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«- ARY OF MEDICINE

NATIONAL LIBRARY OF MEDICINE

OPHTHALMIC DISEASES

AND

BY

A. B. NORTON, M.D.

Professor of Ophthalmology in the College of the Hew York Ophthalmic Hospital; Surgeon the New York Ophthalmic Hospital; Visiting Oculist to the Laura Franklin Free Hospital for Children ; Consulting Oculist to the Protestant Half Orphan Asylum; Associate Editor, Department of Ophthalmology, North American Journal of Homozopathy.

With Fifty-three Illustrations and Twelve Chromo-Lithographic Figures.

PHILADELPHIA BOERICKE & TAK£ 18 92.

LIKHARY

DJJllL

1292.

Copyrighted, 1892, By A. B. Norton, M.D.

DEDICATION.

TO THE MEMORY OF MY BROTHER.

<£eo. g. jiorton, MM.,

Author of the Ophthalmic Therapeutics,

This Book is Affectionately Dedicated as a Tribute to Hi* Life- Work in Ophthalmology.

PREFACE.

The appearance of this work has been due to two causes, namely : The desire to continue the publication of the Ophthalmic Thera- peutics, which was first brought out by Drs. T. F. Allen and George S. Norton, and subsequently a second edition by Dr. Norton alone. Both editions having received the hearty support and com- mendation of the profession, and the last being now nearly exhausted, it has seemed best that it should be continued. In its present form we hope that it will prove of even greater value than before.

This work has also been completed in order to continue and carry out the plans of my brother, the late Dr. George S. Norton. For several years prior to his death it had been his desire to present to the profession a text-book upon ophthalmology, devoting especial attention to the homoeopathic treatment of the diseases of the eye. His extended experience and labor in the field of ophthalmology made him particularly well qualified to bring forth a valuable work in this line. Finding, however, that the extensive demands upon his time from both college and hospital work, in addition to a large private practice, such a work would become too severe a tax upon his strength, he arranged with the writer to bring out such a book together. The plan and scope of the work was then thoroughly considered and mapped out. The work was commenced and some of it completed when Dr. Norton's illness and death put a stop to further progress. After some months of careful consideration and grave doubts as to the ability of the writer to complete the task creditably, it was finally decided to finish the undertaking.

The scope of the work as originally planned has been followed out closely and was to give as concisely as possible all the essential features necessary to a thorough knowledge of the diseases of the eye, commencing with sufficient anatomy of the various structures to aid in an understanding of their diseases.

vi

PREFACE.

In treating of the different diseases it has been our aim to follow a definite and systematic order, taking up successively the pathology, symptoms, course, causes, diagnosis, prognosis and treatment of each separate disease.

As the object of the work has been to furnish the student and the general practitioner with a concise, practical manual, all useless ver- biage has been discarded and the effort made to present a practical condensation of all important facts, believing such a book to be of more value to the student than one which hides the kernel under a profuse, even though interesting, envelopment.

Special attention has been devoted to the homoeopathic treatment of diseases; at the same time, knowing the importance of both local and operative measures, it has been our aim to omit nothing that may be of value in these methods. The homoeopathic treatment has, of course, been practically that of the last edition of the Ophthalmic Therapeutics, to which several new remedies and many new symp- toms of old ones have been added ; on the other hand, some of the old remedies have been cut down by dropping out the reports of some of the clinical cases and occasionally some general symptom of the drug. In the revision of this department of the work all homoe- opathic publications of the last ten years, together with copious case records of my brother's as well as my own, have been carefully sifted and scrutinized. As this work practically includes all of the old Ophthalmic Therapeutics, it seems appropriate to quote from the prefaces of that work.

In the first edition the authors say :

" Material for this work has been accumulating for many years, especially since the adoption of the homoeopathic method by the New York Ophthalmic Hospital.

" When we first took our chairs in that institution there were few indications for remedies associated with definite lesions of the eye ; our cases were diagnosticated and then carefully examined at all points for indications of the remedy, and from time to time groups of remedies have become associated with definite lesions and char- acteristic local indications recognized.

" These local indications seem at times to be purely clinical or empirical, but they have always, or nearly always, been discovered while co-existing with positive and pure symptoms of the remedy,

PREFACE.

vii

but they so often occur independently of the latter that they fre- quently assume a relatively greater importance.

" Our knowledge of the pure effects of drugs upon the eye is un- fortunately meagre, often quite indefinite and unsatisfactory ; still, we have endeavored to keep to the standard and have only per- mitted the introduction of clinical matter when the evidence has seemed to justify.

" It is proper to explain that the plan of this work is substan- tially the same as that projected by Dr. Allen a few years since and prematurely announced ; the material then in hand has been aug- mented by the observations of Dr. Norton, the whole work written out by him and revised by us jointly.

" Incomplete as we know it to be, we feel that its publication should not be longer delayed and we offer it to the profession for most critical examination. All the symptomatology given in this work has been verified ; when no authority is referred to, the editors are responsible, except when general reference is made to cases reported. Some observations may be ill-founded ; many, we feel sure, will prove reliable and contribute to the preservation and restoration of sight."

In the preface to the second edition, Dr. Norton says:

" The many additions to ophthalmic therapeutics within the past

six years, have rendered necessary a complete revision of this little

manual.

" Part First (Pctt't Second of the present tvor'Ic) has been wholly rewritten and several new remedies added. The verified symp- tomatology, which precedes the clinical application of each drug, has been taken from 'Allen's Encyclopedia of Pure Materia Medica/ with such other confirmations as have been made by the author. The clinical indications have, however, received chief attention, as a further experienc3 of six years in a large oph- thalmic clinic has naturally developed new remedies and new indi- cations lor old remedies. Much valuable aid has also been received from leading oculists throughout the country who have kindly sent cases and clinical indications from their own practice, to which their names will be found appended as authority. More -pace has been given, as will be. noticed, to illustrative cases, with a view of showing the actual symptoms of the disease, for which the

viii

PREFACE.

remedy should be prescribed, and the results of treatment. In order to make this section as practical and reliable as possible, con- siderable matter found in the first edition has been eliminated. For instance, all material gathered from doubtful sources, from practi- tioners not personally known to the writer, or, in whom he has not the most implicit confidence as to their ability to correctly diagnos- ticate and truthfully report their cases, also all statements which further experience has failed to verify, are omitted in this edition. Statements and clinical cases in the first edition which were only verified by Dr. Allen are so indicated in the text. In every in- stance when no authority is given, the author may be considered responsible."

With the issuance of the second edition, Dr. Allen withdrew from the work, and, in an introduction to that edition, says:

" Some years have elapsed since the issue of ' Alleu and Norton's Ophthalmic Therapeutics/ the edition has been sold and a new one demanded. Our colleague, Dr. Norton, has continued to work in the field with unwearied perseverance and with striking success; the writer has been called to labor more particularly in the broader field of general Materia Medica and deems it proper that his name should not continue to be associated with Dr. Norton's in this work, simply because to Dr. Norton is wholly due the honor of having revised and enlarged this work.

" While there is no doubt that the conditions of the eye, in diseases of that organ, is a most important factor in the selection of the remedy, still we must not forget that eye diseases are often, perhaps generally, the expression of a general cachexia, the remedy for which can only be found by a close examination of the whole individual. A knowledge of remedies for any disease of the eye has been attained in the beginning only by a study of the whole case, and, if it has been found that for certain pathological states but few drugs are ap- propriate, it must still be kept in view that new remedies are to be found and that any case may require a drug hitherto unused for its cure. Among the most brilliant pathological generalizations in ophthalmic therapeutics may be mentioned the use of Gelsemium, for intra-ocular inflammations, characterized by serous exudation ; Rhus tox., for suppurative intra-ocular and orbital inflammations ; Bryonia, for plastic-exudation, and, we may be permitted to add,

PREFACE.

ix

the American Aconite (A., uncinatum) for ciliary and peri-orbital neuralgia. No therapeutist will, however, be content to limit his remedial resources, in any one of the above diseases, to the remedy mentioned. Pilocarpine may be required instead of Gelsemium ; Silicea in place of Rhus; Phytolacca in place of Bryonia, or Spigelia instead of Aconite ; how shall we decide ? And the selection must be accurate and prompt, for in the eye, more than anywhere else, delay is dangerous : the symptoms must always be studied."

In closing, the author desires to acknowledge his indebtedness to Dr. George A. Shepard for his valuable aid in searching out all notes of reference, together with the examination and compilation from all the homoeopathic literature of every symptom or verification they contained for the Ophthalmic Therapeutics.

To Dr. William H. Bleecker we also extend our sincere thanks, for his inestimable services in preparing a most thorough index, together with a careful revision of the proof of the entire work.

A. B. Norton.

152 West Thirty-fourth Street, August 15, 1892.

CONTENTS.

CHAPTER I.

DISEASES OF THE EYELIDS.

Anatomy — Blepharitis Acuta — Blepharitis Ciliaris — Hordeolum-Ptosis — Blepharo- spasms— Nictitatio — Blepharophimosis — Trichiasis and Distichiasis — Entro- pium — Ectropium — Sy rnblepharon — Ankyloblepharon — Epicanthus — Mol- hiscum Contagiosum — Xanthelasma — Milium — Papillomata — Dermoid Cyst — Naevi — Chalazion — Epithelioma — Lupus and Sarcoma — Herpes Zoster Front- alis— Syphilitic Ulcers, Chancre and Gummata — Contusions — Wounds — Burns and Scalds, 17

CHAPTER II.

AFFECTIONS OF THE LACHRYMAL APPARATUS.

Anatomy — Dacryoadenitis — Hypertrophy of the Lachrymal Gland — Tumors of the Lachrymal Gland — Strictura Ductus Lachrymalis — Dacryocystitis Catar- rhalis— Dacryocystitis Phlegmonosa — Fistula Lachrymalis, . . .43

CHAPTER III.

DISEASES OF THE ORBIT.

Anatomy— Cellulitis Orbitaj— Tenonitis— Periostitis Orbitse — Caries and Necrosis —Empyema of the Frontal Sinus— Tumores Orbitae— Wounds and Injuries of the Orbit — Morbus Basedowii, 52

CHAPTER IV.

AFFECTIONS OF THE OCTTLAR MUSCLES.

Anatomy— Paralysis of Ocular Muscles— Paralysis, External Kectus— Paralysis, Superior Oblique— Paralysis, Internal Rectus— Paralysis, Superior Rectus— Paralysis, Inferior Rectus— Paralysis, Inferior Oblique— Complete Paralysis of the Third Nerve— Strabismus or Squint— Strabismus Convergens— Strabis- mus Divergens— Strabismus Sursum and Deorsum Vergens— Nystagmus — Muscular Asthenopia— Hyperphoria— Esophoria— Exophoria, . . .62

xii

CONTENTS.

CHAPTER V.

DISEASES OF THE CONJUNCTIVA.

Anatomy— Hyperemia — Conjunctivitis Catarrlialis— Conjunctivitis Purulenta — Ophthalmia Neonatorum— Conjunctivitis Gouorrhceica— Conjunctivitis Diph- theritica—Conjunctivitis Crouposa — Conjunctivitis Follicularis— Conjunctivitis Traehomatosa— Papillary Trachoma— Conjunctivitis Phlyctenularis— Conjunc- tivitis Vernalis — Amyloid Degeneration of the Conjunctiva — Xerosis Conjunc- tive— Pterygium— Subconjunctival Effusions — Subconjunctival Emphysema — Tuberculosis Conjunctivae — Lesions of the Conjunctiva — Tumors of the Con- junctiva, 97

CHAPTER VI.

DISEASES OF THE CORNEA.

Anatomy — Inflammation of the Cornea — Keratitis Phlyctenularis— Keratitis Fasic- ularis — Keratitis Pannosa — Keratitis Vesiculosa — Ulcus Cornese— Hypopyon Keratitis — Asthenic Ulcer — Keratitis Dendritica — Abscessus Corneae — Kera- titis Neuro-Paralytica — Keratitis Parenchymatosa — Keratitis Bullosa — Desce- metitis — Opacities of the Cornea — Staphyloma Cornea? — Keratoconus — Kerato- Globus — Injuries and Wounds of the Cornea — Tumors of the Cornea, . 146

CHAPTER VII.

DISEASES OF THE SCLERA. Anatomy — Episcleritis— Scleritis — Staphyloma Sclere — Injuries of the Sclera, 185

CHAPTER VIII,

DISEASES OF THE IRIS.

Anatomy — Hyperemia Iridis — Iritis — Iritis Syphilitica — Iritis Rheumatica— Iritis Spongiosa — Iritis Parenchymatosa — Iritis Traumatica — Iritis Serosa — Tumors of the Iris — Mydriasis — Myosis — Hippus — Iridodonesis — Iridoncosis — Hyperemia — Iridodialysis — Coloboma Iridis — Aniridia — Membrana Pupil- laris Persistans — Heterochrony — Operations on the Iris, . . . 190

CHAPTER IX.

DISEASES OF THE CILIARY BODY.

Anatomy — Cyclitis — Cyclitis Plastica — Cyclitis Serosa — Cyclitis Purulenta — Injur- ies Implicating the Ciliary Region — Paresis Musculus Ciliaris — Spasmus Mus- culus Ciliaris — Irido-Choroiditis, 214

CONTENTS.

xiii

CHAPTER X.

SYMPATHETIC OPHTHALMIA. Symptoms — Causes— Treatment 225

CHAPTER XI.

DISEASES OF THE CHOROID.

Anatomy — Hyperemia — Choroiditis — Choroiditis Serosa — Choroiditis Disseminata Simplex — Choroiditis Areolaris — Choroiditis Circumscripta — Choroiditis Syphilitica — Choroiditis Metastatica — Choroiditis Suppurativa — Sclerotico- Choroiditis, Anterior — Sclerotico-Choroiditis, Posterior — Senile Changes of the Choroid — Albinism — Tumors of the Choroid — Ossification of the Choroid — Haemorrhages in the Choroid — Detachment of the Choroid — Eupture of the Choroid — Coloboma of the Choroid, 231

CHAPTER XII.

DISEASES OF THE RETINA.

Anatomy — Hyperemia Retinae — Retinitis Simplex — Retinitis Nyctalopica — Reti- nitis Albuminurica — Retinitis Diabetica— Retinitis Leucocythsemica — Retinitis Haemorrhagica — Retinitis Syphilitica — Retinitis Punctata Albescens — Reti- nitis Proliferans — Retinitis Pigmentosa — Detachment of the Retina — Ischaemia Retinae — Embolia Arteria Centralis Retinae — Hyperesthesia Retinae — Commo- tio Retinae — Glioma Retinae, 256

CHAPTER XIII.

DISEASES OF THE OPTIC NERVE.

Anatomy — Opaque Nerve Fibres— Coloboma of the Sheath — Hypersemia of the Disc — Haemorrhage of the Optic Nerve — Neuritis Optica — Neuritis Retro- bulbars— Atrophia Nervus Opticus — Injury of the Optic Nerve — Tumors of the Optic Nerve, 288

CHAPTER XIV.

AMBLYOPIA AND AMAUROSIS.

Congenital Amblyopia — Traumatic Amblyopia — Amblyopia from Lightning — Amblyopia from Loss of Blood — Toxic Amblyopia— Hysterical Amblyopia — Pretended Amblyopia — Hemeralopia — Snow Blindness — Color blindness — Hemianopsia, . 308

xiv

CONTENTS.

CHAPTER XV.

DISEASES OF THE VITREOUS BODY.

Anatomy — Hyalitis Suppurativa — Opacitates Vitrei — Haemorrhage into the Vitre- ous— Foreign Bodies in the Vitreous — Cysticercus in the Vitreous — Persistent Hyaloid Artery — Detachment of the Vitreous, ..... 317

CHAPTER XVI.

DISEASES OF THE CRYSTALLINE LENS.

Anatomy — Cataract — Varieties of Cataract — Complete Congenital Cataract— Cataracta Lamellaris — Cataracta Zonalaris — Cataracta Polaris Anterior — Oata- racta Pyramidalis — Cataracta Polaris Posticum — Cataracta Traumatica — Cata- racta Secondaria — Cataracta Capsularis — Operative Treatment of Cataract — Aphakia — Luxatio Lentis, 324

CHAPTER XVII.

GLAUCOMA.

Anatomy — Physiology of Secretion and Excretion — Pathology — Symptoms — Course — Causes — Diagnosis — Prognosis — Treatment — Varieties of Glaucoma — Glau- coma Acuta — Glaucoma Chronica — Glaucoma Simplex — Glaucoma Hemor- rhagica— Glaucoma Absolutum — Glaucoma Consecutiva, . . . 355

PART SECOND.

Acetic Acid to Zincum,

377-538

PART I.

OPHTHALMIC DISEASES.

OPHTHALMIC DISEASES.

CHAPTER I. Diseases of the Eyelids.

Anatomy. — The eyelids form the external covering of the eve- balls, and serve to protect the eye from injury, both from excessive light and from foreign substances ; they also serve at the same time to distribute to the eyes the moisture secreted by the various glands.

The eyelids, or palpebral, are two thin movable folds, the upper being the larger and more movable of the two; their movement is both voluntary and involuntary, the latter action being due to the orbicularis muscle. The opening of the lids is chiefly by the action of the levator palpebrte superioris lifting the upper lid ; when opened an elliptical space is left between the margins of the lids; this open- ing varies greatly, being larger in prominent eyes than in sunken ones, and greater when looking upward. The angles of junction of the upper and lower lids are called canthi; the outer canthus is more acute than the inner ; near the extremity of the inner canthus is found on both the upper and lower lid a slight elevation, the apex of which is pierced by a small orifice, the punctura lachrymale, the commence- ment of the small channels or canalicidi leading to the tear sac.

The eyelids are composed of four layers, arranged from without inward in the following order, the integument, a layer of muscular fibres, the tarsus, or as often erroneously called the tarsal cartilage, and the conjunctiva. The integument, which is extremely thin but similar in every other respect to the integument elsewhere, becomes, at the margins of the lids, continuous with the conjunctiva.

The muscular fibres consist of the orbicularis palpebrarum, a large, flat, voluntary muscle extending over the orbital margins above and below and terminating by tendinous attachments at the angles of the

2

18

DISEASES OF THE EYELIDS.

lids, the tendons, together with some fibres of the muscle, being in- serted in the adjacent bony wall. The fibres of the orbicularis which lie upon the tarsi are paler than the others, and certain bundles of these which give to the lid its involuntary action are known as the ciliary muscle of Riolani. The orbicularis is some- what adherent to the skin, but glides loosely over the tarsus. Its fibres are more or less circular in arrangement, and, acting as a sphincter, serves to close the eyes.

Fig. 1.

Section through Upper Eyelid. A, the ciliary muscles of Riolanus ; B, follicles of the eye-lashes ; C, opening of the Meibomian follicles.

The levator palpebrce swperioris arises at the apex of the orbit and passing along its upper wall becomes intermingled in front of the tarsus with the orbicularis ; other fibres become attached to the upper edge of the tarsus, and still others go to the conjunctiva. This muscle is supplied by a branch from the third nerve, and its action is, as its name implies, to raise the upper lid. The lower lid is supplied with a prolongation from the inferior rectus, whose in- sertion and action is analogous to that of the levator palpebrae.

The tarsi are two thin, elongated plates composed of condensed fibrous tissue, and serve to form the framework of the lids; they are united to each other and to the adjacent bone through the medium of the internal and external lateral ligaments.

The conjunctiva is a delicate mucous membrane which commences

BLEPHARITIS ACUTA.

19

at the free border of the lid, where it is continuous with the skin ; it lines the inner surface of the lids and is then reflected upon the globe, over which it passes and becomes continuous with the cornea. The palpebral portion is thicker and more vascular than that cover- ing the globe, and is firmly attached to the tarsus. Where it passes from the lids to the globe it is thin aud loose, and forms what are called the fornix conjunctivae.

The cilia are short, thick, curved hairs, arranged in double or triple rows at the margins of the lids; their follicles are surrounded by sebaceous glands and the glands of Moll. Within the tarsus are embedded the Meibomian glands, which in structure resemble the sebaceous glands. These various glands by their secretions serve to lubricate the eye, and discharge their secretion through excretory ducts, opening by minute orifices upon the free border of the lids between the rows of cilia.

Blepharitis Acuta {Acute Phlegmonous Inflammation [Ab- scess] of the Lids). — Suppuration of the connective tissue of the lid is generally the result of trauma, and is then due to a breaking down of the blood-clot formed at the time of the contusion. It may also follow debilitating diseases, or be associated with adenitis in scrofulous children. There will be great swelling of the lid, with more or less heat, redness and pain. Fluctuation may be detected early, and inflammation of the conjunctiva is apt to be associated with this disease. General inflammation of the lid may sometimes be seen in children without suppuration ; while in cachectic subjects we may have a gangrenous condition.

Treatment. — By a careful selection of our remedy in the first stage, wc can often cause the inflammation to subside before suppu- ration has taken place. It is also possible to promote the resolution and discharge of pus already formed. Cold (iced) applications are recommended if the disease is seen at the outset; but if we suspect that the formation of pus has commenced, a change to hot applica- tions (poultices) should be made.

As soon as fluctuation can be felt, a free incision into the swelling parallel to the margin of the lids should be made, in order to give free vent to the confined pus. After the escape of the pus, warm applications of Calendula and water (ten drops to the ounce) are ad- vised. A compress bandage should also be employed if the abscess

20

DISEASES OF THE EYELIDS.

is extensive, so as to keep the lid in position and the walls of the abscess in contact, and thus hasten the union.

If it has already spontaneously opened, the perforation should be enlarged, if it be insufficient and unfavorably situated ; also if there be several apertures, they should be united by an incision, in order to leave as small a cicatrix as possible. A generous diet should be prescribed. For remedies, see blepharitis ciliaris.

Blepharitis Ciliaris {Tinea Tarsi, Ophthalmia Tarsi, Blepharitis Marginalia, Blepharo- Adenitis, etc ). — Inflammation of the edges of the eyelids is met with in various degrees, from the most simple form, where there is merely a slight hypersemia of the border of the lids, to the most severe, in which we find large ulcerations or a smooth, thickened, everted condition of the lids.

Symptoms. — At the commencement there is a slight burning and smarting in the eyelids, which is aggravated by cold winds, smoke, dust, exposure to bright light, or use of the eyes at close work. There is agglutination of the eyelids in the morning, with dry scales or scabs adhering to the margins of the lids; photophobia and lach- rymation are present. In the advanced cases the hair follicles may be destroyed and the cilia fall out, or they may be of a stunted or irregular growth ; the thickening and eversion of the lids may cause ectropium.

