion. It is more likely than the simple ulcer to affect both eyes, sometimes coming on in the second when the first has nearly recovered. Little or no pain is complained of, and the con- junctiva is but slightly injected. There is scarcely any increased lachrymation or intolerance of fight. Prognosis. — The result is generally favorable, but it is not uncommon for the symptoms to increase for a time, until the constitutional condition can be modified, — and they often linger for weeks, and occasionally for months, before the full effect of reme- dies can be obtained. Patients must not be allowed to despond because they observe a temporary diminu- tion of vision. Treatment. — Local means bear but a subordinate 102 DISEASES OF THE EYE. part to the general treatment. This should be of a tonic character, with such alteratives as the iod. po- tass., or with some preparation of iron or other rem- edy adapted to the indications in each case. More stimulating apphcations than those employed in treatment of simple ulcer may be sometimes made use of. Collyria containing wine of opium or acetic acid may be applied, if they do not greatly increase the injection of the conjunctiva. In other instances, the mild astringent collyria advised for simple ulcera- tion prove more advantageous. Atropia may be employed, if the central cloudiness is so dense that vision is nearly lost, — in order that dilatation of the pupil may allow of the perception of objects, — and the eyes may be kept under its in- fluence until moderate transparency of the cornea is regained. COENEITIS OB KERATITIS. Interstitial inflammation of the cornea leaves the surface intact, but gives rise to deposits among the laminae. These are apparently efiusions of lymph. They seem to be capable of being completely re- absorbed, — of undergoing a purulent transformation, forming small abscesses, which may discharge exter- nally or into the anterior chamber, — or of becom- ing organized and acquiring a permanent character. The opacity assumes different forms, — the cloudi- ness being in some cases disseminated, or, as it were, COENEITIS OE KERATITIS. 103 infiltrated through the tissue, giving it the dull appearance of ground glass ; in others, accumulated in distinct masses. In rare instances the cornea assumes a slight reddish tinge, as if everywhere permeated by an abnormal vascularity, and there is sometimes evident bulging, as if from softening of the corneal substance. These appearances are read- ily distinguished from that thickening of the conjunc- tival layer of the cornea sometimes termed pannus, where the front of the globe has been for a long time irritated by granular lids. The vessels of the sclerotica are congested, exhib- iting the purplish tint peculiar to them, whilst the conjunctiva remains nearly free from injection. At times, when the opacity is concentrated in a single mass, the sclerotic vessels are enlarged only in the vicinity of the cloudy deposit. This vascularity, as well as the orbital and supra-orbital pain, are similar to the injection and pain observed in iritis ; but, though the two structures, the cornea and iris, are very frequently implicated in the same attack, such is not necessarily the case. The absence of evidence of congestion in the iris, and the presence of corneal symptoms, wHl enable us to form our diagnosis. The pain, too, is less intense than in iritis, though weari- some and annoying to the patient. When observed as a consequence of inherited syphilis, this disease is accompanied, as has been conclusively shown by Mr. Jonathan Hutchinson, of London, by a train of other 104 DISEASES OF THE EYE. characteristic phenomena. Among the most remai-k- able of these are a coarse skin, broad and sunken bridge of tlie nose, and teeth irregularly set and with singular notches in the edges of the incisors. The affection is rai-e, even in large ophthalmic institutions, and I have seldom met witli it ; but my experience confirms the conclusions of Mr. Hutchinson, whose admirable papers on the subject are a valuable addi- tion to ophthalmic Hterature. When occurring, the disease is Ukely to extend from the centre to the entire extent of the -cornea, cutting off all view of the anterior chamber or iris. Iritis may be suspected to exist as a complication, if pain should be present in any considerable amount, and it is prudent, at all events, to keep tiie pupil un- der the influence of atropia whilst the uis is obscured. Apparent softening and partial ati'ophy of the globe may occur, but the eyes escape the unfavorable prog- nosis, which would seem to be justified, — sometimes happily recovering beyond all expectation. Causes. — This form of inflammation of tlie cornea may occur spontaneously, but it is often conjoined with, or a sequel of, iritis. It is generally met with under pecuhar circumstances ; first, where iritis has existed in persons of rheumatic diathesis, who have become debilitated or anhsemic ; .secondly, and most frequently, in conjimction with syphiUtic iritis, either as it occurs in adults as a tertiary symptom or in the constitutional uilierited syphilis of children or young COENEITIS OR KEEATITIS. 105 persons. In adults it generally supervenes during the decline of the iritis, and is often far more trouble- some than the precursory affection. JPrognosis. — This disease is often subdued without leaving behind it any morbid changes of structure ; but where the opacity has been considerable, it some- times degenerates to a chalky deposit ; or, if mostly absorbed, appears to cause so much disturbance of the ari'angement of the corneal fibres that the normal transparency of this structure and perfection of its refractive function are never restored. As a rule, except in the cases of hereditary syphi- litic origin, these opacities seem to have a more permanent character than those of apparently equal density resulting from simple ulceration. The sub- jects of the hereditary constitutional disease being mostly young, complete resolution is to be hoped for ; but even in the most favorable cases the cloudi- ness continues for weeks or m.onths, and one eye may become affected during the decline of the dis- ease in the other. Treatment. — Much of the treatment must be gen- eral rather than local. In hereditary cases a mild mercurial treatment appears to have an excellent effect in a certain number of patients ; but even here the general cachexia calls in many instances for tonic measures, either used alone or combined with the specific treatment. The iod. potass, is an excellent alterative in some circumstances. Where the affec- 5* 106 DISEASES OF THE EYE. tion of the cornea follows syphilitic iritis in adults, a similar plan is to be pursued ; the physician being careful not to employ too active measm-es where the system is already in a veiy low condition from the eflPects of tlie primary constitutional affection. When the inflammation of tlie cornea is met with in adults in whom there is no reason to suspect any other cause than a strumous diathesis, or after rheumatic iritis, the state of the system usually indicates the employment of tonics, or such alteratives as may improve the quality of the blood and antagonize any morbid peculiarities of constitution. The frequent complication with iritis calls for atten- tion to tlie state of tlie pupil, and the use of ati'opia is important, not only to prevent contraction and synecliia, but as having also a. sedative effect where pain is complained of in or around tlie eye. A few leeches may be applied to tlie temple, if indicated by any increased urgency of symptoms. Anodyne lotions, composed of simple infusions of opium or poppy capsules, or of the latter combined with al- thea-root, sassafras-pitli, or quince-seeds, may be of service in relieving pain and the feeling of tension. They are generally most acceptable when used tepid. The eye should never be kept covered with wai'm bandages, or have poultices appHed to it, — these tending to favor softening of tlie cornea. OPACITIES OF THE COENEA. 107 OPACITIES OF THE COENEA. We are so often consulted on account of opacities of the cornea, that it is very important to be able to decide at once as to their nature and prognosis. The physician should know how to distinguish the cloudi- ness accompanying actual disease from the opacity resulting from affections which have passed away, leaving these effects behind them ; and should know what amount of change is to be expected in the ftiture, either from the processes of nature or the results of treatment. The appearances of the cornea when actually the seat of morbid processes, have been already described. After these processes have terminated, we may still perceive some blood-vessels on or near any opaque spot which may remain ; but these are not to be regarded as detrimental, — on the contrary, they are essential to the absorption of the cloudy effiasion, — and when this is accomplished they disappear. In recent cases, especially in children, if ulceration has not perforated the cornea, we may predict that the opacity wiU nearly or quite disappear as the child grows older. Strabismus sometimes comes on as a consequence of central opacity, and disappears after its absorption. These slighter opacities are termed nebulae. The more extensive and dense opacities resulting from very large ulcers, especially the per- forating ulcers resulting from neglected conjunctivitis 108 DISEASES OF. THE EYE. (to which the term leucoma is apphed), may lessen in diameter, so as to allow of more or less vision where it had been wholly abolished, or to admit of a suc- cessful operation for artificial pupil ; but they can neither be absorbed nor removed by operation. De- posits of decomposed acetate of lead may be scraped off if they do not extend below the epitlielial layer, and perfect transparency restored ; but if they have become incorporated with the proper substance of the cornea, interference is almost useless. These deposits are generally slightly raised above the surface, and of a dead white color. In eyes where the epitliehal layer had been detached, and raised in the form of a blister, I have removed the clouded epithelium over the whole extent of the cornea, and had the satisfac- tion of finding a transparent surface beneath. The cornea continued clear, and vision sufficiently good to allow tlie patient to read a fair, ordinary type. Much pain was complained of after the operation, as is the case where the cornea is accidentally abraded. If perforating ulcer has been followed by anterior synechia or adhesion of the iris to the cornea, there must always be a considerable cloudiness at this point ; but the halo which surrounds it narrows and fades, and great improvement in vision may result, as the cloudiness disappeai's from all but the central spot where adhesion has formed. Treatment. — Various astringent or stimulating col- lyria have been lauded as efficient for the removal of AKCUS SENILIS. 109 opacities of the cornea. It is well, perhaps, to pre- scribe some mild and grateful application, since it prevents the patient or his friends from resorting to the thousand infallible specifics which are con- stantly pressed upon their notice. But we must not claim too much for our remedy. It is best to say that the removal of the cloud must take place very gradually, and that the means we advise will do as much as can be done to promote its disappearance. The absorption will go on more rapidly in young persons, or after an acute ulceration of short dura- tion ; but the process is Httle hastened by the use of local or general remedies if the subject is healthy. The fact that reparation goes on whilst various means are used by the patient, has given reputation to nu- merous empirical applications ; but it would have gone on equally rapidly, so far as my experience has enabled me to judge, had the case been left to nature. Therefore let our interference be at least harmless. Opaque deposits of lead, or altered epithe- lium, may be dissected off carefully with cataract- knives, minute toothed forceps, and ^ fine scissors. AKCUS SENILIS. A cloudy ring near the margin of the cornea, sometimes complete, at others only extending partly around it, is often observed in old, and now and then in young persons. It is regarded by some authors as an indication of fatty degeneration of the heart ; 110 DISEASES OF THE. EYE. but, as far as the eye is concerned, is not to be con- sidered a disease deserving attention. The fears of the patient may be allayed by assurances that the change will be limited to the border of the cornea, and will not affect the field of the pupil or interfere with vision. Charlatans are in the habit of terrifying patients by predictions that "the sight will become covered " unless their services are retained, but these predictions are utterly groundless. CONICAL CORNEA. The cornea is now and then observed to undergo a change of curvature, the central portion giving way and forming a cone. The change comes on in- sidiously, the patient finding his vision less distinct, yet experiencing no pain, nor perceiving any injec- tion of the eye. At the outset, the physician per- ceives a peculiarity in the reflection of light from the cornea, even when close inspection detects only a very slight departure from its normal curvature. As the disease advances, the change becomes more and more marked ; the conical form being very apparent, and vision more imperfect. The apex of the cone may remain transparent ; but in marked cases of the disease it most frequently becomes shghtly clouded, without the occurrence of ulceration. Notwithstand- ing the extreme thinning which seems to exist in these instances, I have never known ■ rupture of conical cornea to occur ; though in hydrophthalmia this misfortune is extremely common. CONICAL COENEA. Ill Vision is imperfect from the excessive refraction of the rays as they enter the eye ; and concave glasses, though of service in mild cases of the dis- ease, are scarcely a palliative where the alteration has reached an advanced degree. Frequently the pupil is large, the iris tremulous in the superabun- dant aqueous humor, and the entire globe slightly softer to the touch than natural. The disease usually declares itself in both eyes ; but seldom begins in both at the same time. Causes. — It generally commences in youth or early adult life, and though most likely to attack those of feeble constitution, it is by no means confined to such. I have seen marked specimens of the disease in young men of vigorous health. Excessive use of the eyes does not seem to have any agency as a remote or proximate cause ; nor does the aifection appear to be induced by any pecuharities of habits or food. Prognosis. — In healthy persons we may hope for an arrest of the disease ; which, after reaching a certain point, sometimes comes to a stand, and does not afterward either recede or advance. Observa- tion of this fact leads us to endeavor by tonic treat- ment to obtain a similar result in individuals of lymphatic or delicate constitution. Any absolute res- toration of the natural form of the cornea, by pres- sure, puncture, evacuation of the aqueous humor, extraction of the lens, or other means, seems to be 112 DISEASES OF THE EYE. impossible. But thougli, as a rule, I have opposed puncture and evacuation of the aqueous, yet I have seen very great benefit follow it in one aggravated instance, where vision was almost completely gone, and was restored to a very useful degree even for reading, after an operation. The improvement con- tinued for some two or three years, at the end of which periods I repeated the operation a second, and again a third time, with hke good results. The change for the worse is often so gradual that the patient observes a lessening of vision when we are unable to detect any alteration from one month to another in the apparent condition of the cornea. Treatment. — Palliatives rather than restoratives afford our sole resource, except from surgical inter- ference. Vt^e may essay to ai-rest the further ad- vance of the organic changes by tonic general treat- ment, and by prudent use of the eyes, so that no vascular congestion may be occasioned by strong efforts to distinguish objects. Concave glasses are sometimes an auxihary to • vision, in shght degrees of the affection. Disks of buffalo-horn, perforated by a small slit, have been of use, by virtually lessening the diameter of the pupil, and cutting off lateral pencils of rays. Rea- soning on tliese facts, Mr. Bowman, of London, was led to devise a method of operation by which tlie edge of tlie pupil is drawn tlirough and allowed to form adhesions with a small puncture of the cornea. FOEEIGN BODIES IN THE COKNEA. 113 He advises performing the operation at both the upper and lower edges of the pupU, so that its form may be changed to a vertical sht. The operation is to be done by puncturing the cornea near its lower margin, drawing out the iris by means of a short, blunt hook, with which the edge of the pupil is seized, and securing it outside the corneal wound by a very fine ligature. This gives the pupil a balloon- shape. If considered desirable to perform a second operation, the puncture is to be made at the upper edge of the cornea, and the iris drawn out in the same manner, thus giving the pupil a slit-like form. If the first operation results in a fair ai^ount of vision, a second is not indispensable, as the gain from a second operation is much less in proportion than that derived from the first. Should puncture of the cornea for the evacuation of the aqueous humor be resorted to, the operation maj be done at any convenient point near the edge of the cornea. FOEEIGN BODIES IN THE COENEA. From its exposed position, the cornea is liable to be struck by small, flying particles, which are often driven deeply into its substance, and are diiScuIt of removal on account of the extreme mobility of the eye, which has become irritated by their pres- ence and exceedingly sensitive. If not removed, they continue for a long time a source of annoyance. 114 DISEASES OF THE EYE. and may give rise to serious symptoms, though they are eventually thrown off by ulceration. Soft sub- stances, grains of gunpowder, &c., may remain im- bedded without causing irritation ; becoming incor- porated, as it were, with the corneal tissue. The mode of removing these particles is the same as already described for those lodged in the conjunc- tival layer of the cornea ; but should they have pene- trated so far as to be partially within the anterior chamber, it is sometimes necessary to make pressure against them from beliind, with a fine needle passed through the cornea, whilst their extraction is being attempted. STAPHYLOMA OF THE CORNEA. When nearly the entire cornea has been destroyed by extensive ulceration, the action of the recti muscles frequently pushes forward the lens and iris; or the iris alone is displaced. A cicatrix results, made up of a new tissue taking the place of the disorganized structures, and forming a projection beyond the nor- mal curvature of the front of the globe. When this is not very prominent, it causes httle irritation, and though unsightly, need not be removed unless tlie patient desires to wear an artificial eye. When tlie the bulging is excessive, it is frequently necessaiy to excise a portion of the mass, that the patient may be relieved from the irritation occasioned by its fric- tion against the lids, and from the repulsive de- STAPHYLOMA OF THE COENEA. 115 formity. Excision may be performed by transfixing it and forming a flap witb a cataract-knife or thin bistoury, and clipping off the flap with scissors. Care should be taken not to carry the instruments so far back as to impinge upon the lens or vitreous, if these are still healthy. In some cases we may simply re- move an oval portion of the centre of the staphyloma, allowing the edges to fall together, or even uniting them by a single fine suture. The globe is thus re- stored to about its natural size, and where a patient cannot afford an artificial eye, has a better look than when merely the stump of an eyeball remains ; as is the case where suppuration follows too extensive excision, as well as in cases where the vitreous had already undergone a process of softening previous to the operation. Ether should always be administered unless the patient's steadiness can be relied on, and always in cases of children ; as the operation is sometimes attended with no little pain. 116 DISEASES OF THE EYE. CHAPTER VIII. APrsCTIONS OF THE SCLEROTICA. Notwithstanding the elaborate endeavors of au- thors to define simple inflammation of the sclerotica, I believe that it rarely, perhaps never, occurs as a distinct or primary disease. Complicated forms of disease, sometimes described as rheumatic ophthal- mia, &c., involving more than one of the tissues of the globe, are certainly not unfrequent ; but the sclerotica seems peculiarly free from tendency to become inflamed. Injection of its vessels takes place whenever the cornea or iris are seriously af- fected, or when the entire globe is attacked or an abscess forms within it ; its structure may become thinned from disease of the choroid ; but in all these circumstances the alterations in other parts precede those of the sclerotica, and are the impor- tant objects of our attention. Certainly the sclerot- ica never calls for special care, in any of these affections, but the treatment of its symptoms merges in that of other parts which are simultaneously dis- ordered. AFFECTIONS OF THE SCLEROTICA. 117 "WOUNDS OF THE SOLEEOTICA. Incised wounds of the sclerotica implicate, of course, the conjunctiva, and generally extend to the choroid, retina, and vitreous mass. Should any considerable protrusion of the vitreous or other in- ternal parts of the glohe exist, it may be necessary to excise this by a quick cut with fine curved scis- sors ; but should the protrusion be sHght, it is bet- ter to leave it undisturbed till we can observe if it act as a source of much irritation. In this case it must be excised ; otherwise the only treatment re- quired is entire rest. The lids in many instances should be kept closed by strips of court-plaster. We should carefully abstain feoia the use of collyria or lotions, as any such disturbance of the reparative pro- cess can only do harm. Rupture of the sclerotica may be caused by a blow, and may exist without lesion of the conjunc- ■ tiva. The same rules, as to quiet and non-inter- ference, apply to the treatment of this injury; but the prognosis is less favorable than in cases of in- cised wounds, as all the important parts of the eye have probably been injured by the shock. In rare cases, the lens is forced through the wound, and remains between the sclerotica and conjunctiva. It is to be carefully extracted, — the incision of the conjtmctiva being made at a distance from the rup- ture of the sclerotica, that the valvular flap thus 118 DISEASES OF THB EYE. created may form an obstacle to prolapsus of the vitreous humor. THINNING OP THE SCLEROTICA. This is sometimes observed where the choroid has long been affected in strumous subjects, and seems to be accompanied by tension of the globe from in- creased secretion of its contained humors. A certain degree of tliis alteration is not incompatible with vis- ion, and it now and then yields to the use of the iodide potassii and tonic ti'eatment ; but it is oftener concomitant with serious organic alterations of inter- nal parts and is little amenable to remedies. STAPHYLOMA OF THE SCLEROTICA. One or more protrusions of the choroid or corpus ciliare through the thinned sclerotica are not unfre- quently observed in patients of strumous constitution. They are situated for the most part between the edge of the cornea and tlie attachments of the recti muscles, though they sometimes form posteriorly, where tlie sclerotica is firmer. These small tumors have a bluish-black color, and vaiy in size and form, some- times being a single rounded elevation, sometimes a cluster of such elevations, and again an elongated ridge partially or wholly surrounding the cornea. They bear a certain resemblance to melanotic tumors of the globe, but may be readily distinguished by gently touching them with a probe, when their fluid STAPHYLOMA OF THE SCLEROTICA. 119 contents will allow ttem to yield to the pressure ; or by puncture. They sometimes enlarge to such an extent as to prevent the lids from closing. Staphyloma in a slight degree may be amenable to treatment ; but where extensive, it involves so many more important changes that vision is usually lost, even if complete disorganization of the globe do not occur. Puncture of the projecting point and even excision may now and then be admissible when the tumor is small ; but as in these cases little incon- venience is felt from its presence, it is best in most instances to leave it untouched. When the staphy- loma is so large as to be hideous, or annoying to the patient, the anterior part of the globe may be re- moved, or the globe may be excised within the orbital capsule, the patient being placed under the influence of ether. This operation for removing the anterior portion generally involves, in these cases, subsequent suppuration, and shrinking of the entire globe ; but, as also where excision has been practised, an artificial eye may be worn to hide the deformity, after the parts have become firmly cicatrized. Excision, which would seem to be a much more formidable procedure, is in reality less serious as an operation than ablation of the anterior half of the globe. After the removal of the front of the globe, unless the lens, or at ♦least the vitreous mass, can be left undisturbed, there is considerable danger of hemorrhage from the internal vessels of the globe; 120 DISEASES OF THE EYE. and if this do not occur, the process of suppuration of the textures of the globe keeps up, for several weeks, a painful inflammation and swelling of the globe and lids. On the contrary, after excision of the globe without the removal of the fibrous capsule in which it revolves, there is seldom any hemorrhage requiring ligature of a vessel ; and the simple incision of the conjunctiva, into which the operation is in fact resolved, is healed at the end of two or three days. The only possible reason in favor of the removal of a part instead of the whole globe is, that the resulting stump is supposed to be rather better adapted for sup- porting an artificial eye. But even as regards this point there is very sUght difference. Whenever, therefore, the poverty of the patient or any other reason would preclude his wearing an artificial substitute, removal of the entire globe rather than its anterior half should be preferred. AFFECTIONS OF THE HJIS. 121 CHAPTER IX. AITECTIONS OF THE EBIS. The iris appears to be only slightly susceptible to become inflamed after traumatic injury, unless a for- eign body is lodged in its tissue or continuous pres- sure is made upon it. Large fissures may extend across it or around its margin, or a segment may be excised, in operations for artificial pupil or for relief of glaucoma, without the appearance of a single morbid symptom. I have never seen iritis ensue, in any instance, in patients on whom I have per- formed or witnessed these operations. But where the iris is pressed upon by a swollen or dislocated lens, or when a fragment of percussion cap or other foreign body is imbedded in it, a form of infiamma- tion is induced which can rarely be controlled until the exciting cause has first been removed. Except under such circumstances of continued irritation as I have described, I shall recognize two varieties only of iritis ; viz. the rheumatic and the syphilitic; the form sometimes described as stru- mous iritis being apparently an affection dependent on inherited venereal taint, though differing wholly from syphihtic iritis appearing after direct infection. 1'2'2 DISEASES OF THE EYE. RHEUMATIC IRITIS. Exposure to unfavorable atmospheric influences — as, for instance, to cold or damp winds, which, in another person, would cause at most an attack of catarrhal conjunctivitis — will frequently induce iritis in an individual of rheumatic diathesis. The hability is greater when the exposure occurs after the eyes have been stimulated by use or by bright hght. Symptoms. — A slight soreness when the globe is moved or pressed upon, apparently seated at the points of insertion of the recti muscles, is sometimes complained of as the earliest symptom, — before any congestion of the iris or injection of the circum- corneal zone of vessels can be perceived. These last-named phenomena are soon superadded, while, at the same time, the patient begins to notice that his sight is less perfect than usual. The characters of the disease are broadly distinct from those of inflammation of the external mem- branes, as seen in conjunctivitis. The pain, instead of being a smarting or itching, evidentiy situated on the surface of the globe or hds, is of an aching charactei" and deep-seated when the u'is is involved, often severe, sometimes agonizing; described by the patient as if tension of the eye even to bursting were taking place. It frequently extends to the supra- orbital or other branches of tlie fiftli pair of nerves, often causing great tenderness of the scalp over the EHEUMATIC IRITIS. 123 whole of the affected side. Usually it is remittent, returning with increased severity at evening, or in the night, after a comparatively tranquil day. Very large anodynes are often ineffectual to procure sleep. The injection affects a different set of vessels from those which become enlarged in conjunctivitis. It is not now a scarlet network, covering the whole anterior portion of the sclerotica and nearly conceal- ing it, especially marked at the line where the con- junctiva is reflected from the lids upon the globe ; but consists in the development of hitherto unseen straight filiform vessels, having their largest calibre close to the margin of the cornea, and fading to in- visibility as they extend upon the sclerotica, leaving most of the globe, at the outset of the attack, free from injection. If, later in the course of the disease, the conjunctiva becomes more or less involved, the zone of purplish or lake-colored vessels may still be detected beneath the conjunctival network. The condition of the external membrane requires little attention, as it spontaneously improves upon the sub- sidence of the internal inflammation on which it depends. The muco-purulent secretion proper to conjunc- tivitis is wanting, or nearly so, in attacks of iritis, and is replaced by a copious lachrymal flow. There is also, as a rule, great intolerance of light, which rarely exists, in any degree, in conjunctival affections, unless the cornea becomes involved. 124 DISEASES OF THE EYE. Now and then the disease comes on insidiously, no severe pain or considerable injection giving the patient -warning of the advent of serious disease ; and permanent mischief may have been accomplished before he applies for advice. On inspection of the eye, in addition to the appear- ances above ' described, marked changes can be per- ceived in the iris. It has a turgid, swollen aspect ; often projecting beyond its natural plane towards the anterior chamber. Its brilliant lustre and striated appearance are lost, and its tissue seems infiltrated. These changes result from the congestion of its vessels or the extravasation of lymph into its sub- stance. This effusion, blending with the natural color of the iris, changes this to a darker shade ; a blue iris acquiring a greenish, and a brown iris a reddish tint. Tubercles, or small masses of lymph, are sometimes formed in the substance of the iris, or upon its free edge. The intolerance of light tends strongly to con- tract the pupil, and this contraction is favored and kept up by the congestion of the iris or efiiision into its substance. This tendency constitutes the only formidable danger to be apprehended from the dis- ease ; as, unless means are used in the early stages to dilate the pupil, it cannot afterward be fully acted on by mydriatics, and the edge of the pupil forms adhesions to the capsule of the lens, constituting what is termed posterior synechia, — or its area becomes EHEUMATIC lEITIS. 125 even blocked up by deposits of lymph, thus abol- ishing vision. Adhesions of limited extent may not seriously interfere with the recovery of excellent vision ; but they place the eye in a less favorable condition for resisting future attacks should any such occur, — and of this there is, unfortunately, always more or less chance where an individual has once been affected. Prognosis. — K early and properly treated, the result is almost always, if not invariably, favorable. The severe symptoms yield, the pain and injection gradually subside, the photophobia disappears, and the normal movements of the pupil are restored. The dimness of vision, however, often continues for several weeks after the injection has vanished ; but, if the physician detects no traces of organic change in the iris or pupil, he may confidently assure his patient that vision will be completely restored after a short time. If reasonably prudent, the patient may enjoy im- munity from a second attack ; but he should be cautious, at least for some months, in regard to ex- posure to glare of Hght from the snow or ft'om light surfaces, or to cold or damp winds. If resid- ing at a distance, it is well that he should be pro- vided with a solution of atropia, by means of which he can secure prompt dilatation of the pupil at the outset of any fresh attack, and maintain this en- largement tUl he can have suitable professional advice. 126 DISEASES OF THE EYE. When the disease is not seen till a later period, and has been allowed to take its own course, the prognosis wiU depend on the extent of the patho- logical changes wliich have taken place. If the adhesions are but slight, or if they can be detached by dilatation of the pupil, very good vision may be preserved. But where they implicate the entire cir- cumference of the pupil, and its area is covered with lymph, vision is likely to be nearly or wholly lost. Moreover, a new danger arises ; the aqueous fluid secreted behind the iris, no longer finding access through the pupil to the anterior chamber, some- times distends the ii'is to such a degree as to cause disorganization, which extends to other internal parts of the eye, and annihilates all hope of a restoration of sight by the performance of an operation for arti- ficial pupil, which would otherwise have been prac- ticable. Treatment. — I believe this disease to belong to the class known as self-limited, having a tendency to recovery in about thi-ee weeks, provided tlie morbid processes do not reach the point of pro- ducing extensive adhesions of the pupil ; but having also a tendency to produce serious organic altera- tions, and to have a longer duration, where these processes ai"e excessively violent and are permitted to go on unchecked. If this opinion be well founded, one important point in treatment has a high prece- dence above all others, — the maintenance of dilata- RHEUMATIC IRITIS. 127 tion of the pupil. In fact, without undervaluing other remedies, indicated at times by the general condition, I am confident that atropia and opium — the former to enlarge the pupil, the latter to control the pain attending the disease — are the essentials in the management of this affection. It follows that I attach little value to mercury in the treatment of this affection, though it has formerly been regarded as almost a specific, and has been often cited as an instance of the power of remedies in arresting morbid processes. Such dissent from the doctrine of all the authorities demands a full explanation. From the time when iritis was described by Schmidt, of Vienna, as a dis- tinct disease, the precept has been strongly inculcated that mercury must be given in the early stages, oth- erwise the golden opportunity for bringing the patient imder its influence would be lost, and success could scarcely be hoped for. The authorities having thus insisted on the importance of an early resort to this remedy, each practitioner has been afraid to take the responsibility of deviating, in the treatment of so grave an affection, from the course declared to be the only path of safety. Thus very few oppor- tunities occurred for observing the natural course of the disease, — as the milder cases, which did not require treatment by medical men, recovered, and never presented themselves to their notice, — whilst the severer cases, in which, the pupil having 128 DISEASES OF THE EYE. been left to itself, occlusion had resulted and vision "was destroyed, were brought forward as examples of the ravages of tlie affection when uninfluenced by mercury. But tlie authorities also advised the free local use of belladonna at the same time that mercury was administered internally. ^Yhenever, therefore, a patient who had been thus treated, se- cundum artem, fully recovered, the credit was given, not where as I beUeved it belonged, to the belladonna or stramonium, under tlie influence of which tlie pupil had been kept widely expanded, — but to the mercury, which had been canonically given, even to the extent of producing pfyalism. When the result was less happy, it was ascribed, not to the neglect or the too tardy use of belladonna (which was too often the case), but to the supposed fiict that mercury was not given as soon or as freely as it should have been, or to a want of susceptibility to its influence on the part of the patient. The remark often made, that the sjTnptoms did not begin to yield till tlie gums were touched, proves notliing under these circumstances ; as after a certain period they would equally have given way had the supposed specific been withheld. The want of any absolute specific power has been admitted, of late years, in the attempts made to provide substitutes, as turpentine, &c., in cases where mercmy seemed inefficacious or evidently disagreed. Observation of many cases which came under my RHEUMATIC JEITIS. 