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W. B. SAUNDERS COMPANY 
West Washington Square Philadelphia 
London: 9, Henrietta Street, Covent Garden DISEASES OF THE EYE 
A HANDBOOK OF OPHTHALMIC PRACTICE 
.FOR STUDENTS AND PRACTITIONERS 
BY 
GEORGE E. deSCHWEINITZ, M.D., LL.D. (Univ, of Pa.) 
KA , 
Professor of Ophthalmology in the University of Pennsylvania; Ophthalmic 
Surgeon to the University Hospital; Consulting Ophthalmic Surgeon to the 
Philadelphia Polyclinic Hospital, the Philadelphia General Hospital, 
and the Orthopedic Hospital and Infirmary for Nervous Diseases 
EIGHTH EDITION, RESET 
WITH 386 ILLUSTRATIONS 
AND 7 COLORED PLATES 
PHILADELPHIA AND LONDON 
W. B. SAUNDERS COMPANY Copyright, 1892, by W. B. Saunders, Reprinted January, 1893, and August, 1893. Revised, reprinted, 
and recopyrighted May, 1896. Reprinted August, 1897. Revised, reprinted, and recopyrighted 
January, 1899. Revised, entirely reset, electrotyped, reprinted, and recopyrighted October, 
1902. Revised, reprinted, and recopyrighted January, 1905. Revised, reprinted, 
and recopyrighted April, 1910. Revised, reprinted, and recopyrighted May, 
1913. Reprinted April, 1915. Revised, entirely reset, reprinted, 
and recopyrighted May, 1916. 
Copyright, 1916, by W. B. Saunders Company. 
PRINTED IN AMERICA 
PRESS OF 
W. B. SAUNDERS COMPANY 
PHILADELPHIA PREFACE TO THE EIGHTH EDITION 
In the Eighth Edition of this text-book its chapters have been revised 
thoroughly in an endeavor to include due reference to the important 
ophthalmic observations and therapeutic measures which have been 
made and recommended during the last three years. 
A new feature in this edition is the introduction of the metric equiva- 
lents of the doses of the remedies and the strengths of the solutions pre- 
viously recorded only according to the old system. Reference to the 
following subjects appears for the first time: Clifford Walker's Method 
of Testing the Visual Field; Squirrel Plague Conjunctivitis; Swimming 
Bath Conjunctivitis; Anaphylactic Keratitis; Family Cerebral Degenera- 
tion with Macular Changes; the Ocular Symptoms of Disease of the 
Pituitary Body; Sclerectomy with a Punch (Holth's Operation); Pre- 
liminary Capsulotomy (Homer Smith's Operation); Iridotasis (Borthen's 
Method); Thread Drainage of the Anterior Chamber (Zorab's Opera- 
tion); Extraction of Cataract in the Capsule after Subluxation of the 
Lens with Capsule Forceps (Stanculeanu's Method, Arnold Knapp's 
Method); Capsulomuscular Advancement with Partial Resection 
(Ziegler's Method); Tenotomy of the Inferior Oblique; Window 
Resection of the Nasal Duct (West's Operation). 
A portion of the chapter on Iritis has been rewritten, especially as it 
relates to Autotoxemic Iritis and Iritis Secondary to Mucous Membrane 
Infections. Lieut.-Col. Elliot has very kindly written the description 
of Corneoscleral Trephining, ordinarily known as Elliot's Operation. 
To Dr. William M. Sweet the author is indebted for a description of his 
revised method of localizing foreign bodies within the eye by means of the 
a-rays. As in previous editions, the section devoted to Skiascopy, or the 
Shadow Test, is from the pen of Dr. Edward Jackson. A number of 
new illustrations have been inserted. The entire work has been reset 
and appears in a new and greatly improved form. 
The author trusts that these additions and alterations will prove to be 
satisfactory, and he desires again to express his high appreciation of the 
cordial reception which has thus far been accorded to his work. 
G. E. deS. 
1705 Walnut Street, 
Philadelphia, Pa. 
May, 1916. 
7 CONTENTS 
CHAPTER I 
PAGE 
General Optical Principles 17 
Transmission of Light, 17-Refraction, 17-Index of Refraction, 17- 
Prisms, 18-Refraction through a Prism, 18-Angle of Deviation, 19- 
Numbering Prisms, 19-Dennett's Method, 19-Prentice's Method, 20-- 
Rays of Light, 20-Lenses, 23-Foci of Convex Lenses, 23-Foci of Concave 
Lenses, 24-Formation of Images by Lenses, 25-Focal Distance of a Lens, 
28-Numeration of Lenses, 28-The Diopter, 28-Spheric Lenses, 30- 
Cylindric Lenses, 30-Toric Lenses, 30-Combination of Lenses, 30- 
Visual Angle, 34-Visual Acuteness, 35-Limit of Perception, 35-Normal 
Acuteness of Vision, 35-Accommodation, 35-Angle Gamma, 41-Angle 
Alpha, 41-Convergence, 43-Meter Angle, 44. 
CHAPTER II 
Examination of the Patient and External Examination of the Eye- 
Functional Testing 47 
Direct Inspection of the Eye, 47-Blood-vessels of the Conjunctiva, 49- 
Temperature of Conjunctiva, 50-Inspection of the Cornea, 50-Diameter 
of Cornea, 51-Sensibility of Cornea, 51-Oblique Illumination, 51-The 
Corneal Loupe, 52-The Color of the Iris, 52-The Pupil, 53-Measure- 
ment of the Pupil, 54-Mobility of the Iris, 55-Pupil-reflexes, 55-Inner- 
vation of the Iris and Explanation of the Pupil-reflexes, 57-Dilatation of 
the Pupil, 61-Contraction of the Pupil, 62-Convergence Anomalies of the 
Pupils, 63-Unequal Pupils, 64-Special and Paradoxic Pupil-phenomena, 
64-Testing Acuteness of Vision, 65-Light-sense, 66-Color-sense, 67- 
Method of Holmgren, 67-Method of Thomson, 68-Lantern-test, 69- 
Pseudo-isochromatic Plates of Stilling, 70-Special Tests, 70-Accommoda- 
tion, 70-Mobility of the Eyes, 71-Balance of the External Eye Muscles, 
71-Orthophoria, 71-Heterophoria, 71-Heterotropia, 71-Esophoria, 
72-Exophoria, 72-Hyperphoria, 72-Cyclophoria, 72-The Screen 
(Cover) and Parallax Tests, 72-Prism Tests, 73- Equilibrium Test, 73- 
Obtuse-angled Prism Test, 75-Insufficiency of the Oblique Muscles (Cyclo- 
phoria), 76-Cobalt Test, 76-The Rod Test, 77-Power of Convergence, 
78-Field of Vision, 79-Binocular Field of Vision, 82-Abnormalities of 
Visual Field and Scotomas, 85-Tension, 86-Proptosis, Exophthalmos, 88 
-Position of the Eyes, 88. 
CHAPTER III 
Reflection. The Ophthalmoscope and its Theory. Ophthalmoscopy 
and Skiascopy 89 
Reflection, 89-The Ophthalmoscope, 91-Direct Method, 92-Size of the 
Image, 95-Indirect Method, 95-Size of the Image, 96-Ophthalmoscopy, 
96-Direct Method of Ophthalmoscopy, 96-Examination of the Cornea 
9 10 
CONTENTS 
PAGE 
and Lens by Transmitted Light, 98-Examination of the Vitreous, 99- 
Location of Opacities in the Transparent Media, 99-The Optic Nerve, 
100-The Blood-vessels, 101-Physiologic Variations, 102-The Retina, 
104-Macula Lutea, 104-The Choroid, 105-Determination of Refrac- 
tion by the Ophthalmoscope, 106-Ophthalmoscopy by the Indirect 
Method, 108-Ophthalmodiaphanoscopy, 110-Ophthalmometry, 110- 
Optometry, 111-Skiascopy, 111-The Use of Mydriatics, 117. 
CHAPTER IV 
Normal and Abnormal Refraction 120 
Emmetropia, 120-Ametropia, 121-Hyperopia, 121-Determination and 
Correction of Hyperopia, 123-Ordering of Glasses, 125-Myopia, 127- 
Determination and Correction of Myopia, 133-Treatment of Myopia, 135 
-Ordering of Glasses, 136-Astigmatism, 138-Seat of Astigmatism, 138- 
Regular Astigmatism, 141-Recognition of Astigmatism, 143-Correction 
of Astigmatism, 143-Ordering of Glasses, 146-Irregular Astigmatism, 
147--Surgical Treatment of Astigmatism, 147-Anisometropia, 148- 
Presbyopia, 148-Correction of Presbyopia, 149-Bifocal Lenses, 153- 
Spectacles and their Adjustment, 1&4. 
CHAPTER V 
Diseases of the Eyelids . 158 
Congenital Anomalies, 158-Edema of the Lids, 160-Erythema of Lids, 
160-Urticaria, 160-Erysipelas, 161-Abscess of the Lid, 161-Furuncle 
of the Lid, 161-Blastomycosis of the Eyelid, 161-Hordeolum, 162- 
Exanthematous Eruptions, 162-Eczema of the Lids, 163-Herpes Zoster 
Ophthalmicus, 163-Herpes Facialis of the Lids, 164-Blepharitis, 165-• 
Phthiriasis, 168-Sporotrichosis of the Lids, 168-Syphilis of the Lids, 168- 
Tumors and Hypertrophies, 169-Xanthelasma, 171-Chalazion, 171- 
Sarcoma, 173-Lymphomas, 174-Carcinoma, 174-Lupus Vulgaris, 176- 
Lepra, 177-Xeroderma Pigmentosum, 177-Elephantiasis Arabum, 177- 
Tarsitis, 177-Blepharospasm, 178--Ptosis, 179-Blepharochalasis, 179- 
Lagophthalmos, 180-Symblepharon, 180-Ankyloblepharon, 180-Bleph- 
arophimosis, 181-Trichiasis and Distichiasis, 181-Alopecia of the Eyelids, 
181-Entropion, 182-Ectropion, 182-Seborrhea, 183--Milium, 183- 
Molluscum Contagiosum, 184-Ephidrosis, 184-Chromidrosis, 184- 
Sebaceous Cysts, 185-Injuries, 185. 
CHAPTER VI 
Diseases of the Conjunctiva 187 
Congenital Anomalies, 187-Hyperemia, 187-Conjunctivitis (Ophthal- 
mia), 188-Simple or Catarrhal Conjunctivitis, 188-Acute Contagious 
Conjunctivitis, 190-Pneumococcus Conjunctivitis, 191-Influenza Bacil- 
lus Conjunctivitis, 191-Swimming-bath Conjunctivitis, 192-Diplo- 
bacillus Conjunctivitis, 192-Catarrhal Epidemic Conjunctivitis, 194- 
Exanthematous Conjunctivitis, 195-Purulent Conjunctivitis, 195- 
Conjunctivitis Neonatorum, 195-Inclusion-blenorrhea of Newborn, 203- 
Purulent Conjunctivitis in Young Girls, 203-Gonorrheal Conjunctivitis, 
204-Metastatic Gonorrheal Conjunctivitis, 207-Non-specific Purulent 
Conjunctivitis, 207-Croupous Conjunctivitis, 208-Diphtheritic Con- CONTENTS 
11 
PAGE 
junctivitis, 209-Phlyctenular Conjunctivitis, 211-Vernal Conjunctivitis, 
212-Follicular Conjunctivitis, 214-Granular Conjunctivitis (Trachoma), 
215-Sequels of Granular Lids, 221-Parinaud's Conjunctivitis, 226- 
Sporotrichosis of Conjunctiva, 227-Chronic Conjunctivitis, 227-Egyp- 
tian and Military Conjunctivitis, 228-Lacrimal Conjunctivitis, 228- 
Lithiasis Conjunctivae, 228-Toxic Conjunctivitis, 228-Atropin Con- 
junctivitis, 228-Conjunctivitis Nodosa, 229-Xerophthalmos, 230- 
Amyloid Disease of the Conjunctiva, 230-Conjunctivitis Petrificans, 230- 
Pterygium, 231-Pinguecula, 231-Abscess of the Conjunctiva, 231- 
Ecchymosis of the Conjunctiva, 232-Chemosis, 232-Emphysema, 232- 
Lymphangiectasis, 232-Syphilis, 232-Tumors and Cysts, 233-Lepra, 
236-Lupus, 236-Tubercle, 237-Pemphigus, 238-Injuries, 238-Affec- 
tions of the Caruncle, 239-Argyria Conjunctivae, 240. 
CHAPTER VII 
Diseases of the Cornea 241 
Keratitis, 241-Phlyctenular Keratitis, 241-Ulcers of the Cornea, 244- 
Results of Corneal Ulceration, 258-Staphyloma, 259-Keratomalacia, 
262-Neuroparalytic Keratitis, 262-Keratitis E Lagophthalmo, 263- 
Herpetic Keratitis, 264-Rosacea Keratitis, 265--Keratitis Bullosa, 265- 
Vascular Keratitis, 265-Parenchymatous Keratitis, 266-Keratitis 
Punctata Syphilitica, 272-Keratitis Punctata, 272-Keratitis Profunda, 
273--Keratitis Superficialis Punctata, 273-Keratitis Marginalis Profunda, 
274-Keratitis Disciformis, 275-Grill-like Keratitis, 275-Marginal De- 
generation of the Cornea, 276--Epithelial Dystrophy of the Cornea, 276-- 
Filamentous Keratitis, 277-Riband-like Keratitis, 277-Blood-staining of 
the Cornea, 278-Arcus Senilis, 278-Conical Cornea, 278-Hydroph- 
thalmos, 280-Injuries, 280-Traumatic Keratitis, 280-Foreign Bodies, 
281-Relapsing Traumatic Keratitis Bullosa, 281-Wounds, 282-Burns 
and Scalds, 282-Peripheral Annular Infiltration of the Cornea, 283- 
Traumatic Striped Keratitis, 283-Obstetric Injuries, 284-Tumors and 
Cysts, 284-Congenital Anomalies, 285. 
CHAPTER VIII 
Diseases of the Sclera 287 
Episcleritis, 287-Fugacious Periodic Episcleritis, 288-Scleritis, 288- 
Sclerokerato-iritis, 290-Annular Scleritis, 291-Posterior Scleritis, 291- 
Staphyloma, 291-Abscess and Ulcers, 292-Tumors, 292-Injuries, 292- 
Foreign Bodies, 293-Congenital Pigmentation, 297-Blue Sclerotics, 298. 
CHAPTER IX 
Diseases of the Iris 299 
Congenital Anomalies, 299-Hyperemia, 301-Iritis, 301-Types of Iritis, 
306-Syphilitic Iritis, 306-Rheumatic Iritis, 310-Gouty Iritis, 312- 
Diabetic Iritis, 312-Gonorrheal Iritis, 313-Scrofulous Iritis, 314-Infec- 
tious Disease Iritis, 314-Traumatic Iritis, 314-Sympathetic Iritis, 314- 
Secondary Iritis, 315-Serous Iritis, 315-Chronic Iritis, 315-Operations 
for Iritis, 315-Tumors, 316-Tubercle, 317-Sarcoma, 318-Injuries, 318 
-Foreign Bodies, 319-Iridodialysis, 319-Rupture of the Sphincter, 320- 
Displacement of the Iris, 320-Anomalies of the Anterior Chamber, 320. 12 
CONTENTS 
CHAPTER X 
PAGE 
Diseases of the Ciliary Body and Sympathetic Irritation and Inflam- 
mation 322 
Cyclitis and Iridocyclitis, 322-Plastic Cyclitis, 322-Purulent Cyclitis, 
323-Uveitis or Serous Cyclitis, 323-Injuries of the Ciliary Body, 329- 
Syphilis of the Ciliary Body, 329-Tumors of the Ciliary Body, 331- 
Sympathetic Irritation, 331-Sympathetic Inflammation (Ophthalmitis), 
331. 
• CHAPTER XI 
Diseases of the Choroid 343 
Congenital Anomalies, 343-Hyperemia, 344-Choroiditis, 345-Super- 
ficial, 347-Deep, 347-Diffuse Exudative Choroiditis, 347-Disseminated, 
349-Circumscribed Plastic, 350-Anterior, 351--Central, 352-Unclassi- 
fied forms of Choroiditis, 354-Myopic, 356-Suppurative Choroiditis and 
Iridochoroiditis, 357-Panophthalmitis, 357-Tumors, 359-Sarcoma, 
364-Carcinoma, 364-Tubercle, 364-Injuries, 365-Foreign Bodies, 366 
-Rupture, 366-Hemorrhage, 366-Detachment, 366-Ossification, 367- 
Atrophy of the Eyeball, 367-Essential Phthisis Bulbi (Ophthalmo- 
malacia), 367. 
CHAPTER XII 
Glaucoma 368 
Varieties of Glaucoma, 368-Acute Glaucoma, 375-Subacute Glaucoma, 
377-Chronic Glaucoma, 377-Treatment, 386-Secondary Glaucoma, 
392-Hemorrhagic Glaucoma, 392-Complicated Glaucoma, 393. 
CHAPTER XIII 
Diseases of the Crystalline Lens 394 
Congenital Anomalies, 394-Coloboma, 394-Lenticonus, 394-Cataract, 
394-Varieties of Cataract, 394-Senile Cataract, 401-Juvenile Cataract, 
401-Congenital Cataract, 402-Complicated or Secondary Cataract, 404- 
Traumatic Cataract, 405-After-cataract, 405-Capsular Cataract, 406- 
Capsulolenticular Cataract, 406-Artificial Ripening, 408-Treatment of 
Immature Cataract, 408-Treatment of Mature and Complete Cataract, 
409-Treatment of Partial Congenital Cataract, 410-Dislocation of the 
Crystalline Lens, 411-Foreign Bodies in the Lens, 413. 
Diseases of the Vitreous 414 
Pus in Vitreous, 414--Opacities, 415-Muscae Volitantes, 417-Hemorrhage, 
417-Synchysis, 418-Synchysis Scintillans, 419-Blood-vessel Formation, 
419-Foreign Bodies, 420-Entozoa, 420-Detachment, 420-Persistent 
Hyaloid Artery, 420. 
CHAPTER XIV 
CHAPTER XV 
Diseases of the Retina 421 
Hyperemia, 421-Anemia, 422-Hyperesthesia, 422-Anesthesia, 423- 
Cyanosis, 424-Retinitis, 425-Types of Retinitis, 427-Serous, 427- 
Parenchymatous, 427-Syphilitic, 428-Hereditary Syphilitic Choroido- 
retinitis, 431-Metastatic, 432-Hemorrhagic, 432-Albuminuric, 433 
Albuminuric Retinitis in Pregnancy, 436-Diabetic, 438-Leukemic, 439- CONTENTS 
13 
PAGE 
Proliferating, 440-Circinate, 441-Central Punctate, 442-Striated 
Retinitis, 442-Pigmentary Degeneration, 442-Detachment, 447- 
Hemorrhages, 451-Changes in the Retinal Vessels, 453-Angioid Streaks 
in the Retina, 455-Exudative Retinitis, 455-Aneurysms, 456-Angio- 
matosis of Retina, 456-Obstruction of the Central Artery of Retina, 
including Embolism and Thrombosis, 457-Thrombosis of the Central 
Vein, 460-Traumatisms, 461-Retinal Changes from the Effect of Sun- 
light and Electric Light, 463-Glioma, 464-Subretinal Cysticercus, 466- 
Cysts of the Retina, 466-Symmetric Changes at the Macula Lutea in 
Infancy, 466-Family Cerebral Degeneration with Macular Changes, 467- 
Macular Atrophy of the Retina, 468. 
CHAPTER XVI 
Diseases of the Optic Nerve : 469 
Congenital Anomalies, 469-Hyperemia, 470-Anemia, 471-Intra-ocular 
Optic-nerve Inflammation and Edema, 471-Intra-ocular Optic Neuritis 
(Choked Disk), 471-Atrophy of the Optic Nerve, 482-Varieties of Optic- 
nerve Atrophy, 484-Primary Atrophy, 484-Secondary Atrophy, 485- 
Consecutive Atrophy, 485-Retinitic and Choroiditic Atrophy, 485- 
Hereditary Optic-nerve Atrophy, 486-Orbital Optic Neuritis (Retro- 
bulbar Neuritis; Central Amblyopia), 488-Injury of the Optic Nerve, 492- 
Tumors, 492-Hyaline Bodies (Drusen) in the Papilla, 493. 
CHAPTER XVII 
Amblyopia, Amaurosis, and Disturbances of Vision Without Ophthalmo- 
scopic Changes 495 
Congenital Amblyopia, 495-Congenital Amblyopia for Colors (Color- 
blindness), 496-Congenital Total Color-blindness, 498-Congenital 
Word-blindness, 498-Reflex Amblyopia, 498-Traumatic Amblyopia, 
499-Uremic Amblyopia or Amaurosis, 500-Glycosuric Amblyopia, 500- 
Malarial Amblyopia, 500-Amblyopia from Loss of Blood, 501-Ambly- 
opia from the Abuse of Drugs, 501-Quinin Amaurosis, 501-Methyl- 
alcohol Blindness or Amaurosis, 502-Arsenic Amblyopia, 503-Hysteric 
Amblyopia, 504-Pretended Amblyopia, 505-Night-blindness, 506- 
Day-blindness, 506-Snow-blindness, 507-Erythropsia, 507-Micropsia, 
508-Macropsia, 508. 
CHAPTER XVIII 
Amblyopia of the Visual Field, Scotomas, and Hemianopsia 509 
Partial Fugacious Amaurosis, 509-Amblyopia of the Visual Field, 509- 
Scotomas. 509-Hemianopsia, 512-Visual Tract, 512-Varieties of 
Hemianopsia, 514-Peculiarities of the Dividing Line, 516-Significance of 
Hemianopsia, M6-The Pupil in Hemianopsia, 517. 
CHAPTER XIX 
Movements of the Eyeballs and their Anomalies 519 
Anatomy and Physiologic Action of the Ocular Muscles, 519-Rotation of 
the Eyeball Around the Visual Line, 520-Associated Movements, 521- 14 
CONTENTS 
PAGE 
Binocular Vision, 521-Overcoming Prisms, 522-Field of Fixation, 522- 
Strabismus, Squint, or Heterotropia, 523-Paralysis of the Exterior Ocular 
Muscles, 526-Varieties of Diplopia, 528-Paralysis of the External Rectus, 
528-Paralysis of the Internal Rectus, 529-Paralysis of the Superior Rec- 
tus, 529-Paralysis of the Inferior Oblique, 530-Paralysis of the Inferior 
Rectus, 531-Paralysis of the Superior Oblique, 532-Oculomotor Paralysis, 
532-Method of Examination and Diagnosis of the Affected Eye, 533-Re- 
current Oculomotor Paralysis, 536-Congenital Paralysis, 537-Retraction 
Movements of the Eyeball Associated with Congenital Defects in the Ex- 
ternal Ocular Muscles, 537-Relative Frequency of Paralysis of the Orbital 
Muscles, 538-Ophthalmoplegia, 539-Associated Ocular Paralyses, 540- 
Divergence Paralysis, 541-Convergence Paralysis, 541-Paralysis of the 
Inferior Ocular Muscles, 541-Concomitant Squint, 542-Varieties of Con- 
comitant Squint, 542--Causes of Concomitant Squint, 542-Single Vision 
in Concomitant Squint, 545-Measurement of Squint, 546-Treatment of 
Concomitant Squint, 547-Vertical Squint, 553-Results of Operation in 
Convergent Squint, 553-Spastic Strabismus, 554-Abnormal Balance 
of the Ocular Muscles (Heterophoria), 554-Difference between Hetero- 
phoria and Heterotropia, 556-Nystagmus, 561--Monocular Diplopia, 563. 
CHAPTER XX 
Diseases of the Lacrimal Apparatus 564 
Dacryo-adenitis, 564-Hypertrophy of the Lacrimal Gland, 564-Atrophy 
of the Lacrimal Gland, 564-Spontaneous Prolapse of the Lacrimal Gland, 
564-Traumatic Dislocation of the Lacrimal Gland, 565-Fistula of the 
Lacrimal Gland, 565-Syphilis of the Lacrimal Gland, 565-Dacryops, 
565-Tumors of the Lacrimal Gland, 565-Mikulicz's Disease, 566- 
Anomalies of the Puncta Lacrimalia and Canaliculi, 566-Anomalies of 
the Lacrimal Sac and Nasal Duct, 566-Dacryocystitis, 567-Prelacrimal 
Sac Abscess, 567-Fistula of the Lacrimal Sac, 567-Obstruction of the 
Nasal Duct, 568-Cause of Disease of the Lacrimal Sac and Nasal Duct, 
568-Character of the Lacrimal Secretion under Pathologic Conditions, 569. 
CHAPTER XXI 
Diseases of the Orbit 573 
Congenital Anomalies, 573-Periostitis, 574-Caries and Necrosis, 575- 
Cellulitis, 576-Inflammation of the Oculo-orbital Fascia, 578-Throm- 
bosis of the Cavernous Sinus, 578-Tumors and Cysts of the Orbit, 578- 
Pulsating Exophthalmos, 582-Exophthalmic Goiter, 583-Affections or 
Diseases of the Sinuses, 585-Diseases of the Frontal Sinus, 585-Diseases 
of the Ethmoid, 586-Diseases of the Sphenoid, 587-Diseases of the 
Antrum, 588-Injuries, 591-Dislocation of the Eyeball, 591-Enoph- 
thalmos, 592-Exophthalmos, 592-Intermittent Exophthalmos, 592. 
CHAPTER XXII 
Operations 593 
Preparation of the Skin of the Region of Operation, 593-Preparation of the 
Instruments, 593-Dressings, 593-Sutures, 594-General Anesthesia, 594 
-Local Anesthesia, 595-Infiltration Anesthesia, 597-Siegrist's Method 
of Local Anesthesia, 597-Local Hemostasis, 598-Operations upon CONTENTS 
15 
the Eyelids, 598-Epilation of the Eyelashes, 598-Removal of a Meibo- 
mian Cyst, 599-Operations for Ptosis, 599-Tarsorrhaphy, 603-Cantho- 
plasty, 604-Operations for Trichiasis, 605-Operation for Artificial Lid- 
border, 605-Operations for Entropion, 607-Operations for Ectropion, 
608-Blepharoplasty, 611-Transplantation without a Pedicle, 614- 
Thiersch's Method of Skin-grafting, 614-Operations on the Conjunctiva, 
614-Operations for Pterygium, 614-Operations for Symblepharon, 615- 
Transplantation of Rabbit's Conjunctiva, 616-Operations for Trachoma, 
617-Grattage, 617-Subconjunctival Injections, 619-Operations on the 
Cornea, 619-Paracentesis Corneae, 619-Application of the Actual 
Cautery, 619-Saemisch's Section, 620-Operations for Staphyloma, 620-■ 
Tattooing the Cornea, 621-Operations upon the Iris, 622-Iridectomy, 
622-Iridotomy, 626-Iritoectomy, 626-V-shaped Iridotomy, 627- 
Division of Anterior Synechiae, 628-Operations upon the Sclera, 628- 
Sclerotomy, 628-Combined Iridectomy and Sclerectomy, 629-Sclerec- 
tomy with a Trephine, 631-Sclerocorneal Trephining, 632-Cyclo- 
dialysis, 635-Enucleation of the Eyeball, 636-Insertion of Artificial Eyes, 
638-Evisceration of the Eyeball, 639-Mules' Operation, 640-Implan- 
tation of an Artificial Globe in Tenon's Capsule after Removal of the 
Eyeball, 640-Operations for Prosthesis in Cases of Cicatricial Orbit, 641- 
Removal of Metallic Foreign Bodies from the Interior of the Eye, 642- 
Extirpation of the Whole Contents of the Orbit, 643-Removal of Tumors 
and Cysts from the Orbit, 645-Resection of the Temporal Wall of the 
Orbit, 646-Operations for Cataract, 647-Needle Operation (Discission), 
647-Suction Method, 649-Linear Extraction, 649-Extraction of Hard 
Cataract, 650-Extraction without Iridectomy, 650-Extraction with 
Iridectomy, 651-Extraction without Capsulotomy, 651-Preparation 
of the Patient and the Eye, 651-Position of the Patient, 653-Instru- 
ments, Solutions, and Dressings, 653-After-treatment, 658-Accidents 
during Cataract Extraction, 658-Smith's Operation for Extraction of 
Cataract, 660-Anomalies in the Healing Process, 663-Choice of an 
Operation, 668-Preliminary Iridectomy, 669-Operations for After- 
cataract (Secondary Cataract), 669-Operations upon the Eye Muscles, 
671-Complete Tenotomy, 671-Tenotomy of the Inferior Oblique, 672- 
Complications in Tenotomy Operations, 673-Partial or Graduated Tenot- 
omy, 674-Advancement or Readjustment, 675-Reese's Muscle-resection 
Operation, 678-Operation for Shortening the Tendon, 680-Advance- 
ment of the Capsule of Tenon, 689-Operations upon the Lacrimal Appara- 
us, 681-Slitting the Canaliculus, 681-Introduction of the Lacrimal 
Probe, 681-Incision of a Stricture, 682-Introduction of the Lacrimal 
Syringe, 682-Excision of the Lacrimal Sac, 682-Extirpation of the 
Lacrimal Gland, 684-Extirpation of the Palpebral Portion of the Lacrimal 
Gland, 685-Toti's Operation, 685-West's Operation, 685. 
APPENDIX 
The Use of the Ophthalmometer, 687-The Use of the Tropometer, 690- 
Localization of Foreign Bodies in the Eyeball with the Rontgen Rays, 692. 
Index 699 DISEASES OF THE EYE 
CHAPTER I 
GENERAL OPTICAL PRINCIPLES 
Transmission of Light.-By light is meant that physical force 
or form of energy which, acting on the sentient elements of the retina, 
causes the mental perception of the specific energy, that is, sight or 
vision. 
From each point of the surface of a luminous body light or rays of 
light proceed in straight lines in all directions, and in order to explain 
the transmission of light it is assumed that throughout the universe 
there exists an exceedingly tenuous matter to which the term ether is 
applied (see page 20). Exactly what the vibrating disturbances are 
which constitute light is not certainly known. 
Refraction.-By refraction of light is meant the alteration which 
takes place in the direction of luminous rays, which pass obliquely 
from one medium into another of different density. 
A ray of light passing through air keeps the same direction until 
it strikes obliquely the surface of a denser medium, when its course is 
changed toward the perpendicular to that surface. If this denser 
medium is a piece of glass bounded by parallel sides, the ray, as it 
passes through the second surface, is bent back again into the rarer 
medium. 
Rays passing from a denser into a rarer medium are deviated from 
the perpendicular. The ray now has a direction parallel to its original 
course; the sides being parallel, the deviation at each surface is equal 
in extent, but opposite in direction (Fig. 1). 
If the denser medium is bounded by oblique surfaces, the devia- 
tion at the second surface does not restore the ray to its original direc- 
tion, but it still more increases the alteration of its direction (Fig. 2). 
Index of Refraction.-The deviation of the ray from its course 
depends upon the difference in the density of the two media. 
A ray passing obliquely from one medium into another of the same 
density is not bent from its course. The relative resistance of a sub- 
stance to the passage of light is expressed by its index of refraction. 
The absolute index of refraction is its resistance as compared with 
vacuum; but as there is very little difference between the indices of 
refraction of air and of vacuum, air is considered as 1 for all calculations 
in lenses. 
17 18 
GENERAL OPTICAL PRINCIPLES 
As the difference in the density of the two media increases, the ray 
is bent more sharply from its course, and the angle it forms with the 
perpendicular after refraction by a denser medium is proportionably 
smaller than the angle formed by the ray before refraction. 
Fig. 1.-Refraction of light through a plate of glass bounded by plane surfaces which 
are parallel: A-B is the incident ray; B-C, the same ray, refracted by the first surface, 
nearer to the perpendicular, P-P; C-D, the same ray, refracted by the second surface, 
becomes parallel to A-B, its original direction. The ray H-K, perpendicular to the sur- 
faces B and C, undergoes no refraction. 
The angle formed by the ray with the perpendicular to the surface 
of the second medium is called the angle of incidence-angle 1. The 
angle formed by the ray with the perpendicular after refraction is 
called the angle of refraction-angle R. The sine of the angle of inci- 
dence, divided by the sine of the 
angle of refraction, gives the index 
of refraction. Glass used in the 
manufacture of spectacles has an 
index of refraction of about 1.53. 
Prisms.-A prism is a portion of 
glass or other refracting substance 
bounded by two plane surfaces which 
are inclined to each other, forming an 
angle, which is called the refracting 
angle, or simply the angle of the prism 
(Fig. 2, af and is expressed in de- 
grees. Prisms are often designated by the numbers of degrees in the 
refracting angle. 
The sides of the prism converge to a thin edge at one extremity, 
called the apex (Fig. 2, A); at the other extremity they diverge from 
each other and form the base (Fig. 2, B-Cf 
Refraction Through a Prism.-If a ray of light from an object 
(Fig. 2, 0) passes through a prism the refractive index of which is 
greater than air, the deviation is always from the apex toward the 
base of the prism. 
To the eye of an observer placed at the other side of the prism 
(Fig. 2, E~) the refracted ray seems to come from the direction of the 
Fig. 2.-Refraction through a 
denser medium having oblique surfaces. 
At each surface the ray is bent toward 
the base of the figure. NUMBERING OF PRISMS 
19 
apex (Fig. 2, O'), since a ray is projected backward over the course 
given to it by its last refraction, and a single object appears double 
if, with both eyes open, a prism of sufficient strength is placed before 
one of them. The angle which the ray in this last direction forms 
with the ray in its original direction is called the angle of deviation. 
When one eye, on account of muscular weakness, is unable to direct 
its visual line to the point of fixation, a prism will alter the direction 
of the ray from the point of fixation so that it coincides with the visual 
line of the weaker eye. The refractive properties of a prism are utilized 
to test the strength of the ocular muscles (see pages 74 and 555), to 
neutralize the diplopia caused by abnormal 
deviation of the visual line-for example, 
in paralytic strabismus and in the treat- 
ment of heterophoria (see page 559)-to 
detect malingerers who feign monocular 
blindness (see page 505), and in the applica- 
tion of the Wildbrand-Saenger test to de- 
termine the situation of the lesion in 
hemianopsia (see page 518). 
Angle of Deviation.-The angle of de- 
viation is the angle formed by the incideni 
ray with the refracted ray. The amouni 
of this angle is somewhat more than one- 
half of the refracting angle of the prism for all prisms between 1° 
and 10°, but for practical purposes the two may be considered equal. 
Above this the deviation rapidly increases. 
When the angle of incidence, formed by a ray in the interior of a 
prism, amounts to 40° 49', the angle of refraction equals 90°; the angle 
of deviation, the difference between the two, then equals 49° 11'. When 
the refraction which takes place at each surface of a prism is equal, 
the minimum amount of deviation is present. When the ray is per- 
pendicular to one surface, the angle of incidence at the second surface 
equals the angle of the prism; the deviation is greater in this case, as all 
the refraction takes place at one surface. A table of the minimum 
deviation of prisms is given on page 20. 
Numbering of Prisms.-The designation of prisms by their 
angular deviation, instead of by their refracting angles, was urged by 
Dr. Edward Jackson, of Denver, before the Ninth International Medical 
Congress. Two methods of accomplishing this have been proposed: 
Dennett's Method: The Centrad.-Dr. William S. Dennett's 
calculation has for its base an arc called the radian, whose length equals 
the radius of its curvature. Such an arc equals 57.295°. A prism which 
will produce an angular deviation of the one-hundredth part of this arc 
is called one centrad. The deviation of such a prism would, therefore, 
be 0.57295°. The merit of this method consists in the uniformity of 
the deviation, 10 centrads having exactly ten times the deviation of 
1 centrad. The deviations are so many hundredths of the radius 
measured on the arc. 
Fig. 3.-Deviation pro- 
duced by a prism: I, Angle of 
incidence; R, angle of refrac- 
tion; D, angle of deviation; 
R + D = I; D equals in weak 
prisms about | of R (Jackson). 20 
GENERAL OPTICAL PRINCIPLES 
Prentice's Method: The Prism-diopter.-Mr. Charles F. Prentice 
proposes, as the standard of deviation, a prism which shall deflect a 
ray of light 1 cm. at a plane 1 meter distant-that is, the hundredth 
part of the radius measured on the tangent. This he calls the prism- 
diopter. The value of the centrad and prism-diopter are given below 
(see table). 
There are two practical advantages connected with the method 
of Mr. Prentice which also can be applied to the centrad. The prismatic 
deviation of a decentered lens may be very readily found, as Prentice 
has shown by the following rule: If a lens be decentered 1 cm., the 
prismatic deviation of the lens will be equal to as many prism-diopters 
as the number of diopters in the lens. Thus, if a 4-diopter lens be 
decentered 1 cm., the prismatic deviation will be 4 prism-diopters, or 
4 centrads, since centrad and prism-diopter exactly equal each other. 
The same lens decentered 0.5 cm. would produce 2 prism-diopters or 
centrads of deviation. 
Table of Relative Values of Centrads and Prism-diopters, Prepared by 
James Wallace. 
Centrads. 
Pristn-diopters. 
Refracting angle of 
prism required. 
1 
1 
1.06° 
2 
2.0001 
2.16° 
3 
3.0013 
3.24° 
4 
4.0028 
4.32° 
5 
5.0045 
5.40° 
6 v.. 
6.0063 
6.47° 
7 
7.0115 
7.54° 
8 
8.0172 
8.62° 
9 
9.0244 
9.68° 
10 
10.0333 
10.73° 
15 
15.114 
16.1° 
20 
20.270 
21.13° 
40 
42.288 
39.0073° 
The prisms represent the minimum deviation with 
an index of refraction of 1.53. 
The relation to the meter angle (see page 44) is also very simple. 
One-half the interpupillary distance is the sine of the meter angle. 
The ratio of this to the point of fixation in hundredths gives nearly 
the number of prism-diopters, or centrads of deviation, embraced in 
any number of meter angles. For example, if the interpupillary dis- 
tance is 60 mm., one-half of this is 30 mm.; assuming the amount of 
convergence to be 4 meter angles, 25 cm., or 250 mm., is the distance 
of the point of fixation. The deviation of the visual line then is 30 in 
250, or 12 in 100 = 12 centrads, or 12 P. D. For small arcs the tangent 
and the sine agree very closely with the arc. Four meter angles of 
convergence then represent 12 centrads of deviation or 12 prism- 
diopters. 
Rays of Light.-Any luminous point diffuses light in all direc- 
tions in straight lines called rays. As the rays proceed from the lumin- 
ous source, those which diverge from one another become more widely 
separated (Fig. 4). RAYS OF LIGHT 
21 
If a circular aperture 1 cm. in diameter be made in a metal plate 
and a luminous point be placed at different distances from it--for 
example, at 1 meter and at 10 meters-the rays coming from 10 meters, 
which pass through the aperture, will be less diverging than those which 
come from 1 meter. A cone of light will pass through the aperture in 
each case, but the shape of it will be different according to the distance 
of the light from the aperture in the screen. When the round hole, 
1 cm. in diameter, is 1 meter distant from 
the point of light, the cone has a base 1 
cm. in diameter, and the apex is situated 
in the luminous point 100 cm. distant. 
The rays have diverged 1 cm. in travel- 
ing 100; the metal plate has cut off all 
other rays having a greater divergence. 
If the cone of light passes through the 
aperture and falls upon a distant wall, the 
cone will preserve the same proportions- 
viz., the base will be tAo of the altitude. 
If the wall be 5 times the distance of the 
screen from the light, a luminous circle 5 
cm. in diameter will be formed upon 
the wall. If, now, the light is removed to a point 10 meters from the 
screen (1000 cm.), a cone of light is formed whose base is 1 cm. and 
whose altitude is 1000. The rays which pass through the aperture 
have now only tV of the divergence of the rays in the former case; the 
base of the cone is Tcnny of the altitude. The cone of light will now form 
a circle on the wall 5 meters beyond the aperture, only 1.5 cm. in diam- 
eter. If the point of light be at a very great distance, there will be no 
Fig. 4.-Divergence of rays from 
a luminous source (Loring). 
Fig. 5.-Rays diverging from the candle A pass through the aperture in the screen 5', 
and form the cone of light whose base is the distance a-a'. Rays from a more distant 
candle, B, having a greater divergence than b-b', are intercepted by the screen <S (Wallace). 
difference in the size of the luminous circle and the aperture in the 
screen; the size of the circle remains about 1 cm. on the wall at 5 meters 
from the screen. The rays, therefore, have a nearly parallel direction. 
This is shown in Fig. 5. 
Rays which enter the pupil of the eye from a point 6 meters distant 
have so little divergence that they may be considered parallel. The 
average size of the pupil being 4 mm., the divergence is only 
All rays diverging more widely than this are excluded by this width of 
the pupil. 22 
GENERAL OPTICAL PRINCIPLES 
The relation to the eye of rays diverging from 6 meters or coming 
from an infinite distance is practically identical, but for lenses of long 
focal distance and large aperture an infinite distance is required in 
order to obtain parallel rays. Thus the sun and stars are so remote 
that the rays coming from them have no appreciable divergence, and 
they are considered parallel. 
Parallel rays must emanate, as has been explained before, from a 
distant object. They are brought together by a lens at its principal 
focus. Conversely, rays which diverge from the principal focus of a 
lens are parallel to one another after being refracted by the lens 
Divergent rays emanate from an object nearer than infinity. A 
greater refractive power must be exercised to bring them together at 
the same distance behind a lens than is required for rays which are 
parallel; consequently, divergent rays are united at a point farther 
than the principal focus. The nearer the point of divergence lies to 
the lens, the farther away from the lens is the point where the rays 
converge to a focus. 
Fig. 6.-Lenses as prisms. 
Convergent rays do not exist in nature. Only such rays are 
convergent which have passed through a convex lens or have been 
reflected from a concave mirror. 
Significance of the Different Rays.-The refraction of the eye 
is determined by the character which the rays must have in order to 
be brought to a focus on the retina. 
An emmetropic eye, with relaxed accommodation, requires rays to 
be parallel in order that they shall meet on the retina. 
A myopic eye requires rays to diverge from some near point in order 
to meet on its retina. 
A hyperopic eye requires rays which already have convergence to 
some point in order to unite them on its retina. 
An emmetropic eye emits parallel rays. 
A myopic eye emits convergent rays. 
A hyperopic eye emits divergent rays. CONJUGATE FOCUS OF A CONVEX LENS 
23 
Lenses.-A lens is a portion of glass or other transparent substance 
bounded by two curved surfaces, or by one curved surface and one 
plane surface. The curved surfaces are convex, elevated in the center, 
and thin at the edge; or they are concave, hollowed out in the center and 
thick at the edge. 
A lens may be regarded as a series of prisms with the refracting 
angles increasing in value from the center toward the periphery. 
* In a convex lens the bases of the prisms are directed toward the 
center of the lens, and rays, therefore, are refracted toward the axis 
which passes through the center. In a concave lens the bases of the 
prisms are directed away from the center, and rays, therefore, are 
refracted away from the axis. As the angles increase from the center 
outward, the peripheral rays will be refracted more than the central 
rays. The result of this is that in a convex lens the rays after refrac- 
tion converge to the same point, the increased bending of the more 
peripheral rays just sufficing to compensate for their greater distance 
from the axis. In a concave lens the rays diverge more widely as they 
Fig. 7.-Principal focus of a convex lens. The parallel rays a, b, c, d are refracted by 
the lens so as to unite at the point F on the axis P. The ray P undergoes no refraction. 
F is the principal focus. 
pass through the peripheral parts of the lens, with the result of making 
them appear to have diverged from a common point. 
Focus of a Convex Lens.-The point to which rays converge 
after refraction by a convex lens is called its focus. 
Principal Focus of a Convex Lens.-The principal focus of a 
lens is the focus for parallel rays. As the most distant rays are only 
parallel, never convergent, the principal focus is the shortest focus, 
unless the lens is combined with another convex lens or concave mirror. 
Rays diverging from the principal focus of a lens are rendered parallel 
after passing through the lens, and come to a focus at an infinite dis- 
tance. 
Conjugate Focus of a Convex Lens.-When rays diverge from 
any point nearer than infinity, they are brought together at a point 
on the other side of the lens farther than the principal focus. The 
point from which rays diverge and the point to which they converge 
are called conjugate foci. As the point of divergence approaches the 
lens the point of convergence recedes; when the point of divergence is 24 
GENERAL OPTICAL PRINCIPLES 
at twice the focal distance of the lens, the point of convergence is at an 
equal distance on the other side. The conjugate foci are now equal. 
As the point of divergence approaches still closer the point of con- 
vergence is at a greater distance, until, when the point from which the 
rays diverge is at the principal focus, the rays converge at an infinite 
distance. 
Fig. 8.-Conjugate focus of a convex lens. The two dots in the axis represent the 
principal foci, one being marked F. Rays diverging from O converge after refraction to 
the point F', farther than the principal focus. Rays from F' also converge after refrac- 
tion to O. 0 and F are conjugate foci. 
Rays diverging from either of these points converge toward the 
other. When rays diverge from a point whose distance is equal to or 
greater than the principal focus, the conjugate focus is positive. When 
the distance is less than the principal focus, the conjugate focus is nega- 
tive. 