Course. — The course of the disease is usually very chronic, and yet should be cured by thorough and prolonged treatment.

Causes. — The disease occurs most frequently in young, delicate persons of a strumous diathesis, and, as the causes are so closely asso- ciated with the treatment, they will be considered further under that heading.

Treatment. — First, we should examine the refraction, and, if any error is found, correct the same with the proper glass, as in some cases this alone will cure the entire trouble.

In rare cases the presence of lice on the eyelashes may be the ex- citing cause (phtheiriasis ciliarum), when we should be careful to remove them and apply either cosmoline or some mercurial oint- ment, which will destroy them and prevent their recurrence.

Fungous growths in the hair follicles are also said to cause this disease, in which case the hairs should be extirpated, and either external or internal medication employed.

BLEPHARITIS CILIA RIS.

21

Another cause is frequently found in affections of the lachrymal canal, particularly catarrh of the lachrymal sac and stricture of the duct; in these cases the tears, being hindered from flowing through their natural passage into the nose, collect in the eye, flow over the lids and down the cheek ; thus the retention of the tears will cause an inflammation of the margins and eventually of the whole structure of the lids. Any other affection which will have the same result (flowing of the tears over the lids) will, of course, produce the same trouble, and this is often found in slight degrees of eversion of the lower lids (ectropium), which displaces the puncta lachrvmalis and thus prevents the tears from passing into the sac. In all such cases the first thing to be done is to open the canaliculus into the sac, and, if necessary, the nasal duct into the nose, so as to give a free passage for the tears into that organ, after which the treatment is the same as in uncomplicated cases.

But the most common causes of ciliary blepharitis are exposure to wind, dust, smoke, etc., especially when complicated with want of cleanliness; it is for this reason we see this trouble so frequently among the poorer classes. As it is upon this point — cleanliness — that the success of our treatment depends to a great extent, we should impress upon the patient's mind the necessity of it in terms as forcible as possible.

They should be directed to remove the scales or crusts from the margins of the lids as soon as formed, not allowing them to remain even a few minutes. This should not be done by rubbing, as the patient is inclined to do on account of the itching sensation, for by so doing, excoriations are made, lymph is thrown out and new scabs form, which only aggravate the inflammation. But they should be directed to moisten the crusts in warm water and then carefully remove them with a piece of fine linen, or by drawing the cilia between the thumb and fingers ; at the same time gentle traction may be made on the lashes, so as to remove all that are loose, as they act only as foreign bodies. Sometimes the scabs are so thick and firm that moistening in warm water is not sufficient to remove them; in such cases, hot compresses or poultices should be applied for ten or twenty minutes at a time, until they can be easily taken away.

In the treatment of chronic inflammation of the margins of the lids, external applications are of great value and without their use a cure

22

DISEASES OF THE EYELIDS.

is often impossible. It is true that a careful attention to cleanliness, together with the internal administration of the indicated remedy, will cure a large proportion of our cases, but the duration of treat- ment will be usually much longer than if we employ local means at the same time we give internal remedies.

Cosmoline or Vaseline. — This unguent has been of great service in the treatment of ciliary blepharitis. It may be used alone or to form a base for the administration of other remedies. It prevents the formation of new scales and the agglutination of the lids, besides seeming to exert a ben°ficial influence over the progress of the dis- ease. This, like all other ointments, should be used once or twice a day, or even oftener, if the case is very severe. All scales or crusts should first be carefully removed; after which a very little of the ointment may be applied to the edge of the lids with the finger or a camel's hair brush. The smallest amount possible, to oil the ciliary margins of the lids, should be applied, as an aggravation of the in- flammation may result from its too free use.

Grapho-vaseline. — Graphites, as will be seen in the symptoma- tology, is more commonly indicated in ciliary blepharitis than any other one remedy. Many cures have resulted from its internal administration alone, when indicated, but more brilliant results may be obtained by employing at the same time locally the following colly Hum :

R . Graphites, gr. ij.

Vaseline, ^ij.

Misce.

Mercury. — For years this has been a favorite local application in ciliary blepharitis. It seems to be better adapted to the severe forms of inflammation of the lids than Graphites, for there is more redness, more swelling, more secretion and more tendency toward ulceration. The two following prescriptions have been employed with the most favorable results, especially the yellow oxide:

R. Hydrarg. oxyd. flav., ........ gr. ij.

Vaseline, .......... ^ij.

Misce.

R. Liq. Hydrarg. Nitr., gtt. iij.

Ol. Morrhuse, ......... ^jj,

Misce.

BLEPHARITIS CILIA RIS.

23

In some cases more of the mercury is used, in others less, accord- ing to the severity of the symptoms.

Various other ointments and washes have been used with variable success. The use of milk, cream, lard and simple cerate, to prevent the lids from sticking together, have also been of aid, with internal medication.

Aconite. — Chiefly called for in the acute variety of this trouble, especially when caused from exposure to cold dry winds and in the very first stage of blepharitis acuta. The lids — especially the upper — are red and swollen, with a tight feeling in them, while great heat, dryness, burning and sensitiveness to air are present; the dry heat is tempo- rarily relieved by cold water. The conjunctiva is usually implicated.

Alumina. — Chronic inflammation of the lids (particularly if com- plicated with granulations), characterized by burning and dryness of the lids, especially in the evening; itching, dryness, and excoriation (d the canthi. Absence of lachrymation. There is not usually much destruction of tissue nor great thickening of the lids.

Antimonium crud. — Obstinate cases in which the lids are red, swollen and moist, with pustules on the face. Especially in cross child ren . Pustules on the ciliary margins.

Apis mel. — Incipient stage of abscess, before the formation of pus, if there is great puffiness of the lids, especially of the upper, with stinging pains. Much reddish-blue swelling of the lids; temporary relief from cold water. There is often chemosis and the lachryma- tion is profuse, hot and burning (Rhus), though not acrid, as under Arsenicum. Drowsiness and absence of thirst are often present.

Argentum nit. — Lids sore, very red and swollen, especially when complicated with granular conjunctivitis or some other external trouble. There is usually profuse discharge from the eyes, causing firm agglutination in the morning. The symptoms are often relieved in the cold air, or by cold applications, and may be associated with head- ache, pain in the root of nose, etc.

Arsenicum. — Inflammation of the margins of the lids, which are thick, red and excoriated by the burning, acrid lachrymation. The cheek may also be excoriated. The lids are sometimes cederaatously swollen and spasmodically closed, especially when the cornea is at the same time affected. The characteristic burning pains are impor- tant and usually present. The general condition of the patient

24

DISEASES OF THE EYELIDS.

decides us in the selection, as the great prostration, restlessness, aggra- vation after midnight and thirst are commonly seen in scrofulous children. Often useful in the early stages of abscess of the lids.

Aurum. — Rarely useful in uncomplicated blepharitis, except when occurring in scrofulous or syphilitic subjects, after the abuse of Mer- cury. The lids may be red and ulcerated, with stinging, pricking or itching pain in them. Cilia rapidly fall out.

Calcarea carb. — Blepharitis occurring in persons inclined to grow fat, or in unhealthy, "pot-bellied" children of a scrofulous diathesis who sweat much about the head. The lids are red, swollen and in- durated. Inflammation of the margins of the lids, causing loss of the eyelashes, with thick, purulent, excoriating discharge and burn- ing, sticking pains. Great itching and burning of the margins of the lids, particularly at the canthi ; throbbing pain in the lids. Most of the eye symptoms are worse in the morning, on moving the eyes, and in damp weather. Great reliance should be placed on the general cachexia of the patient.

Calcarea iodata. — Seems to act better than the carbonate in blepharitis found in those unhealthy children afflicted with enlarge- ment of the glands and especially of the tonsils.

Causticum. — Blepharitis, with warts on the eyebrows and lids. The symptoms are ameliorated in the open air. Feeling of sand in the eye.

Chamomilla. — Of benefit as an intercurrent remedy, even if it does not complete the cure, in cross, peevish children who want to be carried. The local symptoms are not marked.

Cinnabaris. — Ciliary blepharitis, with dull pain over or around the eye. There may be dryness of the eye, or considerable discharge.

Croton tig. — When there is complicated with the blepharitis a vesicular eruption on the lids and face.

Euphrasia. — A valuable remedy, if the lids are red, swollen and excoriated by the profuse, acrid, muco-purulent discharge, or even if ulcerated. The lachrymation is also prof use, acrid and burning ; often accompanied by fluent coryza. The cheek around the eye is also usually sore and red from the nature of the discharges.

Graphites. — This is one of the most important remedies we pos- sess for the chronic form of this disease, though it may be indicated in acute attacks, especially if complicated with ulcers or pustules on

BLEPHARITIS CILIAEIS.

25

the cornea. Particularly useful if the inflammation occurs in scrof- ulous subjects covered with eczematous eruptions chiefly on the head and behind the ears, which arc moid, fissured and bleed easily. The edges of the lids are slightly swollen, of a pale red color and covered with dry scales or scurfs, or the margins may be ulcerated. The in- flammation may he confined to the canthi, especially the outer, which have a great tendency to crack and bleed, upon any attempt to open the lids. Burning and dryness of the lids are often present, also biting and itching, causing a constant desire to rub them. It is important in eczema of (he lids, if the eruption is moist, with ten- dency to crack, while the margins are covered with scales or crusts.

Hepar sulph. — This is the remedy most frequently employed in acute phlegmonous inflammation, especially after the first stage has passed and suppuration is about to, or has already, taken place. The lids are inflamed, as if erysipelas had invaded them, with throbbing, aching, stinging pains, and very sensitive to touch; the pains are ag- gravated by cold and from contact, but ameliorated by warmth. It may also be useful in certain forms of blepharitis in which the lids are inflamed, sore and corroded, as if eaten out, or if small red swell- ings are found along the margins of the lids, which are painful in the evening and upon touch. There is general amelioration from wan nth. Often called for when the Meibomian glands are affected, ifor eczema palpebrarum, in which the scabs are thick and honeycombed in character on and around the lids, it is very valuable.

Mercurius sol. — Very favorable results have been gained by this remedy in blepharitis, especially if dependent upon or found in a syphilitic subject, or if caused from working over fires or forges. The lids are thick, red, sivollen and ulcerated (particularly the upper) and sensitive to heat or cold and to touch. Profuse acrid lachryma- tion is usually present, which makes the lids sore, red and painful, especially worse in the open air or by the constant application of cold water. All the symptoms are worse in the evening after going to bed and from warmth in general, also from the glare of a fire or any artificial light. The concomitant symptoms should receive special attention, as excoriation of the nose from the acrid coryza, flabby condition of the tongue, nocturnal pains, etc., etc.

Mercurius corr. — This form of Mercury differs very little in its symptomatology from the above, and that is chiefly in degree, as the

26

DISEASES OF THE EYELIDS.

pains are generally more severe and spasmodic in character, lachry- mation more profuse and acrid, secretions thinner and more excoriat- ing and inflammatory swelling greater than in any other prepara- tion. It has proved curative in inflammatory swelling of indurated lids, inflammatory swelling of cheeks and parts around the orbits, which are covered with small pustules, and especially in scrofulous inflammation of the lids. Nocturnal aggravation of the symptoms is usually present.

Mezereum.— Blepharitis accompanied by tinea capitis; or eczema of the lids and head, characterized by thick hard scabs, from under which pus exudes on pressure.

Natrum mur. — Ciliary blepharitis, particularly if caused by the use of caustics (nitrate of silver). The lids are thick and inflamed, smart and burn, with a feeling of sand in the eye. The lachryma- tion is acrid, excoriating the lids and cheeks, making them glossy and shining ; often accompanied by eczema.

Nux vom. — Chronic inflammation of the lids, with smarting and dryness, especially worse in the morning. It is particularly indicated in ciliary blepharitis dependent upon gastric disturbances.

Petroleum. — Has been of benefit in ciliary blepharitis, especially if combined with the use of cosmoline externally. Great reliance should be placed on the occipital headache, rough skin, etc., gener- ally found when this drug is indicated, though it has been used with advantage, when no marked symptoms were present.

Psorinum. — Old chronic cases of inflammation of the lids, espe- cially when subject to occasional exacerbations. It has also been of service in the acute variety when the internal surface of the lids was chiefly affected, with considerable photophobia. Particularly indicated in a strumous diathesis, with unhealthy, offensive discharges from the eyes.

Pulsatilla. — Blepharitis, both acute and chronic, especially if the glands of the lids are affected (blepharo-adenitis) or when there is a great tendency to the formation of styes or abscesses on the margin of the palpebrse. Blepharitis resulting from high living or fat food and when accompanied by acne of the face ; also in cases in which the lachrymal passages are involved. The swelling, redness and discharges vary, though the latter are more often profuse and bland, causing agglutination of the lids in the morning. Itching and bum-

BLEPHARITIS CILIARIS.

27

ing are the chief sensations experienced. The symptoms are usually aggravated in the evening, in a warm room or in a cold draught of air, but ameliorated in the cool open air.

Rhus tox. — Its chief use is in acute phlegmonous inflammation of the lids and erysipelas; lids oedematously swollen (especially the upper) and accompanied by profuse lachrymation; there may be ery- sipelatous swelling of the lids, with vesicles on the skin ; chemosis is often present. The pains are worse at night, and in cold, damp weather, but relieved by warm applications. It may be of service in acute aggravations of chronic inflammation from exposure in wet weather or when worse at that time, with much swelling of the lids and profuse lachrymation.

Sepia. — Chronic inflammation of the edges of the lids with scales on the cilia and small pustules on the lid margins (acne ciliaris). Feeling as if the lids were too heavy, or as if they were too tight and did not cover the ball. Worse morning and evening.

Silicea. — Blepharitis from working in a damp place or being in the cold air. (Calc, Rhus.) Indicated in abscess, after suppuration has commenced. Silicea is more particularly called for in the car- buncular form, and especially if the patient is very nervous and the local symptoms are accompanied by sharp pains in the head, relieved by wrapping up warm.

Staphisagria. — Blepharitis, in which the margins of the lids are dry, with hard nodules on the borders and destruction of the hair follicles. Itching of the lids.

Sulphur. — A remedy called for, especially in the chronic form of this disease and when found in children of a strumous diathesis who are irritable and cross by day and restless and feverish by night ; also for blepharitis appearing after the suppression of an eruption or when the patient is covered with eczema. The lids are red, swollen and agglutinated in the morning, or there may be numerous small itching pustules on the margins. The pains are usually of a sticking character, though we may have itching, biting, burning and a variety of other sensations in the lids. There is generally great aversion to water so that they cannot bear to have the eyes washed. Eczematous affections of the lids, like eczema in other portions of the body, which indicate Sulphur, are often controlled.

Tellurium. — Eczema of the lids, especially if complicated with a

28

DISEASES OF THE EYELIDS.

moist eruption behind the ears and offensive otorrhcea smelling like fish brine.

In addition to the above, the following remedies have also proved serviceable : Ant. crud., Arg. met., Lyco., Merc, nitr., Merc, prot., Sang., Seneg.

Hordeolum (Stye). — Is an acute inflammation of the cellular tissue of the lid leading to suppuration and pointiug at the edge of the lid. The location of the inflammation is usually in the tissue surrounding a hair follicle.

Symptoms. — At first it appears as a circumscribed redness and swelling, which soon extends so that the whole lid will often become oeclematously swollen. There is much severe throbbing pain. Often times there are two or more at the same time or they may occur iu successive crops.

Course. — They will usually point and break in three or four days, though they may undergo absorption without breaking.

Causes. — It is usually due to general debility, associated with over use of the eyes, especially in hypermetropes ; chronic blepharitis, or conjunctivitis and exposure to cold winds may cause it.

Treatment. — We are not often called upon to prescribe for a single stye, but usually to prevent the recurrence of successive crops. If the case is seen at its very outset, especially if severe, cold com- presses may be used with advantage, though usually more benefit is derived, especially after its commencement, from hot poultices. If pus has formed, as shown by a yellow point, a small incision can be made to permit its ready escape. If dependent, as it frequently is, upon impairment of the general health, proper hygienic measures must be advised.

Graphites. — Useful in preventing the recurrence of styes. (Com- pare general symptoms of patient.)

Hepar. — Indicated if suppuration has already commenced, with throbbing pain, great sensitiveness to touch and amelioration by warmth.

Pulsatilla. — This is an excellent remedy for styes of every descrip- tion and in every stage of the disease. If given early, before the formation of pus, it will often cause them to abort; if used later, relief from the pain and hastening of the process of cure is fre- quently produced, while, as a remedy for the prevention of the recur-

HORDEOLUM — PTOSIS.

29

rence of successive crops, it is often of great value. It is especially useful if dependent upon some gastric derangement, as from indulgence in high living, fat food, etc., and if accompanied by acne of the face ; also when found in amenorrhoeic females or the peculiar Pulsatilla temperament.

Staphisagria. — Recurrence of styes, especially on the lower lid, which are inclined to abort and leave little hard nodules in the lids.

Sulphur. — To prevent the recurrence of successive crops, espec- ially in a strumous diathesis, as shown by eruptions, boils, etc., on various portions of the body. Cannot bear to have the eyes washed and is restless and feverish at niffht.

Thuja. — Obstinate forms of styes, which seem to resist treatment and form little hard nodules on the margins of the lids.

The following remedies have also been recommended and used with advantage : Aeon., Arsen., Calc, Caust., Con., Lyco., Merc, Pic ac, Phosph. ac, Rhus and Silicea.

Ptosis is a drooping of the upper lid, due to either partial or com- plete paralysis of the levator palpebra? superioris. It may occur alone or be associated with a paralysis of the other muscles supplied by the third nerve, and is sometimes congenital. When complete, the upper lid covers nearly the whole of the cornea. The most fre- quent causes are syphilis, when of a central origin, and trauma when peripheral.

Treatment. — Chief reliance must be placed upon internal medi- cation, though sometimes Electricity proves of great value, either used alone or in connection with the indicated remedy. If the disease — dependent upon irremediable causes — resists all treatment, opera- tive measures must be resorted to.

Alumina. — The upper lids are weak, seem to hang down as if paralyzed, especially the left. Burning dryness in the eyes, especially on looking up. Absence of lachrymation. Particularly useful for loss of power in the upper lids met with in old, dry cases of granula- tions.

Causticum. — More benefit has probably been derived from this remedy in the treatment of ptosis than from any other. Its special indication is drooping of the lid resulting from exposure to cold (Rhus, from damp cold). The symptoms in the provings very strongly point to Caust. as a remedy in this disorder, as "inclination to close

30

DISEASES OF THE EYELIDS.

the eyes ; they close involuntarily. Sensation of heaviness in the upper lid, as if he could not raise it easily," etc.

Euphrasia. — If caused from exposure to cold and wet and ac- companied by catarrhal symptoms of the conjunctiva.

Ledum. — Ptosis resulting from an injury, with ecchy mosis of the lids and conjunctiva.

Rhus tox. — Especially if found in a rheuynatio diatliesis and if the cause can he traced to working in the wet, getting the feet damp, or to change in the weat/ier. Heaviness and stiffness of the lids, like a paralysis, as if it were difficult to move them. There may be aching, drawing pains in the head and face, or they may be absent. The concomitant symptoms will point to its selection, though it has proved useful when none are present.

Spigelia. — Ptosis, resulting from inflammation or other causes, in which sharp, stabbing pains through the eye are present. Sometimes hot, scalding lachrymation accompanies the above.

Gelsemiwm, Stannum and Conium have been favorably employed in this affection, especially the former. (Compare paralysis of the muscles.)

Many operative measures have been recommended for the relief of Ptosis. The old method was simply the removal of a portion of the skin and fibres of the orbicularis muscle, and this, in some cases of partial ptosis, may suffice.

Pagenslecher, in 1881, introduced the operation of inserting sub- cutaneous sutures, running from near the margin of the lid to the forehead above the brow, and tied tightly, expecting by the result- ing cicatrices, as the sutures cut their way out, to raise the lid.

Wecker combines the operation of sutures with the old method of excision, as follows : He removes an elliptical portion of the skin and muscular fibres. He then inserts a strong thread above the brow, running underneath the skin to the upper edge of the wound, over which it passes to the lower border of the wound and then pierces the skin near the free border of the lid ; it is now carried parallel to the lid for about five millimetres, where the puncture is again made and it travels backward on a reverse course, parallel to its downward path, to the brow. The two ends are now tied to- gether over a roll of plaster and tightened from time to time as they become loose (Figs. 2 and 3). Two such sutures are introduced

BLEPHAIIOSPASMUS.

31

The wound is in this way closed, and, as the sutures cut through, cicatrices are formed which hold the lid up permanently.

Blepharospasms. — Spasmodic closure of the lids is often asso- ciated with photophobia from some conjunctival irritation, or it may be due to a foreign body, an ulcer of the cornea, iritis, refractive errors, carious teeth, or other reflex conditions. The spasm of the lid may be of the tonic variety, in which there is continued and complete closure of the lids, with perhaps an inversion of the eye- lashes, which will of course cause great irritation of the eye; or it

Fig. 2. Fig. 3.

Wecker's Operation for Ptosis. Wecker's Operation (completed).

may be a clonic spasm, when the contractions are intermittent, last- ing but a few seconds at a time.

Treatm KNT. — This should first be directed to the cause of the irritation, and, as it is usually dependent upon corneal troubles, is relieved with them. When, however, it is independent of other affections, remedies must be prescribed for the spasm per se.

Agaricus.— Twitchings of the lids, with a feeling of heaviness in them, relieved during sleep and sometimes temporarily by washing in cold water. Spasms of the lids. It is very rare to meet a case of morbid nictitation which will not yield to this remedy. (Four-drop doses of the tincture two or three times a day will often relieve when the potencies fail.)

82

DISEASES OF THE EYELIDS.

Other remedies which have proved useful in individual eases are Alumina, Cicuta, Ignatia, Nux v., Physos. and Pulsat. Division of the affected nerve may be necessary in aggravated cases. The use of electricity is often of great value in some cases— the positive pole is applied behind the mastoid and the negative on the surface of the lid. Canthotomy, the division of the structures at the outer canthus by means of scissors, may be valuable in cases of tonic spasm.

Nictitatio. — Constant blinking is frequently met with, especially in children and nervous, delicate persons. This condition is gener- ally due to some irritation in the eye itself, or may be reflex, from worms, decayed teeth, etc. Remove the cause, if determinable, and Agaricus will complete the cure.

Blepharophimosis. — Narrowing of the palpebral opening is usu- ally caused by chronic trachoma and is relieved by canthotomy.

Trichiasis and Distichiasis. — Where there is an irregularity in the shape and position of the eye-lashes so that they become curved in and in contact with the eye, it is called trichiasis, and where there

Fig. 4.