129 notice where the patient had been treated with mer- cury to the fullest extent, but nothing had been done to dilate the pupil, and where the result was most disastrous ; and reflection on the mode of action of the constitutional and local remedies, induced me to vary from the treatment I had always previously pursued according to the approved method, in certain cases which came under my care, where the patients were in such a condition as contra-indicated the use of mercury unless as an imperative necessity. These were treated by anodynes and tonics, and the pupil kept fully under the influence of belladonna, and they terminated far more favorably than the severity of the attack and the state of the patient had allowed me to expect. Encouraged by excellent results in these cases, I was led to try a similar plan in other instances ; and I am confident that I never saw better results ensue, in the hands of others or myself, from the old method. If it be in our power, then, to spare the patient the infliction of the grave inconveniences and protracted convalescence often occasioned by the free use of mercury, and to relieve him as well and as quickly by other remedies, we may gladly accept the alternative. A few words as to the anatomical reasons which give so much importance to the action of belladonna and its kindred remedies. Referring to the construc- tion and relations of the parts, we observe that the lens is largely convex, and the iris suspended, a plane 6* I 130 DISEASES OF THE EYE. surface, a short distance in front of it. In a normal condition of the eye, the edge of the iris, when die pupil is contracted, probably touches and glides over the convex surface of the crystalline. Much more close must be the contact when the pupil is strongly contracted by photophobia and the iris turgid and thickened from inflammation. If, in these conditions, plastic lymph is effused, the formation of adhesions, and even of a deposit covering the whole field of the diminished pupil, is a most probable occurrence. But if we can effect even moderate enlargement of the pupil, the relations of the pai'ts are greatly modi- fied. The edge of the pupil is now at some distance fi'om the retreating convex surface of the lens, and their cohesion has become impossible so long as these relative positions are maintained. With these brief arguments in support of a plan which I have followed for years in every form of iritis, and of which I am constantly receiving fi'esh sanction from confreres in Europe and at home, I pass to the details of treatment. The most important indication, the securing am- ple dilatation of the pupil, is best fulfilled by the use of a solution of atropia. Formerly, the extract of belladonna or stramonium, moistened with water or combined with ointment, was freely and fre- quently smeared around the orbit ; or a filtered solution of the same was di'opped into the eye. But the nauseous odor of the extract, its variable EHEUMATIC lEITIS. 131 strength, its liability to become decomposed if pre- scribed in solution, and the discomfort attending its use, were strong reasons for substituting atropia. The sulphate of atropia, readily soluble in water, can now be procured at a moderate price. If, how- ever, the physician does not have this at hand when needed, the extract of belladonna or stramonium, well rubbed up with water, in the proportion of from twenty to forty grains to the ounce, and fil- tered, is an efficient substitute. It may be dropped into the eye once or twice a day, and causes only slight irritation if fireshly prepared ; as it should be every few days, at least in warm weather. The appKcation of the extract around the orbit, in the form of paste or ointment, is disagreeable to the patient, and, unless portions of it are rubbed into the eye, it acts very slowly and inefficiently. It is but a clumsy way of accomplishing the object desired. When the eye is uninflamed, and we wish merely to dilate the pupil, a solution of no greater strength than half a grain of the neutral sulphate of atropia in an ounce of water is sufficient for the purpose, — acting in from fifteen to thirty minutes. But in cases where the iris has already become more or less congested it is necessary to employ a stronger solution. Five grains to the ounce is nearly cer- tain to act efficiently ; but if adhesions are already formed, or if the congestion and thickening of the 132 DISEASES" OF THE EYE. ' iris are excessive, the strength of the solution may be doubled. A drop may be put into the eye once, or in severe cases twice, in twenty-four hours, by means of a camel's-hair pencil. The lower hd is to be drawn down for an instant, the brush introduced into the palpebral sinus, and the lid allowed to return to its place, thus squeezing a drop of liquid from the brush by pressure between the lid and the globe. Atropia seems also to have a secondary influence, in lessening the amount of pain ; perhaps by dimin- ishing the congestion of the iris. Some caution is necessary in the use of very strong solutions of atropia, as they are not required for ef- fecting the object, and several instances are recorded where serious cerebral symptoms have followed the instillation of a drop or two of a strong solution (of thirty grains to the ounce), into the eyes of aged persons and children. As the severity of the symptoms subsides, atropia may be less often applied ; but the iris should be kept under its influence till we have assurance, from the improved condition of this membrane, that adhesion is no longer to be apprehended. No ill consequences result from its use, even for a long period, the pupil ordinarily resuming its contractile functions within a short time after the applications are discontinued. Another important indication is to control the pain, as the severe nocturnal paroxysms seem to have an effect to increase the effusion of lymph. We may RHEUMATIC IRITIS. 133 sometimes attain this object by relieving the circula- tion in and around the eye by the application of three or four leeches to the temple, at the same time pre- scribing a hot foot-bath before the patient retires. The leeches should be placed on a level with the eye, and some distance from it, as, if applied above the eyebrow or too near the lids, swelling of the palpebrse is apt to ensue, producing painful pressure on the globe. Bleeding from the bites should be encouraged for an hour after the leeches fall off, by the applica- tion of poultices or of cloths wrung out of hot water. In most severe attacks these means are insufficient to do more than mitigate the pain, and we must resort to opiates for its complete relief. These should be given in sufficient quantity, however much this may be ; a dose, judged to be a suitable one, being pre- scribed ; and if requisite repeated hourly, till the patient is relieved. Very large amounts of opium or morphia are sometimes required to subdue the agonizing pain, and procure sleep. Warm fomentations, especially with an infusion of opium or poppy capsules, are sometimes soothing. In other cases, lotions with tepid water or milk and water, are preferred by the patient. Infusions of chamomile flowers, rose-leaves, or other simple reme- dies may be used, if desired by the patient ; but they have probably no other efficacy than that derived from the lukewarm temperature at which they should be applied. Hot pediluvia seem to be often useful from their derivative action. 134 DISEASES OF THE EYE. Very severe pain and tension may sometimes be relieved by puncturing the cornea, and permitting the escape of the aqueous humor. The best instrument for this little operation is one devised by M. Des- marres for the purpose, and is shaped hke a broad cataract-needle, but with a guard at a short distance from the point to prevent it from plunging into the eye, if the patient should make a sudden movement. The puncture may be made with a cataract-needle, or even with the point of a clean lancet, if the patient is steady, — if the above-named instrument is not at hand. The humor should be allowed to escape a second time, a few moments after the punc- ture, the edges of the wound being slightly separated to allow of the discharge of the reaccumulated fluid. After a second evacuation the secretion takes place more slowly, and the vessels of the eye appear to be in some degree unloaded. The operation is unat- tended with the slightest risk if skilfully performed, and the little wound heals at once. The puncture should be made near the margin of the cornea, that there may be no chance of any impediment to vision by the slight cicatrix. These means are sufEcient, in most cases, for securing a fortunate termination of the disease, and as speedy a recovery as the nature of the affection and severity of the attack will admit of; without the employment of any remedies having a claim to specific action through the constitution of the patient. RHEUMATIC IRITIS. 135 But as this form of iritis seems to be but a manifes- tation of the rheumatic diathesis pervading the whole system, it is well, in many instances, to give the patient the benefit of any means which may seem adapted to have a favorable influence on his general condition. Among these the physician will select such as in his judgment will suit each particular case. For promoting the absorption of any deposit of lymph which may have been effused, the iodide of potassium appears to have as much influence as is possessed by any remedy ; the use of atropia being at the same time continued to exert traction on the bands of adhesion. As regards the effect of mercury as a resolvent of effused lymph, I have seen so many cases where the pupil has become and remained obliterated by de- posits, where mercury had been most lavishly, and, as would be thought, judiciously administered ; and, on the other hand, have so often seen the lymph ab- sorbed, and the congestion of the iris resolved where only tonics had been given; that I cannot coincide in a belief in the specific properties of this as sur- passing those of any other remedy. A large pro- portion of the cases of both rheumatic and syphilitic iritis can be safely, quickly, and pleasantly relieved without it, and with a more rapid recovery of perfect health than where it is given. Many a case will perhaps be cited in the reader's mind, which seemed 136 DISEASES OF THE EYE. to go on more favorably, when, after a trial of other remedies, this was resorted to ; but here the attack had aheady lasted a considerable time, and had prob- ably reached its acme. As I have before stated, ex- perience justifies us in believing, that from a certain point, varying in different cases, there is an evident tendency towards recovery, provided the deposit of adhesive lymph has not been so considerable as to fill the pupil and cement its edge to the surface of the lens. Given at this turning-point of the disease, when even an expectant treatment would have been followed by a favorable result, mercury has obtained credit which belonged to the vis medicatrix naturce, or to other means employed conjointly with it. Where adhesions have actually formed between the edge of the pupil and the capsule of the crystal- line lens, they may frequently be detached by means of atropia ; or, if they cannot thus be entirely sep- arated, they may be so far elongated as to allow free play of the iris, and lessen the danger of the forma- tion of further adhesions in the event of another attack. Where adhesion has taken place to such an extent that the movements of the iris are interfered with and an u'ritable condition of this structure is kept up, the bands of lymph may be detached by means of an extremely minute hook designed for this purpose, blunted at its extremity so as not to endanger the lens. It is dexterously introduced tlirough a small puncture SYPHILITIC ntlTIS. 137 of the cornea, "witliout evacuating the aqueous humor, and is then carefully passed between the edge of the pupil and the lens, dividing or tearing away the adhesions. The patient should be under the influ- ence of ether, that immobility of his eye may be secured. After the operation, the pupil should be dilated by atropia, to prevent reformation of adhe- sions. A similar operation for detaching the efiused lymph fi-om the edge of the pupil and the crystal- line capsule may often be resorted to where the pupU has become wholly closed, instead of the formation of an artificial pupU for the restoration of ^Tsion. SYPHILITIC IRITIS. The iris is the seat of one of the manifestations of constitutional syphilitic infection. Syw/ptoms. — In most cases the symptoms diflFer from those of rheumatic iritis, to such an extent as to render diagnosis easy, without reference to other specific phenomena which may be present; but in- stances occur where the appearances, though sus- picious, wUl not warrant our regarding the disease as positively of this character, unless other facts con- cur to establish our opinion. The change of color in the iris, loss of its natural brilhancy and striated appearance, and its evident congestion, are usually more marked than in the rheumatic form of the afiection. There is also a greater tendency to effusion, and well-defined deposits or tubercles of lymph are more frequently seen in the 138 DISEASES OF THE EYE. substance or along the pupillary edge of the iris. These deposits were once regarded as characteristic of the syphilitic variety of the disease; but they may occur, though more rarely, in rheumatic attacks. The pupil is generally irregular, and it has more ap- parent turbidity than in rheumatic cases. It is by no means uncommon, as the phenomena proper to the iris begin to subside, and even when they have nearly disappeared, to encounter an acces- sion of new symptoms, in the form of interstitial in- flammation of the cornea. This complication is not only dangerous, as being hable to cause structural changes of the cornea resulting in an opaque cica- trix, but also as tending to keep up the original iritic affection. Prognosis. — The subjects of this disease are so frequently cachectic, that more than ordinary diffi- culty may be anticipated in arresting its course. Yet, if the pupil has been well dilated early in the attack, and no large tubercles are developed along its edge, there is little danger of a bad result. When the use of atropia has been neglected in the first stages, the puffy iris is often beyond its power at a later period, the swollen tissue being capable of no change of position. In these circumstances some of the unfortunate sequelse already described in speak- ing of rheumatic iritis are likely to occur. Treatment, — As in rheumatic iritis, the use of atropia, or some agent of similar effect, is of the first importance. Other local remedies of a soothing ten- CONGENITAL SYPHILITIC lEITIS. 139 dency and the internal administration of anodynes should also he had recourse to, as recommended for the treatment of the rheumatic form of the disease. Local depletion should he cautiously advised, if at all, and the general treatment should have a tonic char- acter, as is often indicated by the condition of the patient. Where interstitial comeitis exists as a com- plication, the use of mercurials may he admissible, and of these the iodide is one of the best prepara- tions in its effects on these cases. CONGENITA! SYPHILITIC lEITIS. The iris is, in a few rare instances, attacked with inflammation, evidently of syphihtic origin, withia a few months, or even years, after birth. The symp- toms are less intense, so far as regards injection or pain, than in the disease as it occurs in adults ; but the iris itself often exhibits extensive deposits of lymph and marked changes of color and structure. The patient is generally puny, and other symptoms of congenital syphilis are to be observed on different parts of its body. Any disease of the iris in very young children may be suspected to arise from con- stitutional infection. Treatment. — Atropia is not to be neglected. With this local means we combine remedies for the im- provement of the general condition. The adminis- tration of hydrar. cum crett, associated with tonics, seems to have a most happy effect. 140 DISEASES OF THE EYE. CHAPTER X. AITECTIONS OF THE CRYSTALLINE LENS. DISLOCATION OP THE CRYSTALLINE. Though most frequently occasioned by a blow upon the eyeball, displacement of the lens may occur spontaneously. Some years since, an interesting ex- ample of this very unusual condition came under my observation, which is worthy of being recorded. The patient had a feeble constitution, and had always had weak sight, as she expressed it, since having measles, scarlatina, and variola, in quick succession, in child- hood. A few days before I saw her, her age being at this time about thirty-five, in stooping to raise a tub, she became conscious of some change in her right eye, which was followed by circum-orbital pain and by nausea. She afterward noticed a transparent mass in the anterior chamber. After lying on her back at night this appearance was no longer seen, but her sight was less good than before. The same phenomena occurred on again stooping about her work, and when I saw her, the transparent lens of the right eye was lying in the anterior chamber. Its weight caused the iris to form a pouch, so that the lower margin of the lens was a line or more below DISLOCATION OF THE CETSTALLINE. 141 the cornea, its upper edge extending rather above the middle of the pupil. The edge of the lens was sharply defined, as much so as the edge of a smoothly-ground cataract-glass of one inch focus. No attachments could be seen, and it was evident that none passed through the pupil, which was somewhat contracted. There was no injection of the eye, but she had a constant sense of nausea and discomfort. Vision was indistinct ; but on trial with cataract-glasses, I found she could read with a lens of two inches focus. As the sight of the other eye was imperfect, I examined this also, and observed marked tremulous- ness of the iris, as seen after the lens has been removed byi an operation for cataract. I at once suspected that displacement of the lens had occurred in this eye also, — as, although I could not see it floating in the posterior chamber, there was an appearance at the lower part of the iris as if some body were lying there, and were impelled against it as the globe moved in various directions. On test- ing this eye with cataract-glasses, she saw perfectly. Causing her to lie down on her back upon a couch, with the eyes closed, the right lens soon slipped back through the pupil, and became invisible in the posterior chamber. She now saw distinctly with a glass of half an inch less focus than that which suited the left eye, using for reading two inches, and for distant vision four inches radius. 142 DISEASES OF THE EYE. I repeatedly saw this patient when the lens had slipped into the anterior chamber of the right eye ; and in December, 1854, I exhibited her in this condition to the Boston Society for Medical Im- provement. On one occasion, the presence of the lens in the anterior chamber caused so much irrita- tion that the pupil contracted strongly, and the lens could not recede till atropia had been employed to dilate it. Quite recently another case of double spontaneous dislocation has been reported, as observed by Pro- fessor Arlt, of Vienna ; where he found it necessary to extract the lens from one eye. I have also seen the lens displaced by a blow upon the eye, without losing its transparency, the patient seeing tolerably well when stooping forward or when lying on his back ; but losing all distinct vision as he brought his head to an upright position, when the lens could be observed to fall backward with a hinge- like motion, as if its suspensory attachments remained unsevered at the lower edge. Most often, however, the lens becomes opaque after these accidents ; either from interruption of its nutri- tion or from rupture of the capsule. If no irritation is caused by the displaced mass, it may be left to itself, and, in cases where the capsule has been torn, will become absorbed ; but if it excites inflammatory action, especially when it has been thrown into the anterior chamber or fixed in the CONGENITAL CATAEACT. 143 distended pupil, it shotdd be extracted. When pressing on the iris from behind, and thus causing serious- symptoms, relief may often be given and ab- sorption hastened, by division with a cataract needle. When protruded through a rupture of the scle- rotica, and lying beneath the conjunctiva, it should be extracted, the incision for its removal being at a distance from the wound of the sclerotic coat. CATAEACT. This term should be limited to opacity of the crystalline lens or its capsule, — excluding all those deposits of lymph occupying the field of the pupil which were formerly designated false cataract, and all opacities having their seat in the vitreous mass or the posterior parts of the eye. This afiection assumes a variety of forms under different circum- stances, and should be described under several heads. CONGENITAL CATAEACT. This form of cataract, although most frequently existing from birth, is sometimes developed at a later period, even after the age of puberty. But whether existing in infancy or observed afterward, the appear- ances are the same, and are quite different from those characterizing the cataracts of elderly persons. The lens shows a grayish or bluish-white opacity, some- times perfectly uniform, like milk diluted with water, 144 DISEASES OF THE EYE. in other cases mottled with specks of a chalky white. Radii are rarely seen ; but a more dense nucleus is sometimes observed, through translucent cortical lay- ers of the lens. In a certain number of cases, the opacity occupies at first only the centre of the lens, and allows of fairly distinct vision when the pupil is dilated, appearing in these instances as if the lens were but imperfectly developed. This appearance is, however, deceptive, and the entire lens usually be- comes cloudy as the child approaches puberty. Where blindness has existed from birth, it is us- ually accompanied with much oscillation of the globe, in irregular movements, — the patient never having learned to control the direction of the eyes, from having been unable to fix them upon objects. Causes. — Hereditary predisposition is a not unfre- quent cause of this form of cataract, — which may affect several members of the same family. I have seen an instance where seven individuals of one fam- ily had cataract ; — at another time I operated in one day upon the six eyes of three children in a family where yet another child and the mother were also affected, — two other children remaining thus far exempt. The result was perfectly successful in all the eyes operated on. The cases of the mother and youngest child are equally favorable, but the opera- tion has been postponed, for their convenience. I have operated in a number of other instances on two or three cases in the same family. But, though fre- COHGENITAL CATARACT. 145 quently hereditary, the disease is by no means neces- sarily so. Prognosis. — As in all other forms of cataract, the removal of the lens is the only radical cure ; though in a few cases, where the opacity is central only, atropia will greatly increase the amount of vision. In such cases it may be used as a temporary pallia- tive ; or, if the amount of vision conferred by its aid is sufficient for the patient's purposes, it may be employed for an indefinite period instead of resorting to an operation. The operation is, however, far from formidable, and almost invariably successfiil. I have never, except in two instances, seen more than very transient irritation as a consequence of this operation, and in those the symptoms subsided without bad results. Operation. — The pupil should be previously dilated by the use of atropia, and if the patient is a young child, ether should be administered to secure immo- bility of the eye. He may then be laid upon a table near a window, and supported by pillows, in such a position that the light may fall fayorably upon the eye. The surgeon should stand behind the patient's head, and elevate the upper lid with the forefinger of one hand, while the other hand holds the instrument. An assistant may depress the lower lid with one finger ; but the operator does not absolutely need the services of an aid. Should the eye oscillate to a troublesome degree, it may be controlled by seizing the conjunc- 146 DISEASES OF THE EYE. tiva with fine forceps, ivliicli may be held by tlie same hand which raises the hd. The operation may be performed through the cornea or sclerotica. Operation through the Cornea. — A very fine needle is introduced through the cornea, at a point midway between its edge and centre, and the anterior capsule is then incised or fi"eely lacerated, and the lenticular substance divided to a greater or less extent, accord- ing to the judgment of the operator. If but a small opening be made in the capsule, and the centre of the lens broken up by a drUHng movement, the risk of irritation of the iris by pressure of fragments of the lens against it is much less than when the whole mass of the lens is at once divided. Even should the operation require to be repeated, this may be done with Kttle danger, as the bulk of the lens will have become diminished by partial absorption. The division of the capsule allowing the aqueous humor to act on the lenticular substance, the first effect is the expansion of the latter, as it imbibes the' fluid. Until absorption can have made some progress, the swollen firagments may exert dangerous pressure upon the iris ; a fact which should be borne in mind by the surgeon during the performance of the opera- tion. Some authorities advise that no attempt should be made to completely divide the lens or its capsule, so as to obtain absorption as the result of a single operation; but prefer to repeat it several times if CONGENITAL CATARACT. 147 necessary. It is seldom, however, that this is con- venient for the friends of the patient, who often come from a distance to obtain skilful advice. In such cases we may often resort to a method of operating which is more certain to effect complete removal of the lens, without requiring to be repeated, than the method by division through the cornea; though it is not to be denied that the risk of at least temporary irritation is somewhat enhanced. Operation through the Sclerotica. — As in the opera- tion through the cornea, a very fine needle is to be employed. It is to be introduced through the scle- rotica, about a line from the margin of the cornea, and its point carried over the upper edge of the lens and brought to the centre of the pupil. The needle is then to be carried backward, so as to divide the lens and capsule. This movement may be repeated, so as to separate the lens into smaller fragments, and these should be placed in such a position that the iris shall not be pressed upon, or some of them may even be pushed with the point of the needle into the ante- rior chamber. Treatment after Operation. — After either operation the room should be somewhat darkened, and the eyes kept under the influence of atropia. No bandage or covering for the eyes is necessary, the exclusion of light from the room being a sufficient precaution against inflammatory action. Compresses wet with cold water may be laid over the eye if much pain is 148 DISEASES OF THE EYE. complained of. As in otlier soft cataracts, nausea and vomiting are sometimes felt, for a few hours only. Where the patient has attained a reasonable age, ether may be dispensed with, — as the actual pain attending the operation is insignificant. The patient may sit or recline. If sitting, the surgeon may stand behind him, supporting his head, and raising the upper lid with the hand not required for the opera- tion, — or the lid may be raised by an assistant standing behind the patient, whilst the surgeon sits in front, and depresses the lower lid with one hand, while he operates with the other. The surgeon should acquire the requisite skill to enable him to operate with either the right or left hand. He may thus conveniently operate on one eye with his right and on the other with his left hand, without changing his position. Time requisite for Absorption. — The time required for absorption varies from a few days to as many months, in proportion to the vigor of the patient, the softness of the lens, and the extent to which it is broken up. The process goes on slowly at first, but afterward, when softenilig and disintegration of the masses has commenced, more and more rapidly. Congenital cataracts are softer than those met with in advanced life, except when these latter have resulted from traumatic injury. TRAUMATIC CATAKACT. 149 TRAUMATIC CATARACT. This may be occasioned by any wound of the cap- sule of the lens, allowing the aqueous to penetrate to its substance ; or by smart blows upon the eye, rup- turing the capsule or separating its suspensory attach- ments. As I have already stated, I met with two instances from one small town, where a blow from the knot at the end of a whip-lash, received in crack- ing a whip, had caused traumatic opacity of the lens. When following puncture or rupture of the capsule, lenticular cloudiness soon begins to exhibit itself; but when occasioned by detachment of the suspen- sory ligament, and the probable interruption of perfect nutrition of the lens, it may come on at a much later period, often several months, and even years, after the injury. The most remarkable in- stance I have known of tardy manifestation of this pathological change, I have mentioned in speaking of traumatic injuries of the eye. It occurred in a girl who was accidentally hit in the eye with a stone thrown by a boy. I found but a small wound of the conjunctiva ; but from the direction in which the blow was received, I felt sure that severe concussion of the eyeball must have attended it, and stated to her parents my apprehensions that cataract might subse- quently result. But, as many months passed by with no appearance of morbid change, I told her friends that I regarded the danger as past. Eight years 150 DISEASES OF THE EYE. after, nothing having happened to the eye in the mean time, cataract exhibited itself, and after waiting some two years longer it was successfiilly removed. Traumatic cataract has a uniform slightly bluish- white tint, like that of milk largely diluted with water, — so long as the lens remains undissolved; but, when this has become absorbed, the capsule, if it remain suspended beliind the pupU, may have the appearance of a thin gauze merely, or it may form a dense yellowish mass, or even undergo cretaceous degeneration. Often it is so extremely thin that it is only to be detected on most careful examination, — the pupU, at first sight, appearing to be perfectly clear. Treatment. — When the capsule has been exten- sively torn by a sharp body or by concussion, the lens is often absorbed by the aqueous humor, without a necessity for any operation ; and it is well to delay interference if we have reason to think this may be the case, keeping the pupil dilated if the iris seems to be pressed upon injuriously. Operation. — The pupil should be dilated by means of atropia, before the operation. Ether may be given if the patient is a child, or is very timid. As traumatic cataract is invariably quite soft (ex- cept in cases where the lens has already been absorbed, and only tiie toughened capsule remains), we may generally operate with safety for its complete removal at a single sitting. This may be done through the TRAUMATIC CATARACT. 151 coniea or sclerotica. If done through the cornea, care must be taken to divide the posterior as well as the anterior capsule ; otherwise there is danger that the masses of lenticular substance, confined be- tween the posterior capsule and the iris, may make destructive pressure on the latter membrane. When done through the sclerotica, thorough division of the entire lens and capsule may be accomplished, and the pieces disposed of in such a manner that no harm shall result from their expansion. The pupil is to be kept fully dilated by atropia until the frag- ments of lens are so far absorbed as not to press upon the iris. The operative manoeuvres are the same as directed for congenital cataract, and their description need not be repeated here. Removal of Portions of Capsule. — Should a portion of capsule be the only remaining obstruction to vision, it may often be sufficiently torn by a fine needle introduced through the sclerotica or cornea. When this is difficult, from its toughness and elasticity, two fine needles may be inserted at dififerent places in the cornea, and their points being passed through the centre of the capsule, are then to be separated so as to tear it. The minute canula forceps of recent in- vention also offers an excellent means for removing these elastic and other more dense obstructions from the field of the pupil. A puncture is made in the cornea, near its outer margin, with a broad cataract- needle ; or, if required, a larger opening may be 152 DISEASES OF THE EYE. made with a comea-knife. Tlu'ough this the for- ceps is inserted, being kept closed by pressure of the thumb on the trigger, till it reaches the capsule. Pressure is then relaxed, the capsule seized between the toothed branches of the instrument, which are again closed together by a movement of the thumb, and the opaque membrane is withdrawn in its grasp. After this operation a fresh secretion of aqueous humor refills tlie anterior chamber, and the wound of the cornea readily heals. As no very sensitive parts are touched, we seldom have an unpleasant symptom subsequently to the operation. It is neces- sary to be careful, however, that no shred of capsule is left entangled in the hps of the wound and at the same time undetached from its posterior adhesions, as in such case it would press upon the edge of the pupil as soon as the influence of the atropia was sus- pended. Nor should any minute portion, even if detached posteriorly, be left in the corneal wound ; as union is thereby prevented. The patient should be secluded from light, and kept quiet ; but no ap- plications to the eye are necessary unless pain should supervene. COMMON LENTICULAR CATARACT. Except when resulting from traumatic mjury, or having the form which has been described under the head of Congenital Cataract, opacity of the lens is generally met with in persons who have passed the HARD AND SOFT CATAEACT. 153 middle period of life. The morbid change is usually in the lens only, the capsule not being impUcated, as was formerly believed to be frequently the case. Both eyes are sooner or later affected, and usually within a few months, or at most a few years, of each other, though I have seen an instance where more than twenty years intervened between the formation of cataract in the first and the second eye. Sard or Nuclear, and Soft or Cortical Forms of Cataract. — Two important divisions are recognized, — hard and soft cataract. In the former, the opacity begins in the nucleus of the lens, and gradually dif- fiises itself through its whole substance ; in soft cata- ract, the cortical layers are first affected, generally in radiating lines, by which the lens is divided into segments which may retain transparency for a con- siderable time. These divisions are not merely in- teresting as regards diagnosis ; but, as we shall see, they have an importance as regards treatment. Causes. — On referring to my notes of several hundreds of cases in which I have operated, I find that in nearly half, the patients were aware that cata- ract had appeared in one or more members of their family, on either the father's or mother's side. Be- yond this hereditary predisposition, I am not aware that any cause can be named as especially active in producing the disease. Persons of every condition, temperament, and occupation seem alike liable to it. Diabetes is often accompanied by cataract; and the 7* 154 DISEASES OF THE EYE. fact that opacity of the lens may be produced, as a temporary condition, in frogs and some other animals, by injection of a solution of sugar into the cellular tissue beneath the skm, — and that this opacity may disappear again, — in connection with the frequent presence of cataract in diabetic patients, is well wortliy of attention ; as it afFords a glimpse of hope that care- ful research and inquiry may some day further eluci- date the pathology of cataract, and possibly enable us to employ other than surgical means for its removal. The precise nature of the changes which consti- tute this disease of the lens is imperfectly understood. Perhaps some interference with the nutrition of the lens, occasioning alterations of its structure analogous to atheromatous degeneration of the blood-vessels in other parts of the body, is the most probable expla- nation. Symptoms. — Patients afflicted with cataract have a different bearing from those suffering from blindness from other causes. They have still, except in the advanced stages, a degree of vision in a subdued light, — and we see them shading the eyes by bend- ing the head, or by a visor or some similar protection, and endeavoring to find their way and to discern objects ; whilst those totally blind from other disease usually carry the body and head erect, and have little of the groping aspect of those attempting to see. The loss of vision is generally gradual, the patient complaining that objects seem enveloped in fog, or. CATARACT : SYMPTOMS. 