Virtual Focus of a Convex Lens.-When rays diverge from some 
point nearer to a lens than its principal focus, the rays after refraction 
still continue divergent. These divergent rays, if traced backward, 
Fig. 9.-Virtual focus of a convex lens. Rays from the point O, less than the prin- 
cipal focal distance, diverge after refraction as if they came from the point V. V is the 
virtual focus of O. 
would meet in a point on the same side of the lens from which they 
diverged. This point is called a negative, or virtual, focus, because the 
rays do not really meet here, but are given a direction by the lens as 
if they had diverged from this point (Fig. 9). Therefore the point 
from which rays diverge and the point to which they converge are focal 
points. 
Foci of Concave Lenses.-The foci of concave lenses for parallel 
or divergent rays are virtual, or negative. They are the points from 
which the rays seem to diverge after passing through the lens. FORMATION OF IMAGES BY A LENS: OPTICAL CENTER 
25 
Principal Focus of a Concave Lens.-When parallel rays fall 
upon a concave lens they are rendered divergent. If these rays be 
traced backward, they will seem to have diverged f^pm a point near 
the lens. This point is the principal focus (Fig. 10). 
Fig. 10.-Principal focus of a concave lens. Parallel rays a, b, d, e, after refraction 
by the concave lens L, are rendered divergent as if they came from the point F on the axis 
c. The ray c is not refracted. F, the principal focus of a concave lens, is virtual. 
Conjugate foci of concave lenses are also virtual and found in a 
similar manner. 
Formation of Images by a Lens: Optical Center.-In the lens 
(Fig. 11) the point 0 on the axis is called the optical center. Any ray 
Fig. 11.-O, Optical center of lens. The point C" i's the center of curvature for the 
surface S". The point C is the center of curvature for the surface S'. A ray passing 
from C" to C would be perpendicular to both surfaces. It would pass through without 
deviation. This ray is called the axial ray, or axis. 
The radii C'-J" and C'-J', being parallel, a ray in the lens passing in the direction 
J'-J" must form equal angles at the two surfaces. The point where this ray intersects 
the axis is the optical center (Landolt). 
passing through this point is refracted equally at both surfaces, since it 
forms equal angles with the radii of the two surfaces. The direction 
of the ray is, therefore, the same after refraction by the second surface 
as it was before refraction by the first. For thin lenses it may be said 26 
GENERAL OPTICAL PRINCIPLES 
that any ray directed to the optical center passes through without 
deviation. These rays are called secondary axes. 
The ray drawn from any point in an object to the optical center of 
a lens gives the line on which the image of the point is to be found. A 
ray from the same point in the object, passing parallel to the axis of the 
Fig. 12.-Position and size of image formed by convex lens. The ray A, K', from 
the point A, being directed to the optical center of the lens, continues its course in a parallel 
direction, K"-A". Another ray passing from A parallel to the axis Lr, L", is refracted 
through <p", the principal focus, and, intersecting the ray A-K"-A", determines the posi- 
tion of the image of the point A. Still another ray passing from A through the anterior 
principal focus <p', after refraction, is parallel with the axis L'-L", and meets the other 
rays in the point A" (Landolt). 
lens, would be refracted through the principal focus of the lens, since 
the principal focus is the focus for parallel rays (Fig. 12). 
In order to find the position and size of an image formed by a lens 
it is only necessary to draw two lines from each extremity of the object: 
one passes through the optical center of the lens, and the other, parallel 
Fig. 13.-Image formed by a convex lens: O-B is the object; O'-B' is the inverted image. 
with the axis of the lens, would be refracted to the principal focus. 
The position of the image is found at the points where these lines inter- 
sect. 
The size of the image is proportional to the size of the object as the 
distance of the image from the optical center is to the distance of the 
object from the optical center. When the object is situated at a greater 
distance from the lens than its principal focus, the image is a real, 
inverted one. FORMATION OF IMAGES BY A LENS: OPTICAL CENTER 
27 
In the figure (Fig. 13) 0-B is the object; the rays diverging from 0 
intersect in O', which is the position of the image of the point 0. Simi- 
larly the rays from A unite in B', the position of the image of the point 
B; B'-O' is the image of 0-B. 
When the object is situated nearer to the lens than its principal 
focus, the image is a virtual, erect one. 
Fig. 14.-Virtual image of a convex lens: C-D is the object; C-D' is the virtual image, 
erect and magnified. 
The virtual image of a convex lens appears to be at the point from 
which the rays refracted by the lens seem to have diverged (Fig. 14). 
From the point C, of the object C-D, the ray C-S is parallel to the axis. 
It, therefore, is refracted to the principal focus, P. The ray C-0 passes 
through unchanged. By projecting these rays backward they meet in 
C', the image of the point C. The rays from the point D seem to have 
diverged from D'. An enlarged, erect image is thus formed in C'-D'. 
Fig. 15.-Virtual image of a concave lens: O'-B' is the virtual image of the candle, 0-B, 
erect and diminished in size. 
The image formed by a concave lens is mostly virtual and dimin- 
ished. Two rays, proceeding from a point 0, in the object, one parallel 
to the axis, which seems, after refraction, to have diverged from the 
principal focus, and is traced backward, and the other, which is directed 
to the optical center, at their intersection, denote the position of this 
point in the image (Fig. 15). The enlarged image formed by a convex 
lens, and the diminished image formed by a concave lens, as described 28 
GENERAL OPTICAL PRINCIPLES 
in the preceding paragraph, are among the most obvious effects of such 
lenses as they are ordinarily used. It must be remembered, however, 
that convex lenses are not essentially magnifiers nor concave lenses 
essentially minifiers, inasmuch as their effect on images depends upon 
their position with reference to optical systems which they supplement. 
Focal Distance of a Lens.-The distance from the optical center 
of a lens to the focal point is called the focal distance. 
The length of this depends upon the radii of curvature of the surfaces 
of the lens and on its index of refraction. Representing the radius by r, 
the index of refraction of the lens by n, that of air being 1, F = . 
A \Tl 1) 
is the formula for obtaining the focus of a bispheric convex or concave 
lens. The formula for a planospheric lens is F = ---. The refraction 
is effected at one surface if the rays are parallel as they enter or pass 
from the plane surface; otherwise refraction occurs at the plane as well 
as at the curved surface. 
Numeration of Lenses.-The refractive power of a lens is the 
inverse of its focal distance. If the refractive power of a lens whose 
focal distance is 1 meter is represented by 1, then a lens whose focal 
distance is 2 meters has only one-half the refractive power of the first, 
since the rays are not bent so sharply by the second lens. Again, if a 
lens bends rays so sharply that they meet the axis at 0.5 meter distance, 
its refractive power is twice that of a lens of 1 meter focus. 
The focus of a biconvex lens (with equal radii), made of glass with 
an index of 1.50, has the same length as the radius of curvature. 
F = r- = r- 
2 (n -1) 2(1.50-1) 
F = r. 
Glass used in spectacle lenses has an index of 1.53, consequently- 
F = - 
1.06 
r = 1.06 F. 
In the old system the lenses were marked according to their radii 
of curvature in Paris inches, and the focal distance was somewhat less 
than the radius of curvature. As all the lenses in use had longer focal 
distances than 1 inch, they were fractions of the refractive power of a 
lens of 1 inch focus-viz., |, f, A, etc. 
In 1867 Nagel proposed to number lenses by their refractive power. 
By adopting as a standard a lens of longer focal distance than 1 inch- 
viz., 1 meter (40 inches)-the greater number of lenses are made multi- 
ples of refractive power of the standard, and are based on their focal 
lengths in meters and fractions of a meter, instead of being based on 
their radii of curvature. 
The term diopter was proposed by Monoyer for a lens of 1 meter NUMERATION OF LENSES 
29 
focus. A lens of 2 meters focus is only | the refractive power, or 
0.50 D. The present scale of lenses comprises a series from 0.12 to 
22 D. Between 0.12 and 1.25 D the lenses have an interval of 0.12 D. 
From 1.25 to 5 D the interval is 0.25 D; from 5 to 8 D an interval of 
0.50 D; from 8 to 18 D an interval of 1 D; and from 18 to 22 D the in- 
terval is 2 D. This uniformity in the intervals between the lenses is 
an important advantage over the old system, in which the lack of uni- 
formity in this respect was a conspicuous feature. 
To find the focal length of any lens in the dioptric system divide 
1 meter, or 100 cm., by the number of diopters: thus the focal length 
of a lens of 5 D is = 20 cm. 
5 
Number of lens 
Focal distance in 
Focal distance in 
Nearest corre- 
in diopters. 
millimeters. 
English inches. 
old system. 
0.12 
8000 
314.96 
0.25 
4000 
157.48 
144 
0.37 
2666 
104.99 
0.50 
2000 
78.74 
72 
Interval of 0.12 D 
0.62 
1600 
62.99 
60 
0.75 
1333 
52.5 
48 
0.87 
1143 
44.99 
42 
1 
1000 
39.37 
. 36 
1.12 
888 
34.99 
1.25 
800 
31.5 
30 
1.5 
666 
26.22 
24 
1.75 
571 
22.48 
2 
500 
19.69 
20 
2.25 
444 
17.48 
18 
2.50 
400 
15.75 
16 
2.75 
363 
14.31 
15 or 14 
3 
333 
13.12 
13 
Interval of 0.25 D 
3.25 
308 
12.11 
12 
3.50 
285 
11.25 
11 
3.75 
267 
10.49 
10 
4 
250 
9.84 
9 
4.25 
235 
9.26 
8 
4.50 
222 
8.74 
8 
4.75 
210 
8.29 
5 
200 
7.87 
5.50 
182 
7.16 
7 
6 
166 
6.54 
Interval of 0.5 D <j 
6.50 
154 
6.06 
6 
7 
143 
5.63 
5 
7.50 
133 
5.25 
8 
125 
4.92 
9 
111 
4.37 
4.5 
10 
100 
3.94 
4 
11 
91 
3.58 
3.5 
12 
83 
3.27 
3.25 
Interval of 1 D < 
• 13 
77 
3.03 
3 
14 
71 
2.8 . 
2.75 
15 
66 
2.64 
16 
62 
2.44 
2.5 
17 
59 
2.32 
2.25 
18 
55 
2.17 
Interval of 2 D J 
20 
50 
1.97 
2 
22 
45 
1.79 30 
GENERAL OPTICAL PRINCIPLES 
In the old system the lenses are ground with a radius of curvature 
in Paris inches. The focal length is almost exactly the same in English 
inches as the radius of curvature is in French inches. The English inch 
= 25.4 mm.; the French inch = 27.07 mm.; 25.4 X 1.06 = 26.92. 
In column three of the table the focus is given in English inches, 
as it is customary to compare the French lenses with the diopters by 
their focal length in English inches. A lens of 1 diopter has a focal 
length of 39.37 English inches. 
There is no lens in the old system 
which corresponds to it exactly. 
The nearest equivalent would be 
a lens of 40 inches. 
The lenses used for spectacles 
are spheric and cylindric. 
Spheric Lenses.-A spheric 
lens is represented by a section of 
a sphere, or of two sections of a 
sphere placed together by their 
plane surfaces. Light -passing 
through a spheric lens is re- 
fracted equally in all planes. 
Cylindric Lenses.-A cylin- 
dric lens is a section of a cylinder 
parallel to its axis. Light passing 
through a cylindric lens is not re- 
fracted in a plane parallel to its 
axis, but in a plane perpendicular 
to the axis; rays are rendered con- 
vergent or divergent according as 
the cylinder is convex or concave 
(Figs. 17, 18). 
Convex lenses are designated 
+ ; concave lenses, -. 
Toric Lenses.-A solid developed by the revolution of a circle 
about any axis other than its diameter is known as a torus. A toric 
lens may be described as one which is cut from a toric surface by a plane 
parallel to its axis of development. The optical centering of such a 
lens requires that both its centers, the center of its circle and the 
center about which in its development the circle revolves, shall be on 
the axis of the system (W. S. Dennett). With the toric lens the angle 
of distinct view is increased, but a certain amount of astigmatism 
remains in the greater number of powers. To eliminate this astig- 
matism of oblique pencils of light M. von Rohr has developed a lens 
which it is claimed "reproduces any given definite point of an object 
as a distinct point in the image, that is, a lens which is corrected for 
astigmatism over the entire field of vision in all powers." To this lens 
the name Punktai has been given. 
Combination of Lenses.-If two or more lenses are placed to- 
Fig. 16.-1. Biconvex lens. 2. Plano- 
convex lens. 3. Concavoconvex lens, con- 
vergent meniscus. 4. Biconcave lens. 5. 
Planoconcave lens. 6. ' Convexoconcave 
lens, divergent meniscus. COMBINATION OF LENSES 
31 
gether, for example, + 2 diopters, + 3 diopters, and + 4 diopters, the 
combination forms a dioptric power equal to their sum-viz., 9 diopters; 
Fig. 17.-Convex cylindric lens, formed by a section of a cylinder parallel to its axis, 
which acts like a plane lens {1, 2, 3, JB, in a direction parallel to the axis of the cylinder 
(A, B), and like a convex lens (a, b, c), in a direction perpendicular to the axis (Elschnig). 
such a combination has, if composed of thin lenses, a focal distance of 
= 11 cm. If these lenses are placed at their focal distance from 
Fig. 18.-Concave cylindric lens, formed from a solid cylinder; in a plane parallel to 
the axis it acts like a plane lens (1, 2, 3, 4)> but in a plane perpendicular to the axis like 
a concave lens (a, b, c, d) (Elschnig). 
an object, the rays coming from the object, after passing through the 
lenses, are parallel. 32 
GENERAL OPTICAL PRINCIPLES 
Two or more concave lenses placed together likewise produce a 
dioptric effect equal to their sum. 
Combination of Convex and Concave Lenses.-If a concave 
and a convex lens of equal strength are placed together, they will 
neutralize each other so exactly that a distant object viewed through 
them will appear neither enlarged nor diminished, and there will be no 
prismatic deviation on gently shaking the lenses in a direction parallel 
to the surface. 
Should they be unequal in strength, on shaking them an object 
(the edge of a wall or window frame is suitable) will be displaced toward 
the center of the lens if the concave is stronger, and away from the 
center if the convex is stronger. The value of the combination will be 
the difference between the strength of the two. For instance, a + 3 
diopter and a - 2 diopter equal + 1 diopter; a + 2 diopter and a - 4 
diopter = - 2 diopter. 
A - 2-diopter lens gives to parallel rays a direction as if they came 
from a point 50 cm. away. Conversely, rays diverging from any near 
point may be represented by a concave lens, the principal focus of 
which equals that distance. Let rays, for example, diverge from a point 
15 cm. away; they evidently are similar to parallel rays which have 
passed through a concave lens of 15 cm. local distance, Vt- - 6.66 
diopters. 
If it is desired to find the conjugate focal distance of any lens for 
rays which diverge from 15 cm., 6.66 should be subtracted from the 
dioptric power of the lens; the remainder gives a lens the focal distance 
of which is the conjugate desired. If it is desired to find the conjugate 
focal distance of a 12-diopter lens for rays which diverge from 15 cm., 
6.66 should be subtracted from 12 = 5.33 diopters; 18.8 cm. is the con- 
jugate focal distance. 
Combination of Cylindric Lenses with Spheric Lenses.-A 
cylindric lens is curved only in the direction perpendicular to its axis; 
rays which enter the lens are refracted in this plane to the focus of the 
lens exactly as in the case of a spheric lens. 
In the opposite direction, that is, parallel to its axis, the surface of a 
cylindric lens is flat; rays entering are not refracted in this plane, but 
pass through unchanged. The effect of a cylindric lens placed in front 
of the eye is to increase or diminish its refraction in the direction at 
right angles to its axis, but in the opposite direction the refractive power 
is unchanged (see Figs. 17, 18). 
A convex 4-diopter cylindric lens, with its axis in a vertical direc- 
tion (written + 4 D cyl., axis 90°), increases the refraction in the hori- 
zontal direction 4 diopters, but does not alter the refraction in the 
vertical direction. The horizontal plane is expressed by the term 
horizontal meridian; the vertical plane by the term vertical meridian. 
A concave cylindric lens of 4 diopters, with its axis horizontal 
(written - 4 D cyl., axis 180°), diminishes the refraction of the vertical 
meridian 4 diopters, but does not affect the refraction of the horizontal 
meridian. COMBINATION OF CYLINDRIC LENSES WITH SPHERIC LENSES 
33 
A convex lens of 3 diopters, combined with a convex cylindric lens 
of 2 diopters, with its axis vertical (written + 3 D Q 4- 2 D cyl., 
axis 90°), adds to the horizontal meridian + 5 diopters, but to the 
vertical meridian only 3 diopters. 
The combination of a convex spheric lens with a concave cylindric 
lens has the following effect: In the direction parallel to the axis of the 
cylinder the combination equals the full refraction of the spheric; in 
the direction at right angles to the axis of the cylinder the refraction is 
equal to the difference between the two lenses. If the convex spheric 
is stronger than the concave cylinder, the difference is still represented 
by a convex glass. For example, + 2 D sph., 3 - 1.50 D cyl., axis 
180° = + 0.50 D sph., 3 + 1.50 D cyl., axis 90°, because + 2 D in the 
meridian of 180° is not diminished, but in the meridian of 90° it is 
reduced to + 0.50 D. Now, + 0.50 D sph. produces this amount of 
refraction at 90°, and supplies + 0.50 D of the requisite + 2 D at 180°, 
leaving + 1.50 D to be supplemented by a cylindric lens with its axis 
at 90°. 
In place of writing + 2 D sph., 3 - 1-50 D cyl., axis 180°, a more 
simple expression would be + 0.50 D sph., 3 + 1.50 D cyl., axis 90°. 
Where, however, the concave cylindric lens is stronger than the 
convex spheric, the difference is represented by a concave lens, thus 
+ 3 D sph., 3 - 6.50 D cyl., axis 180°, signifies in the horizontal mer- 
idian convex 3 D, and in the vertical meridian concave 3.50 D. It is 
necessary to combine a convex with a concave lens in order to obtain 
this effect. The refractive power of this combination can be ex- 
pressed in three different ways: 
+ 3 D sph., 3 -• 6.50 D cyl., axis 180°. 
- 3.50 D sph., 3 + 6.50 D cyl., axis 90°. 
+ 3 D cyl., axis 90°, 3 - 3.50 D cyl., axis 180°. 
In the first combination + 3 D sph. gives the + 3 D necessary for 
the horizontal meridian, but increases the refraction of the vertical 
meridian 3 D instead of diminishing it; therefore the - 6.50 D cyl., 
axis 180°, expends 3 D of its refractive power in neutralizing the effect 
of the + 3 D sph., and with the remainder diminishes the refraction of 
the vertical meridian 3.50 D. 
In the second combination, - 3.50 D sph., 3 + 6.50 D cyl., axis 
90°, the concave spheric lens diminishes the refraction of the vertical 
meridian 3.50 D, but also diminishes the refraction of the horizontal 
meridian 3.50 D; as this already requires + 3 D, we must add + 3.50 D 
more to compensate for the concave spheric, making + 6.50 cyl., 
axis 90°. 
In the third combination, + 3 D cyl., axis 90°, 3 ~ 3.50 D cyl., 
axis 180°, + 3 D cyl., axis 90° increases the refraction of the horizontal 
meridian without altering the refraction of the vertical meridian, and 
the - 3.50 D cyl., axis 180° diminishes the refraction of the vertical 
meridian without affecting the refraction of the horizontal. 
With the combination of a convex spheric and cylindric lens, e. g., 
+ 3 D sph., 3 + 2 D cyl., axis 90°, a concave 0.50 D cylinder with its 34 
GENERAL OPTICAL PRINCIPLES 
axis at right angles to the axis of the convex cylinder, in this case at 
180°, diminishes the refraction of the vertical meridian 0.50 D, the 
combination then equals + 2.50 D in the vertical meridian and + 5 D 
in the horizontal = + 2.50 D sph., Q + 2.50 D cyl., axis 90°. 
A convex cylinder + 0.50 D added to the same combination, with 
its axis at right angles to the axis of the first cylinder, that is, + 0.50 D 
cyL, axis 180° with + 3 D sph., (3 + 2 D cyl., axis 90°, increases the 
refraction in the vertical meridian + 0.50 D. The combination then 
equals + 3.50 D in the vertical meridian, + 5 D in the horizontal. 
This is obtained by + 3.50 D sph., Q + 1.50 D cyl., axis 90°. 
Visual Angle.-The apparent size of an object depends upon the 
size of the visual angle. 
The visual angle is the angle formed by the lines drawn from the 
two extremities of an object to the nodal point of the eye. The nodal 
point of the eye is analogous to the optical center of a lens. It is situated 
15 mm. in front of the retina and 7 mm. behind the cornea. Rays 
directed to this point pass through without deviation. 
As the rays directed to the nodal point of the eye are not refracted, 
but continue the same course until they strike the retina, if lines are 
Fig. 19.-The visual angle. 
drawn from the extremities of an object through the nodal point of the 
eye, and continued until they fall upon the retina, the size of the retinal 
image of the object is obtained. 
The figure shows that the object, in order to subtend the same 
angle, must be larger the farther it is removed from the eye. The 
letter A, seen clearly at 6 meters, would have to be three times as large 
in order to be seen distinctly at 18 meters, and ten times as large in order 
to be seen clearly at 60 meters. The visual angle in the three cases 
remains the same. 
Retinal Image in Emmetropia.-In the emmetropic eye the 
nodal point is situated 7 mm. behind the cornea and 15 mm. in front of 
the retina. The size of the retinal image is to the size of the object as 
the distance from the retina to the nodal point (15 mm.) is to the distance 
from the nodal point to the object. Therefore, if an object is situated 
at 1 meter distance (1000 mm.), its image will be the size of the 
object. 
Retinal Image in Ametropia.-In the hyperopic eye, the axis of 
which is shorter than -that of the emmetropic eye, the retina is situated MECHANISM OF ACCOMMODATION 
35 
nearer the nodal point; the image is, therefore, smaller. In myopia the 
axis of the eye is longer; the retinal image is, therefore, larger. 
Visual Acuteness; Limit of Perception.-An object 1 cm. in size, 
placed 1 meter distant from a normal emmetropic eye (that is, an eye 
without any error of refraction), is plainly visible. If this object is 
moved farther and farther away, it forms a progressively smaller visual 
angle, until a point is reached beyond which it cannot be perceived, 
owing to the diminutive size of the visual angle. The limit of percep- 
tion has now been reached. 
The angle which the object subtends at this distance from the eye 
represents the maximum acuteness of vision. An object twice the size 
would be seen distinctly at twice this distance. An object one-half the 
size could not be distinctly seen at more than half this distance. In 
general terms the size of the object denoting the acuteness of vision is 
always proportional to the distance. 
Normal Acuteness of Vision.-Snellen determined the normal 
acuteness of vision to be the power of distinguishing letters subtending 
an angle of 5'. These letters are formed of strokes whose width is 
I the size of each letter; consequently they are seen under an angle of 
only 1'. The openings in the letters and the spaces between contigu- 
ous strokes, as nearly as possible, are made to conform to the same 
angle. 
Fig. 20.-Two of Snellen's test-types. 
The relation of the size of the letter to the distance at which it should 
be discerned by a normal eye is expressed by twice the tangent of half 
the angle of 5' = 0.001454. The size of a letter the perception of 
which constitutes normal vision at a given distance may be obtained by 
multiplying the distance by 0.001454. At the distance of 1 meter the 
size of this standard letter is 1.45 mm. (0.001454 X 1000 mm.). At 
a distance of 6 meters the size of the letter required is 8.7 mm. (1.454 
X 6). The size of the retinal image of a standard letter of 6 meters = 
■6o' °f 8-7 = 0.02175 mm., and the strokes, or openings, being 4 the 
size, have an image of 0.00435 mm. A large number of people, after 
correction of their ametropia, have a visual acuteness of 1.25 of normal, 
and, therefore, letters constructed on an angle of 4' have been used for 
testing visual acuteness. The retinal images of the strokes of such 
letters are f of 0.00435 = 0.00348 mm. The size of the cones of the 
macular region varies from 0.0033 to 0.0036 mm., showing a most 
interesting relation between the limit of perception and the anatomic 
structure of the retina. 
ACCOMMODATION 
Mechanism of Accommodation.-Inasmuch as the eye is inex- 
tensible, it cannot adapt itself for the perception of objects situated 36 
GENERAL OPTICAL PRINCIPLES 
at different distances by increasing the length of its axis, but only by 
increasing the refractive power of its lens. Rays diverging from near 
objects are thus brought to a focus at the same distance as the rays 
diverging from remote objects. This power the eye possesses of adapt- 
ing its refraction for different distances is called accommodation, and the 
change required in its optical adjustment is effected by the ciliary 
muscle in the following manner: The ciliary muscle, which lies between 
the sclera and the ciliary processes, and which is attached posteriorly 
to the choroid tract by fibers known as the tensor choroideoe, contracts. 
This contraction draws forward the choroid and ciliary processes, to 
which is attached the suspensory ligament of the lens or zonula of Zinn. 
Hence the zonula is relaxed, and the tension which it has exerted on the 
lens capsule is removed. The crystalline lens, a soft and elastic body, 
Fig. 21.-A, Accommodation according to Helmholtz. The dotted line represents the 
thicker form assumed by the lens when the traction of the zonula is diminished by the 
contraction of the ciliary muscle. B, Accommodation according to Tscherning. The 
unbroken lines show the lens at rest. The dotted lines show the change occurring during 
accommodation, supposed to be due to the traction of the zonula being increased by the 
contraction of the ciliary muscle (Cutler). 
thus freed from compression, tends to assume a spheric shape, bulges 
forward, and becomes more convex. It has, in effect, added to its ante- 
rior surface another convex lens. As the ciliary muscle contracts more 
vigorously, this added convex lens becomes stronger. This is the Helm- 
holtz theory, and attempts to disprove it have not been successful, as 
has been ably shown by C. Hess. 
Tscherning holds a different view of the mechanism of accommo- 
dation, thus expressed by Colman Ward Cutler: Accommodation does 
not depend on a relaxation of the zonula of Zinn, but on its tension 
through the agency of the ciliary muscle, whereby the peripheral portion 
of the lens is flattened and the curve of the anterior surface, from an 
approximately spheric, approaches a hyperboloid form. 
Karl Grossmann's careful investigation of a case of congenital 
aniridia indicates that the following changes occur during accommoda- RANGE OF ACCOMMODATION 
37 
tion: The diameter of the lens equator becomes smaller; the antero- 
posterior diameter of the lens increases; the anterior pole of the lens 
moves forward, and its posterior pole backward; both the anterior and 
posterior surfaces of the lens form a lenticonus; the lens in toto moves 
upward and inward. 
Exercise of Accommodation.-If an emmetropic individual 
wishes to see an object situated, for example, 25 cm. distant, he must 
exercise his power of accommodation to such a degree that in effect 
he adds to his crystalline lens another lens of 4 diopters-i. e., one hav- 
ing a focal length of 25 cm. Rays diverging from 25 cm. are thus given 
a parallel direction and are brought to a focus on the retina by the 
original refractive power of the eye. 
The degree of accommodation varies according to the distance of 
the object; it is not possible for an eye to be adapted for two different 
distances at one time. By means of the accommodation the eye is 
Fig. 22.-Increased convexity of the lens during accommodation. The solid white 
outline of the lens, I, shows its form when relaxed. The dotted line shows the increased 
curvature of the anterior surface during accommodation, and its advancement forward into 
the anterior chamber, a. Z is the suspensory ligament; m, the ciliary muscle; and i, the 
iris (Landolt). 
adjusted for all distances between its farthest and nearest point of dis- 
tinct vision. 
The far point of an eye, punctum remotum, is the point from which 
come rays having the least divergence, or toward which go rays having 
the greatest convergence that allows their focusing on the retina. 
From this point rays are focused on the retina with the ciliary muscle 
entirely relaxed, the refraction of the eye being at its minimum, R. 
This point, or its distance from the eye, is designated r. 
The near point of an eye, punctum proximum, or p, is the point 
from which come the most divergent rays that can be focused on the 
retina. These are focused with the ciliary muscle contracted to its 
fullest extent, and the eye in its condition of the maximum refraction, 
expressed by P. The space lying between R and P is called the region 
of accommodation. 
The range of accommodation, likewise denominated the power 38 
GENERAL OPTICAL PRINCIPLES 
or amplitude of accommodation, is the difference between the refractive 
power of the eye accommodated for its far point and accommodated for 
its near point. This is expressed by J. A = P - R. 
As the refractive power is the inverse of the focal distance, the 
refractive power of the eye, when accommodated for its far point r, is 
R = p If we express the value of r in meters, we shall then have the 
refractive power of the eye expressed in diopters, a diopter being a lens 
of 1 meter focus. If r = 1 meter, R = j = 1 diopter = 1 D. If r is 
infinitely distant, R - = 0. 
In the same manner - = P, the refractive power of the eye when 
accommodated for its nearest point. If we obtain the value of p in 
centimeters and wish to know how many diopters it equals, we must 
divide 100 by the number of centimeters equal to p. Let P = 10 cm., 
then P = = 10 D. If p is expressed in fractions of a meter, we 
obtain the same result: by dividing 1 by the value of p, in meters, 10 cm. 
= of a meter. P = ^- = 10 D, or, in decimals, 1 -p 0.1 meter = 
10 To 
10 D-that is, in order to focus rays from 10 cm., we require 10 times 
as much accommodation as is necessary to focus rays from 1 meter, and 
since an eye adapted to a distance of 1 meter exerts 1 diopter of accom- 
modation at a distance of th meter, or 10 cm., it must exert 10 diopters 
of accommodation. 
To find the range of accommodation we must first determine the 
far point. This is accomplished by means of test-letters held in front 
of the patient. If the patient has maximum acuteness of distant vis- 
ion, r is infinite [when P = = 0] or negative. If vision is less than 
normal at 6 meters, but is normal at 1.5 meters, r = 1.5 meters; R then 
= - = 0.66 D. If distant vision becomes or remains distinct when a 
1.5 
convex glass of 2 D is placed before the eye, then R = - 2D; that is, 
the far point of such an eye is negative, a point behind the retina toward 
which rays converge. This condition is further discussed on page 123. 
The near point is usually found by gradually approaching a card 
containing fine print until the nearest point from the eye at which it 
still remains distinct is reached. The distance of this point from the 
anterior surface of the cornea is measured. For this purpose large 
print may be reduced by photolithographing, so as to subtend the 
standard angle of 5' at a distance of 25 cm. or less, and is usually arranged 
on suitably shaped cards. According to Duane, the best test object for 
practical purposes is a simple engraved line 0.2 mm. thick and 3 mm. 
long, which, when brought within the near point, blurs slightly and 
then doubles. In making his estimates he prefers to reckon from the RANGE OF ACCOMMODATION 
39 
anterior focus of the eye-i. e., from a point 13 mm. in front of the 
cornea. 
The formula for obtaining the range of accommodation is A = P - R. 
If p is at 20 cm., P - = 5 D, and r is at infinity, R = 0, then 
A = P - 5 D. This is the case in emmetropia. 
If p is at 10 cm., P = = 10 D, and r is at 25 cm., R = = 
.LU 
4 D, then yl = 10 D - 4 D = 6 D. This is the case in myopia of 4 D. 
P is greater than A. 
If p is at 50 cm., P = ^2? - 2D, and r is negative, - 25 cm. R = 
OU 
-1^ = - 4D. A = 2 - (- 4). = 2 + 4 = 6 D. This is the range 
of accommodation in a hyperope of 4 D, and equals the sum of P and R.1 
The near point is closer to the eye in young life, while the lens is 
soft; as age advances the lens becomes harder and the near point gradu- 
ally recedes until, at about the age of seventy, the near point has reached 
infinity, and p and r then coincide, and there is no range of accommoda- 
tion. 
The range of accommodation is nearly constant for the same age, so 
that if p is nearer than it should be, myopia maybe suspected, or if it is 
farther away than the average, hyperopia (Fig. 23). For this purpose 
the table given below is often used, which records the average of P in 
diopters and p in centimeters for the different ages. (Compare with 
Fig. 23.) 
Table of the Range of Accommodation. 
10 years 14 diopters p = 7 cm. 
15 " 12 " " = 8.3 " 
20 " 10 " " = 10 " 
25 " 8.5 " " = 12 " 
30 " 7 " " = 14 " 
35 " 5.5 " " = 18 " 
40 " 4.5 " " = 22 " 
45 " 3.5 " " = 28 " 
50 " 2.5 " " = 40 " 
55 " 1.75 " " = 55 " 
60 " 1 " " = 100 " 
65 " 0.75 " " = 133 " 
70 " 0.25 " " = 400 " 
75 " 0 " " = <x " 
Duane and J. B. Thomas, in an attempt to determine the normal 
range of accommodation, have reached conclusions somewhat at 
variance with those of Donders, which are usually recorded. The 
accommodation in childhood and youth they found to be not so high 
as he states. The accommodation does not decrease year after year 
by any steady sweep, inasmuch as it may remain unchanged for years 
at some periods of life. After fifty-one the accommodation remains 
1 p refers to the distance of the near point in centimeters. P refers to the refractive 
power of the eye in accommodation for p. r refers to the distance of the far point. R 
refers to the refraction of the eye when accommodated for r. 40 
GENERAL OPTICAL PRINCIPLES 
nearly constant, diminishing only 0.50 D in ten years. Duane's re- 
searches are calculated to fix not only the mean range of accommoda- 
tion, but also the upper and lower limits at each age. 
Abnormal Accommodation.-Failure of accommodation due to 
age is termed presbyopia (see page 148). The chief anomalies of 
accommodation, adopting and quoting Duane's classification, are 
Fig. 23.-Range of accommodation at different ages. The numbers on the left hand 
give the strength of the lens, which placed before the emmetropic eye at a distance of 
13 mm. from the apex of the cornea (i. e., placed at the anterior focus of the eye), can re- 
place the accommodation of the eye at the given age, and hence is equivalent to the ac- 
commodation, so far as regards the increase of refractivity in the eye which the latter 
produces. These numbers, therefore, give the range of accommodation of the eye. The 
right-hand numbers give the focal distances of these lenses (in centimeters). The distance 
of the near point from the apex of the cornea is found by adding to the focal strength 
of the lens its distance from the cornea (i. e., 13 mm.). Obviously, no single observer can 
follow the progress of the range of accommodation from youth to age in one and the same 
individual. The progress of accommodation can, therefore, be found only by determining 
it in a large number of persons with normal eyes at different ages, and taking the mean of 
the observations. This is shown by the continuous line, which indicates the mean posi- 
tion of the near point (without reckoning in the 13 mm.) of an emmetropic eye at differ- 
ent ages. The upper and lower dotted lines give the least and the greatest distance of the 
near point that has been found in the individual cases. They accordingly show the limits 
within which the position of the near point can still be regarded as normal. The ring 
denotes the limit of presbyopia as conventionally set. (After Donders, amended and 
described by Duane.) 
insufficiency of accommodation (see also p. 122), in which the accommo- 
dation is constantly below the lower limit; ill-sustained accommodation, 
in which accommodation is normal in amount, but soon gives out; 
inertia of accommodation, in which difficulty in changing from one accom- 
modative state to the other is experienced; inequality of accommodation 
(see also page 150), in which the accommodation in the two eyes is not ANGLE GAMMA: ANGLE ALPHA 
41 
the same; and excessive accommodation, in which the accommodation is 
persistently above the normal limit. 
Insufficiency of accommodation, according to Duane, usually occurs, 
and it is not infrequent between the ages of eighteen and forty-five. 
Theoretically, it is due to undue rigidity of the lens or weakness of the 
ciliary muscle, and may be associated with an undue effort of converg- 
ence, that is, convergence excess (see page 555), but also and more 
frequently with convergence insufficiency (see page 555). The main 
symptom is asthenopia, and prominent causes are various toxemias due 
to tuberculosis, intestinal disorders, nasopharyngeal, tonsillar, and 
dental disease, hypopituitarism, neurasthenia, overwork, eye strain, 
and vascular hypertension. In the author's experience early arterio- 
sclerosis is a common cause of this condition. Evidently the remedies 
are removal of the cause, suitable correcting glasses, with an addition 
for reading to correct the unnatural presbyopia, and, in the author's 
experience, the instillation of a weak eserin or pilocarpin solution, 
which, however, Duane has not found to be of much avail. Unequal 
accommodation, when non-pathologic in origin, may give rise to much 
discomfort, especially when the presbyopic age is approached or reached, 
and must be recognized in the correcting glasses (see also page 150). 
Angle Gamma: Angle Alpha.-The eye, in looking at any object, 
is directed forward in such a manner that the image is formed on the 
macula lutea. The eye is now said to "fix" the object. A line drawn 
from the object thus fixed to the macula lutea is called the visual line, 
or visual axis. 
The point about which the eye revolves, in order to be brought into 
this position, is called the center of rotation, and has its position 14 mm. 
back of the cornea. The line which connects the object with the center 
of rotation is designated the line of fixation. 
The optic axis is an imaginary line passing through the center of the 
cornea and lens and the point of rotation to the posterior pole of the 
eye-i. e., a point usually between the macula and optic papilla. 
If the macula lutea coincided with the posterior extremity of the 
optic axis, the visual line, line of fixation, and optic axis would also 
coincide. Generally, this coincidence does not exist. In emmetropia 
and hyperopia the optic axis passes to the inner side of the macula lutea, 
and the visual line and line of fixation then form angles with the optic 
axis. In Fig. 24 A-A' is the optic axis passing through the center of the 
cornea, C, the nodal points of the eye, K'-K", and the center of rota- 
tion, M. O-F is the visual line connecting the object, 0, with the fovea, 
F. O-M is the line of fixation, drawn from 0 to the center of rotation, M. 
The eye, in order to fix 0, has its optic axis, A-A', deviated outward. 
The angle formed by the line of fixation, O-M, with the optic axis A-A', 
is called the angle gamma, p, or the angle formed by the visual line with 
the optic axis may be considered as the angle gamma. 
The significance of this angle is that a person, while really fixing 
an object, seems to have a divergence of the visual lines-divergent 
squint. In estimating the degree of a divergent strabismus it is neces- 42 
GENERAL OPTICAL PRINCIPLES 
sary to consider the value of this angle. The amount of the angle 
gamma is usually 5°, but it may reach as much as 10°. When the ante- 
rior extremity of the visual line passes to the inner side of the optic 
axis, the angle gamma is positive, or +; this is the usual condition 
in emmetropia and hyperopia. The convergence of the visual line 
exceeds the convergence of the optic axis by the amount of this angle. 
Fig. 24.-Angle alpha and angle gamma: A-A', Optic axis; O-F, visual line; 0-M, line 
of fixation; E-L, major axis of corneal ellipse. The line of fixation does not correspond with 
the optic axis, but forms the angle O-M-A, angle gamma nearly equal to the angle O-X-A, 
formed by the visual line with the optic axis. O-X-A may be considered as the angle 
gamma. The visual line does not pass through the summit of the corneal curve, E, but 
forms with the axis of the cornea, E-L, the angle O-X-E, the angle alpha (Landolt). 
When the visual line coincides with the optic axis, there is no angle 
gamma. The visual line in high myopia sometimes passes to the outer 
side of the optic axis. The eyeball must then be deviated inward in 
order to fix on the object. This produces the effect of a convergent 
squint. It must be distinguished from squint; and if convergent 
strabismus also exists, the value of this angle must be deducted from CONVERGENCE 
43 
the apparent squint. In this latter form of the angle gamma, where the 
anterior extremity of the visual line passes to the outside of the optic 
axis, the angle is negative, or -. The convergence of the visual line is 
less than the convergence of the optic axis by the amount of this angle. 
The amount of this angle may be measured by placing the patient 
before the perimeter as if his field were to be taken (see page 547). The 
eye is fixed on the central point, and a lighted candle is moved along the 
arc in a horizontal direction until its reflection is obtained from the por- 
tion of the cornea corresponding to the center of the pupil. The posi- 
tion of the candle may now be read from the arc in degrees, and repre- 
sents the size of the angle gamma. 
The apex of the cornea does not generally coincide with the center 
of the cornea, but is displaced laterally. The major axis of the corneal 
ellipse, represented in the figure by E-L, therefore forms an angle with 
the visual line. The angle alpha is the angle formed by the visual line 
with the major axis of the corneal ellipse. It is positive when the major 
axis of the cornea passes to the outer side of the visual line; if the corneal 
axis passes to the inner side of the visual line, the angle alpha is negative. 
In the figure the angle 0-X-A is the angle gamma; the angle 0-X-E is 
the angle alpha. 
From what has been said it will be seen that the visual line is a 
secondary axis to the optical system of the eye. The oblique position 
of the refracting surfaces to the visual line may be the cause of an in- 
creased refraction in the horizontal meridian constituting astigmatism. 
Ill the visual act of one eye the sensation conveyed to the brain is 
projected outward over the same course by which it arrived-that is, 
the object is referred to a position in the field of vision which it actually 
occupies. If the projection outward of the images of the two eyes is 
such that they overlie each other, the person will have single vision; if, 
however, they are projected in different positions, double vision is the 
result. 
The images are projected in different positions when they are not 
formed on identical points of the two retinas. The fovea centralis being 
the most sensitive portion of the retina, the eye is naturally so directed 
toward an object that the image is formed upon it. The eye is then said 
to fix the object. The fovese of the two eyes are identical points, and 
images formed on them are projected outward so as to overlie or fuse 
into each other; points at a corresponding distance to the right of each 
fovea, or to the left, or upward or downward, are also identical, and 
images formed on them produce but a single impression. Objects in 
the field of vision to the right of the point of fixation form a retinal 
image to the left of the fovea. Objects to the left of the point of fixa- 
tion form an image to the right of the fovea (see Figs. 229, 230). All 
images formed on the retina to the right of the fovea are projected 
outward to the left. Those formed on the left of the fovea are pro- 
CONVERGENCE 44 
GENERAL OPTICAL PRINCIPLES 
jected to the right; in the same way those formed on the upper part 
of the retina are projected downward, and those formed on the lower 
part of the retina are projected upward. 
The eyeballs are separated laterally, on 
the average, 64 mm. in adult eyes. In look- 
ing at a distant object, if the axes of the eye 
are parallel, the images are formed on corre- 
sponding points of the retinas, but when the 
object is at some nearer point, the eyes must 
be turned inward in fixing the object, to com- 
pensate for their lateral separation. This 
function of the eyes is termed convergence. 
The eyeball is rotated inward by the inter- 
nal rectus muscle, so that its visual line is 
directed toward the object. This function is 
very closely associated with that of accommo- 
dation; one cannot act in any very great de- 
gree without the other also coming into play. 
The movement inward of the eye is measured 
by the angular deviation of the visual line, 
termed the angle of convergence. 
The unit of convergence is the angle 
through which the visual axis moves to fix on 
a point 1 meter distant. This is termed 1- 
meter angle of convergence (Nagel; Fig. 25). 
If the object fixed is only | meter distant, 
the movement will be twice as great; it is then 
2-meter angles. A point at | meter would 
require 3-meter angles, and so on; 10-meter 
angles of convergence mean that the eye is 
directed to a point only meter distant. 
Meter Angle.-In the figure, 0 and 0 represent 
the centers of rotation of the two eyes; 0-0' is the 
distance between these points, termed the interocular 
distance. It is measured by the distance between the 
pupils during fixation for remote objects. 0-M is 
one-half this distance. 
The line C-M is perpendicular to 0-0'. When the 
object is situated on the line C-M, the convergence 
of each eye is equal. When the visual lines J-0 and 
J'-O' are parallel, the angle of convergence is nil; when, however, the visual lines are 
directed to C, 1 meter distant, 0-J has deviated to 0-C. J-O-C' is the angle 
through which the visual line has moved to fix on C. This is 1-meter angle of con- 
vergence. 
C-M being parallel to J-0, O-C'-M is equal to J-O-C. 
In the right-angled triangle O-C'-M, 0-M equals one-half the interocular dis- 
tance. 
0-C' = the distance of the point of fixation. 
= the sine of the angle O-C'-M. 
Fig. 25.-Meter angles of 
convergence (Landolt). AMPLITUDE OF CONVERGENCE 
45 
The average interocular distance is 64 mm. 0-M = | of 64, or 32 mm. 0-C is 
1 meter distant. 
0-M 32 
n = -- = 0.32 = the sine of 1-meter angle. This corresponds to 1° 50'. 
C/-C lUuu 
If the eye is directed to a point J meter distant, C", the visual line will deviate 
twice as much-that is, it deviates 32 mm. at j meter distance. If the point of 
fixation is only Th meter distant, the amount of convergence will equal 10-meter 
angles. 
To find the value of this in degrees we employ the same formula as above: 
0-M . 
n ,no = sine of angle O-Cw-M. 0-M = 32. O-C10 = Ay meter = 100 mm. 
C/ u 
32 
-= 0.32, the sine of angle of convergence = 18° 40'. 
The value of the meter angles in degrees is obtained very nearly by multiplying 
1° 50' by the number of meter angles. The value of the meter angle varies with 
the interocular distance, and as there is considerable difference in this distance, a 
separate calculation is necessary for each individual. 