Gruening's Epilating Forceps.

is a double row of lashes, one of which is in contact with the eye, it is called distichiasis. These conditions are usually due to blepha- ritis, trachoma, injuries, burns, etc.

Treatment. — Where there are but a few ingrowing lashes, epila- tion, if often repeated, may cause an atrophy of the hair bulbs and in this way cure the case (Fig. 4).

Electrolysis, as a curative measure, is most serviceable when the lashes to be destroyed are not too numerous. This is done by in- serting a needle into the hair follicle and then connecting it with the negative pole of the battery, the positive being applied to the temple.

Arlt's operation, when modified to meet the exigencies of the case, seems to be the most generally advisable method of operating for the severe cases and is shown in the illustration (Fig. 5.) An in-

TRICHIASIS — ENTROPIUM.

33

cision two or three mm. in depth is made along the free border of the lid, splitting it into two layers. A narrow strip of skin is then excised from the lid, cutting down to the first incision, as shown in the dotted lines in Fig. 5, so that the cilia remain in a bridge of tissue, which is shifted upward and its upper edge attached by sutures to the skin of the lid — its lower margin being left free.

Fig. 5.

Arlt's Operation for Trichiasis.

Entropium is an inversion of the eyelid. We find two varieties of entropium; first the spasmodic, which is usually of the lower lid and is due to a spasmodic contraction of the orbicularis muscle. It is often met with in old people, sometimes coming on after opera- tions, and is due to the lax condition of the skin. It may also be due to irritation from a foreign body, from keratitis, etc. The second variety of entropium is the cicatricial and is the result of granular and diphtheritic conjunctivitis, burns, etc., where there has been loss of substance in the conjunctiva. The condition gradually comes on during the process of cicatrization and results in an opacity of the cornea.

TREATMENT. — In the spasmodic entropium a cure may often be effected by painting the parts with collodion, which should be re- newed every two or three days, or oftener, in order to keep the lid in position. Adhesive strips may be applied for the same purpose. If these measures do not suffice, and always in the cicatricial entro- pium, operative interference must be resorted to before a cure can be

3

34

DISEASES OF THE EYELIDS.

made. Owing lo the excessive vascularity of the lids, free haemor- rhage occurs from any operation upon the lids unless controlled by the use of entropiura forceps (Fig. 6.) There are various operations for the relief of entropiura, of which perhaps Green's is the most serviceable in the majority of casts. This is made by everting the lid and making an incision parallel to and about two mm. above its free border through the entire thickness of the tarsus, from the conjunctival side, the incision to extend from one canthus to the other. A strip of skin about two mm. wide and from one to two mm. above the cilia is then removed. Three sutures are then passed from the conjunctival side of the cilia through the free edge of the tarsus to just above the lower border of the skin wound; from there they pass through the muscular fibres on the outer surface of

Fig. 6.

Knapp's Eiitropium Forceps.

the tarsus and emerge from the skin about half an inch above the upper border of the wound. On tying these sutures the ciliary border is everted and the skin wound closed.

Streatfeild's operation is the removal of a strip of skin with sub- jacent muscular fibres and a portion of the tarsus, just above the border of the lid, by cutting a deep V-shaped groove in its outer surface.

Other operations are Arlt's, already described, and those of Hotz, Snellen, Pope and others.

Remedies may possibly be useful, if the inversion is recent and only slight in degreee. The following are suggested : Aconite, Ar- gent, nit., Calc. and Natrum mur.

Ectropium is an eversion of the eyelids. The eversion may be slight or so great as to expose almost the whole of the palpebral

ECTROPIUM.

35

conjunctiva. Ectropium is also divided into two classes, the con- junctiva/, due to chronic inflammation and swelling of the conjunc- tiva, which separates the lid margin from the eye, and this separa- tion serves to increase the trouble by causing the tears to flow over the lid, which, in its turn by this irritation, aggravates the existing trouble. This form is also sometimes seen in children — due to the swelling and inflammation of the conjunctiva, with contraction of the orbicularis. The cicatricial ectropium is due to a contraction after loss of the skin of the lids or of the face, following burns, wounds, abscesses, caries of the edge of the orbit with adhesions of the skin, etc.

TREATMENT. — In cases of conjunctival ectropium we may some-

FlG. 7. Fig. 8.

Wharton Jones' Operation. Wharton Jones' Operation (eonipkted).

times give relief by replacing the lid and retaining it there for sev- eral days by the use of the compress bandage. Scarification or re- moval of a strip of the conjunctiva to reduce the obstruction from thickening of the conjunctiva, together with the slitting up of the canaliculus, to permit the passage of the tears through the normal channels, may be tried. Other operations recommended to correct this affection are legion, and, as they must necessarily vary in nearly every case, according to the cause, degree and position of the eversion, but two will be detailed.

No plastic operation should be attempted until all tendency to

36

DISEASES OF THE EYELIDS.

contraction of the cicatrices has disappeared. In all flap operations allowance must be made for shrinking.

In Wharton Jones' operation a V-shaped (Fig. 7) incision is made to include all the cicatricial tissue possible; the flap thus formed is to be dissected from the underlying tissues, and the skin at either side undermined sufficiently to allow of the lid being re- turned to its normal position. The exposed surface is then to be covered by bringing together the edges of the V-shaped wound with sutures so that it becomes Y-shaped (Fig. 8).

Dieffen bach's operation is made by dissecting away the diseased

Fig. 9. Fig. 10.

Dieffenbach's Operation. Dieffcnbach's Operation (completed).

tissue by a triangular incision. A flap of skin is then loosened by careful dissection from the immediate neighborhood and shifted up on the exposed surface, where it is kept in position by pins and su- tures. (See Figs. 9 and 10.) The surface from which the flap was removed, if small, will become covered by growth of the integument from the edges of the wound; but, when large, it should be filled with grafts of skin from other parts of the body. The ectropium may also be corrected by skin grafting from other parts.

Apis. — Is especially indicated in the first stage of this affection, in which the swelling of the conjunctiva is very great.

Argent, nit. — If the lids are swollen, inflamed, everted and the punota Iqehrymalia very red and prominent. The discharge of tears and pus is profuse.

SYMBLEPHAKO.Y.

37

Hamamelis vir.— A dilute solution of "Pond's Extract" applied locally is said to have cured a case occurring during the course of a severe conjunctivitis.

Little reliance must be placed upon internal medication in either entropium or ectropium, as operative measures are almost invariably necessary, except occasionally in the first stage.

Symblepharon.— Adhesion of the eyelid to the eyeball. This con- dition occurs when, as the result of destruction of the mucous mem- brane from burns or injuries, or after diphtheritic or trachomatous conjunctivitis, two opposed portions of the conjunctiva grow together and may be either partial, when but one or more bands extend between the lid and globe, or complete, when the entire surface of

Fig. 11.

Symblepharon.

the lid is attached to the globe. The lower lid is most commonly adherent, and more or less limitations in the movements of the eye ensues. It may comprise the cul-de-sacs or the border of the lids (Fig. 11). The thickness of the adherent portions may vary, and we will have a sarcomatous, membranous or fibrinous symblepharon. The mucous membrane in these cases is destroyed to such an extent that simply dividing the adhesions will do no good, as they will at once grow together again. There are two methods of operating upon these cases with some prospect of success. First by separating the affected portions and inserting flaps brought from near by or from the oppo- site side of the cornea between them; or, second, failing in this, to transplant from another person.

Anchyloblepharon is an adhesion of the ciliary margins of the eyelid-. It may be complete or partial, acquired from burns or

38

DISEASES OF THE EYELIDS.

wounds, or congenital. The treatment is by inserting a grooved director behind the lids and dividing the adhesions.

Epicanthus is a congenital deformity in which a cresentic fold of skin projects in front of the inner can thus. As the child grows it disappears altogether, or becomes much less noticeable, so that opera- tive interference is only called for iu high degrees for cosmetic pur- poses. The operation is to remove an elliptical piece of skin from the bridge of the nose and uniting the edges of the wound together with sutures, care being taken to secure union by first intention by preventing any dragging on the stitches.

Molluscum Contagiosum is an affection of the sebaceous glands- It consists of small, round, whitish prominences which may become inflamed and go on to suppuration. It is a hypertrophy of the gland and the tumor is composed of epithelial elements. For treat- ment see chalazion.

Xanthelasma is a fatty degeneration of the connective tissue of the skin. They appear as yellowish patches, especially on the upper lid. They may be removed by excision for cosmetic purposes.

Milium are small, circular, white tumors. They are removed by incision and pressing out of the contents.

Papillomata (warts) are occasionally found upon the edge of the eyelid and upon the conjunctiva. They should be snipped off.

Dermoid cyst is congenital, and contains hair-follicles, hairs, connective tissue, fat, etc. It is generally situated at the outer angle of the orbit, develops slowly and causes but little inconvenience. It should be removed without rupturing the tumor, if possible.

Nsevi are found on the eyelids and are similar in appearances to those occurring elsewhere. They are best removed by the galvano- puncture.

Chalazion (Meibomian or Tarsal Cyst) is a small tumor situated in the substance of the lid, and is caused by a retention of the secre- tion of a Meibomian gland, followed by an inflammation of the sur- rounding tissues. It varies in size, rarely growing larger than a good-sized pea ; several may occur at the same time or they may recur in successive crops. The skin is movable over them, but the tumor is adherent to the tissues.

It develops slowly, causing no inconvenience for months. It may suppurate, and, when it does, it usually points on the conjunctiva.

TUMORS OF THE EYELIDS.

Treatment. — Excision, as a rule, is the most satisfactory treat- ment of tarsal tumors, providing there are only one or two. But as it is usually tedious and painful to remove entire a small solid tumor, we may substitute for excision, opening of the tumor squeezing out its contents, and stirring up the sac with the point of a knife. This will cause a slight inflammation which will hasten absorption. It may have to be repeated several times, but, as there will belittle pain at- tending the operation, no objection will be made by the patient. This is also the most efficacious treatment in cases of multiple tumors. A fter opening and at other times also, I usually apply locally the in- dicated remedy — especially the tincture of Thuja. In the case of cystic tumors the whole of the cyst wall should be removed ; it may be destroyed by the use of a seton, but removal with the knife is usually more satisfactory. Many cases have been cured by internal medication alone, and remedies should always be employed, whether the knife is used or not, for they no doubt hasten the cure and serve to prevent recurrence.

Calcarea carb. — Tarsal tumors occurring in fat, flabby subjects.

Causticum. — Tumors, especially warts, found on the lids and eye- brows.

Conium. — Indurations of the lids remaining after inflammation.

Hepar. — Tarsal tumors that have become inflamed and are sensi- tive to touch. It also aids absorption after operation.

Pulsatilla. — Tarsal tumors of recent origin that are subject to in- flammation, or are accompanied by catarrhal conditions of the eye. The temperament and general symptoms will decide the choice.

Staphisagria. — An important remedy for tumors of the lid. Enlargement of the glands of the lids, which are red and accom- panied by tensive tearing pains, especially in the evening. For little ind lu rations of the lids, resulting from styes, or for successive crops of small tarsal tumors, this drug is especially indicated.

Thuja. — This is one of the most valuable remedies for tarsal tumors, whether single or multiple, especially if they appear like a condyloma, either of the internal or external surface of the lid. We have seen them disappear by simply giving the drug internally, though it usually seems to act more speedily if we use, at the same time, the tincture externally. It is also recommended for the pre- vention of their return after removal by the knife and for hasten-

40

DISEASES OF THE EYELIDS.

ing their absorption after operation. For condylomata, or warty excrescences on the lids, especially if occurring in syphilitic subjects, this drug deserves attention.

Zincum. — Tumors of the lids with soreness and itching in the internal canthi.

Baryta carb. and iod., Graph., Lyco., Kali iod., Merc, Nitric acid, Sep., Sil. and Sulph. may be required.

Epithelioma is the most frequent malignant growth affecting the evelid. It rarely occurs before the age of forty, and appears first as small hard nodules, and later becomes covered with a scab, which, on being removed, shows a slight excoriation ; this increases to an ulceration of considerable depth, with purulent secretion and irre- gular, hardened edges. It may remain indolent for months, then assume an active stage, leading rapidly to extensive destruction of tissue. In the early stages there is little or no pain, but becomes excessively painful in the later stages.

Lupus and Sarcoma have both been found affecting the eyelids. A lupoid growth is more slow in development than an epithelioma, and both may result in ulceration; but, as Noyes1 so well says, "A discrimination between them is hardly needful for practical pur- poses."

Treatment. — Excision is advised in all malignant growths of the lids, if the disease is circumscribed and moderate in extent ; care being taken that all the morbid tissue is removed. The edges of the wound may be brought together by sutures, or a plastic operation may be made, bringing the integument from the temple or some adjoining point.

Juler2 advises scraping away all the diseased tissue by means of a small steel scoop. This is attended with considerable haemorrhage, and is tedious, but he claims its success in arresting this malignant affection is marvellous.

Various caustics have also been employed, chief among which may be mentioned caustic potash, nitrate of silver, chloride of zinc, arsenic paste and acetic acid. An objection to the use of caustics lies in the deformity apt to occur afterward. Electrolysis has been recom- mended.

1 Diseases of the Eye, 1890.

3 Ophthalmic Science and Practice, 1884.

HERPES ZOSTER FRONTALIS.

41

If the disease is very extensive, involving the tissues of the face to such an extent that extirpation is impracticable, we then rely chiefly upon our internal remedies, using only such local applications as prove agreeable and of temporary relief to the patient. For in- stance, if the discharge is profuse and offensive, a weak solution of carbolic acid, salicylic acid, or some other disinfectant proves of ser- vice. An application from which we have often seen excellent results is carbolic acid and linseed oil (4 grains to the ounce) ; it relieves the patient and seems to exert a beneficial effect over the progress of the disease.

Apis. — Lupus non exedens, sharp, stinging pains, and tendency toward puffin ess of the lower lids.

Hydrocotyle asiatica. — Has obtained a high reputation in the hands of Dr. Boileau as a remedy for lupus and deserves our atten- tion. (We have, however, failed to perceive any results from its use).

Phytolacca dec. — Benefit seems to have been derived in reliev- ing, if not curing, malignant ulcers of the lids, when used both exter- nally and internally.

Thuja. — Epithelioma of the lids.

Herpes Zoster Frontalis commences with severe neuralgic pains along the frontal and nasal nerves. The skin becomes swollen and red, covered with herpetic vesicles which unite, crusts form upon them and ultimately leave deep cicatrices. The disease involves one- half of the face, never extending beyond the median line, and has often associated with it corneal ulcers and" iritis.

Treatment. — The remedies most useful are: Ars., Croton tig., Electricity, Graph., Merc, Puis., Ranunculus bulb, and Rhus.

Syphilitic Ulcers, Chancre, and Gummata are all occasionally found on the eyelids, and should be treated the same as occurring elsewhere. The most useful remedies are the following, prescribed according to general indications: Ars., Apis, Aurum, Cannab., He- par, Kali, iod., Merc, Nitric ac, and Thuja.

Contusions are very often found, and are frequently accompanied by some lesion of the globe or orbit.

TREATMENT. — Immediately after contused wounds of the lids, cold compresses .should be employed ; they should be applied with a firm bandage, which often proves of advantage in limiting the amount of ecchymosis.

42

DISEASES OF THE EYELIDS.

Arnica, our great remedy for all contusions, deserves its extensive reputation for curing "black eyes," as there is no other drug better adapted to this condition. A solution of the tincture in water, ten drops to the ounce, is usually employed, though both stronger and weaker solutions are in vogue. Ledum, used in the same manner, has also proved of service.

Wounds. — We may have an incised, lacerated, or penetrating wound of the lid ; and, in all cases, the condition of the orbit and globe should be carefully examined to see if they remain intact.

Treatment. — The first object in view should be to bring to- gether the edges of the wound by means of sutures, adhesive strips or collodion : after which the application of a solution of Calendula, ten drops to the ounce of water, may be applied. If the tissues are very much bruised Arnica may be employed, though, as a rule, Cal- endula will be found more useful in cut wounds. If the wound is incised, without any contusion, and the edges are early brought accu- rately together, a dry dressing will often be found most beneficial.

Hamamelisand Ledum have both been recommended for wounds of the lids.

Burns and Scalds must be treated as usual in other parts of the body, except that care should be taken to prevent the union of the lids (ankyloblepharon) by frequently opening them, and by inunc- tion of the edges with simple-cerate or cosmoline; also, great atten- tion should be paid to the prevention of a cicatrix (which causes ectropium) by keeping the skin on the stretch by a bandage during the period of cicatrization. Cosmoline is especially recommended as an external application.

When dependent upon the stings of insects, the sting should be removed and cold-water dressings applied.

ANATOMY.

43

CHAPTER II.

Affections of the Lachrymal Apparatus.

Anatomy. — The lachrymal gland is lodged in a fossa at the outer and upper part of the orbit and close to its anterior margin. It is separated into two portions by a septum of connective tissue, the larger part of the gland being about twenty mm. in length and ten to twelve in breadth. It is an acinous gland like the salivary. The excretory ducts, some ten to fourteen in number, run from both por-

Fig. 12.

Dissections of the Lachrymal Apparatus.

tions of the gland to the upper and outer part of the superior fornix of the conjunctiva. The secretion of the lachrymal gland is faintly alkaline, containing about 1.25 per cent, of sodium chloride and .5 per cent, of albumin. It serves to moisten the anterior surface of the eye, and passes off through the puncta, canaliculi, lachrymal sac, and nasal duct, into the inferior meatus of the nose (Fig. 12). The puncta are the two minute openings of the canaliculi, on the free

44

AFFECTIONS OF THE LACHRYMAL APPARATUS.

margin and about six mm. from the inner angle of the lids. The canaliculi, both upper and lower, extend from the puncta to the lachrymal sac, just before reaching which they unite. The upper canaliculus is slightly smaller than the lower, and first ascends, then turns downward and inward. The lower canaliculus first descends, then runs horizontally to the sac. The lachrymal sac is the upper dilated portion of the nasal duct. It is located in a groove formed by the lachrymal and superior maxillary bones; its upper end is closed and rounded. The nasal duct extends from the lachrymal sac to the inferior meatus of the nose. The bony canal is lined with a fibrous membrane, and this, in turn, by cylindric epithelium like that of the nostrils. It is highly vascular and thrown into folds at two or three points. The total length of the sac and duct is about one inch. Its direction is downward, backward and slightly inward. The tears are forced into the excretory passages by muscular action, aided by a kind of suction caused by the muscular fibres of the puncta and canaliculi.

Dacryoadenitis. — Inflammation of the lachrymal gland is ex- tremely rare. In the acute form the symptoms are, great swelling and redness of the upper lid at its outer angle. The globe may be displaced downward and inward by the swelling. The pain is severe and increased by touch. The conjunctiva is inflamed and may be chemosed. The inflammation may terminate by resolution, suppu- ration, or run into the chronic form, in which all the acute symptoms are less severe, merely a considerable swelling- remaining. Dacryo- adenitis is generally caused by injury, and this fact, together with its symptoms, makes it very difficult to diagnose from periostitis of the orbit or abscess of the lid.

Treatment. — When in the early stage, before there is a forma- tion of pus, ice will often cut short an attack which might otherwise go on to suppuration. As soon, however, as there is evidence of suppuration, we should resort to hot fomentations in order to pro- mote suppuration, and, when well established, a free incision should be made through the conjunctiva, if possible. The most useful remedies are Aeon., Apis., llepar, Rhus, and Silicea. For indica- tions see dacryocystitis phlegmonosa.

Hypertrophy of the Lachrymal Gland is very rare. It is a cir- cumscribed, nodular tumor of gradual growth and has been known

STRICTURA DUCTUS LACHRYMALIS.

45

to occur in children and infants. If it increases sufficiently to cause interference with the movements of the eyeball it should be re- moved.

Tumors of the Lachrymal Gland, such as fibroids, saroomatas, adenomas, hydatid cysts and cancers have all been recorded. They require extirpation of the gland.

Anomalies of the Puncta and Canaliculi. — Eversion of the puncta is frequently found in blepharitis and conjunctivitis, causing epiphora, or watering of the eye.

The same result will occur from a narrowing or stoppage of the canaliculus, wounds of the lid involving the canaliculus, or foreign bodies in the canaliculi blocking the passage of the tears. Obstruc- tion of the canaliculus can be relieved by slitting up the canal with the canaliculus knife (Fig. 13), a narrow-bladed, probe-pointed

Fig. 13.

Agnew's Canaliculus Knife.

knife, which is to be entered into the puncta vertically, the handle then brought to a horizontal position, when the knife is pushed di- rectly inward until it reaches the inner wall (the lid being kept taut with the thumb of the other hand), the knife is then brought to the vertical position, cutting through the whole length of the canalicu- lus. The edge of the- knife should be kept toward the conjunctiva during its passage, so as to divide the canaliculus close to the muco- cutaneous junction.

Strictura Ductus Lachrymalis. — Stricture of the nasal duct is the most common affection of the lachrymal apparatus.

Symptoms. — The symptoms are few. The chief characteristic symptom of stricture is the overflow of tears, which is increased on exposure to cold wind or bright light. There is also often noticed a dryness of the nostril on the same side as the stricture. Usually on making pressure with the finger over the sac we can press out from tiie puncta a few drops of clear viscid secretion. We may also find a slight conjunctivitis present.

Causes. — The cause of this affection is often difficult to determine It may come on as an extension of a nasal catarrh. Injury or peri-

46 AFFECTIONS OF THE LACHRYMAL APPARATUS.

ostitis of the nasal bones, carious teeth, or pressure from tumors in that vicinity may cause it.

Dacryocystitis Catarrhalis. — Catarrhal inflammation of the lach- rymal sac is generally the result of a stricture or associated with it. While, on the other hand, the catarrhal inflammation may be the cause of the stricture, as the swelling of the mucous membrane will in itself cause a damming up of the secretions. The retention of the tears causes a gradual distension of the sac — a swelling at the inner angle of the eye. By making firm pressure on this swelling the mucus can be pressed either out of the canaliculus or down through the nasal duct into the nose. The contents of the swelling may be either clear and transparent or mixed with pus. This disease usu- ally develops very slowly, with simply the history of having had a watery eye for a long while previous to noticing any swelling of the sac, and often times they will notice a dryness of the corresponding nostril. The swelling is usually free from pain or sensitiveness to touch.

Treatment. — Since lachrymal diseases are frequently dependent upon nasal catarrh, treatment must be directed to this affection; if aggravated by the presence of nasal polypi, or caused by foreign bodies, these must of course be removed.