155 especially while the opacity is still limited to some cortical radii, that objects are multiplied or distorted. Where the opacity is nuclear, the patient generally sees much better at twilight or in a cloudy day, and in such cases we may employ atropia with great advantage, as a palHative, to increase the amount of vision, whUe we await a proper or convenient time for the performance of an operation. In fact, bella- donna is frequently used by charlatans to impose upon patients, — who are assured that a radical cure has been effected, when, in fact, the pupil has merely been dilated. The influence of the belladonna is continued, by repeated applications, till the itinerant charlatan has time to open the patient's purse and to take his own departure ; after which the eye is per- haps left to itself, or, if dilatation of the pupil is kept up, the gradual extension of the opacity towards the circumference of the lens renders this dilatation no longer a benefit to vision. No pain attends the formation of cataract ; any sen- sations which may be felt being due to other causes. On examining the eye, we find various degrees of opacity of the pupil. Now and then, even when vision has become materially diminished, the cloudi- ness of the lens is so slight that it can scarcely be perceived even after dilatation of the pupil. In such cases a magnifying lens will sometimes disclose it, or it may be detected by concentrating an increased amount of light upon the field of the pupil by means 156 DISEASES OF THE EYE. of a lens of moderate power. The ophthalmoscope affords another and very efficient means of detecting shght opacities. Ordinarily, however, when the dis- ease has made such progress as to lead the patient to apply for advice, we can perceive the opacity, on close inspection, without artificial aid, especially if we dilate the pupil. In the harder forms of cataract the opacity shows itself as a uniform grayish or amber cloudiness of the nucleus of the lens, gradually shading off towards the circumference, and without distinct radii. The space between the edge of the pupil and the opacity seems considerable, and a shadow is thrown by the iris upon the clouded lens. The pupil dilates and contracts as in a healthy eye. When the disease assumes the character of what we term soft cataract, the cloudiness commences, as a rule, at the periphery of the lens, or in its anterior or posterior cortical layers, extending in radiating lines, and leaving the intervening spaces nearly or wholly free from obscux'ity. In the incipient stages we often see only small dots of opacity, which are afterward to extend themselves to lines converging to the centre. Convex radii on the anterior, and concave in the posterior cortical portions may fre- quently be seen, the central nucleus remaining for a time transparent. In these instances patients may have tolerable vision, even for years from the time of the evident commencement of the pathological CATABACT ■- PEOGNOSIS. 157 change. These appeai'ances were once erroneously supposed to have their seat in the anterior and pos- terior capsule. As the disease progresses, the por- tions between the radii become altered, and the lens acquires a cream-colored or grayish, and sometimes pearly aspect, with or without a persistence of the radiating lines. A very uniform light color, with occasionally an irregularly turbid appearance, some- times marks a fluid cataract, so thin in consistence that I have seen it flow into the anterior chamber in a milky jet upon opening the capsule. A mottled appearance is sometimes exhibited in other forms of .soft cataract, certain spots showing a clearer white than the rest of the mass. Progywsis. — In cases of cataract having other than a traumatic origin we must regard the disease as likely to be developed sooner or later in both eyes. How soon after the failure of one eye the other may become affected, we cannot certainly predict; nor are we able, on a single inspection, to pronounce on the probable rapidity of the morbid change, after the disease has declared itself. It is common to observe a very slow development during the earlier stages, with a comparatively sudden failure of sight and rap- idly increased opacity after the affection has reached a certain point. So far as the results of operation are concerned, the prognosis is very favorable ; failure, in skiliul hands, being an exception to the general rule. 158 DISEASES OF THE EYE. T)-eatmmt. — I have referred to the palliative use of atropia in certain cases of cataract. Where tlie patient derives increased sight from enlargement of the pupil he may be supplied with a solution of sulphate of atropia of from two to five grains to the ounce of water, of which he may have a drop applied every day to the inside of the lower hd with a small camel's-hair pencil. This may be continued until, with the advance of the disease, relief is no longer derived from its use. Convex, and in some rare instances concave, glasses ai'e of matei'ial service in a proportion of cases of incipient cataract. The temporary advan- tage derived by the patient from such auxiliaries is at times quite a matter of surprise ; and there is no objection to their use during the short time that they continue to be of service. But all these means of transient relief have no influence in retarding or removing the disease ; — for a radical cure an operation is our sole resource. Charlatans have always assumed to be able to rid patients of their infirmity by other treatment ; but, at the Ophthalmic Congress held some years since at Brussels, the testimony was unanimous that not a single instance of successful cure other than by surgical interference had been authenticated. Cases have occurred, to be sure, where cataract has fkllen from its suspensory attachments or been displaced by a blow; but these events are beyond the hmits of CATARACT : TIME FOE OPERATING. 159 expectation, and, so far as they go, confirm the pro- priety of operation. Season for Operating. — As regards the proper time for operating, and the maturity the disease should be allowed to reach, our practice must vary with circum- stances. In America, any season of the year, except during the extreme heats of summer, seems equally favorable, though it is well to avoid operating when a long storm is present, or seems to be impending. Much more stress than its importance deserved was formerly laid upon the ripeness, as it was termed, of cataract. But it is desirable that the disease should be well advanced before an operation is performed, as the patient then becomes satisfied of the hopeless- ness of his condition unless relieved by skilful treat- ment, and is likely to be more tractable and to follow any instructions laid down for him with im- phcit care. As a rule, one eye should not be oper- ated on so long as the other exhibits no sign of dis- ease ; but, as the development of cataract in the second eye within a brief period may be considered inevitable, we are justified in operating without wait- ing for its appearance in this eye, provided the patient is about to go to a great distance, where- he will not at a future time be within reach of skilful aid. When both eyes are evidently affected, the operation may be delayed till vision is almost entirely lost, — and may then be performed on both at the same time, — if judged expedient. But generally the convenience 160 DISEASES OF THE El-E. or necessities of the patient -will reqviire that one eye should be operated on while the other fs but partially obscured. If, in tliis case, some time should be re- quired for the removal of the lens by absorption after an operation by division, the individual has in the mean time the use of the other eye, and, if the result of the first operation is success, he is relieved from his infirmity, and restored to usefulness without having undergone the penance of watching the slow approach of total bhndness wliile waiting for the dis- ease to reach its climax in the second eye. Preparation for the Operation. — The nearer the condition of the patient approaches the standard of health, the better is his chance of a successful result fi-om the operation. If previously well, he should continue in his usual habits, without being subjected to any special preparation. If debilitated, or if ex/- ceedingly plethoric, it may be desirable to fortify or to reduce his general system previous to operating. Clioice of Method. — Several modes of operation are adapted to the difierent forms of cataract. If the lens is so soft as to allow of its being readily absorbed after division, this operation — or that which is termed linear extraction, i. e. extraction through a small opening in the cornea — is by far the safest method. If harder, it may be displaced by reclination, or ex- tracted from the eye. The latter is the most scien- tific mode of procedure, and in the hands of skilful operators gives the best result ; for, though unques- OPEEATIONS FOE CATAEACT. 16l tionably more difficult of execution than mere recli- nation, yet the flap of the cornea reunited, all danger is at an end ; whereas, after reclination, or, as it is also termed, couching, there is for a considerable time a chance of reascension of the lens, or of its causing serious inflammation by pressure on the parts to the vicinity of which it has been displaced. As a general rule, then, we should prefer extraction in cases of nuclear cataract, — resorting to the operation by couching only in exceptional cases, or where some special contra indication for extraction is observed in the patient. Position during Operation. — Operators are not agreed as to the best position for the patient in opera- tions for cataract. English surgeons, in many in- stances, prefer the recumbent position, while on the Continent the sitting posture is more in favor. In public institutions, where everything can be arranged so as to afford the most favorable light, and the utmost convenience to the operator, the recumbent position is perhaps the most desirable. In private practice, where arrangements must be made extempore, it is easier to place a patient in a good hght when seated, than if upon a couch. This position also seems less formidable to the patient. If seated, the chair occupied by the patient should be so low that his head may be nearly on a level with the breast of the surgeon. His hands should clasp the sides of his chair, that he may the better resist 162 DISEASES OF THE EYE. any impulse to raise them. His head should be supported by the assistant, who stands behmd him •vvitli one foot thrown backward so as to give a fii'm support in case the patient should start. One hand of the assistant should be placed under the patient's chin, and with the first and second fingers of the other he is to raise the upper lid of the eye to be operated on. If the right eye, the left hand should be employed to raise the lid ; if the left eye, the right hand should be made use of; as thus the other fingers of the hand are less in the surgeon's way. When the patient still enjoys vision with the other eye, it should be bandaged previous to the operation, that its movements may not involve motion of the eye to be operated on. The pupil should have been previously enlarged by atropia. Operation hy Division Uirough the Cornea. — When tolerable sight remains in the other eye, we may operate by simple division of the capsule, allowing the lens to be slowly dissolved by the action of the aqueous humor ; without incurring the risk of too great swelhng of the fi'agments, which sometimes attends free division of the entire lens. In this method, a very fine needle, held in the same position as a writing-pen, between the thumb and fingers, is passed through the cornea, midway between its centre and edge, and tlie capsule is to be opened by one or two small scratches with the point of the needle. If thought prudent, the lens may also be CATABACT : OPERATION BY DIVISION. 163 divided to a certain extent, and its absorption thus facilitated. Where the lens proves to be very soft, and therefore likely to swell upon imbibition of the aqueous humor, the needle may be carelully passed through the lens to lacerate the posterior capsule, so, as to allow of expansion in this direction, and avoid the danger arising from confinement of the swollen lens between the posterior capsule and the iris. After the bulk of the crystalline has been reduced by the absorption resulting from this operation, a second and more complete division of both lens and capsule may be made, through the cornea or scle- rotica ; provided the process of absorption seems to be suspended, or goes on too slowly for the patient's convenience, thus rendering a second operation ad- visable. Division through the Sclerotica. — When division is performed through the sclerotica, the needle, held as before directed, is to be introduced about a hue from the margin of the cornea, and brought over the lens into the field of the pupil, taking care to pass it between the iris and the anterior capsule, and not inside the capsule. Its cutting edge is then to be used for free division of the lens and its enveloping membrane. The larger fragments are to be carried away from contact with the iris ; and if convenient some of them may be pushed into the anterior chamber. The operation through the cornea is ab- solutely painless, and that through the sclerotica is 161 DISEASES OF THE EYE. usually no more painAil than the prick of a needle upon the skin. Treatment after Operation. — The eyes should be kept closed, and generally a bandage should be worn after the operation. So long as any danger of press- ure upon the iris may be thought to exist, the pupil should be kept under the influence of atropia. The light in the apartment should be moderated. After free division of the lens, tlie patient is often scarcely conscious that any change has been effected in the condition of his eye. In other exactly similar cases, and from no apparent cause, severe pain in the eye and head, with excessive nausea and vomiting, comes on in a few hours after the operation. This seems little amenable to treatment ; large opiates or otlier remedies having scarcely any influence in relieving it ; but it seldom continues more than twenty-four or thirty hours. The patient should be told, after the operation, that this may possibly hap- pen, and assured that it need not cause any anxiety as to the favorable progress of his eye, and will be but a temporary suffering. Without this forewarn- ing, he might become much alarmed should the symptoms occur. Operation hy Linear Extraction. — This operation is, in fact, a combination of division and extraction. The lens is first divided with a fine needle, introduced through the cornea. The corneal wound is then enlarged with a broad needle, or a cornea-knife, and CATAEACT : OPERATION BY DECLINATION. 165 the lenticular fragments are removed through this opening, which should not exceed two lines in length, by means of a small scoop or curette. The posterior capsule should not he disturbed and often retains its transparency. When it does not continue clear, it may be subsequently removed by the aid of canula forceps. This is an excellent mode of removing very soft cataracts. Operations for Sard Cataract. — When the lens has such a degree of hardness that its division could not be easily effected, — or, if accomplished, a long time would be required for absorption of the fragments, — operations by extraction or reclination are to be pre- ferred. Operation hy Reclination or Couching. — The pupil should be well dilated by atropia before the opera- tion. A slightly-curved, lance-headed needle, some- what larger than that used for division, is best adapted for this method. In all operations with the needle, the instrument is to be held like a pen between the thumb and the first and second fingers, and should not be tightly grasped. The third and fourth fingers, or the fourth alone, should, if the patient is in a sitting posture, be fixed on the malar prominence, and give support to the hand, which, resting thus on the cheek of the patient, follows any slight movement of his head. The surgeon should never support his hand by resting his elbow upon his own or the patient's knee. All lightness of touch 166 DISEASES OF THE ETE. would thus be sacrificed, and a slight motion might have fatal consequences to the eye. It should be passed tlu-ough the sclerotica, its convex surfece up- ward, at the distance of a line from the cornea; its point being directed towards the centre of the globe, that the iris may not be wounded should the patient suddenly move his eye. The posterior capsule may now be lacerated to fecilitate the displacement. The needle is then to be turned one quarter on its axis, so as to bring the convex surface of its head parallel with the iris. In this position it is to be brought over and ia front of the lens, taking care that it shall pass before and not within the anterior capsule. Instead of turning the edge of the needle towards the crystal- line, as when we propose to divide the cataract, press- ure is made against the lens at about its centre, with the slightly concave surface of the head of the needle, and it is thus carried downward and backward towards the lower and outer part of the globe. The needle should retain its position for a few sec- onds, till the lens has become sufficiently covered by portions of the vitreous to prevent its reascension. It is then to be disengaged by a slight rotatory move- ment, and withdrawn from the eye in the same position as that in which it was introduced, i. e. with its convex face upwai-d. The dots on the handle of the instrument indicate the position of its head when this cannot be seen within tlie globe. Care should be taken that the needle is not placed CATAEACT : OPERATION BY EECLINATION. 167 SO much above or below the horizontal diameter of the lens that this shall be tilted forward into the anterior chamber. We should also be sure that the lens is carried so far from the iris and ciliary processes that pressure shall not be made upon them in case expansion of the crystalline should take place. Nor, on the other hand, must it be pressed hard upon the retina, as serious injury of this delicate structure must ensue. If the patient has been seated during the opera- tion, it is well for him to remain so for some hours, if he is comfortable. When he lies down he must not stoop in undressing, but should be carefully assisted. He should sit upon the edge of the bed and he down backward, the hand of a friend or nurse supporting his shoulder, without turning his face downward ; as it is important to avoid incurring the possible chance of reascension of the lens. The Hds do not require to be confined by strips of plaster ; but the patient should be directed to keep his eyes closed, and they should be covered with a dry compress and light bandage. The room should be darkened, and the pupil kept under the influence of atropia. After a few days, if all goes on well, the patient may be allowed more hberty ; but he should remain in a subdued light, and wear a shade for some little time after all injection and sensitiveness have disappeared. Should severe pain come on at any time after the operation, cold wet 168 DISEASES OF THE EYE. compresses, fi-equently changed, may be laid upon the lid, a purgative given, and a few leeches applied to the temple. The operation of couching is most applicable to those cases where the eyes are so deep set that extraction is difficult of execution, and to those where we have reason to suspect, from the tremu- lousness of the iris, that the vitreous is abnormally fluid and might escape from the eye should the cornea be opened. The first of tliese diflficidties may, however, be surmounted by seizing the con- junctiva, including the sub-conjunctival cellular tis- sue, with forceps, and holding the globe in a position which allows section of the cornea to be made with more facility. This operation often gives a very flattering imme- diate result, — the patient at once recovering vision ; and were it not for tlie after effects sometimes ensuing, it would be the sole method employed, as being most easy of execution. But the presence of so large a mass, acting almost as a foreign body, in a part of the globe where slight displacement may bring it into contact with most sensitive structures and excite destructive inflammation, constitutes a source of so much danger, that tliis method is sel- dom employed by skilful operators. But in un- practised hands, I believe this method, with all its defects, will result in fewer failures than the opera- tion by extraction, which requires a nicer delicacy CATAEACT: OPERATION BY EXTRACTION. 169 of manipulation. Where, therefore, a patient is not able to leave his home, but must place himself under the care of surgeons of small experience, this opera- tion may be selected, and when carefully performed, offers a very good chance of a fortunate result. Operation hy Extraction. — The position of the patient may be either sitting or lying, as the sur- geon may prefer. If sitting, the same rules are to be observed, as regards the position of the patient and the surgeon's assistant, as have been given for the operation by reclination. The assistant should raise the lid by alternate traction with the first and second fingers, so as to include all the folds of skin ; otherwise, if only the edge of the Hd is secured, there may be inversion of the tarsal cartilage, as the patient contracts the orbicularis muscle, which will bring the everted lid into contact with the knife. The eye- lashes should be brought to the supra-orbital ridge, where being retained by the finger, they assist in securing the lid in a proper position. The aid should be careful to make no pressure on the globe, unless at the express desire of the surgeon. Seated in front of his patient, the surgeon de- presses the lower lid with a finger of one hand, and holds the instrument as he would a writing-pen, be- tween the thumb and two fingers of the other. The other fingers rest upon the malar prominence, and give support to the hand. These should remain fixed, all movements of the knife being executed by 8 170 DISEASES OF THE EYE. extension and flexion of tlie other fingers. It is desirable that tlie surgeon should be ambidexter, ca- pable of operating with his right hand on the left and his left hand on tlie right eye. Should the patient bo unsteady, so that he cannot keep his eye fixedly in the direction required by the surgeon, — or in case he has been deprived of volun- tary control of it by tlie influence of anaesthetics, — it should be held in a proper position by seisdng a fold of conjunctiva and the subjacent tissue witli artery forceps. By their means, the aid may keep the globe perfectly steady, very greatly facilitating the section of the cornea. He should be ready in- stantly to relax his hold on a signal or request from the surgeon. The knife should be held parallel to the cornea, and before inserting its point it should be cai'ried across in front of the eye, that the operator may be sure that his fingers are so placed as to allow of the completion of the incision of the cornea by a movement of simple extension of those fingers, with- out moving from the support on tlie cheek. The knife has a triangular form, adapting it for cutting when merely pushed forwards. The cornea may be divided upwards or down- wai'ds. The lower section has the advantage of being more easy of execution, — as the natural ten- dency of tlie eye to roll upwards fa\ors the accom- plishment of the incision. Its disadvantages are, that after the operation the edge of the lower lid is CATARACT : OPERATION BY EXTRACTION. 171 more likely to insinuate itself beneath the flap of the wound and disturb the healing process, — and that hernia of the iris can more readily occur. The in- cision upwards is more difficult ; but when effected, the wound is covered by the upper lid, which by a slight pressure tends to keep its edges in apposition. The lid is not in a position to disturb the wound, and there is somewhat less risk of prolapse of the iris or vitreous humor. The instrument is to penetrate the cornea near its edge, and in the line of its horizontal diameter ; its point being turned slightly towards the iris till the anterior chamber is entered, that it may not glide between the corneal laminae. It is then to be pushed quickly but very steadily forward, the blade parallel with the iris, and counter puncture made at the op- posite point of the diameter. The incision is to be completed by continuing to push forward the knife ; but the last fibres of the upper edge of the cornea should be very cautiously divided, especially in case any spasmodic contraction of the muscles should be perceived by the operator ; otherwise there is danger that not only the lens but a large portion of the vitreous may be expelled from the eye. Should the spasmodic action be excessive, the knife may be with- drawn previous to division of these fibres, and the lids allowed to close for a few moments, after which the incision may be finished with a narrow, probe- pointed knife. 172 DISEASES OF THE EYE. In making the incision, great steadiness is required to prevent the escape of the aqueous humor by the side of the knife, as, if this occurs, the iris falls in front of the edge of the instrument. Should this happen, efforts must be made to disengage the knife ; but if these fall, and but a small portion of iris is implicated, the section of the cornea may be com- pleted, even should the iris be wounded or excised to a limited extent. If too much of the iris is involved, it is better to withdraw the triangular knife, and sub- stitute a narrow, probe-pointed one for finishing the flap. If the patient is agitated, lie may be allowed a brief repose before proceeding to the second part of the operation. A cataract-needle, or a small hook designed for this purpose, is to be placed with its shaft across the wound, and slid in this position till it reaches the diameter of the pupil. It is then to be slightly with- drawn, its point carried through the pupil, and the anterior capsule freely divided by crucial incision. This second step accomplished, the lens often slips through the pupil, and presents itself at the corneal wound, without any pressure having been employed. If it does not, gentle pressure may be made on the globe, below or above the cornea, by the finger or a curette. Should the lens be arrested in its transit through the pupil or the corneal incision, it may be assisted by the curette, or by the needle which us- ually is placed at the other end of the same handle, CATARACT : OPERATION BY EXTRACTION. 173 — all haste being avoided, and every movement of the operation executed with the greatest delicacy. The aid now closes the lid, taking care to lift it as it were over the flap of the cornea. The patient should be told to keep the lids quietly shut, as if asleep. After a few- moments, if all has gone on favorably, he may be turned away from the light and allowed to open his eye and distinguish some object. This is for him an assurance of success, and renders him more content during the days when the eyes must be kept under restraint. The lids are then to be secured, in both eyes, by narrow strips of court- plaster extending across the lids in oblique directions. If no pain or swelling of the lid comes on, it is proper not to disturb these strips for four or five days, at the end of which time the wound has generally united. But even when we find this to be the case, it is well to reapply them for two or three days longer. Should any severe circum-orbital pain be complained of, or much swelling of the globe or in- creased secretion be observed, — it is best to remove the adhesive strips and examine the condition of the wound at an earlier period than when we have reason to believe that all is going on well. Should any of the vitreous humor escape during the operation, the surgeon and his assistant must not allow themselves to be disconcerted and act precip- itately ; but the lids should be carefully closed, and remain thus till all spasmodic action has subsided. 17-i DISEASES OF THE EYE. If any portion of vitreous then protrudes between the lips of the wound of the cornea, no effort should be made to return it, but it should be excised with sharp scissors, without seizing it with forceps or em- ploying the curette, as, if these are made use of, there is danger that a still larger portion may be dragged forth. This accident should be carefully guarded against, as the presence of vitreous humor in the field of the pupil or the corneal wound is liable to interfere with the all-important process of immediate union. But though in appearance so hopeless a mis- fortune, the loss of a large amount, — even as much as one third of the vitreous mass, — may occur, with- out seriously affecting the amount of vision. If the patient can sleep on his back, with his head somewhat raised, this is the best position. He should have been divested of some of his clothing previ- ously to the operation, and in being undressed must have the aid of others. He must not stoop forward on any account. A dry compress and light bandage may be placed over his eyes, and his room should be darkened. An opiate may often be given at night with advantage. Should there be reason to ■ fear that he may touch or rub his eyes during sleep, he should be watched by an attendant, or if this cannot be -done, his wrists should be confined by a towel or other easy bandage, which is to be fastened at the sides of the bed, so loosely that he may be able to move his arms, but not to reach his eyes. CATARACT : OPERATION BY EXTRACTION. 175 The after treatment should consist of a continuance of the above-described means, unless urgent symp- toms declare themselves. In this case, compresses constantly wet with cold water should be laid over the eyes, and a few leeches may be applied to the temple, but not too near the eye. When there is reason to fear that hernia of the iris has occurred, the eye should be at once examined, and if present, the hernia should, if possible," be replaced by a probe or curette. When this cannot be done, the protruding portion should be excised by a clip with fine scissors. Opiates may be given when required for the relief of pain. Purgatives are not desirable, as it is important that the patient should be disturbed as little as pos- sible. He may have a moderate diet of articles requiring little mastication. After we have reason to think union of the corneal wound has taken place, the patient may be allowed to sit up, and even to walk about with the assistance of another person. In a few days more the eyes may be opened ; but little light should be admitted for some time longer. Should the surgeon prefer to place the patient to be operated on in the recumbent position, the posi- tions are the same as previously directed for the operation on children affected with congenital cat- aract. The incision and other steps of the operation are to be executed as just described. 176 DISEASES OF THE EYE. CATAKACT-GLASSES. After the loss of the crystalline lens, it is nearly always necessary to compensate for its absence by a cataract-glass of proper focal power. Some persons see large objects with tolerable distinctness without such extraneous aid, but generally, even for them, objects are much more clearly defined on employing a glass of suitable strength. The majority of patients select a lens of four, four and a quarter, or four and a half inches focus, for looking at large objects. Some see very well with a lower number, and some require as high as three and a half or even three inches radius. Another glass is necessary for reading and seeing minute objects, generally from two and a half to two inches focus. Very rarely we meet with an individ- ual who, having previously been very short-sighted, can see, even to read, without assistance irom a glass, after extraction of the crystalline. The glasses for distant objects may be worn at all times. Those for reading or work must never be kept on after these occupations are finished, as eyes may be fatally injured by imprudent use of lenses of very high power, — as, for instance, where these are worn for sewing or knitting, and at the same time the eyes are frequently turned to other objects in the room. As the thickness of these glasses of short focus renders them heavy, and sometimes brings on head- SECONDARY OPERATIONS FOE CATARACT. 177 ache when they are continuously worn, it is well, where only one eye requires a cataract-glass, to insert a plane glass, or one of slight convexity, in the other half of the spectacles. Cataract-glasses should not be given to the patient till the operation has been fully recovered from, and the eye has had time to conform itself to its new con- dition. The patient's vision is then to be carefully tested with glasses of different foci, and that number selected which appears to give him what most nearly approaches natural vision. Too strong a glass should not be allowed, as it frequently causes a sensation of giddiness, and is less agreeable and useful than one of lower power. After a time, if a shorter focus is evidently more serviceable and more grateful to the eye than that first selected, the patient may be per- mitted to exchange the lower for a higher number. If, on the contrary, the eye gains strength, and is able to see equally well with a less power, the change should certainly be made in this direction. SECONDAKT OPERATIONS FOE CATARACT. The capsule of the lens being nearly always trans- parent at the time of an operation for cataract, it sometimes happens that it is not so extensively divided or separated from its suspensory attachments as to allow of its absorption, or of its shrinking upon -itself to a degree which leaves the pupil free from obstruction. Now and then, in these cases, we must 8* I. 178 DISEASES OF THE EYE. make a most critical examination before we are able to detect the slight, gauzy veil which prevents perfect vision. More frequently, the relics of the capsule may be seen with tolerable readiness in the form of a bluish- white membrane or fine whitish filaments. If these cover but certain portions of the pupil, vision may sometimes be rendered sufficient for all purposes by the use of atropia. If not, they may be removed with slight inconvenience or risk. In some instances, their elasticity and toughness render it almost impos- sible to detach or divide them with a cataract-needle, and they require to be torn by the simultaneous use of two needles, or extracted with canula forceps. In many cases, however, a fine needle introduced through the sclerotica readily detaches or cuts these obstacles, and excellent vision is at once regained. After such an operation, the patient should be careful to avoid too much light, or use of his eyes, for a few days ; but no very strict confinement to the house is usually necessary after the first or second day. Where two needles are employed, they are to be directed upon the capsule from different points of the cornea, and the membrane is then to be torn by moving them in opposite directions. Should the can- ula forceps be preferred, a puncture is made near the outer edge of the cornea with a very broad needle. Through this aperture the canula forceps is intro- duced, closed, and the blades being allowed to sep- arate by relaxing the spring of the instmment, the GLAUCOMATOUS CATARACT. 