A more simple method of determining the value of the meter angle 
is to find its relation to -the centrad. The centrad is a prism which 
deviates a ray the t^o part of the radius, measured on the arc (see page 
19). The deviation of the meter angle is measured on the sine. For 
the angles obtained, the sine and arc are almost equal. 
One-meter angle equals a deviation of 32 mm. (the average distance 
between the centers of rotation of the eyes being 64 mm.) at 1 meter 
distance = 32 in 1000 mm., or 3.2 in 100 = 3.2 centrads. One centrad 
= 0.57295°; 3.2 centrads = 1° 50'. Ten-meter angles equal a devia- 
tion of 32 mm. in meter, 100 mm., 32 in 100, or 32 centrads - 18° 20'. 
A 32-centrad prism not only gives us the value of 10-meter angles of 
convergence, but, placed before the eye with the base inward, it takes 
the place of 10-meter angles of convergence, so that the eye, without 
any convergence, would see an object on the line C'-M, 10 cm. distant, 
as if it were situated at a remote distance. 
The convergence becomes greater as the point of fixation approaches 
nearer. The number of meter angles is, therefore, inversely propor- 
tional to the distance expressed in meters. We thus designate the 
convergence in terms which indicate the same number of units of con- 
vergence as the diopters of accommodation necessary for the same 
distance. An emmetrope, in looking at an object 0.25 meter distant, 
would employ 4-meter angles of convergence and 4 diopters of accom- 
modation. 
The amplitude of convergence is the number of meter angles of 
convergence which the eyes can call into action. It is measured from 
the far point of convergence to the near point of convergence. 
The far point of convergence is the point to which the visual lines 
are directed when the convergence is relaxed to its utmost; the near 
point of convergence is the point to which the visual lines are directed 
when the convergence is at its maximum. If in the minimum degree of 
convergence the visual lines are parallel, the far point of convergence 
will be at an infinite distance. Usually the visual lines actually diverge 
forward at the minimum of convergence, constituting an outward squint, 46 
GENERAL OPTICAL PRINCIPLES 
and converge by their posterior extremities toward a point behind the 
eyes. When this is the case, the far point and a portion of the amplitude 
of convergence are negative. In some cases, with the convergence 
relaxed to its fullest extent, the visual lines still deviate inward, con- 
stituting an internal squint. The convergence will in such a case always 
be entirely positive. 
Relation between Accommodation and Convergence: Relative 
Accommodation.-While the two functions of convergence and 
accommodation, as has already been stated, are closely associated, there 
is still some independence of action. In other words, it is possible to 
accommodate several diopters without any convergence and to con- 
verge several meter-angles without accommodation. If the visual axes 
converge to a given point, the accommodation may be increased to a 
certain limit. The increased amount of accommodation exercised 
in these circumstances is measured by the ability to overcome con- 
cave glasses while the object still remains distinctly in view, and is de- 
nominated the positive part of the relative accommodation. It is also 
possible, while the visual lines converge for a given near point, to relax 
the accommodation from its association with that degree of converg- 
ence by placing convex glasses before the eyes, the object still remaining 
distinctly in view. This relatively diminished amount of accommoda- 
tion is called the negative part of the relative accommodation. That con- 
vergence may be altered while the same effort of accommodation is 
maintained is demonstrable by placing a prism with its base inward 
before one eye, which then rotates outward, in order that the object 
may be .seen singly, this object at the same time being perfectly distinct. 
Evidently the same effort of accommodation has been maintained, al- 
though the convergence of the visual axes is altered. At the far point 
of accommodation and convergence the accommodation has somewhat 
more play; at the near point, however, convergence has much the 
larger movement. The amplitude of convergence does not always 
diminish with age, as does the accommodation. Some persons, how- 
ever, have a diminished convergence power or endurance, owing to 
changes in the ocular muscles similar in kind, though less in degree, to 
the senile changes which usually occur in other parts of the muscular 
system. Lucien Howe has designed an apparatus for the clinical 
measurement of the relative accommodation at the near point. CHAPTER II 
EXAMINATION OF THE PATIENT AND EXTERNAL EXAMI- 
NATION OF THE EYE; FUNCTIONAL TESTING 
A systematic examination of each patient should be made in 
order to secure the .preservation of careful records. For this purpose 
the following order of examination may be used: 
Name and residence. 
Age, sex, race, married, single, or widowed. 
Family history: hereditary tendencies; general and ocular health of parents, 
brothers, sisters, etc. 
Personal history: children, their general and ocular health; miscarriages; meno- 
pause; former illnesses; syphilis; gonorrhea; injuries. 
Occupation: relation of work to present indisposition. 
Habits: brain use; tobacco; alcohol; tea and coffee; narcotics; sexual. 
Date and mode of onset and supposed cause of present trouble; outline of its 
course. 
Organs of digestion: teeth; mouth; tongue; tonsils; stomach; intestines. 
Organs of respiration: nose; accessory sinuses; throat; lungs. 
Organs of circulation: heart; pulse; blood. 
Kidneys: examination of urine. 
Abdominal organs: liver; spleen. 
Organs of generation; menses; leukorrhea; uterine disease; urethral and seminal 
vesicle and prostatic disease. 
Wassermann test and tests for tuberculosis: fixation-complement test for gonor- 
rhea. 
Metabolic analysis. 
Nervous system; intelligence; evidences of hysteria; hallucinations; sleep; vertigo; 
gait; station; tendon- and muscle-jerks; paralysis; tremor; pain; subjective sensa- 
tions; convulsions; headaches and their position. 
Eyes: previous attacks of inflammation; injuries; infections; ocular palsy or 
squint; amblyopia; previous use of glasses; ability to use eyes. 
Direct inspection and examination of eyes: inspection of the skull and orbits 
(symmetry or asymmetry); ciliary borders; puncta lacrimalia; upper and lower 
culdesacs; conjunctivae; caruncles; corneae (oblique illumination and loupe); 
irides (mobility and color); anterior chambers (depth and character of contents); 
vision; accommodation; balance external eye muscles; adduction, abduction, sur- 
sumduction; position of eyes; mobility of globe; tonometer; tension; light-sense; 
color-sense; fields of vision; field of fixation; ophthalmoscope; ophthalmometer; 
retinoscope; test-lenses. 
This schedule of examination must be modified to suit individual 
cases, as the patient presents trivial local lesions directly discoverable 
by inspection, or forms of disease requiring detailed study for their 
proper interpretation. 
Direct Inspection of the Eye.-After the preliminary examination 
which the patient demands, the surgeon proceeds to the direct inspec- 
tion of the. eve. The surface of the lids should be examined for swollen 
47 48 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
superficial veins, a common index of inflammation of the globe; their 
edges for inflammation, parasites, and misplaced cilia; the puncta for 
permeability, pressure at the same time being made over the lacrimal 
sac in order to express from it through the puncta any contained fluid; 
the upper and the lower conjunctival culdesac for accumulated secre- 
tion, granulations, and foreign bodies; the palpebral conjunctiva for 
hardened secretion in glands; the caruncles for swelling, attached foreign 
bodies, and irritation by incurved cilia; and the conjunctiva for the in- 
formation to be derived from its blood-vessels. 
In order to evert the lid, observe the following rule: Require the 
patient to turn the eye strongly downward, seize gently the central 
eyelashes of the upper lid between the index-finger and thumb of the 
left hand, draw the lid downward and away from the ball, place the 
point of the thumb of the right hand above the tarsal cartilage of the lid 
Fig. 26.-Position of hands in the act of everting the eyelid. 
which is to be everted, the remaining fingers being steadied on the brow, 
and, by a quick movement, turn the edge of the lid over the point of 
the thumb, while this is simultaneously depressed. During the entire 
maneuver insist upon the downward direction of the patient's eyes; 
otherwise the lid cannot be turned without undue force and pain. 
When there are no lashes on the upper ciliary margin, the lower lid 
should be pushed beneath the edge of the upper in such a manner that 
it acts as a wedge on which the superior lid is then everted. In this 
manner the lid can be everted with the fingers of one hand. Care 
should be exercised to expose the tissues of the upper culdesac which 
lie beneath the folded lid. 
The surgeon should inspect the skin of the face and forehead, ex- 
amine the orbits by palpation, ascertain the action of the orbicularis by 
causing the patient to close his eyes as if in sleep, and study the length, BLOOD-VESSELS OF THE CONJUNCTIVA 
49 
width, and symmetry of the palpebral fissures and the condition of the 
commissural angles. 
Blood=vessels of the Conjunctiva.-In health only a few con- 
spicuous blood-vessels are evident; in inflammation many more become 
visible. The arteries of the conjunctiva are derived from the palpebral 
and lacrimal branches of the ophthalmic; those of the episcleral tissue 
arise from the anterior ciliary branches of the ophthalmic, while the 
border of the cornea is surrounded by a plexus of capillary loops derived 
from the anterior ciliary vessels. This blood-supply may be con- 
veniently divided, according to the late Mr. Nettleship, into three 
systems: 
System I.-Posterior conjunctival vessels, whose congestion produces 
a bright red, velvety color, moving, on pressure of the eyelids, with the 
Fig. 27.-Eyelid everted for examination of its under surface and the upper part of globe. 
shifting of the conjunctiva, usually associated with mucopurulent 
secretion, and indicating conjunctivitis. Conjunctival congestion is 
most intense at the fornix and in its neighborhood, and decreases as the 
corneal margin is approached. 
System II.-Anterior ciliary vessels, composed of perforating and 
non-perforating arteries and veins. The perforating arteries, which 
supply the sclerotic, iris, and ciliary bodies, are the branches seen in 
health entering about 5 mm. from the corneal margin, their points of 
entrance, in dark-complexioned people, often being distinctly tinted. 
The non-perforating (episcleral) branches, invisible in the normal 
eye, produce, when congested, a pink zone surrounding the cornea 
("ciliary congestion," "circumcorneal zone"), not moving on pressure 
of the lids with the shifting of the conjunctiva, unassociated with 
4 50 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
purulent discharge, and one indication of iritis. Ciliary congestion is 
most distinct around the corneal margin and lessens as the fornix is 
approached. As Haab remarks, the most congested circumcorneal 
zone is least involved in pure conjunctival congestion. 
The perforating veins and their non-perforating (episcleral) twigs, 
when congested, create a zone of dusky hue, often a symptom of glau- 
coma, or appear in unequal, deep-seated patches of lilac or violaceous 
color, indicating cyclitis or scleritis. 
System 111.-Anterior conjunctival vessels and the plexus of capil- 
laries surrounding the cornea, derived from anterior ciliary vessels 
through whose numerous small branches anastomosis between System I 
and II takes place. Their congestion produces a circle of bright-red 
injection, often partly on the cornea, a sign of inflammation of this 
membrane, and typified in the early vascular stages of interstitial 
keratitis (see page 267). 
In addition to these three varieties of congestion, numerous depart- 
ures are noticeable, making it impossible to separate the form and 
specify the individual system involved. In these types is found a 
definite local injection, as the leash of vessels, passing to a corneal ulcer; 
or all the systems are commingled in a general inflammation. The 
blood-vessels of the conjunctiva can be well studied with a Zeiss corneal 
microscope. 
Temperature of the Conjunctival Sac.-According to Silex, the 
temperature of the lower human conjunctival fold is 35.55° C. (95.99° F.) 
-i. e., about 2° C. lower than that of the rectum. There is an average 
increase of 0.98° C. in inflamed eyes, the highest temperature being 
found in acute iritis. The temperature of the cornea is about 29° C.- 
84.2 F. (Leber). 
Inspection of the cornea reveals inflammation, vascularization, 
ulceration, opacities, and foreign bodies. Slight irregularities are de- 
tected by placing the patient before a window, while the eyes are made 
to follow the uplifted finger held about 1 foot from the face, and moved 
in various directions. The image of the window-bars reflected from the 
cornea will be broken as it crosses the spot of inequality. 
A more accurate method is to employ a keratoscope (Placido's disk). 
This instrument consists of a disk shaped like a target, upon which are 
drawn concentric black circles, a sight-hole being in the center. The 
patient is placed with his back to the window, while the surgeon holds 
the instrument in front of the eye, and, looking through the central 
aperture, observes the reflections of the circles from the cornea. If 
these are broken or distorted, the indications of irregularity in the 
surface are present. 
Minute abrasions and ulcers may be found by dropping on the 
eye a concentrated alkaline solution of fluorescein (Gruebler's fluor- 
escein, 2 per cent.; carbonate of soda, 3.5 per cent.), which colors 
green that portion of the cornea deprived of its epithelium, or in 
which the corneal epithelium is diseased, while the healthy epithelium 
remains unaffected. Epithelium in the immediate neighborhood of a OBLIQUE ILLUMINATION 
51 
corneal ulcer, although apparently not involved in the process, will also 
take the stain, as pointed out by Benson. Cocain solution instilled 
prior to or after the application of fluorescein distinctly enhances its 
staining properties, and the epithelium of the cornea, which has been 
softened by repeated instillations of cocain, will take on the fluorescein 
stain. When the lesion is not very recent, or when it is covered with 
necrotic tissue, the coloration will be yellowish or yellowish green. 
This substance also reveals defects of the endothelium of the cornea, 
and E. von Hippel maintains that it produces a deep-seated color- 
ation of the cornea only when the endothelium is absent or diseased 
(see page 334). C. A. Wood prefers a 2 per cent, solution of potassic 
fluorescide without the preliminary use of cocain. Toluidin-blue, as 
suggested by Veasey, and eosin may likewise be used as coloring agents. 
The Width of the Cornea.-This may be measured approximately 
by holding before it a rule marked in millimeters, and noting the num- 
ber of spaces its width occupies, or with Priestley Smith's keratometer, 
which consists of a scale situated between two planoconvex lenses. 
The average horizontal diameter of the normal cornea is 11.6 mm. 
(Priestley Smith). 
The Sensibility of the Cornea.-This may be tested by gently 
touching the surface of this membrane with a wisp of cotton twisted 
to a fine point. If sensation is normal, the touch should be instantly 
followed by the reflex act of winking {palpebral reflex), although even 
when the cornea is insensitive closure of the lid may occur if the test- 
object comes into the field of the pupil. This is not due to 'contact, 
but represents the retinal lid-closure reflex. In organic anesthesia the 
lacrimal reflex is wanting, but is present in hysteric anesthesia. The 
opposite eye should always be tested as a control. 
Oblique illumination is a method of examination by which the 
cornea, the anterior chamber, the iris, and, if the pupil is dilated, the 
lens and even the anterior layers of the vitreous may be studied. The 
surgeon places the patient 2 feet from the source of illumination, and 
focuses a beam of light with a 2- or 3-inch lens upon the cornea, at the 
same time observing the surface under examination through a lens of 
the same focal distance, held between the thumb and forefinger, the dis- 
engaged fingers being utilized to elevate the upper lid (Fig. 28). 
The distance of the lens must be varied slightly, according as the 
cornea, iris, or crystalline lens is brought within its focus, the patient 
being required to look up, down, and to either side, while all the anterior 
surfaces and media of the eye are illuminated. In order to detect for- 
eign bodies in the cornea, the light should be directed at an acute angle. 
If the posterior pole of the lens is to be examined, the light is thrown 
perpendicularly into the pupil, the surgeon placing his eye in the same 
direction without interfering with the light. 
By this method minute abrasions, previously undetected foreign 
bodies, channels of old vessels, and other corneal changes may be ex- 
amined. The character of the aqueous humor, the depth of the anterior 
chamber, the surface of the iris, the presence of synechiae, small tumors, 52 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
atrophic fibers, and persisting pupillary membrane are evident, and, 
finally, opacities in the anterior capsule and axis of the lens are dis- 
coverable. 
The Corneal Loupe.-This is a lens, properly mounted, by means 
of which the cornea is strongly magnified, and which should be em- 
ployed with oblique illumination. A "corneal microscope" or a specially 
prepared lens of high power permits the study of minute changes in 
this membrane and in the iris, and is utilized for the examination of 
the traces of former vascularization, particularly after interstitial kera- 
titis (see page 267), and by its help even the circulation of the blood in 
the vessels of a pannus may be studied. The Zeiss corneal microscope 
is particularly valuable in these respects. 
Dr. Edward Jackson has designed a binocular magnifying lens which 
possesses material advantages. Berger has constructed on the same 
Fig. 28.-Method of oblique illumination. 
principle a useful corneal loupe, the value of which is enhanced by the 
attachment of an electric lamp as designed by Shumway, and E. Treacher 
Collins has arranged a binocular magnifier mounted on a spectacle frame, 
similar to the Hess loupe, which also carries an electric lamp. The 
Zeiss binocular magnifier is a most useful instrument, its optical system 
being so constructed that plane surfaces appear flat to the eyes. 
The Color of the Iris.-The color of the irides varies: blue and 
gray are the predominating hues in northern countries; brown occurs 
next in frequency; while the various admixtures produce yellow and 
green shades. Black irides are never seen; but dark irides, taking into 
account the whole population of the world, are of the most frequent 
occurrence. The color of the iris depends upon the amount and loca- 
tion of the pigment in it. Thus, if the coloring-matter does not exist 
in the stroma, but only in the posterior layer, the blue iris is evident, 
but if there is much pigment in the stroma, the brown or dark-brown THE PUPIL 
53 
iris appears. The color of the iris of all newborn children is of a light 
grayish blue; the stromal pigment is developed subsequently.1 
Slight differences in shade between the two irides are not uncom- 
mon; more rarely, even in health, the irides differ in color (chromatic 
asymmetry, heterochromia iridis), one being brown or greenish, the other 
blue or gray. Almost invariably, in cases of this sort, one iris corre- 
sponds in color with the irides of one parent, and the remaining iris with 
those of the other parent. Instead of uniform pigmentation, a single 
triangular patch or several irregular spots of dark color may appear 
upon one or both irides (piebald irides). This condition is sometimes 
temporary. Chromatic asymmetry, while perfectly compatible with 
health, has been observed in patients with neuropathic tendencies- 
chorea and epilepsy (Fere); the pupil of the blue eye may be smaller 
than that of the fellow eye; physiologic albuminuria may be present 
(T. Harrison Butler). In many instances there is liability to disease 
on the part of the lighter eye (cataract, cyclitis); indeed, the evidences 
of cyclitis, according to Fuchs, are nearly always present. For this 
complicated type T. Harrison Butler suggests the name heterochromic 
cyclitis. Examination reveals punctate keratitis, vitreous opacities, 
sometimes choroiditis and cataract. The opaque lens may be ex- 
tracted and the results of operation are usually successful (Butler). 
This phenomenon may appear in several members of the same family. 
According to some authors the deficiency of pigment in heterochromia 
iridis is due to a lesion of the cervical sympathetic. 
Discoloration from disease results in one iris being green, that of the 
yellow being blue, and indicates iritis or cyclitis; it is often an early 
symptom of inflammation of the iris, and should be looked for in every 
inflamed eye. When the dark segments seen in a piebald iris are small, 
they have been mistaken by incautious observers for foreign bodies. 
The Pupil.-The size of the pupil in health varies with exposure 
to light and with accommodation and convergence. Changes in its 
width also depend upon the quantity of blood in the vessels of the iris, 
the elasticity of the iris-tissue, and certain mechanical conditions. 
Under normal conditions the pupils-subject as they are to many 
influences-manifest certain fluctuations, amounting, according to 
Schwarz, to 0.3 mm., even when the chief factors are practically con- 
stant. The pupil is generally small in old age, in the newborn, and in 
eyes with hyperopic refraction; it is larger in youth, and in eyes with 
myopic refraction. Women are apt to have wider pupils than men. 
Exceptions to these statements are not infrequent, especially in so far 
as the relation of errors of refraction to pupil-width is concerned. 
Usually it is stated that the pupil is smaller in blue irides than in dark 
ones. Some recent investigations indicate that this is not the case. 
With the accommodation at rest, the diameter of the pupil varies in 
daylight from 2.44 to 5.82 mm., the average diameter being 4.14 mm. 
(Woinow). The position of the pupil is a little to the nasal side of the 
1 Ely records two dark irides in more than 1000 newborn children; one child was 
a negro. 54 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
center of the cornea, and, under similar illumination, the pupils should 
be round and of equal size (see also page 55). Slight inequality of the 
pupils is sometimes seen in healthy persons, and may be a congenital 
condition. Several instances of cat-like pupils have been observed in 
human eyes. In these circumstances the pupil in strong illumination 
takes on the form of a narrow- elliptical slit (Greeff). 
In addition to the factors already detailed which influence the size 
of the pupil, the adaptation of the retina to light must be taken into 
account, as Schirmer has shown. The pupil is exposed to clear daylight 
coming through a large window 1 meter distant, and the eye is permitted 
an adaptation of three minutes. Under such conditions a difference in 
width of 0.25 mm. has been determined. For the physiologic size of 
the pupil thus obtained Schwarz prefers the term adapted width of the 
pupil. 
It is much to be regretted that the recorded variations in the diam- 
eter of the pupil are commonly imperfect, and that the loose state- 
ments, "pupils dilated," "pupils contracted," "pupils medium-sized," 
have crept into many reports. 
Fig. 29.-Simple pupillometer. 
Measurement of the Pupil.-The pupil can be measured approx- 
imately by holding before it a rule, marked in millimeters, and noting 
the number of spaces its width occupies. The chief objection to -this 
method is that the distance subtended on the rule is less than the diam- 
eter of the pupil, in proportion as the distance from the observer's eye 
is less to the rule than to the pupil (Jackson). 
A great variety of instruments, known as pupiUometers, have been 
devised for the accurate measurement of the width of the pupil. A 
simple and serviceable device is an instrument which consists of a scale 
of circles held close to the observed eye, the scale being rotated until that 
circle which matches the pupil in size is reached (Fig. 29). Priestley 
Smith's keratometer (see page 51) may be used for the same purpose. 
Haab's pupillometer, which consists of a number of black disks, varying 
from 1.5 to 8 mm. in diameter, arranged in a perpendicular row, with 
which the pupil is compared, is a useful instrument. Care must be 
taken that the hand using these instruments does not cast a shadow- 
on the examined eye. Such examinations suffice for ordinary clinical 
work. For more exact determinations the photographic method of 
pupillometry is employed. MOBILITY OF THE IRIS 
55 
All examinations should be made under a uniformly strong light, 
and the character of light should be stated. 
Mobility of the Iris.-Pupil-reflexes.-The mobility of the iris is 
tested to find the presence of attachments between the iris and the lens 
(synechiae), or atrophy of the iris, or to ascertain the sensitiveness to 
light of the retina or visual center. 
Variations in the size of the pupil depend upon variations in the 
contractility of the iris and upon alterations in the lumen of its blood- 
vessels. These pupillary movements1 are controlled by the pupil 
muscles (see page 57) which are set in motion either by reflex stimuli, or 
by association with other voluntary or involuntary movements, that is, 
by synkinesis, to adopt Parsons' term. Such movements are often 
called puinl-reactions or pupil-reflexes. They are as follows: 
1. The direct light-reflex of the pupil-that is, the contraction of the 
pupil obtained by illuminating the pupillary area. It may be tested 
as follows: The patient is placed before a window in diffuse daylight, 
and one eye is carefully excluded. He is directed to look into the dis- 
tance with the exposed eye, which is then shaded, and, if it is normal, a 
considerable dilatation of the pupil will occur. On removing the 
covering hand or card, contraction to the same size as that which ex- 
isted before the test was applied takes place. The test may also be 
conducted in the following manner: The patient is seated as before de- 
scribed, and both eyes, which gaze steadily in the direction of the light, 
are covered with the examiner's hand or a card, and after a few seconds 
the cover is removed from one eye and the initial width and the rapidity 
and completeness of the contraction of the exposed pupil is observed. 
The same procedure is repeated with the other eye. Again, inasmuch 
as a properly lighted window is not always available, the test should be 
made with artificial illumination. The patient is seated in a dark room 
in front of the source of illumination (Argand burner, Welsbach light, 
lamp, or electric light), and looks into distance. Convergence and 
accommodation are relaxed, and the diameter of the pupil is measured 
with a pupillometer. Next, light is reflected into the eye with the 
ophthalmoscope mirror and the pupil reaction noted. Finally, the 
patient is required to face the light and the pupil area is subjected to 
oblique illumination (see page 51) and the effects observed. This 
is the method recommended by Bach. Even more satisfactory results 
are obtained if the source of illumination is a narrow beam of electric 
light obtained, for example, from a Wurdemann transilluminator 
(see page 363) upon which a cap containing a small condensing lens is 
fitted, as in the model designed by Veasey. 
2. The consensual light-reflex, or indirect reflex action of the pupil- 
that is, the contraction of the pupil of one eye, which is evident when the 
pupillary area of the opposite eye is illuminated. The test is made as 
follows: One eye is completely excluded from the source of illumination, 
and the other shaded in such a manner that the pupil can be observed 
1 This term is so well established and so commonly employed by clinicians that, in 
spite of the objections to it which have been urged, it should be retained. 56 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
beneath the cover. The completely excluded eye is now uncovered 
and the light directed into its pupil, the reaction which occurs in the 
shaded pupil being at the same time observed. Although the pupil of 
one eye acts under normal conditions in unison with its fellow, the direct 
and indirect reactions are not equal in intensity. According to Bach, the 
direct reaction to light is greater than the consensual. The statement, 
often made, that in normal eyes the pupils should be equal, not only 
with both eyes open but with one eye shaded, is not strictly correct, and 
usually the difference in width may be demonstrated by allowing for 
some seconds the stronger illumination to fall on one pupil (Bach). 
3. The accommodation- and convergence-reaction, called also the 
associated action of the pupil, or the accommodation synkinesis-that is, 
the contraction of the pupil which takes place when the visual axes 
converge upon a near point. Usually the test is made as follows: The 
patient is required to look into distance and then quickly to direct his 
eyes at a near object-for example, the point of a pencil held at a dis- 
tance of about 10 cm. Under normal conditions a contraction of the 
pupils will occur-that is, the sphincter of the iris contracts in asso- 
ciation with the ciliary muscle and the internal recti. Bach's procedure 
is the following: The patient, seated facing a wall between two windows, 
is required to observe for twenty seconds a small white button placed 
50 cm. from his eyes. The button is then gradually approached. No 
change in the pupil is observed until the object reaches a distance of 
40 cm. from the eye, as it is usually gradual at first. When a distance 
of 20-15 cm. is reached the contraction is stronger and may occur 
suddenly, associated with a strong convergence impulse. The ampli- 
tude of contraction, which is less marked than that which follows the 
action of light, varies between 0.25 and 0.75 mm.; exceptionally it is 
greater. Generally, it is less marked in old than in young persons. 
Refraction anomalies, according to Bach, produce no marked difference 
in the degree of contraction during convergence, except that in high 
myopia the reaction is sometimes delayed and less in amplitude. -The 
associated movement of the pupil is much more closely connected with 
convergence than with accommodation; indeed, it is chiefly due to the 
impulse of convergence. If, experimentally, accommodation and con- 
vergence are dissociated, accommodation may take place without pupil 
contraction, but convergence cannot occur without contraction of the 
pupil (Swanzy and Werner). 
4. The sensory reflex of the pupil, sometimes called the skin-reflex, 
or the pain-reaction-that is, a slight dilatation of the pupil which occurs 
on stimulating sensory nerves. It may be tested by pinching the skin 
of the neck, or, better, by applying to it a faradic brush. 
5. The cerebral cortex reflex of the pupil is thus described by its dis- 
coverer, Dr. Haab: "If in a room illuminated only by a lamp or candle- 
flame, the light is placed so that it will shine laterally into a person's 
eyes while they look directly forward into the darkness, a marked con- 
traction of both pupils takes place whenever the attention is directed 
toward the light, with no change in the position of the eyes. As long INNERVATION OF IRIS AND EXPLANATION OF PUPIL-REFLEXES 
57 
as the attention is directed to the light and fixation of the eyes on the 
dark wall is maintained the pupils remain contracted, but as soon as 
the attention is transferred to the point of fixation they dilate, although 
the quantity of light entering the eye has remained constant and all 
movements of accommodation and convergence are excluded." 
The clinical significance of this reflex has not been ascertained, al- 
though Haab believes it may have some important bearing on the 
theory of attention, and that it should be investigated in all patients 
submitted to neurologic examination. 
The observation of Piltz that in some persons the pupils contract 
or dilate when they call up a vivid mental picture of a bright or dark 
object has given rise to the term imagination reflex of the pupils. 
6. The palpebral (lid-closure) reflex of the pupil, also denominated the 
orbicularis pupillary reaction, the Gifford-Galassi reflex, and the West- 
phal-Piltz reaction, was discovered by Von Graefe. It consists of a 
contraction of the pupil which occurs when a forcible effort is made to 
close the lids. It has been explained by assuming that an associated 
stimulation of the sphincter nucleus takes place during closure of the 
lid, or that it is due to the mechanical effect produced by strong contrac- 
tion of the orbicularis. 
When a pupil has been contracted under the influence of light, con- 
vergence, or accommodation, and the stimulus is withdrawn, the pupil 
will return to the size it had before the stimulus was applied, if the 
conditions remain the same. This return or relaxation has been called 
by Walter Jessop the dilatation- or relaxation-reflex of the pupil. 
Innervation of the Iris and Explanation of the Pupikreflexes.- 
The muscular tissue of the iris is divided into the sphincter pupilloe, 
a well-marked circular band of involuntary muscle surrounding the 
pupillary margin of the iris, and certain radially placed fibers, much 
less clearly marked, situated near the posterior surface, called the 
dilatator pupilloe.1 These two muscles are called the pupillary muscles, 
and each has a separate and independent motor-nerve supply which 
constitute the miotic and mydriatic nerves. 
The third (oculomotor) nerve innervates the sphincter of the pupil, 
and contains the pupillo-constricting fibers which arise from its nucleus 
in the aqueduct of Sylvius. From this point the fibers proceed in the 
main trunk of the nerve to the orbit, and pass into the branch which 
supplies the inferior oblique, which they leave by way of the twig which 
constitutes the short root of the ciliary ganglion,2 and finally arrive at 
the sphincter by the short ciliary nerves which penetrate the sclerotic 
around the optic nerve, and pass forward in the choroid and ciliary 
body to their destination in the iris. This line of communication be- 
tween the nucleus of the third nerve and the sphincter of the pupil is 
1 The existence of a dilator muscle in the iris is denied by some authors, but the com- 
bined anatomic and physiologic evidence of its presence seems to be conclusive. 
2 As Langley and Anderson have shown, there is a cell-station in the ciliary ganglion. 
The root-fibers which belong to the oculomotor end in the ganglion, and with the cells 
of the ciliary ganglion a new neuron begins for the fibers which pass to the ciliary muscle 
and the sphincter of the pupil. 58 
EXTERNAL EXAMINATION OF THE EYF-FUNCTIONAL TESTING 
called the miotic tract or efferent path, and is also known as the centrif- 
ugal pathway of the pupil reflex. Stimulation of it produces contrac- 
tion of the pupil; section of it, moderate dilatation. 
The cervical sympathetic innervates the dilatator of the pupil. 
The dilatator tract proceeds from a center in the medulla (or from a 
Fig. 30.-Diagram of the efferent pupillary paths. Dotted lines, pupilloconstrictor: 
III nuc., nucleus of third nerve; c. g., ciliary ganglion; s. c., short ciliary nerves. Solid 
lines, pupillodilatator: Dil., hypothetical dilatator center in the medulla; c.c-sp. i., Budge's 
centrum ciliospinale inferius; DI, DII, Dill, first, second, and third dorsal nerves; r. c., 
ramus communicans; Stellate g., stellate ganglion; ann. V, annulus of Vieussens; i. c. g., 
inferior cervical ganglion; cerv. symp., cervical sympathetic; s. c. g., superior cervical gang- 
lion; Gass, g., Gasserian ganglion; VI, V2, V3, first, second, and third divisions of the 
fifth nerve; V nasal, nasal branch of the ophthalmic (first) division of the fifth nerve; I. c., 
long ciliary nerves. (Description and diagram from J. Herbert Parsons.) 
point in the aqueduct) into the lateral columns of the spinal cord as 
far as the third dorsal nerve. The pupillodilating fibers leave the 
cord by the ventral roots of the first, second, and third dorsal nerves 
and follow their communicating branches to the superior cervical 
ganglion. They pass upward in the ascending or carotid branch of the 
first cervical ganglion and arrive at the plexus around the internal INNERVATION OF IRIS AND EXPLANATION OF PUPIL-REFLEXES 
59 
carotid and the Gasserian ganglion. They reach the eyeball through the 
nasal branch of the ophthalmic nerve and its long ciliary nerves which 
perforate the sclerotic, and are distributed to the ciliary muscle and 
iris. The tract just described is called the mydriatic tract. Stimulation 
of it causes dilatation of the pupil; section of it, moderate contraction 
(Fig. 30). 
Inasmuch as the iris is not under the control of the will, the con- 
traction of the pupil which occurs when the eye is exposed to the source 
of light in the manner described is a reflex-that is, its motor nerves are 
excited to action indirectly by the reflex stimulus of light. This light 
reflex is under the control of the constrictor center, which the stimuli 
reach by passing along a tract which is known as the afferent pathway, 
the exact course of which is as yet uncertain, but it is probably some- 
what as follows: The fibers of the pupil-reflex tract begin in the retina 
and arise from all parts of it and proceed in the cptic nerves, and are 
in all probability to be histologically differentiated from those which 
are concerned with vision.1 In the chiasm these pupillary fibers undergo 
partial decussation and enter the optic tracts, which they leave just in 
advance of the external (lateral) geniculate body, and reach the third 
nerve nucleus. From a special part of this nucleus, probably the small- 
celled median nuclei, the pupilloconstrictor fibers arise and reach the 
sphincter of the iris, constituting the efferent, miotic, or centrifugal 
pathway already described2 (Fig. 31). 
The direct light reflex of the pupil is the result of an active con- 
strictor effect, the stimuli passing along the afferent pathway to the 
sphincter center in the third nucleus, and from there by the efferent 
pathway to the termination of the miotic fibers in the iris. 
The consensual or indirect light reflex of the pupil occurs because 
the stimulus passes to the opposite eye, either by reason of the decussa- 
tion of the fibers in the chiasm or because of its transference from one 
nucleus to the other. 
The sensory reflex of the pupil is a dilator reflex called into existence 
by various sensory stimuli. According to Parsons, it is due in part to 
augmentation of the dilator tone through the sympathetic, and in part 
to inhibition of the constrictor tone. 
The convergence and accommodation reaction of the pupil is not a 
reflex, but an associated movement, and has been ascribed to the 
effect of a stimulus which reaches the convergence center in the third 
1 According to some observers (Hess) the portion of the retina which receives the light 
rays, giving origin to the pupil-reflexes, is confined to a small central area with a radius 
of about 3 mm. 
2 The path by which the pupillary fibers leave the optic tract to reach the third nucleus, 
in the language of Parsons, is as yet conjectural. This author, referring to the pupillo- 
constrictor path, thinks it is probable that the fibers pass through the superior brachium 
of the quadrigeminal body to the superior colliculus, there making new connections with 
the cells which convey the impulses to the third nucleus of the same and also the opposite 
side. Von Hippel states that after the pupil fibers leave a tract in advance of the external 
geniculate body, they run up and in toward the median line, and as they enter the white 
substance of the corpora quadrigemina, they radiate, part of them going to the roof, and 
another part, under the aqueduct, toward the sphincter nucleus. It is probable that 
there is a connection between the two sphincter nuclei over the median line through the 
ganglion-cell processes. 60 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
nucleus, and is diffused to the cells which innervate the ciliary muscle. 
According to Schwarz, it is possible that a single cerebral impulse to 
accommodate both eyes to near vision stimulates simultaneously the 
nuclei which regulate convergence, accommodation, and pupil contrac- 
tion. 
The cerebral cortical reflex or, better, reaction of the pupil, is of com- 
plex nature and results from psychic stimuli. The explanation of the 
lid-closure reflex of the pupil has been given (see page 57). 
Not only may constriction of the iris, and therefore contraction of 
the pupil, be due to contraction of the constrictor (sphincter) muscle, 
but it also may be caused by relaxation of the dilatator muscle and dila- 
Fig. 31.-Diagram of the afferent and efferent pupillary paths for light stimuli. Affer- 
ent paths from left sides of retinae, thick solid lines; afferent paths from right sides of retinae, 
thick dotted lines; efferent paths of left eye, thin solid lines; efferent paths of right eye, thin 
dotted lines: Ir., iris; R, retina; II, optic nerve; o. tr., optic tract; Coll. Supr., colliculus 
superior or anterior corpus quadrigeminum; Hird. nuc., nucleus of third nerve; e. g. b., 
external geniculate body; c. g., ciliary ganglion; s. c. n., short ciliary nerves. (Description 
and diagram from J. Herbert Parsons.) 
tation of the blood-vessels of the iris. As before stated, the evidence 
strongly indicates that the light reflex is an active constrictor effect, 
although some writers maintain that it should be explained by an in- 
hibitory dilatator influence. Instead of locating the center for the light 
reflex of the pupil in the small cells which occupy the median part of the 
third nucleus, Marina has placed it in the ciliary ganglion. Bach has 
described an inhibitory constrictor and an inhibitory dilator center in 
the spinal end of the floor of the fourth ventricle, and, according to 
him, irritation of these centers will lead either to dilatation or contrac- 
tion of the pupil. The presence of these centers is denied by a number 
of observers. DILATATION OF THE PUPIL 
61 
Not only may dilatation of the pupil be due to contraction of the 
dilatator muscle (dilatator pupillse), but may also be caused by relaxa- 
tion of the constrictor (sphincter) muscle and to constriction of the 
blood-vessels in the iris. The dilatator pathway has been described 
(see page 58). Budge and Waller believed that the origin of the pupil- 
dilating fibers should be referred to the spinal cord in a region between 
the exits of the sixth cervical and fourth dorsal or thoracic nerve (prob- 
ably opposite the seventh cervical and first thoracic), which is known as 
Budge's ciliospinal center (see Fig. 30). Although certain clinical and 
experimental evidence is in favor of this center, its existence has not 
been proved. Not only is the sympathetic pathway of the pupils con- 
cerned with maintaining a certain tone in the dilatator muscle of the 
iris, but it is also capable of being actively awakened by various 
sensory stimuli. 
Dilatation of the pupil occurs in glaucoma, in optic-nerve atrophy, 
in orbital disease, and under the influence of mydriatics. It is further 
seen in fright, emotion, in deep inspiration or expiration, anemia, in 
depressed nervous tone, aortic insufficiency, cutaneous stimulation 
(skin-reflex'), and irritation of the cervical sympathetic. If paralysis 
of accommodation is associated with dilatation of the pupil, objects 
may appear smaller than normal (micropsia). 
In diseases of the nervous system, dilatation of the pupil, when of 
cerebral origin, indicates extensive lesion; when of spinal origin, irrita- 
tion of the part (McEwen). Systematic writers have divided dilatation 
into irritation mydriasis, caused by irritation of the pupil-dilating center 
or fibers, and paralytic mydriasis (iridoplegia), caused by paralysis of the 
pupil-contracting center or fibers. 
In irritation or spastic mydriasis the pupil may be moderately or 
widely dilated. It reacts somewhat to light, accommodation, and 
convergence if the dilatation is not extreme; but if it is, these reactions 
may be lacking. Cocain usually produces no further dilatation of such 
a pupil, nor is it readily contracted by pilocarpin, and sometimes not at 
all. It is seen in hyperemia and irritation of the cervical part of the 
spinal cord, in spinal meningitis, in tumor of the cord, sometimes in 
tumor of the cerebrum, in acute mania, and in early tabes dorsalis and 
paretic dementia. Spasmodic mydriasis has been observed in a healthy 
subject (Cramer). 
In paralytic mydriasis (sphincter paralysis) the pupil is dilated, but 
not necessarily ad maximum. It does not react to light, accommoda- 
tion, and convergence, and the condition is sometimes described as 
pupillary rigidity. If there is only paresis and not paralysis of the 
sphincter, a sluggish reaction to light, accommodation, and convergence 
may be obtained. Cocain still further dilates a pupil of this character, 
and it is contracted by the action of pilocarpin. 
Paralytic mydriasis may be caused by a lesion in the sphincter, the 
sphincter nucleus, or the centrifugal tract. It is seen in disease of the 
base of the brain affecting the third nerve or its nucleus, in pressure on 
the cerebrum great in degree, in late stages of meningitis, in edema of 62 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
the cortex, in cerebral softening, in hemorrhage of the centrum ovale, 
and cerebral peduncles. 
In medicinal mydriasis-i. e., one caused by atropin or a similar 
drug or by certain toxins-there is paralysis of accommodation, and the 
pupil is unaffected by pilocarpin. 
Contraction of the pupil {miosis) appears in congestions of the 
iris, in traumatisms of the iris (traumatic miosis), in certain fevers, 
in plethora, venous obstruction, mitral disease, pulmonary congestion, 
paralysis of the sympathetic, and under the influence of miotics. Dur- 
ing sleep the pupils are contracted. If spasm of accommodation is 
associated with contraction of the pupil, objects may appear larger than 
normal {macropsia). 
If the miosis is of cerebral origin, it indicates an early irritative stage 
of the affection (meningitis, etc.); if of spinal origin, a depression, 
paralysis, or even destruction of the part (McEwen). 
Systematic writers have divided contraction of the pupil into 
irritation miosis, caused by irritation of the pupil-contracting center or 
fibers, and paralytic miosis, caused by paralysis of the pupil-dilating center 
or fiber. The same factors which cause miosis may cause mydriasis, 
the determining factor being the degree and the duration of the lesion. 
In irritation or spastic miosis the pupil is contracted, in medium 
degree if one etiologic factor is active, ad maximum if both are con- 
cerned. Such a pupil dilates little or not at all in the dark, and usually 
is unaffected by the action of light. It is readily dilated by a mydriatic 
(atropin), and still further contracted by pilocarpin. The active lesion 
may reside in the iris, in the sphincter nucleus, or in the centrifugal 
pathway. According to some authors spastic miosis may be indi- 
rectly caused by failure of the inhibitory influences to act on the 
sphincter nucleus (Schwarz). 
Irritation or spastic miosis may be caused by inflammatory affec- 
tions of the base of the brain and the meninges in their early stages, 
by brain abscess, by beginning sinus disease, in the early period of cere- 
bral neoplasms, in small hemorrhages in the cerebellum, at the onset 
of cerebral apoplexy, and in apoplexy of the pons. It is also seen in 
hysteria, at the beginning of epileptic attacks, in certain toxemias, in 
tobacco amblyopia, and under the influence of long-sustained efforts 
of accommodation. 
In paralytic miosis {dilatator paralysis) the pupil is contracted, but 
its motility is preserved in that it reacts to light and the impulse of con- 
vergence. In the dark it dilates, but less perfectly than a normal pupil. 
Such a pupil is dilated by mydriatics, but only partially; it is contracted 
still further by miotics. 
Paralytic miosis may be caused by lesions in the cord above the dorsal 
vertebra, and is especially noteworthy in tabes dorsalis {spinal miosis). 
It is also seen in paralysis of the insane, pseudodementia paralytica of 
syphilitic origin, in some forms of bulbar paralysis, and in some varieties 
of multiple neuritis (Mills). It is caused also by injury to the cervical 
sympathetic, or by pressure, for example, from enlarged cervical glands CONTRACTION OF THE PUPIL 
63 
or an aneurysm. If the cervical sympathetic is paralyzed, with the 
miosis there is enophthalmos and ptosis (sympathetic ptosis). 
A pupil which does not react, either directly or indirectly (consen- 
sually), to the influence of light, but contracts promptly on converg- 
ence of the visual axes, exhibits the condition to which the term reflex 
inactivity or immobility of the pupil is applied, and which also is known as 
the Argyll Robertson pupil. Usually the condition is bilateral, but uni- 
lateral reflex inactivity or immobility is also seen, and even where the 
failure of light reaction is bilateral, one pupil may be smaller than the 
other, although both are miotic pupils. Sometimes the same reflex 
immobility is present when the pupils are dilated. Frequently the 
affected pupils are not round, but slightly oval or pointed. The seat 
of the lesion in these circumstances is not certainly known. It has been 
placed in the fibers which pass from the proximal end of the optic nerve 
to the oculomotor nuclei by some authors, and by others is considered to 
be nuclear. Bach believes that it may be located in the spinal end 
of the sinus rhomboidalis, and Marina and Lafon place the causal 
lesion in the ciliary ganglion. 
Reflex immobile or inactive pupils are especially noteworthy in tabes 
dorsalis and paretic dementia, and, as is well known, may precede the 
general signs of these diseases by many years. They also occur in 
syphilis, but have also been observed in non-syphilitic affections and in 
alcoholic neuritis. If miosis is present it has been attributed to a sym- 
pathetic affection and to tonic contraction of the sphincter, but Bach 
thinks that it depends upon an irritation of the reflex inhibitory center 
which he believes he has discovered. According to the same author 
the Argyll Robertson pupil may remain unilateral for years, and exist 
as an isolated symptom. 
The reverse of the Argyll Robertson symptom has been observed, 
that is to say, the pupil reacts to light, but fails to react to convergence, 
and has been ascribed to disease in a special part of the oculomotor 
nucleus. 