As in nearly all cases of blennorrhoea of the sac, a more or less firm stricture of the lachrymal duct is present, this will require our special attention. Slight or moderate strictures (almost always de- pendent upon catarrhal inflammation) may be treated by appropriate medication, from which better results will be finally obtained than from probing. If there is a stricture in the canaliculus, as is often the case, at the entrance to the sac, so as to prevent the collection of tears and diseased secretions in the sac from being readily pressed out, the canaliculus should be divided at once. If the stricture in the nasal duct is so great as to almost close it, or if there is closure, the best operation to divide the stricture is that of Stillings, who, after slitting the canaliculus (as already described), introduces into the lachrymal sac a triangular shaped knife (Fig. 14) in the same way as a probe, and then forces it down two or three times in succes- sion, the blade being turned in a different direction at each passage. Blood issuing from the nostrils is proof that the passage has been opened. Care should be taken for a day or two after the operation

DACRYOCYS I ITIS CATARRH A LIS.

47

to sec that the canaliculus does not close, and, commencing on the second day after the operation, the duet should be probed every two or three days until it remains permanently opened.

A passage sufficient to admit of a Bowman probe from No. 5 to 8 (varying in different cases) should be secured (Fig. 15) The use of larger probes has been recommended, but in my experience they have not proved as satisfactory. If there is very little catarrhal in- flammation, especially in children, it is not always necessary to probe

Fig. 14.

J/CMAMNzCQ

Stilling's Knife for Stricture oi the Lachrymal Passage.

after Stillings's operation. A far better method than operating, when it can be carried out, is that of gradual dilatation of the strictures by using larger and larger probes. Commencing with No. 0 or 00, the canaliculus and duct can be gradually distended so as to admit of a No. 4 or 5 Bowman probe without even slitting the canaliculus.

Fig. 15.

G.TIEMAMM & CO.

Bowman's Set of Probes, Nos. 1, 2, 3, 4, 5, 6, 7, 8.

Rarely, where the puncta is occluded, it will be necessary to slightly nick it with the point of the knife so as to admit of the smallest sized probe. The advantages of this method seems to lay in the fact that we do not destroy the function of the parts and that the normal suction action of the canal is retained. This plan, of course, is not practical in very firm or bony strictures. Marked benefit has also been observed from electrolysis, and there is no doubt it should be more extensively employed. My plan has been to insert a probe in the usual way until it comes in contact with the stricture, then

48

AFFECTIONS OF THE LACHRYMAL APPARATUS.

attaching the probe to the negative pole of a battery, apply the posi- tive to the temple, and make gentle pressure as the stricture yields. Usually four or five treatments will be sufficient to keep the passage permanently opened.

In the treatment of the blennorrhea, a free vent for the secretions through the opened or unopened canaliculus being present, the patient should be instructed to pre^s out the matter several times a day. Also anything that tends to produce irritation, as cold winds and over exertion of the eyes, should be avoided. Mild astringent injections of boracic acid, sulphate of zinc of a two to four per cent, solution or some similar preparation may sometimes prove very ser- viceable.

Fig. 16.

Agnew's Lachrymal Syringe.

Recently I have been using with good results an injection of the blue pyoktanin, 1 to 1,000.

Aconite. — Inflammation of the lachrymal sac, with great heat, dryness, tenderness, sharp pains and general fever.

Argentum nit. — Discharge very profuse, caruncula lachrymalis swollen, looking like a lump of red flesh ; conjunctiva usually con- gested.

Aurum triph. — Catarrh of the lachrymal sac, with desire to bore into that side of the nose; nose obstructed, compelling to breathe through the mouth; nostrils sore, the left discharges continually.

Calendula. — As a local application in blennorrhcei of the sac has been found useful, especially in cases of great tenderness after the canaliculus has been opened.

Euphrasia. — Much thick, yellow, acrid discharge, making the lids sore and excoriated. Blurring of the vision relieved by winking. Thin, watery, bland discharge from the nose.

Hepar sulph. — Inflammation of the lachrymal sac after pus has

DACRYOCYSTITIS PHLEGMOXOSA.

49

formed or in blermorrhoea, with great sensitiveness to touch and to cold, with profuse discharge. Also useful in controlling the dis- charge after the canaliculus has been opened.

Mercurius. — Discharge thin and excoriating ; acrid coryza ; noc- turnal aggravation.

Petroleum. — Discharge from the lachrymal sac, with roughness of the cheek, occipital headache, and other marked concomitant symptoms.

Pulsatilla. — One of the most important remedies for dacryocys- titis, which may sometimes be cut short at its very beginning with it, and may be useful at any stage of the inflammation., It is also important in blennorrhoea of the sac, if the discharge is profuse and bland. Profuse thick and bland discharge from the nose; especially beneficial in children.

Silicea. — Occasionally indicated in dacryocystitis characterized by the usual symptoms; even cases that have far advanced toward sup- puration have been checked. Blennorrhoea of the lachrymal sac often calls for it. The patient is particularly sensitive to cold air and wishes to keep warmly covered.

Staunum. — Very favorable results have frequently been ob- tained in controlling the yellow-white discharge from the lachry- mal sac, itching or sharp pain in the inner canthus, especially at night.

Other remedies which have been recommended and proved useful are Bell., Calc, Cinnab., Hydrast., Kali iod., Merc, prot., Nat. mur., Nux, Sulph. and Zinc, sulph.

Dacryocystitis Phlegmonosa. — Phlegmonous inflammation of the lachrymal sac may be considered as merely a higher stage or ex- tension of the preceding disease.

Symptoms. — In this the swelling is greatly increased and ex- tremely sensitive to touch. The integument becomes very tense and assumes a dusky- red hue. There is usually an ©edematous in- filtration of the surrounding parts, viz : Eyelids, side of the nose and cheek. There is intense pain and heat, with sometimes general symptoms of chills, fever and vomiting. The conjunctiva may be inflamed and even chemosed. The appearance at this time resem- bles an abscess of the cellular tissue overlying the lachrymal sac

and must be carefully differentiated, but in dacryocystitis phlegmo-

4

50

AFFECTIONS OF THE LACHRYMAL APPARATUS.

nosa firm pressure over the swelling will usually empty the tumor either through the puncta or downward through the nose, while in abscess it will not. In dacryocystitis we also have the previous his- tory of a long-continued lachrvmation, which is, of course, absent in abscess.

Course. — If left to itself the swelling usually increases steadily, the skin over the sac becomes thinner and thinner, until it finally gives way, causing a fistula of the lachrymal sac, which often-times is extremely difficult to heal.

Cause. — The exciting cause of a phlegmon of the sac is probably in the majority of cases a simple cold in the head, which serves to aggravate an already existing catarrh of the sac.

Treatment. — At the commencement of an inflammation of the lachrymal sac, before the formation of pus has begun, cold com- presses (even ice) are advisable, which, together with the indicated remedy, may cause the inflammation to abort before an abscess has formed.

As soon, however, as pus has begun to collect in the lachrymal sac, our treatment must undergo a decided change. The first and most important step to be taken is the opening of the canaliculus into the sac and the evacuation of its contents, thus giving the pus free exit through the natural channel. This, as we have said, must be done as soon as suppuration is suspected, for, if not attended to, an opening externally will be made, and a lachrymal fistula may be the result. But if the disease has so far advanced that perforation is inevitable, a free incision into the sac should be made externally, after which, and also in case the abscess has opened spontaneously, warm compresses may be employed for twenty-four or forty-eight hours, but must not be continued too long. After the subsidence of the inflammation this opening will usually close without trouble, though it may be necessary to open the nasal duct and establish a free passage for the tears before it does so. Probing of the nasal duct should be avoided until the severity of the inflammation has sub- sided. Warm applications should be substituted for the cold as soon as suppuration has commenced. Among the best of those in use is a solution of calendula. Internal medication during the whole course of the disease will form an important feature in the treatment.

Aconite. — In the first stage, when the lids are much swollen, with

FISTULA LACHRYMALIS.

51

a tight feeling in them ; chemosis, with much heat and sensitiveness m and around the eye, and a sensation as if the eyeball were pro- truding, making the lids tense.

Apis mel. — Before the formation of pus. Lids cedematously swollen, with stinging, shooting pains. Patient drowsy, without thirst.

Hepar sulph. — Especially after pus has formed. Lids swollen and very sensitive to both touch and cold. Throbbing pains.

Mercurius. — In the later stages, after pus has become thin in character and especially when occurring in syphilitic patients. Pains in and around the eye, always worse at night.

Pulsatilla. — Iu the early stages, when there is considerable swell- ing of the lids, with burning pains. Profuse lachrymation, aggra- vated in the open air. Pulsatilla will sometimes abort an inflam- mation and prevent the formation of pus, even when the swelling is extensive and sensitive to touch.

Silicea. — Is often indicated in dacryocystitis characterized by pain, swelling, tenderness and lachrymation, especially if patient takes cold easily or is very sensitive to a draught of air.

Fistula Lachrymalis.— An opening externally of the lachrymal sac when the result of an abscess breaking, is often very obstinate and difficult to heal ; hence, when evidently about to break, it should be opened with a bistoury.

TREATMENT. — The first point to be attended to is to see that the passage is free into the nose. We must therefore slit up the canali- culus and divide any stricture found in the nasal duct, providing it is sufficient to interfere with the flow of tears; after which the canal should be kept open.

The fistula must now be healed, and, if recent, this is best done by touching the edges with a stick of nitrate of silver. The galvano- cautery, lightly applied to the edges of the fistula, may also greatly aid the healing process. Packing it with alumen exsiccatum has also proved of advantage. If the edges of the fistula are healed and covered with smooth skin, it will be necessary to pare the edges and unite with a suture.

The following remedies have been advised and may have been of service in recent cases, though we doubt if any effect can be obtained in old chronic fistula? : Brom., Calc, Fluoric ac, Lach., Merc, Nat. mur., Petrol., Sil. and Sulph.

52

DISEASES OF THE OKBIT.

CHAPTER III.

Diseases of the Orbit.

Anatomy. — The shape of the orbit is that of a quadrangular pyr- amid, the base or facial opening, the four walls and the apex. The axes of the orbits converge posteriorly at an angle varying in differ- ent individuals. The bones entering into the formation of the orbital walls are the frontal, sphenoid, superior maxillary, malar, palate, ethmoid and lachrymal. The optic foramen, situated at the apex of the orbit, transmits the optic nerve and the ophthalmic artery. The superior orbital fissure transmits the third, fourth and sixth nerves, ophthalmic branch of the trigeminus and the superior and inferior ophthalmic veins. The inferior orbital fissure gives passage to the malar and infraorbital nerves, infraorbital vessels and a facial branch of the ophthalmic vein. The supraorbital notch, at the upper and inner margin of the orbit, contains the supraorbital nerves and artery as they pass to the forehead. The orbit, in addi- tion to the eyeball, vessels, muscles, etc., contains considerable adi- pose tissue.

Tenon's Capsule is the limiting membrane between the cellulo- fatty tissue and the globe and conjunctiva. It ensheaths to some extent the muscles, vessels, nerves, etc., that pass through it, and is continuous with the periosteum of the orbit as well as with the con- junctiva. It is somewhat analogous to the pleura, and serves as a cup in which the globe revolves. It constitutes a secondary attach- ment for the ocular muscles, and by this attachment it renders it possible to sever the tendon of a muscle without losing its entire action upon the eye, for it still remains in connection with the eye through Tenon's capsule, unless too extensive lateral cuts have been made, separating the tendon from the capsule. The dura mater is firmly attached at the sphenoidal fissure and optic foramen and is continuous with the outer sheath of the optic nerve and with the periosteum of the orbit.

Cellulitis Orbitae. — Inflammation of the cellular tissue of the orbit

CELLULITIS ORBIT.E.

53

may occur as a simple edematous cellulitis or in a far more active form as a phlegmonous cellulitis.

Symptoms. — In cedematous cellulitis the eye will be slightly- bulged forward, its movements limited and sometimes diplopia is complained of. There is usually in these mild cases little or no swelling or redness of the lids or conjunctiva, and but little dull pain, except on pressure upon the globe. This form of cellulitis generally occurs in young and delicate children, and usually subsides within a few days.

In the severer form, or phlegmonous cellulitis, the onset is apt to be accompanied with a chill and rise in temperature. There will be swelling and dusky discoloration of the lids, especially the upper, and a more or less intense pain, greatly increased by pressure upon the globe. The eyeball is protruded directly forward, and its move- ments limited in all directions; in some severe cases it will have ab- solutely no motion. (In periostitis the protrusion of the eye and the limitation in its movement is in but one direction.) The conjunctiva is chemosed. Diplopia is usually present and the vision may be greatly impaired. Digital examination will find the tissues firm, tense and very painful to the touch. In extreme cases the eyeball may become involved and end in panophthalmitis.

Causes. — Various and frequently obscure. May be metastatic from phlebitis, septicaemia, puerperal fever, etc. It is often coinci- dent with facial erysipelas. May result from injuries, periostitis and inflammation of the lachrymal gland.

Prognosis. — Is always serious as it usually leads to suppuration. The large majority recover, though it may terminate fatally through meningitis and abscess of the brain.

Treatment — When this form of inflammation results from an injury, or the introduction of a foreign body, the latter should be first removed, and then cold compresses of Calendula solution, or ice bags, be employed to subdue the inflammatory symptoms. But if suppuration has already set in, poultices should be applied to pro- mote the discharge of pus, which should be evacuated at an early period, by a free incision through the conjunctiva if practicable, if not, through the lid itself. Care should be taken that the pus has free vent at all times. Noyes (loc. cit.) advises an early incision, even before pus forms, claiming its value " as a means of arresting the

54

DISEASES OF THE ORBIT.

phlegmonous inflammation and the formation of pus," as by the in- cision "the tension of the oculo-orbital fascia is relieved, the vessels are unloaded, serum finds vent and the tissues are relaxed." Diet and rest should be prescribed according to the general tone of the patient and severity of the attack.

Aconite. — In the first stage, when the lids are much swollen, with a tight feeling in them ; chemosis, with much heat and sensi- tiveness in and around the eye, and a sensation as if the eyeball were protruding, making the lids tense, associated with the general Aco- nite fever.

Apis mel. — Before the formation of pus. Lids cedematously swollen, with stinging, shooting pains. Patient drowsy, without thirst.

Hepar sulph. — Especially after pus has formed. Lids swollen and very sensitive to both touch and cold. The pains are usually of a throbbing character.

Lachesis. — Orbital cellulitis following squint operation, point of tenotomy sloughing, with a black spot in the centre; chemosis, and much discharge, with general Lach. condition.

Mercurius. — In the later stages after pus has formed, and even after it has discharged for some time and has become thin in charac- ter, especially if occurring in a syphilitic subject. There is often much pain in and around the eye, always worse at night,

Phytolacca.— Inflammation of the cellular tissue of the orbit without much pain, slow in its course and with little tendency to suppuration. The eye will be protruded and the infiltration into the orbit and lids will be hard and unyielding to touch.

Rhus tox. — This is a remedy of the very first importance in this form of inflammation, whether or not of traumatic origin. The lids are cedematously swollen, as well as the conjunctiva, and, upon opening them, a profuse gush of tears takes place. The pains vary in char- acter and may be greatly influenced by any change in the weather. Panophthalmitis is liable to complicate the trouble. See under Rhus. Other remedies may be thought of, as Ars., Bell., Bry., Kali iod., Sil., Sulphur.

Tenonitis. — Inflammation of the capsule of Tenon is a compara- tively rare disease which may follow operations for strabismus and less frequently occurs idiopathically, especially in those of a rheu- matic diathesis.

PERIOSTITIS ORBITS.

55

SYMPTOMS. — There may be slight swelling of the lids, chemosis of the conjunctiva, exophthalmos and diminished mobility of the eye. Pain more or less severe, especially on pressure, is apt to be present.

Treatment. — Internal medication is all sufficient in this disease and the most serviceable remedies are Kalmia lat., Kali iod., Rhus and Puis.

Periostitis Orbitse. — Inflammation of the orbital periosteum may result from injuries or occur idiopathically in rheumatic, syphilitic or scrofulous subjects. The disease is most commonly found in early life and its usual location is the margin of the orbit.

Symptoms. — There is present pain, especially from pressure on the bone, oedema of the lids, chemosis and a tense, swollen, sensitive spot in which fluctuation may be detected later. Periostitis in its acute form resembles very closely a phlegmonous cellulitis, and must be differentiated by the acute pain on pressure upon the orbital margin; by less swelling and redness of the lids; the inflammation is more circumscribed, so that the displacement of the eyeball is in one direction and its mobility is more restricted in one direction.

In the chronic form of periostitis there is simply slight swelling of the upper lid and supraorbital pain, together with localized swell- ing at the seat of the inflammation.

CoURSE.-When chronic, it is very tedious, lasting months or years, and is apt to result in caries of the bone, fistula?, deformity of the lids, etc. In the acute form, if the abscess is near the surface and promptly opened, it may heal in a short time; but if deep and neglected, or if occurring in one of a syphilitic or scrofulous constitu- tion, will usually be much more serious.

Caries and Necrosis of the orbital walls is almost universally a result of periostitis, although it may occur in the bone itself with- out a previous inflammation of the periosteum. After the abscess has opened, a fistula is formed which leads to the roughened and de- nuded bone. The discharge of pus through the fistula has the pe- culiarly fetid odor of osseous caries. The general symptoms of peri- ostitis are present in caries, and, in addition, the diseased bone can be detected by the probe.

Treatment. — The general plan of treatment is very similar to that recommended for cellulitis, as we should at first endeavor to

56

DISEASES OF THE ORBIT.

prevent destruction of tissue, but, if that does occur, give the pus free vent. If the bone should be diseased the opening must be kept open and an injection of a solution of carbolic acid 1 to 100, or of the sulphate of zinc gr. x to 5j may be used with advantage. If any loose pieces of the bone are discovered they should be removed. The remedies described under cellulitis are also applicable to this disease; in addition to which we note the following:

Aurum. — For both periostitis and caries, when dependent upon or complicated with a mercurio-sypkilitic dyscrasia; also useful in stru- mous subjects. The pains are tense, and seem to be in the bones, are worse at night, bone sensitive to touch and the patient is excessively sensitive to pain.

Calc. hypophos. — In appreciable doses, has been used as a " tis- sue remedy" in scrofulous subjects, apparently with good results.

Kali iod. — This form of potash is one of the most important remedies we possess for periostitis. It is especially adapted to the syphilitic variety, though useful when dependent upon other causes. The pain is usually marked, though may be absent entirely. The lids will often be cedematous The crude salt in large doses has seemed to act more rapidly than the attenuations.

Mercurius.— As described under cellulitis, will be found very useful in both periostitis and caries, particularly when dependent upon syphilis, as the nocturnal aggravation is very marked under both the drug and disease. The different forms are employed accord- ing to general indications.

Silicea. — Its action upon diseased bone renders it especially valu- able in caries of the orbit. The roughened bone and moderately profuse yellow-white discharge are the principal indications, though the weakened general condition, relief from warmth and other con- comitant symptoms will be present.

The following remedies may be required: Asaf., Calc. carb., Flu- oric acid, Hecla lava, Lyco., Mezer., Nitr. ac, Petrol., Phosphor, and Sulphur.

Empyema of the Frontal Sinus is extremely rare. The cause is uncertain. It may occur at any time of life, except in young chil- dren. The early swelling and distension are unnoticed, but it finally perforates the bony wall and a swelling appears at the upper and inner angle of the orbit, causing epiphora, displacement of the eye

TUMORES ORBIT .33.

57

downward, forward, and outward, with diplopia. The patient may have had headache for a long time, or it may have caused but little discomfort.

Treatment. — Similar to that given for cellulitis and periostitis.

Tumores Orbit*. — In the orbit may be found both benign and malignant tumors, which may have developed primarily in the orbit or have spread from the eyeball or face. They usually cause more or less exophthalmos and restriction in the mobility of the eye; the displacement of the eye depends upon the location of the growth. The eye may suffer from inflammation, the optic nerve may become inflamed or atrophic, the retina detached, etc. The examina- tion should be directed to the degree and direction of the exophthal- mos; to the impairment in motion, whether in one direction or all ; to the feel of the growth, its smoochuess, mobility, solidity, pulsa- tion, fluctuation, etc.

We note the effect of pressure upon the eyeball, if it causes pain on being pushed backward, or if the position of the tumor is altered. We inspect the nostrils, the pharynx, the frontal and maxillary sinuses. The tumor maybe explored with the hypodermic syringe. The history of the case should be elicited for hereditary tendency, the progress of the growth whether slow or rapid, whether associated with pain or not. All these points and many more should be con- sidered as an aid to diagnosis, prognosis and treatment. Nearly all varieties of tumors may be found in the orbit, viz.: Osteoma, nsevi, angioma, lipoma, fibroma, cysts (dermoid or hydatid), neuro-fibroma, lymphoma, sarcoma, scirrhus, encephalocele, epithelioma, etc.

Treatment. — The most approved method of treatment of all tumors of the orbit is to remove them as early as possible, endeavor- ing to save the eye whenever sight is present, unless it be a malig- nant growth and there is danger of not removing the whole of the tumor without sacrificing the globe; in which case it is usually better to remove all the contents of the orbit. A careful diagnosis must be made before operating, in order to aid in the operation and pre- vent the opening of a vascular tumor.

Electricity is of great value in removing vascular tumors of the orbit. When the growth is small the negative pole may be applied by a sponge to the temple, but if large both poles should be attached to platinum needles, two or three inches in length, which are then to

58

DISEASES OF THE ORBIT.

be inserted into the tumor. The positive needle should remain in one position while the negative may be inserted at different points for a few moments at a time. Care should be taken to make the first sitting brief, from fear of a too severe inflammatory reaction.

Our remedies are the same as for tumors in other portions of the body, though we would especially mention Thuja and Kali iodata, which have been of service in some cases.

Wounds and Injuries of the Orbit may prove serious from in- flammation of the orbital tissue, or periostitis, which they may cause. Injury causing fracture of the orbital walls may prove more or less serious according to the location and extent of the fracture ; a slight lesion of the orbital margin may heal without trouble; in fracture of the frontal or ethmoidal cells we will usually have emphysema of the orbit and lids, due to an entrance of air into the cellular tissue. If the injury has occurred in the vault of the orbit, we may have a serious inflammation of the brain or its membranes. Fracture of the roof of the orbit has frequently been found with a fracture of the base of the skull. Out of 86 cases of fracture of the base of the skull, fracture of the orbital roof was found in 79. 1 Haemorrhage into the cellular tissue is very apt to occur in all injuries or wounds of the orbit. Foreign bodies of large size have frequently remained imbedded in the orbital tissues for a long while without creating any material disturbance.