179 membrane is seized. The blades are then brought together by pressure upon the spring, and the capsule is withdrawn in their grasp. Vision is thus' often instantaneously improved. GLAUCOMATOUS CATARACT. A variety of cataract, sometimes mistaken for cat- aracta simplex, often accompanies advanced stages of glaucoma. It may be distinguished by its dirty greenish-white or sea-green color, its apparently large size, pressing forward against a widely-expanded pupil, — and by the evidences of disorganization in other parts of the eye ; such as a diseased aspect of the iris, enlarged, tortuous veins of the sclerotica, stony hardness of the globe, and the absence of per- ception of light. Its true character is also shown by the history of the case, — in most instances com- prising severe pain, which does not attend the for- mation of ordinary cataract. It is needless to say that an operation for cataract can be of no avail when fatal changes have taken place in all the contiguous parts, as in the condi- tion in question. 180 DISEASES OF THE EYE. CHAPTER XI. AITECTIONS OF THE "V^TEEOI^S HTJMOE. SYNCHISIS, OR SOFTENING OP THE VITKEOUS. This condition may exist without serious altera- tion of vision. It is to be suspected when the iris Las a marked tremulous motion to and fro, as if suspended in a considerable amount of fluid. In this case it might be a reason for performing some other operation, rather than extraction, for cataract. The ophthalmoscope discloses, in some of these in- stances, large numbers of minute spots, apparently of organized fibrine, interspersed or not with crystals of cholesterine. These may be visible to tlie patient, giving rise to one form of " muscae voUtantes," on his moving the eye. In other cases, softening of the vitreous is accompanied by other changes in the eye and loss of sight ; the eyeball feeling soft when pressed upon. SPARKLING STNCHISIS. Crystals of cholesterine are sometimes seen in con- siderable quantity in the vitreous, especially where this has been more or less disturbed in operations for cataract with the needle. They float upwai-d as the SPARKLING SYNCHISIS. 181 person moves the eye, and fall to the bottom of the posterior chamber like a shower of gold rain, when the eye is in repose. They can be readily seen with- out the ophthalmoscope. This phenomenon involves a fluid condition of a part at least of the vitreous. No treatment has any effect, so far as I know, to restore an altered vitreous to its natural condi- tion, but the cholesterine" crystals sometimes seem to diminish or disappear after a time. 182 DISEASES OF THE EYE. CHAPTER XII. OPEEATIOXS rOR ARTIFICIAIi PUPIL. This operation is called for when the natural pupil has become closed in consequence of disease or acci- dent, or when it is rendered useless by being covered by large and incurable opacity of tlie cornea. It is not to be advised, however, when the other eye is stiU healthy ; as more embarrassment would arise from the want of harmony in the two eyes, than benefit from the amount of yision obtained in the eye operated on. As necessary conditions to success, the eye must have recovered from any inflammation whicli may have created the necessity for operation, the cornea must be transparent in a sufficiently large space, and the anterior chamber not entirely obliterated. It is desirable also that the eye should be free from evi- dences of disease in other of its parts. The opera- tion should not be too hastily resorted to in cases of opacity of the cornea, for this often improves to a sui-prising extent, if time be allowed for absorption of the cloudy effusion. It is useless to describe all tlie operative proce- dures which have been imagined ; but I shall give OPERATIONS FOE ARTIFICIAL PUPIL. 183 the details of three principal methods, which include provision for almost every circumstance which can arise. The sitting position is preferable, as the patient can be brought near a window so that the light may- fall very favorably, and the surgeon has a rather more delicate command of his own hand and arm than when standing. The surgeon should never, however, support his arm by resting the elbow on his knee, as if he cannot otherwise command per- fect steadiness of hand he should not operate. The patient should, in most cases, be fully under the influence of some ansesthetic. In addition to the aid who is to stand behind the patient and raise the lid, it is well to have one or two other assistants. The lid should be carefully held, and as a precaution it is well, in all operations on the eye, to have the skin of the lid and the fingers of the aid perfectly dry, that no slipping may occur. The other aids should be ready to render any service which may be asked of them, and, if a portion of iris is to be excised, one of them should be prepared with fine scissors to clip off the amount drawn out, instantly, on a signal from the surgeon. The same general rules as to positions are to be followed as have been laid down for operations for cataract. Where the pupil has become closed by a deposit 184 DISEASES OF THE EYE. of IjTiiph or adhesion of capsule, after an operation for cataract, the obstruction may often be removed, and the natural pupil restored, by seizing and with- drawing the foreign substance with canula forceps, or by dividing the adhesions with a cataract-needle. Where this cannot be done without involving risk of a new attack of inflammation, and where the fibres of the iris are put upon the stretch, either by adhesion to the foreign deposit or capsule, or to the cornea, an incision across these fibres gives a very fair result. A very minute knife may be introduced through the cornea or sclerotica, and the iris divided to the required extent by a slight sawing motion. But, unless the tension of the iris has been considerable, its fibres do not retract sufficiently, and the aperture heals. In most cases where an operation is called for, excision of a portion of iris is necessary to secure a permanent opening of the requisite dimensions for vision. In a majority of cases requiring the formation of an artificial pupil the cornea is cloudy over a large extent. We are, therefore, sometimes compelled to make our new aperture wherever the healthy con- dition of the cornea and iris will permit. But where we can elect, the situation to be preferred is towards the lower, or lower and inner part of the cornea ; the rays of light thus Mling most favorably upon the retina. The inner side of the cornea is ne:^ to be chosen, and the outer or upper side to OPERATIONS FOE ARTIFICIAL PUPIL. 185 be resorted to only when no other alternative exists. If possible, the new opening should be formed near the natural situation of the pupil. When this is the aim of the operator, an incision is made near the edge of the cornea with a lancet-shaped knife or a cataract-knife, and an exceedingly fine-toothed forceps or the canula forceps being introduced, the iris is seized at a point as central as the circumstances will admit of, and, being torn from its adhesions, is drawn through the wound of the cornea to a suffi- cient extent. It is then to be quickly excised, close to the cornea, by the assistant who has been charged with this duty. He should hold the scissors in read- iness for instant use, near the eye, and should, if possible, have as steady a hand as the operator him- self The portion excised will give the size of the new pupil, and it is better that this should be too small rather than too large ; the patient's vision being more distinct and less dazzled than when a very large aperture is formed. Another excellent mode of ob- taining the result, to be preferred in many cases to the method above described, is the plan proposed by Mr. Critchett, of London, for placing a very fine ligature around the iris, close to the cornea, instead of excising it. When the centre of the cornea is entirely opaque but the pupil is in its natural condition, we may dis- place the pupil by a similar method of operating, using sometimes a blunt hook, which is to engage,lhe 186 DISEASES OF THE EYE. edge of the pupil, instead of tlie forceps. Ligature rather than excision of the iris offers most advantages in this operation, — the edge of tlie pupil being re- tained in contact with the cornea till it becomes adherent, — enabling us to limit the extent of the displacement as we may desire, with more accuracy than when excision is performed. When, in addition to extensive opacity of the centre of the cornea, the edge of the pupil has be- come completely adherent to it, forming what is termed anterior synechia, tlie opening in the cornea must be made at or near its centi-e, perhaps tlirough a spot already opaque, to spare as much as possible the small space remaining transparent. The iris is seized as before, but in this case near its ciliary at- tachments, that the artificial pupil may be situated at its edge, and is to be withdrawn and excised rather than ligatured. Considerable hemorrhage takes place into the an- terior chamber from the torn vessels of the iris, and it is often impossible to judge at the moment of oper- ation as to its precise result, all the parts becoming obscured and hidden by the effused blood ; but the effusion is absorbed in a few days, and the patient begins to see. In all these operations, the greatest care must be had not to wound the capsule of the lens, when it remains in place and transparent, as in doing so we should occasion traumatic cataract. The eye having always been extensively injured OPERATIONS FOR ARTIFICIAL PUPIL. 187 by accident or disease in cases requiring an operation for artificial pupil, the patient has reason to be grate- ful if he recovers even a small degree of useful vision, so as to be able to find his way without a guide ; but, when the mischief has not gone too far, we often gain far more brilliant results, the patient being even able to read with facility. I have at this moment under my notice an old man of seventy-six, previously entirely blind, who can read a newspaper, without glasses, through a pupil which I made for him two years since. As we know that the iris is very susceptible to take on morbid processes when pressed upon or in- jured, we might fear the consequences of any violence so great as that inflicted by tearing or cutting away a considerable portion of its tissue. But in all the instances where I witnessed or performed the oper- ation, I do not recollect ever to have seen inflam- mation result. The after-treatment, therefore, is of the mildest. The patient should remain in a dark- ened room and keep the eyes for the most part closed. At first they may be covered with a compress and bandage. His diet should be moderate, but not closely restricted. After three or four days the eyes may be uncovered, and every precaution dispensed with, except the avoidance of strong light and draughts of air. Glasses are to be employed after the operation, if required by the conditions of the eye. 188 DISEASES OF THE EYE. CHAPTER XIII. AFFECTIONS INVOLVING THE ENTIEJE GLOBE. GLAUCOMA. Though better understood since the application of the ophthalmoscope to diagnosis, tliis is still, in many respects, an obscure disease. It begins with certain changes in the posterior parts of the globe, and probably hypersecretion of vitreous humor ; causing great distension, and terminating in extensive disor- ganization of the retina, choroid, and iris, opacity of the lens, and a peculiar cloudiness of the cornea. The disease seldom occurs before the middle period of life, and in this country is rare at any age. It is met with in acute and chronic forms. In an acute attack, intense deep-seated pain some- times comes on instantaneously, accompanied by diminution or even absolute extinction of vision. Ex- amination shows some, but not great injection of the vessels of the globe, — usually fixed and irregular di- latation of the pupil, and a muddy appearance of its field, — and hardness of the globe, which feels like a marble when pressed upon through the lid. When the bottom of the eye can be seen by the ophthal- moscope, it reveals changes in the optic papilla, GLAUCOMA. 189 which is cupped. The vessels of the retina appear to be bent out of their usual course, and are con- gested. If the symptoms are not speedily arrested, the ap- pearances characteristic of an advanced stage of the affection — which will be described under the head of chronic glaucoma — soon present themselves, and vision is hopelessly lost. At the outset I have found internal tonic remedies and alteratives, combined with general and local anodynes and with local deple- tion, of service in arresting undoubted cases of this disease. Until recently, glaucoma was deemed incurable, or nearly so, unless arrested at a very early period ; but since operations for the relief of the intra-ocular pressure were devised by Von Grafe, of Berlin, and Messrs. Bowman, Critchett, and others of London, recovery may sometimes be hoped for as a result of surgical measures. As performed by Von Grafe, the operation consists in making an opening through the sclerotica, a little behind the edge of the cornea, and removing through this about one third part of the iris, with a view of affording free communication between the posterior and anterior chambers. Other distinguished oculists consider it unnecessaiy to perform so serious a muti- lation, but have found it sufficient, in numerous cases, to evacuate a portion of the aqueous or vitreous humors through a less extensive opening, and draw 190 DISEASES OF THE EYE. a small portion of the iris into the wound. During the time wliich elapses before the wound is healed a slow evacuation of any super secretion of fluid takes place, and the tension of tlie globe is thus re- lieved to an extent which is not effected by mere puncture, which seems insuiBcient to arrest the course of the affection. Relief of constriction by other means, as for instance by division of the cihary body, has also been proposed, and its execution ap- parently followed by good results. Should an operation be performed for the removal of a portion of the iris, its upper part should gen- erally be sacrificed, as in this situation the effects of the unnatural size of the pupil are rendered more tolerable by its being partially covered by tlie upper lid, which at the same time masks the deformity and moderates the painful influx of light. I have seen the intensity of light very annoying to the patient after Grafe's operation, when a different portion of iris had been removed. Sufficient time has scarcely elapsed for determining the relative value of some of the operations proposed for the relief of glaucoma. While, on the one hand, the heretofore almost inevitable advance of the dis- ease leads us to grasp eagerly at anything which promises success, we must endeavor to learn with how little injury we may secure good residts, and whether these results are to be permanent. In esti- mating the success attending the operation, it will be GLAUCOMA. 191 necessary to exclude instances where it has been performed for alleged but not demonstrated cases of this affection. Instead of assuming the violent form we have just described, the pathological changes may make their approaches most insidiously, even in the second eye of the same patient who has lost one eye suddenly, and vision is sometimes thus lost without any suffer- ing. In the earlier stages we iind no other symptom than the gradual diminution of vision, with perhaps slight discoloration of the field of the pupil. At a later period this change of color is more marked, the pupil is irregularly dilated, and the globe begins to feel hard to the touch. At length the lens be- comes opaque, and pressed forward through the widely dilated pupil till it touches the cornea, — the iris is disorganized, — vessels passing from the in- terior of the globe over the sclerotica are enlarged, and form a congested anastomosis around the cornea, — the sclerotica grows thin, and perhaps bulges in staphylomatous projections, and the cornea has a dull look, and sometimes shows vesications of its surface. The globe has a stony hardness. This condition may terminate by the giving way of the cornea, or after continuing for a time may subside into atrophy of the globe. In the advanced degrees of glaucoma no hope can be indulged of a restoration of vision ; but, in case pain should supervene, an operation may be advisable 192 DISEASES OF THE EYE. for the removal of tension. In the earlier degrees of the affection the modes of operating abeady de- scribed are perhaps the surest resource ; unless, as we sometimes observe, the symptoms are promptly arrested by measures for the improvement of the health of the patient. Alteratives of a depressing action or antiphlogistic measures are not to be ad- vised, and merely local applications are of Uttle avail, except for the relief of pain. HTDR OPHTHALMIA. Dropsy of the eye may be distinguished from conical cornea by tlie more uniform enlargement of all the anterior parts or of the v^hole globe. Hap- pily it is of rare occurrence; but several cases are now and then met with, in one femily. Of this ten- dency to affect brothers and sisters I have seen examples in families otherwise healthy, and having some members exempt from the disease. The prognosis is more unfavorable than in conical cornea ; the disease being seldom more than retarded in its course, and terminating at length in abolition of all useful vision, if it does not even go on to bursting of the cornea and collapse of the globe. A limited degree of this affection is sometimes seen after corneitis or other inflammation ; but the disposition to increase is present only to a slight extent in these circumstances. Great care should be used to keep up the general ENCEPHALOID. 193 health of the patient ; and, when the disease is rec- ognized, all use of the eyes upon ohjects which require much effort to distinguish them should be avoided. As the cornea grows thin from distension, all blows and shocks must be guarded against, — as instant rupture may ensue. I have never seen the disease arrested by para- centesis oculi ; but, from having watched the progress of cases where the eye had been repeatedly punc- tured, have considered it quite as likely to advance the disease, by exciting increased secretion of aque- ous fluid, as to retard it in any manner. CANCER OF THE EYE. Malignant disease of the eye develops itself in the form of encephaloid, melanosis, and scirrhus ; the frequency of examples of each being in the order named. ENCEPHALOID. This variety of cancerous affection is almost always met with in very young subjects. It commences far back in the eye, and is first noticed as a yellowish discoloration of the field of the pupil. This appear- ance is frequently mistaken for cataract by those of hmited experience in diseases of the eye ; but the practised observer perceives that it is more deeply situated than the lens and must arise from a deposit 194 DISEASES OF THE EYE. of scrofulous or purulent matter, or from commen- cing malignant growth. It may continue sluggish for months ; but when once it begins to make percep- tible advance towards the cornea, its course is gener- ally rapid. The child loses vision of the eye at an early period ; but little pain is complained of till tlie globe begins to feel distended, when tlie disease hits reached, but has not penetrated, the cornea. As the opacity extends, and advances towards the iris and lens, the pupil is expanded and the lens loses its transparency. Further progress of the disease causes distension of the eyeball and disorganization of the iris and lens. The cornea may give way, or may resist for some time and be carried forward by the tumor, which soon fills the orbit and begins to pro- trude beyond its ca^aty. The enlargement goes on till the patient dies exhausted. An extremely offen- sive odor is often given off from tlie mass, requiring the use of disinfectants. The amount of pain is variable ; sometimes it is severe, but in a case re- cently under my notice, the tumor in a child of five years reached a size beyond tliat of a man's fist, and led to a fatal termination, without having given rise to any pain or fretfulness ; the only symptoms complained of being some wakefulness and loss of appetite. Diagnosis and Treatment. — It is difficult, and in fact even impossible in some instances, to form a positive diagnosis at the outset, except with the aid MELANOSIS. 195 of the ophthalmoscope, as to whether the appearances indicate the formation of purulent or scrofulous de- posit or a commencement of fatal disease. The his- tory of the case may aid us in this respect. As regards treatment, the question of accurate diagnosis is unimportant. Whether the disease be a mere deposit or a morbid growth, we can be but in- active spectators. Vision will, in any event, be lost, and our interference can do nothing to preserve it. If the disease be malignant, our endeavors to avert its fatal tendencies will be powerless, — if non-malignant, it may be left to itself, at least until some slight inter- vention is required to hasten the exit of any purulent matter which is finding its way through the cornea. It is hard to declare a child doomed to slow exhaus- tion by a lingering and painful disease ; but the re- appearance of the fangous growth is so prompt, and its progress usually so much more rapid, after an operation for removal of the affected globe, that it is inexpedient to attempt it. All which remains for us is, to relieve pain as it arises, and render the patient comfortable as far as may be in our power. The fcetor accompanying the enlargement of the tumor is to be lessened by suitable disinfectants. MELANOSIS. Melanotic deposit is developed in various parts of the interior or exterior -of the globe, in the form of black or brownish masses of soft consistence. The 196 DISEASES OF THE EYE. aflfection is less rapid in its march than encephaloid, but it leads to the same result ; and tliough the chances of operation are not so absolutely unfavor- able, there is little encouragement to hope for secu- rity against relapse. SCIREHUS. This rare disease of the globe seems to most fre- quently attack eyes which have suffered from pre- vious inflammation or chronic disease. The organ becomes hard and nodulated, and the morbid growth gradually involves tlie contiguous parts. In the earlier stages, an operation for removal of the globe might be admissible ; especially as the operation is in itself slight, and involves no risk. But too often a prompt reappearance of morbid growth is the only result. There ai-e cases, however, of the development, of tumors, having their origin in the cornea or iris, w^hich bear a certain resemblance to scirrhous dis- ease, but seem to belong to the class of epitheUal growths. These may be removed with the assurance that the disease will not return. It is rarely neces- sary to take away more than the anterior part of the eyeball, — as the other structures are not involved. OPHTHALMITIS. This term is used to designate an inflammation in which all the tissues of the globe become almost OPHTHALMITIS. 197 simultaneously affected, and in which the hds and the cellular tissue of the orbit participate. Causes. — This phlegmonous affection of the globe sometimes comes on as one of the sequelae of typhoid or puerperal fevers, or is connected with phlebitis. I have also seen it induced by a slight injury, or by taking cold, in eyes which were previously exten- sively diseased and staphylomatous. Symptoms. — There is at first so little injection of the vessels of the eye, that, were it not for serous chemosis which exists without apparent cause, there would be little in the aspect of the globe to attract our attention. This chemosis, however, together with the intense pain, the intolerance of -light, and loss of vision, which begin to be complained of, prove that serious changes are going on in the posterior parts of the organ. As the disease reaches a second stage, the con- junctiva and the cellular tissue beneath it become thickened and livid, the iris loses its healthy appear- ance, and sometimes the transparency of the cornea and the crystalline lens is rapidly lost. No percep- tion of light remains. The inflammation extends to the cellular tissue of the orbit, which becomes swollen and indurated to such an extent as to cause much protrusion of the eyeball, at the same time that the lids become greatly swollen and livid. The consti- tutional febrile symptoms are of extreme intensity, and the agony sometimes endured is sufficient to 198 DISEL\SES OF THE EYE. render a patient delirious, — the pain having a pul- sative chai-acter, resembhug that accompanying the formation of pus in other situations where it is con- fined by firm fibrous tissue. When the crystalhne and cornea continue mod- erately clear, matter can be seen collecting in tlie bottom of the eye. It generally comes to the sur- face, and is discharged through the cornea. Diagnosis and Treatment. — Phlegmon of tlie eye is sometimes supposed to exist when the pus, instead of being within the eye, is behind it, in the space between the globe and the ocular capsule, or fibrous socket in which the globe is enclosed and revolves. The symptoms are nearly the same in apparent se- verity, and, in all cases not recognized at the outset, vision is lost, from pressure on the eyeball, in cases of inflammation of the ocular capsule, as certainly as if matter had formed in the globe itself. But as to the question of treatment, the difference is exceedingly important ; in case of suppm-ation within the globe, not only the function, but the form of the eye must be eventually lost, and it is there- fore proper to lay open the resisting tunics of the ball, to relieve the intense suffering and promote a more speedy recovery. But where tlie deposit of pus is within the capsule only, it tends to discharge, not through the cornea, but between the insertions of the recti muscles, where at first sight it seems to have made its way through the sclerotica, but in OPHTHALMITIS. 199 reality has only done so through the conjunctiva and the expansions of the tendons. Any evacuation of the contents of the globe is here wholly unnecessary and would occasion needless deformity. The matter may be reached by puncturing the ocular capsule at any spot between the muscles where it appears disposed to point, and if the diagnosis is made suffi- ciently early, it is not impossible that vision may be preserved by its prompt evacuation. Treatment. — In the very early stages, local de- pletion and active derivative treatment afford a chance, though a small one, of averting the fatal termination as regards the eye itself, and even, in some cases, as to the life of the individual. The sup- purative process once commenced within the globe, no resource is left us except palliatives and a prompt interference at the earliest moment when the indica- tions for evacuation of the pus become clear. Yet we are now and then compelled, by a regard to the future peace of mind of the patient and his friends, to delay a resort to the bistoury longer than would be warranted by our own judgment. While the eyeball still looks, to them, as if merely suffer- ing from an external inflammation, and scarcely any change has manifested itself in the internal parts of the eye or in the cornea, — to lay open the globe for the relief of suifering would in their opinion be a needless sacrifice, and one which they would ever regret. But when the disease has gone so far that 200 DISEASES OB' THE EYE. pus is actually present in quantity, and ready to follow the knife, tliey can no longer flatter tliem- selves with a behef that the eye might have been saved had not the surgeon opened it, and are quite ready to acknowledge the wisdom of his measures for abridging the patient's suffering. Poultices may be applied with advantage after the operation, to accelerate the discharge. They should be very soft, moist, and light. Those composed of boiled apple, or arrow-root, preserve their moisture longer than those of bread, linseed-meal, or slippery- elm-bai-k. After a short period they should be laid aside for mild astringent solutions, tliat the atrophy of the globe may be as slight as possible. An artificial eye may be worn to conceal tlie deformity after the parts have become healed. SYMPATHETIC OPHTHALMIA. When one eye has been lost by accident, espe- cially if the accident has been caused by a blow from some jagged foreign body, or if the loss of the eye has been attended with long-continued severe symptoms, there is a predisposition in the other eye to take on a peculiar and most unfavorable form of inflammation. This by no means happens in all, or in a large proportion of cases ; but it is not a rare occurrence. The symptoms may appear in a few weeks, or be delayed as many years from tlie time of the original SYMPATHETIC OPHTHALMIA. 201 injury. When they do appear, however, they have characteristic features which serve to distinguish this from all other internal inflammations of the eye. Though the eye first injured is usually lost, such is not invariably the case, — as I have operated suc- cessfully for artificial pupil on an injured eye, where the other had been rendered entirely blind by this sympathetic form of inflammation. Symptoms. — The iris exhibits, in most instances, at the time it comes under our notice, the first evi- dence of disease, becoming changed in color, con- gested, and sluggish. The usual means for dilating the pupil have little efficacy, and the tendency to effusion exists in so high a degree that the pupillary orifice becomes blocked up by a firm deposit, not- withstanding every effort to keep it free. The retina and choroid seem to be at the same time involved, and vision is gradually lost. Very little pain is felt ; but the disease goes on sluggishly, generally ending in a certain amount of atrophy of the globe. Treatment. — The results of treatment of the affected eye are usually very unsatisfactory ; yet, if commenced in the earliest period after the invasion of the disease, it may lead to a happy result. The misfortune is, that in most instances the approaches of the disease are so insidious that our aid is not invoked until too late to prevent the extension of ravages which have already commenced. .The patient or his friends should be admonished, in many cases of injury of an eye, to 9* 202 DISEASES OF THE EYE. apply at once for advice if they observe any symp- toms in the opposite eje. Where there is reason to beheve that a foreign body is still retained and acting as an irritant in the wounded eye, — and sometimes where tliere is no such suspicion, it is advisable to remove the useless relic of an eyeball, in the hope that tlie cause of tlie sympathetic reflex action may be got rid of. The mode of performing the operation will be described hereafter. Local depletion by leeches to the temple, tlie use of a strong solution of atropia, and such general treatment as may be indicated by the condition of the patient, should be employed without loss of time. The iodides of mercury and potassium, and some- times pure tonics, may be considered suitable reme- dies for exerting a favorable influence, if the patient is seen before irreparable mischief has been already done. In some cases the eye preserves a good appear- ance ; but where it undergoes atrophy to such an extent as to amount to deformity, it is not desirable to adapt an artificial eye, as, where no vision exists on either side, any endeavor to conceal the changes which have occurred, except by means of a shade, is scarcely worth the ti-ouble it occasions the patient. OPEKATION FOR REMOVING THE EYEBALL. The removal of the eye has been regai-ded, and formerly justly so, as one of the most formidable OPERATION FOR REMOVING THE EYEBALL. 203 of operations. By the methods once pursued, and before the use of anaesthetics in surgery, it was some- thing to be shrunk from and avoided, unless as a last necessity. Now, however, the mode of effecting it is so simple, the unconsciousness of the patient so complete, and the recovery so prompt, that we can resort to it on various occasions with great ad- vantage, and even substitute it, in many instances, for puncture or partial removal of the globe. We should perform this operation, rather than merely lay the eye open, in cases where we have reason to fear that a constant irritation kept up by the presence of some foreign body within a disorgan- ized eye may excite sympathetic ophthalmia in the other globe. We are thus sure of extirpating the source of irritation, which is perhaps fixed in the tunics of the eyeball, and might not be discharged if the contents of the globe were removed by suppu- ration after an incision only had been made. Where the globe is disorganized and enlarged by excessive staphyloma or hydrophthalmia, the deformity and discomfort may be relieved either by evacuating the contents of the globe and allowing it to collapse, or by removal of the organ. If merely punctured, the interior suppurates, with much infiltration of all the parts within and around the orbit, — and it is only after some weeks that the process is completed and the stump of the globe cicatrized. If, on the other hand, the eye is at once removed, the slight wound heals in 204 DISEASES OF THE E-iT:. two or three days, requiring no treatment and giving no annoyance to the patient. The only reason which could exist, then, for laying open the globe in any case in preference to removing it, would be the ex- pectation that in so doing the patient would be better able to wear an artificial eye. But where the oper- ation has been carefully done, and the orbital capsule with the muscles which pass through and have slight attachments to it, are preserved, the person can enjoy as much, or nearly as much power of control over an artificial eye as when the shrunken tunics of the ball still remain in tlie orbit. Not only is cicatri- zation almost immediately accomphshed after the removal of the globe, but the patient is relieved from the greater danger of hemorrhage which attends the mere evacuation of the eye, and from the serious chances which may ensue from so considerable a sup- puration and inflammation in close proximity to the brain. I have never seen more than the slightest loss of blood during and after the removal of an eye in the mode I shall describe ; whereas hemorrhage is not an infrequent occurrence from the vessels of the choroid and retina when deprived of their usual support by the loss of the humors of the eye after the globe has been laid open. Method of Operation. — It is proper, unless strong contra-indications exist, to render the patient insen- sible by ansesthetics before proceeding to extirpate the eye. This being done, the lids ai-e to be widely OPERATION FOK REMOVING THE EYEBALL. 