Unilateral reflex iridoplegia, or a condition in which one pupil is 
unaffected by varying degrees of illumination of both eyes, but reacts 
to accommodation, while the pupil of the other eye responds to a 
separate light stimulus of either eye, and which is seen in tabes dorsalis 
and syphilitic cases, should be distinguished from unilateral reflex 
blindness, caused, for example, by interruption of the conducting power 
of one optic nerve. In unilateral reflex blindness illumination of the 
pupil area on that side fails to elicit either the direct or the indirect 
pupil-reflex. 
Convergence Anomalies of the Pupils.-As already noted, in com- 
plete rigidity of the pupil, such as occurs with total paralysis of the 
sphincter, there is no convergence reaction, but it is conceivable, as 
Schwarz points out, that a common disturbance of convergence reac- 
tion and light reaction, due to interruption of the corresponding path- 
ways leading to the sphincter nucleus, may occur without paralysis of the 
sphincter. 64 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
Occasionally a pupil which is inactive to light stimulus, but which 
contracts on convergence, will remain in this contracted condition for 
a considerable length of time before it slowly returns to its original size. 
This phenomenon has been called the myotonic pupil movement by Sanger, 
and neurotonic convergence reaction by Piltz. It has been noted in tabes 
dorsalis, in multiple sclerosis, migraine, and alcoholism. Failure of the 
convergence reaction of the pupil, unassociated with disturbances of the 
light reflex, although rare, may occur. It may be complete or incom- 
plete, and the convergence rigidity may be associated with paralysis 
of accommodation, or this may be absent. 
The palpebral reflex of the pupil, according to Bach, may be seen 
in normal eyes, and is perhaps accountable for some of the contradic- 
tory observations which have been made on the pupil reflexes. If 
there is sphincter paralysis it is abolished, but sometimes it appears, 
although light reaction and convergence reaction are absent, when it 
must be assumed that the sphincter itself is not paralyzed, or, at least, 
not completely disabled. 
Unequal pupils (anisocoria) are rarely seen in health. If there is 
recent wide dilatation of one pupil and no disease of the eye, the instilla- 
tion of a mydriatic may be suspected. Unequal pupils occur in eyes 
with widely dissimilar refraction, if one eye is blind, in aneurysm, pul- 
monary tuberculosis, dental disease, sinusitis, traumatism, and in dis- 
eases of the nervous system. If the disease is cerebral, the inequality 
denotes unilateral or focal brain disease. Anisocoria is not uncommon 
in tabes, disseminated sclerosis, and paretic dementia. 
Varying inequality of the pupils (springing or alternating mydriasis') 
or a one-sided mydriasis, now occurring on the one side and now on the 
other, is a serious premonitory symptom of insanity, and has been 
noted in general paralysis and locomotor ataxia. It is doubtful if it 
occurs in healthy persons, but the so-called false alternating mydriasis, 
according to Piltz and Frenkel, may be due to an inequality in the 
reflex excitability to light of the two eyes, or to inequality in the re- 
sponse to accommodation or spasm of the orbicularis muscles. 
Special and Paradoxic Pupillary Phenomena.-The hemiopic 
pupillary inaction is referred to on page 518. Dilatation of the pupil 
under the influence of light stimulus and contraction when it has been 
shaded have been described in cases of meningitis as paradoxic pupillary 
reactions. 
The phenomenon has been explained by assuming a reflex stimula- 
tion of the dilatator by a psychic influence, or that the action of the 
dilatator is indirectly increased because there is rapid exhaustion of 
the sphincter (Silex). The opposite condition, paradoxic pupil dilata- 
tion, is the antithesis of the condition just described, and has been 
observed frequently in experimental work in connection with the rela- 
tion of the sympathetic to the eye. Paradoxic convergence reaction 
-that is, a dilatation of the pupil on convergence of the visual axes 
-has been recorded. 
Hippus is a rhythmic contraction and dilatation of the pupil without TESTING ACUTENESS OF VISION 
65 
alteration of illumination or fixation. It is a normal phenomenon due 
to the constantly varying sensitive and psychic reflexes, but occurs in 
exaggerated degree in hysteria, mania, meningitis, and other diseases 
of the nervous mechanism. 
Testing Acuteness of Vision.-The acuteness of vision is the power 
of distinguishing form and size, and is a function of the macula lutea, 
the peripheral portions of the retina having only indifferent ability to 
distinguish form and size. 
In order to determine the acuteness of sight, test-types are em- 
ployed, in which the letters are of various sizes, and constructed accord- 
ing to the methods described on page 35. 
When it is desired to make the test, the patient is placed 6 meters 
from the type-card, in a well-lighted room, and each eye is tried sepa- 
rately. If the letters of No. 6 (20 feet approximately) are read, vision 
is normal, or 1, but if, at the same distance, letters no smaller than those 
numbered 18 (60 feet) can be discerned, vision is It is usual to ex- 
press these results according to the formula V = in which V stands 
for visual acuteness, d for the distance of the patient from the card, 
and D for the distance at which the type should be read; so that in these 
instances the vision would be recorded and or in feet, and -. 
6 18 xx lx 
The rays coming from the letters at 6 meters' distance have so little 
divergence when they reach the eye that they are usually considered 
parallel. Hence, if the patient sees distinctly at this distance, his 
vision is perfect at the longest range (see also page 38). In point of 
fact, however, there is an appreciable divergence of the rays from the 
distance mentioned, equivalent to one-sixth of a diopter, and in the final 
adjustment of glasses this divergence should be recognized. Any other 
distance may be chosen, provided it does not place the patient closer to 
the test-card than 3 meters, at which close range the function of accom- 
modation would introduce an element of inaccuracy. Thus, the scale 
made use of by de Wecker, and elaborated by Oliver, assumes 
v (- approximately | instead of as v- In like manner, a 4-meter 
5 \xv * / 6 1. 
distance may be utilized, as has been done by Edward Jackson. This 
author urges the standardizing of all cards of test letters by comparison 
of the visibility of each line of letters with that of a graded series of 
broken rings which he has designed and has had prepared. 
The acuteness of sight, as tested with types constructed on the basis 
of an angle of 5', does not always yield accurately the highest vision 
attainable; indeed, many good eyes possess a vision of % of the 
standard angle. For this reason Dr. James Wallace has arranged a 
series of test-types in which an angle of 4' has been substituted as the 
basis of each letter. 
For the purpose of a control test, and also for determining visual 
acuteness of illiterate persons, cards are employed on which a number 
of differently arranged dots are placed, of sizes which should be counted 
5 66 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
at different distances, and among these Burchardt's international tests 
are the most useful. For the same purpose incomplete squares corre- 
sponding in size to the test-letters have been constructed, the incom- 
plete sides being turned successively in different directions. Wolff- 
berg has designed a useful test which consists of small pictures of well- 
known objects, which in size approximately conform to the standard 
angle. 
If the patient fails to decipher the largest letters at the distance 
employed, he should be moved closer to the card; thus, he may be unable 
to read the type numbered 60 at 6 meters, but may discern this at 
4 meters, V = or of normal. Still further depreciation of visual 
60 15 
acuteness is recorded by requiring the subject to count the outstretched 
fingers at various distances, 0.2, 1, or 2 meters, V = counting fingers 
at 0.2 meter, etc. For determining the lower degrees of sharpness of 
vision by a method more precise than the one just described, Landolt's 
optotypes may be employed.1 If the patient is unable to count fingers, 
his ability to perceive the movements of the hand at 0.5, 1, or 2 meters is 
tested, V = movement of the hand at 0.5 meter, etc. When the ability 
to distinguish form (qualitative light perception) no longer exists, the per- 
ception of light should be investigated by alternately screening and 
shading the eye, by illuminating the eye with light reflected from a 
mirror, or focused upon it with a condensing lens. 
Light=sense.-Having determined the acuteness of vision by 
means of the test-letters, the examiner has ascertained the form-sense, 
and may proceed to try a second subdivision of the sense of sight, the 
light-sense, which is the power possessed by the retina, or center of vision, 
of appreciating variations in the intensity of the source of illumination. 
An instrument called a photometer is employed for this purpose, and 
consists essentially of an apparatus-for example, the one designed by 
Izard and Chibret-by which the intensity of two sources of light may 
be compared. The patient, looking into the instrument, sees two 
equally bright disks. One disk is now made darker, and the power of the 
eye to perceive the difference in the illumination of the two disks ascer- 
tained; or one disk is made entirely dark, and then gradually illumin- 
ated, and the smallest degree of light noted by which the patient can 
perceive the disk coming from the darkness. The former is called the 
light-difference (L. D.), and the latter the light-minimum (L. M.). In 
more exact language, to quote Percival Hay,2 who has designed a 
photometer, by light-difference is meant the minimal difference capable 
of being perceived-the threshold of discrimination, and by light- 
minimum is meant the minimal stimulus capable of being perceived- 
the threshold of sensibility. By means of Forster's photometer the 
lowest limit of illumination with which an object is still visible (the 
minimum stimulus) is ascertained. The light-sense may also be tested 
with gray letters on a white ground, those of Bjerrum being constructed 
1 Ophthalmic Record, 1899, vol. viii, p. 624. 
2 Archives of Ophthalmology, 1905, vol. xxxiv, p. 160. METHOD OF HOLMGREN 
67 
on the same principle as Snellen's types. For determining the "light- 
minimum" R. Wallace Henry's photometer is very useful. Ives and 
H. Maxwell Langdon have improved the accuracy of the last men- 
tioned instrument by using electricity with a rheostat and ammeter in 
the circuit as the source of illumination, and having the amount of 
light controlled by an iris diaphragm instead of varying thicknesses of 
opal glass, as suggested by Henry. Some information in regard to the 
light-sense may be obtained by testing the acuteness of vision on two 
cards, under a different degree of illumination, and by comparing the 
results with a similar examination of a subject believed to have normal 
power of appreciating different degrees of illumination. De Wecker's 
photometric types may also be employed. These consist of white letters 
placed upon gray backgrounds of different intensities. 
Color=sense.-A third subdivision of the sense of sight is the color- 
sense, or the power which the retina has of perceiving color, or that 
sensation which results from the impression of light-waves having a 
certain refrangibility. This examination is of especial interest in the 
detection of color-blindness (see page 496). 
1. Method of Holmgren.-This consists in testing the power 
of a person to match various colors, conveniently used in the form of 
colored yarns. The set of worsteds contains three large test-skeins, 
namely: (1) light pure green, (2) rose-purple, (3) red; and 150 small skeins 
of the following colors: red, orange, yellow, yellow-green, pure green, 
blue-green, blue, violet, purple, pink, brown, and gray. In addition, 
there are several shades of each color, and a number of gradations of 
each tint, from the deepest to the lightest. According to Holmgren, 
the method of examination should be as follows: 
"The wools are placed in a heap on a large table, covered by a light 
cloth and in broad daylight. A skein of the test-color is taken from the 
pile and laid far enough away from the others not to be confounded with 
them during the examination. The person examined is required to 
select other skeins from the pile nearly resembling it in color, and to 
place them by the side of the sample. He is made thoroughly to under- 
stand that he is required to search the heap for the skeins which make 
an impression on his chromatic sense, and quite independently of any 
name he may give the color similar to that made by the test-skein. 
The examiner should explain that resemblance in every respect is not 
necessary; that there are no two specimens exactly alike; that the only 
question is the resemblance of the color, and that, consequently, the 
candidate must endeavor to find something similar in shade, some- 
thing lighter and darker of the same color, etc. 
"Test I.-The green test-skein is presented. The examination 
must continue until the candidate has placed near the test-skein all the 
other skeins of the same color; or else, with these or separately, one or 
more of the skeins of the class of confusion colors, or until he has suffi- 
ciently proved, by his manner, that he can easily and unerringly dis- 
tinguish the confusion colors, or gives unmistakable proof of a diffi- 
culty in accomplishing it. The candidate who places with the test-skein 68 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
confusion colors (gray, drab, fawn, light pink or yellow)-that is to say, 
finds that they resemble the test-color-is color-blind; while if he evinces 
a manifest disposition to do so, though he does not absolutely do so, he 
has a feeble chromatic sense. 
"Test II.-The rose-purple skein is presented. The examination 
must continue until the candidate has placed all or the greater part of 
the skeins of the same shade near the sample; or else, simultaneously or 
separately, one or more skeins of the confusion colors. If he confuses 
the colors, he will select either the light or deep shades , of blue and 
violet, especially the deep, or the light and deep shades of one kind of 
green, or gray inclining to blue. A candidate who is proved color- 
blind by the first test, and who in the second test selects only purple 
skeins, is incompletely color-blind. If in the second test he selects with 
the purple blue or violet, or one of them, he is completely red-blind. If 
in the second test he selects with purple only green or gray, or one of 
them, he is completely green-blind. The red-blind never select the colors 
taken by the green-blind, and vice versa. The green-blind will often 
place a violet or blue skein by the side of the green, but it will then only 
be the brightest of these colors. 
"Test III.-The red skein is presented. The test, which is applied 
to those completely color-blind, should be continued until the person 
examined has placed beside the test-skein all the skeins belonging to 
this hue, or the greater part, or else one or more confusion colors. The 
red-blind chooses besides the red, green, and shades of brown, which, to 
the normal sense, seem darker than red. On the other hand, the green- 
blind selects shades of these colors which appear lighter than red. 
"The absence of all except one color sensation {monochromatic 
vision) will be recognized by confusion of every hue having the same 
intensity of light. Violet-blindness will be recognized by a genuine con- 
fuison of purple, red, and orange in the second test." 
2. Method of Thomson.-The late Dr. William Thomson devised 
the following arrangement of the yarns: The set consists of a large 
green and a large rose test-skein, and 40 small skeins, each marked with 
a bangle having a concealed number, extending from 1 to 40, placed in 
a double box, so arranged as to keep the two series apart. 
The large green skein being placed near by, the small skeins from 1 
to 20 are placed in good daylight, and the employee under examination 
is directed to select 10 shades of the same color as the test-skein. One 
with normal vision will choose promptly the 10 greens with odd numbers. 
A color-blind person will hesitate, and his selections will contain 
some even numbers, and the confusion colors will be shades of brown, 
etc., containing some red, or shades of gray, and will indicate the color 
defect. These figures are to be recorded on a blank, and the 20 skeins 
are to be removed. The large rose skein is then used, and the examina- 
tion repeated in like manner with skeins numbered from 21 to 40, and 
the result recorded. The confusion skeins, which have even numbers, 
are blue, green, and gray. From the selections made by the man found 
color defective by the green test we are able to decide the character of THE LANTERN TEST 
69 
his color-blindness. Those selecting blues are red-blind, those taking 
greens and grays are green-blind, according to the nomenclature of 
Holmgren. There are 10 roses and 10 confusion colors in the second 
series. 
3. The Lantern Test.-To control and also to substitute the 
various wool-tests, lanterns for detecting color-blindness are employed. 
Useful models have been designed by William Thomson, Charles H. 
Williams, and Edridge-Green. Concerning lantern tests, Dr. Thomson 
wrote as follows: "Whilst the wool-tests have been accepted universally 
as requisite for the detection of color defects, the employees of railroads 
and their friends have always objected to their use as having no relation 
to their daily duties, and have demanded such colors as are employed as 
signals. Furthermore, for two-fifths of the time during the night of an 
employee's life he is expected to govern his actions by colored lights, and 
hence a lantern which can imitate the night signals in form, color, in- 
tensity, and size, as they appear under all obstructions caused by rain, 
snow, fog, and smoke, is desirable. Its power over the wools to detect 
the central amblyopias of tobacco, alcohol, drugs, and disease, that would 
not be revealed by the skeins, makes it a necessity." 
Dr. Thomson described his lantern as follows: "It consists of an asbestos chim- 
ney, which can be placed on the kerosene lamp in universal use on railroads, or over 
an Argand or other gas light, electric lamp, or spring candle-stick. Two disks, 4 
inches in diameter, are so placed upon the chimney as to permit of their being super- 
imposed partly. The lower disk contains seven glasses in apertures J inch in diameter, 
having the white, red, green, and blue colors in general use on railroads. This may 
be considered the 'examination in chief,' whilst the upper disk, when combined with 
the lower by turning one or both, furnishes the 'cross-examination.' The upper 
disk has two apertures, one W inch, the other J inch, with white glass. The other 
five have one white ground glass, one deep London smoke, one pink, one green, and 
one cobalt-blue glass. 
"The combination of the white ground and the smoke glass with the reds and 
greens of the lower disk enables all atmospheric conditions to be imitated, and the 
lights to be diminished in brightness and tint. The use of the small opening enables 
size and distance of signals to be imitated. 
"The standard for color-sense is taken as an opening of inch at 20 feet. A 
man failing to see the colored light at this distance may have it increased ten times 
= by using the large openings. Again failing, he may approach to 1 foot and 
reveal a color-sense equal to only. The resemblance to the tests for form by 
Snellen's letter is to be noted. Since the color-blind depend alone on intensity of 
brightness to distinguish the white, green, and red signals, the diminishing effect of 
the ground glass and of the London smoke often reveals the defect. The cobalt, 
transmitting blue and red both, is usually described by the color-blind as blue, which 
color they always see well, being blind for red. The cobalt, combined with the lower 
reds, gives a very deep red color, which, when compared with the usual red, may 
induce the color-blind to name one red, the other green. Combined with the lower 
blue it gives a deep pink, called blue by the color-blind. 
"In the pink, London smoke, and light green glasses in the upper disk I have 
imitated the 'confusion colors.' The pink looks cherry red to the normal eye, but it 
transmits both red and blue by the spectroscope, hence the color-blind pronounce 
it blue, or, when backed by a yellow flame, white. The light green is also called 
white, as is also the light gray of the London smoke. Hence we have in these three 
glasses tints which the color-blind name white, and reveal their defect thereby. 
"The upper disk has its seven openings marked by the letters of the alphabet, 70 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
and the lower by the numerals from one to seven. The examination should be made 
in a darkened room, and the results reported on a blank, the details being used when 
requisite. The man examined is expected to call or name the colors and to recognize 
them at 20 feet." 
4. The Pseudo=isochromatic Plates of Stilling.-These consist 
of a series of plates (10 in number), each plate containing 4 squares 
filled by small, irregular, colored spots, among which other spots in a 
confusion color, made to conform to an Arabic figure, are placed. The 
test-plate is held in a good light, and the examiner requires the subject 
to distinguish the tracings. These plates are said to be of practical 
use. 
5. Special Tests.-These include the use of the spectroscope and 
various forms of chromatometers, the chromatophotometer of Chibret 
being the instrument that is perhaps most valuable. 
Direct vision for colors may be studied by placing the patient at a 
given distance from a chart or disk of graduated colors, and noting the 
amount of surface exposure which is required for the color to be properly 
recognized. In the scale of De Wecker and Masselon the colored sur- 
face, 2 cm. square, should be recognized at 5 meters; that is, the chro- 
matic vision or V. C. or C. = 1; if a colored test must be four times this 
size in order to be recognized, C = |, etc. Snydacker affixes to the 
ordinary type card squares of red (2.5 and 5 mm. in size) and green 
(3 and 6 mm. in size), the test being made at 6 meters. Failure to 
differentiate the larger test objects suggests the need of perimetric ex- 
amination; also central scotomas for red and green may be thus rapidly 
detected (see page 85). 
Accommodation has been defined to be those changes in the 
optical adjustment of the eye effected by the ciliary muscle, and in 
practice is measured by finding the nearest point at which fine print can 
be clearly deciphered, or by Duane's test (see page 38). The type 
usually adopted is that known as Snellen's 0.5 or Jager's 1 (see also 
page 38). 
In order to study the phenomena of accommodation the student 
should record: (1) The nearest point of perfectly distinct vision attain- 
able with the smallest readable type, or the punctum proximum (abbre- 
viated p. p., or simply p.). (2) The farthest point of distinct vision, or 
punctum remotum (abbreviated p. r., or simply r.f (3) The range, 
amplitude of accommodation, or the expression of the amount of accom- 
modative effort of which the eye is capable. This is expressed in the 
number of that convex lens, placed close to the cornea, whose focal 
length equals the distance from the near point to the cornea, and which 
gives rays a direction as if they had come from the far point; thus, if the 
near point be 7 cm., the lens which expresses the amplitude of accom- 
modation is + 14 D = 14. (4) Relative accommodation, or that in- 
dependent portion of this function which can be exercised without 
alteration in a given amount of convergence, and which is divided 
into a negative portion, or that portion which is already in use, and BALANCE OF THE EXTERNAL EYE MUSCLES 
71 
a positive portion, or that portion which is not in use (see also pages 
35 and 46). 
Mobility of the Eyes.-This is tested by causing the patient to 
follow, with his eyes, the head remaining stationary, the movements 
of the uplifted finger, which is directed to the right, to the left, upward 
and downward; or, better, a small electric light, the reflections of which 
from the corneas can be noted. Both eyes must be observed, and note 
made of any lagging in their movements, or of the failure of either eye 
readily to turn into the nasal or temporal canthus. At the same time 
the relation of the movements of the upper lid to those of the eyeball 
is recorded. The attention of the patient must be centered upon the 
moving test, and allowance should be made for the imperfect mobility 
of highly myopic eyes. Any asymmetry of the skull or difference in the 
level of the two orbital margins may be observed, because such condi- 
tions are not infrequently associated with ametropic eyes, especially 
when the two eyes possess great inequality in refractive conditions. 
(For accurate determination of ocular rotations see page 522, and Ap- 
pendix, page 690.) 
Balance of the External Eye Muscles.-Under normal condi- 
tions perfect equilibrium of the external eye muscles is present, and there 
is no interference with binocular fixation and binocular single vision 
(see page 521). Under abnormal conditions the movements of the 
eyes may be deranged so that one eye deviates, or tends to deviate, 
from the point of fixation-that is, from the object which it is regarding. 
These deviations may be classified thus: 
1. Manifest deviation-that is, a deviation of an eye which the 
patient cannot overcome. This is known as strabismus, squint, or 
heterotropia, and is fully considered on pages 523 and 526. 
2. Latent deviation-that is, a tendency of the visual line to deviate 
from the point of fixation. This tendency, however, is overcome by a 
muscular effort, owing to the stimulus which the eyes always have to 
maintain binocular single vision. It is generally described by the term 
latent squint, suppressed squint, or heterophoria. It is frequently de- 
signated insufficiency of the ocular muscles, and was called by von Graefe 
dynamic strabismus (see page 554). 
According to G. T. Stevens,1 the various conditions of equilibrium 
or variation from it may be arranged in four classes: 
1. Orthophoria, a tending of the visual lines in parallelism. 
2. Heterophoria, a tending of the visual lines in some other direction, but. with 
ability to adjust them habitually for single vision. 
3. Heterotropia, a deviation of the visual lines from parallelism in such manner 
that they cannot habitually be united at the same point of fixation. 
4. Anotropia, katotropia; or anophoria, katophoria-variations from equilibrium 
which may or may not be consistent with parallelism of the visual lines, but in which, 
with the least innervation of the eye muscles, the visual lines of both eyes would fall 
below (katotropia) or rise above (anotropia) the most favorable plane for the minimum 
effort. Thus with ano- or katotropia there may be associated heterophoria or hetero- 
tropia. 
1A System of Diseases of the Eye, edited by Norris and Oliver, vol. ii, p. 171. 72 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
Heterophoria may be divided into the following specific conditions: 
1. Esophoria, a tending of the visual lines inward. 
2. Exophoria, a tending of the visual lines outward. 
3. Hyperphoria (right or left), a tending of the visual line of one eye (right or 
left) in a direction above its fellow, constituting, as the case may be, right or left 
hyperphoria. 
The term does not imply that the line to which it is referred is too high, but that it 
tends higher than the other, without indicating which may be at fault. 
The compound tendencies are: 
1. Hyperesophoria (right or left), a tendency of one visual line to rise above the 
other, with a tendency also of the lines inward. 
2. Hyperexophoria (right of left), a tendency of one visual line to rise above the 
other, with a tendency also outward. 
Heterotropia may be divided into two subclasses: 
(a) Deviations consistent with a physiologic state of the muscles and nerves, as 
in the ordinary concomitant squint. 
(6) Deviations resulting from pathologic conditions-as, for example, deviations 
from paralysis or from mechanical causes. 
The specific divisions of the subclass (a) are: 
1. Esotropia, a deviation of the visual lines inward. 
2. Exotropia, a deviation of the visual lines outward. 
3. Hypertropia (right or left), a deviation of one visual line above the other. 
4. Hyperesotropia and hyperexotropia are the compound deviations. 
Cyclophoria is a term introduced by Savage to describe want of equilibrium of the 
oblique muscles. 
In order to ascertain the condition of the ocular muscles the follow- 
ing tests are employed: 
1. The Screen (Cover) and Parallax Tests.-Require the patient 
to regard a small point of light upon a black background 5 or 6 meters 
distant, or a round black spot 1 inch in diameter in the center of a white 
card-board at a similar distance. Cover the left eye with a screen, 
making sure that the patient is fixing the test-object with his right eye. 
Pass the screen rapidly from the left to the right, and observe the 
movements of the eye which take place behind the cover. Outward 
deviation indicates exophoria; inward deviation, esophoria; vertical 
deviation, hyperphoria. The prism, placed base inward, which neutral- 
izes the outward deviation is a measure of the exophoria; the prism, 
placed base outward, which neutralizes the inward deviation is a 
measure of the esophoria; the prism, placed base up or base down, which 
neutralizes the vertical deviation is a measure of the hyperphoria. 
While the screen is being moved rapidly from one eye to the other 
request the patient to describe the apparent movement of the test- 
object. If this moves in the same direction in which the cover is moved, 
exophoria is indicated; if in the opposite direction, esophoria; if upward 
or downward, hyperphoria. These apparent movements may be neutral- 
ized as before with appropriately placed prisms. 
Require the patient to fix upon a fine object, as a pencil-point, held 
below the horizontal, 20 or 25 cm. from the eye, and, in order to remove 
the control of binocular vision, cover one eye with a card or the hand, 
and observe whether the eye under cover deviates inward or outward, 
upward or downward, and returns to fixation when the cover is removed, 
and neutralize the movement with appropriately placed prisms. BALANCE OF THE EXTERNAL EYE MUSCLES 
73 
2. Prism Tests.-A small flame is placed against a dark background 
at 5 or 6 meters from the patient, and on a level with his eyes. In an 
accurately adjusted trial-frame a prism of 7° is inserted, base down, 
before one eye-for example, the right. Vertical diplopia is induced, 
and the upper image belongs to the right eye. If the flames stand one 
directly over the other, there is no inclination to divergence or con- 
vergence. If the upper image stands to the left, there is exophoria; 
if to the right, esophoria. That prism placed with its base in or out 
before the left eye, according to circumstances, which brings the two 
images into a vertical line, measures the degree of the deviation. 
In order to test the functions of the vertical muscles at a distance 
of 6 meters the patient is seated as before, and a prism of sufficient 
strength to induce homonymous diplopia is placed before one eye,- 
for example, the right,-i. e., with its base toward the nose. If the 
images are on the same level, no deviating tendency is present. If, for 
example, the right image rises higher than the other, the visual line of 
the right eye tends to be lower than that of its fellow, and there is 
hyperphoria. That prism, placed with its base down before the left 
eye, which restores the images to the horizontal level, measures the 
degree of deviation. 
3. Equilibrium Test.-In order to test the functions of the lateral 
muscles at the ordinary working distance, or 30 cm., it is customary to 
employ the equilibrium test of von Graefe, in which a card, having upon 
it a large dot, through which a fine line is drawn, is held 25 or 30 cm. 
from the eyes, diplopia being induced by means of a prism of 10°, base 
up or down, before one eye. A more accurate test-object is a small dot 
and fine line, or a single word printed in fine type, requiring accurate 
fixation and a sustained effort of accommodation. If, the prism being 
placed base down before the right eye, the images stand exactly one 
above the other, equilibrium is evident; if the upper image (image of 
the right eye) stands to the left of the lower image, there is crossed 
lateral deviation; and that prism, placed before the left eye with its base 
toward the nose, which restores the images to a vertical line, measures 
the tendency to divergence or exophoria. If the upper image stands to 
the right of the lower, there is homonymous lateral deviation; and that 
prism, placed before the left eye with its base toward the temple, which 
restores the images to a vertical line, measures the tendency to con- 
vergence or esophoria. The vertical muscles should also be tested at 
the ordinary working distance with a prism placed before one eye, 
with the base before the nose, as already described above. 
Edward Jackson's test for muscle balance at the working distance 
is useful. It consists of a small white square on a black ground, which 
is held at a distance of 33 cm. from the eyes, and which is regarded 
through a strong convex cylinder (10 or 12 D) placed before one eye. 
The white spot appears as a gray streak, which seems to pass through 
the spot if there is orthophoria, but to one or other side of it, or above 
or below it, if there is heterophoria. The axis of the cylinder must be 
vertical to test the vertical balance, and horizontal to test the lateral 74 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
balance. The Maddox rod test (see page 77) has also been adapted to 
the working distance, the test-object being a small illuminated square on 
a black ground, which is viewed at the near point through a Maddox rod. 
Schild and B. F. Baer, Jr. have designed useful instruments. 
4. In order to test the convergence near point, approach a finger or 
pencil to the nearest point upon which the eyes can converge. This 
should be situated at no greater distance than 8 cm. (3| inches) from 
the eyes-that is, 2.5 to 4.5 cm. (1-lf inches) from the nose. If, before 
this point is reached, outward deviation of one eye occurs, the amount 
of convergence is deficient. 
5. In order to ascertain the power of adduction (properly prism-con- 
vergence), abduction (properly prism-divergence), and sursumduction 
(sursumvergence), the strongest prism which the lateral and vertical 
muscles can overcome is found (see page 521).1 
Beginning with adduction (prism-convergence), find the strongest 
prism placed before one eye, with its base toward the temple, through 
which the flame still remains single. The test should begin with a weak 
prism, the strength of which is gradually increased until the limit is 
ascertained. This varies from 30° to 60°, the higher degrees, however, 
in most instances being attained only after 
a reasonable degree of practice. 
In like manner abduction (prism-diver- 
gence) is tested, the prism now being 
turned with its base toward the nose; 6° 
to 8° of prism should be overcome. The 
ratio between adduction and abduction 
should be 6 to 1 (Stevens)-i. e., if ad- 
duction is 48°, abduction should be 8°; 
but, according to Risley, in carefully cor- 
rected or emmetropic eyes, the ratio is 3 
to 1. Banister found the primary adduc- 
tion for 6 meters to be only 14°. As 
Hansell and Reber properly observe, no arbitrary standard of the 
ratio between prism-convergence and prism-divergence can be given, 
although the latter is fairly constant under normal conditions. 
Sursumduction (sursumvergence), or the power of uniting the image 
of the candle-flame, seen through a prism placed with its base down- 
ward before one eye, with the image of the same object as seen by the 
other eye, is ascertained by beginning the trial with a weak prism, J° 
or 1°, and gradually increasing its strength. The limit is usually 2°, but 
may be as high as 6° or 8°. Right sursumvergence is equivalent to the 
degree of that prism placed base down before the right eye (or base up 
before the left), and left sursumvergence to the degree of that prism placed 
Fig. 32.-Risley's rotary prism. 
1 According to Duane, the term "adduction" is properly applied only to the amount 
(40°-50°) by which each eye can turn inward when moving parallel with its fellow (associ- 
ated adduction, or adduction proper); " abduction," to the absolute degree of rotation of each 
eye outward in performing associated parallel movements, which is 40°-50°; "sursumduc- 
tion," to the absolute degree of movement of either eye upward-a movement of some 40° 
in extent. BALANCE OF THE EXTERNAL EYE MUSCLES 
75 
base down before the left eye (base up before the right) through which 
the test-object still remains single. Right and left sursumvergence are 
normally equal. 
If the eyes of the patient under examination are ametropic, the 
proper correcting lenses should be placed before them, and the ex- 
amination for the various forms of heterophoria made through this 
glass, which should be accurately centered. 
Practically all the examinations for muscular errors can be made 
with a series of prisms and a 'trial-frame, but they are facilitated by 
the use of certain instruments of precision, especially some form of 
Herschel or revolving prism, the one devised by Risley being the best. 
The latter consists of two prisms, superimposed with their bases in 
opposite directions, constituting a total value of 45°. They are mounted 
in a cell which has a delicately milled edge, and fits in the ordinary trial- 
frame. The milled edge permits convenient turning in the frame, so 
that the base or apex of the prisms can be readily placed in any desired 
direction. The prisms are caused to rotate in opposite directions by 
means of a milled screw-head, projecting from the front of the cell. 
Fig. 33.-Stevens' phorometer. 
With this rotary prism the strength of the abducting, adducting, and 
supra- and infraducting muscles can be measured. If the rotary prism 
is placed before the left eye with the zero mark vertical and the screw 
turned to the right or left, it will cause the base of the resulting prisms 
to be either inward or outward-that is, toward the nose or temple, as 
may be desired; or it may be placed with the zero mark horizontal, and 
the base turned upward or downward. All examinations for muscular 
defects may be ascertained with a phorometer. A number of excellent 
models are available. 
6. Obtuse-angled Prism Test.-One of the simplest tests of the 
ocular muscles is the obtuse-angled prism of Maddox. This is composed 
of "two weak prisms of 3° united by their bases. On looking through 
the line thus formed at a distant flame, two false images of it are seen, 
one higher and one lower than the real image seen by the other eye, the 
position of which, to the right or the left of the line between the false 
images, indicates the equilibrium of the eye. A faint band of light, of 
the same breadth as the two false images, is seen extended between 
them" (Fig. 34). The answers of the patient may be materially assisted 76 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
by placing a red glass before one eye, and thus tinting the real image. 
If this stands directly in the center between the two false images, all 
forms of latent deviation are eliminated; if it stands to the right or to the 
left, there is exophoria or esophoria; if it stands above or below the 
center, or is fused with either the upper or the lower image, there is 
hyperphoria. 
7. Insufficiency of the oblique muscles (cyclophoria), according to 
Savage, may be detected "by placing a Maddox prism, with its axis 
vertical, before one eye, the other being covered, which regards a 
horizontal line on a card 18 inches distant. 
This line appears to be two, each parallel with 
the other. The other eye is now uncovered, and 
a third line is seen between the other two, 
with which it should be parallel. Want of 
harmony in the oblique muscles is shown by 
want of parallelism of the middle with the other 
two lines, the right end of the middle line point- 
ing toward the bottom and the left end toward 
the top line, or vice versa, depending upon the 
nature of the case" (Fig. 35). 
Fig. 34.-Position of 
the images as seen through 
the obtuse-angled prism of 
Maddox. 
Fig. 35.-Tests for insufficiency of oblique muscles: 
1, Insufficiency of left superior oblique; 2, insufficiency 
of left inferior oblique; 3, insufficiency of right superior 
oblique; 4, insufficiency of right inferior oblique; 5, equi- 
librium of oblique muscles (Savage). 
8. Cobalt Test.-A trial-frame armed on one side-for example, the 
right-with a piece of cobalt glass is placed in position and the patient 
required to regard the test-light. The right image will be smaller than 
the left, and have a blue center and a red border if the patient is hyper- 
opic or emmetropic, and a red center with a blue border if the patient is 
myopic. Suitably placed prisms, which unite the images, are the 
measures of the deviation. BALANCE OF THE EXTERNAL EYE MUSCLES 
77 
9. The Rod Test.-This test was designed by Maddox, and depends 
upon the property of transparent cylinders to cause apparent elongation 
of an object viewed through them, so that a point of light becomes a 
line of light so dissimilar from the test- 
light that the images are not united. It 
may be suitably employed by having 
mounted in a cell, which will fit in the 
trial-frame, a transparent glass rod colored 
red, | inch long, and about the thickness of 
the ordinary stirring rod used by chemists, 
or a series of glass rods placed one above 
the other (Fig. 36). 
The examination for horizontal deviation 
is thus described: "Seat the patient at 6 
meters from a circle of light 5 mm. in di- 
ameter, and place the rod horizontally before 
one eye. If the line passes through the circle of light, there is ortho- 
phoria (equipoise), as far as the horizontal movements of the eyes are 
Fig. 36.-Maddox multiple rod. 
Fig. 37.-Maddox's rod test for horizontal deviation. The rod is before the right eye. 
a, The line passes through the circle of light-orthophoria, b, The line passes to the 
right of the light-latent convergence, or esophoria. c, The line passes to the left of the 
light-latent divergence, or exophoria. 
concerned. Should the line lie to either side of the circle of light, as 
in most people it will, there is either latent convergence or latent diver- 
Fig. 38.-Maddox's rod test for vertical deviation. The rod is before the right eye. 
a, The line passes through the circle of light-orthophoria, b, The line passes below the 
light. The upper image belongs to the left eye-right hyperphoria, c, The line passes 
above the light. The upper image belongs to the right eye-left hyperphoria. 
gence; the former, if the line is on the same side as the rod (homon- 
ymous diplopia); the latter, if on the other side (crossed diplopia)." 78 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
Iii order to test the vertical deviation, the rod is placed vertically 
before the eye; a horizontal line of light appears, and the patient is 
asked if the line passes directly through the flame or if it appears above 
or below it. The following rule, quoted from Maddox, will suffice to 
indicate the "hyperphoric" eye: "If the circle of light is lowest, there is 
a tendency to upward deviation of the naked eye; if the line is lowest, 
of the eye before which the rod is placed."1 
The measurement of the extent of the deviation may be made in 
the ordinary way by finding that prism, placed before the naked eye 
(preferably with the rotary prism of Risley), which brings the line and 
flame together. 
Of the various tests described, the Maddox rod is simple, and for all 
practical purposes accurate, especially when it is employed to estimate 
vertical deviations. According to Duane, it is apt to indicate an ex- 
cess of deviation, particularly in esophoria. Hansell and Reber doubt 
if the prism-test reveals the true state of the muscle balance. They 
have found distinct contradictions between its results and those of the 
Maddox rod and other tests, and this is a matter of common experience. 
It is probable that the screen and parallax tests, if carefully and re- 
peatedly performed, give, as Duane believes, most trustworthy infor- 
mation. 
Power of Convergence.-In order to determine the maximum of 
convergence, an instrument known as an ophthalmodynamometer may be 
employed. The best one has been devised by Landolt,2 and consists of 
a metallic cylinder, blackened on the outside, placed over a candle- 
flame. The cylinder contains a vertical slit, 0.3 mm. wide, covered by 
ground glass. The luminous vertical line thus produced is the object 
of fixation. Beneath the cylinder is attached a tape-measure graduated 
on one side in centimeters, and on the other in the corresponding num- 
ber of meter angles. The fixation object is gradually approached in 
the median line toward the patient, until that point where double vision 
occurs is reached, or the nearest point (punctum proximum) of converg- 
ence, and the distance in centimeters read from one side of the tape, 
and the corresponding maximum of convergence in meter angles on the 
other. 
The minimum of convergence may also be ascertained with the 
instrument, but when this is negative it is determined by finding the 
strongest abducting prism-that is, base in before one eye--which will 
not cause diplopia while the patient is fixing a candle-flame at 6 meters. 
If the number of the prism is divided by 7, the quotient will approxi- 
mately give in meter angles the amount of deviation of each eye when the 
prism is placed before one. The amplitude of convergence is equivalent 
to the difference between the maximum and minimum of convergence 
-that is, a - p - r. Thus, if the normal average of maximum 
convergence is 9.5 meter angles and the average minimum of 
convergence is - 1 meter angle, the amplitude of convergence 
1 Dr. Swan M. Burnett substituted for the Maddox rod a 6 D cylinder. 
2 Landolt's Refraction and Accommodation of the Eye, p. 283. THE FIELD OF VISION 
79 
would be a = 9.5 - (- 1) = 10.5 meter angles. (See Meter Angles, 
page 44.) 
The Field of Vision.-When the visual axis of one eye is directed 
to a stationary point, not only is the object thus "fixed" visible, but also 
all other objects contained within a given space, which is large or small, 
in proportion to the distance of the fixation point from the eye. This 
space is the field of vision, and the objects within it imprint their images 
upon the peripheral portions of the retina, or those which are indepen- 
dent of the macula lutea. In contradistinction to visual acuteness and 
refraction, which pertain to the macula in the act of direct vision, the 
function of sight capable of being performed by the rest of the retina is 
called indirect vision. 
The limits of the visual field may be roughly ascertained in the 
following manner: Place the patient with his back to the source of light, 
and have him fix the eye under examination, the other being covered, 
upon the center of the face of the observer or upon the eye of the ob- 
server which is directly opposite his own, at a distance of 2 feet. Then 
let the surgeon move his fingers in various directions midway between 
himself and the patient, on a plane with his own face, until the limits 
of indirect vision are determined, controlling at the same time the 
extent and direction of the movements by his own field of vision. This 
method suffices to discover any considerable limitation, and, in the 
event of such discovery, should be supplemented by a more exact 
procedure. 
If it is desired to have a map of the field not larger than 45° in extent, 
let the patient be placed 25 cm. from a blackboard, which may be con- 
veniently ruled in squares, and fix the eye under observation upon a small 
white mark. The observer then moves the test-object-a piece of white 
paper 1 cm. square, affixed to a black handle-from the periphery 
toward fixation, until the object is seen. If eight peripheral points are 
marked and afterward joined by a line, a fair map of the field of vision 
will be obtained,1 which may be transcribed upon a chart, like the one 
originally suggested by Joy Jeffries (Fig. 39). In like manner the 
campimeter of de Wecker may be employed. A useful hand campimeter 
has been designed by L. C. Peter. 
Beyond 45° this method ceases to be accurate, because on a flat 
surface the object is too far away from the eye; rays perpendicular to 
the visual line coming from a peripheral object would be parallel to the 
1 The value in degrees of the squares on the blackboard may be ascertained by the 
following table, provided the eye is placed exactly at 25 cm. from the fixation point: 
2.2 cm. = 5° in the perimeter semicircle. 
4.4 " = 10° 
6.7 " = 15° 
9.1 " = 20° 
11.7 " = 25° 
14.4 " = 30° 
17.5 " = 35° 
21 " = 40° 
25 " = 45° 
30 " = 50° 
36.7 " = 55° 
43.3 " = 60° 80 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
blackboard, and could not arise from it, or any object passed across its 
surface. 
Hence, the investigation of the periphery of the retina requires 
the use of an instrument known as a perimeter. This consists essentially 
of an arc marked in degrees, which rotates around a central pivot, that 
at the same time may be the fixing-point of the patient's eye, which is 
placed 30 cm. distant (the center of curvature of the perimeter arc), or 
the eye may be directed upon a porcelain button on a bar, placed 15° 
from the center, to the left, if the right eye is to be examined; vice versa, 
if the left is under observation. The test-object, 1 to 2 cm. in diameter, 
affixed upon a carrier, is moved from without inward, and the point 
noted on each meridian where it is recognized. The result is tran- 
scribed upon a chart, prepared by having ruled upon it radial lines to 
White 
Blue---- 
Re d 
Fig. 39.-Limits of the normal field for white, blue, and red, transcribed upon a blackboard 
(after Norris). 
correspond to the various positions of the arc, and concentric circles to 
note the degrees. 
Many ingenious instruments have been devised, especially such as 
are self-registering, among which may be mentioned those of McHardy, 
Stevens, Skeel, and Priestley Smith. "Electric light perimeters" have 
been constructed by C. H. Williams and William Sweet. Rapid and 
accurate work, however, cannot be accomplished as satisfactorily with 
self-registering perimeters and a sliding object holder as with test-ob- 
jects attached to a slender black rod or a slender wire. The hand 
perimeter of Schweigger for bedside examinations and the more elabor- 
ate one of Wildbrand, which can be adjusted while the patient lies upon 
his back, are useful instruments. 
The physiologic limits of the form field, or, what is practically the 
same thing, the field when this has been mapped with a square of white 
1.5 cm. in width, are: outward, 90°; outward and upward, 70°; upward, THE FIELD OF VISION 
81 
50 ; upward and inward, 55°; inward, 60°; inward and downward, 55°; 
downward, 72°; downward and outward, 85°.1 
Fig. 40.-Perimeter. The examination may be made with the carrier which moves 
along the semicircle, or the test-objects may be carried along this by means of dark disks 
attached to a long handle, each disk containing in its center the test-object. The patient's 
chin is placed in the curved chin-rest; the notched end of the upright bar is brought in 
contact with the face, directly beneath the eye to be examined, which attentively fixes 
the center of the semicircle. The other eye should be covered, preferably with a neatly 
adjusted bandage. The record chart is inserted at the back of the instrument, and, by 
means of an ivory vernier, the examiner is enabled to mark exactly with a pencil the point 
on the chart corresponding to the position on the semicircle, at which the patient sees the 
test-object. The various marks are then joined by a continuous line, and a map of the 
field is obtained (see Fig. 41). 
1 Baas finds the average result of ten observers as follows: Outward, 99°; upward, 65°; 
inward, 63°; downward, 76°. Figures indicating a minimal field, or smallest physiologic 
field, have been recorded, varying from 90° (Foerster) to 50° (Treitel) outward; 55° to 21° 
upward; 60° to 40° inward; 70° to 40° downward. The smaller of these limits cannot be 
regarded as physiologic, and the greater is about equal to the average working field. 