Treatment. — When a foreign body has penetrated the orbit it should be removed as soon as possible, after which cold compresses of calendula in solution, or bags of ice, should be applied.

If there has been an effusion of blood into the orbit, as the result of any injury, or when spontaneous (as is rarely the case), causing the eye to protrude, a cold compress and a firm bandage will be found very beneficial. In emphysema of the orbit and lids a com- press bandage will be required.

Morbus Basedowii (Exophthalmic Goitre, Graves' Disease).

Symptoms. — The main symptoms of this disease are: rapidity of the heart's action, enlargement of the thyroid and protrusion of the eyes, although any one of these symptoms may be absent. The acceleration of the heart's action is the earliest, most con- stant and essential symptom, and this may reach from 100 to 200

1 Berlin : Graefe and Saemisch, Handbuch der Aiigenheilltunde, 1880.

MORBUS BASEDOWII.

59

beats per minute and may be weak and irregular. Linnell1 in an excellent paper on this disease calls attention to one case in which there was no change in the pulse beat, whether sitting or standing, the usual variation returning as the case improved. The heart symptoms are usually first developed, followed later by the en- largement of the thyroid and the exophthalmos either simultane- ously or in succession. The goitre may develop suddenly, has a soft, elastic feel and the size of the enlargement varies greatly. The enlargement of the thyroid and the exophthalmos are originally due to vascular engorgement. The exophthalmos is almost universally bilateral, though it may be confined to one side. The degree of protrusion varies. It may be so excessive that the lids are unable to cover the eye; it may be but transient, confined to one or both eyes, or may be altogether absent. The protrusion is straight for- ward, causes no interference with the movements of the eye, and the eyes may be pressed back into their normal position, but will become prominent again on relief of the pressure. The exophthalmos gives the patient a frightened, staring appearance. On turning the eyes downward the upper lid either does not follow it at all, or moves along for a certain distance and then remains stationary. This pe- culiarity, called Graefe's sign, because first noticed by him, is of much diagnostic value, because highly characteristic of this disease, and is rarely if ever found in exophthalmos from any other cause. Other symptoms of this disease are dyspnoea and excessive nervous- ness. There is usually excessive nervous excitability and tremulous- ness of the hands. The disposition is often changed. The patient is easily frightened and flushes readily. Epistaxis or haemorrhage from other parts may occur. Dilatation and pulsation of the retinal arteries has been observed. Anaemia is often present, and in women may be associated with menstrual disturbances ; rapid emaciation may occur in some cases. Exposure of the cornea and conjunctiva may result in inflammation or ulceration.

Course. — The disease as a rule is very chronic, lasting for several years with frequent temporary improvements and relapses; the symptoms may then gradually subside, though often some enlarge- ment of the thyroid or exophthalmos will remain permanently. Rarely death occurs in this disease from organic disease of the heart

1 Trans. Amer. Inst. Homce., 1892.

60

DISEASES OF THE ORBIT.

or exhaustion. The majority of these cases, however, practically recover.

Causes. — Basedow's disease is much more often found in women than in men, some authorities claiming that over 85 per cent, of all cases are found in women. The majority of cases occur between the age of puberty and thirty in women, while the average age in men for the appearance of this disease is from thirty to fifty.

This disease has at various times been attributed to a disease of the sympathetic, to rheumatism, etc., and, while its cause has not yet been definitely demonstrated, it will probably be found in some central lesion located near the vaso-motor centre and the origin of the pneumogastric. It is generally brought on by some mental shock, by exhaustion from disease, excessive haemorrhages, or severe labor.

Treatment. — We are compelled to place our chief reliance upon internal remedies in the treatment of this disorder, though there are several measures which may be employed as adjuvants. Galvaniza- tion of the sympathetic in the neck has been followed by very good success in many instances, especially when combined with internal medication.

To promote a permanent cure, rest, especially in the country; freedom from all excitement, especially emotional ; exercise in open air; a generous diet, and abstinence from all stimulants, are particu- larly required and should be insisted upon whenever practicable.

Amyl nit. — Cases have been entirely cured by olfaction of this drug alone. The eyes are protruding, staring, and the conjunctival vessels injected, as well as those of the fundus. Especially indicated when there are frequent flushes of the face and head, oppressed res- piration, etc.

Badiago. — Exophthalmic goitre, with aching pains in the poste- rior portion of the eyeballs, aggravated on moving them, accompa- nied by tremulous palpitation of the heart and glandular swellings. The pulse is rapid and irregular.

Cactus grand. — Cases of exophthalmic goitre have been im- proved, when prescribed on the heart symptoms.

Ferrum. — Both the iodide and acetate have been followed by favorable results, especially when the disease comes on after the sup- pression of the menses ; protruding eyes, enlargement of the thyroid,

MORBUS BASEDOWII.

61

palpitation of the heart and excessive nervousness. Linnell found good results from the simultaneous use of Iron and Digilalis in one case, after both had been tried separately with no benefit.

Lycopus virg. — Judging from its provings, in which we find a rapid, irregular, intermittent and very compressible pulse, together with a bellows murmur over the heart and large vessels, it should be a valuable remedy in this disorder. Linnell (he. cit.) reports very gratifying results from the use of this remedy.

Spongia. — Exophthalmos, enlargement of the thyroid and palpi- tation of the heart, great uneasiness and easily frightened, especially at night ; stitches in the ball and burning around the eyes, with lach- rymation in the light; the eye feels twisted around; chromopsies, especially deep red, and photopsies, even when the eye is closed at night — all indicate this drug, which has proved serviceable.

Nat. mur. and Baryta c. are reported to have cured well-marked cases. Other remedies which have been recommended are Ars., Bell., Brom., Calc, Iod., Phos., Sil., Sulph. and Veratrum alb. and viride.

G2

AFFECTIONS OF THE OCULAR MUSCLES.

CHAPTER IV. Affections of the Ocular Muscles.

Anatomy. — The movements of the eyeball are carried on through the action of six voluntary muscles ; four of these passing directly from their origin, around the optic foramen, to their insertion in the sclerotic, are called the recti muscles. These muscles are inserted at varying distances, from 6.5 to 8 mm. from the corneal margin, and are distinguished by their relations to the eyeball, as internal, external, superior and inferior rectus. The insertion of the internal rectus is the nearest to the corneal margin, and that of the superior rectus is the most posterior.

The remaining muscles, from their taking a curved direction around the eyeball, are known as the superior and inferior oblique muscles. The obliquus superior arises at the optic foramen, passes forward along the upper part of the inner orbital wall to a pulley attached at the superior-internal angle at the front of the orbit; from here it is reflected backward and outward between the superior rec- tus and the eyeball, and is inserted into the sclerotic, 16 to 18 mm. from the corneal margin on the posterior and outer part of the globe, between the superior and external recti.

The obliquus inferior arises from the inner and anterior part of the floor of the orbit and passes outward and backward between the inferior and external recti and the globe, and is inserted near the superior oblique, between the superior and external rectus, 17 to 19 mm. from the corneal margin. The internal, superior and inferior recti and the inferior oblique are supplied by the third nerve (oculo- motorius), the superior oblique by the fourth (patheticus) and the external rectus by the sixth (abducens).

The action of all these muscles is to turn the eye around a point, called the centre of rotation, situated on the antero-posterior axis of the globe, about 14 mm. behind the anterior surface of the cornea and about 10 mm. in front of the posterior surface of the lens. These six muscles form three pairs of antagonistic muscles. The

ANATOMY OF THE OCULAR MUSCLES.

63

axis of rotation of the internal and external recti is vertical, as these muscles turn the globe directly inward and outward. The axis of rotation of the superior and inferior recti is horizontal, although not exactly straight across ; it forms an angle of 67° with the visual axis, the nasal end of the line being in front of the temporal. The axis of the superior and inferior oblique is also horizontal, forming an angle of 38° with the visual axis and with the temporal extremity in front of the nasal (Fig. 17).

Fig. 17.

Axes of Ocular Muscles.

Taken singly, the muscles act as follows: The internal rectus draws the cornea directly inward, the external rectus turns the cor- nea directly outward, the superior rectus turns the cornea upward and slightly inward, the inferior rectus draws the cornea downward and slightly inward, the superior oblique, taking its point of action from the pulley through which it passes, turns the cornea downward and outward and rotates from above downward; the inferior oblique turns the cornea upward and outward and rotates it from below up- ward .

64

AFFECTIONS OF THE OOULAK MUSCLES.

Each movement of the eye results from the combined action of certain muscles, and there is never a period at which one or the other is entirely inactive, as by its living and elastic tension it aids in guiding a definite movement, even though it does not take part in it. In looking directly upward both the superior rectus and inferior oblique are brought into action, the inclination inward of the former being counteracted by the outward tendency of the latter, and so in all other movements of the eye the action of all the muscles must be considered. Paralysis of any one muscle will cause all movements of the eye to be less sure.

The function of the ocular muscles is to secure single vision with the two eyes by directing both eyes to the point of fixation in such a manner that the image of the object fixed shall fall simultaneously on the macula lutea of each eye. When this is done, all objects lying in the same horopter will form images upon the respective retinae which will be equidistant from the fovea centralis and will, therefore, be appreciated as single, giving what is called binocular vision.

The horopter, as described by Mueller, is represented by a circle which passes through the centres of rotation of each eye and through the apex of the point of fixation of the visual lines. All objects be- yond or inside the horopter will cast images on parts of the retinae not equidistant from the fovea and will create the impression of two objects or double vision ; for example, holding two pins in the same line, one eight inches and the other twenty from the eyes, on looking at the nearest pin the other is seen double, and vice versa. This double vision of objects not lying in the horopter causes no annoy- ance, because the mind ignores the impression of objects with which it does not concern itself. The symmetrical position of the physio- logical centres of the retina is the anatomical ground for binocular vision. If a distant object be fixed with parallel lines of vision, to fix an object at one side which throws its image in both eyes at an equal distance from the macula lutea, both eyes must move through an equal angle; consequently, equal innervation on both sides is necessary for the symmetrical movements of the eyes. All objects are seen single only when retinal images fall on corresponding points of the two retinae. If the visual line of the left eye be di- rected on an object and there is convergence of the right eye, the

PARALYSIS OF OCULAR MUSCLES.

65

image, which would in the left eye be formed on the fovea in the right would fall upon the retina to the inner side of the fovea and would be projected outward to the right of the object fixed, or homonymous diplopia. If there is divergence of the right eye at the time the visual line of the left eye is directed upon an object, the impression from the object fixed would in the right eye fall upon the retina to the outer side of the fovea and when projected outward would appear to the left of the object fixed, causing crossed or hete- ronymous diplopia. The displacement of the false image is always in the direction which is opposite to that of the deviation of the eye. When the eye deviates inward, the diplopia is homonymous; when outward, heteronymous ; when upward, the false image is below, and, when downward, it is above. The false image is the image of the deviating eye.

Paralysis of Ocular Muscles. — We may have one or more mus- cles paralyzed, and the cause may be either orbital or intracranial ; if the latter, it may be along the course of the nerves or in the brain. Lesions of the spinal cord may cause paralysis through fibres which proceed to the brain.

Symptoms. — The characteristic indications of paralysis are false position of the eye, limitation and irregularity in motion, and double images. As secondary effects, we find dizziness, nausea, headache, incorrect projection of the field of vision and inability to guide the hands or feet aright. If only one eye is involved the inclination is to close it. Another peculiar effect is the attitude which the head assumes to obviate the double images. In paralysis the secondary deviation is always greater than the primary, while in concomitant strabismus the primary and secondary deviations are equal. The primary deviation is the deviation of the affected eye when the healthy eye fixes, while the secondary deviation is the deviation of the good eye when the affected eye fixes. If recovery does not occur, there follows secondary contraction of the opposing or associated muscle. For example, in paralysis of the right external rectus, from diminished resistance, the right internal rectus will turn the eye unduly inward, and the left internal rectus will also undergo con- traction, and, if the right eye looks directly forward, the left will consequently squint inward. This fact in old cases often makes the diagnosis as to which muscle was first affected very difficult.

5

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AFFECTIONS OF THE OCULAR MUSCLES.

Causes. — The effective causes are localized periostitis, inflamma- tions of the sheath of the nerves, basilar meningitis, haemorrhages, tumors, degeneration of nerve structure or of the cerebral nerve centres, injuries, diphtheria, rheumatism, draught of air, etc. The majority of cases of ocular paralysis occur in syphilitic subjects and are most frequently of orbital origin. Paralysis may also be the first premonition of sclerosis of the spinal cord. Both eyes may be affected, and the cause then is intracranial and generally basilar. Paralysis may occur at any age and may be temporary or perma- nent.

Diagnosis. — Theoretically the examination of the double images should render the diagnosis easy and accurate, but in practice the inability of many patients to appreciate and describe the relations of the images, together with secondary contractions and involuntary compensations, makes it often-times extremely difficult to attain an accurate chart of the double images. In many recent cases we can tell what muscle is affected without an analysis of the double images. The movement of the eye in the direction of action of the paralyzed muscle is less than normal, and is increased in the opposite direc- tion; its movements are irregular and jerky. The inclination of the head, when present, will be such as to favor the lamed muscle and will be in its line of action. When, however, there is any uncer- tainty as to the muscle affected, the examination of the double images should always be made. The double images are best detected by having one eye covered with a red glass, and the patient to describe the position and inclination of the two lights (one red and the other white) seen when looking at the flame of a candle eight to ten feet away. The images are to be noted in the different parts of the field as follows: First on the level with the patient's eyes directly in front, then to the right and left, and also at about three feet above and below this level at the centre, right and left. The use of the red glass aids the patient in detecting the two images and at the same time informs the physician to which eye each belongs.

Paralysis, External Rectus. — Paralysis of the external rectus muscle causes a limitation in the outward movement of the eye. In complete paralysis the eye can only be turned but little beyond the median line, while in incomplete it may often go to nearly the nor- mal limit, but with an irregular, jerking motion. The deviation of

PARALYSIS OF OCULAR MUSCLES.

(57

the affected eye is inward; the diplopia is homonymous; the double images are on the same level and parallel, and the distance between the images increases on looking toward the affected side. The line which separates that part of the field in which there is single vision from that in which it is double is not exactly vertical, but is inclined obliquely, the diplopia extending further toward the healthy side below than above.

Paralysis, Superior Oblique.— The restriction in motion is down- ward and outward, and in complete paralysis of this muscle the mo- tion downward is diminished. The deviation of the affected eye is upward and inward, and the image of the affected eye is inclined in- ward at the top, owing to the torsion actiou of this muscle on the eyeball. The obliquity of the false image is increased on looking toward the affected side. The diplopia is homonymous and present only in the lower part of the field. The image of the affected eye is lower than that of the healthy eye, and the difference in height between the two images is increased on looking downward and toward the healthy side. The image of the affected eye generally appears nearer to the patient than that of the healthy eye. The direction of the healthy eye, when the diseased eye fixes, is down- ward and inward. The line of demarcation between the true and false images is slightly oblique to the horizontal, the end correspond- ing to the affected side being lower. The face is inclined downward and to the healthy side.

Paralysis, Internal Rectus.— In this, the restricted movement is inward, the affected eye is outward, the diplopia is heteronymous, the double images are parallel and of the same height, the distance between them increases on looking toward the healthy side and on looking upward. The line of demarcation between the true and false images is oblique to the vertical, the diplopia extending further toward the healthy side above than below. The face is turned in the direction of the affected eye.

Paralysis, Superior Rectus. — The restricted motion is upward and slightly inward, the deviation of the affected eye is downward and on looking up is downward and outward; diplopia is slightly crossed and in the upper part of the field the false image is higher than the true, its upper end is inclined to the healthy side; the dif- ference in height between the two images increases on looking up-

68

AFFECTIONS OF THE OCULAR MUSCLES.

ward and the obliquity increases on looking to the healthy side. The line of demarcation is inclined to the horizontal, the diplopia extending lower toward the affected side. The face is directed slightly upward.

Paralysis, Inferior Rectus. — In this we find the restricted move- ment is downward, the deviation of the affected eye is upward and outward, the diplopia is slightly crossed, especially in the lower part of the field; the false images are lower and inclined toward the affected side ; the difference in height increases on looking down- ward and to the affected side, and the obliquity increases on looking toward the healthy side. The line of demarcation is inclined to the horizontal, the diplopia extending higher toward the affected side. The face is inclined downward and slightly toward the affected side.

Paralysis, Inferior Oblique. — The restricted movement is upward and outward, the deviation of the affected eye is downward and in- ward, the diplopia is slightly homonymous and especially in the upper part of the field the image of the affected eye is higher and inclined outward, the difference in height increases on looking up- ward and inward and the obliquity increases on looking to the affected side. The line of demarcation is inclined to the horizontal, the diplopia extending lower toward the affected side. The face is directed upward and slightly toward the sound side.

Complete Paralysis of the Third Nerve. — In this there is ptosis, slight exophthalmos, pupil moderately dilated, accommodation para- lyzed; movements are restricted in all directions excepting directly outward; the deviation of the affected eye is outward ; there is hete- ronymous diplopia, the false image is oblique and inclined toward the healthy side; it also appears higher than the true image and nearer to the patient. The distance between the images increases on looking toward the sound side, and the difference in height increases on looking upward. The face is inclined toward the sound side and slightly upward.

Treatment. — The treatment varies according to the nature of the cause, which should always receive due consideration in the se- lection of a drug. Our chief reliance must be on internal medi- cation.

Prismatic glasses to which we frequently resort, may be used for two purposes : 1. To relieve the annoying diplopia by giving that

PARALYSIS OF OCULAR MUSCLES.

60

prism which neutralizes the double vision. 2. For the purpose of exercising the paralyzed muscle by using a weak prism, which nearly fuses the double images, when by the exercise of the will they may be brought together; by daily using weaker and weaker prisms much improvement can be made in restoring the muscle power.

Both faradization and galvanization have proved valuable aids in the cure of these disorders, either alone or in connection with the appropriate remedy.

Forcible movements of the eye made by seizing the conjunctiva over the insertion of the paralyzed muscle with the fixation forceps and strongly turning the eye in the direction of action of the weakened muscle and then in the directly opposite direction has proved of very great value in my hands. Under Cocaine this causes no pain.

As a last resort, after the condition has existed sufficiently long to render all hopes of improvement by other means impossible, careful tenotomy of the opposing muscle may be performed, with or without advancement of the paralyzed muscle, according to the degree of deviation.

Aconite. — Paresis from exposure to a draught of cold air.

Argentum nit. — For weakness of the ciliary muscle or even par- alysis of the accommodation, manifest advantage has been derived.

Arnica. — Paralysis of the muscles resulting from a blow or injury.

Causticum. — Paralysis of the muscles resulting from exposure to cold. It has been especially successful in paralysis of the sphincter pupillffi (mydriasis), of the ciliary muscle, levator palpebral superioris (ptosis), orbicularis and external rectus. Its action is not found con- fined to any one nerve, but is useful in paralysis of any of the ocu- lar muscles, if the particular cause and general indications are present.

Chelidonium. — Paresis of the right external rectus. Distant ob- jects are blurred, and on looking steadily two are seen. Pain in the eye on looking up.

Cuprum acet. — Insufficiency or paralysis of the external rectus muscle.

Euphrasia. — Paralysis of the muscles, particularly of the third pair of nerves, caused from exposure to cold and wet; especially if catarrhal symptoms of the conjunctiva, blurring of the eyes relieved by winking, etc., are present.

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AFFECTIONS OF THE OCULAR MUSCLES.

Gelsemium. — A valuable remedy in all forms of paralysis of the ocular muscles, especially of the external rectus. Paresis from diph- theria, or associated with paralysis of the muscles of the throat.

Kali iodata. — The iodide of potassium is more commonly indi- cated than any other drug in paralysis of the muscles, of syphilitic origin. Appreciable doses are usually employed.

Merc. iod. flav. — Paralysis of the third pair, especially if syphil- itic in origin.

Nux. vom. — Paresis or paralysis of the ocular muscles, particu- larly if caused or made worse by the use of stimulants or tobacco.

Paris quad. — Paralysis of the iris and ciliary muscle, with pain drawing from the eye to the back of the head; or pain as if the eyes were pulled into the head. Eyes sensitive to touch.

Phosphorus. — Paralysis of the muscles caused from or accom- panied by spermatorrhoea or sexual abuse.

Rhus tox. — A remedy often indicated in paralysis of the ocular muscles resulting from rheumatism or exposure in cold wet weather and getting the feet wet. Causticum is very similar in its action, though it is more especially adapted to those cases resulting from ex- posure to cold dry weather.

Senega. — Want of power of the superior rectus or superior ob- lique, in which the diplopia is relieved by bending the head backward. The other muscles may be complicated in the trouble.

Spigelia. — When associated with sharp, stabbing pain through the eye and head.

Alumina, Aurum, Conium, Hyoscyamus and Sulphur have also been used with advantage. Other remedies may be called for by general indications.

Strabismus or Squint is inability to bring the visual axes of both eyes to meet at a certain point, or when the point fixed casts its image only on the macula lutea of one eye, while in the other it falls on some eccentric part of the retina. If the squinting eye deviates in- ward, it is called strabismus convergens; if outward, divergens ; if upward, sursum vergens, and if downward, deorsum vergens. The squint in concomitant strabismus differs from that of paralysis in the following points: The primary and secondary deviation are equal in strabismus, while in paralytic squint the secondary deviation is greater than the primary. In strabismus the extent of the move-

STRABISMUS CONVERGEXS.

71

merit in the two eyes is normal and equal, while in paralysis the mobility of the eye decreases in the direction of action of the para- lyzed muscle. Diplopia is generally absent in strabismus; but, when present, is found in all parts of the field, and in strabismus there is no particular inclination of the head.

Strabismus is usually mono-lateral, that is a faulty position of one eye; or it may be alternating, when the patient will be able to fixate objects with either eye separately, and when doing so the other eye becomes the squinting one. The strabismus may also be intermit- tent or constant. Strabismus is not observed after death, during deep sleep or in deep narcosis.

Concomitant squint is very seldom accompanied by diplopia. This is believed to be due to a suppression of the retinal image in the squinting eye. for, being that of some object with which the mind is not interested, it is simply ignored at will.