205 separated by an assistant, — and, if sufficient room IS not thus obtained, the outer commissure may be divided, — to be afterward reunited by one or two points of suture. A fold of conjunctiva is then to be raised with forceps, and this membrane divided with scissors close to the cornea, and around its entire circumference. The muscles of the globe are then to be successively drawn out with a blunt hook, such as is employed in the operation for strabismus, and divided. Last of all, the globe is to be slightly drawn forward, and the optic nerve cut across with curved scissors. The capsule in which the eye revolves is left intact, or at most is but slightly injured by the operation. Nothing more than a wet compress and bandage need be applied after the operation in most instances. Should there be more than a slight oozing of blood after the first few moments, ice-water may be applied, or the vessels may be twisted or tied if thought de- sirable. But any such necessity will rarely occur. A short time should elapse before an attempt is made to wear an artificial eye. 206 DISEASES OF THE EYE. CHAPTER XTV. AETIFICIAIi EYES. T±ESE substitutes for one of tlie most expressive of the human features have been brought to a beau- tiful perfection. They have the form of a shell merely, so as to be hght and movable, and to adapt tliem to be worn over a pai'tially ati'ophied globe, A sohd ball, like the eyes intended for stuffed ani- mals and birds, would be so heavy as to be immov- able. They are made of various forms and sizes, to adapt them to the cavity in which tliey are to be placed, and have the color of the iris and size of tlie pupil varied, so as to match the various conditions and appearances of the healthy eye opposite to which they are to be worn. Most of those in use are of Paris manu&cture, though a few are made in tliis country. If well-adapted, an artificial eye causes no dis- comfort, and is a most striking improvement to the countenance of the wearer. If possible, it should resemble the other eye in color, size of the pupil, and prominence, and should move in all directions with the movements of the other eye. But it should be slightly too little prominent and too small, rather AETIFICIAL EYES. 207 than the reverse, as too much projection gives a staring expression which at once attracts attention, while if shghtly less than the other eye the differ- ence will not be observed. If too large, or of un- suitable form, an eye acceptable in other respects may be ground to the proper size ; but unless the ground edge be afterward smoothed and rounded off by being melted, it is more liable to fret the con- junctiva than when it can be left in its original shape. If possible, the individual should himself go to make a selection from an assortment kept by those who sell them, as the fit is more certain to be accu- rate than when the most perfect representation of the other eye, and the best measurements of the cavity, are sent to the manufacturer. An artificial eye should be worn as little as pos- sible, that it may be preserved from the loss of polish which always results, after a time, from its being bathed in the conjunctival secretions. It should always be removed at night, and w^hen convenient should be taken out once a day, and the eye bathed with cold water. If worn constantly, its surface soon becomes altered and rough, and if still con- tinued in wear after this change has taken place, it speedily gives rise to irritation of the conjunctiva, which increases to such a height of inflammation that copious secretion is poured out, and the conjunctiva becomes thickened and covered with exuberant gran- 208 DISEASES OF THE EYE. ulatiohs. Should the person still persist in wearing the roughened eye, the cavity becomes filled by tliese fungous growtlis ; by wliicli tlie artificial eye is at length crowded from its place, and its re-introduc- tion rendered impossible. As soon, therefore, as tlie polish of the eye begins to be destroyed, it should be repolished, or exchanged for another. With care, an eye may be worn from one to tliree years with- out requiring to be retouched ; and, if not broken by carelessness or in tlie process of renewing the polish of its surface, it may last for eight or ten years, or more. There is no danger, or next to none, of their being broken, while being worn, by any violence. Till the individual becomes accustomed to insert- ing and remo^^ng it, he should lean over a bed whilst doing so, that it may not be broken if he should let it fall. The eye is first to be dipped in water, — its longest end, or that which extends the greatest distance beyond the iris, is to be introduced as far as possible under tlie upper lid, then turned towards the outer canthus, and, the lower lid being now drawn down, the eye slips into its place. To remove it, the head of a pin, the end of a tooth of shell-comb in which a slight notch has been cut, or some similar contrivance, is insinuated behind the lower edge of the eye, and, the lower lid being de- pressed, the eye is slightly, drawn forward, and drops into the hand held to receive it. After removal the AKTIFICIAL EYES. 209 eje should be careftiUy washed and wiped, and "laid on soft paper. If left in water during the night, it is softened, its surface rendered more susceptible to be acted on by the orbital secretions, and its polish sooner destroyed. We sometimes observe the orbital cavity irregular in outline, and perhaps limited by more or less ex- tensive adhesions between the lids and the globe. The patient is eager to have these divided, that no obstacle may prevent the insertion of an artificial eye. But unless these .adhesions are small, or we can arrange our incision to allow of bringing the cut sur- faces together in a different position so as not to have apposition of raw surfaces, we should interfere only with great caution with such bands of adhesion. It is easy to divide them, and to insert an artificial eye ; but even its presence will not prevent retrac- tion of the parts to perhaps even worse than their former condition, as cicatrization takes place. It is far better to endeavor to stretch these adhesions, or make them conform to the desired shape of artificial eye, by first inserting a small eye, which after a few days may be exchanged for others progressively in- creased in size. It is not necessary that an eye which exhibits disagreeable deformity should be much lessened in size, to admit of its being covered by an artificial eye. Where it is still rather large, an elliptical- shaped portion of the cornea may be removed by 210 DISEASES OF THE EYE. careful incisions with a cataract-knife, without loss of any of tlie contents of tlie posterior part of the globe. The edges of the incisions may be drawn together by a single point of fine suture, superficially inserted; or they may be left; to themselves, the patient being directed to keep quiet and to avoid as far as possible all movements of the eye. Artificial eyes are less worn than they deserve to be, from ignorance of the public in regard to them. Their cost is not very great, (ten dollars being the price for which they are sold in Boston,) and tlieir effect in restoring the natural expression of the coun- tenance is oftentimes truly admirable. INFLAMMATION OF THE CHOROID. 211 CHAPTER XV. ATPECTIONS or THE CHOROID. The intimate relations existing between the cho- roid and retina give a peculiar importance to any- pathological conditions which may be developed in the former, as it is impossible that these should surpass a very narrow hmit without involving the delicate structure and function of the contiguous nervous tissue. INFLAMMATION OF THE CHOEOID. Acute inflammation of the choroid must be accom- panied by so much inflammation of the retina itself, with intolerance of light, that it becomes nearly im- possible to recognize it as a distinct disease. But a passive form of inflammation may be observed by means of the ophthalmoscope. The patient complains of a certain amount of dim- inution of vision, without our being able to satisfy ourselves, by any external signs, of the nature of the causes which have produced the change. Examined by the eye-mirror, we perceive, either merely a gen- eral congestion of the choroidal vessels, or, in more advanced cases, an exudation occupying more or less 212 DISEASES OF THE EYE. of the surface of the choroid. This exudation may become reabsorbed, if small in quantity ; but if not thus removed, it degenerates to cartilaginous or even osseous tissue. Spots of accumulated pigment gran- ules are sometimes seen at the edges of the effused deposit. This chronic inflammation of the choroid seems to depend, in some instances, on syphilitic constitutional infection, and to be amenable to remedies adapted to this condition. Another form of choroiditis has no tendency to exudation, but terminates in atrophy of tlie choroid, with adhesion to the sclerotica. It is attended with extensive alterations of otlier portions of tlie eye, which increase with the advance of the disease, and appears to be uninfluenced by treatment. HEMORRHAGE FROM THE CHOROID. Sudden partial or total loss of vision is sometimes occasioned by rupture of a vessel in the choroid and effusion of blood between this tissue and the retina. When caused by some violent effort, without previous disease of the choroid, the effusion may be absorbed, and vision restored. No treatment is called for, Tiriless to guard against further hemorrhage. When it occurs between the choroid and retina, it may, if of large amount, cause separation of the retina and permanent injury to vision. ABSENCE OF CHOROID PIGMENT-CELLS. 213 SEKOUS EFFUSION FKOM THE CHOROID. This consequence of chronic congestion of the vessels of the membrane is important, from the sep- aration of the retina which it occasions. It will be again referred to in treatmg of the affections of that tissue. ABSENCE OP CHOEOID PI&MENT-CELI-S. This phenomenon is occasionally observed in albi- nos, and is generally attended with considerable sen- sitiveness to Hght, but not necessarily with any defect of vision. In fact, I have seen it accompany a re- markable degree of visual power. It may therefore be regarded as a curious anomaly, rather than a morbid condition. 214 DISEASES OF THE EYE. CHAPTER XVI. ATFECTIONS OF THE KETINA. Pkior to the invention of the ophthalmoscope, a large number of cases iu which vision was enfeebled or lost, but in which no visible transformations had taken place in the tunics or media of the eye, were ascribed to changes in the retina or optic nerve, and were classed together under the head of amaurosis. But the revelations of this instrument, and tlie ad- vance in other respects in the knowledge of eye dis- eases, have enabled us to explain many instances of impairment of sight as due to obvious lesions, and to classify them accordingly ; and, on the other hand, allow us to give encouraging assurances to many a patient who would once have been deemed a victim of at least incipient amaurosis. Before describing what we may still term, as a matter of convenience, amaurotic affections, some of which are more or less obscure in their origin and seat, I shall speak of certain admitted and clearly definable morbid changes occurring in the retina ; premising, however, that most of the lesions observed in tliis structure are not primary, but depend on dis- ease of the choroid, which has been at least a pre- disposing cause of the retuial affection. APOPLEXY OF THE EETINA. 215 INFLAMMATION OF THE EETINA. Acute retinitis, uncomplicated with, inflammation of other membranes of the eye, is exceedingly rare, and it is principally its more passive forms of which we may detect the presence by the aid of the oph- thalmoscope. Considerable congestion of the retinal circulation may exist without more than temporary derange- ment of the visual power, and we may offer every encouragement to patients who perceive their vision enfeebled, if we find evidence of hypersemia without structural alteration. Our prognosis must be more guarded if we discover that exudation has occurred, though even this may exist, to a limited extent, along the larger branches of the vessels, without serious diminution of vision. The treatment should consist in local depletion by leeches applied to the temple, and the use of deriv- atives to divert the circulation to other parts of the body ; together with such alteratives as may seem adapted to prevent exudation, or to promote its ab- sorption, should such means be required by an ad- vance of the disease. APOPLEXY OF THE RETINA. Hemorrhage may occur from rupture of a retinal vessel previously weakened by congestion, and has also been observed in the form of minute effusions 216 DISEASES OF THE EYD. from a number of points. The blood thus poured out may be absorbed, and vision re-established. Every precaution should be taken to lessen the excessive vascular fulness by derivative measures, and by local depletion, if this appears to be indicated by continued plethora. ANH^MIA OF THE EETrHA. A condition of the retina the opposite of conges- tion — marked by diminution or obliteration of the retinal vessels and atrophy of the papilla of the optic nerve — is occasionally met with in those born blind. It is principally interesting as a pathological fact, as it allows of nothing but a positively unfavor- able prognosis, and is not a subject for treatment. FATTY DEGENERATION OF THE KETINA. This morbid transformation is a not unfrequent concomitant of Bright's disease of the kidney, and appears to occur only in this connection. Partial vision may be retained, even till death, only a portion of the retina having become affected. SEPARATION OF THE RETINA. An extreme degi'ee of separation of the retina from the choroid by a serous effusion may be recog- nized by the naked eye, especially if the pupil be previously dilated. A thin membrane, sometimes studded with whitish flocculi and crystals of cholesn ENCEPHALOID OF THE RETINA. 217 terine, may be seen, rolling upon itself with every movement of the eye, in the space which should be occupied by the vitreous humor. In lesser degrees, the ophthalmoscope alone can disclose the cause of the diminished vision of which the patient complains. It is oftenest the upper parts of objects which cannot • be seen by the patient, the effusion gravitating to the lowest portion of the retina, and causing separation at this point, which is thus rendered incapable of forming images of objects. If hemorrhagic, rather than serous effusion, has been the cause of the sep- aration, the symptoms will be similar, except that the raised portion of membrane will be less trans- parent, but will have a reddish or brownish color. In the minor degrees of this affection the fluid may be re-absorbed, and the retina resume its place, and, in a measure, its functions. But after the relations of the retina to other parts have been extensively dis- turbed there can be no hope of a recovery of its powers, and treatment can only be of service if directed to prevent a partial from becoming a total separation, by enjoining such precautions as may seem judicious. ENCEPHALOID OF THE KETINA. This variety of cancer of the eye has been else- where described, and is here referred to merely to remark, that it may be detected, by means of the oph- thalmoscope, in its early stages, while it is still but a 10 218 DISEASES OF THE EYE. small, irregular tumor at the bottom of the eye. But the young subjects in whom the disease usually occurs rarely complain of any symptoms or call our attention to the eye until the morbid growth may be seen by- unassisted vision. The instrument is then useful by enabling us to determine if the disease has malignant features, or is merely a scrofulous deposit. AMAtlEOTIC AFFECTIONS. 219 CHAPTER XVII. AMAUROTIC AI'FECTIONS. The term amaurosis has been vaguely applied to all conditions where, vision being affected without apparent alterations in other parts of the eye, the symptoms have been considered to originate in changes more or less obscure in the retina, optic nerve, or brain. The use of the ophthalmoscope has enabled us to substitute a disease for a symptom in a large proportion of cases ; but there still remain a considerable number of pathological conditions, result- ing from widely different causes, to which we must ascribe the production of one common symptom, diminution of sight,- without being always able to determine the manner in which these various agen- cies exert their influence on the delicate nervous structures concerned in special sensation. I shall classify separately certain temporary and partial disturbances of visual power; confining our attention, for the present, to those forms of the affec- tion which have a more permanent character and do not depend on well-known and easily removed condi- tions. Symptoms. — A patient with confirmed amaurosis 220 DISEASES OF THE EYE. lias almost invariably a vacant, wandering expression, and makes no attempt to concentrate his eyes upon objects. His pupils are generally widely dilated and insensible to light. These are the only objective symptoms proper to this affection ; for where we observe softening or opacity of the media of the eye, or changes of retinal structure, we may give the disease its appropriate place, and remove it fi'om the list of amaurotic affections. Even tliese symptoms may also be present where some of the morbid changes already described have taken place. But if one eye only is amaurotic, we shall not perceive either of the two symptoms above named unless each eye is examined while the other is closed, as dilatation and contraction of the pupil will take place in the diseased synchronously with the healthy eye. Nor must we assume enlargement of the pupil with dimness of vision as necessarily indicating amaurosis, — for these symptoms coexist, often in a high degree, in mydriasis, which may have been produced by paralysis of the third pair, or by the use of bella- donna, and in which neidier the retina nor optic nerve are in the least at fault, vision being perfect if refraction be corrected, and the adaptive power replaced, by allowing the patient to look through a pin-hole or other small aperture in a card, held before his eye to cut off the lateral rays coming from the object looked at, or by giving him a convex-glass of suitable power. AMAUROTIC AFFECTIONS. 221 For most of our information in regard to his con- dition we are compelled to depend on the patient's account of himself, and not, as in many other dis- eases of the eye, on our own observation. It is im- portant to obtain from him every particular in regard to the time and manner of the invasion of the dis- ease ; what were the earliest symptoms noticed, and what had been his previous history, and the history of his family as regards any afFection of the eye, or any other disease to which he might be supposed to inherit a tendency. By these means we may be able to trace a probable cause for the blindness for which he seeks relief, and form a judgment as to his chance for recovery. As a rule, amaurotic patients see best in a clear day. Pain is often complained of, and if felt within the head is, in many cases, a symptom of cerebral disease, especially if the amaurosis is also accom- panied by squinting, or partial paralysis. Causes. — In some families, otherwise apparently healthy, amaurosis comes on at about the same age in several members, and this disposition may be ob- served in successive generations. Different members are sometimes affected with various degrees of blind- ness. Sudden exposure to intense light in looking at the midday sun, or a stroke of lightning, may cause in- stantaneous loss of sight, — the special sensibility of the retina being at once extinguished. Long-contin- 222 DISEASES OF THE EYE. ued work upon bright objects, such as shining plates of metal, mar induce more or less loss of vision. Any pressure upon the retina, the optic nerve, or the portion of the brain from which it derives, by tumors developed in proximity to them, or in such a situation as to interfere with the free return of blood from their vessels, constitutes an efficient cause of this affection. The same is true as regards any circumstances increasing the flow of blood towards the head. Hydrocephalus is not unfrequently accom- panied by complete amam'osis. Blows on the head, or on that point of the supra- orbital ridge where a branch of the fifth pair of nerves passes out upon the forehead, are sometimes followed by loss of vision ; the fifth pair having in- timate relations witli the nutrition and ftinctions of the eye. Frequently, however, in these cases, ex- amination with the ophthalmoscope will disclose more or less lesion resulting from the blow, within the globe itself. Amaurosis is also one of the symptoms of lead poisoning, sometimes preceding every other serious manifestation of its effects. The free use of alcoholic stimulants or of tobacco seems to be an occasional cause of the loss of visual power, and should be interdicted if diere is reason to suspect that an injurious influence is kept up by indulgence in them. The same may be said of excessive sexual indul- gence or mastui'bation. AMAUROTIC AFFECTIONS. 223 Prognosis. — Our hope of relieving amaurotic af- fections must depend on their supposed cause, and the extent of lesion which we presume to have occurred. If hereditary or constitutional, or if re- sulting from hydrocephalus or advanced cerebral dis- ease, we can have little expectation of deriving any advantage from treatment. When the symptoms result from vascular pressure, from blows, or the action of poisonous substances, we may hope for amelioration or recovery. The less the duration of the disease, the more favorable — other things being equal — will be our prognosis. Treatment. — Many of the curable cases depend on such causes that we may hope to obtain good effects from local depletion with active derivation by purga- tives and counter-irritants. Leeches or cupping on the temple may be had recourse to, and repeated at short intervals. More advantage is gained, except in very acute cases, from the repeated application of two or three leeches, at intervals of a few days, than from a large number at one time. Dry cupping on the back of the neck is sometimes useful. Counter-irritants may be applied to the temples or behind the ears ; but their value in ophthalmic practice, in the opinion of the best authorities, is much less than was formerly supposed. Where suppressed menstruation, or arrival at the critical period, may be supposed to have been a predisposing cause, an issue on the arm may be established, if thought to be indicated by the con- dition of the patient. 224 DISEASES OF THE EYE. Mercurials have enjoyed high repute ; but their "warmest advocates admit, of late years, the impor- tance of refraining from their indiscriminate use. Tlie iodide of potassium may be of service where mercury would be of questionable utility, and espe- cially where lead is believed to have induced the symptoms. All the remedies employed should be directed to the removal of the supposed cause, by means appropriate to tlie condition of the patient in any given case. Electricity is regarded by the best authorities as of very uncertain effect. For myself, I have seen no instance in which I believed it to have been of advan- tage, and many in which the patients thought they had been injured by its use. I have, therefore, never employed it ; but I have watched its effects on many individuals, and regard it as likely to be very seldom useful, so far as its effect is to be immediately exerted on the eye. Strychnia was at one time much employed ; but on merely empirical and not rational grounds. It seems to have deservedly lost favor, having no effect what- ever on those parts of the nervous system concerned in special sensation. The use of saturated tincture of aconite and prepa- rations containing veratria, applied in the region of branches of the supra-orbital nerve or other divisions of the fifth pair, seems to be desirable in some cases, for the sake of the relief often afforded to the pain AMAUEOTIC AFFECTIONS. 225 complained of by the patient. Whether or not they could have a direct influence on the important symp- toms would depend on the causes which gave rise to them. Collyria, or other applications to the eye itself, would be useless. Of course it is important to remove all exciting causes of the affection. Any occupation for which a person -is evidently unfit should be given up, upon any suspicion that its pursuit will involve the loss of vision. Indulgences at table, or in smoking, should be curtailed, if there be reason to attribute to them any agency in bringing on the disease. Ve- nereal excesses should be carefully refrained from, under penalty of a continuance or increase of the symptoms. A peculiar feature of this disease is the disposition of patients who have confirmed, and nearly or quite complete amaurosis, to self-deception. They are ever trying to persuade themselves that they see a little more, and, though often disappointed, appear to be always willing to believe any flattering impostor who tells them they are gaining. This credulous tendency leads them to entertain enthusiastic expectations in regard to every new mode of treatment, especially if proposed by a man of acknowledged skill, and they constantly endeavor to persuade their physician, their friends, and themselves, that they are improving under the course pursued. The physician should, there- 10* o 226 DISEASES OF THE EYE. fore, test their vision, quietly, from time to time, and observe for himself whether the avowed gain is real or imaginary ; otherwise he may be too sanguine and express too much confidence as to the results of his treatment, only to be a sharer in his patient's disap- pointment. TEMPOKAEY AFFECTIONS OF VISION. 227 CHAPTER XVIII. TEMPORAET AJFFECTIONS OF VISION. A FEW peculiar conditions, in which vision is tem- porarily diminished or lost, are often classed with amaurotic affections ; hut seem to deserve a special description. Among these may be placed the ina- bility to see at night, which, though sometimes a symptom in amaurosis, is in other cases but the temporary consequence of special causes ; and the loss of vision sometimes occurring during pregnancy or lactation. NIGHT BLINDNESS. This symptom may attack persons in any circum- stances of climate or occupation, but is by far most frequent in those who are exposed to strong con- _ trasts of light and considerable fatigues, with perhaps an improper or innutritious diet, as is often the case with soldiers and sailors. It is most common among natives of temperate climates who are exposed to the bright sun and intense heat of southern lati- tudes, to which they are unaccustomed. During daylight the individual sees as well as ever, or complains only of a certain sensitiveness to light ; 228 DISEASES OF THE EYE. but at nightfall he becomes unable to ^uide . himself or distinguish objects. Sometimes he sees tolerably well in a bright artificial light ; in other instances this scarcely increases his visual power. The symptoms disappear the next day, to be renewed at evening. When the patient is plethoric, or has been sub- jected to the influence of a bright glare of hght, it may be advisable to administer a purgative', and to resort to moderate local depletion, at the outset of treatment. But in much the larger number of cases patients exhibit an opposite state of the system, and if evacuants are used at all, they must be followed by tonic and sometimes by anti-scorbutic treatment. If the symptoms do not yield to these means, with a few days repose of the eyes in a moderate light, the patient should be removed from the climate or the situation which may have originated the disease. LOSS OF VISUAL POWER DURING PREGNANCY OK LACTATION. In some women, most frequently those of nervous or hysterical constitution, partial or even total loss of vision may occur during a part of the period of one or successive pregnancies. In others it occurs during lactation. It may continue, in some instances, from one of these conditions to the other, but I have never seen it persist for more than a brief time. When accompanying pregnancy, the patient may be comforted with the assurance that it will probably be recoveted from after parturition. TEMPORARY AFFECTIOHS OF VISION. 229 The treatment, during pregnancy, must consist in endeavors to remcJve any special exhausting or de- pressing causes ; and if necessary in fortifying the patient by generous diet, tonics, or a change of air. If the same means do not remove the symptoms when manifested during lactation, weaning must be insisted on as the only prudent course. 330 DISEASES OF THE EYE. CHAPTER XIX. PECinDIAEITIES OF VISION. INABILITY TO DISTINGUISH CBETAIN COLORS. The individuals thus affected are usually so from birth, and have most difficulty in discriminating be- tween red and green, though other colors are some- times confounded. When congenital, treatment is useless. If the symptom manifests itself in the course of other diseases, no special remedies are to be directed solely to it, and we may look for its re- moval as relief of the primary disease is obtained. INCREASED SENSIBILITY TO LIGHT AND ACUTENESS OF VISION. These two conditions are usually associated in the rare disease to which I refer ; though, in the acute form, the sensibility is exalted to such a degree, that even in absolute darkness the lids are spasmodically closed at the outset of the affection, and the intoler- ance of hght prevents all exercise of visual effort. The disease often assumes a chronic form, and is most frequent in young persons. It is not more common in one sex than the other, though when observed in male subjects, they have, usually, what INCREASED SENSIBILITY TO LIGHT. 231 may. be regarded as analogous to the hysterical tem- perament in females. I have seen, however, marked exceptions to the rule, having met with the disease in individuals of robust health and excellent nervous and mental condition. I have known it follow a fall upon the lower extremity of the spine ; but except in this instance have not observed what could be regarded as exciting causes. It is said to be some- times a consequence of long confinement in dark cells. The affection varies in degree, some persons being able to bear exposure at twilight, and to go out freely in the night-time, while others cannot bear even this amount of light, but keep the eyes con- stantly covered with close, thick bandages. Gen- erally, the patient can allow the eyes to be uncov- ered ■ in nearly total darkness, though he may have severe pain in exposing himself to daylight, even with his eyes protected by bandages through which it would seem impossible for a ray to penetrate. In almost absolute darkness, the patient can some- times see to read a fine print, and is frequently able to distinguish objects and persons. He often com- plains of the appearance of colored or brigh* spots before his eyes. In extreme cases it is almost impossible to obtain a glance at the eyes in a full or even a moderate licht ; and the disinclination of the patient to permit an examination does not arise from perversity or hys- 232 DISEASES OF THE EYE. terical apprehension, but often from a well-grounded belief that the symptoms will be materially aug- mented by any such inspection, experience having demonstrated to him that they are thus augmented. In these circumstances, it is not necessary to insist on looking at the eyes ; for, when seen, they exhibit no phenomena to aid us in our treatment. They may be slightly injected, from having been so much covered, and they generally have a peculiar glazed expression, similar to that sometimes observed in the eyes of persons who have for years worn spec- tacles, when the glasses are taken off for a few moments. The want of the, appearances of inflammation or ulceration, the age of the patient, and history of the case, distinguish this disease from ordinary photo- phobia. The duration of the disease is very variable. It may continue for months or years, and at length dis appear almost at once. After an interval of exemp- tion it may return, and persist for a considerable time, notwithstanding the use of remedies which ap- peared to have been previously effectual. In other cases ife'subsides spontaneously or yields to treatment within a brief period. The treatment should be both constitutional and local. Tonics and antispasmodics are indicated in a large proportion of cases. Every effort should be made to discover and remove any causes which may PECULIARITIES OF VISION. 233 have a possible influence in keeping up the symptoms. Derivatives are often of service, and remedies having a special influence upon the nervous system are in- dicated. As local applications, those which may be used in the form of vapor are preferable to other means. The patient's head may be covered, so as to concentrate the vapor upon the eyes and forehead, or a cup containing the hot liquid may be held near the eyes. We can thus hope to act on the circum-orbital branches of the fifth pair, which seems to be impli- cated in the production of the symptoms, at the same time with the eyeball. Aqueous infusions of opium or other sedatives, used hot, may be thus employed, or the vapor may have a more stimulating character, if desired, by adding a little of one of the anodyne tinc- tures to boiling water. The tinct. saponis et opii of the old pharmacopoeia seems often serviceable. A solution of iodine in chloroform, ten to twenty grains to the ounce, allowed to. act as vapor upon the parts contiguous to the. eye, the lids being kept closed, also answers an excellent purpose. These means should be used once or twice a day. The patient should be advised to take exercise, and allowed such a diet as seems best adapted to his general condition. . He should be encouraged to accustom the eyes gradu- ally to more and more light, and after a time to attempt to use them for purposes which do not de- mand any considerable exertion. He must not be allowed to entertain a morbid dread of light as likely 234 DISEASES OF THE EYE. to cause blindness, for such is by no means the ten- dency of the disease, — and even if he feels some pain after unusual exposure, he must not give it too much attention, unless it persists and seems evidently to lead to a decided relapse. In some hysterical cases, a forced exposure has sometimes had a similar influ- ence to that produced by a sudden fright in hysterical aphonia. But such a procedure should not be re- solved on without due consideration, and when the physician is satisfied that the symptoms are kept up after their cause has been removed. This veritable affection is to be distinguished from the simulated inability to bear light sometimes met ' with in hysterical persons. Close observation of these latter when their attention is otherwise occu- pied will enable the physician to convince himself that the symptoms are in a measure voluntary, and by inquiry he may often discover an evident motive for the assumption of an affection so well adapted to attract sympathy and relieve the individual from the necessity for disagreeable exertions or duties. MUSCJE VOLITANTES. The appearance observed by patients as if flies or small particles of soot were floating, or as if the vapor from a hot stove were rising and falling before the eye, is a frequent cause of anxious inquiry from them, as to whether these phenomena are a precursor of blindness. The impression has been very common MUSCJ; VOLITANTES. 235 that they were symptoms of incipient amaurosis, and patients have sometimes been subjected to long-con- tinued active treatment for their removal, as well as to most intense and unfounded mental anxiety. These floating spots have been ascribed by some authors to different classes of corpuscles, situated mostly in the vitreous, and actually moving before the retina with the movements of the globe. But they cannot be detected with the ophthalmoscope or seen upon dissection in many of the instances where patients have been annoyed by them. As they are met with in all persons under certain circumstances, and do not interfere with vision, they are not to be regarded as a disease, unless accom- panied by other symptoms. Most individuals can perceive them after more than ordinary use of the eyes upon small objects, after loss of sleep, or when much fatigued or in a state of debility; especially if they make an effort to discover them. They have sometimes a resemblance to flies, in other cases to filaments, or strings of pearly or watery globules. If the eye be turned quickly to- wards the ceiling or the sky, they ascend, to fall again, gradually, when the eye is left at rest. In reading they move from side to side of the page, never covering the exact spot looked at, but always a little on one side of it. It is when the person is thus employed that the minute black speck is the source of most annoyance. 236 DISEASES OF THE EYE. If an individual direct his attention to these ap- pearances they seem to become multiplied ; if, on the contrary, he is convinced of their slight impor- tance, and as far as possible ignores their presence, he soon ceases to be conscious of them, except now and then. As their presence seems to be more constant after the eyes have been overworked, it is well to advise that these should not be too long employed on objects which task their power of endurance. The general health of the patient should also be looked after, if need be. But the most important recommendation we can give the person who applies for advice is, to dismiss all apprehension as to the tendency of these phenom- ena to any serious result, and to think of or notice them as seldom as he can. By so doing he will usually be relieved from their constant presence, and if they should be sometimes observed during his whole life he will find them very endurable, when satisfied as to their harmlessness. As a rule, floating muscse are not entirely got rid of, and they may increase ; but they never degenerate into the fixed spectra which are evidence of actual changes in the retina or media of the eye and are sometimes the initial symptom of grave organic dis- ease ; though of course cases will sometimes be met with where the two orders of phenomena may coexist. SPECTEAL ILLUSIONS. 237 DOUBLE VISION. Vision of two objects is not uncommon as a symp- tom of paralysis of one or more of the muscles of the globe, where it is attributable to the loss of corre- spondence of the axes of the two eyes ; but it may also occur where there is no apparent deviation of visual direction. It is sometimes impossible for the patient to tell which of two objects he sees is the real one, and he cannot even guide himself safely without closing one eye. This condition of things is most common in persons recovering from fever, or in professional men who have been too closely confined to fatiguing duties. Rest, abstinence from much use of the eyes, and above all, travelling, are to be recommended. The prognosis is favorable where the symptom does not depend on organic change. Double vision with one eye alone is an effect of some disturbance of the refractive power and may sometimes be remedied by glasses. SPECTRAL ILLUSIONS. Patients are occasionally seen, who seem, to them- selves, to perceive objects which are not really pres- ent. Mental or bodily depression favors the occur- rence of this phenomenon. The symptom sometimes persists for weeks or months, but disappears with an improvement of the geuBral condition. 