Wolff berg insists that a field obtained under ordinary daylight illumination should be con- 
trolled by one obtained with reduced illumination. He further maintains that a field 
found to be "normal" in good daylight must, under reduced illumination, so long as the 
fixation spot remains visible, suffer no change in its outer limits and normal continuity. 
. Bjerrum, in 1899, proposed an addition to the usual method of examining the field of 
vision, a description of which is condensed from Berry's translation of the original paper. 
The addition consists in making use of white objects which subtend a very small visual 
angle. The examinations are made at a distance of 2 meters, using a large black screen 2 
meters in breadth, which can be let down from the ceiling to the floor. At this distance the 
blind-spot (see page 85), instead of measuring 2.5 cm., as on an ordinary perimeter, 
measures 20 cm. in diameter; and everything else is in the same proportion. 
The objects used by Bjerrum are small circular disks of ivory, fixed on the end of a 82 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
These measurements, which represent the relative visual field, vary 
within normal limits, and, transcribed upon a chart, produce the fol- 
lowing figure (Fig. 41). 
From this it is evident that the field of vision is not circular, being 
greatest in extent outward and below, and most restricted inward and 
above. This restriction is partly due to the presence of the edge of the 
orbit and the nose, and partly, as Landolt has pointed out, because the 
outer part of the retina is less used than the inner, and its functions, 
therefore, are less developed. Hence, as each portion of the field 
corresponds to the opposite por- 
tion of the retina, the inner part 
is smaller than the outer. 
It must be remembered, 
however, that the size of the 
field of vision varies with the 
size of the visual angle sub- 
tended by the test-object with 
which the examination is con- 
ducted, and for the sake of ac- 
curacy the size of the object 
should be given as well as its 
distance from the patient's eye. 
Moreover, the visual field should 
not be mapped with test-objects 
of one size only. As Rbnne, 
quoted by Traquair, says: "An 
examination of the field of vision 
in which only one object is used is in itself just as inadequate as an 
examination of visual acuteness with a test card which has letters of 
only one size." 
Binocular Field of Vision.-The field of vision for each eye having 
been defined, it remains to point out that the field of vision which 
pertains to the two eyes, or that portion in which binocular vision is 
possible, constitutes only the area where the central and inner parts 
Fig. 41.-Diagram Sf the field of vision 
for white (1 cm. square test-object), tran- 
scribed upon a perimeter chart. 
long, dull black rod. They vary from 10 to 1 mm. in diameter. The examination is 
begun in the ordinary manner (at 30 cm.), with the 10-mm. disk, and then continued at 2 
meters' distance with a 3-mm. disk. In the first case the visual angle approximately is 2°; 
in the second, 5'. The normal boundaries in the first instance have been given; in the 
second they are 35° outward, 30° inward, 28° downward, and 25° upward. Small con- 
centric limitations are unimportant, but the method is valuable in finding sector-shaped 
defects, irregular limitations, and scotomas, and should supplement ordinary perimetric 
work in all important examinations (see page 85). W. G. Sym and A. H. H. Sinclair have 
well described the necessary apparatus for Bjerrum's test for scotomas in the field of vision 
(Ophthalmic Review, 1906, vol. xxv, p. 141); T. B. Holloway has designed a conveniently 
mounted set of Bjerrum's tests, white and colored (Transactions of American Ophthalmo- 
logical Society, 1911, vol. xii, p. 966); and H. M. Traquair (Ophthalmic Review, 1914, vol. 
xxxiii, p. 65) gives an excellent account of the quantitative method in perimetry. Clifford 
B. Walker, in his examinations of patients with intracranial lesions in Harvey Cushing's ser- 
vice, finds it necessary to investigate the field for test-objects varying in visual angle from 
1 or 2 minutes to about 8°, and has designed a series of nine circular rimless colored and 
white disks supported on wire handles which cover the required range, takingthe " normal " 
or 5-mm. disk as the unit. In this series the smallest disk is 0.15 mm. and the largest 4 
cm. in diameter. His special perimeter has a radius of 28.6 cm. and a large working surface 
60° by 130° in extent. THE FIELD OF VISION 
83 
overlap. This is evident from the diagram. The continuous line L 
bounds the field of vision of the left eye, and the dotted line R the visual 
field of the right eye. The central white area corresponds to the por- 
tion common to both eyes, or to that area in which all objects are seen 
at the same time with both eyes; the shaded areas correspond to the 
portions in which binocular vision is wanting. In the middle of the 
white area lies the fixation point/, and on each side of it the blind-spots 
of the right and left eye, r and I. 
Having thus determined the limits and continuity of the visual field, 
the functions of the peripheral parts of the retina in regard to percep- 
tion of colors, acuteness of vision, and appreciation of light should be 
investigated. 
The color-field is mapped in the manner described in connection 
with the general visual field, the squares of white being replaced by 
pieces of colored paper. 
Fig. 42.-Binocular field of vision (Moser). 
The order in which the colors are recognized from without inward is: 
(1) Blue; (2) yellow; (3) orange; (4) red; (5) green; (6) violet. In 
practical work, blue, red, and green are the colors employed, red and 
green being the color-sense most usually affected in pathologic cases. 
Non-saturated colors are not correctly recognized when the test-object 
is first seen. Thus, yellow at first appears white; orange, yellow'; red, 
brown; green, white, gray, or gray-blue; and violet, blue. The physio- 
logic limits of the color-fields, which, like those of the general field, are 
subject to variations, when estimated with a 1 cm. square test-object, 
the eye being 30 cm. from the fixing point, correspond closely to the 
following: 
Blue. 
Red. 
Green. 
Outward 
80 
65 
50 
Outward and upward . . 
60 
45 
40 
Upward 
40 
33 
27 
Upward and inward 
45 
30 
25 
Inward 
45 
30 
25 
Inward and downward 
50 
35 
27 
Downward 
58 
45 
30 
Downward and outward 
75 
55 
45 
These, when transcribed upon a chart, are represented in Fig. 43. 
The numbers represent the usual limits at which the color-test 1 cm. 
square is recognized as such. They do not indicate its greatest intensity. 84 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
which is perceived only at the fixation point. In order to avoid dis- 
crepancies, the character of the light, the nature and saturation of the 
color, and the size of the test-object should be stated in describing 
examinations. Always the visual field for colors as well as for white 
should be investigated with test-objects of various sizes. 
It should be remembered that the boundaries of the color-field which 
have been described result from examination with test-objects not 
greater than 1 or 1| cm. square. With larger areas of color it will be 
found, as Gowers and others 
have shown, that the color- 
fields differ in extent very little 
from the fields for white. 
According to Wolffberg, the 
color-limits contract concen- 
trically as the illumination is 
reduced, but if the photo- 
chemical and neuroptic ap- 
paratus is normal, there will 
be no change in the normal 
sequence of the color-limits. 
Blue should be employed in 
investigating defects in the 
photochemical apparatus, as it 
is the color first to disappear 
in reduced illumination; red 
suffers promptly in reduced 
excitability of the neuroptic 
apparatus. 
The acuteness of the vision of the peripheral parts of the retina may be 
tested with small squares of black paper (6, 5.3, and 2 mm. black quad- 
drants on a white ground), separated from one another by their own 
width, by noting the point in each meridian where they are recognized 
as separate objects; or with gray patches of different intensity on a 
white ground (Ward Holden). 
The light-sense of the periphery of the retina may be tested con- 
veniently with Ward Holden's tests. One card has a 1 mm. black 
point on one side and a 15 mm. quadrant of light gray, having four- 
fifths of the intensity of white, on the other. With a perimeter of 30 cm. 
radius the black point and gray patch are each seen by a normal eye 
outward, 45°; upward, 30°; inward, 35°; downward, 35°. The second 
card has a 3 mm. black point on one side and a darker gray patch, having 
three-fifths of the intensity of white, on the other. Each is seen on the 
perimeter arc outward, 70°; upward, 45°; inward, 55°; downward, 55°. 
Card 2 will reveal slight disturbances of light-sense near the periphery 
and card 1 in the intermediate and central zones. 
The perception of light, according to the experiments of Landolt, is 
the most constant function of the healthy retina, and remains nearly 
the same throughout its surface, while the color- and form-sense rapidly 
Fig. 43.-Diagram of the field of vision for 
blue, red, and green. The outer continuous line 
indicates the limit of the form-field; the broken 
lines, the limits of the color-fields. THE FIELD OF VISION 
85 
lessen toward the periphery. For practical purposes, a candle-flame 
passed along the arm of the perimeter may be used as a test-object; 
and, if vision is very defective, a second candle is made the point of 
fixation. Progressive diminution of light-sense from center to periph- 
ery will be found if test-objects of varying luminous intensity, with the 
illumination of ordinary daylight, are employed. 
The adaptation of the retina may be estimated according to Wil- 
brand's method by investigating the visual field in a dark room with 
test-object and fixation point streaked with luminous paint. The ex- 
amination is made as soon as the patient enters the dark room and again 
in ten minutes. This interval is sufficient to enable the normal eye 
to adapt itself so that the extent of the visual field corresponds to that 
of a white object in diffuse daylight. Delayed adaptation is a phenom- 
enon found in many pathologic conditions. 
Abnormalities of Visual Field and Scotomas.-The most frequent 
departures from those limits of the visual field assumed to be normal 
are general or concentric contraction; contraction limited especially to 
one or the other side; peripheral defects in the form of re-entering angles; 
absence of one segment or quadrant; and absence of the entire right or 
left half of the field. 
In addition to these defects, search should be made for dark areas 
within the limits of the visual field, or scotomas. These are distin- 
guished as positive when they are perceived by the patient in his visual 
field, and negative when within the confines of a portion of the visual 
field the image of an external object is usually not perceived, and the 
affected area is generally not discovered until the field is examined. 
Negative scotomas, however, may also be positive in the sense that the 
affected areas of the retina which are insensitive to luminous impression 
can be recognized as dark areas and be projected exteriorly (Fuchs). 
Negative scotomas are further divided into absolute and relative. Within 
an absolute scotoma all perception of light is wanting, while within the 
confines of a relative scotoma the perception of light is merely di- 
minished. The latter are color scotomas, usually for red and green. 
Scotomas are further subdivided, according to their situation and form, 
into central, paracentral, ring, peripapillary, and peripheral.1 A normal 
eye will develop a relative central scotoma in a darkened room, and if 
the darkness is increased the scotoma becomes absolute (Hess). 
In every normal eye there is a physiologic scotoma, corresponding 
to the position of the optic nerve entrance, which usually may be found 
15° to the outer side of and 3° below the point of fixation; the interval, 
according to Landolt, being greater in hyperopic than in myopic eyes. 
This is known as Mariotte's blind-spot. It is surrounded by a narrow 
zone of relative amblyopia for white about 1° in width. According 
to Hansell, the average distance of the center of the blind-spot from 
1 For a scotoma which lies between the fixation point and the blind-spot, such as 
occurs in toxic ambylopia (see page 489), Traquair proposes the name centrocecal scotoma, 
and for other defects of the central part of the field the terms supracentral, infracentral, 
nasocentral, temporocentral, and for defects adjacent to the papilla, supracecal, temporo- 
cecal, etc. 86 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
fixation point is almost identical in emmetropia and hyperopia, but in 
myopia is about 5 mm. greater. Should the horizontal diameter of the 
blind-spot for motion exceed 6°, according to Van der Hoeve, it is larger 
than normal, and may indicate the presence of beginning pathologic 
change. 
For the detection of scotomas, small test-objects, white or colored, 
| cm. square, are employed, which are moved in different directions 
from the point which the eye under observation attentively fixes, and 
the spot marked where the object begins to disappear or change its 
color. The arm of the perimeter is usually marked near the center in 
half-degrees for this purpose. All examinations around the center of 
the field of vision, and hence the examination for scotomas, are readily 
made upon a blackboard or a campimeter. 
Berry urges that the ordinary test for scotomas be supplemented by 
making an examination of the particular area of the field at a distance 
of 2 meters or more, so as to obtain a larger projection of the blind por- 
tion, and to be able to work with smaller retinal images, without neces- 
sitating the use of very small objects (see Bjerrum's method, footnote, 
page 81). Special instruments for detecting and measuring scotomas- 
scotometers-have been designed by Priestley Smith and P. C. Bardsley. 
Haitz employs a stereoscope with diagrams which gives binocular 
fixation. The card before the eye to be tested is covered with small 
squares with which the defect is detected and mapped; each side of a 
square subtends an angle of 1 degree at the distance at which the card 
is used.1 
Tension.-This term indicates the resistance of the ocular tunics, 
and is clinically demonstrable by palpating the globe with the finger- 
tips. The middle and ring-fingers are placed upon the brow of the 
patient, the tips of the index-fingers upon the eyeball, and gentle to-and- 
fro pressure made, the eyes being directed downward. This pressure 
must be made in such a manner as not to push the ball into the orbit; 
otherwise no information of its true resistance is obtained. The tension 
of one eye must always be compared with that of its fellow, and, in any 
doubtful case, the results may be contrasted with those obtained by 
examining an eye known to be normal in another patient of similar a^e. 
Normal tension is often expressed by the sign Tn, and the depart- 
ures from it formerly were indicated by the symbols + ?, + 1, + 2, 
+ 3, and - ?, - 1, - 2, - 3; the plus signs referred to increased, and 
the minus signs to decreased, resistance. In physiologic experiments, 
various kinds of apparatus, constructed upon the principle of the man- 
ometer, are employed, and for clinical purposes instruments known as 
tonometers have been devised. The most useful of these is the one 
designed by Schiotz. A modification of this tonometer has been con- 
structed by Gradle, and W. McLean has designed a direct reading to- 
nometer with constant weight factor. 
1 For a full description of various instruments designed for detecting and measuring 
scotomas, see J. Jameson Evans' article on "The Field of Vision" in The Ophthalmoscope, 
1911, vol. ix, p. 699. TENSION 
87 
The principle of the eye tonometer is thus defined by Priestley 
Smith: The instrument measures the impressibility of the eyeball, and 
from the degree of impressibility we infer the intra-ocular pressure. 
The Schiotz instrument is now in common use, and its construction 
may be readily understood from the accompanying diagram (Fig. 44). 
The patient should lie upon a table or reclining chair, with the head thrown back, 
and be requested to look directly upward. The eyeball is rendered insensitive with 
holocain (2 per cent, solution, three instillations at in- 
tervals of three minutes; Marple prefers a 2 per cent, 
solution of cocain) and the lids are separated without 
making pressure on the globe. Next, the surgeon, 
holding the instrument (with the 5.5 gm. weight in 
place) by the two arms attached to the cuff, which 
slips up and down the hollow cylinder, brings its foot- 
piece exactly at rest on the cornea, the cuff being slid 
down so as to be about the middle of the cylinder. 
The instrument should stand freely, resting exactly on 
the center of the cornea. The deflection of the needle 
is recorded, and from a diagram which accompanies 
the instrument it may be seen with how many milli- 
meters of mercury the deflection of the needle corre- 
sponds; thus, should the needle, with the 5.5 gm. weight 
in place, register 3, this corresponds to 25 mm. of 
mercury. Schiotz advises that three measurements 
shall be made and the average of the readings re- 
corded. Some surgeons prefer a single reading taken 
with great care, but, as Priestley Smith insists, it is not 
safe to rely on a single reading; it should be confirmed 
by at least two additional readings. There are four 
weights, respectively 5.5, 7.5, 10, and 15 gm. If the 
needle is not deflected beyond 1, the measurement 
should be repeated with a greater weight. Accord- 
ing to Schiotz, deflections between 2 and 4 mm. yield 
the most accurate results. The foot-piece of the in- 
strument should be cleansed in a boric acid solution. 
The normal pressure, it is usually stated, 
varies from 14 to 28 mm. of Hg., that is, 14 is 
the low and 28 the high physiologic limit, although an eye with 
a tension above 25 should be regarded with suspicion. According 
to Schiotz, normal tension varies between 15.5 and 25; according to 
Marple, between 15 and 25; according to Stock, between 12 and 26, 
and according to Heilbrun, between 12 and 27. Neither the state of 
the refraction nor the age has an appreciable effect on the ocular ten- 
sion, nor is it influenced by mydriatics, except that cocain slightly 
diminishes the tension of the normal eye (Heilbrun). According to 
Heilbrun, eserin and pilocarpin usually lower slightly the tension of the 
normal eye, an observation which is not confirmed by Marple's results. 
In this respect the author's observations agree with those of Heilbrun. 
Although records in the form of mm. Hg., as stated above, are usually 
made, as Priestley Smith points out, the reading and not the supposed 
equivalent in mm. Hg. should be stated (see also page 368). To 
Fig. 44.-Schiotz tonom- 
eter. 88 
EXTERNAL EXAMINATION OF THE EYE-FUNCTIONAL TESTING 
estimate the ocular tension by means of the finger test is not a safe nor 
an accurate procedure, and in all cases where this is an important ob- 
servation the tonometer should be used. 
Proptosis, exophthalmos, or protrusion of the eye, may be caused 
by orbital diseases and tumors, sinusitis, tenotomy and paralysis of 
the ocular muscles, Graves' disease, and sometimes by chronic nephritis 
(L. Barker), and by intracranial neoplasms, especially if situated in the 
middle fossa of the skull; while enlargement of the ball is the result 
of various conditions residing within the globe-myopia, buphthalmos, 
intra-ocular tumor, and staphyloma. If the cause is unilateral, the 
resulting condition is asymmetric, and the two eyes may be compared 
by observing the relative positions of the apices of the cornese with each 
other and with the line of the brows. For measuring the degree of 
exophthalmos Edward Jackson has devised a simple scale or proptometer. 
A useful and accurate instrument for this purpose is the exophthalmometer 
of Hertel. A more elaborate instrument is the one designed by Loh- 
mann. A slight protrusion of the eyeball takes place when the palpe- 
bral opening is voluntarily decidedly widened (see also page 592). 
The eyeball is apparently sunken ^enophthalmos) in some cases of 
ptosis, in wasting of the orbital fat, in orbital injury, and is diminished 
in size in high grades of hyperopia and congenital failures of develop- 
ment. As Nettleship has pointed out, the amount of exposed sclera 
decides the apparent protrusion or recession of the' eyeball (see also 
page 592). 
Position of the Eyes.-Instead of presenting parallel visual axes, 
one eye may be deviated inward, outward, downward, or upward, con- 
stituting one of the various types of strabismus (see page 523), a con- 
dition which may or may not be associated with diplopia (see page 528). CHAPTER III 
REFLECTION, THE OPHTHALMOSCOPE AND ITS THEORY. 
OPHTHALMOSCOPY AND SKIASCOPY 
Reflection.-When light falls upon a polished surface a portion of 
it is reflected. The angle of reflection is always equal to the angle of 
incidence. A polished surface, capable of reflecting light, is called a 
mirror. Mirrors are plane, concave, 
or convex. 
A plane mirror reflects the rays 
falling upon it, so that they seem to 
come from a point as far back of the 
mirror as the object lies in front of 
it. It does not render the rays either 
convergent or divergent, nor does 
it lessen their convergence or diver- 
gence. Rays parallel before reflec- 
tion are parallel after reflection. Rays convergent or divergent before 
reflection maintain the same relation after reflection. In the figure, 
rays from the object 0-B, falling upon the mirror, M, are reflected so that 
they enter the observer's eye, and seem to him to come from O'-B', 
situated as far back of the mirror as 0-B is in front of it. The image is 
Fig. 45.-Reflection from a plane mirror. 
Fig. 46.-Reflection from a concave mirror. 
not inverted. The rays have a divergence from a point whose distance 
is equal to the sum of the distance from the light to the mirror, and of 
the distance from the mirror to the eye (compare Skiascopy). 
A concave mirror converges parallel rays of light to its principal focus, 
and forms a real, inverted image in front of the mirror. 
89 90 
OPHTHALMOSCOPY AND SKIASCOPY 
The principal focus of a concave mirror is equal to one-half the length 
T 
of its radius of curvature, F = -. 
A 
The conjugate focal distance for any point greater than the principal 
focus may be found by the following formula: /' represents the distance 
from which the rays diverge (the lamp or candle); f" is the distance of 
the conjugate focus. 
f + f F- 
1 1 _ 1 
f" ~ F~ f 
This is understood by recollecting that F is the focus for parallel 
rays, and that the focus is the inverse of the reflective or catoptric power 
of the mirror. The rays which diverge from f' require of catoptric 
power to render them parallel. This diminishes the catoptric power of 
the mirror to 
± the focal length of J" is the conjugate focal distance 
required. 
Example.-The ophthalmoscopic mirror has a focus of 20 cm., its radius of cur- 
vature being 40 cm. A candle is situated at 30 cm. in front of it, and we wish to 
know the conjugate focal distance: 
F = 20 cm. f' = 30 cm. ± f" = 60 cm. 
OU J J £\j OU uu 
The rays of the candle would be rendered convergent to a point 60 cm. in front of 
the mirror. The light being placed at a greater distance than the principal focus, the 
rays are convergent. 
A convex mirror renders parallel rays divergent as if they came from 
its principal focus, which is negative, situated behind the mirror, at a 
distance equal to one-half the radius of curvature. The image is erect 
and small. 
The conjugate focal distances for convex mirrors are obtained by 
the same formula as for concave mirrors, the sign - being prefixed to 
F and f". 
The cornea, by reflecting light, corresponds to a convex mirror, and 
in this relation is important in ophthalmometry. The principal focus 
of the corneal mirror is about 4 mm., the radius of curvature being 
7.829 mm. The size of the image reflected from the cornea is pro- 
portional to the size of the object as the focus of the corneal mirror, 
4 mm., is to the distance of the object. A candle-flame 20 mm. in diam- 
eterv situated at 100 mm., gives a corneal image whose size is found in 
this manner: Image : 20 : : 4 : 100. iFFFF = Image = 0.8 mm. 
1UU THE OPHTHALMOSCOPE 
91 
If the radius of curvature is greater, the image is also greater; if the 
radius of curvature is smaller, the image is smaller. By this means 
curvature ametropia may be measured. 
The size of the cornea image is so very small that it would not be 
feasible to attempt direct measurement of it. If two candles which 
are ^separated some distance are employed as an object, each candle 
represents one extremity of the object. The size of the object is, then, 
the distance between the two candles; the size of the image is the dis- 
tance between the reflected images of the candles. Suppose this dis- 
tance to be 3 mm. and by means of a double refracting prism two 
images of each candle are seen; if they are displaced by the prism exactly 
3 mm., so that a straight line passes through all the images, two of them 
must overlie, as the images are 3 mm. apart. Small variations in curva- 
ture will now be manifest if the two images, which should overlie exactly, 
shoot past each other or fail to come together. The change of form in the 
crystalline lens during accommodation is proved by this experiment. 
THE OPHTHALMOSCOPE 
For the purpose of studying the interior of the living eye an instru- 
ment known as the ophthalmoscope, the invention of which, in 1851, we 
owe to the genius of von Helmholtz, must be employed. The original 
Helmholtz ophthalmoscope was composed, in general terms, of three 
thin glass plates, set in a suitable frame at an angle of 56 degrees to the 
line of sight, by means of which the light was reflected into the observed 
eye. With this instrument the details of the eye-ground can be studied 
under a weak illumination. 
The modern ophthalmoscope consists essentially of a concave sil- 
vered mirror for illuminating the eye, and of lenses .for measuring and 
modifying its refraction (refraction ophthalmoscope'). The mirror is 
perforated, as originally suggested by Rente, and swings to either side, 
so that the obliquely incident rays may be reflected into the eye with- 
out having to tilt the entire instrument, and thus narrow the aperture 
and render the lenses astigmatic. The lenses are inserted in a disk, 
invented by Rekoss, which can be rotated in front of the sight-hole. 
A plane mirror, which can be substituted for the concave mirror, is a 
valuable addition. Many ophthalmoscopes contain two disks, which 
can be used either singly or in combination. This arrangement affords 
a series of lenses from 0.50 to 24 D concave, and from 0.50 to 23 D 
convex, with which the observer is enabled to view distinctly the details 
of the eye-ground in all forms of ametropia. A lens varying from 13 to 
20 D accompanies the instrument for focal illumination of the cornea 
and lens, and for use in the indirect method of ophthalmoscopy. Among 
the many ophthalmoscopes at the student's disposal, in the author's 
opinion none is better than the Loring instrument (Fig. 47). Excellent 
models have been designed by Edward Jackson, B. A. Randall, and 
A. S. Morton. 
Electric ophthalmoscopes, for which we are largely indebted to W. S. 
Dennett, are very useful in the examination of bedridden patients. The 92 
OPHTHALMOSCOPY AND SKIASCOPY 
source of illumination consists of an electric bulb in the end of the handle, 
the light of which is condensed by a lens on a suitably tilted mirror 
which reflects it into the eye; indeed, they are essential for accurate 
work. W. B. Marple's electric ophthalmoscope is, in the opinion of the 
author, the best of these instruments thus far designed (Fig. 48). A 
convenient model is the one designed by George Crampton, the handle 
of which contains the electric battery, and admirable ophthalmoscopes 
Fig. 47.-Loring's ophthalmoscope, with tilting mirror, complete disk of lenses from 
- 1 to - 8 and 0 to + 7, and supplemental quadrant containing ± 0.5 and 16 D. 
This affords 66 glasses or combinations from -p 23 to - 24 D. 
of this character have been devised by S. Lewis Ziegler, Claiborne, and 
Charles H. May. 
Large demonstrating ophthalmoscopes have a distinct value in oph- 
thalmoscopic work. The Gullstrand ophthalmoscope is the most per- 
fect instrument of the type. It is free from annoying reflections and 
furnishes magnifications from 5 to 40 times in monocular and 20 times in 
binocular observations. 
Direct Method.-The rays from the concave mirror, somewhat 
converging, enter the pupil and are brought to a focus in the vitreous 
humor. After reaching their focus the rays diverge again and spread 
out on the retina into a circle of diffusion. The portion of the retina 
thus illuminated sends rays back again, which pass through the dioptric DIRECT METHOD 
93 
media of the eye and are refracted to its far point-that is, if the eye is 
emmetropic, they emerge parallel and would meet at an infinite dis- 
tance; if the eye is myopic, they converge to their far point in front of 
the eye; if the eye is hyperopic, they diverge from their far point back 
of the eye (see also page 106). 
An observer's eye, in order to focus these rays, must be adapted to 
them. If the patient is emmetropic, the observer's eye must also be 
rendered emmetropic. If the patient is hyperopic, the emmetropic 
Fig. 49.-Examination in the erect image when the eye 
examined is hyperopic, emmetropic, or myopic. In each 
figure three rays are shown emanating from a luminous point 
on the eye-ground. In hyperopia they diverge after leaving 
the eye; in emmetropia they are parallel; in myopia they con- 
verge. _ f, The posterior focus; H, principal plane of the 
dioptric system of the examined eye; Be, observer. The 
ophthalmoscope is not shown (Haab). 
Fig. 48.-Marple's elec- 
tric ophthalmoscope. 
observer must add a convex glass to his eye, or use his accommodation, 
in order to make the divergent rays parallel. If the patient's eye is 
myopic, the emmetropic observer must place a concave glass before his 
eye to render the convergent rays parallel. If the observer is ametropic, 
he must first correct his ametropia with suitable lenses (see also page 107). 
A hyperopic observer might see distinctly the eye of a myopic patient, or 
a myopic observer might see the eye of a hyperope. In either case the 
hyperopia must at least be as great as the myopia. 94 
OPHTHALMOSCOPY AND SKIASCOPY 
In this method the observer sees the eye just as he would see an 
object through a convex glass or simple microscope. The image of the 
eye-ground is a virtual one-that is, it seems to be behind the eye. 
It is magnified and erect. 
The formation of the image in the direct method may be understood by 
examining Fig. 50. 
Divergent rays and convergent rays have been described, but always 
in relation to one point (see page 22). It is now necessary to consider 
their meaning in reference to an image. 
An image is composed of a succession of points; each one of these 
points represents a point in the object. From the point in the object 
one ray passes to the optical center of the lens or lenses, and maintains 
Fig. 50.-Diagram of the direct method with the formation of an upright image: Rays 
from the source of light, L, are received upon the concave mirror, M, and converged upon the 
observed eye, Obd, within which they cross and illuminate an area of its fundus. From an 
area A-B thus lighted, rays pass out of the pupil (parallel if it be emmetropic, as here 
represented) through the sight-hole of the mirror, and, entering the observer's eye, Obr, 
are focused upon his retina. An image is there formed as though the object seen were at 
a great distance, and the perceptive centers project it into space as though the object were 
at some arbitrary distance (e. g., 25 cm.). By the laws of magnification by a simple lens 
the image is embraced between the lines passing from the optical center of the magnifying 
lens (the refracting system of the observed eye), through the extremities of the object, and 
has the size A'-B', A"-B", etc., according to the distance of projection. In hyperopia 
rays from A and B would be divergent, and the observer would have to render these rays 
parallel by a convex glass or by using his accommodation. In myopia these rays would be 
convergent, and a concave glass would be required to neutralize their convergence and 
render them parallel (B. A. Randall). 
the same direction after passing through it. This ray is called the axial 
ray; it passes to the corresponding point in the image. Other rays from 
the same point in the object diverge from the axial ray at various angles; 
a bundle of these rays is called a pencil. The size of a pencil is deter- 
mined by the diameter of a lens or the aperture of the pupil. The lens 
gives these unequally diverging rays a direction to a common point or 
focus. From each point in the illuminated part of the retina a pencil 
of rays falls upon the crystalline lens and cornea. The size of this 
pencil equals the diameter of the pupil; to form an image each pencil of 
rays must be concentrated into one point. By diverging and converg- 
ing rays is meant the relation the rays from each point bear to each other, 
not the relation of rays from different points. INDIRECT METHOD 
95 
Size of the Image.-The details of the eye-ground are considerably 
magnified in the direct method of examination. In the emmetropic 
eye the enlargement is found by the following formula: The distance 
of the retina from the nodal point (optical center) of the eye is 15 mm. 
The observer projects the image which he sees to the point at which 
small objects are usually held, say 250 mm. The enlargement of the 
disk is proportional to these two distances, 15 : 250 : : 1.5 mm. : 25 
mm. 16.6 = the enlargement. It is comparable to looking at the 
disk through a lens of 15 mm. focus, 66 diopters. 
It is to be remembered that the farther this image is projected, the 
larger it appears. In hyperopia the enlargement is less than this. In 
myopia, on the contrary, it is greater. 
Indirect Method.-In the indirect method of ophthalmoscopy a 
real, inverted image of the interior of the eye is obtained by means 
of a strong convex lens (object-lens), the principle involved being similar 
to that of a compound microscope. 
The observer holds the object-lens (a convex lens of about 20 diop- 
ters) close to the patient's eye, and, placing a convex lens of 5 diopters 
(eye-piece) behind the ophthalmoscope, throws the light into the pupil 
and moves his eye nearer to or farther from the patient's eye until he 
distinctly sees a vessel or a portion of the nerve-that is, a real image of 
the eye-ground is formed by the object-lens at its focal distance in front 
of the eye. The observer sees this image, in which all the relations of 
objects are reversed. His eye is at a distance from the image equal to the 
focus of the lens in the ophthalmoscope-viz., 20 cm. 
The image being inverted, the lower portion of it corresponds to the 
upper part of the eye-ground, and the right side of the image corre- 
sponds to the left side of the eye. If the observer moves upward, the 
image moves downward; if the observer moves to the right, the image 
moves to the left. Consequently, the upper part of the image must be 
viewed if it is desired to see the lower part of the eye-ground, and the 
right side of the image if parts of the fundus to the left are to be ex- 
amined. 
A comparison between the images as seen by the direct and indirect 
method may be stated thus: If, in the direct method with the disk in 
view, the observer moves his head to the right, he brings into view a 
portion of the retina to the left of the disk. The disk now moves out of 
the field toward the right, and disappears behind the right edge of the 
pupil. The image, therefore, moves with the observer. If, in the in- 
direct method with the image of the disk in view, the observer also moves 
his head to the right, he sees the image of the same portion of the retina 
as in the direct method; but this being to the left of the disk, its image 
occupies a point to the right of that of the disk. The disk thus appears 
to have moved toward the left. The image, therefore, moves contrary 
to the movement of the observer's head. Movements in other directions 
are explained in the same way. 
The formation of the inverted image in ophthalmoscopy may be 
understood by examining Fig. 51. 96 
OPHTHALMOSCOPY AND SKIASCOPY 
In hyperopia and emmetropia a convex lens is necessary to render the 
rays convergent. In myopia the rays emerge convergent, and the 
convex lens may be dispensed with in the higher grades, though it is still 
an advantage because it increases the area of the fundus visible at one 
time. 
Size of the Image.-The enlargement of the image in this method is 
less than it is in the direct method, but a larger portion of the eye-ground 
is visible at one time. 
The size of the real image of the eye-ground of an emmetropic eye 
formed by the convex object-lens held at its own focal length from the 
eye is determined by the following formula: The size of the disk is to 
the size of the image as the distance from the retina to the nodal point 
(15 mm.) is to the focal length of the object-glass. If the lens has a focal 
length of 75 mm., the ratio is 15 :75; the enlargement is then 5 diam- 
eters. A lens of 60 mm. focus would equal an enlargement of 4 
diameters-15 : 60. 
Fig. 51.-Diagram of the indirect method giving an inverted image: Rays from the 
source of light, L, converged toward the observed eye, Obd, by the concave mirror, M, are 
intercepted by the lens, Obj, and after coming to a focus diverge again and light up the 
fundus. From a part of the illuminated fundus A-B rays pass out of the pupil to be again 
intercepted by the lens 0 and form an inverted real image at its anterior focus A'-B'. 
This real image is viewed by the observer's eye behind the sight-hole of the mirror with the 
aid of a magnifying lens, Oc, and is seen enlarged, as at A"-B" (B. A. Randall). 
The observer will see this image under a higher angle in proportion 
as he comes closer; it will then appear larger. To do this, he must either 
use his accommodation or place a convex lens (eye-piece) behind the 
ophthalmoscope. When the eye-piece is used, a virtual image of the 
aerial image, still more enlarged, is produced, just as in the compound 
microscope. If the object-lens is withdrawn farther than its focal 
length from the observed eye, the image in myopia becomes larger, in 
hyperopia smaller, and in emmetropia remains the same. If the lens is 
brought closer to the eye, the image becomes smaller in myopia and 
larger in hyperopia. 
Ophthalmoscopy.-The investigation of the deeper structures and 
interior of the eye by means of the ophthalmoscope may, therefore, be 
practised with (1) the direct, and (2) the indirect method. 
1. The Direct Method (Method of the Erect or Upright Image).- 
The patient should be seated in a darkened room with his back to the OPHTHALMOSCOPY 
97 
source of illumination-an Argand burner or properly constructed and 
shaded electric light being suitable-which is placed behind and to the 
side of his head, on a level with the ear, the face being in shadow, while 
the rays of light just fall upon the outer canthus of the eye. This will 
enable the observer to come quite close to the eye without interfering 
with the path of the illuminating beam. The surgeon sits at that side 
of the patient which corresponds to the eye under examination-for 
example, the right-his position being preferably on a slightly higher 
level than that of the subject. He now takes the ophthalmoscope in 
his right hand, looks through the sight-hole with his right eye, at a dis- 
tance of about 50 cm. from the observed eye (the convex border of the 
instrument being in contact with the concave margin of his brow), 
meanwhile keeping the other eye open, and reflects the light into the 
right eye of the patient. If the left eye is to be examined, the ophthal- 
moscope is held in the left hand. 
If an electric ophthalmoscope is used, the instrument carries the source 
of illumination. Moreover, it is not necessary that the room shall be 
darkened. 
If the patient looks directly into the light, the pupil, provided this is 
not dilated with a mydriatic, will contract, and no satisfactory view is 
possible. He must hence be directed to turn the head slightly to the 
right, and gaze into vacancy in the farthest limit of the room, when the 
pupil will be seen illuminated by a red glare-the reflection from the 
choroid coat-bright if the pupil is large, and dull if it is small. No 
details of the fundus are as yet visible at this distance (50 cm.) unless 
a certain grade of myopia is present or a considerable degree of hyper- 
opia (see page 106). 
The beginner should now practise keeping the light steadily in 
position, and may estimate the success of his endeavor by observing the 
glare in the pupil. If this changes in color or disappears, the light has 
shifted from its proper position because the examiner has failed to 
retain his elbow in close contact with his side, and allowed it to move 
outward and away from his body, the head meanwhile being bent to one 
or the other side of the vertical position it should assume in a direct 
line with that of the subject-feature to feature. This may be under- 
stood by observing the two accompanying illustrations (Figs. 52 and 
53). 
Having gained control of the light, the observer gradually approaches 
the eye of the patient, taking care that the red glare, which is tinted 
slightly yellow on the nasal side, marking the position of the optic 
papilla, remains unaltered, and comes as close as possible-within 1 inch 
or even nearer. If the maneuver has been successful, and the light 
directed slightly toward the nasal side, the most prominent feature 
in the eye-ground-the optic nerve-will come into view'; or a retinal 
vessel may first be manifest, and should be follov'ed to the papilla as a 
stream would be to its source. 
Before proceeding to study the details of the fundus the student 
should make certain preliminary examinations. 98 
OPHTHALMOSCOPY AND SKIASCOPY 
Fig. 52.-Ophthalmoscopic examination. Method of the upright image. Observer and 
patient in the correct position. 
Fig. 53.-Ophthalmoscopic examination. Method of the upright image. Observer in an 
incorrect position. 
(a) Examination of the cornea and lens by transmitted light 
is made by placing a + 7 D or 16 D lens behind the mirror, coming close 
to the eye-that is, until the object to be examined is within the focal LOCATION OF OPACITIES IN THE TRANSPARENT MEDIA 
99 
distance of the lens employed, and reflecting the light into the eye in 
the manner already described. 
A foreign body on the cornea, a macula, a deposit on the posterior 
layer of the cornea, or an opacity in the lens appears as a black object 
against the red background, in contradistinction to its appearance in 
its true color under oblique illumination (see page 51). 
At the same time the mobility of the iris should be tested, and an 
observation made as to whether the iris reacts promptly and evenly 
under the influence of the light directed into the pupil at various angles. 
(5) Examination of the vitreous is made by reflecting the light 
with the concave or, better, the plane ophthalmoscopic mirror, from a 
distance of 30 cm. into the eye, while this is moved in various directions 
so as to bring into view opacities which have a lateral situation or which 
have sunk to the bottom of the vitreous chamber. 
Vitreous opacities and detached retina are seen in the erect position 
if the observer is sufficiently far away, because they are within his 
range of accommodation. Small vitreous opacities appear dark; larger 
ones have a grayish appearance. If he approaches closely, he must 
place behind the mirror a convex lens, in the manner just described, to 
bring them into focus, and should always use this method. 
(c) Location of Opacities in the Transparent Media.-If, the 
observer using the ophthalmoscopic mirror in the manner described in 
the previous paragraph, an opacity is seen to be freely movable, it must 
be in the vitreous. Should the opacity move only with the movement 
of the eye, but not spontaneously, it probably is situated in the cornea 
or in the lens, although it may be present in the vitreous in the form 
of a fixed opacity. In these circumstances a differential diagnosis can 
frequently be made by means of oblique illumination. Should this 
method prove insufficient, the situation of the opacity may be ascer- 
tained by means of its parallactic movement in relation to the border of 
the pupil. Fuchs states the rule as follows: 
The observer looks directly forward into the eye and notes the 
position of an opacity within the pupillary space. Next, while the 
patient keeps his eye entirely quiet, the examiner slowly moves from 
side to side and observes if the opacity retains or does not retain the 
same position in the pupillary space. If the opacity retains its posi- 
tion unchanged, it lies in the pupillary plane upon or immediately 
under the anterior capsule of the lens. If it does not retain its original 
position, it is situated in front of or behind this plane-in front of the 
plane if the opacity moves in a direction opposite to the direction of the 
movement of the observing eye, and behind the plane if the opacity 
moves in the same direction as the observing eye. The quicker the 
change of position takes place, the farther is the opacity removed from 
the pupillary plane. 
Instead of proceeding in this manner, the observer may retain his 
position unaltered and cause the patient to move his eye in various 
directions. 
When an opacity is far back in close relation with the retina, its 100 
OPHTHALMOSCOPY AND SKIASCOPY 
location may be judged by noting its relation to the movement of the 
retinal vessels. How far forward it lies in the vitreous may be accu- 
rately measured by means of convex lenses (see page 107). 
Having ascertained that the media are clear, and having approached 
sufficiently close, the details of the fundus oculi are brought into view 
and studied seriatim. 
If either surgeon or patient is myopic, the necessary concave lens 
which corrects the error must first be placed in position; while, if hyper- 
opia exists, the fundus is visible without the aid of a glass, provided the 
hyperopia is not in excess of the power of accommodation. 
Beginners, however, often fail to obtain an image of sharp definition, 
owing to inability to relax accommodation, and succeed in seeing the 
details clearly only through a concave glass. The power of relaxing the 
accommodation comes with practice. 
The optic nerve appears as a nearly round or slightly oval disk, 
situated toward the nasal side, varying in color from a grayish pink to 
a more decided red, the tint being most marked upon the nasal half, 
while the center is occupied by a whiter patch-the "light spot"- 
marking the position of the entrance and emergence of the retinal 
vessels. The general tint of the optic disk varies with the age and com- 
plexion of the patient and with the intensity of the color of the sur- 
rounding eye-ground. 
The papilla is bounded by two rings. The outer one, dark colored^ 
usually incomplete or existing only as a slight crescent of pigment upon 
one or the other side, is the choroidal ring, and represents the border 
of the choroidal coat, where this is pierced by the optic nerve. Within 
this is a faint white stripe, more distinct in elderly people, the scleral 
ring, which indicates the rim of the sclerotic coat, or, according to 
Loring, the connective-tissue elements of the inner sheath of the nerve 
{connective-tissue ring). The choroidal ring is often imperfectly pro- 
duced or entirely absent. 
The central white patch may be noticeable only by contrasting it 
with the color of its surroundings, or it may be a distinct excavation, 
occupying the center of the disk, and having sharp borders, one of 
which often shelves slightly outward. This is the physiologic cup, and 
is the space left by the radiation of the nerve-fibers toward the retina, 
having a floor of white color, because it is composed of the interlacing 
opaque fibrous tissue, or lamina cribrosa, which underlies the optic 
papilla. It is often stippled in appearance, owing to the lack of light 
reflected by the non-medullated nerve-fibers, which pass through the 
spaces of the lamina. According to Schoen, the so-called physiologic 
excavations are due to dragging of the vaginal processes of the optic 
nerve and lamina cribrosa from overexertion of the accommodation, 
and hence are found in adult eyes more commonly than in the eyes of 
children. They are usually but not always bilateral, and one may be 
larger than the other. Schweigger traced hereditary transmission in 
some large physiologic excavations, but doubted if they were associated 
with any particular refractive condition of the eye. Plate I. 
1 he normal fundus of the right eye examined by the direct method 
of ophthalmoscopy. THE BLOOD-VESSELS 
101 
The Blood=vessels.-From the central light-spot the principal 
retinal arteries emerge, and into it the chief venous trunks empty. Usually 
one venous and one arterial stem pass directly upward and downward, 
and on the edge of the disk, or a short distance from it, each divides into 
two branches. Sometimes this division has taken place in the axis of 
the nerve behind the lamina, and two arteries and two veins appear 
directly in the central opening of the papilla, or porus opticus. The 
arteries traverse the surface of the eye-ground, dividing dichotomously 
into numerous branches, and, passing above and below, spread in greater 
size and number over the temporal half of the retina, sending small 
branches toward the macula; and in smaller size and less number over 
the nasal side. Fine branches arising from the central large trunks, or 
springing directly from the nerve, pass outward and inward, and also 
undergo numerous divisions. 
The veins pass over the eye-ground in the same general direction 
as the arteries, and in close relation to them, emptying usually by means 
of two large branches into the center of the disk. 
According to the situation of the vessels, they are named, respec- 
tively, upper and lower temporal artery and vein, upper and lower nasal 
artery and vein, and macular and nasal arteries and veins. 
The veins are dark red in color, contrasting with the bright, natural, 
blood-red color of the arteries. They are slightly tortuous, and larger 
than the arteries in the proportion of 3 to 2. The difference in color 
between veins and arteries is most marked in the major branches. In 
the finer twigs, after four or five divisions, the distinction between 
arteries and veins is often possible only by tracing them to their source. 
Each vessel usually presents a double contour, owing to a bright 
stripe which passes along the center, leaving a red line on either side. 
This so-called light-reflex has been ascribed to a condensation by the 
refractive action of the blood column of the rays of light which have 
passed through the vessel from in front, and have been reflected back 
slightly from the posterior wall, but chiefly from the underlying tissues.1 
It is more marked upon the arteries than upon the veins, and, indeed, 
is often absent as the latter cross the disk, being visible in a minor 
degree when they lie at some distance in the retina. 