Binocular vision, according to von Graefe, is absent in about 90 per cent, of the cases of strabismus, that it can be produced by prisms in about 25 per cent., and exists after operation in about 50 per cent. Its presence is proved at once by the existence of binocular diplopia, and when not present it is determined by having the patient look at the flame of a candle at the distance of six or eight feet through a prism placed before one eye, when either diplopia or a corrective squint will occur, if the prism is not too strong, for the patient will endeavor to overcome the prism by squinting and fusing the images, or if neither of these effects occur, absence of binocular vision is proven. Binocular vision is frequently only lost over certain por- tions of the retina.

Apparent Strabismus is the condition where there is a deviation of the optic axes, and yet both eyes fixate and neither moves when the other is closed. This is due to the relation between the optic axis and the visual line. If the optic axis lies to the outer side of the visual line, we have an apparent divergent squint, and, if to the inner side, may have the reverse — an apparent convergent squint.

Strabismus Convergens is the most common form of squint met with, and usually develops between the second and seventh years of life. Diplopia is generally present in all cases which develop later than childhood.

Causes. — In a great majority of cases ii is found to exist in con-

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AFFECTIONS OF THE OCULAR MUSCLES.

nection with hypermetropia. Donders first called attention to the relation of hypermetropia to convergent strabismus, and showed it to be present in about 75 percent, of the cases; other authorities since then have placed it as high as 85 per cent. It has also been estimated that about 16 per cent, of all hypermetropes squint. It is usually the median or slight degrees of hypermetropia that most often induces strabismus. Hypermetropia causes strabismus on account of the normal or physiological relation between convergence and accommo- dation ; that is, with an increase of convergence the relative rauge of accommodation approaches the eye. All hypermetropic eyes re- quire a strong tension of the accommodation for distinct vision, and hence to aid the accommodation they are inclined to converge too much. The reason that only a few of all hypermetropes squint, and that those are mostly of the slighter degrees of hypermetropia, is be- cause, that as a result of too strong continued convergence the hyper- metrope soon learns to give up binocular vision, as he finds he can secure a more distinct image, with less strain on the accommodation, by monocular fixation, and hence allows the poorer eye to squint; while in the high degrees of hypermetropia there will be but slight cause for sacrificing binocular vision when, in spite of too strong convergence, distinct retinal images cannot be obtained. In the medium and lower grades of hypermetropia there does exist the in- clination to exchange binocular vision for monocular fixation when any cause makes binocular fixation less valuable, as in differences in refraction, astigmatism, corneal opacities, etc., affecting only one eye. It has also been found by Schweigger and others that the non- squinting eye does not possess full acuity of vision, and this induces squint by an effort to secure by convergence as large an image as possible. Another contributing factor in the causation of conver- gent squint is an insufficiency of the external recti muscles, which arises from the fac»- that in hyperopia there is a deviation inward of the visual lines, and the constant effort necessary on the part of the external recti to maintain parallelism of the visual lines finally results in insufficiency, which favors strabismus convergens. As other pre- disposing causes we find constantly working in poor light, excessive use of the eyes for near work, weakened ciliary muscle and constant looking to one side. Convergent squint may also be found in myopic eyes, due to a preponderance of the internal recti. Macula of the

STRABISMUS CONVERGENS.

73

cornea also cause squint from confusion of the retinal images, which cannot be suppressed while falling upon identical points of the two retinae; hence the eye turns in order to throw the image upon some eccentric part of the retina where it may be suppressed, and the eye is more apt to turn in on account of the greater strength of the inter- nal rectus.

In convergent strabismus amblyopia is usually present in the squinting eye. The amblyopia is considered by some to be a con- sequence of the squint and by others as the cause. It is probable that both views are correct, and that in some cases it is the cause of the squint, while in others the amblyopia results from the squint. It is easy to understand that the squinting eye will become ambly- opic from long disuse, and in these cases, where it is a consequence of the squint, it is called amblyopia ex anopsia; in other cases,

Fig. 18.

Lawrence's Strabismometer.

where there may be a difference in the degree of the hypermetropia in the two eyes, the child would naturally use the best eye for vision and allow the poorer eye to turn, in order to more readily suppress the indistinct image. Hence we must conclude that a slight pre- existing amblyopia in one eye, associated with hypermetropia, will have a tendency to cause convergence, and after the squint has be- come established the amblyopia may increase from disuse.

Strabismus convergens is by far the most common form of squint met with, and is, in the majority of cases, a stationary monolateral squint. The degree of the strabismus can be obtained sufficiently accurate for all practical purposes by means of the strabismometer — an ivory scale shaped to fit the lower lid and graduated in millime- tres on its free edge (Fig. 18). It is used by covering the good eye and fixing with the squinting eye, the Oon the scale is then placed directly under the centre of the pupil, the good eye is then uncov-

74

AFFECTIONS OF THE OCULAR MUSCLES.

ered and the squinting eye allowed to resume its ordinary position ; the number then exactly under the centre of the pupil gives the linear measure of the deviating eye in millimetres.

Strabismus Divergens is much less frequently seen than conver- gent squint and generally develops later, after childhood has passed. It is frequently in the beginning periodic, but usually becomes per- manent later; it may also be alternating; generally, however, it is monolateral and concomitant, in that the deviation of the affected eye, or primary deviation, will be equal to the deviation of the good eye, or secondary deviation. Diplopia is usually present at the com- mencement of the affection, especially when periodic, but gradually disappears as the condition advances.

Causes. — While convergent strabismus is usually associated with hypermetropia, divergence is, on the other hand, most often associ- ated with myopia. In myopic eyes the antero-posterior axis of the globe is much increased, and the movements of the eye in the hori- zontal plane are diminished.

The shape of the myopic eye causes a greater tension and resist- ance on the part of the external rectus, because from its position it comes in contact with the eyeball more than does any of the other muscles of the eye. A greater resistance and strength in the exter- nal rectus causes a relative insufficiency of the internal, which leads to divergence. At first convergence is possible, but the necessary tension cannot long be sustained and the eye diverges, when we will have, in place of accommodative movements, only associated move- ments inward, until finally the insufficiency of the interni become so great that in associated movement inward the squinting eye will fall behind the other.

In some cases where there is myopia of one eye and emraetropia or hypermetropia of the other a similar process ensues: the myopic eye will then usually be used for near vision, because it is impossible to secure binocular vision for reading, and as the myopic eye can be used without any exertion of the accommodation, it is almost in- variably used, while the other eye is used for distant vision. The absence of accommodation is sufficient to give the emmetropic eye a relatively divergent position, while the associated, instead of the accommodative, movement results in a preponderance of the externi. Macula of the cornea may also cause divergence as well as con-

STRA BISMTJS TREATM EXT.

75

vergence, if in such a location that suppression of the indistinct image can be more readily attained by turning the eye outward instead of inward.

Strabismus Sursum and Deorsum Vergens are usually seen as a complication <>f lateral deviation and disappear when the lateral de- viation is relieved. A concomitant vertical deviation, however, may occiii- alone, and, when it does is increased, if an upward deviation, on looking inward, and if downward the squint is the greatest on looking outward. Diplopia is usually present in cases of vertical deviation.

Treatment. — This should first be directed toward preventing the development of the squint. Whenever a tendency to squint is noticed, the child should be prevented from reading, writing and all near use of the eyes as much as possible. As soon as the child is old enough to wear glasses the refractive error should be corrected. My rule is to wait until they are about five years old, and then to prescribe a glass of about a .25 to a .50 D less than the total refrac- tive error as shown by the ophthalmoscope, to be worn constantly. The use of atropine to paralyze the accommodation, and thus pre- venting near vision, if continued for several weeks, will often greatly benefit an inclination to convergent squint. If the case is one of permanent strabismus, and an early operation is not desired, the good eve should be covered for a short period daily and the child com- pelled to use the affected eye. In this way the vision of the squint- ing eye will be retained. The fact must also be borne in mind in the treatment of convergent squint that there is a tendency in some cases to a gradual disappearance of the squint as the child grows older, and, when this does occur, it is usually not earlier than the tenth year and often much later.

The use of remedies has in the early stages of many cases relieved the tendency to permanent strabismus.

Cicuta vir. — Indicated in strabismus convergens occurring in children, particularly if spasmodic in nature, or caused from convul- sions, to which the child is subject.

Jaborandi. — Strabismus convergens, periodic and resulting from spasm of the internal recti; also for the return of squint after opera- tion.

If helminthiasis has been the cause, Cina, Cyclamen or Spigelia

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AFFECTIONS OF THE OCULAR MUSCLES.

may be required. If due to spasms, convulsions, or any intra- cranial disorders, Agar., Bell., Eserine, Gels., Hyos., Nux or Strain, would be first suggested to our minds. Calc. or Chin, sulph. may be indicated.

In all cases the cause of the difficulty must be determined, if pos- sible, for this, in connection with the general condition of the patient, will govern us in the selection of the remedy.

Operative Treatment for strabismus may be by either tenotomy of the contracted muscle, advancement of the weak or opposing muscle, or by both combined. The operation for the relief of squint was first suggested by Taylor in the seventeenth century ; his method, however, was unsuccessful, and, consequently, abandoned. In 1839, Dieffenbach made the first successful operation for squint; the method practiced by him was to divide the belly of the muscle in- stead of its tendon, thereby greatly impairing the action of the muscle and often causing the eye to turn in the opposite direction. At a later period von Graefe placed the operation upon a scientific basis by suggesting the division of the tendon instead of the body of the muscle, and his operation, with some slight modifications, is the one in more common use at present. As to the time when the operation should be made, my preference is to wait until the child is at least seven years of age, unless it is a very pronounced permanent squint, when a tenotomy, aiming to correct only a portion of the squint, may be made at a much earlier age.

As to the advisability of operating upon one or both eyes at the same sitting, authorities seem to be about equally divided. It is, however, always my rule to operate upon but one eye at a time, taking at first the eye with the greatest deviation and making a free division of the muscle, and a few weeks later making a second ope- ration upon the other eye, if needed. Previous to operating we should determine the cause of the squint, the vision, the relative power of the muscles, and the degree of the deviation in each eye. The technique of the operation is the same, irrespective of the muscle operated upon.

Tenotomy of the Internal Rectus. — As this operation is quite pain- ful, an anaesthetic should be used. Four to six instillations of a 4 per cent, solution of cocaine at intervals of about five minutes renders the operation painless, and is to be preferred to a general

OPERATIONS FOR STRABISMUS.

77

anaesthetic because we are better able to judge of the effect accom- plished. In young or excessively nervous subjects, ether or chloro- form may have to be used. The instruments required are a specu- lum, fixation forceps, curved scissors and strabismus hook (Figs. 19 to 22). The lids should be widely separated by the speculum ; the conjunctiva and subconjunctival tissue directly over the inser-

Fig. 19. Fig. 20. Fig. 21. Fig. 22.

Strabismus Hooks.

tion of the muscle to be divided is seized with the fixation forceps, and with a pair of curved, blunt-pointed scissors, make a vertical cut down to the muscle, which is then separated from the sub- conjunctival tissue by dissecting backward with the scissors as far as it is desired to have the muscle slide for its re-attachment. The

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AFFECTIONS OF THE OCULAR MUSCLES.

strabismus hook is now to be introduced behind the muscle at its lower edge, and, with the point pressed against the eyeball, turned upward beneath the tendon, which is then to be divided close to its insertion. The hook should then be inserted again to see if all the lateral expansions of the tendon have been divided ; but too frequent and extensive excursions of the hook should be avoided, as it tends to increase the inflammatory action. Care must be exercised that too extensive dissections of Tenon's capsule, both above and below the muscle, are not made, as the capsule of Tenon serves as a sec- ondary attachment for the ocular muscles, and, if too freely separated from the sclerotic, the effect of the operation may be too greatly in- creased and the power of the muscle so much affected that it will have little or no action upon the movements of the eye. The sink- ing of the caruncle is also the result of a too free dissection of Tenon's capsule.

The use of the suture to limit the effect of the operation, if too extensive, may be necessary; it is introduced through the conjunc- tiva at the margin of the cornea atid then through the conjunctiva over the muscle. In convergent strabismus, with good vision in both eyes, the patient should be able after the operation to fixate and hold the eyes on an object at a distance of about eight inches. If the vision is poor, or the muscles weak, a convergence at twelve inches is sufficient. Diplopia, with the images near together for two or three days after the operation, is not unfavorable, as it is usually due to the inflammatory action and disappears as the inflammation sub- sides.

The effect of an operation for convergent squint may be increased, if desired, by a strong suture passed through a fold of the conjunctiva at the outer side near to the cornea, and then carried through the skin at the external cnnthus, one end above and the other below, about one-eighth of an inch apart, and then tied ; or they may be fastened to the skin by strapping. The eye is thus held in the proper posi- tion for two days, when the muscle should have become reattached and the suture removed.

Subconjunctival Tenotomy is preferred by many to the operation just described. This is made by snipping the conjunctiva along the lower edge of the insertion of the muscle with blunt straight scissors (Fig. 23). The subconjunctival tissues are then separated over the

OPERATIONS FOR STRABISMUS.

70

muscle, the strabismus hook is then inserted, catching up the muscle on the hook. The scissors are now introduced, one blade in front and the other behind the muscle, which is held on the stretch by the hook, and it is divided subconjunctival ly.

Advancement of the Muscle is designed to increase the power of a muscle by shortening it. This operation is useful in cases of ex-

FiG. 23.

Blunt-pointed Straight Scissors.

treme divergence and especially in those cases whore the operation for convergent strabismus has resulted in a deviation in the opposite direction, and hence the internal rectus is the muscle most frequently advanced. A tenotomy of the opposing muscle is usually necessary and is made by some at the same time and by others later.

Qritchett's Operation, somewhat modified, has proven of the most value in our hands, and hence is preferred. The patient in this operation should be etherized, the lids separated by the speculum and a vertical incision three-fourths of an inch in length and about one- tenth of an inch from the corneal border is then made through the conjunctiva. The conjunctiva and subconjunctival tissues are now

Fig. 24.

De Wecker's Double Strabismus Hook.

dissected back to the insertion of the muscle, which is then divided close to its insertion. The muscle and tissues overlaying it are then held together en manse with De Wecker's double strabismus hook (Fig. '24). Three sutures with a needle at each end are used and are now introduced from within outward through the flap of the con- junctiva at the margin of the cornea, one being placed opposite the

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AFFECTIONS OF THE OCULAR MUSCLES.

horizontal meridian of the cornea and the others one above and one below. A fourth suture may also be employed, running vertically through the flap of the conjunctiva at the corneal border, to strengthen and prevent the other sutures from tearing out. The needles at the other end of the sutures are next passed from within outward, the first through the middle of the muscle and the others through its upper and lower borders (Fig. 25). These sutures are passed through the muscle, well back from its extremity, and through the conjunctiva. A semilunar fold of the conjunctiva, subconjunctival tissue and muscle is then cut away, varying in amount according to the effect desired. This done, the muscle is advanced by tying the three sutures, the middle suture being first tied. As the greatest

Fig. 25.

Operation for Advancement of Internal Rectus.

strain falls upon the middle suture, it should be made of heavier thread than the others or used double. This operation differs from Critchett's in two particulars — first the reinforcing vertical su- ture, and secondly in that a portion of the end of the muscle is cut away.

The After- Treatment. — Simple tenotomy creates no serious reac- tion, and the patients are allowed to return to their homes and to use their eyes as much as is desired. Bathing the eyes in cold water or a solution of calendula gives some relief of the soreness experienced for the first day or two. No bandage should be allowed (except while returning home from the operation), for from protec- tion of the eyes there is not that incentive to parallelism of the visual axes which occurs when the eyes are being used. The ad- vancement of the muscle is accompanied by considerable pain and

NYSTAGMUS.

81

swelling, which is usually controlled by keeping the patient in bed with both eyes bandaged, the ice bag applied locally and aconite given internally.

Nystagmus (Oscillation of the Eyeballs). — These movements are involuntary, exceedingly rapid, almost rhythmical and affect both eyes at the same time. The mobility of the eye is not otherwise im- paired. The oscillation is generally in the horizontal direction, but may be vertical or in the direction of a single muscle. It is usually permanent, but may be periodic and in some positions of the eye may have a point of rest. Nystagmus is increased in near vision and from excitement ; in some cases it is complicated by similar movements of the head, but in an opposite direction. The sight is always impaired, but objects are seen as they are by the patient.

Causes. — Generally occurs in early childhood and is principally the result of amblyopia, as in congenital opacities of the cornea, con- genital cataract, or total blindness.

The nystagmus of miners is a peculiar form of this affection, which first comes on while working in the darkness of the mines, and, as it progresses, lasts through the day, but increases as twilight comes on and has often associated with it night-blindness. These patients are often made dizzy and greatly annoyed by the apparent movement of objects. This form of nystagmus is due to the work done in an in- sufficient light and with the eyes turned in an unnatural position.

Prognosis. — When once developed, it generally remains, although it may diminish somewhat in advanced life.

Trp:atment. — If strabismus coexists with nystagmus, tenotomy of the contracted muscle should be made. If there is any anomaly of refraction, it must be corrected with glasses.

Agaricus. — Very useful in all spasmodic affections of the muscles of the eye, especially if associated with spasm of the lids, or general chorea. Twitchings of the lids varying from frequent winking to spasmodic closure of them. Twitchings of the eyeballs with various sensations in and around them, chiefly pressing and aching. Eye- ball sensitive to touch. The spasmodic movements are absent during s/c<j>, bat return on waking and may be transiently relieved by wash- ing in cold water.

Belladonna. — If accompanied by headache and hyperesthesia of the senses.

6

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AFFECTIONS OF THE OCULAR MUSCLES.

Hyoscyamus. — Spasmodic action of the eyeballs.

Ignatia. — Morbid nictitation and spasmodic affections occurring in nervous, hysterical women.

Jaborandi, Physostig., Nnx, Puis, and Sulph. have also been used with benefit, as may any of that class of remedies denominated our antispasmodics.

Muscular Asthenopia. — This term is applied in a general way to various tired and strained sensations about the eyes and head result- ing from insufficiency of some of the extrinsic muscles of the eye. Special attention was first directed to this subject by von Graefe, which until within a few years had received but meagre attention and had been applied especially to an insufficiency of the internal recti muscles. Within the last five or ten years, however, hardly a number of our current ophthalmological literature has appeared without containing more or less reference to some of the muscular anomalies, and, while vast strides have been made in our knowledge of these defects and their treatment, still any conscientious worker in this field must realize that but the first steps have been taken, and what are now generally considered as valuable facts may five years hence seem truly ridiculous. To Dr. George T. Stevens is due the credit of having been the one to first turn the present atten- tion of ophthalmologists in this direction, and, while we cannot accept in full his methods of treatment, must acknowledge that by his efforts researches in this line have been greatly advanced and stimulated. An exhaustive consideration of the insufficiencies of the ocular muscles is of course impossible within the limits of an ordinary text-book, and it is for this reason presumably that none of the more recent works upon the eye give this subject the atten- tion that it seems it should receive. Another reason is possibly that, owing to the rapid advances in this direction, the knowledge that one may have to retract to-morrow what is written to-day renders one advisedly cautious in the handling of this subject, but the important relation that exists between defects of the ocular mus- cles and various reflex disorders makes it imperative that the subject be considered to the extent of our present knowledge.

It is a well recognized fact that defects of the ocular muscles can and do cause various reflex disorders, such as vertigo, general nerv- ous excitements, gastric derangements, neuralgic pains of the back,

MUSCULAR ASTHENOPIA.

83

head, etc. On the other hand, many asthenopic symptoms of the eve may be the effect of some remote disorder such as uterine disturb- ances, etc. In treating of muscular asthenopia frequent reference will be made to the writings of Dr. Stevens as found in the Archives of Ophthalmology, vols, xvi., xvii. and xviii , and his work on Functional Nervous Diseases. We shall also adopt the terms sug- gested by him as more accurately describing the various forms of insufficiency, viz.: Orthophoria: A tending of the visual lines to parallelism. Heterophoria: A tending of these lines in some other way. Esophoria: A tending of the visual lines inward. Exo- phoria : A tending of the lines outward. Hyperphoria (right or left) : A tending of the right or left visual line in a direction above its fellow; this term does not imply that the line referred to is too high, but that it is higher than the other, without indicating which may be at fault. Hyper esophoria : A tending upward and inward. Hyperexophoria : A tending upward and outward. The designa- nation " right " or " left " must be applied to these two terms.

The examination for heterophoria may be practiced by a number of methods.

Stevens' Phorometer (Fig. 26). In this test the patient, while holding the head erect, looks at a lighted candle at the distance of twenty feet, which should be nearly upon a level with the eyes. Then with the refractive error, if any, corrected, prisms of suffi- cient power to produce diplopia are placed with the base inward before each eye. The images thus produced are homonymous, and, if seen exactly on the same horizontal plane, there is no ten- dency to a vertical deviation. If, however, one image is higher than that of the other, there is absence of the vertical equilibrium, or hyperphoria. If the left image is higher than the right, it indi- cates that the visual line of the left eye is lower than that of the right, or that the visual line of the right eye has a tendency to rise above that of the left; this is right hyperphoria. If the right image is seen above that of the left, it is known as left hyperphoria. The degree of the deviation is shown by the prism, which, when placed with the base up or down before one eye, brings the two images ex- actly on the same horizontal plane. Diplopia is again induced by placing a prism with the base up or down before one eye, and, if the two images are now exactly vertical, no deviation in the horizontal

84

AFFECTIONS OF THE OCULAR MUSCLES.

plane is shown. A prism of 7° is usually sufficient to cause vertical diplopia when placed with the base up or down before one eye. Say, with the base down before the right eye, if, now, the upper image appears more at the right than the lower, it indicates esophoria; but, if the upper image is to the left of the lower, exophoria is shown. The degree of the horizontal deviation is shown by the

Fig. 26.

Stevens' Phororneter.

degree of the prism which, when placed with the base in or out before either eye, brings and holds the images in a vertical line.

Examination should then be made in the same way at the distance of eighteen inches to determine the condition of the muscles in ac- commodation, and for this purpose a small white cross on a black background is used in the Stevens' phororneter.

MUSCULAR ASTHENOPIA.

85

Tin Prentice Phorometer is claimed by the inventor to be an im- provement over that devised by Dr. Stevens, in that it detects the latent as well as the manifest heterophoria. It is a recognized fact that in many cases there is a latent insufficiency that can often only be determined after long or frequently repeated examinations. The Prentice instrument will show heterophoria in cases where Stevens' will show none, and a higher degree of trouble in the majority of those cases showing some heterophoria by Stevens' test.