238 DISEASES OF THE EYE. Vision of colored or bright spots is complained of by some patients. When not connected with other disease, these visual impressions are due in most instances to some peculiarity of conformation in the eye, and are not likely to be influenced by treatment beyond the avoidance of any causes which have seemed to have had any agency in producing them. AFFECTIONS OF ADAPTIVE POWER OF THE EYE. 239 CHAPTER XX. AFFECTIONS OF THE ADAPTIVE POWEE OF THE EYE. In a normal condition, the eye is capable of adapt- ing itself, at once and without effort, to near or re- mote, small or large, objects. The precise mechan- ism by which the necessary changes of refraction are effected has long been a subject of inquiry and dis- cussion ; but it is now admitted that the power of accommodation of the eye to different distances is due principally to slight changes of form in the crys- talline lens, — its antero-posterior diameter, and con- sequently its convexity and refractive power, being increased or diminished by action of the ciliary mus- cle. The varying diameter of the pupil, governed by movements of the iris, also plays an important part by admitting or excluding lateral pencils of rays. When the ciliary muscle is paralyzed and the pupil widely dilated by the action of belladonna or other mydriatics, the accommodative power is abolished, and a person is rendered unable to see small objects with distinctness, except by the aid of additional refraction obtained by placing a convex glass before the eye. In the majority of persons, up to the middle period of life, this power of adaptation is exerted instantly 240 DISEASES OF THE EYE. and unconsciously, as the observer directs his atten- tion to various objects. But a want of perfection in this ability to change the vision at -will or even with- out conscious vohtion, exists, as a natural or acquired condition, in a large number of individuals ; and is scarcely regarded by them as an infirmity, so long as they are able, by artificial aid from glasses, to place themselves on a par with others. These variations from the average standard of adaptive power are, however, defects, and require most careful management ; otherwise the attempts made to perform the duties or enjoy the piivileges allowed to those who possess a full measure of this power, whether such attempts are made without as- sistance from lenses or with such as are ill-chosen, give rise to grave pathological conditions. In ordinary eyes, about sixteen inches may be re- garded as the point of most distinct vision. Any great variation from this focal distance constitutes long or short sightedness. mtopia; or short-sightedness. This affection consists in a want of distinct vision beyond a short distance, arising from too great refrac- tive power in the eyes. At a given distance, varying greatly in different individuals, vision is perfect ; and is even extraordinarily good, almost microscopic, for minute objects placed very near the eyes. Cases in which short sight is a symptom, accompa- MYOPIA ; OE SHOET-SIGHTEDNESS. 241 nied by other disease of the eye, are not included in our present description. Frequently, but not by any means invariably, the eyes of short-sighted persons are more convex and prominent than usual, and the pupil dilated. No other marked phenomena are to be observed on ex- amination, except the habit, usual with those affected, of half closing the lids when endeavoring to see ob- jects at a little distance. Some of the lateral pencils of rays are excluded by this action, leaving the more direct rays, which undergo little refraction, to form a more distinct image on the retina. For the same reason, the person sees quite distinctly in looking through a pin-hole in a card, only a few direct rays being then admitted to the eye. Causes. — Very few children seem to be affected in their earliest years, — or perhaps I should rather say, very few are conscious of being thus aflfected, — though the tendency is often inherited, and the symptoms may make their appearance in several members of a family. The age of puberty and the few succeeding years is the time when the myopia seems to have its most frequent development. Not uncommonly, the fact that a person does not see as well at a distance as others becomes accidentally dis- closed, on his taking up a pair of concave glasses, which seem to him to have revealed a new world ; giving him a clearness of perception of distant objects of which he never before had an idea. 11 p 242 DISEASES OF THE EYE. Apart from this hereditaiy predisposition, pro- longed use of tlie eyes in study, or in the exercise of trades requiring close employment of the eyes upon small objects, appear to be the principal causes of myopia. We rarely meet with this defect among sailors or savages, who are accustomed to look for ob- jects at gx'eat distances from them but seldom make use of the eyes for examining delicate objects. On the conti-ary, a large proportion of the cases of short sight are found among literary men, whose eyes are constantly employed in pursuits requiring close ob- servation. Prognosis. — As myopes advance in age, we might expect to find tlieir infirmity diminished. Such a spontaneous change seems, however, of rare occur- rence. But when persevering and continued efforts are made to obviate the defect by proper ti-aining, very much may be gained in focal distance. On the other hand, vision may become so much more limited in range, by too close devotion to literary pursuits or the improper use of concave lenses, that a person becomes scarcely able to see at all, with or witliout tlieir aid. One very effectual mode of inducing tliis result is by weai-ing strong concave glasses both for reading and for looking at distant objects, or wearing them in malcing sketches in the country, where vision is turned from the distant horizon to the portfolio a few inches only from the eye. The prognosis is more favorable in acquired than in hereditary myopia. MYOPIA ; OR SHORT-SIGHTEDNESS. 243 Treatment. — Where the affection is extreme in degree, and especially when the family predisposition is strong, it is seldom worth the while to deprive a person of the pleasure and benefit to be derived from properly chosen glasses. But, in many instances of acquired myopia, temporary self-denial, with proper exercise of the eyes, may so extend the focal distance that a good degree of sight may be enjoyed without resorting to eye-glasses or spectacles. This is espe- cially desirable, as, besides other inconveniences, it is quite an annoyance to be compelled to wear glasses in cold weather, the glasses being instantly bedewed with moisture on coming from a low temperature into a warm room. The sight should be exercised upon distant objects, and, with practice, details may be made out which were at first undistinguishable. If certain difficidt studies or occupations must be continued, they should be pursued only during daylight, and with frequent intervals of rest ; taking care at the same time that the eyes are not allowed to come nearer and nearer the book or work, but are kept at as long a distance as is compatible with clear vision. In reading, the book should be held as far from the eyes as the print can be distinctly seen, and an effort should be made gradually but slowly to increase the distance. If a person has enfeebled his vision or limited its range, by the abuse of too strong lenses, it is some- times necessary that he should abandon for a time 24-i DISEASES OF THE EYE. the use of all glasses, or employ them only rarely and as a necessity, until the eyes can be weaned, as it were, from the auxiliaries to which they have been so long accustomed. The same No. of glass is worn for all purposes by some individuals, without inconvenience ; but in other cases this course results, after a time, in an inability to derive the usual assistance from the glass, and neither minute nor distant objects can be clearly seen. In these instances the strong No. generally employed must be laid aside, and the eyes allowed a brief interval, at least, of rest, before making a new selection. Two pairs of spectacles should then be obtained, — one, of the focus with which distant things can be well seen, the other of less power, for reading and writing, if the convenience of the person requires them to enable him to avoid the necessity of stooping forward. As a rule, in order to avoid the condition just described, glasses should be laid aside when a myopic person is engaged in reading and similar occupations. The tendency to an increase of the infirmity is thus counteracted, and the same lens will afford clearer vision of things at a distance than when it also serves for near objects. But if the individual is extremely short-sighted, it may be necessary for his health to allow him some assistance while writing, that he may sit erect, and not have his digestion and comfort interfered with by a cramped MYOPIA ; OR SHORT-SIGHTEDNESS. 245 posture. A sliding music-stand on the piano may be used, to bring the musical score within a proper dis- tance of the eye, and a similar mechanical contrivance may be resorted to for writing, the desk beiug brought up to the required level. If some further aid be needed during these occupations, the glasses selected for this purpose should be very shallow, usually sev- eral numbers less strong than those for distant vision. It is only in exceptional cases that the same glasses may be allowed to be constantly worn ; where they have become as it were second nature, do not occa- sion unpleasant symptoms, and seem to bring the eye as nearly as possible to a normal condition. Spectacles are to be preferred to eye-glasses, as they retain their place more steadily in front of the eyes. If eye-glasses are chosen as a matter of taste, they should be double rather than single ; otherwise vision of the two eyes is rendered unequal, and the eye least employed often becomes enfeebled from disuse. Whatever glasses are made use of, they should be worn parallel to the plane of the iris. Allowing them to become obliquely displaced in front' of the eyes increases their refractive power but at the same time renders it irregular. If a higher No. is really needed, it should be procured, rather than to endeavor to dispense with it by an improper position of the glasses. 246 DISEASES OF THE EYE. Double concave glasses are preferable to those termed periscopic or having a meniscus form. Peri- scopic glasses offer only one advantfige, — that of giv- ing a slightly increased lateral range of vision without turning tlie head. They are therefore better adapted to the purposes of myopes, than to aged persons who only require spectacles for direct vision of near ob- jects ; but their refraction is less fi-ee from aberration than is that of double concaves, which are therefore most practically useful. Further directions as to the choice of spectacles will be given in a subsequent chapter. I will there- fore only state the general rule which should govern those who are short-sighted. They should select the lowest power with which objects are made reasonably distinct; rejecting those which diminish the size of objects while they increase their clearness of outline beyond the natural degree. By the aid of those which are just sufficient, a person may often see for years without fatigue of the eyes, and without in- creasing the focal power of his lenses ; whereas, if he commence with those which give to objects im- natural brilliancy and reduced size, he wears them with less comfort, sees less well without them, and soon finds his myopia increased, so tliat he is com- pelled to take a stronger glass to obtain the same effect which he at first enjoyed. If he now yields to the renewed temptation, and substitutes a yet stronger glass than is required for those he has worn, he soon PRESBYOPIA ; OR LONG-SIGHTEDNESS. 247 finds them also inadequate, and may end by reaching a point where he is nearly unable to see with any glasses. Having adopted a glass of suitable focus, a change to a higher power should not be hastily made ; though there is no objection to such a change when the first has evidently become insufiicient. PEESBTOPIA; OR LONG-SIGHTEDNESS. With the exception of those who are myopic, most persons of about forty-five years of age begin to ex- perience difficulty, at times, in the perception of small objects. Distant things are still seen as clearly and readily as ever ; but in attempting to read a fine print, to thread a needle, or examine minute details, the light seems insufficient, and the object blurred and indistinct. If he persist in his endeavor to define the objects, they become yet more confiised, and he begins to feel pain in and above the eyes. At first, these symptoms are only perceived in the evening or in a dim light ; and the individual reads or works very well in a clear day, or by concentrating light upon the object, or by removing it further from the eyes and thus allowing the refracted image to be formed upon the retina instead of beyond it. After a time the same want of clear perception is observed at all hours and in all situations ; and, but for arti- ficial aid, the occupation of many a man of letters and many an ingenious workman would be gone. 248 DISEASES OF THE EYK. Causes. — The changes in the globe which cause insufficient refraction and this imperfect vision, can seldom be discovered from any alteration in its ex- ternal appearance. As greater prominence of the eye is sometimes observed in the myope, so unusual flatness has been described as accompanying long- sight. But though this may exist, its degree is not sufficient to make it obvious. Probably more or less change takes place in all the parts concerned in re- fraction. That mere flattening cannot explain the phenomena is shown by the instances, which are not unfrequent, of very aged people, who, after having worn glasses for many years, are able to throw them aside and read without assistance. Now and then we meet with instances where long or old sightedness is present at a very early age. In two families lately under my notice several members have been compelled to make use of glasses, for reading, from the ages of from seven to ten years, — and as they grew a little older were also under the necessity of wearing a lower power of convex lenses for seeing distant objects. No apparent peculiarity of conformation existed in their eyes. Presbyopia is hastened and increased by too long- continued, fatiguing use of the eyes, and by putting on spectacles belonging to older persons when they are not required. Those whose pursuits keep their attention constantly occupied on distant objects are frequently affected at an eai'lier period than others. PKESBYOPU; OE LONG-SIGHTEDNESS. 249 Treatment — The coquettishness which makes some persons unwilling to confess their need of glasses, and the prejudice which others have against resorting to them, from a belief that if they refuse their aid they can, after a short time, see as well without as with them, are both sources of much injury to sight. When the period actually arrives that the eyes begin to see less readily, they are but fatigued and strained by forced attempts to continue occupations for which they have become incompetent. The fact that a few persons, who perhaps were naturally more or less short-sighted, are able to go on to an advanced age without employing spectacles for reading and writing, by no means constitutes a general rule ; though such individuals are often found advising abstinence from glasses as a sure means of placing others in the same category with their own exceptional cases. It is needless to say their advice is ill-judged. The adoption of glasses may, however, be post- poned for a while, if the individual will relinquish his endeavors to use the eyes for purposes to which he finds them unequal. By avoiding reading or similar employments by artificial light, and refraining from continuing them after the eyes are fatigued, he may be able to dispense with auxiliaries to vision for months or years. But if unable or unwilling to make this temporary sacrifice of his usual pursuits, and satisfied, that with assistance from lenses of feeble 11* 250 DISEASES OF THE EYE. power, lie can be relieved from the painful sensa- tions accompanying efforts to see small objects with his naked eye, — he should accept the alternative, even though his age may be considerably less than the average period for the manifestation of pres- byopia. On the other hand, we are not hastily to advise glasses in all cases where they may seem at first sight to be required ; for we meet with examples where rest from fatiguing avocations, rather than artificial help in pursuing them, is imperatively called for, and where glasses would be but a tem- poraiy relief to over-strained organs. One reason for the belief that eyes are injured by taking glasses, as it is thought, too soon, has arisen from the imprudent manner in which they are often assumed. A person beginning to require very bright light for reading or sewing, and to hold things at a longer distance than formerly, is told by some relative very much older than himself to try Ids glasses, and finding that with these objects appear beautifully distinct and large, he resorts to their help on all occasions. But, being of a focus altogether too high for the reqtiirements of his own eyes, he soon finds their use for any considerable time is followed by pain, and that he sees less well, with or without them, than at first. In the mean time, however, he has created an inability to derive sufficient assist- ance from glasses of lower power, which he might PRESBYOPIA V OR LONG-SIGHTEDNESS. 251 have continued to wear for a long time, with com- fort and advantage, had he commenced with them. The only plan to be adopted under these circum- stances is, to give up all glasses for a short time, and then select those of the lowest power which will ren- der vision distinct. On first assuming glasses, they should not be worn too long at a time, as the eyes may be fatigued by their unaccustomed presence, no matter how judi- ciously they may have been selected. After a little time, they may be used freely, for hours together, though it is well now and then to reheve the eyes by laying aside the spectacles and looking for a few mo- ments at large objects. The glasses for reading and sewing should not be worn when these occupations are finished. Many persons do their eyes much harm by keeping their glasses upon the nose when moving aboulr'the house, or while engaged in conversation. The eyes thus become less able to accommodate themselves to near or distant objects ; their focus being limited, as it were, to that of the glasses ; and a necessity is soon created for a change to a higher power in order to derive the usual assistance in minute vision. In selecting glasses, those should be chosen which render small objects quite clear, at the ordinary dis- tance at which a book or work would be held, — but which do not magnify them. It is well to choose them in a moderate light, that they may be suffi- 252 DISEASES OF THE EYE. ciently strong for use in tlie evening as well as by day. Thus chosen, the same pair of spectacles may often be worn for a considerable number of years, without requiring to be changed for those of higher power. When they become insufficient, they are to be replaced by others selected on the same principle. As I have already stated, if too high a focus is taken at the outset, the eyes are over-stimulated, and soon become so enfeebled as to require further aid, which, if ill adapted, speedily becomes, in its turn, incompe- tent to answer the purpose. Those who ai"e excessively long-sighted often need lenses for ordinary out-of-door vision, as well as for small objects. They should never permit themselves to wear their reading-glasses for these purposes of distant vision, but should procure a much feebler pair, sufficient to give a natural appearance to per- sons and things at a distance, without dazzling or confusing the eyes. CHOICE OF SPECTACLES OK EYE-GLASSES. 253 CHAPTER XXI. CHOICE OF SPECTACLES OR ETE-GLASSES. In addition to the rules already given for short and long sighted persons, some general directions in re- gard to glasses may be useful. As a rule, double concave and double convex lenses are preferable to those which have one plane surface or are concavo-convex. I have already mentioned the advantages and defects of periscopic glasses. Those who use glasses both for seeing at a distance and for reading, sometimes have them set together in spectacle frames, — the upper half or two thirds of the glass being of the focus adapted to distant vision, the lower half or third of the focus required for reading. They are thus spared the trouble of having two pairs of glasses ; but the plan has some disadvan- tages, it being more difficult to secixre accurate re- fraction and avoid confusion of sight. Most of the lenses used for spectacles are made from carefully selected glass. Those of quartz crys- tal are less easily scratched, and, if ground with proper reference to the axis of crystallization, are preferable to those of glass. If not thus ground, 254 DISEASES OF THE EYE. they are inferior. Carefully prepared lenses of crys- tal are too expensive to be in common use. Lenses are ground upon accurate spherical sur- faces, having certain established radii. These sur- faces are convex for the concave, and concave for the convex glasses. The best mode of numbering the glasses is that according to the radii of the circle on which they are ground; this being also their focus. According to this scale, the smaller the No. the higher the power. For convex glasses the French scale begins with ninety-six inches, or eight feet radius. Varying at first twelve inches from one number to another, at seventy-two inches the dif- ference becomes but six inches. At twenty inches focus the difference is but two inches, and at sixteen, but one inch between the Nos. From five inches the glasses (which are those usually worn after operations for cataract to replace the crystalline lens) have a variation of but a quarter of an inch from number to number. Concave glasses are arranged according to a similar scale, beginning with seventy-two inches. Those residing at a distance from cities are liaUe to much imposition as regards the quality of glasses. Many of those fabricated are rejected as imperfect by opticians who are judges of them. These are sold to jewellers and country shopkeepers, and a still lower grade to pedlers, — who" are none of them able to discriminate between those which are perfect and CHOICE OF SPECTACLES OR EYE-GLASSES. 255 those inaccurately ground, — and by them are dis- tributed everywhere. It is not to be wondered at that persons supphed with a handful of such glasses of different powers, and with no one to guide them in making a selection, should often make choice of a focus quite unsuited to their wants. The form of the frames of spectacles and eye- glasses varies with the caprice of the public and the opticians. At present and for some time the prevail- ing fashion — and a most sensible one — has been a large oval or approaching to an oval form. This harmonizes with the shape of the border of the orbit and with the eye as seen between the lids, and its large size gives a good range of vision, and renders the frame itself less visible to the wearer. It is to be hoped that the smaller octagonal frames once in vogue may never be restored to favor. The distance from the centre of one glass to that of the other should be about two and a half inches, — that being the average distance between the eyes ; but in fitting different individuals an optician can adapt the dis- tance at the same time that he makes the bridge between the glasses conform to the nose of the wearer. The frames may be of gold, silver, steel, or tortoise-shell, according to the taste and means of the wearer. They should be light, so as not to be bur- densome to the noSjC, but sufficiently strong. Light steel bows are the least conspicuous. Silver mount- ings are perhaps most economical for the poor, as 256 DISEASES OF THE EYE. they are less likely to be broken, and can be more easily repaired than those of steel, which, if of good quality, are of about equal cost. Very cheap glasses should always be regarded with suspicion. Eye-glasses may be oval or round, according to fancy. Of late years those with a steel spring, by which they are kept upon the nose, are much worn. But the spring should not be so strong as to pinch uncomfortably, nor so weak as to allow the glasses to take an oblique position to the plane of the iris. Double eye-glasses should be used. Glasses should not be carried in the pocket or •worn from the neck unprotected by a case, as their perfection is soon marred by scratches. They should not be fingered, and if soiled or damp should be wiped with a bit of chamois or wash leather, or fine soft linen. When possible, any one desiring glasses should go in person to select them fi-om the establishment of a good optician. No description of the age of the in- dividual, or calculation based upon his point of dis- tinct vision, will insure so good a selection as can be made after actual trial. But if unable to go, the age and sex, the distance at which an ordinary print can best be seen with the naked eye, the fact as to whether or not glasses have been previously worn, and if so, how long and with how many changes, should all be accurately stated. If glasses have been worn, they should be sent, specifying whether the CHOICE OF SPECTACLES OE EYE-GLASSES. 25T frames have fitted, and whether the glasses have or not suited the eyes. When several pairs can be ob- tained, and the choice made after testing them at home, and at his leisure, a person is sometimes able to make a better selection. English and American opticians have generally- favored the adoption of a glass of forty-eight or even of thirty-six inches focus as the first No. for those who have never before worn spectacles for reading. But I am satisfied the continental oculists are right in insisting that these Nos. are in some instances too strong for those who take them for the first time. A lens of seventy-two inches radius sometimes gives more comfortable and natural vision than one of higher power. If sufficient to give perfect distinct- ness to minute objects in a moderate light, it is better to take this to begin with, as it is easy to ascend the scale should it become too feeble. As I have before said, glasses should have little magnifying effect for the person using them. If, however, the eyes re- quire glasses of forty-eight or thirty-six inches focus for reading, these may be accorded. Should a per- son, assuming glasses for the first time, desire a No. much stronger than these, the eyes should be care- fully examined and tested before the choice is ap- proved. At a more advanced age, or when glasses have been already worn, any No. required by the individual may be assented to ; care being taken that the focus is not greater than is actually needed. Q 258 DISEASES OF THE EYE. The same principles are to be applied in selecting concave glasses for short sight. The least power ■which will satisfy the wants of the beginner is best for him ; and, on increasing their strength at any time, he should confine himself to the same limit of necessity or convenience. Occasionally we find it necessary to advise glasses of difierent foci for the two eyes, on account of a marked natural or acquired inequahty ; but in many instances even those who have a considerable diflFer- ence of range do not see as well with glasses adapted to each eye as with two glasses of equal power, the actual fact differing firom what theory would have led us to suppose. The No. of glasses probably required by an indi- vidual may be determined approximately by calcu- lations based on the difference between his point of distinct vision and tlie distance at which we wish him to read. But, though theoretically perfect, ob- servation proves that here also the results of mathe- matical calculation are liable to be defective in their practical application ; and that the best choice is obtained by actual trial. Should it be desired, how- ever, to attempt a selection according to such a formula, the distance in inches at which a person reads may be multiplied by the distance at which we wish him to see, and this product, divided by the difference between the two distances will give the focal length in inches of the glass required. If, for CHOICE OF SPECTACLES OE EYE-GLASSES 259 instance, twenty inches is the nearest point at which a person reads with distinctness, and we wish to give him the power of reading at twelve inches, we have, 20 multiphed by 12 = 240 ; this sum, divided by eight, gives thirty inches as the focal length probably required. I have found a full set of glasses of the greatest service in aiding in the adaptation of spectacles to difficult cases ; as well as in determining nice ques- tions of diagnosis. Cataract-glasses have been spoken of in another chapter ; their use occurring mostly under circum- stances connected with operations for the removal of the crystalline lens. 260 DISEASES OF THE EYE. CHAPTER XXII. ASTHENOPIA. The want of power to apply the eyes continuously to small objects constitutes one of the most trouble- some affections of these organs. The patients are mostly young, and find themselves hindered, in the pursuits to which they wish to be devoted, by this inability. Vision is as good as ever ; distant objects can be looked at without fatigue, and minute things can be distinctly seen ; but after a short period of application, a sensation of fatigue commences, and goes on increasing till the individual is forced, nolens volens, to suspend his work. The sense of weariness extends itself to the forehead, and more or less pain ensues, not only in the eyes, but in the entire frontal region. Sometimes these symptoms compel the pa- tient to desist from his efforts, without any dimness of sight having been produced ; in other cases, this is added to the other phenomena, and contributes to force a suspension of his occupation. After even a few moments of rest, the person is usually able to resume his employtnent, but he cannot continue it long without a reappearance of the symptoms. Some individuals can use the eyes for a considerable time, ASTHENOPIA. ' 261 even an hour or two, before the supervention of the troublesome sensations ; others find their eyes tolerant of only a few moments' close application. On examining the eyes of such persons we seldom see any marked changes. Sometimes an inactive, dull expression, difficult to describe, may be observed by a practitioner of experience. No pain is complained of in some of the cases, except after exertion of the eyes ; in other instances a dull pain, and perhaps slight sensitiveness to light, is much of the time present. Causes. — The exanthematous and febrile diseases seem to be not unfrequent causes of this condition of the eyes, even when they have not been used im- prudently during convalescence. Great care should be taken, after attacks of measles and scarlatina, to avoid too constant use of the eyes, even for some time after recovery. Imprudent use in reading, during convalescence from any disease, is a fertile source of asthenopia. The habit of reading in bed, often in an unfavorable position as regards the light, the use of the eyes during twihght or in a feebly illuminated room, long-continued study by artificial light and during the hours required for sleep, undue exercise of the eyes for objects requiring close atten- tion, as embroidery, &c., — all these causes are fre- quently the origin of this aflFection in its most trou- blesome forms. The application of naturally long- sighted eyes to trades requiring close attention, as 262 DISEASES OF THE EYE. engraving, watch-making, &c., often develops the symptoms of asthenopia. The tone of the system is generally low, and many of the patients are of excitable nervous tem- perament. Any agencies tending to reduce the strength, and especially to exhaust the nervous sys- tem, are therefore likely to induce the disease. Anxiety, watching, and habits of masturbation in either sex, especially when the eyes are at the same time severely taxed, are efficient causes of this pecu- liar weakness of vision. Diagnosis. — The essential character of the affec- tion seems to consist in some disturbance of the faculty of accommodation ; the retina not being in- volved except as in all circumstances where an irregularly refracted image is formed upon it. It is to be distinguished from presbyopia, and from com- mencing amaurotic symptoms. The patient who is simply long-sighted does not see small objects dis- tinctly, even on first looking at them, but with the aid of a suitable convex lens everything becomes clear ; whereas an asthenopic patient sees as well as ever when he first looks at anything minute or after a little rest. The amaurotic patient has indistinct perception of large as well as small objects, and, if able to discern them at all, it is oflen after a continued effort, by which his eye seems to have its power developed and brought into action, instead of being lessened, as is the case in asthenopia. ASTHENOPIA. 263 Prognosis. — A feature of this affection which ren- ders it peculiarly annoying to the conscientious prac- titioner, is the impossibility of predicting its course. Nothing in the history or symptoms of any given case enables him to judge with certainty whether a prompt recovery will be effected, or whether the morbid condition may be of indefinite duration. If it evidently depends on some curable derangement of the system, the prognosis is more favorable than when it has apparently been induced by excessive exertion of the eyes. Yet, in cases seemingly the most favorable, we are often disappointed in the re- sults of our efforts, while in other subjects this fickle disease vanishes almost as soon as it appears, or yields suddenly to a change of remedies, after having held out against means which seemed of better promise than those which appear to be crowned with success. Of one thing the patient may be assured; that there is no tendency, in this disease, towards blind- ness. He may be unable to pursue his studies, or avocations requiring continued application ; but he need fear no worse fate. Treatment. — The origin of many cases of the affection in overwork, and the frequent failure of what appears to be well-adapted treatment, has led some to believe that rest was the only, and was an effectual means of restoration. Such is not the case. It is very common to see cases which have been left to themselves for years, the individuals abstaining 264 DISEASES OF THE EYE, from even an insignificant amount of use of the eyes, and placing them in the most favorable circum- stances, without realizing the least improvement. Yet these same cases sometimes prove readily ame- nable to treatment. Though indisposed to admit the efficacy of entire abstinence from use of the eyes, I by no means un- dervalue the benefit to be derived from partial repose of the affected organs. The patient should use them for purposes which cause least fatigue, and for short periods only at a time. While doing so, it is well to relieve them occasionally by looking ofi" from the book or work, and fixing them for a moment on larger objects. K slight uneasiness or pain is felt, the occupation need not be laid aside, as it is better not to regard too seriously symptoms which have become as it were a habit ; but if the pain increases, and is accompanied with dimness of vision, or if experience has proved that the pain persists in any case for a long time after the use of the eyes is suspended, it is proper to abandon ftirther efforts for the time being, and allow an interval to elapse before renewing them. Many persons whose eyes cannot bear two or three hours continuous employment, are able to use them to this amount, or even more in the day, provided the work is done piecemeal, not more than a quarter or half an hour at one time, with suitable intervals of rest. If this plan is followed, proper attention ASTHENOPIA. 