Pulsation.-The retinal arterial pulse has been classified by Ballan- 
tyne aS follows: (1) Locomotor pulse, that is, a rhythmic displacement of 
the artery almost synchronous with the cardiac systole; (2) the expansile 
pulse, being a broadening of the blood column; (3) the capillary pulse, 
being a variation in the tint of the optic disk, and (4) the pressure pulse, 
a rhythmic collapse or disappearance of the artery, observed in glau- 
coma, and produced by pressure on the eyeball, and sometimes called 
1 The cause of the light streak was usually attributed to reflection from the anterior 
surface of the vessel wall or the anterior surface of the blood column, until Loring main- 
tained that the refraction of light was the chief cause of the phenomenon. A. E. Davis 
endeavored experimentally to confirm Loring's conclusion. Story rejects Loring's theory, 
and assumes that the reflex comes from the vessel walls. Dimmer ascribes the retinal 
reflex to the axial blood-stream in the arteries and in the veins to the surface of the blood- 
stream. Elschnig believes that both in arteries and veins it is the surface of the blood 
column which causes the reflex. 102 
OPHTHALMOSCOPY AND SKIASCOPY 
the collapsing pulse. The locomotor pulse is physiologic, at least not 
pathologic; the expansile pulse may occur in healthy persons, or may be 
associated with aortic insufficiency; the capillary pulse is seen with 
aortic regurgitation; the pressure or collapsing pulse is observed in 
glaucoma, in aortic regurgitation, and in syncope. 
Spontaneous pulsation in the veins is a frequent phenomenon. 
Lang and Barrett found it in 73.8 per cent.; Veasey, in 58.3, and the 
author, in 62.1 per cent, of their examinations. It may be produced by 
a slight pressure upon the globe. The spontaneous pulse is due to a 
communication of the arterial pulsation to the vein, as these vessels lie 
side by side in the optic nerve, or may be explained by the theory of 
Donders, that during the systole of the heart (diastole of the retinal 
arteries) an increased tension in the vitreous is communicated to the 
walls of the retinal veins, especially the larger ones, at their exit from 
the eye where the least resistance is offered, obstructing the flow of 
blood and compressing their lumen. The blood coming from the capil- 
laries overcomes this resistance and the vessels regain their caliber, 
alternate collapse and distention thus being produced. According to 
Turk, the venous pulse is due to a continuation of the arterial pulse- 
wave through the capillaries into the veins. 
Physiologic Variations.-The papilla, instead of being round or 
slightly oval, with a vertical long axis, is often distinctly irregular in 
outline, or has its long axis in a horizontal or oblique direction. Its 
outer half may be embraced by a crescent of greater or less choroidal 
changes, the so-called conus. A congenital crescent of white appear- 
ance, the underlying conus, may sometimes be seen below (see page 470), 
and occasionally is very broad, approximating in appearance a coloboma 
of the nerve-sheath (see page 469). 
The physiologic cup varies in size, area, and depth. Normally situ- 
ated on the temporal side, it may be a deep pit, funnel shaped, with 
overhanging margins over which the vessels sharply bend, or very 
shallow and dish-like, sloping to the temporal side, or deep and sharply 
marked on its inner side, but shading outward. 
The distribution of the vessels is subject to numerous variations-so 
much so that it would be difficult to find it the same in any two eyes. 
The usual departure from the ordinary type is the one already referred 
to, in which four major branches (two arteries and two veins) appear at 
the center of the porus, instead of two large branches which later divide 
at or near the margin of the disk. Anomalies of the veins upon the disk, 
in the form of unusual bifurcations, are occasionally seen. Division 
of the vein just before entering the disk; division at the margin; the for- 
mation of a vascular circle and final reunion in a single vessel; and 
anastomosis of the central vein with an aberrant vein, or one which has 
penetrated the inner side of the disk, have been described (Randall). 
The veins are normally more tortuous than the arteries. Both sets of 
vessels present this appearance in marked degree in certain pathologic 
conditions, but also occasionally as an anomaly without such signif- 
icance (Fig. 54). Again, the vessels may stand forward from the disk PHYSIOLOGIC VARIATIONS 
103 
in a high curve, or twine around each other, as we sometimes see two 
stems on a vine. Marked enlargement of the anastomoses about the 
nerve entrance, which anastomoses, according to Leber, connect the 
retinal and ciliary vascular systems at the level of the papilla and at 
the level of the choroid, have been described by George Coats. 
An anomaly of not infrequent occurrence (7 to 10 per cent, of ex- 
amined eyes) is a cilioretinal vessel, usually, according to Elschnig, an 
artery, which appears at the temporal border of the disk, then arches 
outward or away from the papilla, enters the retina, and pursues a gen- 
eral course toward the macula. A large cilioretinal vessel may take the 
place of one of the temporal arteries. According to Elschnig, a cilio- 
Fig. 54.-Congenital tortuosity of vessels. Note the breadth of the scleral ring. 
retinal vessel may be a primary branch of a ciliary artery which pierces 
the sclera obliquely, without sending a branch to the choroid, and then 
enters the intrascleral or intrachoroidal part of the optic nerve, or an 
offset of a ciliary vessel which primarily enters the choroid, where it 
divides, and one branch passes on into the retina and produces the 
anomaly in question. Cilioretinal veins may arise from the choroidal 
vascular system. Opticociliary vessels are uncommon. They are prac- 
tically always veins, only two instances of opticociliary arteries having 
been reported (Coats). They pass from the central vessels to the disk 
border, where they disappear under the retina into the choroid. In 
reporting a case of this character W. T. Shoemaker regards the anom- 
alous vessel as representing an aberrant choroidal vein. 104 
OPHTHALMOSCOPY AND SKIASCOPY 
The Retina.-Inasmuch as the retina is practically transparent, a 
study of this membrane is hardly possible without a consideration of the 
underlying choroid and even the sclera. 
In certain persons, especially of dark complexion, the retina assumes 
a grayish tint in the neighborhood of the papilla, most marked upon 
its nasal half. This faint opacity is slightly streaked, the striations 
indirectly corresponding to the expansion of the optic nerve-fibers. 
Eyes long subjected to the strain of uncorrected ametropia furnish an 
exaggerated picture of this appearance, which, if at all extensive and 
associated with similar opacities along the lines of the vessels, assumes 
pathologic importance (see Retinitis). 
In the eye-ground of young subjects, particularly along the line of 
the vessels, numerous wave-like, glistening reflexes may be seen to follow 
one after another with the slightest movements of the ophthalmoscopic 
mirror. The effect is similar to the shimmer seen on the surface of cer- 
tain silks, and has been designated by English writers shot-silk retina. It 
is unusual to find the phenomenon in individuals over thirty, its occur- 
rence being marked in direct proportion to the youth of the subject. 
Macula Lutea.-About two disks' diameter to the outer side of 
the papilla, and slightly below the horizontal meridian, there is a circular 
or slightly oval spot, equal in area to the end of the optic nerve, darker 
in color than the surrounding fundus, uncrossed by any visible retinal 
vessel, but toward which the finer twigs of the major branches pass, 
fringing its boundary. This region is the macula lutea, or yellow spot, 
and is that portion of the eye-ground concerned with the functions of 
direct vision. 
Its center is occupied by the foveal reflex, which marks the edge of 
the fovea centralis, and which may appear as a spot of light, a small circle 
with reddish center, a shifting crescent, or a shining line. This, in turn, 
is surrounded by a dark area (the dark spot of the macula), sometimes 
containing a number of brownish-black or light colored or even glisten- 
ing granules, often called Gunn's dots, which have no pathologic signifi- 
cance. Finally, the margin of the macula is bounded by a glistening 
whitish ring or halo (macular reflex). 
The method of examination determines whether all these character- 
istics of the macula lutea can be observed. They are fairly constant, 
however, with the exception of the halo, and are notable in young 
children. Ordinarily, the macular ring is best seen with the indirect 
image in young eyes, where it is apt to assume an oval shape; but accord- 
ing to Lindsay Johnson, even with the upright image, if the source of 
illumination be gradually lowered, a time is arrived at when more 
light is reflected from the macula than from the general fundus, and at 
that moment the ring appears. In elderly people the region usually 
cannot be well recognized except by the absence of vessels and its darker 
color, but even in them careful focusing will not infrequently reveal the 
foveal reflex. In albinos it is still more difficult to define this area. 
Although no vessels visible to the ophthalmoscope cross the macula, 
except as an anomaly (Randall, Johnson), the region is abundantly THE CHOROID 
105 
supplied with capillaries, which can be shown by artificial injection, 
which surround the fovea in a close loop, but do not occupy it. The 
student may find the region difficult to study because the light falling 
upon it causes the pupil to contract, the view being further hindered by 
the corneal reflex. Hence the pupil should be dilated, when the macula 
may be brought into view by requiring the patient to look directly into 
the ophthalmoscopic mirror, or may be found by turning the light out- 
ward from the lower edge of the disk. The region should always be 
studied with the utmost care. 
The appearances in the macula depend partly upon the disposition 
of the layers of the retina in this region. At its margin the retina is 
much increased in thickness by an extra development of the layer of the 
ganglion cells, while the fovea is produced by the hollowing out of the 
center of the macular region. The macular reflex, or ring, therefore, 
may be considered as a reflection arising from the thickened macular 
circumference, and the foveal reflex as a reflection from the edge of the 
fovea. The variations, according to Johnson, are due to the direction 
and the shape of the sloping sides of the pit, but, according to Dimmer, 
depend upon the kind of ophthalmoscopic mirror which is employed, the 
reflex being the inverted image of the center of the mirror. According 
to Piersol, the color of the macula depends upon the presence of a yel- 
lowish pigment within the layers internal to the visual cells, the latter 
elements remaining colorless; in consequence of this arrangement the 
fovea, in which the neuro-epithelium alone exists, is devoid of pigment, 
and, therefore, appears as a light spot within the colored area. The 
dark-brown spot of the macula is generally believed to depend upon the 
thinning of the retina at this spot, with a more decided pigmentation 
in the epithelium. Dimmer, however, thinks that it is also produced 
by absence of the slight veiling of the retina at this point, which is 
manifest in the surrounding more compact layers. 
The Choroid.-The bright glare which illuminates the pupil when 
the light is thrown into it from the ophthalmoscopic mirror, and de- 
velops into the uniform red color of the fundus, when this is brought 
into view, arises from the choroid. The rays of light pass through the 
transparent retina to its pigment epithelium, which in ophthalmoscopic 
work is accredited to the choroid, and in part are absorbed and in part 
reflected. The greater the quantity of the pigment, the greater the 
amount of absorption, so that the color of the eye-ground depends upon 
the degree of saturation in this epithelium, and varies from an almost 
slaty color in the dark-skinned races to a dark red in persons of blond 
complexion. A light yellowish-red or brownish color is often evident. 
In very fair people the imperfect development of pigment-cells of 
the choroid exposes the larger choroid vessels, which are evident as a 
meshwork of tortuous red bands with intervening spaces of lighter or 
darker color, and which are distinguishable from the retinal arteries and 
veins by their flat appearance and absence of the light streak. A nearly 
perfect exposure of the choroidal vessels is seen in albinos. It is not 
usually possible with the ophthlamoscope to differentiate the arteries 106 
OPHTHALMOSCOPY AND SKIASCOPY 
and veins of this system, although the latter are of greater size, and, near 
the equator of the eye, converge toward the venae vorticosse, being sepa- 
rated by larger and longer spaces. In decided brunettes these spaces are 
more deeply tinted than the vessels, which appear "like light streams 
separated by dark islands'' (Nettleship). A fair general idea of what 
tint may be expected in the fundus may be obtained by observing the 
color of the patient's hair. 
All the details of the eye-ground may be studied with greater ease 
through a dilated pupil, and, on beginning his studies, the student may 
with propriety employ a mydriatic-euphthalmin, cocain, or homatropin, 
not atropin-provided no signs of glaucoma are present Having ac- 
quired a knowledge of the normal appearance thus seen, he must now 
practise with the undilated pupil. 
The disk and macula having been studied, the peripheral parts of 
the eye-ground should be examined by throwing the light inward, 
upward, and downward, the head of the observer being moved corre- 
spondingly to comply with the changed direction of the mirror. Even 
when the central part of the fundus presents the usual characteristic red 
tint, the choroidal vessels are frequently exposed in the periphery, present- 
ing the appearance just described, and having no pathologic significance. 
Determination of Refraction by the Ophthalmoscope.-The 
estimation of the refraction of the eye by means of the ophthalmoscope 
results in either a qualitative or a quantitative determination. 
The former is obtained in the following manner: Hold the ophthal- 
moscope 30 to 50 cm. from the patient's eye, and, looking through the 
central aperture of the mirror, unaided by a glass, observe if any vessels 
come into view. Their appearance means that the eye is either hyper- 
opic or myopic. Now move the head from side to side, and note if the 
vessels move apparently in the same or in a direction opposite to the 
movements of the head. If the former, the eye is hyperopic; if the 
latter, myopic. Inasmuch as the image of the vessels in low degrees of 
myopia would be formed only at a considerable distance from the ob- 
served eye (30 to 120 cm.), and since no sharp image would be obtained 
in either emmetropia or low degrees of hyperopia farther away than 
30 cm., any considerable degree of ametropia may be excluded by failure 
to obtain a direct image except at a long range or a very short distance 
from the patient's eye. 
Before attempting a quantitative estimation of refraction by means 
of the ophthalmoscope, certain fundamental rules must be observed: 
1. Both surgeon and patient must have relaxed accommodation. 
2. A certain definite spot in the eye-ground upon which to focus 
should be selected. 
3. The observer should approach as close as possible to the eye under 
observation. 
4. In order to ascertain correctly the refraction error, the observer 
must be emmetropic, or, if not, render his eye emmetropic by using the 
proper correcting lens, in the form either of spectacles or of an equivalent 
glass placed behind the sight-hole of the ophthalmoscope. DETERMINATION OF REFRACTION BY THE OPHTHALMOSCOPE 
107 
The emmetropic observer can see the details of the myopic eye- 
ground only dimly without the aid of a correcting glass, and not at all 
if the myopia is of high degree. By placing concave glasses behind the 
sight-hole of the ophthalmoscope the convergent rays which leave the 
observed eye are rendered less and less convergent, until that glass is 
reached which just yields a distinct image-i. e., one which has ren- 
dered the convergent rays parallel. 
The emmetropic observer can see the details of a hyperopic eye- 
ground distinctly without the aid of a correcting glass, unless the hyper- 
opia is of very high degree, by an effort of accommodation which renders 
his crystalline lens more convex, and thus causes the divergent rays which 
leave a hyperopic eye to become parallel. But, with accommodation 
relaxed, he sees distinctly the details of the fundus through a convex 
lens placed behind the ophthalmoscope; this should be substituted for 
other stronger convex lenses until the strongest one is reached with 
which a clear image is. still possible-i. e., one which has rendered the 
divergent rays parallel, while the next highest number creates a blur 
over the details of the eye-ground. 
From what has been said it follows that the strongest convex lens, 
placed in position in the ophthalmoscope, with which the emmetropic 
observer can still see the details of the fundus at the point selected 
measures the degree of hyperopia; the weakest concave lens, the degree 
of myopia. The hyperopia usually is somewhat greater, and the myopia 
somewhat less, than the result obtained by ophthalmoscopic examination. 
In order to estimate the refraction of the eye examined, the hyper- 
opic observer must subtract from the convex, or add to the concave, 
lens, which yields him a sharp image of the fundus, the amount of his 
own error, while the myopic observer must add to the convex, or sub- 
tract from the concave, lens, with which he sees the eye-ground the 
degree of his own near-sightedness. 
In order to calculate the amount of lengthening or shortening of the 
eye equal to a lens which neutralizes the myopia or hyperopia in any 
given case, and provided the distance between the surgeon's eye and 
that of the patient is not more than 2.5 cm., the following table, which 
was prepared by the late Mr. Nettleship, is useful: 
Hyperopia of 1 D represents a shortening of 0.3 mm. 
" 2 " " " 0.5 " 
" 3 " " " 1 " 
" 5 " " " 1.5 " 
" 6 " " " 2 " 
" 9 " " " 3 " 
" 12 " " " 4 
" 18 " " " 6 
Myopia of ID represents a lengthening of 0.3 " 
" 2 " " " 0.5 " 
" 3 " " " 0.9 " 
" 5 " " " 1.3 " 
" 6 " " " 1.75 " 
" 9 " " " 2.6 " 
" 12 " " " 3.5 " 
" 18 " " " 5 " 108 
OPHTHALMOSCOPY AND SKIASCOPY 
By this table the depth of an excavation in the papilla may be 
measured. For instance, if the bottom of the pit required - 5 D for its 
sharp examination, and the margin of the nerve was seen without any 
glass, the depth of the excavation would be 1.3 mm. 
The presence of astigmatism may be ascertained by means of the 
ophthalmoscope and the upright image because all points of the portion 
of the fundus under examination are not in focus at the same time- 
e. g., the retinal vessels running in the directions which correspond to the 
principal meridians. 
Thus, when two vessels cross each other at right angles, the vertical 
branch may be sharply seen, while the horizontal one presents a blurred 
image, or the upper and lower margins of the disk may be clear, but the 
lateral borders indistinct. The 
amount of hyperopia or myopia of 
the vertical meridian is equal to 
the strongest convex, or weakest 
concave, glass which makes dis- 
tinct the vessels running in a hori- 
zontal direction. The refraction 
of the horizontal meridian is de- 
termined by the glass which yields 
a clear image of the vessels run- 
ning in a vertical direction. As 
the vessels do not correspond to 
the layer of the rods and cones, 
the measurement is an approxima- 
tion. 
Compound astigmatism is de- 
termined by finding, in hyperopia, 
the strongest convex lens which 
the vessels in each meridian will 
bear with the preservation of a 
distinct image, and subtracting 
the one from the other, thus find- 
ing the difference between the 
meridians-i. e., the amount of astigmatism. In high degrees of astig- 
matism the optic disk usually appears as an ellipse, its long axis corre- 
sponding with the meridian of greatest refraction. 
The measurement of astigmatism in this manner, with any degree 
of accuracy, requires much practice, a perfect control of the accommoda- 
tion, and even then must never be employed to the exclusion of other 
and more trustworthy methods. 
2. The Indirect Method (Method of the Inverted Image).-The 
patient and surgeon are seated in the same relative positions as have 
already been described in connection with the direct method, and, if 
the right eye is to be examined, the ophthalmoscope is held in the right 
hand at a distance of 30 cm. from the patient, who is instructed to look 
at the right ear of the examiner. A convex lens of 20 D, held between 
Fig. 55.--Focusing of the vessels by the 
meridians of an astigmatic eye; the parallel 
lines on each vessel represent the direction 
of the meridians through which a distinct 
image of the vessel is obtained. DETERMINATION OF REFRACTION BY THE OPHTHALMOSCOPE 
109 
the surgeon's left thumb and index-finger, while the remaining fingers 
are rested upon the brow to steady the hand, is placed at about its own 
focal length in front of the patient's eye, directly in the path of the rays 
returning from the fundus, which are thus brought to a focus and form 
an aerial image between the observer and the glass. 
If the left eye is to be examined, the ophthalmoscope is held in the 
left hand, and the patient instructed to look at the surgeon's left ear, 
while the lens, grasped in the fingers of the right hand in the manner 
just described, is placed in position. 
The image which is found at a certain distance in front of the object- 
glass may not present itself to the observer as a distinct picture, owing 
to his inability to accommodate for the point of its formation. This 
accommodative strain may be relieved and the image magnified by 
Fig. 56.-Method of an indirect examination with the ophthalmoscope. 
placing behind the ophthalmoscope a convex glass of 5 D, which adapts 
the emmetropic observer, with relaxed accommodation, for a point 20 cm. 
distant. If the observer is presbyopic, or has a deficient amplitude of 
accommodation, this additional lens is absolutely necessary; while if he 
is hyperopic, the degree of his hyperopia should be added to the glass 
used as a magnifier. The observer possessing a moderate degree of 
myopia requires no lens in the ophthalmoscope, because he views the 
aerial image at his far point, while if his myopia is of high grade, he will 
need a weak concave glass. 
With the indirect method of examination the field is larger than in 
the direct method. Although individual objects in the field are small 
and sharply defined, the details of the fundus are less perfectly revealed 
than with the direct method. In young subjects in the macular region 
a bright reflex encircles an elliptic dark area containing in its center a 110 
OPHTHALMOSCOPY AND SKIASCOPY 
reddish or, less frequently, a bright point surrounded by a small brilliant 
ring. These characteristics are not always present. 
A qualitative estimation of the refraction with the indirect method 
may be ascertained with the mirror alone, in the manner already de- 
scribed (see page 108). Furthermore, ametropia of high degree may be 
recognized by varying the distance of the object-lens from the eye. 
Withdrawal of the lens from the eye causes the image to appear smaller 
in hyperopia, larger in myopia. 
The measurement of the degree or quantity of the refraction and the 
estimation of astigmatism by the indirect method were at one time 
much practised, but in practical work the methods are so far inferior to 
those usually employed (skiascopy, ophthalmometry) that their de- 
scription is omitted. 
Ophthalmodiaphanoscopy.-With the ophthalmodiaphanoscope, 
designed by Carl Hertzell, it is possible to make examinations of all 
parts of the eyeball and of the orbit around and posterior to the globe. 
Dr. H. F. Hansell thus describes the instrument: It consists of an 
80-candlepower electric lamp, strengthened] by a reflector, which in- 
creases the power of the light to 100 candlepower. The lamp is held by 
the patient far back in his mouth and a black mask is adjusted to pro- 
tect the face. The anterior rays pass through the buccal plate of the 
superior maxillary bone, through the antrum and its roof to the floor 
of the orbit; the posterior rays pass through the hard and soft palate, 
the lateral walls of the nose, the anterior cells of the sphenoid, and pass 
to the median orbital walls. The eye-ground is illuminated from be- 
hind, below, and from the median side. The observer approaches the 
lighted pupil as near as possible and examines the illuminated fundus 
without the aid of any other instrument. If the eyes are ametropic 
(myopic) a correcting glass should be worn, and Hansell finds mydriasis 
advantageous. According to Hertzell, the optic nerve appears more 
opaque than it does in ordinary ophthalmoscopic examination, its 
outlines are sharply defined, and if a pigment ring exists, it is distinct. 
The retinal veins are very dark, the arteries somewhat lighter in color; 
the macula appears as a dark spot. Retinal hemorrhages appear as 
dark, sharply defined areas. A tumor would diminish the illumination 
and obscure the fundus details. The brilliant transillumination of the 
sinuses and orbit is instantly obstructed by the presence of a growth, 
thickening, or opacity, and the diagnosis thereby facilitated. The 
author's experience with the instrument is limited to a few observations 
made with Dr. Hansell; it seems to be of distinct value in the diagnosis 
of orbital and sinus disease. 
Ophthalmometry.-This term indicates mensuration of the eye, 
and, as usually employed, is limited in its application to the measure- 
ment of the radius of curvature of the cornea (keratometry). In order 
to practice ophthalmometry, instruments for taking the measurement of 
the radius of curvature of the cornea have been constructed, and are 
known as ophthalmometers. The ophthalmometer most in use is the one 
devised by Javal and Schiotz. SKIASCOPY, OR THE SHADOW-TEST (RETINOSCOPY) 
111 
Other instruments are those designed by Leroy and Dubois, Reid, 
Hardy, Chambers-Inskeep, and Sutcliffe. In the opinion of the author, 
a suitable ophthalmometer, or, more accurately, keratometer, is of the 
greatest service in determining the refraction of the cornea and the 
direction of its principal meridians. None of these instruments should 
be used to the exclusion of other methods, especially the employment of 
mydriatics and skiascopy. (For a full description of the method of 
using the ophthalmometer see Appendix, page 687.) 
Optometry is a term which indicates the principles involved in the 
measurement of the refraction of an eye by its limits of distinct vision. 
The instrument which thus serves to determine the refraction of the eye 
is called an optometer. 
Optometers are based upon a number of principles. For instance, 
a single convex lens by which the direction of the luminous rays emanat- 
ing from an object is changed, and consequently the determination of 
the refraction of the eye rendered possible, constitutes an optometer. 
Other optometers are based upon the principle of a telescope; still others 
upon the measurement of circles of diffusion, upon Schemer's experi- 
ment, and upon the chromatic aberration of the eye. It would not be 
possible, in the limits of this manual, to describe in detail the principles 
involved or the various forms of apparatus which have been employed. 
Should the student desire to pursue the subject, he may with advantage 
consult the chapter devoted to this method found in Landolt's Refrac- 
tion and Accommodation of the Eye. 
Of the many instruments constructed in recent times for the pur- 
pose of estimating the refraction of the eye, and to which the name 
refractometer is usually applied, the best is the one devised by the late 
Dr. William Thomson.1 
Skiascopy, or the Shadow=test (Retinoscopy).2-This is a 
method of determining the refraction of the eye by observing the direc- 
tion in which the light appears to move across the pupil, when it is made 
to move back and forth across the face by rotation of the mirror which 
reflects it to the eye. 
With the ophthalmoscope, as has already been explained, the ob- 
server may look into a myopic eye from close in front of it and see an 
erect image of the fundus, which he can render clear by the proper con- 
cave lens; or, in the same eye, from a greater distance, he can view an 
inverted image of the fundus, with or without the intervention of a 
convex lens. The point at which the change from the erect to the in- 
verted image occurs has been called the point of reversal. It is the point 
for which the eye is focused, and is the far point of distinct vision. 
Skiascopy is simply an accurate method of determining this point of 
reversal. 
To apply the test with the plane mirror the surgeon faces the patient 
at a distance of about 1 meter or less; and, holding the mirror to his 
own eye, reflects on the patient's face the light from a lamp placed near 
1 Transactions of the American Ophthalmological Society, 1902, vol. ix. 
2 This section has been prepared and revised by Dr. Edward Jackson. 112 
OPHTHALMOSCOPY AND SKIASCOPY 
the mirror, and covered with an opaque shade having an aperture 3 to 
6 mm. in diameter. By rotating the mirror the area of light it throws on 
the face is made to move up and down, or from side to side, or obliquely. 
The part of the light that falls on the patient's pupil is condensed on 
his retina, forming there a small light area which also moves as the mirror 
is rotated; for the plane mirror this retinal light area always moves in 
the same direction as, or "with," the light on the face. 
In Fig. 57 L represents the lamp-flame, screened from the patient, 
and J. and B two positions of the plane mirror. When the mirror is at 
A, the light that enters the eye will come as though from a flame at I, 
and will be condensed toward a, on the lower part of the retina. At 
this time the light falls on the lower part of the face. But when the 
mirror is rotated to B, the light entering the eye comes from the direc- 
tion I', and is condensed toward b, on the upper part of the retina. At 
the same time the light on the face moves upward. The positions of the 
retina in hyperopia, emmetropia, and myopia are shown at H, E, and M. 
Fig. 57.-Skiascopy with the plane mirror. 
Fig. 58.-Skiascopy with the concave mirror. 
It will be noted that in all these forms of ametropia the movement of the 
light on the retina is with the light on the face. When skiascopy is 
practised with a concave mirror, the lamp-flame which serves as a source 
of light must be placed behind the patient; and the light area on the 
retina moves in an opposite direction "against" the light on the face, 
"against" the movement of the mirror. 
In Fig. 58 the action of the concave mirror is represented. When 
the mirror is at A, the light that enters the eye comes from the focus 
of the mirror at I, conjugate to the position of the lamp-flame, and is SKIASCOPY, OR THE SHADOW-TEST (rETINOSCOPY) 
113 
condensed toward a, on the upper part of the retina; and when the 
mirror is at B the light enters from I', the new position of this conjugate 
focus, to be condensed toward b, on the lower part of the retina-that is, 
as the light has moved upward on the face, it has moved downward on 
the retina, and this is true for either H, E, or M. 
The following account assumes the use of the plane mirror, but will 
apply equally for the concave mirror, if one bears in mind that with the 
latter the movement in the pupil is always in the opposite direction, and 
that the lens before the patient's eye must be changed, instead of chang- 
ing the surgeon's distance from the patient (see page 116). 
We have thus seen what is the real movement of the light on the 
retina, as it would appear in the back of an enucleated eye with the 
sclera and choroid removed, but the surgeon does not see it in that way; 
he can only watch the apparent movement as seen through the pupil. 
This will be the same as the real movement, with the light on the face 
[plane mirror] when he sees an erect image, and in the opposite direc- 
tion when he sees an inverted image. 
In Fig. 59 M represents a myopic eyeball, from the retina of which 
rays come out and are focused at B, the point of reversal. Anywhere 
Fig. 59.-Rays coming from a myopic eyeball. 
closer to the eye than this, as at A, an erect image is seen; the light 
in the pupil seems to move with the light on the face. Anywhere beyond 
the point of reversal, as at C, an inverted image will be seen, and the 
light in the pupil will appear to move against the light on the face 
(see page 165). Just at the point of reversal B it is impossible to see 
which way the light moves, and the illumination of the pupil is very 
feeble. 
At one or two diopters from the point of reversal the light is com- 
paratively bright. As the examiner goes farther than this from the 
point of reversal, it becomes more and more feeble. With the same 
movement of the mirror the apparent movement of the light in the 
pupil is quicker as the point of reversal is approached. These varia- 
tions in the degree of illumination and rapidity of movement may aid 
the expert in choosing the lens to be next placed before the eye, but the 
thing mainly depended on is the direction of the movement. 
Application in Myopia.-If the surgeon, on throwing the light into 
the eye, finds that its apparent movement in the pupil is against the 
light on the face, he must be farther from the eye than the point of 
reversal (B, Fig. 59). He should then slowly approach the patient, 
still rotating the mirror and watching the apparent movement of the 114 
OPHTHALMOSCOPY AND SKIASCOPY 
light, until he finds this apparent movement is with the light on the face, 
as at A. He is now closer to the patient than the point of reversal, and 
should draw back and observe the greatest distance (A) at which this 
movement with the light on the face can be distinguished; then, draw- 
ing farther back, he observes the nearest point to the eye (C) at which the 
inverted movement can be seen, and the point B, half-way between A 
and C, is to be taken as the point of reversal. These observations should 
be repeated until the exact position of B is established. The distance 
fromB to the eye is then measured; it is the focal distance of the glass 
required to correct the myopia. For instance, if the erect movement is 
seen as far as 55 cm. from the eye, and the reversed movement as near as 
80 cm., the point of reversal will be about 67 cm., and the myopia, 
therefore, 1.50 D. 
If the myopia thus discovered is high, its amount can be most 
accurately determined by putting on a concave lens that will correct 
all of it but 1 or 2 D, measuring what is left by skiascopy, and adding 
this to the strength of the lens used to get the total myopia. 
If, on the other hand, the myopia is very low, the point of reversal 
may be at so great a distance that when near it one cannot see which 
Fig. 60.-Rays emerging from a hyperopic eye. 
way the light is moving in the pupil. In this case a weak convex lens 
must be placed before the eye, the point of reversal found with the lens, 
and then the strength of the lens deducted from the myopia which this 
indicates in order to find the myopia of the eye. 
Application in Hyperopia.-Here the rays from the retina emerge 
divergent, as shown by the broken lines in Fig. 60, and there can be no 
point of reversal anywhere in front of the eye. The surgeon finds the 
apparent movement of the light in the pupil is with the light on the face, 
and it continues to be so, no matter how far he draws back. It is neces- 
sary, then, to place a convex lens (L) before the eye strong enough to 
render the rays convergent, and so to make a point of reversal a con- 
venient distance in front of the eye. This lens does two things: First, 
it overcomes the divergence of the rays; this takes part of its power. 
Second, the remainder of its power makes the rays converge, causing 
a sort of artificial myopia. The point of reversal (B) obtained is the 
point of reversal for this artificial myopia. It is to be determined as 
for natural myopia, and the amount of myopia it represents deducted 
from the total strength of the lens. The remainder will be the power 
required to overcome the divergence of the rays, or the strength of lens 
needed to correct the hyperopia. SKIASCOPY, OR THE SHADOW-TEST (RETINOSCOPY) 
115 
For example, suppose the movement of the light in the pupil is 
found at all distances to be with the movement of the light on the face, 
and on placing a 5 D convex lens before the eye it is found to be still 
with the movement of the light on the face when the examiner ap- 
proaches to a little within 1 meter, but appears reversed if looked at 
from a distance slightly greater than 1 meter. The point of reversal 
then is at 1 meter; 1 D of the strength of the lens is making the rays 
convergent, while the other 4 D have been used to overcome the diver- 
gence of the rays as they came from the eye. Therefore the eye must be 
4 D hyperopic. For accuracy it is better here, as in the case of natural 
myopia, to make the final determination with a lens that brings the point 
of reversal | to 1 meter from the eye. 
Application in Emmetropia.-The application of skiascopy for em- 
metropia is precisely the same as for hyperopia; but it is found that 
the artificial myopia caused by the convex lens equals the full strength 
of the lens, proving that the rays must have emerged from the eye 
parallel. 
Application in Regular Astigmatism.-The principles involved and 
the methods to be employed are essentially the same as in myopia or 
hyperopia; but the refraction has to be determined in the two principal 
meridians instead of in any meridian indifferently, as it can be where 
all meridians are alike. To determine the refraction in a certain 
meridian the light must be made to move back and forth in that par- 
ticular meridian by rotating the mirror about an axis at right angles 
to it. 
The direction of either of these principal meridians is revealed by 
the area of light in the pupil assuming the form of a more or less distinct 
band of light, extending across the pupil in the direction of this meridian, 
when its point of reversal is approached. This band can be clearly 
distinguished only when the surgeon's eye is much nearer to the point 
of reversal for one principal meridian, than to the point of reversal for 
the other principal meridian. In such a position this band is, for the 
higher degrees of astigmatism, very noticeable, and fixes with the 
greatest accuracy the direction of the principal meridian. When the 
band-like appearance is most noticeable, it is easy to cause its ap- 
parent movement from side to side; but it is more difficult to distinguish 
the movement in the direction of the length of the band. Still, this 
latter movement is the one that must be especially watched, and its 
reversal point determined. 
When the astigmatism is very low, the appearance of a band may be 
very indistinct, or not at all perceptible. But in such cases it will be 
found that when the surgeon has reached the point of reversal for move- 
ment of the light in one direction, there is still distinct movement, either 
direct or inverted, in the direction at right angles to this; and he will 
thus know he has tested one meridian of an astigmatism, and must in the 
same way ascertain the point of reversal for the other at right angles to 
it. When the surgeon is closer to the eye than the point of reversal for 
either meridian, the movement will be with the light on the face in all 116 
OPHTHALMOSCOPY AND SKIASCOPY 
directions. When he is at the point of reversal for the meridian which has 
its point the nearer to the eye, there will be no distinguishable movement 
in the direction of the band here visible, but still a movement (with) at 
right angles to it. When he is between the two points of reversal, there 
will, in the direction of the nearer meridian, be an inverted movement of 
the light (movement against), but in the other meridian a direct move- 
ment (movement with). When the farther point of reversal is reached, 
the direct movement in its meridian ceases, while the movement in the 
other meridian continues inverted (against). When the surgeon has 
drawn back beyond both points of reversal, the movement is reversed, 
against the light on the face in all directions. 
Having determined the amount of myopia, natural or artificial, in 
both principal meridians, the strength of the cylinder required to 
correct the astigmatism will, of course, be the difference between the 
refraction for the two meridians. Having thus ascertained it, it is well 
to put this cylinder before the eye and to see if it does accurately correct 
the astigmatism, giving the same point of reversal for all meridians of the 
cornea; and, for accuracy, the spheric lens which will bring this point of 
reversal to the distance of | to 1 meter should be used with it. 
Application in Irregular Astigmatism.-If the pupil is dilated, it 
will always be found that the refraction of the eye varies in different 
parts of it, so that points of reversal for different parts of the pupil lie 
at different distances in front of the eye; and at the point of reversal 
and near it, both direct and reversed movements of the light are visible 
at the same time in these different parts of the pupil. Usually there is 
at the center of the pupil a considerable area that has about the same 
point of reversal, called the visual zone. This is the part through which 
light will come to be focused on the retina when the eye is in use. For 
practical purposes it is to the refraction of the visual zone that attention 
should be paid, the refraction in the other parts of the pupil being of 
little practical importance. On account of the small size of the visual 
zone in many eyes it is. best to apply skiascopy from a distance of less 
than 1 meter from the patient's eye. 
When the visual zone of the pupil differs materially in refraction 
from the part of the pupil that surrounds it, the eye is said to present 
aberration. This is called positive when the center of the pupil is more 
hyperopic or less myopic, and negative when the opposite is the case. 
When the aberration is high, on examining it from near 'the point of 
reversal of the margin of the pupil, the movement of the light will be 
swift at the margin and slow in the center, making it look as if the light 
in the pupil were wheeling around a fixed point at the center. This 
appearance is marked in conical cornea. Aberration of moderate de- 
gree causes the appearance of a ring of light at the margin of the pupil, 
which has a very distinct movement when the point of reversal for the 
center of the pupil has been reached. 
The Concave Mirror.-With the concave mirror the movement 
in the pupil is reversed (see page 113); and one cannot vary much the 
distance of the mirror from the patient's eye, but must keep a fixed THE USE OF MYDRIATICS 
117 
distance (usually somewhat less than 1 meter), and bring the reversal to 
this point by changing the lenses used before the eye. 
The Use of Mydriatics.1-In addition to the use of the mydriatics 
in the treatment of diseases of the eye-e. g., iritis-these drugs are 
employed as aids of an accurate determination of ametropia. With the 
ophthalmometer, without the aid of mydriatics, and with the method 
of skiascopy, in the absence of prolonged mydriasis, good results are 
obtained; but in all patients of suitable age, and in the absence of contra- 
indicating symptoms, an active mydriatic should be employed in the 
measurement of errors of refraction, especially to detect astigmatism. 
The mydriatic accomplishes three purposes: 
1. It dilates the pupil, and permits a thorough exploration of the 
interior of the eye, as well as a more perfect examination of the lens and 
vitreous humor than could be obtained without its aid. The student 
should not, of course, think it necessary to dilate the pupil of each eye 
which he subjects to an ophthalmoscopic examination; but glasses should 
not be adjusted without a thorough knowledge on the part of the ex- 
aminer of all the details of the eye-ground and the transparent media. 
2. It paralyzes the action of the ciliary muscle and places the ac- 
commodation in abeyance, rendering manifest types of ametropia which 
otherwise would remain latent. 
3. It fulfils the important function of giving, during the time of its 
action, physiologic rest to the eye that is under its influence, and con- 
sequently helps to subdue any retinochoroidal disturbance or other 
congestive condition that pre-existing eye-strain may have originated. 
In practice, various mydriatic (cycloplegic) drugs are employed, the 
most common being the sulphates of atropin, hyoscyamin, and duboisin, 
and the hydrobromate of homatropin and scopolamin. 
(a) Atropin.-Atropin sulphate is usually employed in a strength of 
4 grains (0.26 gm.) to the ounce (30 c.c.). A drop of such a solution 
dilates the pupil in about fifteen minutes, and a very few moments later 
begins to paralyze the accommodation, which sustains a full paralysis 
in about two hours. The effect of atropin upon the accommodation 
remains for a week, but if, as is commonly the case, the drug is used 
for several days at a time, this influence is much prolonged, and full 
return to the previous power of accommodation is not secured for 
about twelve or fourteen days. 
In using atropin sulphate for the purpose of correcting errors of 
refraction, a solution of the strength given above should be instilled into 
the eye, one drop at a time, three times for at least a day, preparatory to 
the determination, and in young subjects possessing hyperopic eyes, 
with active ciliary muscles, especially if there is associated spasm of 
accommodation, the drug must be continued for several days, or even 
longer, before the desired result is reached. 
(6) Hyoscyamin is usually employed in the strength of 2 grains 
(0.13 gm.) to the ounce (30 c.c.), in the same manner. It produces 
1 In place of the term "mydriatic" the word "cycloplegic" is sometimes employed if, 
in addition to the mydriasis, there is paralysis of accommodation. 118 
OPHTHALMOSCOPY AND SKIASCOPY 
wide dilatation of the pupil and complete ciliary paralysis, the effect 
of which lasts from six to seven days. Many surgeons prefer this 
drug to atropin, and believe that its effects are equally good, while 
it enjoys the advantage of a much more temporary action upon, the 
function of the ciliary muscle. The salt must be neutral, and the 
solution filtered through neutral paper (Risley). 
(c) Hyoscin and duboisin in similar strength have similar actions, 
the latter drug being even more transitory than hyoscyamin in its effect, 
return to accommodative power occurring in from four to five days. 
Both of them have the disadvantage of producing marked constitutional 
disturbances, at times rendering their employment disadvantageous. 
Hyoscin is chemically and physiologically identical with scopolamin. 
(d) Homatropin is a drug which produces a transitory effect upon 
the ciliary muscle, full return of accommodation occurring in about fifty 
hours after the last instillation. 
To use this drug properly it must be employed by cumulative in- 
stillations in the strength of 8 to 16 grains (0.52-1.04 gm.) to the ounce 
(30 c.c.), one drop of such solution being used every fifteen minutes for 
an hour and a half preceding the determination, and then waiting forty 
minutes. At the end of this time the maximum effect of the drug 
upon the accommodation is secured. In the opinion of some surgeons 
this drug is an insufficient paralyzer of accommodation, but if caution 
in regard to the cumulative instillations is observed, and the rule given 
above carefully followed, entirely satisfactory results may be obtained. 
Its influence may be neutralized by eserin. Some surgeons prefer 
homatropin in gelatin disk form, associated with cocain, in the deter- 
mination of errors of refraction. The author has never been able to 
convince himself of their superiority to a solution of the drug, and 
regards the addition of cocain to the solution as a distinct disad- 
vantage. 
(e) Scopolamin, introduced by Raehlmann, may be employed in the 
strength of 2 grains (0.13 gm.) to the ounce (30 c.c.). Two instillations 
of one drop each forty-five minutes apart are sufficient. Mydriasis 
begins in twelve, and is complete in thirty, minutes; cycloplegia occurs 
in about forty-five minutes. Full return of accommodation may be ex- 
pected in from five to six days. Toxic symptoms-staggering, vertigo, 
and dryness of the throat-may develop. Scopolamin is said to be 
more valuable than atropin in inflammatory affections of the eye, and 
not to increase intra-ocular tension (Raehlmann). 
It is not safe to use strong mydriatics in elderly persons, and they 
must never be employed if there is any symptom of glaucoma. They 
are usually unnecessary when that age has been reached after which the 
accommodation is so weakened that hyperopia ceases to be latent, and 
they are rarely employed after the forty-fifth year; but Hess and Duane 
have demonstrated that hyperopia may be as latent at the age of forty- 
five or fifty as it is in young persons, and, therefore, the need of a 
mydriatic may be equally important. 
Euphthalmin is an active mydriatic in a 5 to 10 per cent, solution. THE USE OF MYDRIATICS 
119 
It produces maximum dilatation of the pupil in about fifteen or twenty 
minutes, and the pupil returns to its normal size in five to six hours. Its 
influence on accommodation is so slight that it has no practical value as a 
cycloplegic. It is an admirable agent for producing brief dilatation of 
the pupil, and, fortunately, it has no perceptible effect upon the cornea. 
It may be combined with cocain, 1 per cent, of each, and its mydriatic 
efficiency thereby enhanced. 
Hydrochlorid of cocain, in addition to its anesthetic action, is, in 2 to 
4 per cent, solution, an excellent mydriatic, but its effect upon the ac- 
commodation is so slight that it is valueless for the purpose of preparing 
an eye for the estimation of any error of refraction. 
Other mydriatic drugs which may be mentioned are ephedrin homat- 
ropin, 1 : 10 (Groenouw); mydrol, 10 per cent.; methylatropin, 5 p'er 
cent., and atroscin. The last-named drug is similar to scopolamin in its 
action. CHAPTER IV 
NORMAL AND ABNORMAL REFRACTION 
The cornea, aqueous humor, crystalline lens, and vitreous body 
are the media by which rays of light passing into the eye are refracted and 
brought to a focus with the production of an image on the retina. Be- 
cause the two surfaces of the cornea are practically parallel and the index 
of refraction of the cornea and the aqueous humor are the same, the 
dioptric apparatus may be reduced to the anterior surface of the cornea 
and the anterior and posterior surfaces of the crystalline lens. The 
cornea is the principal lens when the eye is at rest, and it has a higher 
refractive power than the crystalline lens; but during maximum ac- 
commodative effort the refractive power of the crystalline lens approaches 
that of the cornea. The formation of a distinct retinal image requires 
that the curvature of the corneal meridians shall be symmetric, that the 
plane of the lens shall be perpendicular to the visual line, that its sectors 
shall have a uniform density in corresponding layers, and that the focal 
length of the dioptric apparatus shall correspond with the length of the 
visual axis. 
Emmetropia.-To the normal eye, which produces a distinct image 
of distant objects on the retina, without accommodative effort, the term 
emmetropic is applied, and the condition may be defined as follows: 
Emmetropia is that refractive condition of the eye in which the visual 
axis corresponds exactly u'ith the focal length of the dioptric apparatus when 
at rest; the far point lies at infinity, and the eye, in its condition of minimum 
refraction, is adapted to focus parallel rays on the retina. The principal 
focus lies on the retina. 
The emmetropic eye has an average length of about 22 mm., although 
emmetropia is still possible with a longer or shorter axis, if the curvature 
of the ocular lenses varies in proportion. Emmetropia, although it 
exists but rarely, is the ideal state of refraction. Such an eye has a 
range of vision from infinity to its near point (see table, page 39). 