In the examination with the Prentice phorometer a chart is used instead of the flame of a candle. The chart is made of card-board about two feet in length, divided in the centre by an arrow, on either side of which are five black lines two inches apart and numbered on one side of the arrow in black and the other in red numbers. In testing, the chart is fastened to the wall twenty feet away; for hy- perphoria it is placed vertically, and by prisms, the same as in Stevens' test, with the base toward the nose, the subject is made to sec two charts; if the arrow of one chart points directly to the arrow of the other, there is no manifest hyperphoria. A prism of three degrees, base down, is then placed before one eye, which raises the chart seen by that eye three degrees above its fellow, and the arrow of that chart will then point to one of the numbers above the arrow on the other. Now, by means of a switch, the three-degree prism, base down, is made to slide before the other eye, which lowers the chart to the same distance below its fellow, and if there is no hyperphoria the arrow will point to the same number below the arrow that it did above. The principle of the examination for esophoria or exophoria is, of course, the same.

The inventor claims by this method to do away with the uncon- scious or involuntary effort that is made to hold the two images on the same horizontal plane by the Stevens instrument. One objec- tion to the Prentice phorometer is, that it has not the arm for testing the muscular equilibrium in accommodation, which we believe should always be done. Further from our experience with this phorome- ter, used in the manner advised by Dr. Prentice to bring out, or develop any latent heterophoria, it will, we believe, show in many cases, a greater deviation than really exists.

The Maddox Test is made by using a small glass rod, which may be mounted or held in the hand, and, for hyperphoria, is held exactly

86

AFFECTIONS OF THE OCULAR MUSCLES.

vertical before one eye and a colored glass before the other. When looking at the lighted candle, a long horizontal line of light is seen by the eye in front of which the rod is held, while the other eye sees the natural light. Now, if the line of light passes exactly through the centre of the flame, as seen by the other eye, there is no hyperphoria present ; but if above or below, then hyperphoria is shown, and the degree is represented by the prism which causes the line of light to pass directly through the centre of the flame. The rod is now turned horizontally in front of one eye, causing a vertical line of light which, if passing directly through the flame, shows or- thophoria of the lateral muscles; if the line is to the same side as the eye before which the rod is held, it indicates esophoria; if to the op- posite side, exophoria, and the prism which brings the vertical line of light directly through the flame indicates the degree of esophoria or exophoria. This we believe to be the most reliable test for mus- cular insufficiency at present devised.

The Savage Test for Insufficiency of the Oblique Muscles. — Occa- sionally cases of undoubted eye-strain are met with which are not relieved even after the most careful correction of the refractive error or of any of the already named forms of heterophoria. These cases may be due to an insufficiency of one of the oblique mus- cles, a condition easily detected by Savage's test; but if found, there has been at present no satisfactory suggestion offered as to treatment.

In testing, a double prism of six degrees each, base to base, is held with its axis vertical before one eye and the patient requested to look at a horizontal line on a card eighteen inches away. With the other eye covered, the line appears to be two, each parallel with the other ; on uncovering the other eye, a third line is seen between the other two, with which it should be exactly parallel. If there is any loss of balance between the oblique muscles, this test will show a lack of parallelism of the middle line with the other two, the right end of the middle line will point to the lower line and the left end to the upper line, or vice versa.

With the double prism before the right eye, if the middle line is seen nearer the bottom, there is left hyperphoria; if it extends far- ther to the right than the other two, and not so far to the left, exo- phoria is present; or, if reversed, extending farther to the left and not so far to the right, esophoria is shown. If the right ends of the

H YI >ER PHORI A — ESOPHO RI A .

,87

middle and lower lines converge and the left ends diverge, insuffi- ciency of the superior oblique of the left eye is shown.

Hyperphoria. — By this is meant the condition of the ocular mus- cles in which, with a minimum of tension, a deviation of one visual line above the other would result.

Symptoms. — This condition is apt to cause far greater disturbance than any other variety of heterophoria. A greater or less degree of amblyopia is, according to Stevens, found in a large per cent, of the cases of hyperphoria, and is by him attributed to suppression of images, owing to the inability of the muscles which raise the eye up or down (and which in their most perfect condition have but a very limited action as compared with the other ocular muscles) to maintain the effort required to keep the two eyes on the same hori- zontal plane. Profuse lachrymation is sometimes found and relieved by the correction of the hyperphoria. Spasmodic closure of the lids and involuntary contractions of the muscles of the face may be present. The head is apt to be carried toward the shoulder. Con- stitutional effects, such as neuralgia, headache, persistent nausea, pain in the back, vertigo and neurasthenia have undoubtedly been caused, and relieved by the correction of an existing hyperphoria. Examination as to the power of the muscles in overcoming prisms with the base up or down should always be made. The usual st icugth in normal eyes will vary from 3° to 8° and I have found those who could fuse the images through a prism of 12° with the base up or down.

Esophoria. — Is a condition of insufficiency of the external recti muscles or a tendency to convergence of the visual lines. The method of determining esophoria has been already described, but quite frequently examination reveals an esophoria at the distant point and exophoria in accommodation. In such cases the presence of hyperphoria should always be suspected.

Esophoria as a cause of muscular asthenopia has received but very brief attention in text-books upon ophthalmology, and yet that it can and does cause many annoying cases of asthenopia is now being recognized by the advanced thinkers in this department. Noyes (he. oit), states that out of 100 consecutive cases of muscular astheno- pia, 74 were eases of insufficiency of the external recti (esophoria).

Stevens states (loc. cit.) : " In respect to the clinical importance of

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AFFECTIONS OF THE OCULAR MUSCLES.

esophoria, which occurs in the proportion of more than three to one of exophoria (this has been modified in a later article by Stevens to a proportion of two to one), it plays a much more important rule than the latter as a predisposing cause to a variety of neuroses ; and, as the immediate cause of asthenopia and kindred affections about the eyes, it is an element of great disturbance." My own experi- ence, however, has shown a larger proportionate per cent, of cases of exophoria than has been found by the authorities quoted. This difference has probably been due to the fact, that it is our prac- tice to base the diagnosis, in those cases frequently met with, in which there is found esophoria at the distant point and exophoria in accommodation, upon the condition which seems to be creating the most disturbance. That is, if the asthenopia symptoms are only caused upon use of the eyes at the near point, the case then, we be- lieve, should be considered one of exophoria; and if the distress occurs after use of the eyes at distant vision, one of esophoria. We believe, oculists generally base the diagnosis upon the results found from examination at the distant point alone.

Symptoms. — The disturbing effects from esophoria are more ob- scure and remote than in exophoria. The patient affected with eso- phoria is apt to suffer from headaches at the back of the head and neck, a general sense of illness, nausea, vertigo, etc., on the day fol- lowing a visit to a picture gallery, an attendance at church or theatre, from driving or riding on the cars, in fact from any use of the eyes to maintain parallelism of the visual lines at distant objects. While in exophoria the patient is more apt to suffer with pains in the eyes or head immediately after one or two hours' use of the eyes for reading, sewing, etc. There is often a weakened power of accom- modation, with dilatation of the pupil present. They often com- plain of the annoyance of seeing their nose, or of seeing a black spot before the eyes. Amblyopia is the rule in cases of esophoria exceed- ing 2° (Stevens). Esophoria is found to be almost invariably of a higher degree when the eyes are under atropine.

Examination as to the power of the external recti muscles in over- coming prisms base in shows the average strength to vary from 10° to 14°, yet an abduction of 6° may not be incompatible with ortho- phoria. In some cases of esophoria I have seen a power acquired of overcoming prisms of 24° base in, and still an examination would reveal esophoria.

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89

Exophoria. — Insufficiency of the internal recti, or tendency of the eyes to divergence is, we believe, in spite of the experience of others, the most common form of muscular disturbance. This it would seem natural to expect, especially in the educated classes, from the constant over-use of the internal recti at the near point.

SYMPTOMS. — In exophoria we find the most characteristic symp- toms on using the eyes, the pains are generally in the eyeballs, the patient wants to rub and press them for relief. Often a blurring of the vision ; the letters seem to run together. The headaches occur especially after using the eyes for near work, and are more often frontal, but may be in any part of the head. The power of accommo- dation in exophoria, contrary to that in esophoria, is usually increased; this is owing to the relation existing between convergence and ac- commodation, the insufficiency of the internal recti demands and re- sults in greater action of the accommodation. Examination of the power of the internal recti for overcoming prisms will, like the other muscles, give most variable results; in some cases orthophoria will be established when an adduction of 20° is reached, but usually an adduction of upward of 60° will readily be acquired by a little exer- cise. I have also seen an adduction of 70° or even 80° reached in many eases, and the tests still showed an exophoria.

Heterophoria and its Treatment. — The definition of hete- rophoria, as given by Stevens, of a tending of the visual lines in some other direction than parallelism, applies as well to strabismus, and the difference between the two conditions must be borne in mind. In heterophoria binocular vision is habitually maintained, but by the expenditure of a greater amount of force than is demanded in the perfect equilibrium of the ocular muscles. In strabismus there is, on the contrary, habitual diplopia, though, as a rule, the subject by long suppression of one image has become unconscious of it. Therefore, the dividing line between heterophoria and strabismus should rest on the habitual ability or failure to maintain binocular vision.

In no ophthalmic disorder has it been found so necessary to indi- vidualize the ease as in muscular insufficiency. Sometimes the highesi degrees of heterophoria may be present without asthenopia symptoms, headache or nervous disturbances, while, upon the other hand, the lowest degree may give rise to an aggravated train of symptoms.

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AFFECTIONS OF THE OCULAR MUSCLES.

It is suggested by Stevens that heterophoria and refractive errors, by causing a constant nervous perplexity and irritation, may result in inducing a state of hyperemia or altered nutrition of parts supplied to a certain extent by branches of the some nerves which supply the imperfectly balanced muscles, and which may serve to create patho- logical changes in those parts, viz., the cornea, lens, etc., and claims to have checked the growth of cataract in many cases by correcting the heterophoria. Locomotor ataxia, chorea, epilepsy, acute mania and other mental disorders are claimed to have been cured, by some enthusiasts, through correction of the heterophoria.

These subjects are merely mentioned because, when we come to consider the wide range of reflex disturbances, they may possibly become demonstrated facts in the future, although at present we are not prepared to accept them as such. But when we come to consider the delicate mechanism of the eye and the important part that the ocular muscles perform in the carrying out of the function of this organ, one must become convinced that any insufficiency on their part may serve to create various asthenopic symptoms, headaches, neuralgias and reflex nervous disturbances. We must, however, decry the tendency to attribute all ills that flesh is heir to, to hetero- phoria.

As regards the treatment of heterophoria we desire first to most emphatically protest against the too prevalent operation of graduated tenotomies. It is to be sure far more brilliant to give the sufferer relief by operative measures than by a more or less tedious course of treatment, but have we the right to permanently lame or weaken the power of any muscle so long as the desired end, relief of the patient, can be attained by any other method? In all forms of hete- rophoria there is either an insufficiency of one muscle or a prepon- derance of strength in its opposing muscle, and in order to secure relief the normal equilibrium between these two muscles must be restored. The theory of tenotomy is to weaken the action of the stronger muscle so that the normal balance between it and its oppos- ing muscle may be re-established. The theory of treatment is to strengthen the weaker muscle and thereby re-establish the normal balance. In either method the proper equilibrium is restored; in the first plan by means of two weakened muscles and in the latter by two strong muscles. I have seen many cases where tenotomies

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have given prompt and marked relief for a time, but in six months or a year later they have fallen back into an even worse state than at first. I do not wish to be understood as claiming that no case requires operative treatment, for some of them can only be relieved by operation ; \mt first the weaker muscle should be strengthened to its utmost limit, and then, if relief is not given and the normal bal- ance not restored, a graduated tenotomy may be made.

The operation of graduated tenotomy, as suggested and practiced by Stevens, is as follows : The eyelids being separated, a fold of con- junctiva exactly over the insertion of the muscle is seized, and with the scissors a transverse incision not exceeding one-half of a mm. in length is made through this membrane; with the forceps, pressing the outer cut edge of the conjunctiva backward, the tendon of the muscle is seized in its centre a little behind its insertion and divided with the Bcissors. The hook is then inserted through this opening in the centre of the tendon and the opening enlarged by careful division of the tendon toward the borders until the desired effect is acquired. Under cocaine the patient experiences no pain, and the extent of the operation is regulated by frequent examinations with the phorometer. If too extensive, it may be limited by a very fine suture inserted through the centre of the divided muscle and through the conjunctiva at the inner side of the wound and tying it only sufficiently tight to have the desired effect.

Dr. Stevens has also devised two other operations, tendon resection and tendon contraction, to take the place of the old operation of ad- vancement, in these cases of heterophoria; both of them, from their extreme delicacy and slight reaction, are of much service and may be combined with a careful tenotomy of the stronger muscle. The instruments he has had made for all of these operations are much to be commended for their extreme delicacy.

As already stated, however, the operation, we believe, should be held as a dernier ressort, and treatment first directed toward increas- ing the power of the weaker muscle. This is best accomplished by the use of prisms to exercise and strengthen the muscle, precisely on the same theory as other voluntary muscles of the body are strength- ened by the use of dumb bells, exercise in the gymnasium, etc.

In hyperphoria my practice is to give the patient prisms, set in spectacle frames, with the base up in one eye and down in the other

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AFFECTIONS OF THE OCULAR MUSCLES.

of sufficient strength to cause vertical diplopia with the imagea near together. These are to be worn daily for from ten to twenty minutes, after the double images are fused while looking at objects in the room and at greater distances. The strength of the prisms are increased from time to time, as the superior and inferior' muscles gain power and are able to overcome stronger prisms. The degree of the hyperphoria should be tested frequently to learn when to stop the exercise, that it may not be overdone. I have found in some cases that an ability to overcome prisms of 12° (a prism of 6° base up in one eye, and of 6° base down in the other) can be acquired by this exercise, but usually they will be only able to overcome prisms of from 5° to 8° ; and oftentimes the hyperphoria will be corrected when even a power to overcome a weaker prism than this is acquired.

In esophoria precisely the same method is followed, but of course with the base of the prism set in, toward the nose, before each eye. In this exercise a power of overcoming prisms of from 12° to 16° (divided between the two eyes) is usually obtained, and as high as 24° has been acquired.

In exophoria my method of exercising with prisms is entirely dif- ferent. For this, prisms one and a half to two inches square are used. The patient is seated from fifteen to twenty feet from a lighted candle, the prism is then held with the base out before one eye of sufficient strength to produce horizontal diplopia with the images near enough together to be readily fused by an effort of the patient, the lights are held one, for a moment, when this is removed and a stronger prism placed before the eye. This procedure is fol- lowed, using stronger and stronger prisms, so long as the eye can fuse the images; then the other eye is put through the same train- ing, and the exercise should then cease for that sitting. My experi- ence has been that the best results are gained in exercising: the in- ternal recti every other day; that they will usually gain from 2° to 10° at each sitting, and should always be exercised to the same degree at least as the previous sitting, in order to hold all gain that is made ; that daily exercise or wearing the prisms, as described in hyperphoria, is apt to be too severe a strain upon the muscles in exophoria. The prisms should always be held so that the images are on the same level, else they cannot be fused. In some cases it is

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necessary to use a red glass before one eye, so that the patient can more readily recognize the two images. In low degrees of exophoria the patient should always be exercised by the surgeon; but, where there is considerable exophoria, he may be ordered a set of prisms, shown how to use them and carry out the exercise at home, but always under the direction of the surgeon. My usual directions are to exercise up to a certain degree, when they are to report for ex- amination; if exophoria is still present, they are allowed to go on to a still higher degree, and so on. The power of the internal recti to overcome prisms is readily increased in nearly every case to upward of 60° and in the majority to upward of 70°.

Results from exercising with prisms are always more prompt and satisfactory in cases of exophoria than in either hyperphoria or esophoria, as the internal recti, having much greater power nor- mally, seem to respond more readily to the systematic exercise.

Prisms may also be used for another purpose, viz. : To correct the heterophoria. In this case they serve as a crutch to remove the strain from the weaker muscle. In prescribing prisms for this pur- pose it is better, as a rule, not to put on the full correction of the heterophoria, and they should not be ordered at all until after the prismatic exercise had been carried to its full extent without relief. They should, however, as a rule be worn in preference to an opera- tion, for after their use for some time the muscles may regain their normal balance and the prisms be discarded. Very flattering re- sults have followed the use of even a |° prism.

In all cases the refraction should be carefully examined, and fre- quently it is necessary to make a thorough examination under atro- pine. If any error is detected, it should be as carefully corrected. The muscular equilibrium should be especially examined with the glasses to be used both at distance and in accommodation before pre- scribing them, because convex glasses will increase exophoria and di- minish esophoria. Many cases of esophoria associated with hyper- opia will be wholly corrected by the use of the proper convex glass, which should be as nearly as possible the glass which causes ortho- phoria both in distance and in accommodation. On the contrary, in exophoria associated with hyperopia the weakest glass possible, or □one at all, should be prescribed. Concave glasses will have an opposite effect on exophoria and esophoria to that of convex glasses.

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AFFECTIONS OF THE OCULAR MUSCLES.

Examination of hyperopic eyes under atropine will always show a much higher degree of hyperopia when esophoria is present than when there is exophoria, and hence stronger convex glasses should always be prescribed in hyperopia when esophoria is present than when there is exophoria.

It is, therefore, important to always test the muscles with the eyes in the state they are to be used, viz., with their glasses on.

The effect of glasses for refractive errors on heterophoria can be aided by either combining prisms or by decentering the lenses; the decentering of the lens gives the same effect as the combination with prisms without the annoyance of the additional weight.

Another method of toning up a weakened muscle which may be employed with benefit is forcible stretching of its antagonist in the following manner: After cocainizing the eye, take hold of the eye- ball firmly with fixation forceps over the insertion of the impaired muscle; then force the eye strongly in the direction in which the muscle acts, carrying it also moderately in the opposite direction. Do this two or three times at one sitting. This can be repeated at intervals of trom two days to a week.

Both farad ism and galvanism have also proven of much value in the restoration of muscle power. Gah7anism seems to have given the best results in my hands, and is now universally employed in all cases immediately after the prism exercise, using from six to ten cells, the positive pole applied to the temple and the negative, through a small ball electrode, to the lid directly over the insertion of the impaired muscle. Locally the patient is advised to apply to the closed eyelid three or four times each day a solution of equal parts of brandy and water or a weak solution of the remedy used, especially Ruta, Gels., or Senega.

Internal medication for the relief of asthenopic symptoms is of the first importance.

Aconite. — Asthenopia from over-use of the eyes. Lids spasmodi- cally closed, with a heavy feeling in them; while the eyes feel very hot and dry after using. Conjunctiva may be hyperaemic. Cold water may relieve temporarily the heat in the eyes.

Agaricus. — Asthenopia, especially muscular, if accompanied by sudden jerks of the ball, twitching of the lids, etc.

Argentum nit. — Letters blur, and sight vanishes on reading or writing.

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Calcarea. — Pale, flabby subjects, inclined to grow fat; with cold- ness of the extremities, and perspiration about the head. Eyes pain after using, and are generally worse in damp weather and from warmth. Burning and cutting pains in the lids, and sticking pains in the eyes on reading. Dim vision after fine work. Objects run together.

Cinnabar. — Asthenopia, with p< tin in the inner canthus, extending above or around the eye, worse in the evening and upon using the eves. Soreness over exit of supra-orbital nerve.

Conium. — Letters run together on reading. Burning pain deep in the eye. Great dread of light.

Gelsemium. — Asthenopia, with weakness of the external recti, or if associated with blepharitis or hyperaemia of the conjunctiva. Sore- ness of the eyeballs. Drawing over the eyes. Diplopia w hich can be controlled by an effort of the will.

Kalmia. — Stiff, drawing sensation in the muscles upon moving the eyes ( Nat. linir.).

Lachesis. — Asthenopic symptoms, especially in the left eye, with a variety of pains and sensations, worse upon thinking of them, using the eyes and on waking in the morning.

Lilium tig. — Burning, smarting and heat in the eyes after read- ing, relieved in the open air (Pulsat.). Photophobia.

Mercurialis peren. — Asthenopia, with a sensation of dryness of the eyes and heaviness of the lids. Mitt before the eyes in the morning. Burning pain in the eyes in evening, and upon reading.

Natrum mur. — No remedy is more often indicated in asthenopia than this. The vision soon becomes dim and letters run together upon using the eyes for near vision and sometimes for distant vision. The internal recti are usually weak. The muscles feel stiff and drawn and ache on moving the eye in any direction. Pain in the eye upon looking down. Burning, smarting, itching and heat in the eyes upon reading or writing, with a variety of other sensations, even headache. Heaviness and drooping of the lids on use of the eyes for near vision. The eyes appear irritable, with some dread of light, so the patient desires to close them firmly.

Onosmodium. — Heaviness and dullness of the eyes. Dull, heavy pains and soreness of the eye-ball. Tense, drawing and tired feeling in the ocular muscles. Pain in and over left eye. Pains in the left

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AFFECTIONS OF THE OCULAR MUSCLES.

side of the head. Dull, heavy pain in the occiput with dizzy sensa- tions, eyes feel as though they were wide open, vision blurred. Great muscular prostration and tired feeling over the entire body. The muscles feel unsteady and treacherous, as though you dare not trust them to move.

Phosphorus.— Mistiness and vanishing of vision, with pain and stiffness in the eyeball. Light aggravates, so the patient is better in the twilight. Muscse volitantes. Photopsies.

Rhododendron. — Insufficiency of the internal recti muscles, with darting pains through the eyes and head, always worse before a storm.

Ruta grav. — Aching in and over the eyes, with blurring of the vision after using or straining the eyes at fine work. The eyes feel hot like balls of fire, appear irritable and run water, especially toward evening after working all day.

Senega. — Is a remedy of especial value in cases of asthenopia from hyperphoria. Confused feeling in the head. Dullness of the head, with pressure and weakness of the eyes. Tired, aching or press- ing pains in or around the eye, smarting and burning of the eyes. The headache is of the whole head and not centered in any particu- lar spot and is often relieved in the open air. Aggravation of all the symptoms upon use of the eyes.

Sepia. — Smarting in the eyes and a variety of other sensations may, be experienced, as can be seen by reference to the verified symp- tomatology. Aggravation of the symptoms morning and evening.

Spigelia. — If accompanied by sharp, stabbing pains through the eye and around it, extending back into the head.

In addition to the above, many other remedies have been em- ployed with success. Attention is particularly directed to the fol- lowing : Ammon. carb., Apis, Arn., Asarum, Carb. veg., Caust., Crocus, Euph., Ignat., Kali carb., Ledum, Lith. carb., Macrotin, Nux vom., Paris quad., Phos. ac, Pulsat., Santon and Sulphur.

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CHAPTER V. Diseases of the Conjunctiva.