265 being given to the removal of all exciting causes of the symptoms, and to the improvement of the general health, patients are often able to acquire, in a short time, such a measure of ability to use the eyes as serves to encourage them, and to afford a foundation for further progress. It is often imperatively necessary, where the affec- tion has been induced by close application to some sedentary occupation requiring constant use of the eyes, to advise that the avocation should be changed for one better adapted to their sensitive condition ; otherwise the morbid condition is kept up and treat- ment is of little advantage. Such remedies are to be employed as seem adapted to the condition of the patient. As a rule, tonics and good diet are indicated, rather than depletive measures of any description. The primse vise should be kept in good order and any habitual constipation or diarrhoea corrected. Lupulin, and remedies of this class, have an excellent effect in some instances where the nervous system has lost its tone. Mod- erate exercise in the open air is to be recommended ; but it is important to avoid excessive fatigue, which does harm by bringing on prostration of the nervous functions. It is well to have the patient surrounded by agreeable circumstances, and to devise means for keeping his thoughts occupied by something else than the state of his eyes. As local applications, the vapor of spirit of rose- 12 266 DISEASES OF THE EYE. mary, tinct. sapo. et opii, or tinct. opii added to boiling water, or of sulphuric ether, — held near the eyes once or twice a day, — are sometimes of seirice. Where much pain is complained of, lotions about the eyes, upon the brow and lids, with diluted tinct. of cannabis indica, or appKcations of saturated tinct. of aconite above the eyebrows at bedtime, by means of a small camel's-hair brush, are often effectual means of relief. These not only subdue the pain, but have a favorable influence in other respects in some cases. The aconite should be carefully sponged off in the morning before washing the face, as it causes much pain if it enter the eyes. A mUd collyrium of a soothing rather than stimulating nature, as a solution of borax of ten grains to the ounce, is often grateful to the eyes, and favors their recovery. It is espe- cially serviceable when we find any coexistent roughness or injection of the conjunctiva. Where there is much dilation of the pupil, the solution of sulphate of morphia is frequently beneficial, one or two drops being put into the eye once a day, as contraction of the pupil can sometimes be produced by this means. Lotions about the eyelids with cold or tepid water may be allowed, if grateful to the patient. In other cases where pain is felt after attempts at use, relief from this symptom and permanent advan- tage is often derived from the use of a solution of iodine in chloroform, ten grains to the ounce, which ASTHENOPIA. 267 should be kept in a glass-stoppered "eye-bottle." Once a day, or more frequently if required for the relief of pain, the stopper is removed, and the cup at the mouth of the bottle is applied to the closed lids till the vapor finds its way through them and quite a sensation of heat is felt in the eyeball. The same remedy is also of service in certain cases of photophobia. The bi-sulphuret of carbon, used in a similar manner, is occasionally of service. Convex glasses are often a grateful assistance to eyes thus diseased. They should be used only in cases where the patient is able by their aid to see small objects clearly and with comfort, and should have such focal power as to clearly define without enlarging objects. In young subjects, the glasses may sometimes be used for a time and then laid aside, the eyes regaining their normal capabilities under a course of tonic treatment. It is necessary to add that these auxiliaries are of no service what- ever in many instances of this affection, and they should be advised only after careful consideration of the circumstances of each case ; as otherwise they may impede rather than promote the patient's re- covery. Counter-irritation was formerly largely employed, but is less highly estimated by most of the best recent authorities. My own experience leads me to attach little value to any of its forms, in this class of affections. 268 DISEASES OF THE ETE. A sea- voyage is often recommended; but I have seen little if any benefit from the voyage itself. The change of scene, rest from fatiguing occupations, and mental excitement gained in visiting interesting countries, seem to be of more service than a voyage alone, even in favorable latitudes. Where the voy- age exposes the eyes for a long time to a bright glare of light, involving also the mnui attendant on want of occupation and lack of agreeable companions, it is more likely to do harm than good. STRABISMUS. 269 CHAPTER XXIII. AFFECTIONS OF THE MUSCLES OF THE EYEBALL. STKABISMUS. Strabismus, or squinting, consists in a loss of tiat harmonious muscular action in the two eyes which is necessary to give them a parallel or correspond- ing direction. It is difficult to explain the precise nature of the change in the action of the nerves which supply the muscles of the globe, rendering it impossible to direct both eyes at the same time towards a certain object. It is not paralysis, for as soon as the other eye is covered the affected eye assumes a normal position, and can be turned in all directions. Strabismus is most frequently convergent, the eye being turned towards the nose when the sound eye is looking straight-forward. In a small proportion of cases it is divergent, — very rarely the eye is turned upwards or downwards or obliquely. The degree of variation is sometimes so slight as scarcely to be perceived ; in other instances so extreme that the cornea of the affected eye is hidden from view at the inner canthus. Vision in the eye principally implicated is almost 270 DISEASES OF THE EYE. always less good than in the other when the affec- tion has existed a long time, especially if it date from early childhood. This state of things is often the consequence of the want of harmony in the eyes, as the retina of the affected eye, no longer receiving a distinct image of objects, comes at length to dis- regard the impression made upon it, and is gradu- ally enfeebled by want of use. The fact that great improvement in vision often results from the opera- tion for restoring the proper action of the eyes, indicates the importance of removing the disease at at an early period, before its iniSuence has become confirmed, not only that deformity may be obviated, but that vision may be preserved. Unequal power in the two eyes may also be a cause as well as a con- sequence of this affection ; the strabismus resulting from a semi- voluntary effort to get rid of the dim and confusing image received on one of the retinae. Both eyes are often involved, though one is much more so than the other. To decide which is most affected, the readiest method is to cover first one eye and then the other, observing which of them deviates most. Sometimes the eyes are equally affected, but the strabismus alternates, showing itself first in one, then in the other. The disease is often intermittent at the outset, even where it afterward becomes confirmed. In most of these cases, where the distortion is not excessive, an operation on one eye will be sufficient to restore parallelism. STRABISMUS. 271 Causes. — Scarcely any cases occur wliere the affec- tion is congenital ; but it is sometimes hereditary. The most frequent causes seem to be, some of the diseases of childhood, — as hooping-cough, convul- sions, measles, — imitation of others who are affected, — and a habit in very young children of looking habitually in one direction ; as, for instance, towards -the light entering always at the same side of their bed or cradle, or at a mole upon the nose or face. Opacities of the cornea sometimes give rise to it, an effort being made to receive a more distinct im- pression of objects by turning towards them a trans- parent part of the cornea. If these opacities are but temporary, no operation is to be recommended, as the strabismus will disappear after the opacity which gave rise to it shall have been removed. Strabismus may occur, as a temporary symptom, when a child is suffering from intestinal irritation, difficult dentition, or other causes of morbid excite- ment of the nervous system. Diagnosis. — Strabismus is not to be confounded with the immovable distortion of the eye occasioned by actual paralysis of some of its muscles. This condition of things, which is termed luscitas, may exist where there is a loss of power of motion from disease of the brain or other agencies affecting some of the motor nerves ; or it may be due to a tem- porary abolition of nervous energy, as in cases of paralysis of the third pair after exposure to cold, or after exhausting illness. 272 DISEASES OF THE EYE. Treatment. — When the symptoms are of recent appearance, and especially if we can discover any probable cause, we must endeavor to throw them off by the removal of the circumstances in wliich they originated. In feeble children, tonic regimen, exercise in the open air, a removal for a time to another situation, are often means of preventing the confirmation of an incipient squint. Covering the sound eye, and exercising the other for some time every day, is of advantage in some cases. The use of prismatic glasses, compelling the af- fected eye to take a different position to avoid con- fusion of vision, is a means of cure in some degrees of strabismus. Various goggles, shades, and other mechanical appliances have been contrived, to be worn for the removal of squinting; but they have seldom been of any avail. Since the introduction of the operation for division of the affected muscle, all the former methods of treatment have nearly fallen into disuse ; thus proving their slight actual value as a means of effect- ual relief in confirmed cases. OPEKATIONS FOR STEABISMUS. The operation for division of the muscle on which the deviation of the eye depends has proved so sat- isfactory that it has nearly superseded other remedial OPERATIONS FOE STRABISMUS. 273 measures. It is not to be performed, however, where the strabismus results from causes which it may be hoped are of only temporary effect, — where it is due to paralysis of either the third or sixth pair of nerves, — or in children, where the affection has not become confirmed. / When the deviation is slight, an operation on one eye is generally sufficient ; but where convergence is very marked in both eyes, it is frequently necessary to perform a double operation before perfectly har- monious action is recovered. A second operation should not, however, be too hastily resorted to, as we often obtain an excellent result from a single opera- tion, where, at first sight, it seemed probable that section of both muscles would be required. When the eyes differ in visual power, the weaker of the two should usually be selected for operation in all cases of alternating strabismus. In other in- stances, the same rule generally holds good ; as the eye in which the deviation is most evident is likely to be feeblest in vision. Time for Operating. — Any and all seasons may be selected for the operation, which is of so slight importance, as regards any after effects to be dreaded, that very few precautions are necessary. Position of the Patient. — The patient may sit in front of the operator or recline on a couch. Chil- dren should lie on a couch or be held on the knees of another person. 12* E 274 DISEASES OF THE EYE. If ether be given, the rechning posture is most convenient, though not essential. If the patient is of reasonable age and firmness, the pain of the operation can be very well borne ■without resorting to anaesthetics ; but if the person is nervously apprehensive, or is a young chUd, it is better to administer ether. The operation can thus be more quickly done, and with less disturbance of the parts contiguous to the muscle ; but it is difficult to judge of the precise effect of the operation till the patient recovers from the antesthetic condition, and consciousness and muscular power are restored. It is necessary that the patient should inhale more ether or chloroform, when the eye is to be the seat of operation, than when operations are done at a greater distance from the brain and upon parts less exquisitely sensitive. Modes of Operating. — I shall describe the opera- tion as performed upon the rectus Lnternus, for con- vergent strabismus, all the other operations, when required, being executed in a similar manner. If the surgeon be provided with one of the spring elevators, which keep the eyelids separated without requiring to be held, he can dispense with the ser- vices of an assistant ; but if the operation is per- formed without ether, it is more comfortable for the patient to have his lids held open by the finger ; though it is not necessary to have an experienced aid, — any friend of the patient being able to per- form the duty. OPEEATIOHS FOB STEABISMUS. 275 It is unnecessary to describe all the modifications which have been proposed in the methods of oper- ating. They are virtually comprised in two principal modes : in the sub-conjunctival, the muscle is divided with but a mere puncture of this membrane ; in the other, the conjunctiva is first divided to a certain extent, to expose the muscle, which is then cut. For the sub-conjunctival operation, the instruments necessary are a small hook or forceps to raise a fold of the conjunctiva, a lance-shaped knife curved on its flat surface, and a probe-pointed knife like those used for tenotomy, but having a peculiar bend of its shaft near the handle. It is well to cover the other eye, that the affected eye may move more freely, and may be directed for- wards at the moment of commencing the operation. A fold of the conjunctiva over the lower edge of the internal rectus is raised with the forceps, and the lance-shaped knife is passed through this membrane and the fascia beneath it, and carried into the sheath of the muscle so as to pass behind it. Its convex surface is to be directed towards the globe, that the risk of puncturing the sclerotica may be avoided. The probe-pointed knife is then to be passed through the wound and behind the muscle, which is to be divided by turning the edge of the knife forward, and giving it a slight sawing motion, the patient being directed to turn the eye outwards as much as possible, or, if necessary, the globe being turned in 270 DISEASES OF THE EYE. this direction by seizing it with forceps, so as to render the fibres tense and facilitate tlieir section. The advantages of this method are, that the danger of falhng back of the caruncle to hide itself at the inner canthus, or of tlie formation of granulations in the wound of the conjunctiva are avoided. Its disadvantages are, the considerable ecchymosis which results fi-om the effusion of blood between the con- junctiva and sclerotica, the greater difficulty of de- termining whether all fibres of the muscle have been completely severed, and the danger of penetrating the globe with the instrument used for making the punctm-e ; a danger which has not always been avoided, even by skilfiil operators. For the other method of operation, the instruments required are a forceps for seizing a fold of conjunc- tiva, a pair of straight or curved scissors, and a blunt hook to raise and bring forward the muscle. The usual direction of the incision has been vertical, but some have proposed to make it horizontal to pre- vent falling in of the caruncle. The last plan ren- ders it more difficult to reach and divide the muscle. I prefer an oblique incision, and one of very small size, as offering every facility, and, at the same time, perfect security against the possible objections to the vertical incision. A small fold of the conjunctiva and the sub-conjunctival fascia is to be raised with the forceps, half-way between the cornea and the inner canthus, and divided witli tlie scissors in an OPEEATIONS FOE STRABISMUS. 277 oblique direction, and a little below the equator of the eyeball, that the incision may be over the edge of the muscle. The blunt hook is then passed through the wound, carried behind the muscle, and brought out at its upper edge. This is then to be drawn towards the external wound and divided with the scissors. Should the breadth of the muscle or the smallness of the opening prevent the point of the blunt hook from being brought out at the wound, the conjunctiva may be seized with the forceps, and slid back over the point so as to allow of the division of the muscle without enlarging the conjunctival wound ; or this may be divided to a fiirther extent at the same time with the muscle. Should the eyes not appear parallel on testing them, the blunt hook should be again passed in, to explore if any fibres remain uncut. For some years I have in most cases inserted one or two points of suture, with very deli- cate threads, to bring together the edges of the wound of the conjunctiva ; and, although this is less necessary when only the small oblique incision I have advocated has been made, yet it gives an additional security against the falling back of the caruncula, or the formation of ftingous granulations in the wound, and hastens the recovery. The stitch may be placed so near the edges of the wound that the thread will be readily thrown off after union has taken place. But the case may be left to itself, if it is not possible to place the sutures on ac- 278 DISEASES OF THE EYE. count of returning consciousness as the effect of ether passes off. A very higenious hook has been devised by M. Boyer, the two blades of which may be separated after seizing the muscle, allowing room for the scis- sors to cut between tliem. But, though very con- venient in a case of strabismus instruments, it can perfectly well be dispensed with. In fact, with a pair of scissors, forceps, and a probe, which can readily be bent to the form of a blunt hook, the operation may be well and neatly done. The advantages of this method are, its freedom from the danger of penetration through the scle- rotica, which is regarded by many authorities as sufficient reason for discarding the sub-conjunctival method, its avoidance of the sub-conjunctival effu- sion, which requires considerable time for its ab- sorption, and the facility it gives for satisfying ourselves that every portion of the muscle has been divided. Its disadvantages are, the possibility of slight sinking of the caruncle, or of the appearance of a small ftmgus at the centre of the wound, — neither of which consequences are to be looked for when the fine suture is employed. Both these accidents, and an abnormal protrusion or eversion of the globe, were liable to happen after the operation, when unskilfully done and with a large incision. But these effects are obviated by the sutures and by limiting the incision to a quarter of an inch in length. OPERATIONS FOE STEABISMUS. 279 No after treatment is generally required in either form of operation, except lotions -with tepid water or milk and water and keeping the patient from ex- posure to bad weather during the first two or three days. Should ecchymosis follow the sub-conjunctival method,, the blood will be re-absorbed. Should a fungus make its appearance in the wound, when the conjunctiya has been divided, it may be snipped off with scissors at a single stroke, or will fall off after some time if left to itself. When, on examining the direction of the eyes after the operation, we find that they are not parallel, we are to ascertain with the hook if section of the muscle has been fully accomplished. If the eye can turn completely towards the inner angle there must be some fibres undivided, or some attachments of the fascia or the sheath of the muscle which require separation. If the eye cannot be thus turned, the other eye must be at fault, and the same operation should be performed on the second eye, if deemed necessary. Should there be any question as to the propriety of a second operation, it should be deferred ; as parallelism is sometimes established after a short time, when at first it seemed unlikely to be so. It is often sufficient to divide the muscle in the second eye close to the cornea, taking care not to separate its attachments too largely. We are to avoid large incisions of the conjunc- tiva or fascia, or extensive separation of the sheath 280 DISEASES OF THE EYE. of the muscle fi-om its attachments, lest the gloLe should be everted or should become very prominent. Eversion is a worse deformity than the convergence which ori^nally existed. Should it occur, it may be remedied by division of tlie external rectus, — an operation on one eye being generally sufficient ; or, in extreme cases, by removal of the old cicatrix at the inner angle, and, after liberating the muscle from its new-formed adhesions, bringing it forwai-d and fastening it close behind the cornea by means of fine sutures. The dissection must be very deli- cately executed ; etheriKition being generally em- ployed to secure immobility of the eye and spare the patient the pain of a somewhat prolonged oper- ation. Double vision is sometimes complained of imme- diately after the operation; but, if this has been entirely successful, the diplopia passes off as the muscle becomes re-attached to the globe, and re- covers the power of moving it into proper positions to act with the other in receiving impressions of objects on corresponding points of the retina. Pa- tients sometimes speak of immediate improvement in vision; more frequently, tlie good effects, so fex as sight is concerned, are slowly developed. Very slight symptoms generally follow the opera- tion. Should the patient talce cold, he may have conjunctivitis in a mild form, requiring, however, merely tepid lotions for its relief. But though it is PAEALYSIS OF THE THIED PAIR OF NEBVES. 281 to be considered as involving no consequences en- dangering vision, the operation should be done with the greatest care, as Instances are on record, though as very rare exceptions, where the eyeball has been seriously injured by inflammation arising subsequent to its performance. PABALTSIS OF THE MUSCLES OF THE ETE. The muscles supplied by the third and the sixth pair of nerves are those most frequently affected. Less often the fourth pair is the seat of disease ; and in rare instances two or more of the motor nerves may be simultaneously affected. The diagnosis as to which branches are involved is a question requiring nice observation for its solution. PAEALTSIS OF THE THIED PAIE OP NEEVES. Branches of this pair supply the superior, inferior, and internal recti, the inferior oblique, the levator of the upper Ud, and those fibres of the iris whose action causes contraction of the pupil. One or more of these branches may be paralyzed while the others retain their function. The symp- toms will therefore be more or less extensive, accord- ing to the muscles whose function is suspended from lack of power in the nervous fibres distributed to them. When all the branches of the third pair are impli- cated, the eye is drawn outward by the unopposed 282 DISEASES OF THE EYE. action of the external rectus, the upper lid droops and the pupil is widely dilated. If the lid be raised with the finger, the eye is seen to be nearly immovable, and vision is confused, though it becomes clear, if the patient looks through a small hole in a card or uses a convex glass of sufficient power to regulate the refraction, disturbed by the enlargement of the pupil. Vision is double, except when tlie well eye is turned in the same direction with that of the affected organ. Causes. — This affection may depend on cerebral disease ; in which case the prognosis would be un- favorable ; but it is often induced by other causes, of which I have found exposure to cold and wet the most common. Walking in a rain or snow storm, with one side of the face exposed to a cold wind, is not rarely followed by this pathological condition. It appears also, in some instances, in those whose nervous system has been debilitated by illness. In both these last-named circumstances, the prognosis is most favorable, though recovery may be slow. Treatment. — When we have reason to suspect a sudden cerebral congestion, appropriate derivative or depletive measures may be employed. When pressure on the nerve by an abnormal growth, or extensive disease of tlie brain, is the cause of the symptoms, we can expect no favorable result fi'om remedies. Where we can discover the exciting cause to be of a nature involving less grave lesions, we may hope for complete success from judicious treatment. MYDRIASIS. 283 In- nearly all the cases where no organic change has given rise to the symptoms, we find the system in a condition below the standard of health. Good diet and tonics should therefore be recommended. Stimulating lotions may be applied about the eye- brows and lids. The use of strychnia seems scarcely called for, unless the paralysis persists. Aconite and veratria are sometimes useful. The symptoms gradually subside ; the muscles re- gaining their power, at first partially and afterward entirely. Several weeks often elapse before complete recovery. MYDRIASIS. This disease results from loss of power in the branch of the third pair which presides over the con- traction of the pupil, and may occur without other lesion or any impaired action of the recti muscles. The pupil is widely dilatfed, and vision is confused ; but, to. an accurate observer, no amaurotic symptoms are present. We are able to give great delight to a patient who had feared blindness, by proving to him that vision is as perfect as ever, if he look through a small hole in a card. Mydriasis may exist in one or both eyes, causing in either case an indistinct- ness of vision and a sensation of dazzling if exposed to strong light, as well as a feeling, in many in- stances, as if a foreign body were in the eye. Causes. — This condition may be induced by all 284 DISEASES OF THE EYE. the causes we Lave cited as occasioning paralysis of the third pair. It may also result from blows upon the eye, or from the influence of belladonna, stramo- nium, or other narcotics of similar action upon the nervous system. The internal administration of preparations or portions of these plants, or the ap- plication to the eye of even a very minute quantity of either, speedily induces an ai'tificial mydriasis, which continues several hours or days, according to the amount employed. The affection is sometimes seen in persons, espe- cially females, who have been much debilitated ; without the otlaer branches of the tliird pair having become affected. In this case both eyes generally exhibit the symptom. Enlargement of the pupU is often observed in amaurotic and glaucomatous disease; but these con- ditions are not included in the present description, and the dilatation is then accompanied by symptoms not exhibited in mydriasis, which denote its origin. Treatment. — Local stimulants, such as aconite or veratria, are to be apphed near the eye, and the same general treatment pursued as has been advised in general paralysis of the third pair. A solution of morphia may be dropped into the eye once a day, or diluted wine of opium may be used daily, or oftener, as a collyrium. When the mydi-iasis con- tinues for some time, the patient becomes accustomed to the influx of light, and is less annoyed by it ; but PARALYSIS OF THE SIXTH PAIE. 285 vision does not improve to a corresponding extent. It may be assisted by convex glasses, or, in extreme cases, a weak convex glass may be covered with dark paper except in a small circular space at the centre, so as to cut off all the lateral rays, which require most refraction, and give rise to an indistinct image. PAEALTSIS OF THE SIXTH PAIR OF NEKVES. The external rectus, or abductor, being the sole muscle supplied by this nerve, the eye cannot be turned outwards, and vision is double when the patient looks in the direction of the paralyzed muscle. It can be brought to a central position by the com- bined action of the inferior and superior recti, and its movements are natural in all directions but out- ward. The causes and treatment of this paralysis are similar to those described for paralysis of the third pair. PARALYSIS OF THE FOURTH PAIR OF NERVES. The more rare paralysis of the superior oblique muscle, which is alone supplied by this nerve, is likely to pass unrecognized at first sight. But the patient complains of double vision, and the two ob- jects, instead of being side by side, as in disease of the third or the sixth pair of nerves, are seen one above the other. This double vision disappears if the patient incline his head to one shoulder. 286 DISEASES OF THE EYE. On attentive examination, we can perceive that the cornea of one eye is lower than the other, the globe drooping a little in the orbit. If we incline the head first to one side and then to the opposite, we observe that the eye does not rotate freely on its axis. The same remark may be appHed as to the cause and the management of this, as to the paralysis of other branches previously treated of. ENTOZOA WITHIN THE EYE. The Cysticercus cellulosus is the form of entozoon most frequently met with in the interior of the eye ; though some other varieties have been seen. It has been found under the conjunctiva, in the anterior chamber, in tlie vitreous humor, and between the choroid and retina. The ophthalmoscope has added quite a number to the few previously recorded in- stances in which it has been observed. It appears like a nearly transparent globular mass, having an elongated portion extending from one part of its surface, and if closely watched, this elongated neck and the entire mass can be seen to change its form in slight degi'ees. If accessible, cysticerci should be extracted from the eye ; otherwise no treatment can be of any avail. The examples of other parasites within the eye have been so very rare, that I feel justified in omitting their description from these pages. PTOSIS ; OB FALLING OF THE UPPER LID. 287 CHAPTER XXIV. AEFECTIONS OF THE EYELIDS. Several of the abnormal conditions which may be produced in the eyelids by disease or accident would be unimportant, if they existed in another part of the body, but require special attention on account of their peculiar relations to the organ of vision. PTOSIS; OE FALLING OF THE TJPPEE LID. Falling of the upper hd has been already alluded to as occurring in consequence of paralysis of the. third pair. It may also result from hypertrophy of the lid, or from congenital or other weakness of the levator muscle. These latter cases may be distin- guished from paralysis, by the fact that, if a portion of the integument is held up by forceps, the muscle has then sufficient power to raise the lid. Tem- porary loss of power often follows oedema or inflam- mation of the lid, but is recovered from as the parts regain their normal state, and does not call for sur- gical interference. In cases where the levator is still able to act to a certain extent, it is sufficient to remove an elliptical fold of the integument from the central part of the 288 DISEASES OF THE EYE. lid. A forceps designed for this purpose, having a transverse convex branch at its extremity, is con- venient, but an ordinary forceps may serve the pur- pose. As much skin is seized, in an oval form and horizontal direction, as appears to be suflBcient, and a trial is then made of the patient's ability to open and close the lid. If not enough has been grasped, the eye will be but partially opened ; if too much, the lids cannot be closed. It is particularly impor- tant to avoid the latter contingency, as it is easy to snip away an additional bit of skin, but by no means so to replace any portion which may have been re- moved in excess. Satisfied that the portion seized by the forceps has been well calculated, the surgeon may excise it with curved or straight scissors. After the slight bleeding has ceased, the cut edges may be united by two or three sutures. The wound heals at once, and leaves no perceptible cicatrix. When the levator muscle is palsied or has but slight action, it is sometimes necessary to take away a much broader fold of the skin, and to make the flap extend nearly to the eyebrow, that the occipito frontalis muscle may lend its aid to raise the Ud. CEDEMA OF THE EYELIDS. Serous infiltration of the lids is very common when leeches have been applied above the eyebrows or too near the inner or outer canthus. Care should tliere- fore be taken to avoid placing them close to the eye, PHLEGMONOUS IN^AMMATION OF THE EYELH). 289 and especially atove its level. Infiltration also ac- companies the formation of furuncle of the Hd, inflammation of the lachrymal sac, or any consider- able degree of conjunctivitis. It is also seen in ery- sipelas affecting the lids or the contiguous parts of the face, and occurs as a symptom when arsenical preparations have been administered internally be- yond the point of tolerance. We also meet with it where anasarca is present in other parts of the body. When occurring from accidental causes, of teni- porary action, no other treatment than a mild stim- ulating lotion is required, and even this is rather useful in relieving the patient's uneasiness than in hastening the resolution of the effusion. When it depends on general causes, as for instance on albu- minuria, its continuance will be affected by the course of the primary disease. PHLEGMONOUS INFLAMMATION OF THE EYELID. Inflammation of the lids, followed by suppuration, is not unfrequent in erysipelas, and it may occur idiopathically, especially in children. The lids be- come much swollen, tense, and livid, and severe con- stitutional symptoms are occasionally present. The cellular tissue of the orbit is sometimes involved by extension of the inflammation. As pus is formed, the pain becomes throbbing in its character, and oftentimes severe. 13 8 290 DISEASES OF THE, EYE. Should we fail to arrest the disease in its early stages by derivative treatment and the use of cold local applications, our only resource is to open the abscess as soon as we can detect the formation of matter. If this be not done at an early moment, the pus readily diffiises itself in the loose cellular tissue of the lids, and destroys it to so great an extent, that the movements of the lid become greatly impeded by the adhesions which form between the skin and tarsal cartilage, preventing the skin from being thrown into its natui'al folds. But great care must be used, in opening an abscess of the swollen lids, not to carry the point of the instrument too deeply, as an instance is related where the eyes of an unfor- tunate confrere were laid open by an incautious sur- geon in evacuating a small purulent deposit following erysipelas. WOUNDS AND INJURIES OP THE EYELIDS. In lacerated wounds of the eyelid, even if they involve the integument only, and especially if they have extended to the whole thickness of the Hd, it is important to adjust the parts at once as nearly as possible in their natural positions, securing them if necessary by several fine sutures, in order to avoid tlie after effects produced by irregular cicatrices. These are not only unsightly, but often induce alterations in the eye itself, by depriving it of its natural protec- tion, or by creating ridgy scars or inversion of the WOUNDS AND INJUHIES OF THE EYELIDS. 291 edge of the lid, which injure the globe by perpetual friction. Similar efforts to procure regular cicatrization must be made when the lids have been injured by- fire, scalding or caustic liquids, or hot metal. If the eyeball has been injured at the same time, and a portion of the conjunctiva of both the eye and the Hd has been destroyed, it is almost impossible to prevent cohesion between the raw surfaces of the globe and the lid. Should this be allowed to form, it is afterward very difficult to effect a separation of the adhering surfaces. Every endeavor must there- fore be made to prevent it. As is well known, contusions of the lid usually produce ecchymosis. After a violent blow in a pugi- hstic encounter, or from a fall against some angular object, the ecchymosis sometimes takes the form of a sudden effusion, forming a livid fluctuating tumor. More frequently the discolored appearance of the skin comes on some hours after the accident. Even when the effused blood forms a distinct col- lection, it is not necessary to evacuate the tumor by puncture. Cold evaporating or astringent lotions are all which is needed. Leeches or active treatment are seldom if ever required ; but, on the contrary, leeches or puncture are likely to increase rather than lessen the ecchymosis. Various remedies have enjoyed celebrity, as being of service in hastening the recovery of a black eye, — a most unenviable attraction. 292 DISEASES OF THE EYE. Of these, perhaps arnica is most useful. The bruised root of bryony, and of Solomon's seal, are in favor with pugilists. But the time required for absorption of the effused blood varies so greatly with the amount of injury inflicted, — one spot of ecchymosis disappearing in a day or two, another of similar appearance lasting as many weeks, — that it is difficult to judge of the effect of any remedy in a given case. Nature may be aided in her efforts by any mild means which the judgment of the physician may approve. The discoloration may be masked by painting the skin every day, should a patient be dis- posed to take the trouble thus to hide it. FURUNCLE OP THE EYELIDS. Boils sometimes form upon the lid, or over the lachrymal sac, causing much cedema of the surround- ing parts and a severe burning pain. They fre- quently excite the pulse, and give rise to febrile dis- turbance entirely out of proportion to the apparent insignificance of the disease. Sometimes these may be arrested in their incipient stage, by constant cold applications or by touching the skin with a crayon of nit. argent. More often they go on till a portion of the cellular tissue loses its vitality, and a small slough is formed, which is thrown off in a few days. Warm fomentations and light poultices favor this pro- cess, and give some relief to the pain. An opiate may be given at night, if the pain is so severe as to CANCEE OF THE EYELIDS. 