Glasses are not required for distant vision, neither are they needed for 
reading or close work until that age is reached when the accommodative 
power begins to decline-i. e., about the forty-fifth year. No great de- 
parture from emmetropia can long exist without producing more or less 
disturbance of the function of vision and of the nutrition of the ocular 
tissues, and without originating the numerous and complex general and 
reflex symptoms which arise from "eye-strain." To restore the eye, 
the refraction of which is abnormal, to a condition of emmetropia, or at 
least one approaching it, constitutes a most important part of the prac- 
tice of ophthalmology. This will be more readily conceded when it is 
remembered that emmetropia is comparatively uncommon, occurring 
in not more than 1.5 to 2 per cent, of properly examined eyes. 
120 AMETROPIA 
121 
Ametropia.-To the eye which fails in the requirements just de- 
scribed the term ametropia is applied, and the condition may be defined 
as follows: 
Ametropia is any departure from the normal optical condition-that is, 
from an exact correspondence between the visual axis and the focal length 
of the dioptric apparatus when at rest. The principal focus is not a point 
or does not lie on the retina. 
Ametropia is denominated axial when the length of the eyeball is 
increased or diminished, and curvature when, the axis remaining un- 
changed, the curvature of lenses of the eye undergoes variations. Ame- 
tropia presents itself under three conditions: (1) Hypermetropia, hyper- 
opia, far-sightedness, or over sightedness; (2) myopia, short-sightedness, 
or near-sightedness; (3) astigmatism or astigmia. 
It is convenient to distinguish the first two classes of ametropia by 
the relative position of the principal focus to the retina. 
Hyperopia is that form of ametropia in which the retina is situated in 
front of the principal focus of the eye. The visual axis of the eye is shorter 
than the focal length of the dioptric apparatus ivhen at rest. 
The far point of the eye is negative, and is represented by the point 
behind the eye to which rays must converge before entering the eye, in 
order to be united on the retina. The refractive apparatus of the hyper- 
opic eye, in a condition of minimum refraction, is adapted to bring rays 
converging to this point to a focus on its retina. Rays passing out of a 
hyperopic eye have a divergence as if they came from this point. 
Causes and Varieties.-The eyeball may be abnormally short, con- 
stituting axial hyperopia; a deficiency of 1 mm. in the length of the optic 
axis produces 3 diopters of hyperopia; or its refractive power may be 
deficient, curvature hyperopia; an increase of 1 mm. in the length of the 
radius of curvature of the cornea produces a hyperopia of 6 diopters; or 
the crystalline lens may be absent, aphakial hyperopia. 
Hyperopia is further divided into: (1) Manifest; (2) latent; (3) total. 
Manifest hyperopia (H. m.) is represented by the strongest convex lens 
through which an eye with perfectly intact accommodative power retains 
distinct distant vision; latent hyperopia (H. 1.) is the amount in excess 
of the manifest which can be developed by the use of a cycloplegic-for 
example, atropin; total hyperopia (H. t.) is the sum of the manifest and 
the latent-that is, the entire amount of the hyperopia which is devel- 
oped after paralysis of accommodation or complete relaxation of the 
ciliary muscle. Evidently latent hyperopia is the difference between 
the manifest and the total. Manifest hyperopia is either facultative or 
absolute-facultative when it can be overcome by an effort of accom- 
modation, absolute when it cannot be overcome by an effort of accom- 
modatiom 
Hyperopia is nearly always congenital, and is often hereditary, espe- 
cially its high grades. In some senses it may be regarded as due to an 
imperfect development of the eyeball, which, however, may increase its 
length with the growth of the rest of the body, and this refractive con- 
dition may diminish, pass into emmetropia, or, more rarely, into myopia. 122 
NORMAL AND ABNORMAL REFRACTION 
An apparent increase of hyperopia due to failure of accommodation 
caused by advancing years is often seen-that is, latent hyperopia be- 
comes manifest. A real tendency to slow increase of hyperopia is due 
to gradual increase of the size of the crystalline lens. In early life none 
of the existing hyperopia is absolute unless it is of high degree; after 
sixty-five practically all of it becomes absolute. 
Symptoms.-Hyperopia renders it difficult to maintain a distinct 
image of small objects-e. g., printed matter-for prolonged periods of 
time. If the effort is persisted in, the accommodation becomes ex- 
hausted, aching of the eyes and head-in short, the result of eye-strain- 
appears, and finally the work must be discontinued (accommodative 
asthenopia). Sudden failure of accommodation, with consequent blur- 
ring of vision, is frequent, and often first appears if the patient has been 
weakened by illness. Hyperopes often place a book or small objects in 
a strong light in order to contract the pupil and thus render vision clearer. 
Hyperopia frequently gives rise to spasm of the accommodation, owing 
to the persistent contraction of the ciliary muscle necessary to overcome 
this error of refraction, and then simulates myopia, distant vision be- 
coming indistinct. In these circumstances concave lenses may improve 
vision, and, in ignorance of the true state of affairs, are sometimes pre- 
scribed, much to the detriment of the patient. A mydriatic will reveal 
the real condition of the refraction. It occurs also in myopic eyes, which 
appear to be more myopic than they really are. Spasm is prone to 
occur in individuals of neurasthenic condition, and is a frequent symp- 
tom of hysteria, often associated with cramp of convergence; it bears 
no relation to the vigor of the accommodation, inasmuch as persons 
with relatively feeble accommodation may have a marked cramp of the 
ciliary muscle. Therefore spasm of accommodation is not excess of 
accommodation (see page 41). Spasm of accommodation is not con- 
fined to young subjects, but may occur, and in stubborn form, after 
the fortieth year of life. It may be produced in normal eyes by the 
instillation of a solution of an active miotic. 
Insufficient power of accommodation, i. e., subnormal accommodation, 
may give rise to marked asthenopia. It is attributed by Theobald to a 
congenital insufficiency of the ciliary muscle (see also page 41), and its 
determination and relief in refractive work, as he has insisted, is most 
important. 
Convergent strabismus is often the earliest symptom of hyperopia in 
childhood; it arises in connection with efforts of accommodation. 
When the hyperopia is too great to be managed by the accommodation, 
the affected children frequently hold their books close to their eyes, and, 
by contracting the palpebral fissures, are enabled to see better than 
with the book at a greater distance, because the object is seen under a 
larger visual angle, and the narrow slit between the lids cuts off the 
more divergent rays. These children are often erroneously supposed to 
be near-sighted, and concave glasses are given to them, which increase, 
instead of mitigating, the trouble. 
As a result of hyperopia the coats of the eye become inflamed. AMETROPIA 
123 
Conjunctivitis, blepharitis, styes, chalazia, and congestion of the retina 
and choroid are very frequent complications. Persistent headache, 
aggravated by using the eyes, various nervous symptoms, reflex in their 
nature, as well as disturbances in the visual function, are the common 
results of hyperopia (see also page 141). 
Determination of Hyperopia.-Hyperopia always exists: When 
distant vision is not made worse by a convex glass; when the patient 
can read fine print through a convex glass at a greater distance than its 
focal length; when with the ophthalmoscope the interior of the eye, 
otherwise normal, is seen distinctly with a convex lens; usually when the 
near point lies at a greater distance from the eye than is proper for the 
age; and when the phenomena described in connection with the shadow- 
test on page 114 are present. To ascertain the presence of latent hyper- 
opia a mydriatic should be employed. Its use is imperative in the 
presence of spasm of accommodation. The ciliary muscle is fully de- 
veloped in hyperopic eyes, especially the circular fibers, which may be 
overdeveloped. 
Fig. 61.-Far point of a hyperopic eye. Rays from R on the retina of the hyperopic 
eye after refraction diverge; these rays, prolonged backward, would unite at the point R'. 
R' is the far point. 
Correction of Hyperopia.-The principal focus, F, of the hyperopic 
eye lies behind the retina. Consequently the retina, R, is situated within 
the principal focus, and its conjugate focus or far point, R', is virtual 
(Fig. 61). Rays from R seem, after refraction by the eye, to have come 
from R'; conversely, rays converging to R', after refraction by the eye, 
unite in R on the retina. The rays which come from the retina, R, of 
such an eye, after emerging from the eye are divergent, and, prolonged 
backward, would unite in the point R'. The distance of this point from 
the cornea is the focal length of the glass which corrects the hyperopia; 
The amount of divergence of the emergent rays is dependent on the 
degree of the hyperopia-that is, the distance R lies in front of F. The 
higher the degree of hyperopia is, the farther R lies in front of F, and the 
nearer the point of divergence R' lies to R; conversely, the lower the 
degree of hyperopia is, the nearer the point R lies to F, and the farther 
back the point R' lies. The distance of R' must be less than infinity; 
otherwise, the eye would be emmetropic. 
If parallel rays are given a convergence to the point R' by a convex 
lens placed before the eye, the rays will come to a focus at the point R 
on the retina, since the path of the rays passing into the eye after refrac- 124 
NORMAL AND ABNORMAL REFRACTION 
tion by a convex lens (Fig. 62) is exactly the same as that of the rays 
diverging from the retina and passing outward (see Fig. 61), only the di- 
rection is reversed. The far point, R', of the hyperopic eye is the point 
to which parallel rays must be given a convergence by a convex lens in 
order to come to a focus on the retina. The amount of this necessary 
convergence represents the deficiency between the refraction of the 
hyperopic and that of the emmetropic eye; the degree of hyperopia is, 
therefore, in an inverse ratio to the distance of R'. 
To correct hyperopia the refraction of the eye must be increased 
by a convex lens of sufficient strength to bring F on the retina. This 
glass corrects the hyperopia by shortening the focal length of the dioptric 
apparatus to correspond exactly with the length of the visual axis. The 
far point R' is removed to infinity. Parallel rays come to a focus on the 
retina without any effort of accommodation, and rays emerging from 
the eye are rendered parallel. 
Fig. 62.-Correction of hyperopia by a convex glass. The lens, L, gives to parallel 
rays a convergence toward the point R'; they will consequently be united on the retina, R. 
R' is the virtual conjugate focus of R. 
In order to neutralize the hyperopia that convex glass must be 
selected which gives the greatest visual acuteness. As this is obtained 
when the retinal image is sharply formed, and as this occurs when rays 
are brought to an exact focus on the layer of rods and cones, the maxi- 
mum sharpness of sight is the most satisfactory evidence that rays are 
exactly focused on the retina. If these rays are parallel, the glass 
which brings them to a focus on the retina corrects the hyperopia. 
Rays from objects at 6 meters' distance are sufficiently parallel for this 
purpose. 
Correction of Hyperopia with Test-types and Trial-lenses.-The 
card of test-letters, in good illumination,-either artificial light or ample 
daylight,-is hung on a wall, at 4 to 6 meters from the patient. A pair 
of trial-frames is placed before the patient's eyes and one eye at a time 
examined, the other being screened by an opaque disk. The patient 
is supposed to have his accommodation paralyzed by a mydriatic, or to 
be beyond fifty years of age. He is required to read the smallest letters 
■which he can see distinctly on the card. The resulting sharpness of 
vision is noted. A convex glass is now placed before the eye. If this 
glass improves vision, but does not raise it to normal, stronger lenses 
are tried until the one is obtained which yields the maximum visual AMETROPIA 
125 
acuteness; or, if the stronger glasses do not improve the vision, suc- 
cessively weaker ones are tried until that glass is found which gives the 
greatest sharpness of sight. This is the lens which corrects the hyper- 
opia. If the acuteness of vision is raised to normal by a convex spheric 
lens, it is not likely that astigmatism is present, but every eye should 
be examined with a view to discover any astigmatism. If none exists, 
the convex glass is all that is required to correct the ametropia. 
In the absence of a mydriatic and the presence of some accommoda- 
tive spasm, vision being equal in the two eyes, a more suitable glass may 
often be obtained by testing both eyes simultaneously, because with 
parallel axes the accommodation is more likely to undergo relaxation. 
This effect may be further increased by placing a prism of 2° or 3° 
(centrads) before one eye, with its base inward. The effect of this is to 
relax the internal recti muscles, and indirectly the accommodation. 
It is a good plan to begin by placing before the eyes a lens of stronger 
refraction than the one required, and gradually weakening it by con- 
cave glasses of successively higher numbers until normal vision is reached. 
The glass required is then the difference between the two. 
The proof that the glass selected is the correct one depends upon 
the ability of the patient to focus parallel rays on the retina. Parallel 
rays may be obtained by placing an object at the principal focal distance 
of a convex lens. The principal focal distance of a 4 D lens is 25 cm. 
Therefore if the glass corrects the hyperopia, the patient should be able 
to read fine print at 25 cm. distance with + 4 D added to his correction. 
If he reads at a greater distance than 25 cm., some hyperopia is still 
uncorrected. If he reads at a shorter distance than 25 cm., the hyper- 
opia is probably overcorrected. 
The degree of hyperopia may also be determined by placing a con- 
vex lens before an eye the accommodation of which is paralyzed, and 
by finding the distance at which small type appears most distinct. 
Suppose the lens selected is 4 D (focal distance = 25 cm.), and that the 
patient reads best at 33 cm. Now 33 cm. is farther than the principal 
focus, and the rays, therefore, are convergent after passing through the 
lens, since a 3 D lens would render them parallel; 4 D = 3 + 1 would 
give them a convergence of 1 D to the conjugate focus, 1 meter back of 
the eye; 1 D, therefore, represents the amount of the hvperopia (see page 
126). 
Rule.-Subtract from the lens employed the lens whose focal dis- 
tance equals the distance at which the patient reads. The difference is 
the degree of hyperopia. 
Correction of Hyperopia with the Ophthalmoscope and Shadow-test. 
-To correct hyperopia in children before they are old enough to read, 
the ophthalmoscope and skiascopy are the means upon which reliance 
is placed, but these methods should also be employed in adults. They 
are explained on pages 106 and 111. 
Ordering of Glasses.-After the degree of the hyperopia has been 
determined, the very important question presents itself, What glass 
shall be ordered? While the eye is under the influence of the cycloplegic, 126 
NORMAL AND ABNORMAL REFRACTION 
distant vision is distinct with the full correction; after the effects of the 
drug have disappeared, it is often dim with the full correction, and a 
haze seems to lie over all distant objects, which disappears when the 
glasses are removed. On the other hand, the headache, asthenopia, and 
congestive troubles return if the hyperopia remains uncorrected. Spasm 
of accommodation is the disturbing factor in this problem, and it is so 
variable in different individuals that no precise rule can be given. 
Many persons wear a full correction with comfort, and do not need any 
modification; others will tolerate only a small part of the full correcting 
glass. 
There are two methods of dealing with this difficulty: first, to order 
full correction while the eye is still under the influence of the mydriatic, 
and to insist that this shall be worn constantly during the time that 
the accommodation is returning to its normal state. If distant vision 
remains dim, after full accommodative power has returned, the glasses 
may be weakened sufficiently to secure normal sight for long ranges. 
It should be borne in mind that the glass which gives the best cor- 
rection at 4 or 6 meters is not the correcting glass for the total H, but, 
in reality, is an overcorrection of | to | D. Strictly speaking, rays coming 
from these distances are not parallel, and the glass which focuses them 
perfectly on the retina will not perfectly focus parallel rays. Hence, 
in ordering a full correction, the glass which gives the best vision at 
4 or 6 meters must be weakened by | or | D. If this fact were more 
often remembered, less difficulty would be experienced in inducing pa- 
tients to wear a full correction. 
Second, the eyes are first allowed to regain their full power of ac- 
commodation before the final glass is prescribed, and this is the plan 
which should be pursued. If vision is normal with the full strength of 
the glass, it may be ordered; if not, it should be reduced to that number 
with which full visual acuteness is obtained. This may be only one- 
half, one-fourth, or even less, of the full amount. It is necessary in these 
cases to increase the strength of the glass from time to time as symp- 
toms of fatigue manifest themselves. When the glass ordered for dis- 
tance is only a small part of the full correction, another pair of lenses for 
reading may be ordered which embodies nearly or quite the full amount 
of correction. 
A frequent cause of inability to wear a full correction depends upon 
the development of convergence insufficiency, causing an associated 
action of accommodation with the muscular effort necessary to bring the 
visual axes into a parallel condition (see page 556). 
Instead of ordering the glass nearest in strength to the full correc- 
tion, with which the patient still has normal vision, the lens which 
neutralizes the total hyperopia may be reduced by a given amount, 
usually 0.75 D. Donders advised a glass based upon the manifest H, 
to which one-quarter of the latent H was added. Macnamara recom- 
mends, in absolute hyperopia, the use of a convex glass, the strength of 
which shall be equal to one-half of the sum of the manifest and total 
hyperopia-e. g., manifest H = 1.5 D; total H = 3.5 D. H. m. + H. t. MYOPIA 
127 
= 5 D; ordered + 2.5 D. The author, if convergence is ample, usually 
orders the full correction of H less 0.25 D. If there is exophoria, this 
plan must be modified, or the defect remedied by prisms or by prismatic 
exercises. The indistinct vision, caused by full correction of H, due to a 
disturbance of the relative range of accommodation and convergence, 
may be overcome by systematically training the convergence (see page 
559). Whether a glass shall be 
worn constantly or not depends 
upon the symptoms which the 
hyperopia has produced and the 
character of the patient's work. 
Frequently hyperopes are entirely 
comfortable if reading-glasses alone 
are used. Finally, glasses need 
not be ordered simply because 
hyperopia exists; but only when 
it gives rise to the symptoms 
which have been described. Thus, 
one person may easily manage 
one or more diopters of H without glasses; another may have all manner 
of asthenopic and reflex nervous symptoms produced by 1 D of H or even 
less. 
The visual line is often very much displaced to the inner side of the 
cornea in hyperopia, causing a very large value of the angle gamma. 
Myopia is that form of ametropia in which the retina is situated 
behind the principal focus of the eye, and only those rays which diverge 
from some point nearer than infinity can come to a focus on the retina. 
This point is the far point of the myopic eye. 
Fig. 63.-Angle gamma in hyperopia. 
O-A, The optic axis; N, the nodal point of 
lens; V-M, the visual line, cuts the cornea 
at inner side of optic axis; O-N-V, the 
angle gamma, in this case is positive; M, 
the macula. 
Fig. 64.-Far point of a myopic eye. Rays diverging from the retina, c, will, after 
refraction, converge to r; conversely, rays diverging from r will, after refraction, converge 
to c; r is the far point; r and c are also conjugate foci. 
The far point, therefore, is limited by the amount of divergence 
necessary to bring the focus of the rays on the retina. The higher the 
degree of myopia is, the closer will the far point r lie to the eye. Rays 
coming from the retina converge to the far point and form there an 
image (Fig. 64). This image can be seen by the ophthalmoscope. The 
far point and the retina are conjugate foci (see page 113). 
Cause and Varieties.-Myopia may be produced by increased 
refraction of the cornea or crystalline lens, curvature myopia, or by too 128 
NORMAL AND ABNORMAL REFRACTION 
great a length of the optic axis, axial myopia. In the majority of cases 
myopia is due to elongation of the optic axis, often the result of patho- 
logic changes in the coats of the eye. 
Myopia may also be occasioned by changes in the shape of the 
cornea as a result of disease-for example, conical cornea. Corneal 
opacities are a frequent cause of myopia. According to Frenkel, bi- 
lateral opacities usually produce bilateral myopia, while unilateral 
opacities more frequently give rise to unilateral myopia, which may 
affect either eye, according as the one or other eye is most used for 
near vision. The myopia thus caused appears to be an axial and 
not a curvature myopia. Myopia, unlike hyperopia, is rarely con- 
genital. It usually makes its appearance from the eighth to the 
tenth year, and tends to be progressive, especially during the early 
school years. Sometimes it is the continuation of a process started in 
hyperopic eyes, especially in those with astigmatism, and the gradual 
transition from hyperopia to myopia is not infrequently seen among 
patients who return for examination. According to Risley, there may 
be an arrest of the increase of myopia as the result of treatment and the 
optical correction of ametropia. 
Myopia is more prevalent in some countries than in others, and is 
especially frequent in Germany, in the higher classes of the schools, 
reaching, according to Cohn, 60 per cent. Myopia is said to be more 
common among Jews than among Christians of the same social class 
(Sydney Stephenson). Sattler, however, is unconvinced that there 
really exists a racial inclination to myopia. Harman's statistics indicate 
that most of the cases of myopia in early childhood occur in boys, but 
the highest degrees appear in girls. Although the largest number of 
myopes is found among the upper classes,-that is, among those upon 
whom the demands of modern civilization fall most heavily, and among 
artisans whose work requires close inspection,-high grades of this refrac- 
tive defect may also be found among those who apparently do not use 
their eyes for close work, and occasionally among children who have 
not yet been subjected to the influence of school life. It may be that it 
will be found that these subjects of myopia have been reared under 
conditions in which they have been obliged to devote themselves assid- 
uously to work at very near range (Sattler). 
Myopia is frequently hereditary, and may occur in several members 
of one family. Harman found hereditary transmission in 9 per cent, of 
the cases he investigated. With a strong predisposition to myopia the 
elongation of the eyeball may take place under comparatively unim- 
portant exertion. Although myopia usually begins in childhood, there 
may be a late development of this refractive error, that is, it may occur 
after the twentieth year of life. This late development of myopia has 
been observed in association with constitutional disturbances, with 
malaria (T. Becker), with goiter and obesity (R. Wirtz), and with 
pituitary body struma. 
That acute posterior scleroticochoroiditis may occasion myopia, 
especially posterior staphyloma, as originally taught by Von Graefe, is MYOPIA 
129 
not admitted by Sattler, that is, that it is the cause of the myopia. 
Obvious choroiditic changes, according to him, are to be considered as 
a complication which etiologically has nothing to do with the progres- 
sion of the myopia; although he admits that choroiditis may give rise to 
a rapid increase and pernicious course in myopia. The author has pub- 
lished some observations which indicate that, as the result of severe 
choroiditis, myopia may rapidly develop in certain cases, observations 
which are in accord with the statements of Knies, Priestley Smith, and 
others. Occasionally after an acute illness, especially one of the ex- 
anthemata, a myopia develops, or there may be a sudden increase in a 
pre-existing myopia. Alteration of the refractive power of the lens as 
the result of beginning cataract may cause myopia, the so-called second 
sight (see page 395), and, according to Hirschberg, the late development 
of myopia-that is, after the fortieth year, unassociated with cataract 
formation-is not an uncommon sign of diabetes. Transitory increase 
of hyperopia has also been observed in diabetes, due to changes in the 
lens (Lundsgaard). 
In normal eyes the sclera does not yield to the intra-ocular pressure, 
but if from any cause its resisting power is reduced, distention takes 
place and the anteroposterior axis of the eyeball is elongated. Among 
the causes which have been invoked to explain the elongation of this 
axis of the eye-i. e., the production of myopia-are the following: 
The incentive given by the shape and size of the orbit to greater develop- 
ment of the eyeball; the compression of the eyeball by the external 
muscles, causing distention of its coats backward on account of the 
excessive convergence rendered necessary by the close range at which 
myopes are obliged to work;1 the strain of accommodation; racial pecu- 
liarities; inflammatory changes within the eye-for example, sclerotico- 
choroiditis, induced by habits of life which promote fulness of the veins 
of the head and neck and hinder the egress of the blood from the eye 
or are set up by eye-strain itself induced by excessive study, bad ocular 
hygiene, imperfect illumination, etc.; and an inherited tendency, the 
commencement and increase of the myopia being caused by general and 
local vascular congestion, which are the result of constitutional dis- 
turbance-for example, cardiovascular disease (Batten). 
Although prolonged use of the eyes at near work necessitating ex- 
cessive convergence and muscle pressure explains the acquisition of 
myopia in many cases, only a portion of those subjected to such a strain 
become myopic. Therefore in this number, as Fuchs remarks, special 
additional factors must be present: predisposition, too great approxi- 
mation of the work, improper ocular and general hygiene, spasm of 
accommodation, and, especially, astigmatism. Irregular, inverse, 
and oblique astigmatism are, according to Duane, of marked signifi- 
cance in this respect. 
1 Compression of the eyeball under these circumstances may be caused by the external 
rectus. According to Stilling the superior oblique is the principal compressing muscle in 
myopia, the low position of the trochlea increasing the amount of force which this muscle 
exercises on the globe. Schmidt-Rimpler rejects Stilling's conclusions, and Ramberger's 
measurements do not confirm Stilling's contention that in myopia the vertical diameter of 
the orbit is decreased. 130 
NORMAL AND ABNORMAL REFRACTION 
Among other causes of less moment may be mentioned an unusually 
great distance between the pupils, rendering convergence more difficult, 
a divergent squint, and a large size of the angle gamma (in this case 
negative), demanding more strain on the part of the eye muscles in the 
efforts of convergence. After myopia is once produced the eyeball, by 
its oval shape and greater size, may act as a cause of the further develop- 
ment of this refractive defect by reason of the increased muscular effort 
which is required to rotate such a globe inward during convergence, and 
the compressing effect of the external recti muscles on the increased 
posterior segment of the eyeball. 
At first probably all cases of myopia are progressive, but many are 
checked because the eyes are removed from the strain of close work or 
are placed under better hygienic surroundings; that is, the myopia be- 
comes stationary. Other cases may progress until the increased effort 
of convergence demanded by the increased myopia becomes too difficult 
to sustain, one eye deviates outward and there is produced a divergent 
strabismus. Then further increase of myopia may stop, or the inflam- 
matory changes already set up within the eye may continue, the disten- 
tion of the ocular coats increases, and the most serious organic lesions 
arise; in other words, there is malignant or pernicious myopia. 
Symptoms.-The symptoms of myopia naturally range themselves 
under the two classes, subjective and objective. 
The subjective symptoms are those which arise because the range of 
vision is limited by a radius of a few centimeters. Distant objects are 
not clearly perceived by the myopic patient, because as soon as an ob- 
ject passes beyond his far point it becomes indistinct. According to 
Seggel, the light-sense diminishes with an increase of myopia. Percival 
Hay finds that if refractive errors are low, they do not affect the light- 
sense, but if they are high they tend to increase the light difference. 
Many myopes have an inclination to avoid outdoor sports on 
account of their poor vision, and exhibit a greater fondness for occu- 
pations which come within their range-e. g., reading, drawing, etc.- 
than for others which require good distant vision. The prolonged con- 
gestion of the eyes which such habits entail tends to increase the my- 
opia. Headache and reflex phenomena are unusual accompaniments 
of myopia unless complicated with astigmatism, which is an important 
factor in the further increase of the refraction. Myopia, however, 
frequently causes aching of the eyeballs, very imperfect ocular endur- 
ance, congestion of the conjunctiva-indeed, many of the symptoms 
which are strictly asthenopic, especially when the choroid is under- 
going the changes which are determining the increase in the refractive 
power. That the full enjoyment of outdoor sports is not at all incom- 
patible with the existence of myopia properly corrected is well known, 
and it is an interesting fact, pointed out by Goldberg, that many ex- 
cellent marksmen are myopic. 
The objective symptoms of high myopia may embrace: (1) A notably 
prominent, and elongated eyeball, with a large and somewhat sluggish 
pupil; (2) a rather stupid expression of the countenance from inability MYOPIA 
131 
to note the expression in the face of others; (3) a peculiar manner of 
reading-the book is held stationary and the face is moved from side 
to side, following each line; (4) certain characteristic ophthalmoscopic 
appearances. With the direct method the optic disk appears enlarged; 
at its outer side there often is a crescentic area of whitish hue, depend- 
ing upon alterations in the choroid, known as a conns or myopic crescent. 
This area may begin next to the disk with a space of complete atrophy, 
succeeded by a rim of partial atrophy and pigment disturbance, which 
in its turn merges into a patch of choroidal congestion. Sometimes 
the entire disk is surrounded by areas of choroidal disturbance, and the 
general choroid may exhibit many alterations depending on congestion, 
edema, rarefaction, atrophy, and pigment accumulation (see also page 
130 and Fig. 65). Weiss and B. Alex. Randall have described a curvi- 
Fig. 65.-Eye-ground in progressive myopia. Large posterior staphyloma sur- 
rounding the nerve-head. Macular region occupied by areas of semi-atrophic retino- 
choroidal lesions. 
linear reflex, generally at the nasal side of the disk, as a prodromal sign 
of myopia. (5) Divergent squint. The squinting eye is often ambly- 
opic. Binocular vision does not exist in such a case; the better eye, 
freed from the necessity of convergence, reads at the far point without 
any effort, and glasses for reading are sometimes unsatisfactory because 
the print appears smaller on account of its removal to a distance greater 
than the far point of the eye. 
The visual axis in myopia sometimes passes through the cornea at 
the outer side of the optic axis; the angle gamma is then negative, and the 
eye in looking at a distant object turns inward in order to bring the 
visual line to fix on it, giving rise to an apparent convergent squint 
(Fig. 66). This renders necessary a greater degree of convergence. 
Myopic eyes are popularly considered as strong eyes because they 
see fine print at close ranges. This is true only in those cases in which 132 
NORMAL AND ABNORMAL REFRACTION 
the tunics of the eye have suffered no injury-where, for example, the 
myopia is of moderate degree and the eye-grounds are normal. 
Myopia does not usually decrease with age, but, on the contrary, 
tends to increase up to adult life or later. 
Very high (10 D and higher) degrees of myopia (malignant or per- 
nicious myopia) are often marked by ravages in the structure of the 
choroid and retina. The pigment-cells wander off in some places and 
accumulate in others, producing marked contrasts in the appearance 
of the eye-ground. Large areas of atrophy, glistening white in color, 
alternate with black splotches, and at times hemorrhages occur. The 
macular region is especially prone to degenerative, atrophic, and hemor- 
rhagic changes. According to Hirschberg, these central changes, char- 
acteristic of high myopia, are due to mechanical stretching and not to 
inflammatory processes. The disk is often surrounded by an atrophic 
area, the posterior staphyloma, which represents an area of thinned and 
distended sclera. 
Posterior staphyloma should not be confused with the conus or 
myopic crescent, and, according to Schnabel, who accepts von Jaeger's 
view, it should be regarded as an anomaly in the form of the eye-that 
Fig. 66.-Angle gamma in myopia which is negative. 
is, a malformation and not the result of disease. He believes that 
there is a connection between retinochoroiditis and posterior staphy- 
loma, but that "the primarily emmetropic or hyperopic eye will not 
become affected with retinochoroiditis of the macula in consequence 
of acquired myopia; only eyes with posterior staphyloma resulting from 
congenital malformation have, in addition to excessive myopia, an 
especial predisposition to that grave disorder."1 The vitreous humor is 
semifluid, and floating opacities are often visible, sometimes being so 
large as to obscure vision. Owing to the intimate relation between 
retinal nutrition and the pigmented epithelium of the retina, the loss 
of the latter is followed by diminution in the visual acuteness. In 
high grades of myopia-15 to 20 D, and sometimes still higher- 
the condition of the eye is desperate, and the morbid processes 
may culminate in detachment of the retina and complete blindness. 
Occasionally, in the macular region of myopic eyes may be seen an 
intensely black area, about the size of the nerve-head, with a slightly 
grayish center, and surrounded by a lighter ring. It stands out well 
1 "Relationship of Staphyloma Posticumto Myopia," I. Schnabel, System of Diseases 
of the Eye, edited by Norris and Oliver, vol. iii. MYOPIA 
133 
defined. This is the so-called black spot of the macula in myopia, first 
described by Forster and later by Fuchs. It is interpreted in the visual 
field by a scotoma. The prognosis is unfavorable and the disease may 
be progressive, although, according to some observers, this lesion renders 
the eye less liable to the other complications of myopia. Butler and 
Stargardt have described a central green spot in myopia. 
Fig. 67.-Ciliary body of a myopic eye 
(specimen prepared by Dr. C. M. Hosmer). 
Notice the abnormally flat appearance of 
the ciliary body. 
Fig. 68.-Ciliary body of a hyperopic 
eye (speciman prepared by Dr. C. M. 
Hosmer). 
Not only is corneal astigmatism a potent factor in the increase of 
myopia, but, according to Senn, it bears an important relation to central 
choroiditis and destructive change in the fundus. 
In myopia the ciliary body appears to be flat, and the transverse 
diameter of the ciliary muscle is smaller than it is in the normal eye, 
because its circular fibers, comparatively little employed in the act of 
accommodation, are poorly developed. The sinus of the anterior 
chamber is deeper than it is in emmetropic or hyperopic eyes, and 
Fig. 69.-Manner in which a concave lens causes rays to diverge from the far point of a 
myopic eye. 
hence the tendency to primary glaucoma in myopic eyes is said to be 
lessened. 
Determination and Correction of Myopia.-Myopia may be deter- 
mined: (1) By the position of the punctum proximum of accommoda- 
tion, which is closer to the eye than is normal for the age; (2) by the 
position of the farthest point of distinct vision obtained by test-types; 
(3) by the ophthalmoscope and retinoscope (page 113); (4) by the con- 
cave glass which gives distinct vision at a distance of 4 to 6 meters. 
Only those rays which diverge from a distance not greater than the 134 
NORMAL AND ABNORMAL REFRACTION 
far point can be focused on the retina of the myopic eye. In order that 
it shall see at any greater distance than this the rays must be given a 
divergence as great as if they came from this point (Fig. 69). If the 
greatest distance at which a myopic eye can see fine print is 14 cm., 
in order to see at a still greater distance the eye would require a con- 
cave glass which would give rays a divergence as if they came from 
this point. By dividing 100 by 14 we obtain the number of diopters 
(7) necessary to produce this divergence. As the far point is measured 
from the cornea, the glass must be placed close to the cornea; if the glass 
is removed 1 cm. from the cornea, it is plain that its focal point will also 
be 1 cm. farther away; therefore it is necessary to employ a glass of 
shorter focus. 
Example.-Suppose it is desired to cause the rays to diverge from a point 14 cm. 
in front of the cornea, and the glass is to be placed at 1.5 cm. in front of the cornea; it 
is evident, under these circumstances, that the glass would require to have a focus 
of 14 - 1.50 = 12.5 cm., or = 8 diopters. 
12.5 
The usual position for a glass is about 13 mm. in front of the cornea. 
In low degrees of myopia this does not affect appreciably the strength 
of the glass, but in the higher degrees it makes a serious difference. The 
concave glass is, therefore, somewhat stronger than the actual myopia, 
especially in the higher grades. 
The degree of myopia may be determined approximately by this 
method more rapidly than by beginning the trial at 6 meters with 
glasses (in this instance, concave) in the manner already described in 
connection with hyperopia (see page 124). One example will suffice: 
A patient reads fine print distinctly at 8 cm. from the cornea, but not at a greater 
distance, the eye being under the influence of a cycloplegic; this is its far point. In 
order that the patient may see at an infinite distance, parallel rays must be given a 
divergence as if they came from 8 cm. in front of the cornea. As the glass will be 
placed 13 mm. in front of the cornea, its focal length must be 8 cm. - 1.3 cm. = 6.7 
cm., or 67 mm. mm. equals 15 D, as the number of the concave lens required to 
67 
permit distant vision. A lens of this number should be placed in the trial-frame, and 
the vision determined through it by means of test-types at the usual distance. Per- 
haps a weaker or a stronger lens may give better vision, and hence several numbers 
should be tried in succession, until that glass is selected with which the greatest 
acuteness of vision is attained, and which then represents the correcting lens. 
A patient often will select a glass of higher number than the one 
really required, because the letters have a blacker and sharper appear- 
ance when seen through concave lenses; but unless the stronger glass 
at the same time secures for the patient an increased acuteness of 
vision it should be rejected, and the weaker lens adopted. If several 
lenses give equally good vision, the weakest one should be chosen. 
The method of determining the correcting lens in myopia by means 
of ophthalmoscopy and skiascopy is elsewhere described (see pages 106 
and 111). MYOPIA 
135 
Treatment of Myopia.-This should include 'prophylactic measures 
and the selection of suitable concave glasses. From the eighth to the 
eighteenth year-that is, during school life-myopia specially tends to 
appear and to progress; hence prophylactic means are urgently re- 
quired during this period. No child should be permitted to begin 
school duties until the exact state of the refraction has been determined, 
and if vision is deficient and eye-strain likely to develop, suitable lenses 
should be prescribed. Strict attention should be paid to the following 
conditions: A correct position of the head and body during study, 
secured by means of a suitable desk, the surface of which is so tilted that 
the page of the book lying on it is parallel to the scholar's face, and by 
a chair or stool of proper height both in relation to the desk and the 
floor; the employment of books with sufficiently large and distinctly 
printed type; good illumination coming from behind the scholar and 
preferably over the left shoulder; proper ventilation; restriction of the 
hours of study within reasonable limits and plenty of outdoor exercise. 
These precautions apply with equal force to hours of study at home. 
As Priestley Smith has well said, it is necessary "to suspect every 
myopia, and especially every youthful myopia, of a tendency to in- 
crease, until time has proved it to be stationary; to be doubly suspicious 
in the presence of congestion or atrophy of the eye-ground; and to re- 
examine at intervals of six months, twelve months, or longer, according 
to the nature of the case." These examinations should be made with 
the help of mydriasis-if possible, with atropin. It is particularly im- 
portant frequently to investigate the eyes of the children of myopic 
parents. In some cities-for example, in Berlin-a special curriculum 
is provided for children with a myopia of 6 D and over (Hirschberg). 
Harman also urges that children with high degrees of myopia should be 
instructed in special classes. 
If a tendency to divergence exists in early life, it is sometimes 
proper to remove this by tenotomy of the external rectus as a prevent- 
ive measure against the development of myopia. 
Since Fukala's recommendation removal of the crystalline lens 
(discission, followed by extraction, or phakolysis) has been practised by 
a number of operators for the relief of high myopia (15 D or more). 
Improvement in vision and increase in the distance at which eyes can 
be used in near work are the results of successful operations, which, 
according to von Hippel, may not reach their best standard until a 
year after the operation-checking of the increase of the myopia. 
The chief dangers of the operation are: Intra-ocular hemorrhage, 
detachment of the retina, secondary glaucoma from swelling of the 
lens, iritis, and infection' of the corneal wound. The chief contra- 
indications are: Extensive degeneration of the choroid, retina, or 
vitreous, diminished intra-ocular tension, a tendency to intra-ocular 
hemorrhage, previous loss of one eye from any cause, and advanced age. 
Hirschberg vigorously condemns any tendency to indiscriminate appli- 
cation of the operation and has operated only on carefully selected eyes. 
(For methods of operating see pages 649, 650.) The author's experience 136 
NORMAL AND ABNORMAL REFRACTION 
with the operation has been very limited, but it has been favorable. 
He believes, however, that in the majority of cases correcting lenses, 
even in very high grades of myopia, can be made to serve a more useful 
purpose than operative interference, and has but rarely found it neces- 
sary to advise the operation. Hertel has designed telescopic spectacles. 
They somewhat resemble an automobile goggle. They decrease the size 
of the visual field, but increase the distinctness of distant objects. 
They are intended to be a substitute for operative procedures in high 
myopia.1 To compute the probable correcting glass after loss of the 
crystalline lens, according to Landolt, one should divide by 2 the 
number of diopters of the correcting glass of the complete eye, and when 
concave, subtract it from 11 D, and when convex, add it to 11 D. 
Ordering of Glasses.-After the estimation of the degree of myopia, 
astigmatism having been excluded, or, if present, corrected, the strength 
of the glass suitable for constant use, reading, or other special work must 
be determined. This is decided by the visual acuteness, the range of 
accommodation, the degree of the myopia, and the condition of the 
external ocular muscles. 
Young people (under twenty) with good vision and a moderate 
degree of myopia (6 D and under) should wear the full correction con- 
stantly if the accommodation is ample and no signs of fatigue are evi- 
dent. 
Indeed, full correction is the object to be attained for young persons 
with normal visual acuteness and binocular near vision, no matter how 
high their myopia (Jackson), provided the lens selected shall not be an 
overcorrection when brought close to the eye. The author is con- 
vinced from personal experience that full correction, other things being 
equal, yields the best results in the management of myopia, and espe- 
cially in the prevention of its increase, and this conviction is strength- 
ened by the abundant statistical information on this subject which has 
been collected and analyzed by observers here and abroad. A few 
authors, for example, Hirschberg, are not in accord with this advice. 
Hirschberg advises that if the myopia is beyond 3 D, fully correcting 
glasses should not be worn. Naturally, there are exceptions to the 
rule, and each case requires thoughtful study; but, in general terms, 
the full correction of myopia yields the best results. 
When visual acuteness is imperfect or binocular vision lost, it is 
usually better to order a partial correction for near work, and if the 
patient has attained those years when accommodation naturally fails, 
he must be provided with lenses for close range, or, if his myopia is of 
suitable degree, read without glasses. When wearing a partial correc- 
tion the patient is tempted to improve distant vision by looking ob- 
liquely through the glass. But this gives it a cylindric effect, varying 
with the direction of the visual axis, and is always injurious. 
In high grades of myopia associated with lowered vision it is often 
necessary to diminish the full correction from 1 to 3 D. It is evident 
that the greater the visual acuteness, the farther away the same size 
1 See Archiv. f. Ophthal., Bd. Ixxv, Heft 3, p. 586, 1910. MYOPIA 
137 
of type can be seen; hence the demand on accommodation is less as the 
visual acuteness is greater. 
When strong concave lenses are first worn, a lack of accommodation 
often appears, which is restored by a few months' use of the glasses. 
For the relief of this deficiency it is advisable to give a partial correction 
for near work until ample power of accommodation is gained, when the 
full correction may be used for all purposes. 
As age advances an additional glass should be ordered for reading 
which will give the patient a far point of from 30 to 60 cm. In order 
to obtain this, the full correction must be diminished from 1.50 to 3 D. 
The position of the lens used to correct high grades of myopia is of 
great importance. The nearer the lens is placed to the cornea, the 
stronger it becomes; conversely,' the farther it is removed from the 
cornea, the weaker it is. The strong concave lenses necessary to cor- 
rect high degrees of myopia in this way may sometimes be utilized by 
the patient to gain artificial accommodation. By bringing them close 
to the eye vision is adapted for distance; by pushing them from the eye 
divergence is lessened and the eye is adapted for a closer point. 
The visual acuteness in high myopia is usually reduced, and in 
those cases accompanied by changes in the retina and choroid this 
reduction assumes a considerable grade. Sometimes very slight im- 
provement in distant vision is secured by concave glasses, and near 
vision may not be at all benefited. In these circumstances patients 
see better by using one eye alone and bringing the print or other work 
close to the eye, because the enlarged retinal image compensates for the 
diminished visual acuteness. These cases, however, are seldom en- 
countered, and a concave lens, properly selected, almost always improves 
both near and distant vision. 
Concave glasses diminish the size of the retinal image, especially 
when the glass is removed farther from the eye. The retinal image is 
larger in myopia than in emmetropia, but if the correcting lens is ex- 
actly 13 mm. in front of the cornea, the image is of the same size as in 
emmetropia. 
Concave lenses act as prisms when the visual line passes through 
any portion except the optical center. The optical centers should 
always be separated by a space equal to, and never less than, the 
interpupillary distance, except in those cases of weakness of the in- 
ternal rectus muscles where it is advisable to increase the distance 
between the centers. This produces the effect of a prism with its base 
inward-that is, it lessens the amount of convergence which otherwise 
would be required. The deviation may be calculated from the focal 
distance of the lens and the amount of decentering. The distance the 
optical center is displaced, divided by the focus, equals the tangent of 
the angle of deviation. Myopes with decided esophoria often read 
more comfortably without than with glasses. 
The painful glare of light sometimes caused by wearing concave 
glasses may be modified by tinting them. 
The reading-glasses for myopes are described under Presbyopia. 138 
NORMAL AND ABNORMAL REFRACTION 
Astigmatism (Astigmia).-In the preceding forms of ametropia, 
H. and M., the cornea has been considered as an ellipsoid of revolution, 
so that planes passing through it in various directions, vertical, hori- 
zontal, and oblique, produce sections having an equal curvature. 
Equal refraction, consequently, takes place in these different planes. 
Variations in the curvature of the different meridians produce differences 
in their refractive power; in some of these meridians the eye must, 
therefore, be ametropic. Three conditions may arise: 
1. The eye may be emmetropic in one meridian and ametropic 
(either H. or IM.) in the others. 
2. The eye may be ametropic (H. or M.) in all meridians, but in 
different degrees. 
3. The eye may be ametropic in all meridians, but in some H. and 
in others M. (H. and M.). 
It is convenient to designate the different parts of the eye by imagin- 
ary lines, similar to those employed in geography. 
The axis of the eye is a line drawn from the center of the cornea 
through the center of the ball. Passing through the center of the lens 
and the center of rotation, it penetrates the sclerotic between the optic 
nerve entrance and the macula. The anterior and posterior extremi- 
ties of this line are the poles of the eye. 
A great circle extending round the ball perpendicularly to the axis, 
and at an equal distance from the two poles is called the equator of the 
eye; other great circles passing through the poles are called meridians. 
The lens is described in a similar way by its axis, anterior and poste- 
rior poles, and equator. 