Anatomy. — The conjunctiva is the delicate mucous membrane lining the inner surface of the eyelids; from the lids it is reflected upon the globe and covers the sclerotic as far as the cornea, with which it becomes continuous. The bulbous portion of the conjunc- tiva is formed of three layers — the external epithelial layer, the tissue proper and the subconjunctival tissue.

The epithelial layer is formed of cylindrical cells externally and a deeper layer of flattened circular cells. The tissue proper is a fine reticulated structure, containing nuclei, together with a few elastic elements. The subconjunctival tissue is loose and elastic, with fibres uniting it to the sclerotic. The conjunctiva, especially the portion covering the lid and forming the cul-de sac, contains numerous lymphatic follicles and acinous glands.

The nerve supply of the conjunctiva is very free and is derived from the fifth pair. The blood supply is also extremely abundant, especially in the region of the limbus and around the caruncle.

The function of the conjunctiva is to act as a lubricating surface.

Hyperemia of the Conjunctiva — Symptoms. — The vessels have the appearance of a coarse network. The transparency and smooth- ness of the conjunctiva is lost and the papillae of the lids are more marked, giving it a velvety appearance. The eyes are red, feel hot and heavy, and as though there was sand in them ; there is a smart- ing, itching and a tired feeling on using them, or from exposure to a bright light.

Causes. — The most frequent cause is a prolonged effort of the accommodation in those who have some uncorrected error of refrac- tion, exposure to severe cold or heat, or from foreign bodies. Often seen in those living or working in a vitiated atmosphere. It is also frequently associated with nasal catarrh, hay fever, etc.

7

98

DISEASES OF THE CONJUNCTIVA.

Course. — It may be either acute or chronic, and when chronic it may cause a blepharitis, or become a catarrhal conjunctivitis.

Tee atm ent. — See conjunctivitis catarrhalis.

Conjunctivitis Catarrhalis is a hyperemia of the conjunctiva plus a discharge from the membrane — a simple hypersecretion. The healthy conjunctiva secretes mucus mixed with effete epithelial cells, and, when abundant, it becomes tenacious, stringy and with it small masses of pus. The difference between catarrhal and purulent oph- thalmia is simply one of degree; in catarrh the secretion contains elements of pus, but still is never really purulent, and is much less likely to destroy the corneal epithelium by maceration than does the purulent.

Symptoms. — These are the same as found in hypersemia, but of a higher degree ; the itching, smarting and burning sensations, the pho- tophobia, lachrymation and redness of the eye are all present, and, from the greater inflammation and infiltration, we have chemosis. The discharge from the eye may be more or less excessive, but of a bland or muco-purulent character. The amount of secretion varies, and at night it is apt to accumulate and cause crusts on the cilia. The patient often complains of a temporary blurring of vision and black spots before the eyes, due to small flakes of secretion passing in front of the pupil.

Course. — An acute attack does not usually last more than from one to three weeks, although it may run into the chronic form, espe- cially in cachetic persons, or from unfavorable surroundings. In the chronic form the discharge is less contagious, and the disease is often associated with an inflammation of the lachrymal sac, especially if one eye only is affected.

Causes. — In the acute form, where there is a muco-purulent dis- charge, it is certainly contagious. It may appear as an extension of a nasal catarrh, from an affection of the eyelids, or from an in- flammation of the lachrymal sac. Frequently occurs from an ex- posure to cold, from dust or smoke, from confinement in a close or vitiated atmosphere; often due to refractive errors, and is apt to occur with the exanthemata.

Diagnosis. — As other diseases of the eye may very closely re- semble a catarrhal conjunctivitis, the differential diagnostic points should be considered. The principal diseases usually mistaken for conjunctivitis are iritis, episcleritis and keratitis.

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99

Conjunctivitis.	Iritis.	Episcleritis.	Keratitis.
The redness of the conjunctiva i s general, and on pressure through the lower lid the injected vessels are seen to move with the mem- brane over the sclerotic. There is always redness of the fornix con- junctiva;, a n d usually of the palpebral con- junctiva. There is a muco-puru- lent discharge, more or less pro- fuse. The iris is clear and bright, the pupil reacts readily to light and the cornea is clear.	The redness is deep- seated, surrounds the cornea as a rosy zone, and is not accompanied by redness of the fornix or palpe- pebral conjuncti- va. The injected vessels are be- neath the con- junctiva, and do not move with it. The iris is dis- colored, p 11 p i 1 sluggish and inac- tive and the vis- ion is impaired. There is usually very severe pain in the eye and head, which is generally worse at night.	The redness is of a dusky-red color, U subconjunctival and localized ; it is most often sit- uated over the external rectus muscle, or over the internal. There is usu- ally little or no pain, and the du- ration of the disease is much longer.	The redness is deep- seated, and usu- ally most marked around the cor- nea. The trans- parency of the cornea is always more or less di- minished.

Treatment. — The first point in the treatment should be the re- moval of any exciting cause. To accomplish this the lids should first he everted and examined for the presence of a foreign body, which, if detected, should be removed. If the conjunctivitis depends upon any anomaly of refraction, this should be corrected. If due to straining of the eyes in reading, writing, etc. (especially in the evening), or to exposure to wind, dust or any bright light, as work- ing over a fire, directions to abstain from over-use, or to protect the eves from the injurious causes, should be given. Should the case be very severe, the patient may be confined to his room, though this is rarely required in pleasant weather. As a local remedy in acute in- flammation of the conjunctiva, the use of ice is especially recom- mended. It may be used in rubber bags made for that purpose or by wrapping it in a towel. If prescribed it should be used con- stant/;/ for twenty-four or forty-eight hours or longer, according to the benefit derived. Cleanliness especially should be required. To prevent the formation of crusts on the lids, the edges may be smeared at night with a little vaseline, simple cerate, cream or the like.

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DISEASES OF THE CONJUNCTIVA.

In conjunctivitis, after the acute symptoms have subsided, we some- times find the inflammation will come to a standstill, notwithstand- ing our most careful selection of remedies. In these cases a mild astringent will be found advisable, and the two following prescrip- tions have proven of much value:

R . Sodfe biboratis, 9j

Aqua campborata?, 3uj

Misce.

R Zinci sulpb. gr. ij

Sodium cblorid., gr. iv

Aqua dest, 3*

Misce.

Instil a few drops in the eye four times a day. Atropine should not be used unless there is iritic complication.

The attendants should be warned that the discharge is contagious, and that the sponges, towels, etc., used upon the patient should not be employed for any other purpose.

Aconite. — Is especially indicated in the first stage of catarrhal inflammation, prior to exudation, if the conjunctiva is intensely hy- pertemicand oedematous, with severe pain in the eye, often so terrible that one wishes to die; or, as is more frequently the case, a feeling of burning and general heat in the eye, with great dryness. There may also be an aching or bruised pain, or a feeling as if the ball were enlarged and protruding, making the lids tense. The eye is generally very sensitive, especially to air. This is the first remedy to be thought of for conjunctivitis dependent upon exposure to cold, dry air. For inflammatory conditions of the conjunctiva resulting from the irritant action of foreign bodies in that tissue there is no better remedy. (It is in the Aconite stage that ice is most valuable).

Allium cepa. — Of use in acute catarrhal conjunctivitis associated with a similar condition of the air passages, as in hay fever; the lachrymation is scalding, profuse and not excoriating, though the nasal discharge is so (reverse of Euphrasia).

Alumina. — Inflammation of the conjunctiva, usually chronic and affecting chiefly the palpebral conjunctiva, always aggravated from over-use of the, eyes and accompanied by a sensation of dryness in them, with moderate discharge and a heavy feeling in the lids.

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Apis mel. — Especially called fur in the acute form of conjuntivi- tis, when the conjunctiva is bright red and puffy, lachryraation hot and moderately profuse, and pains in the eye, burning, biting or stinging; sometimes the pains are very severe, darting through the eye, or possibly around the eye and in the brows. Photophobia may be present. The cedematous condition of the lids, especially the upper, which is usually present in the eases in which Apis is indi- cated, is an important symptom. There is generally aggravation in tbe evening and fore part of the night. Although the lachryraation is hot and burning, yet it does not excoriate the lids, as in cases in which Arsenicum is indicated. General symptoms of dropsy, ab- sence of thirst, etc., would suggest this remedy to our minds.

Argentum nit. — Should be employed if the discharge becomes profuse, assuming the character of purulent ophthalmia. It may also be indicated in the chronic form of conjunctivitis, when the conjunctiva is scarlet-red and the papillse hypertrophied. The in- flammatory symptoms usually subside in the open air and are ag- gravated in a warm room.

Arnica. — In conjunctivitis resulting from blows and various inju- ries Arnica is often beneficial.

Arsenicum. — Occasionally useful in acute conjunctivitis with chemosis, much hot, scalding lachryraation, burning pains, especially at night, and cedematous condition of the lids, particularly the lower lid. It is also indicated in the chronic form, if the lachrymation and discharge from the eyes are acrid, excoriating the lids and cheek ; the balls burn as if on fire, especially at night.

Warm applications generally relieve. The attacks of inflamma- tion are frequently periodic and often alternate from one eye to the other.

Belladonna. — The remedy in the early stages of catarrhal con- junctivitis, if there is great dryness of the eyes, with a sense of dry- ness and stiffness in the thickened red lids and smarting, burning pains in the eyes. Photophobia is marked. Much dependence should be placed, however, upon the concomitant symptoms of head- ache, red face, etc.

Calcarea carb. — Occasionally useful in catarrhal conjunctivitis caused by working in water. Eyes hot with feeling of sand in them.

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Causticum. — Conjunctivitis with a feeling of sand in the eyes and dull, aching pain.

Chamomilla.— Catarrhal conjunctivitis occurring in peevish children during dentition. Conjunctiva so congested that blood oozes out.

Cinnabaris. — May be called for in conjunctivitis, especially with

the characteristic symptom of pain above the eye, extending from the internal to the external canthus (usually above, though sometimes below ).

Duboisin. — Chronic hypercemia of the palpebral conjunctiva in hy- peropes.

Euphrasia. — In this drug, we have a very valuable remedy for both acute and chronic catarrhal conjunctivitis, especially acute. It is useful in catarrhal inflammation of the eyes caused by exposure to cold, and also in that of the eyes and nose found in the first stage of measles. In the selection of this drug we are guided chiefly by the objective symptoms as the subjective are not very definite, there being a variety of sensations. The conjunctiva is intensely red ; even chemosis. The lachrymation is profuse, acrid, burning, while the discharge from the eye, which is also quite profuse, is thick, yellow, muco-purulent and acrid, making the lids and cheek sore and excori- ated. (The secretion is also excoriating under Arsenic and Mercu- rius, but is thinner.) Blurring of the vision relieved by winking, de- pendent upon the secretion covering the cornea temporarily, is es- pecially characteristic of this remedy.

Graphites. — Sometimes indicated, especially in the chronic form of catarrhal conjunctivitis, though it is more particularly the remedy for phlyctenular ophthalmia. The redness, photophobia and lach- rymation are usually well marked, but may vary to a great extent. The discharges from the eye, if present, are thin and acrid, while the nose is sore, excoriated and often surrounded by thick, moist scabs. Dry scurfs are frequently found on the lids, while the external canthi (■rack and bleed easily.

Hepar sulph. — Another remedy more useful in strumous oph- thalmia; though it is sometimes employed with benefit in the catar- rhal form, as when the conjunctiva is much congested, even chemo- sis, with considerable photophobia and lachrymation, while the lids are much swollen and very sensitive to touch. The discharge is of

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a muco-purulent character and often well marked. The pains are throbbing, aching or lancinating and relieved by warmth, so that one wishes to keep the eye covered most of the time.

Ignatia. — Has been successfully used in catarrhal ophthalmia in nervous, hysterical subjects, when there has been a sensation as if a grain of sand were rolling around under the lid, with great dryness and lachrymation only when exposed to the sunlight.

Merc. sol. — In Mercury we possess an important remedy for ca- tarrhal conjunctivitis, and this preparation is most commonly re- quired, though some other may be employed, if the concomitant svmptoms so indicate. The redness and dread of light are usually well marked, especially in the evening, by artificial light. The lachrymation is profuse, burning and excoriating and the muco-puru- lt nl discharges thin and acrid, making the lids and cheek red and sore. The pains vary in character and are not confined to the eye, but extend into the forehead and temples, are always worse at night, especially before midnight, in extreme heat or cold and in damp weather, and are often temporarily ameliorated by cold water. It is especially indicated in syphilitic subjects, and when the concomi- tant symptoms of soreness of the head, excoriation of the nose, noc- turnal pains, etc., are present.

Nux vomica. — Is not very often called for in this variety of con- junctivitis. It would be suggested to our minds if there were much dread of light, marked morning aggravation and accompanying gastric; symptoms.

Pulsatilla. — This is another of our standard remedies for catar- rhal conjunctivitis, especially the acute form, though it is also use- ful in the chronic. It is particularly to be thought of in conjunc- tivitis occurring in the colored race, as well as in the mild, tearful female. The redness is variable and may be accompanied by che- mosis. The pains in the eye are burning, itching or lancinating, usually worse in the evening, when in the wind and after reading, but relieved by the cool, open air. The lachrymation is often profuse by day, with a purulent discharge at night; though generally a moderately profuse muco purulent discharge of a white color and bland character, which agglutinates the lids in the morning, is to be found. Gastric and other concomitant symptoms, if present, will influence our choice.

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Rhus tox. — Is the chief remedy for conjunctivitis caused by ex- posure in water (Calc), especially if there is much chemosis, with some photophobia, profuse lachrymation and cedematous swelling of the lids. A rheumatic diathesis would especially suggest this remedy.

Sanguinaria. — Benefit has been derived from its use in catarrhal conditions of the conjunctiva, with burning in the edges of the lids, worse in the afternoon. Haemorrhages in the conjunctiva with ten- dency to trachoma; moderate discharge and pain.

Sepia. — Acute catarrhal conjunctivitis with drawing sensation in the external canthi and smarting in the eyes, ameliorated by bathing in cold water and aggravated morning and evening. Conjunctivitis with muco-purulent discharge from the eyes in the morning and great dryness in the evening.

Sulphur. — This is one of our chief remedies in both the acute and chronic forms of catarrhal conjunctivitis. The degree of redness may vary greatly; it may be confined to one eye or may involve both. The lids may be swollen or remain unaffected. The sharp, darting pains, like pins piercing the eye, occurring at any time of the day or night, will furnish our chief indication. A severe pain dart- ing through the eye back into the head, from 1 to 3 a.m., waking the patient from sleep, is also an important indication. A variety of other sensations may be present; as pressing, tensive, cutting or burning pains, a feeling of sand in the eyes, etc. The patients are usually feverish and restless at night.

Terebinth. — Great redness of the conjunctiva, usually dark in color, with severe pain in the eye and corresponding side of head. Some pain in the back, and urine dark in color.

Zincum. — has been useful in conjunctivitis especially when con- fined to the inner half of the eye, with much discharge ; worse toward evening and in the cool air. Generally there is itching, and perhaps pain, in the internal canthus.

The following remedies have also been used with benefit or may be indicated in occasional cases : Chelidonium, Cuprum sulph., Kali bichr., Natrum mur., Senega, Silicea and Thuja.

Conjunctivitis Purulenta.— ( Ophthalmia Neonatorum, Conjunc- tivitis Gonorrhoeica). — An inflammation of the conjunctiva with a purulent discharge may occur at any time of life, and bears essen-

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tially the same features, whether occurring in the infant soon after birth, or in the adult as a result of infection from a gonorrhoea! or other discharge. It is, however, more commonly spoken of under the heading of its two principal causes as ophthalmia neonatorum and conjunctivitis gonorrhceica ; but, as the pathology, symptoms, course and treatment are practically the same, they will be generally described under the one heading, reserving for each a brief mention of its characteristic peculiarities.

Pathology. — No great changes take place in the conjunctiva. It simply becomes infiltrated with serum, together with a prolifera- tion of cells and lymphoid elements; the blood vessels become di- lated, the capillaries increased in number and there is also some thickening of the epithelium.

Symptoms. — All those of catarrhal conjunctivitis are present in a much higher degree. The most prominent symptom is chemosis, which may be sufficient to overlap the cornea. This is due to serous engorgement, which also extends to the lids, causing a violet colored puffiness. The oedema of the lids is so great as to cause ptosis. The papillae of the conjunctiva are elevated and form villi, which bleed easily and give a thick, swollen appearance to the conjunctiva of the lids. Another most prominent symptom is the discharge, which at first is thin, muco-purulent, but soon becomes distinctly purulent, a thick yellow secretion, and is so excessive that the eye and cheek become literally bathed in pus.

At first there is a feeling of heat and smarting, burning pains in the eye, then ciliary pains and shooting pains in the head set in. In some there is a distinct febrile movement. The swelling of the lids becomes hard and tense, of a dusky red color — the upper lid overhanging the lower.

These symptoms may gradually diminish and the conjunctiva return to the normal condition. The great danger is an involve- ment of the cornea, which may occur in three ways, viz. : First, small facets are formed by a loss of the epithelium, which, if seen and watched, may be prevented from extending ; if not, they ex- tend deeper, unite and form an ulcer, which may terminate by per- foration. Second, there appear toward the centre of the cornea grayish points of infiltration, which increase in size, fuse and tend to form an abscess. Third, infiltration takes place at the margin of

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the cornea in the form of a ring, and ; if this occupies more than a third of the cornea, it indicates an affection of the nutrition and be- comes the starting point of a general necrosis, which almost inevitably causes loss of the eye. The cause of this participation of the cornea is due to either direct action of the infectious matter on the cornea, to direct continuity of inflammation to the substances of the cornea, or to the stoppage of the nutrition of the cornea by the chemosis.

Causes. — Contagion is undoubtedly the direct cause in nearly every case. In infants it usually results from a leucorrhoeal dis- charge at the time of birth. In adults it is more often the result of infection from gonorrhoea. Girls have been affected from an ordi- nary leucorrhoeal discharge. Secretions from a diphtheritic con- junctivitis, or an altered or decomposed discharge from a catarrhal conjunctivitis may cause a purulent ophthalmia.

Prognosis is always serious if the cornea is affected, as perma- nent opacities, staphyloma of the cornea, or even complete destruc- tion of the eye may ensue. Even when the cornea is not affected, do not give a too favorable prognosis, as corneal complications may arise«at any time.

Ophthalmia Neonatorum. — The ophthalmia of the newly-born child is undoubtedly solely the result of inoculation from a leucor- rhoeal or gonorrhoeal discharge from the vagina or cervix and occurs during birth, or later from the soiled linen or sponges. It is only in cases where the eyes are prematurely opened that they contract the contagion, when due to contact with the virus during labor, and it usually manifests itself on the third or fourth day after birth. When resulting from soiled linen, etc., it is usually later in present- ing its appearance, and, when beginning later than the first week, is almost certainly due to some extraneous source of inoculation.

Statistics have shown that in former years a very large proportion of all cases of blindness has resulted from this disease, in different countries varying all the way from 20 to as high as 79 per cent. In late years the attention that has been paid to the prevention of this disease has very materially lowered the percent. Still we are daily meeting cases of permanent blindness from this disease which should be attributed wholly to the ignorance of those attending these cases. Much of this fatality could be obviated by careful disinfection of the vagina at the time of parturition and in cleanliness in the linen and

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the sponges used and the hands of those coming in contact with the child or mother. Careful cleansing of the eyes of the babe with carbolized water or by the instillation of a weak solution of the ni- trate of silver (2 per cent.) should always be practiced in all oases where the mother is suffering from leucorrhcea.

Conjunctivitis Gonorrhceica.— This disease is always due to in- fection. Its onset is often accompanied by a severe arthritis. The inflammatory process is usually very intense and runs a rapid course. The lids are greatly swollen, as is also the palpebral conjunctiva. There is excessive chemosis and purulent secretion.

The disease usually develops in about forty-eight hours; it may occur in either acute or chronic gonorrhoea, and the more active the gonorrhoea is at the time of infection, the more severe will be the in- flammation. The virus of gonorrhoea may also cause diphtheritic conjunctivitis.

The right eye is more often first affected, and it is more frequently found in males than in females. The physician must always handle all cases of purulent conjunctivitis with extreme care, on account of possible infection. This variety of purulent conjunctivitis is more severe than when due to any other cause, as about one-half of all eyes attacked with this disease are lost, while hardly one-third of the other forms of purulent conjunctivitis are fatal.

Treatment of Conjunctivitis Purulenta. — If the attack is very severe, the patient may be confined to a darkened room, or even to lied ; if only one eye is affected, the other should be hermetically closed in order to prevent any of the matter coming in contact with that eye, for this discharge is very contagious, especially in the gon- orrhoeal form, and in that found in new-born children. The healthy eye is best protected by means of a watch-crystal held in place over the eye by strips of adhesive plaster. In this way the eye is her- metically sealed ; the patient can use the eye for necessary vision, and it is always under the observation of the surgeon. Owing to the contagiousness of the secretions great care should be exercised both by the nurse and physician, to protect their own eyes and those of others, by providing that the sponges, towels, etc., are used only by the patient; also, that their hands are thoroughly cleansed before touching another eye, for often the physician and other patients have been inoculated and vision destroyed through carelessness on this

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point. If, by accident, any of the discharge should have got into a healthy eye, lukewarm water should be at once injected under the lids to wash it away; after which, drop in a strong solution of chlorine-water, or a weak solution of nitrate of silver (gr. ij. ad Fresh air and nourishing diet are important aids. But the special and primary point to be attended to in the treatment is cleanliness. To ensure this, the discharges should be often removed by drop- ping warm water into the inner canthus until all the pus has been washed away, or by cleansing with the palpebral syringe. This should be done at intervals of from fifteen minutes to an hour during the day, and occasionally through the night, according to the severity of the case. The use of peroxide of hydrogen is of great aid in the thorough cleansing of the eye, so essential in purulent affections.

In the inflammatory stage of purulent conjunctivitis, ice com- presses will usually be found most valuable, often serving to abort an attack. Ice-bags may be used on the eye, or when the weight of the ice-bag is complained of, cold may be applied by means of four or five thicknesses of old linen, cut about three inches square and laid upon a large cake of ice; these pads are to be conveyed quickly from the ice to the eye and changed every one or two minutes so that the cold will be constant. Carbolic acid, a 1 to 200 solution, or other disinfectants, can be used in combination with the ice, by having a large piece of ice in a large vessel of the solution.

Caustics are directly efficacious by the irritation of the vascular walls, and indirectly by the contraction that follows a considerable discharge of serum, such as accompanies the shedding of the eschar.