293 prevent sleep. The symptoms are relieved at once, when the little sloughy core has been expelled. A similar affection, though of less severity, commonly termed stye, will be described in another section, as affecting the edge of the lids. Carbuncle and malignant pustule are very rarely met with in the eyelids. They require to be treated on general principles, as if occurring elsewhere in the body ; every endeavor being made to sustain the patient's strength, and to neutralize the effect of the morbid poison upon the general system. Any local lesions from loss of substance in the lid should have such attention that unsightly and troublesome cica- trices may be avoided. CANCER OF THE EYELIDS. The more nialignant forms of cancer seldom take their origin from the eyelids. What is termed epi- thelial cancer is more common, though by no means frequent. Its most common seat is near the internal angle ; where it commences, sometimes as a small, wart-like tumor, afterward degenerating into ulceration, some- times as a broad layer of disease extending in the direction of the lachrymal sac. In some instances frequent but gentle applications of a fine-pointed crayon of the nitrate of silver will gradually produce resolution of the morbid growth. Should these fail, excision should be resorted to at 294 DISEASES OF THE EYE. an early period, that it may not be necessary to remove too large an extent of the skin and subja- cent tissue ; and when thus performed, the operation generally effects a radical cure. Syphilitic ulcera- tion of the lids is not to be too readily mistaken for cancer. When occurring, it yields to appropri- ate medical treatment. EXCRESCENCES OF THE EYELIDS. It is important not to regard as malignant any mere warty tumors, or those temporary enlargements frequently seen at the edge of the lid where some previous inflammation of a Meibomian gland has occurred. These latter disappear if touched lightly a few times with a crayon of nitrate of silver. Warts, or the horny excrescences occasionally seen, may be clipped off with scissors. ABNORMAL ADHESION OF THE EYELIDS. Congenital union of the lids to a greater or less extent is now and then seen. It may be a simple phymosis, — the lids opening only a little less exten- sively than in the natural condition, — or it may amount to complete adhesion of the entire edges of the lids. In the first-named case, the child has an unpleasant aspect, the eyes seeming very small, and the bridge of the nose having twice its usual breadth. It is sometimes unable to see directly before it with- ENCYSTED TTMOKS OF THE EYELIDS. 295 out holding the head back, and making strong efforts to raise the lid. The lids may be separated towards the inner angle, but, to avoid reunion, it is necessary to bring the skin and conjunctiva of the upper, and the same surfaces of the lower lid, together, by sutures, to prevent appo- sition and reunion of the original cut surfaces. Complete or nearly complete connection of the two lids is nearly always accompanied by imperfect development of the globe itself and a want of visual capacity. An operation would in such cases be inex- pedient, as it would lead to no result improving the condition of the patient. When adhesion of the edges merely, has occurred, after a burn or other accident, they may be separated, and the skin and lining of each lid united by sutures, if there should be reason to fear reunion. ENOTSTED TUMOES OF THE EYELIDS. Small encysted tumors are very common in the lids. They may occur in persons of every variety of constitution, but are most frequently met with in females whose general system is in a feeble or anae- mic state. Several are often seen in the different lids. I have removed as many as thirteen at one time from an individual. They are oftenest developed between the tarsal cartilage and the skin, projecting outwards to the size of a pea or larger, but also causing thin- ning and perforation of the cartilage, so that on evert- 296 ^ DISEASES OF THE EYE. ing the lid the situation of the tumor can be readily seen. They sometimes discharge their contents, after suppuration, through the conjunctiva. Their contents vary, being sometimes granular or steatomatous ; at other times having more of a fibrous character. It is unnecessary to describe all the differences of growth and situation of these tumors, described by authors under the head of tarsal tumors, encysted tumors, chalazion, &c., as these variations do not affect the prognosis or treatment. They sometimes, though very rarely, disappear spontaneously. More frequently they increase to a size which causes a slight deformity and some sensa- tion qf discomfort from pressure upon the eye. In a few instances their removal seems to be effected by the application of stimulating lotions to the skin of the lid, and of these a strong solution of salt, or brine, seems to be most serviceable. Perhaps also they may now and then be dispersed by fi-equent applications of iodine ointment to the lid ; but this is a more trouble- some remedy than excision itself, requiring to be con- tinued a long time, giving a disagreeable yellowness to the skin, and very uncertain in its result. Excision is the best treatment, if stimulants have been used without success, or if the patient desires to be speedily rid of his encumbrance. This may be performed through the skin or the conjunctiva, according as the tumor is most accessible. If removed through the skin, no scar will be observed from the small incision ENCYSTED TUMOES OF THE EYELIDS. 297 ■which is necessary. A forceps, invented by M. Des- marres, having at one extremity an oval thin steel plate, and at the other a ring of corresponding size, is useful in preventing hemorrhage during the dissection, and thus allowing the operator to remove the tumor more readily and thoroughly. The thin plate is slipped under the lid, and the ring, including within it the tumor, is then screwed down upon the plate, cutting off the circulation and giving the operator a clear view of the parts as he proceeds with his dissec- tion. The application of the instrument is slightly painful, but it assists very much in facilitating and shortening the operation. Opening these little cysts, and breaking up their contents with a probe, or touching their interior with caustic, is less certain to destroy the sac, unless the proceeding is several times repeated, and frequently delays cicatrization by caus- ing fungous granulations to shoot from it. Still, this method may be adopted if the patient has a dread of the radical operation. No afler treatment is required after excision. Where the operation has been performed through the skin, a single suture, or merely a bit of court-plaster, may be employed, according to the size or situation of the wound. The patient may require tonic treat- ment to prevent a formation of other cysts of the lids at some future period. Should removal through the conjunctiva be followed by the protrusion of a fungous growth from the cavity, as may chance to 13* 298 DISEASES OF THE EYE. be the case where the tumor had attained a consid- erable size, the fungous granulation may be readily snipped off with scissors. ALBUMINOUS TUMOR. Small, roundish, white masses are frequently devel- oped in the follicles of the lids or neighboring parts of the face. When they attain some size, a minute orifice forms at their centre and allows the discharge of a milky exudation which is capable of reproducing the affection. This disease, sometimes termed mol- luscum, is most common in children. Small and indolent globular formations are also common in adults. The best treatment is to open the thin covering of these masses with a lancet or cataract-knife, and press out the contents between the thumb-nails, or between the blades of small forceps passed well be- hind the tumor. STEATOMATOUS FIBEOUS CTST. The vicinity of the eyebrow, near the outer angle, is the almost exclusive seat of development of a firm, fibrous cyst, usually containing sebaceous matter mixed with hairs, and sometimes adhering to the bone. The tumor is often congenital. When they lie somewhat deeply, an incision of considerable extent is required for their removal, as they must be dissected carefully from the surround- ing parts. HORDEOLUM j OE STYE. 299 VITILIGO. This name is given to irregular, yellowish patches which seem to be seated between the epidermis and cutis in the loose skin between the edges of the lids and the border of the orbit. They appear to have a tendency to increase and extend around the lids if left to themselves, but their excision seems to effect a radical cure. The operation is easily done, and is not followed by a scar. DISEASES OP THE MEIBOMIAN GLANDS AND CILIAKT BULBS. The Meibomian orifices sometimes become ob- structed, and a small vesicular projection forms at the sharp edge of the lid, which annoys the patient by its friction upon the globe. It is not larger than the head of a small pin, and may be scraped away with a penknife or the point of a pin or needle. The patient may easily learn to do this for himself. hordeolum; oe stye. This disease, named fi-om its fancied resemblance to a grain of barley, consists in a red, hard sweUing at the edge of the lid, accompanied by considerable burning pain, and some febrile symptoms. After a few days, suppuration takes place, and the discharge of pus, and perhaps a small slough, is promptly fol- lowed by a disappearance of all the symptoms. Its 300 DISEASES OF THE EYE. seat is in one of the follicles at the roots of the cilia. Children, and persons of strumous diathesis, are most liable to be affected with a recurrence of these small tumors. It is seldom possible to arrest the course of the swelling when it has begun to be red and painful, but cold applications may be made, sometimes with suc- cess, at the outset. Afterward, warm fomentations are more grateful and serviceable. At night a little simple or rose-water ointment may be applied. When considerable pus has formed, its discharge may be hastened by puncturing the swelling with a lancet, and the symptoms speedily subside upon its evac- uation. To prevent a recurrence, it is important to fortify the system, and to use local means adapted to change the condition of the follicles and the Meibomian glands. The citrine ointment (ung. hydrar. nitratis), diluted with five or six times its weight of simple or rose-water ointment, is an excellent application. About the size of the head of a pin should be melted on the end of the finger, and applied along the edge of the closed hds at bedtime, once in two or three nights, and it is well to continue its use for some weeks, even after the necessity for it has apparently passed away. Two or three grains of the red oxide of mercury, or red precipitate, to a drachm of oint- ment may be substituted for the citrine ointment if a change is desirable. The quantity used should be INFLAMMATION OF MEIBOMIAN AND CILIARY GLANDS. 301 SO small that it may not find its way into the eye, as in doing so it causes unnecessary pain, and acts as an irritant. INFLAMMATION OP THE MEIBOMIAN AND CILIART GLANDS. This compound affection is the most common of all the diseases of the eyelids, and has been described under a great variety of names, — as ophthalmia tarsi, tinea ciliaris, scrofulous blepharitis, &c. It consists in an inflammation affecting both series of the glands situated along the edge of the eyelids, and if allowed to go on unchecked, causes extensive alterations in the tarsal border. The earliest symptoms consist in a slight redness and swelling at one or more points along the edge of the lids, and the formation of small pustules about the roots of the lashes at the centre of the swollen part. These small purulent collections dry, and ad- here to the border of the lid in the form of small scales, the eyelash passing through their centre. If these are allowed to remain, the subjacent surface becomes ulcerated, the conjunctiva swollen, the secre- tion of the Meibomian glands acquires an irritating character, and the disease rapidly extends itself to the glands contiguous to those first affected. The irritation of the parts increases the flow of tears and the conjunctival secretion ; and these, mingling with the morbid discharges from the affected glands, cause excoriation of the edges of the lids and the skin of 802 DISEASES OF THE EYE. the cheek, which, in its turn, gives rise to additional swelling, and aggravates the original disease. The lids are often agglutinated in the morning, and can- not be separated without considerable force and the loss of a number of the cilia ; but the appearance of the parts at once distinguishes this adhesion from that caused by the accumulation of a copious mucous secretion in conjunctivitis. The disease may thus exist, uncomplicated, but it is very common to find it coexistent with ulceration of the cornea, with the eruptive and the catarrhal form of conjunctivitis, and with various evidences of a strumous constitution. Causes. — The strumous diathesis is the strong- est predisposing cause, and where this is present the symptoms may be readily excited by exposure to cold, to irritating fumes, even those of tobacco, to sudden changes of temperature, as also by a constant indulgence in high-seasoned food or alco- holic stimulants. It is by far most frequent, how- ever, among poorly-fed, ill-clothed, neglected chil- dren. Prognosis. — The disease is readily arrested by mild treatment, but when neglected, leads to very grave changes. The glands which secrete the cilia are destroyed, after the symptoms have continued for some time, and the eyelashes are no longer repro- duced ; or if they grow, they take an abnormal direction, turning towards the globe instead of out- INFLAMMATION OF MEIBOfflAN AND CILIAEY GLANDS. SOS wards, and constituting the affection styled trichiasis. The inner line of the edge of the lids loses its well- defined character, and the lids become rounded like the lips, which change, with the absence of eyelashes, constitutes a repulsive deformity. Treatment. — Scarcely any disease is more entirely under the control of treatment, but in severe cases mild remedies must be used for some time after the extinction of the severer symptoms, to bring the glandular structures completely back to their normal condition. No other than mild remedies are admis- sible. General treatment is desirable in a large proportion of the cases which have reached an advanced degree. The diet should be generous, the patient should be warmly clothed, and protected from atmospheric vicissitudes. If the diathesis be strumous, the iodide or some other preparation of iron is of great service. The children of the poor, who are especially liable to this affection, should have a nutritious diet and warm clothing if possible, — and cleanliness, almost univer- sally disregarded, should be insisted on. When com- pHcations are present, in the form of ulceration of the cornea, or conjunctivitis, they should receive prompt attention, as it is almost impossible to remove the glandular inflammation while these exist. But local remedies form the most important part of the treatment. The crusts should be carefuUy removed, every morning, by the patient or those 304 DISEASES OF THE ^YE. having the care of him, after softening them with warm water. During the day, lukewarm fomentations, with milk and water or some mild infusion, assist in sooth- ing the irritability of the parts. If the skin of the lids or the cheek has become excoriated, it is to be protected from contact of the discharges, by smearing it with a small quantity of rose-water or other simple ointment. At bedtime, every night or every other night, about as much of a medicated ointment as would equal the size of ^he head of a pin is to be melted on the end of the finger and applied along the edges of the lids ; the lids being kept closed, that the ointment may remain about the roots of the lashes and orifices of the Meibomian glands without getting into the eye. It is important that the crusts should be previously removed, so that the ointment may come fairly in contact with the affected parts. The citrine ointment, diluted with from four to six times its weight of simple ointment, lard, or rose- water ointment, deserves almost to be considered a specific in this disease ; for there are very few cases which it will not remove, if properly employed. Pure citrine ointment is too strong for general use, and even diluted, as above directed, it should be carefully applied, in small quantity only. Ointment of the red oxide of mercury, with an equal amount of lard, is also very efficient, though the citrine is to be preferred at the commencement. After a time a fresh influ- ence can sometimes be obtained by substituting an- other ointment for that prescribed at the outset. INFLAMMATION OF MEIBOMIAN AND CILIAEY GLANDS. 305 When ulcerations exist beneath the crusts, the cure may be hastened by touching them with a fine-pointed crayon of nitrate of silver ; but should the ulcers be numerous, it is best to touch but few of them at one time ; otherwise, much infiammation of the lid may arise from the use of the caustic over too extensive a surface. Should there be much thickening of the conjunc- tiva, a mild coUyrium, of borax or a weak solution of sulphate of zinc, is of service. The use of mild remedies is the sole plan to be recommended in this disease ; as its chronic nature and the extensive alterations of tissue which often exist render it impossible to remove it at once by any active heroic treatment. When the morbid con- dition has existed for some time, recovery is propor- tionally slow. In most instances, the patient should be told to continue an occasional use of the ointment, once or twice a week, for a month or two after the dis- appearance of all crusting or tumefaction of the edge of the lid, — after in fact he is completely cured ; as he is thus protected from any danger of relapse. If the disease has caused incurable alterations, giving a shining red margin to the lids, and pro- ducing blear-eyedness, before we are consulted, we can only palliate the condition and remove all exist- ing inflammation, by the use of fomentations during the day, and simple ointments at night ; but are un- able to create a new set of ciliary bulbs to take the 306- DISEASES OF THE EYE. place of those which the disease has destroyed. The individual will therefore have no new growth of eye- lashes, where the pathological changes have reached this extreme degree. TRICHIASIS. The inversion of one or more eyelashes is a fre- quent result of disease of their secretory glands, and may lead to serious changes in the eyeball long after the original disease has subsided. They are fre- quently so pale, from constant maceration in the fluids of the conjunctiva, that it is nearly impossible to detect them, except by observing that the watery secretions rise about them, as it were, by force of attraction. The constant friction of these deviated lashes upon the cornea causes much irritation and frequently leads to vascularity, opacity, and ulcera- ' tion of its tissue. The offending cilia should be plucked out at once, and as often as they return if their direction continue abnormal. Frequently, after a few repetitions of this process, the lashes regain their healthy condition and are no longer inverted. Should this treatment prove only palliative, or be tedious to the patient, a radical cure may be effected by removing a narrow bit of integument with the bulbs of the affected cilia, or by uncovering the bulbs by incision through the integument, and removing them, without taking away any portion of the skin. ENTEOPIUM. 307 PHTHEIRIASIS. Crab-lice, of the same species with those sometimes infesting the pubes and arm pits^ are now and then, though rarely, met with upon the eyelashes. I have seen the parasite in this situation only in children who were otherwise cleanly and healthy, and who might have derived them from their attendants. They cling very closely, and are dislodged with some difficulty by means of a needle or fine forceps. They may be mistaken for the crusts resulting from disease of the ciliary glands, unless very closely ob- served. The use of a small quantity of mercurial ointment or the careful application of a little of a solution of corrosive sublimate, two or three grains to the ounce, kills these insects, or weakens their hold so that they may readily be detached. The physician can usually thus effect a cure on the spot ; but if for any rea- son he prefer to spare the feelings of the patient or friends by leaving them uninformed as to the nature of the disease, he may order the use of a very small quantity of citrine ointment, which will generally dispose of the affection, tuto, cito, et jucunde, if ap- plied once or twice while the child is asleep. ENTR OPIUM. Inversion of the edge of the eyeUds, especially the lower, is very common in old persons in whom the 308 DISEASES OF THE EYE. skin has become flaccid, and some slight conjunctival irritation gives rise to frequent contraction of the orbicularis. Entropium is also sometimes occasioned by long-continued inflammation of the glands of the edge of the lids, or by traumatic injury or caustics. When existing for any period, the disease becomes a cause of other morbid alterations, from the friction of the inverted cilia upon the eyeball. If caused by flaccidity of the integuments, entro- pium may often be remedied by keeping the skin of the lid covered with collodion till the tendency to inversion is removed. The same result may some- times be gained by the use of narrow strips of adhe- sive plaster, which are first to be firmly stuck upon the lid, and then drawn down and fastened upon the cheek. When these means are insufiicient, removal of a fold of skin of suflBcient width, with a portion of the orbicularis beneath, is quite sure to be effect- ual. The edges of the wound are to be united by sutures, and the patient is well in two or three days. If the change depend on previous inflammation or injury, the same operation will often suffice for restoring the natural order of things ; but it is neces- sary to remove a larger portion of the muscle, near the ciUary border. Other methods of operating have been devised, but many of them have been based on irrational grounds, and have produced only tem- porary, if any benefit. ECTEOPIUM. 309 ECTEOPIUM. Eversion of the eyelids may occur in three ways, — from external traction, — the edge of the lid being drawn outwards by a cicatrix of the skin resultmg from a burn or injury ; from paralysis of the orbicu- laris ; or from causes acting from within and pushing out the lid. However caused, the everted condition induces excoriation of the skin of the lids and cheek, by the constant flow of tears ; and where it is exces- sive, the cornea is liable to become ulcerated, from the want of protection against atmospheric changes and irritating foreign substances. When displace- ment has existed for a long time, the puncta lachry- malia are frequently closed ; but their situation can almost always be made out, and they are readily re- opened by means of an Anel's probe. When resulting from contraction of a cicatrix, it is useless merely to divide the latter, unless some provision is made for supplying the place of the lost substance by other material, slid from the neighbor- ing parts into the vacuum. In aggravated cases a blepharoplastic operation, after excision of the cica- trix, becomes necessary. If the consequence of paralysis, this must be treated according to its cause, as we have directed in speak- ing of paralysis of the muscles of the eyeball. The larger number of cases of ectropium are pro- duced by causes acting from within the lid. The 310 DISEASES OF THE EYE. swelling of the conjunctiva is sometimes so great, in catarrhal or purulent ophthalmia, that the tarsal car- tilage is completely everted, and if this aversion is not at once replaced, it may continue for an indefinite time, and assume a chronic condition, the conjunctiva being greatly thickened and acquiring almost a cu- ticular character. At first sight, these chronic cases seem to require excision of a portion of the conjunctiva, to allow of a replacement of the lid in its proper relations to the globe ; but this is not essential, and is better refi-ained from, if the patient can be kept under treatment long enough to permit of the restoration of the normal condition by the use of astringents. If excision be resorted to, great care must be exercised to remove but a small portion, as, if the operation is too ex- tensive, entropium may result, after cicatrization has taken place and the conjunctiva has become healthy, from contraction of the scar. In any event, the use of astringents must be combined as a subsequent treatment, should the operation be resorted to. But the best method for these cases of aversion is the frequent application of astringents, — not to tlie most everted portion of the conjunctiva, at the edge of the lids, but to the part of that membrane nearest to that which is still in situ. This portion of the tissue is thus brought more and more nearly to a healthy state ; and as this t^kes place, the parts ly- ing beyond are gradually drawn back towards their ECTKOPIUM. 311 proper position, to become, in their turn, improved. A light touch with a smooth crayon of sulphate of copper is the best way of effecting this improvement. Its action can be limited to the desired spot, and it does not act as an excessive stimulant, as is the case in these instances with solutions of the nitrate of silver. A mild collyrium of the sulphate or acetate of zinc may be dropped into the eye twice or three times a day to keep up an astringent influence. Some patience is required to accompUsh a cure ; but I have never failed to relieve cases of even enormous protrusion of the conjunctiva, in this manner. A short time is usually sufficient to show a decided gain, and to prove that recovery is possible by this method, — and the change for the better goes on more and more rapidly, as the morbid tumefaction of the parts becomes resolved, and they begin to assume once more their normal features and positions. INDEX. Abscess, of globe, 83, 197. lachrymal sac, 69. Acetate of lead, to be disused, 16, 97. Adaptive power, affections of, 239. Adhesions of edge of pupil, 34, 36, 75, 124, 136, 183. Amaurotic affections, 219. Anaesthetics, use of, 145, 150, 183, 203, 274. Aqueous humor, distension by, 126. evacuation of, 134. Arcus senilis, 109. Army ophthalmia, 47. Artificial eyes, 206. pupil, operations for, 182. conditions for suc- cess, 182. Asthenopia, 260. Atropia, use of, 56, 97, 130, 138. strength of solution of, 131. Belladonna, extract of, 131. importance of, 129. use by charlatans, 155. Blear eye, 305. Blepharitis, scrofulous, 301. Cancer of eye, 193. lid, 293. Canula in nasal duct, 66. Capsule of lens, extraction of, 151, 177. wounds of, 78. Cataract, affects both eyes, except when traumatic, 157. congenital, 143. cortical, 153, 156. diabetic, 153. fluid, 157. glaucomatous, 179. hard, 153, 156. hereditary tendency to, 144, 153. Cataract, nuclear, 153, 156. numerous cases of, in one family, 144. operations for, 145, 150, 160. by division, 145, 162. reolination, 165. extraction, 169. operationa for removal of capsule, 151, 177. palliatives for, 158. secondary capsular, 151. time for operating on, 169. Cataract-glasses, 176. Catarrhal conjunctivitis, 29. Chalazion, 296. Chemosis, serous, 44. phlegmonous, 44. Choice of spectacles, 253. Cholesterine, crystals of, 180. Choroid, absence of pigment-ceUs of, 213. hemorrhage from, 212. inflammation of, 211. serious effusion from, 213. Ciliary bulbs, disease of, 301. Colors, inability to distinguish, 230. CoUyria, mode of applying, 20. Conical cornea, 110. operation for, 112. Conjunctiva, chemosis of, 60. cysticerci in, 60. ecchymosis beneath, 58. growths from, 60. inflammations of, 24, 50. injuries of, 73, 76. oedema of, 59. stains of by nitrate of silver, 17. Conjunctivitis, apthous, 27, 57. catarrhal, 29. 314 INDEX. Conjunctivitis, caused by foreign bodies, 24. caused by drauglits of ftir, 26. eruptive, 27. gonorrlioeal, 47. franular, 30. ind of pain in, 11. muco-purulent, 28. ' of new born-infants, 50. papular, 27, 57. purulent, 43. simple, 24. Contraction of pupil in iritis, ten- dency to, 124. Cornea, abrasions of, 73. abscess of, 102. burns of, 74. chemical injuries of, 74. conical, 110. deposits in, 92, 102. dotted opacity of, 100. effusions in, 92, 100, 102. facettes of, 92. foreign bodies in, 113. haziness of, 31, 84, 36, 52, 100, 102. incised wounds of, 76. inflammation of, 102, 138. injuries of, 73, 76, 78. interlaminar effusions in, 92, 102. nebulae of, 107. opacities of, 31, 84, 36, 52, 92, 100, 102, 107. from use of lead, 108. papule on, 27. perforation of, 86, 46, 49, 51, 56, 75, 100. restoration of transparency of, 34. sloughing of, 45, 48, 49, 92. staphyloma of, 114. strumous inflammation of, 100. syphilitic inflammation of, 102, 138. ulcer of, 88, 92. Comeitis, dotted, 100. interstitial, 102, 138. strumous, 100. syphilitic, 102, 138. Counter irritation rarely of much value, 97. Crystalline lens, affections of, 140. dislocation of, 80, 117, 140, 143. Crystalline lens, opacities of, 143. traumatic opacity of, 78. wounds of, 78. Crystalline capsule, removal of, 151. wounds of, 78. Cystioeroua in the eye, 286. Cysts in eyelids, 296. Depletion, local, 20, 21. Dilatation of pupil, importance of, 124, 127, 129. morbid, 220. Diplopia, 237. Dislocation of lens, 80, 117, 140, 143. Disorganization of globe, after iritis, 126, 138. after injury of other eye, 200. Division of vessels of the conjunc- tiva, 21. Double vision, 237. Dropsy of eyeball, 192. Ecchymosis, beneath conjunctiva, 68. of lids, 291. Eotropium, 309. Effusion of blood, after wounds of iris, 186. of senim, from choroid, 213. Egyptian ophthalmia, 43. Euoephaloid of eyeball, 193. Encysted tumors, of lids, 296. Eutozoa within the eye, 286. Entropium, 307. Erysipelas of lids, 289. Exajnination of the eye, mode of, S. in children, 8, 89. Excision, of globe, 120. staphyloma, 114, 119. Excoriation of cheek by secretions, 98. Extraction, of cataract, 169. foreignbodies from the globe, 8L Sds, 25. Eyes, artificial, 206. Eyeball, atrophy of, 84. cancer of, 193. dropsy of, 192. enoephaloid of, 193. epithelial tumors of, 196. inflammation of, 196. melanosis of, 195. operation for removal of, 202. oscillation of, 144. INDEX. 315 Eyeball, phlegmon of, after fever, • 196. seirrhns of, 196. scrofulous deposit in, 194. Eyebrow, encysted tumor of, 298. Eyelashes, inversion of, 306. loss of, 302, 305. Eyelids, adhesion of, 294. albuminous tumor of, 298. cancer of, 293. carbuncle of, 293. contusions of, 291. disease of glands of, 299. drooping of, 287. ecchymosis of, 291. encysted tumors of, 295. erysipelas of, 289. eversion of, 309. fibrous cysts of, 298; furuncle of, 292. inversion of, 307. lice upon, 307. maKgnant pustule of, 293. oedema of, 287. phlegmonous inflammation of, 289. ulcers of, syphilitic, 293. warts of, 294. wounds of, 290. yellow patches in, 299. Far sight, 247. Fistula lachrymalis, 63. Foreign bodies, inside the lids, 24. mode of removal, 25. within the globe, 81. Fungus hsematodes, of globe, 193. Glasses, in incipient cataract, 158. cataract, 176. choice of, 253. for far-sightedness, 247. near-sightedness, 244. periscopic, 246. Glaucoma, 188. operation for relief of, 189. Glaucomatous cataract, 179. Globe, affections involving entire, 188. Gonorrhoeal conjunctivitis, 47. Granulation of lids, effect on globe, 31. importance of complete re- moval of, 34. sec[uel£e of gonorrhceal con- junctivitis, 50. sequelas of purulent conjunc- tivitis, 47. Hardness of globe, abnormal, 191. Hereditary tendency to cataract, 144, 153. Hernia of iris, 50, 76. Hordeolum, 299. Hydrophthalmia, 192, 203. Hypopinm, 92. Inflammations, of the eye, complicated, 33. external, 11. internal, 11. of entire globe, 196. lachrymal sac, 63. Injuries of the conjunctiva, 73, 75. • cornea, 72, 76, 78. crystalline lens, 78. eyebaU, from per- cussion caps, 81. eyelids, 76. iris, 81, 121. Inoculation, danger of from purulent discharges, 33. Intolerance of light, 88, 230. Iris, adhesions of, 126. efliisions into, 124. foreign bodies in, 82. hernia of, 50, 76. injuries of, 81, 121. tremulous. 111. tubercles of lymph in, 124. turgidity of, 124, 137. Iritis, adhesions during, 126, 138. congenital syphilitic, 139. injection in, 123. new treatment of, 127. pain in, 122. principal dangers of, 124. rheumatic, 122. self-limited, 126. syphilitic, 137. traumatic, 121. Lachrymal passages, diseases of, 61. Leeches, where to be applied, 21, 133. Lens and capsule, affections of, 140. Leucoma, 108. Leucorrhoea, cause of ophthalmia in new-born children, 51. Lice, on edges of lids, 307. Long sight, 247. glasses for, 251. Loss of vision, temporary, 227. during lactation, 228. pregnancy, 228. Lymph, deposits of, 125, 135. 316 INDEX. Measles, effects of on eye, 261. Meibomian glands, disease of, 98, 299. Melanosis of eyeball, 195. Mercury, actual value of in iritis, 127. Molluscum, 298. Musose volitantes, 234. Muscles of eyeball, affections of, 269. paralysis of, 281. Mydriasis, 220, 283. Mydriatics, 130. Myopia, 240. resulting from conical cor- nea, 111. glasses for, 244. Near sight, 240. glasses for, 244. Nerves, paralysis of, 281. Night blindness, 227. Nitrate of silver, abuse of, 17. olive stain from, 17. use to be restricted, 18, 56. Obstructions of lachrymal canals, 66. Ocular capsule, abscess within, 198. (Edema of conjunctiva, 59. eyelids, 287. Ointments, objections to as coUyria, Opacities, of the cornea, 31, 34, 36, 52, 92, 100, 102, 107. from use of lead in coUyria, 108. of the lens, 78, 143. Ophthalmia, apthous, 27. catarrhal, 29. Egyptian, 43. gonorrhoea!, 47. neonatorum, 50. of armies, 47. of new-bom infants, 50. post febrile, 197. purulent, 43. rheumatic, 116, 122. stramous, 88. sympathetic, 200. syphilitic, 102, 137. tarsi, 301. Ophthalmitis, 196. phlegmonous, 197. phlebitic, 197. post febrile, 197. puerperal, 197. Ophthalmoscope, description of, 12. mode of using, 14. Oscillation of eye, 144. Pain, as a means of diagnosis, 11, 122. importance of controlling, 132. Paracentesis of the eye, 134, 193. Paralysis of fourth pair of nerves, 285. sixth pair, 285. third pair, 281. Perforation of cornea, 36, 46, 49, 61, 56, 75, 100. Photophobia, 88, 230, simulated, 234. Phtheiriasis, 307. Pinguecula, 57. Post febrile inflammation of eye- ball, 197. Poultices, rarely to be applied, 22, 200. Powders never to be blown into the eye, 98. Presbyopia, 247. glasses for, 261. Pterygium, 66. operation for, 58. Ptosis, 287. operation for, 287. Pupil, abnormal dilation of, 283. artificial, 182. closure of, by lymph, 34, 36, 66, 124, 126, 183, 201. importance of enlargement of in iritis, 129. Puerperal inflammation of eyeball. Pus within the globe, 83, 194, 198. Pustule, malignant, of lids, 293. Remedies, local and general, 15. Retina anhsemia of, 216. apoplexy of, 215. encephaJoid of, 193, 217. fatty disease of, 216. inflammation of, 216. separation of, 213, 216. Rheumatic iritis, 122. Sanious discharge, in gonorrhoesj conjunctivitis, 49, Soarincation of eye, inutility of, 21. SciiThus of eyeball, 196. Sclerotica, rupture of, 117. staphyloma of, 118. thinning of, 118. wounds of, 78, 117. Scrofulous ophthalmia, 88. Short sight, 240. glasses for, 244. Softening of globe, 180. Solutions best for coUyria, 15. INDEX. 317 Spectacles, choice of, 253. Spectra fixed, 236. Spectral illusions, 237. Squinting, 269. Staphyloma, of cornea, 114. sclerotica, 118. operations for, 114, 119, 203. Strabismus, 269. ■ operations for, 272. Strumous ophthalmia, 88. Stye, 299. Style in disease of nasal duct, 66. Sugar of lead, objections to, 16. Sulphate of copper, usefulness of, 18. mode of preparing crayons, 18. manner of applying, 19, 95. Sympathetic ophthalmia, 200. Synchisis, 180. sparkling, 180. Synechia, anterior, 108. posterior, 136. Syphilitic corneitis, 102. iritis, 104, 137. in infants, 139. Syringe, when to be used for injec- tions, 49, 54. Tarsal tumors, 296. Tears, acridity of, 91. increased flow of, in stru- mous ophthalmia, 91. Tinea ciliaris, 301. Traumatic injuries, of eye, 72, 81. from percussion-caps, 81. of cornea, 72, 76, 73.- conjunctiva, 78, 75. Traumatic injuries of crystalline lens, 78. iris, 81, 121. sclerotica, 78. Treatment, general principles of, 15. tonic, yaJne of, 21, 37. Trichiasis, 306. Turgidity of iris, 124, 137. Ulcers of cornea, 88, 92. eyelids strumous, 301. syphilitic, 293. Vascularity, differences in, 10. Vision, double, 237. increased acuteness of, 230. peculiarities of, 230. temporary loss of in preg- nancy, 227. in lactation, 227. Vitiligo, 299. Vitreous humor, cholesterine in, 180. cystioerci in, 286. opacities in, 180. protrusion of, 78. softening of, 180. wounds of, 78. Warts, of conjunctiva, 60. eyelids, 294. Weak sight, 260. Wounds, of eyeball, 72, 76. eyelids, 76. iris, 82. sympathetic inflammation after, 85. THE END. Camilridge : Stereotyped and Printed by Welch, Blgelow, «t Co. 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