When the meridians of the cornea have an equal curvature, the rays 
of light gather in one common focus. Frequently the cornea has mer- 
idians of unequal curvature producing greater refraction in some mer- 
idians and less in others. The rays passing through the meridian of 
highest refraction reach their focus soonest, while those passing through 
the least refracting meridian come to a focus farther back. 
Definition.-Astigmatism (or astigmia) is an ametropia of curvature, and 
the term is applied to that refractive condition of the eye in which a luminous 
point-for example, a star-forms an image on the retina, the shape of 
which image is a line, an oval, or a circle, according to the situation of the 
retina, but never a point. 
Seat of Astigmatism.-Usually the cornea is the seat of astigmatism, 
but astigmatism may also be produced by an oblique position of the 
lens, or by the visual line passing eccentrically through the cornea. 
When' the meridians of the cornea progress evenly in their refrac- 
tion from the lowest to the highest, the astigmatism is termed regular. 
When the curvature in different parts of the same meridian varies,- 
and the meridians vary irregularly in their curvature as the result of 
cicatrices from ulcers or distention of the cornea from inflammation,- 
the astigmatism is called irregular. 
Almost all eyes possess more or less irregular astigmatism. Usually 
it is only slight, and gives no serious inconvenience for ordinary vision, ASTIGMATISM (ASTIGMIA) 
139 
but all points of light, such as stars, distant street-lamps, etc., shoot 
out rays and twinkle as the result of the irregular astigmatism of the 
eye. The seat of this irregular astigmatism is in the crystalline lens. 
In the lenses of young people the union of the sectors is visible by three 
faint lines-the lens star; in the adult secondary rays are also visible. 
Slight differences in the density of the several sectors are sufficient to 
produce a distorted image of a luminous point. 
Principal Meridians.-In regular astigmatism the cornea has one 
meridian with the shortest radius of curvature producing the highest 
refraction, and another meridian, at right angles to this, with the longest 
radius of curvature and the least refraction. These are called the 
principal meridians, and may be situated in any part of the cornea, but 
there is a disposition of the greatest refracting meridian to lie in or near 
a vertical direction, and of the least refracting meridian to lie in a 
horizontal direction. 
If the meridian of greatest refraction is vertical or nearly so, the 
astigmatism is described as with the rule; when the meridian of great- 
est refraction is horizontal or nearly so, the astimgatism is spoken 
of as contrary to the rule or inverse; if the direction of the principal 
meridians approaches 45° and 135°, the astigmatism is often desig- 
nated oblique. 
To simplify the phenomena of astigmatism the principal meridians 
will be considered as running vertically and horizontally with the great- 
est refraction in the vertical, and the least refraction in the horizontal, 
meridian. 
Form of the Image of a Point Focused by an Astigmatic Eye.- 
The rays passing into an astigmatic eye, thus considered, are most 
sharply refracted by the vertical meridian. The bundle of rays, in- 
stead of having a round section, forms a horizontal oval, which becomes 
smaller as the rays travel farther backward; but the vertical diameter 
of the oval lessens most rapidly until, when the focus of the vertical 
meridian is reached, the figure becomes a horizontal line, because all the 
rays are brought to one level and remain diffused only in the horizontal 
direction. 
Farther back the rays, after passing this focus and crossing, diverge 
again vertically, and the figure becomes once more a horizontal oval; 
but shorter because the horitonzal diffusion is diminished. 
Still farther the figure assumes the form of a circle; the diffusion of 
the horizontal rays has become less, and that of the vertical rays more. 
The figure becomes next a vertical oval, then a vertical line as the focus 
of the horizontal meridian is reached. Finally, the section is again a 
vertical oval, the horizontal rays, having passed their focus, cross and 
begin to diverge (Fig. 70). 
It is evident from this that no matter what position the retina may 
occupy, no distinct image can be formed upon it, but there must always 
be overlapping of the images of the different points of an object, causing 
a blur or a wrong impression of its outline. 
Symptoms.-In this manner the acuteness of vision is diminished 140 
NORMAL AND ABNORMAL REFRACTION 
by astigmatism. Letters are not distinctly seen, some letters being 
confused with others-H and N, B and S, F and P, K and X, V and Y. 
The overlapping of the diffusion areas in the retinal image produces, in 
high degrees of astigmatism, an apparent doubling of the object. The 
indistinctness of vision compels a closer approximation of the object, 
with a consequent strain upon the accommodation. 
Astigmatic persons learn to overcome their refractive defect by con- 
tracting the lids close together in order to make a horizontal slit. The 
Fig. 70.-Retinal images of a point in the different forms of astigmatism: A, Com- 
pound hyperopic astigmatism; B, simple hyperopic astigmatism; C, D, E, mixed astig- 
matism; F, simple myopic astigmatism; G, compound myopic astigmatism. 
vertically divergent rays are thus excluded, and the eye, accommodated 
for the horizontally divergent rays, receives a more distinct though 
fainter image. There is an almost characteristic facial expression in 
astigmatism caused by contraction of the lids. 
Astigmatism produces an indistinctness in the appearance of fine 
lines running in certain directions, the direction of the indistinct lines 
being determined by that meridian which has its focus on or nearest 
Fig. 71.-Rays passing through an astigmatic lens (Thorington). 
to the retina. This meridian, therefore, will most nearly approach 
emmetropia; the lines parallel to it will appear indistinct, while those 
parallel to the opposite meridian, or the one farthest removed from 
emmetropia, are most distinctly seen. 
In those cases in which the horizontal meridian is emmetropic and 
the vertical meridian ametropic, fine parallel lines running in a hori- 
zontal direction will appear spread out into thick bars, while vertical 
lines will appear distinct. ASTIGMATISM (ASTIGMIA) 
141 
To understand this, the student should remember that rays diverge 
from a horizontal line in all directions; those which pass through the 
horizontal meridian, if they are not exactly focused, spread out in the 
direction of the line, causing its extremities to appear somewhat faint 
in outline, but do not blur its width. The rays which diverge in vertical 
planes from the different points in the line pass through the vertical 
meridian. If this is not emmetropic, the breadth of the line appears 
thicker; but if the vertical meridian is emmetropic, it forms a distinct 
point in the image, of each point 
in the object, by bringing the rays 
which pass through it to a focus. 
A horizontal line thus appears as a 
succession of distinct points when 
the vertical meridian is emmetropic. 
Vertical lines, in the same way, ap- 
pear most distinct when the hori- 
zontal meridian is nearest to em- 
metropia, or if oblique lines appear 
most distinct, the meridian at right 
angles to their direction is the one 
nearest to emmetropia. Luminous points are drawn out in the direc- 
tion of the ametropic meridian, and luminous circles become elongated 
into ovals. 
Astigmatism may be responsible for the most aggravated types of 
asthenopia and most marked symptoms of eye-strain. Fully 60 per cent, 
of functional headaches are caused by this type of refractive error, either 
alone or in association with other forms of ametropia. The headache 
may vary from a moderate frontal distress to violent explosions of pain, 
and may be situated in any portion of the cranium. That true migraine 
is caused by astigmatism alone is doubtful; that the correction of astig- 
matism is an important, indeed, an essential, part of the treatment of 
this affection should not be disputed. Furthermore, all manner of 
reflex nervous disturbances, vertigo, pseudochorea, habit-spasm, epi- 
leptiform convulsions, melancholia, neurasthenia, tachycardia, night- 
terrors, flatulent and other types of dyspepsia, indigestion, and even 
constipation are the frequent results of astigmatism, not only when the 
error is of high degree, but commonly, indeed, more commonly when 
it exists in low grade, and often unassociated with any symptoms which 
prominently direct attention to the eyes as the cause of the distress. 
Pains strangely and persistently situated in the nape of the neck, be- 
tween and under the shoulder-blades, in the precordium, at the end of 
the spine, and deep in the mastoid may owe their origin to the same 
cause. Tilting of the head and shoulders is often the result of astig- 
matism, and that the same refractive anomaly is the exciting cause of 
some of the cases of lateral curvature of the spine so often seen in young 
subjects has been shown by G. M. Gould. (See also page 558.) 
Regular astigmatism is divided into five varieties, according to the 
relative position of the retina to the foci of the two principal meridians. 
Fig. 72.-Illustrating the appearance 
of lines running in different directions as 
seen by (a) the normal eye and (6) the 
astigmatic eye (Jackson). 142 
NORMAL AND ABNORMAL REFRACTION 
The focus of the horizontal meridian is represented by H., that of the 
vertical meridian by V. 
1. Simple Hyperopic Astigmatism.-In this variety one meridian, 
usually the vertical, is emmetropic, and the horizontal meridian is 
hyperopic. The focus of the vertical meridian is on the retina; the 
Fig. 74.-Foci of the principal meridians in 
simple myopic astigmatism. 
Fig. 73.-Foci of the principal meridians in 
simple hyperopic astigmatism. 
focus of the horizontal meridian is behind the retina (Fig. 73); hori- 
zontal lines appear distinct. 
2. Simple Myopic Astigmatism.-The focus of one meridian, usually 
the horizontal, is situated on the retina, while the focus of the vertical 
meridian lies in front of the retina. The vertical meridian is myopic, 
Fig. 75.-Foci of the principal meridians in 
compound hyperopic astigmatism. 
Fig. 76.-Foci of the principal meridians in 
compound myopic astigmatism. 
and the horizontal meridian emmetropic (F ig. 74); vertical lines appear 
distinct. 
3. Compound Hyperopic Astigmatism.-All meridians are hyperopic, 
but usually the horizontal presents the greatest ametropia. The focus 
of each principal meridian is situated back of 
the retina, that of the vertical generally being 
nearest to it (Fig. 75); horizontal lines are 
usually most distinct. 
4. Compound Myopic Astigmatism. - All 
meridians are myopic, but the vertical presents 
the greatest ametropia. Both principal merid- 
ians have their foci in front of the retina, that 
of the horizontal lying closer to the retina (Fig. 
76); vertical lines are usually most distinct. 
5. Mixed Astigmatism.-The retina lies between the foci of the two 
principal meridians. The horizontal meridian is hyperopic, and the 
vertical meridian is myopic (Fig. 77); no lines appear distinct unless 
the eye simulates myopic astigmatism; in this case the vertical lines 
appear distinct. 
Fig. 77.-Foci of the prin- 
cipal meridians in mixed as- 
tigmatism. ASTIGMATISM (ASTIGMIA) 
143 
Recognition of Astigmatism.-Astigmatism is recognized subjectively 
by the greater distinctness of lines which run in one direction, and the 
blurring of those lines which run in a direction at right angles to this 
(see Fig. 72). The vertical strokes of a letter may appear distinct, 
while the horizontal strokes are hazy. 
A diminished visual acuteness, unimproved by spheric lenses, in 
the absence of organic disease of the eye,-for example, opacity of the 
media or lesions of the fundus, or lesions of the visual centers,-usually 
is due to astigmatism. Patients frequently complain that letters have 
a streaked or smeared appearance; a small jet of flame seems to be 
drawn out in one direction. 
Astigmatism is recognized objectively by the ophthalmoscope (see 
pages 108, 110), the ophthalmometer (see page 110 and Appendix), and 
skiascopy (see page 115). 
Correction of Astigmatism.-Astigmatism may exist in a very low 
degree, associated with a much higher degree of hyperopia or myopia, 
or a marked astigmatism may exist alone, or with ametropia of the 
other meridians, or finally, mixed astigmatism may be present. There 
are several methods by which astigmatism may be measured: 
1. In all cases of hyperopia or myopia, after the highest visual 
acuteness has been developed with spheric lenses, and even if the 
radiating lines on the dial appear equally distinct, a weak convex 
and a weak concave cylindric lens should be alternately placed in 
the trial-frame, in addition to the spheric lens, and their axes rotated 
through 180°. 
If, by this maneuver, vision is improved and the patient enabled 
to read another line of the test-letters, astigmatism is present. For 
example, if the vision of a case of hyperopia of 3 D is improved by 
placing in front of the spheric lens a convex 0.50 D cylinder, with its 
axis vertical, the glass required is + 3 D sph. Q + 0.50 cyl., axis 90° or 
vertical; but if in the same case the maximum vision previously ob- 
tained by + 3 D sph. is not improved by the addition of a convex 
cylindric lens, a concave cylindric lens should be rotated through 180° 
in front of the spheric lens. If, under these circumstances, a concave 
cylinder of 0.50 D with its axis at 180° is found to improve vision and 
equalize the lines, the formula is + 3 D sph. Q - 0.50 D cyl., axis 180°. 
This result may be expressed in a simpler form by the formula + 2.50 D 
sph. O + 0.50 D cyl., axis 90° (see page 33). 
From this it is evident that any spherocylindric combination, in 
which the spheric is designated by a phis (+) and the cylinder by a 
minus ( -) sign, unless the cylinder is stronger than the spheric, can be 
reduced to a simpler form, obtained by subtracting the value of the 
cylinder from that of the spheric lens; the difference is the strength 
of the rquired spheric lens. A cylinder of the same strength as the 
one first employed, with its sign changed to correspond to that of 
the spheric lens, and the axis reversed, completes the process. This 
method of correcting astigmatism is best adapted to those cases in 
which the degree is 0.75 D or less. 144 
NORMAL AND ABNORMAL REFRACTION 
2. The position of the principal meridians is determined by means 
of the clock-face, Snellen's dial, or a series of lines, as is shown in Fig. 78. 
The most distinct lines correspond to the most ametropic meridian; 
therefore a stenopaic slit is inserted in the trial-frame, in a direction at 
right angles to this. If vision is normal in this direction, the meridian 
must be emmetropic and the astigmatism is simple. The slit is then 
turned at right angles to its previous direction, and the glass found which 
Fig. 78.-Wallace's astigmatic chart reduced to one-sixth of its diameter. 
gives the highest vision. The astigmatism is represented by this glass. 
The following are examples: 
Simple Hyperopic Astigmatism.-The patient sees horizontal lines most dis- 
tinctly; the stenopaic slit is placed vertically in front of the eye: and through this 
V = $; with the stenopaic slit horizontally placed, V = ~, with + 1 D added, 
V = hence + 1 D cyl., axis 90°, is the glass required. 
Simple Myopic Astigmatism-The patient sees vertical lines most distinctly; 
the slit is placed horizontally: V = with the slit placed vertically: V - with 
- 1.50 added, V = $ ; hence - 1.50 cyl., axis 180°, is the glass required, 
o 
3. The patient may not perceive any difference in the distinctness 
of the radiating lines until a spheric lens is placed in front of the eye, 
when some of them become more distinct than the others. The slit 
is now introduced in a direction at right angles to the distinct lines. ASTIGMATISM (ASTIGMIA) 
145 
Vision is not normal, but a spheric lens improves it, and that lens which 
gives the best vision with the slit in this direction is selected. The slit is 
then reversed. The visual acuity is less through the slit in this position 
than in the previous one, and a higher lens is necessary to secure the 
best vision. The astigmatism is represented by the difference between 
the stronger and the weaker lens. This is an example of compound 
astigmatism, and is corrected by a spheric lens of the same strength as 
that which neutralizes the least ametropic meridian, and a cylindric 
lens equal to the difference between the two meridians. The following 
are examples: 
Compound Hyperopic Astigmatism.-No lines appear distinct, or perhaps the 
horizontal ones only slightly more distinct than the others, but a convex glass makes 
the horizontal lines decidedly more distinct. The slit is introduced in a vertical direc- 
tion: V - with + 1.50 spheric lens added, V = The slit is now turned in a 
horizontal direction: V = -; with + 3.50 D sph. added, V = -. The glass re- 
30 6 
quired for such a case is + 1.50 D sph. Q + 2D cyl., axis 90°. 
Compound Myopic Astigmatism.-No lines are distinct, but a concave spheric 
lens possibly makes the vertical lines more distinct than the others, if the visual 
acuteness is not too much lowered. The slit is introduced in the horizontal direction: 
U = with - 5 D added, V = ^. The slit is now placed vertically: V = - 
7 D is added, and V rises to The glass required is - 5 D sph. O - 2 D cyl., 
axis 180°. 
All that has been said in regard to the selection of glasses in myopia 
applies equally here. It is often impossible to correct the astigmatism 
accurately in the manner just described, and better results are obtained 
by the first method-that is, by developing the best possible vision with 
spheric lenses, and then adding cylinders to still further improve the 
visual acuteness. 
Mixed Astigmatism.-Hyperopia exists in one principal meridian, 
and myopia in the other. Usually no set of lines appears plainer than 
the rest, but the addition of a concave or convex spheric lens brings out 
some lines more distinctly than the others. Thus a clue to the principal 
meridians is obtained. With the slit before the eye, a convex spheric 
lens is placed in position and the slit rotated until the vision becomes 
more distinct. The hyperopic meridian has then been found. 
Example.-Suppose the hyperopic meridian to be horizontal and V to be most 
improved by + 3 D. The slit is turned to the vertical position, and it is found that a 
- 4 D gives the best vision. The difference between these two meridians is 7 D. 
A + 7 cylinder, axis 90°, placed before such an eye would produce a myopia of 4 
D, while a - 7 cylinder, axis 180°, would produce a hyperopia of 3 D, consequently 
with the + 7 cylinder we must associate a - 4 spheric lens, and with the - 7 D 
cylinder a + 3 D spheric lens. Such a case could be corrected by either of the fol- 
lowing formulas: + 3D sph. O - 7 D cyl., axis 180°; or - 4 D sph. O + 7D cyl., 
axis 90°; or by means of two cylindric lenses with their axes at right angles to each 
other, viz., + 3 D cyl., axis 90° O - 4 D cyl., axis 180°. 146 
NORMAL AND ABNORMAL REFRACTION 
Dr. J. S. Johnson,1 of St. Paul, employs a method of determining 
astigmatism which he calls "the reversal of the clock-dial chart" when 
it is viewed through successive spheric lenses. The first indication of 
such a change marks the dividing line between the hyperopia and the 
astigmatism and between the spheric and cylindric correction. If carried 
carefully to the point of complete reversal, it will also show the ametropia 
of highest degree and thus serve all the purposes of the stenopaic slit. 
Thorington also utilizes this method in determining the acuteness 
of vision, which he maintains under definite conditions is an index of the 
strength of the spheric lens which will give normal vision. For this 
purpose he has designed a series of "metric test-letters and lines." 
The astigmatic lens, or crossed cylinder, as pointed out by Edward 
Jackson, is most useful to determine the amount and also the principal 
meridians of astigmatism. This astigmatic lens is employed as a sup- 
plementary lens; the axis of the cylinder is first placed in the same direc- 
tion as the axis of the cylinder in the trial-frame, and next it is turned 
perpendicular to it. In one position it enhances the effect of the cylinder 
in the trial-frame; in the other it diminishes the effect. Therefore, if 
the vision is unchanged by an astigmatic lens in either of these positions, 
the cylinder in the trial-frame is correct. If the vision is improved by 
the astigmatic lens when placed in one position, but not made better in 
the other position, the cylinder in the trial-frame must be changed 
accordingly.2 Various astigmatic lenses may be used having a value of 
1 D (+ 50 cyl. O - 0.50 cyl.), 0.50 D, and 0.25 D. 
The following additional facts concerning lenses require mention: 
If a spherocylinder is in position before an eye, and vision is improved 
by placing before it another cylinder of the same sign (+ or -), with 
its axis at right angles to that of the first, it shows that a stronger spheric 
and weaker cylinder are required. 
If vision is improved by placing in position another cylinder of the 
same sign, with its' axis parallel to the first, it shows that the same 
spheric with a stronger cylinder should be adopted. 
If vision is improved by placing in position another cylinder of differ- 
ent sign, with its axis parallel to the first, it shows that a weaker cylinder 
with the same spheric lens is needed. 
If vision is improved by placing in position a cylinder of different 
sign, with its axis at right angles to the first, it shows that a weaker 
spheric lens with a stronger cylinder must be employed. 
4. Astigmatism is best estimated and the correcting glass deter- 
mined by objective methods: skiascopy and the ophthalmometer. These 
have been referred to and are elsewhere explained (see pages 110 and 
111). All methods should be tried before the glass is finally ordered, 
and the highest visual acuteness possible should be obtained. 
Ordering of Glasses.-Glasses are ordered for astigmatic eyes 
according to the general rules already given. For distance, the full 
1 Ophthalmic Record, October, 1901. 
2 For full directions in regard to the use of the lens see article by E. Jackson, Ophthal- 
mic Record, August, 1907. ASTIGMATISM (ASTIGMIA) 
147 
correction is ordered in myopic astigmatism and usually in mixed 
astigmatism; in compound hyperopic astigmatism the spheric lens is 
usually weakened to meet the requirements of accommodation, but 
the full cylindric lens should be ordered. In simple hyperopic astig- 
matism it may be necessary to add a concave spheric lens; thus, if the 
correction under full mydriasis at 4 meters should prove to be + 1.50 D 
cyl., axis 90°, the formula for the glass to be worn after return of ac- 
commodation would be - 0.25 D sph. O + 1.50 D cyl., axis 90°. 
In compound myopic astigmatism the spheric lens is sometimes weak- 
ened for near work. Simple myopic astigmatism and mixed astigma- 
tism give an opportunity for simplifying reading-glasses, as will be 
described under Presbyopia. 
At present there is no uniform plan for the designation of the mer- 
idians in astigmatism, and, consequently, formulas for glasses intended 
to correct astigmatism do not have a uniform meaning in all parts of the 
world. Drs. Thomson and Harlan1 have conveniently summarized 
three systems as follows: 
1. The zero is placed at the end of the horizontal meridian to the 
patient's left, and the degrees are counted on the upper semicircle to 
180° at his right. 
2. Zero is placed at the top of the vertical meridian, and the de- 
grees are counted to the nasal and temporal sides to 90° at the hori- 
zontal meridian. 
3. The zero mark is placed at the nasal extremity of the horizontal 
meridian in each eye, and the degrees are counted on the upper semi- 
circle to 180° at the temporal extremity. 
The first is the one in almost universal use in this country, the 
formula for the glasses being written in accordance with the markings 
on the trial-frame. 
Irregular Astigmatism.-A low degree of this defect exists in nearly 
all eyes, but it does not interfere with good vision. When its degree 
is increased by irregularities of the corneal surface from ulcers and cica- 
trices, the vision is very much reduced, and where such lesions are ex- 
tensive, optical therapeutics may be unavailing. Often, however, 
within the pupil space small areas may be found in which the refraction 
is tolerably uniform, and vision may be decidedly improved by lenses- 
spheric and cylindric. All such eyes should be carefully studied by 
objective methods, and full trial with lenses should be made. Steno- 
paic spectacles render vision more distinct, but they embarrass the 
wearer by limiting the field of vision. An iridectomy sometimes im- 
proves vision by displacing the pupil toward a more regular portion 
of the cornea. 
Surgical Treatment of Astigmatism.-It has been proposed to 
correct astigmatism by incising the cornea with a Graefe knife, or by 
producing a wound two-thirds of the depth of the cornea with the 
galvanocautery (Laus). The operation should be performed on the 
1 Archives of Ophthalmology, 1893, vol. xxii, pp. 251-261. This paper contains an 
excellent discussion of this subject and an analysis of the arguments for the various systems. 148 
NORMAL AND ABNORMAL REFRACTION 
meridian of greatest refraction (Borsch). The author has had no ex- 
perience with these procedures. 
Anisometropia.1-This term includes cases in which one eye is 
much more hyperopic or myopic than its fellow, or where one eye is 
astigmatic and the other not, or where myopia exists in one eye and 
hyperopia in the other. No general rule for the management of cases 
of this character can be given, but the author agrees with Duane that 
"in the majority of cases of anisometropia, even those in which the 
difference in refraction exceeds 2 D, the full correction can be applied 
with success." The patient, however, must be required to wear the 
glasses constantly, and must be willing to bear with temporary discom- 
fort while the eyes are becoming accustomed to the lenses. The causes 
which give rise to discomfort may be summarized as follows: Diplopia 
and asthenopia from the unequal prismatic effect of the unequally strong 
lenses; diplopia from imbalance of the ocular muscles, with the full cor- 
recting lenses the double images being more manifest; and difficult 
binocular vision because the retinal images of the two eyes are of a differ- 
ent size, a cause, however, which is considered fallacious by Duane. 
Exophoria and hyperphoria are often associated with anisometropia; 
squint may be caused by this refractive condition and may be mate- 
rially improved by the use of the correcting lenses. If discomfort 
ensues, success may follow the attempt to train the function of the 
more defective eye by temporarily excluding the other from vision. 
Presbyopia.-The accommodation diminishes gradually from early 
life onward, and the near-point recedes farther from the eye with each 
succeeding year. When by this recession the near-point reaches a dis- 
tance of 30 to 40 cm. from normal eyes, it interferes with their use at 
close range, and convex lenses are usually required. Presbyopia has 
now begun, and is a normal result of growing old. 
Causes.-The cause of presbyopia consists in loss of the elasticity 
of the crystalline lens, which is thus prevented from assuming the in- 
creased convexity which constitutes the essential factor of accommoda- 
tion. This increase of convexity, necessary for seeing near objects, 
must be supplied to the eye by a suitable lens. 
Presbyopia usually begins in emmetropic eyes at the age of forty-five. 
Unusual visual acuteness, or vigor of accommodation, however, may 
enable a person to dispense with glasses for several years longer. A 
visual acuteness of permits its possessor to see the same object dis- 
tinctly at 30 cm., which another individual with a vision of only 
would have to hold at 20 cm. Patients occasionally postpone the time 
of wearing reading-glasses by holding fine print in a bright light, the 
resulting contraction of the pupil rendering vision more distinct. Pres- 
byopia is to be distinguished from hyperopia, which is often latent and 
1 This term, according to Suker, is often inaccurately applied. He would employ it 
only to describe an unequal amount or degree of the same kind of refractive error in the 
two eyes. To describe a different kind of refraction in the two eyes he prefers the word 
antimetropia. PRESBYOPIA 
149 
confounded with it. Correction of hyperopia restores the far-point of 
the eye to infinity. 
Correction of Presbyopia.-In the first stages of presbyopia, while 
considerable accommodation still remains, a weak convex lens is re- 
quired, which enables the person to see near objects by rendering the 
rays less divergent, as if they came from a somewhat greater distance. 
There is still a range of vision from the focal distance of the glass 
to the near-point. A person who has an accommodation of 3 D, and 
requires + 1.50 D in addition, will have a range from the focal distance 
1 meter 
of the glass --- = G6 cm. to his near-point through the glass; 3 D 
1 .OU 
। -i i~a ta a m ta 1 meter 
+ 1.50 D = 4.50 D; -r - = 22 cm. 
4.50 
When the accommodation is entirely obliterated at seventy-five 
years of age, the convex glass must be stronger. The rays are now 
rendered parallel, as if they came from an infinite distance, and the 
object must be held at the focus of the lens. There is, therefore, no 
range of vision. 
The presbyopic glass is estimated after the eye has been rendered 
emmetropic by neutralizing any hyperopia or astigmatism which may 
be present (for the management of myopia and myopic astigmatism in 
these circumstances see page 151). 
The near-point of vision should be carefully determined for each 
eye separately. The ability to read 1-meter type at 30 cm. is not equiv- 
alent to the act of accommodating for 30 cm.; in order fairly to accom- 
modate for 30 cm. the patient should be able to read type which repre- 
sents normal vision at 30 cm. (see page 38). If the accommodation is 
normal, the near-point will correspond closely with the figures given in 
the table. The additional refractive power required may then be cal- 
culated. Unduly strong glasses should not be employed in approximat- 
ing the. near-point, lest the far-point be brought too close and serious dis- 
comfort ensue. Most persons read at an average distance of from 33 to 
40 cm., and in early presbyopia considerable range of vision exists on 
either side of these points; but at sixty years and later there is little play 
-the near-point and far-point are close together. A glass with which the 
patient reads easily at 33 to 40 cm. may then be ordered, unless visual 
acuteness is much diminished. 
Table of the Position of Near-point at Different Ages 
Age. 
Accommodation. 
Point. 
45 
3.50 diopters 
29 cm. 
50 
2.50 
ll 
40 
ll 
55 
1.75 
ll 
57 
ll 
60 
1 
ll 
100 
ll 
65 
0.50 
ll 
200 
It 
70 
0.25 
ll 
400 
ll 
75 
00 
ll 
00 
At the age of forty-five it is usually necessary to supply a + 1 D 
spheric lens for reading, provided the eye is emmetropic; if the eye is 150 
NORMAL AND ABNORMAL REFRACTION 
hyperopic, 1 I) + the correction for the hyperopia; if myopia exists, 
+ 1 D is not required. Plus 1 D added to the 3.50 D of accommoda- 
tion which the eye possesses at forty-five years = 4.50 D; this brings p 
to 22 cm. | = 22 1 and r to 100 cm. 
\ 4.50 / 
At fifty years of age + 2 D is usually required, with the same modi- 
fications in case of hyperopia or myopia. This glass, added to the 
accommodation which the eye possesses at 50,-viz., 2.50 D,-also 
makes 4.50 D; this brings 79 to 22 cm., but r is now only 50 cm. distant. 
At fifty-five years, + 2.50 D is the glass usually required, which, 
added to the accommodation (1.75), gives a refractive power of 4.25 D; 
I) = 23.5 cm., r = 40 cm. If stronger lenses than this are used, r is 
brought still closer, and the patient is forced to hold the book near his 
face. If F = g, it is not necessary to order a glass stronger than the 
one recorded; indeed, usually + 2.00 D or 2.25 D is sufficient, as most 
persons prefer a glass which enables them to read, resting the book on 
the lap or the arm of a chair. These glasses are for emmetropic eyes. 
In hyperopia with presbyopia they are to be added to the hyperopic 
correction. Visual discomfort (asthenopia) often develops with the 
first attempts to use presbyopic glasses, owing to the development of 
temporary convergence-insufficiency from relaxation of accommoda- 
tion. In these circumstances it is usually necessary to reduce the 
strength of the glass. 
As visual acuteness diminishes, a stronger lens is necessary to enable 
the object to be held closer, and thus subtend a larger visual angle. 
The glass may be increased to 4, 5, 6, or even D 8. The strong glasses 
necessitate the close approximation of the object and a corresponding 
diminution in the field of vision. The only rule in the selection of such 
glasses is to give that glass which affords the necessary vision with the 
least inconvenience. With very great diminution of sight, requiring 
glasses of 8 or 10 D, binocular vision is impossible, and the better eye 
should be supplied with a correcting glass, and the other excluded from 
vision. 
With binocular vision, the reading-glasses for the two eyes should 
be equal in strength; consequently, when a different degree of ame- 
tropia exists in the two eyes, a corresponding difference should be made 
in the reading-glasses. Occasionally, in the absence of ametropia, or 
even after its correction, when present, there is an inequality of the 
accommodative power in the two eyes. Thus, a patient of fifty years 
may have 2.50 D of accommodation in the right eye, and only 1.50 D 
of accommodation in the left. Under such conditions it is usually neces- 
sary to order a correspondingly stronger reading-glass for the eye with 
the weaker accommodation. 
Frequently, modifications are required in the strength of the glass 
to suit particular vocations-for example, reading music, reading in the 
pulpit, working at a bench, playing cards, etc. In these circumstances 
it is necessarv to ascertain the distance from the eye at which the work PRESBYOPIA 
151 
is placed, and to order a glass whose focal distance is not less, but, if 
possible, somewhat greater than the distance required. Not infre- 
quently the patient must be provided with two sets of glasses-one pair 
for the ordinary reading distance and another of greater focal length for 
work at a longer range. Thus, a patient of fifty-five years may require 
+ 2.25 D for reading, but for playing the piano + 1.25 D. This cor- 
rection of accommodative defects at what may be called an interme- 
diate distance is most important, and the character of the patient's 
work must always be carefully ascertained before ordering a glass. 
In myopia, myopic astigmatism, and mixed astigmatism the rules 
for the selection of reading-glasses require particular mention. Patients 
with low degrees of myopia, not higher than 2 D, do not need reading- 
glasses at as early an age as emmetropic or hyperopic subjects. The 
amount of myopia may be considered the equivalent of the convex glass 
suitable for the correction of the presbyopia. A myopia of 1 D, conse- 
quently, wrnuld enable a person to attain the age of fifty without the 
necessity of reading-glasses. At that age he would require + 1 D for 
reading, and at fifty-five + 1.50 D, and at sixty, possibly + 2 D, de- 
pending upon his visual acuteness. A myope of 2 D could dispense with 
reading-glasses until the age of fifty-five (often until a later period); then 
he would require + 0.50 D; at sixty, possibly + 1 D. A myope of 3 
or 4 D never becomes presbyopic in the ordinary sense; he can read at 
any age without glasses. 
In higher degrees of myopia it is necessary to order a concave glass 
from 2 to 5 D less than the full correction. The age has little influence 
on the amount of reduction; myopes readily relax accommodation; the 
degree of myopia and the visual acuteness are the two important factors. 
A concave glass is given which will extend the far-point to a comfortable 
distance. A myope of 6 D would probably require from - 3 to - 4 D 
for reading; a myope of 10 D, about - D, and a myope of 15 or 20 D 
would require a reduction of 5 or 6 D from the full correction. In these 
high grades vision is much reduced, print cannot be seen unless held close 
to the eye, so that extension of the reading distance is out of the ques- 
tion. The farthest point at which a book can be read should be deter- 
mined, and a glass given of the same length of focus. Prisms are often 
necessary. When the vision is much reduced, myopes usually read with 
one eye without the aid of any glass. 
A patient with simple myopic astigmatism generally should be pro- 
vided with a convex cylinder of the same number, its axis being reversed. 
Thus, a patient whose myopic astigmatism is corrected by - 2 D cyl., 
axis 180°, will be comfortable with a + 2 D cyl., axis 90°. This glass 
produces a myopia of 2 D in all meridians, and because the patient has 
been accustomed to see through a myopic meridian, he prefers this glass 
to the concave cylinder, which makes him accommodate. As a rule, 
simple myopic astigmatism may be utilized to determine the reading- 
glass in patients who have reached the age of thirty-five, provided its 
degree is not too high. A convex cylinder of a strength equal to the 
concave cylinder with its axis reversed will be sufficient. 152 
NORMAL AND ABNORMAL REFRACTION 
If the degree of myopia thus produced is too great for comfortable 
reading, a concave spheric lens may be added to the convex cylinder. 
Thus, an astigmatic eye corrected by a - 4 D cyl., axis 180°, would 
probably require - 1.50 D sph. Q + 4 D cyl., axis 90°. 
If the degree of astigmatism is unequal in the two eyes, a spheric 
lens is required over one eye to equalize the refraction. For example: 
1. R. E. - 5 D cyl., axis 180°. L. E. - 3 D cyl., axis 180°. This 
case requires a - 2 spheric lens to be added to the right eye-viz., - 2D 
sph. C + 5 D cyl., axis 90°, to make its refractive power equal to that 
of the left, + 3 D cyl., axis 90°. 
2. R. E. - 1 D cyl., axis 180°. L. E. - 2.50 D cyl., axis 180°. 
In this instance, according to the circumstances, age, etc., one of the 
following combinations may be ordered: R. E. + 1 D cyl., axis 90°; 
L. E. - 1.50 D sph. Q + 2.50 D cyl., axis 90°; or R. E. + 1.50 D sph. 
O + 1 D cyl., axis 90°; L. E. + 2.50 D cyl., axis 90°. Both of these 
combinations equalize the refraction of the two eyes, the first by produc- 
ing in each eye a myopia of 1 D, the second a myopia of 2.50 D. 
In cases of compound myopic astigmatism, should the myopia 
amount to several diopters, the reading-glass is secured by a sufficient 
reduction of the strength of the spheric without change of the cylindric 
lens. 
If, in lower degrees of compound myopic astigmatism, it is desirable 
to increase the refraction one or more diopters, the procedure is somewhat 
different. Thus, if the combination is - 0.50 D sph. Q - 1 D cyl., 
axis 180°, and the spheric lens is omitted, + 0.50 D is gained; by sub- 
stituting for the concave cylinder a convex cylinder with its axis reversed, 
an additional gain of 1 D is secured; + 1 D cyl., axis 90°, in this case 
is equivalent to adding + 1.50 D sph. to the original combination. If 
still more refractive power is desirable-e. g., + 2 D, + 0.50 D sph. Q 
+ 1 D cyl., axis 90°, gives the additional amount. 
In another combination, - 0.75 D sph. Q - 4 D cyl., axis 180°, 
it is desired to add + 2.50 D for reading. Dropping the - 0.75 D 
spheric lens, + 0.75 D of refractive power is obtained; substituting for 
the concave cylinder, convex 4 D cyl., axis 90°, + 4 D more are gained, 
making + 4.75 D. This is too high, hence it would be necessary to 
combine - 2.25 D sph. Q + 4 D cyl., axis 90°, in order to obtain the 
desired + 2.50 D. A simpler method of procedure in this case would 
be to drop the - 0.75 D spheric lens; the uncorrected myopia would 
then furnish 0.75 D of the requisite 2.50 D, leaving 1.75 to be obtained. 
A + 1.75 D added to the - 4 D cyl., axis 180°, would make the proper 
combination. 
In mixed astigmatism, a combination of spheric lens and cylinder 
is usually employed, and by using a concave spheric and convex cylinder 
the combination necessary to produce any additional refractive power 
can easily be found. 
If the myopia produced by the convex cylinder alone is greater than 
the power of the lens it is desired to add, a concave spheric lens equal 
to the difference is given, thus: To the combination - 3D sph. Q + 5 D PRESBYOPIA 
153 
cyl., axis 90°, it is desirable to add + 2D. - 3 + 2 = - 1, hence - 1 
D sph. Q + 5 D cyl., axis 90°, is the glass required. Again, to - 1 D 
sph. O + 3 D cyl., axis 90°, it is desirable to add + 2.50 D. - 1 + 
2.50 = + 1.50, hence + 1.50 D sph. O + 3 D cyl., axis 90°, is the neces- 
sary glass. The myopia is in this case insufficient. 
It is a point of some importance, in ordering reading-glasses contain- 
ing cylindric lenses, to give attention to the relation of the axes of the 
cylindric lenses. It has been assumed, for the sake of simplicity, that 
the axes of convex cylinders are placed at 90° and the axes of concave 
cylinders at 180°; this is commonly so, but the exceptions are numerous. 
It is a frequent condition in astigmatism to have one principal meridian 
inclined 15° to the right of the vertical in one eye, while the meridian of 
the same refraction in the other eye is inclined the same amount to the 
left of the vertical. This produces no serious disturbance in wearing the 
glasses if they are properly centered, although at first a rectangular 
figure appears like a rhombus. In a little time the eyes adapt them- 
selves to the glasses, and this appearance is lost. 
When the meridians of similar refraction are at greater angles than 
this, especially if the cylindric lenses are strong, there is often incon- 
venience in wearing them on account of the prismatic deviation and the 
unequal distortion of objects which cylindric lenses produce. Occa- 
sionally the axes are as much as 90° apart, one at 45° and the other 
at 135°, or one at 90° and the other at 180°. The glasses now deviate 
rays from an object in different directions, according as the eye looks 
through the glasses above or below the optical centers, or to the right 
or left of them. Such a case would be represented by + 3 D cyl., axis 
180°, in right eye, and + 3 D cyl., axis 90°, in left eye. The difficulty 
is not obviated by ordering a formula like the following: R. 4 3 D cyl., 
axis 180°, L. + 3 D sph. Q - 3 D cyl., axis 180°, because the same dis- 
placement results. It will be found that the best solution of this diffi- 
culty is to ascertain the distance from the eye at which the person usually 
holds the book, and the relative position it occupies to the eye. The 
direction of the visual lines may thus be determined, and the optical 
centers of the glasses should be so placed that the visual lines will pass 
through them. There is then no deviation. Of course, this renders 
necessary a separate pair of glasses for reading. When cylindric lenses 
with axes in unusual directions are required for distance, the optical 
centers should bear the same relation to the visual lines in distant fixa- 
tion. These disturbances are aggravated by removing the glass farther 
from the eye, and, conversely, the trouble diminishes as the glass is 
brought nearer to the eye.1 
Bifocal Lenses.-When presbyopic patients require two sets of 
glasses, one for distance and one for reading and close work, it is the 
custom, instead of providing them with separate sets of glasses, pre- 
scribed according to the rules set forth in the preceding paragraphs, to 
1 Consult interesting papers in the Archives of Ophthalmology, vol. xviii, by Dr. J. A. 
Lippincott; in the Ophthalmic Record, vol. i, No. 1, by Dr. G. C. Savage; and Dr. R. J. 
Phillips, in the Annals of Ophthalmology, vol. ii, p. 31. 154 
NORMAL AND ABNORMAL REFRACTION 
order bifocal lenses (Fig. 79). By means of such glasses the inconve- 
nience of changing spectacles is avoided, and, moreover, the patient's 
eyes are constantly adapted by proper lenses to close and long ranges. 
A spheric lens, suited to needs of accommodation, ground very thin, is 
Fig. 79.-Bifocal lenses: 1, Solid bifocal lenses; 2, cemented bifocal lenses. 
cemented on the lower portion of the distance glass, usually upon its 
inner side. The size of the additional segment varies. Generally one 
12| mm. in height and 22 mm. in length is sufficient. The shape of the 
supplementary lens varies. Commonly it is an oval; sometimes it is 
made in the form of a circle, and some- 
times it is dome shaped. Solid and single 
crystal bifocal lenses are also manufac- 
tured. A particularly graceful form of 
bifocal lens has been designed by J. L. 
Borsch, of Philadelphia (Fig. 80). In 
this, for the usual presbyopic segment, 
there is substituted a small lens 15 mm. 
in diameter, made of flint glass and sunk 
into the distance lens, which is made of 
crown glass. The increased refraction of 
the small lens depends upon the higher 
index of the flint glass. Its exposed sur- 
face is ground to the same curvature as that of the larger lens. Lenses 
of this character are usually known as "concealed" or "kryptok" bifocals. 
Fig. 80.-Borsch's bifocal lenses. 
SPECTACLES AND THEIR ADJUSTMENT 
After the refraction of the eye has been determined and the proper 
combination of lenses selected, the glasses should be properly ground, 
mounted in spectacle-frames, and correctly adjusted to the patient's 
eyes. In place of spectacle-frames so called "eye-glasses" are much 
employed; if they can be firmly adjusted, and the spherocylindric com- 
bination is not of high degree, there is no serious objection to their use, 
although they can never be as accurately applied as spectacles. Patients 
should not be allowed to wear glasses until the surgeon has satisfied him- 
self that the formula for the lenses has been faithfully followed by the 
manufacturing optician. SPECTACLES AND THEIR ADJUSTMENT 
155 
In order to do this he proceeds as follows: If a simple spheric lens 
has been ordered, this and a spheric lens from the trial-case, of the same 
number but opposite refractive character, are placed in close contact 
and some distant object observed through the combination, while the 
glasses at the same time are gently moved up and down and to and fro. 
If the glass is correct, this maneuver has no influence upon the size or 
position of the object, which appears exactly as it would if it had been 
looked at through a piece of plane glass. The glasses are then said to 
neutralize each other. If the lens ordered does not neutralize the test- 
glass from the trial-box, a weaker or stronger number is tried until the 
glass is found which produces complete or nearly complete neutralization. 
Thick bispheric lenses of different refractive character will not neutral- 
ize each other entirely, even if they are of the same number. The con- 
vex lens always preponderates. With a suitable "lens-measure" the 
character of a lens can be quickly determined. 
If a cylindric lens has been ordered and has been correctly ground, 
it will be neutralized by a cylinder of the same number but of opposite 
refraction, with its axis turned to the same angle as that of the lens 
ordered. On shaking these two lenses, which are placed in contact, 
there should be no motion of the object viewed through them. The 
direction of the axis of a cylinder may be determined by finding the posi- 
tion in which the lens may be shaken without producing any motion of 
the object. For example, if the axis of the cylinder is vertical, no motion 
in the object looked at would occur when the spectacle lens is moved up 
and down. A line drawn on the glass with a pen marks this, and by 
placing the lens thus marked on a 'protractor, the degree of the angle 
may be read off. 
A combination of spheric and cylindric lenses is to be tested by a 
spheric lens held on the spheric surface of the spectacle lens, and a 
cylindric lens held on the cylindric surface of the spectacle lens, and 
proceeding in the manner just described. 
The optical center is ascertained as follows: The lens is held by its 
edges between the finger and thumb, and, care being taken not to hold 
it obliquely, it is passed from right to left until the test-object (a vertical 
line) forms a continuous line above the lens, through the lens, and below 
the lens. If the axis of the lens is not exactly in line with the test- 
object, the part seen above and below the lens will not coincide with the 
part seen through the lens. When a continuous line is obtained through 
the lens with the object above and below, the lens should be marked with 
a line drawn across its surface over the part where the line is seen, 
just as the outline of a figure is traced on a transparent plate. The 
glass is now turned around so that the line is at right angles to its 
former position; another portion of the lens is found through which 
the test-object is also seen in a continuous line with the part above 
and below. This is traced on the glass with ink, and the intersection of 
the two lines thus traced marks one extremity of the axis of the lens. 
In most lenses the distance from the surface to the center is so slight 
that we may consider this point on the surface as the center, and each 156 
NORMAL AND ABNORMAL REFRACTION 
lens should have its center marked by a dot of ink. Strong lenses may 
be centered more easily by using the window-bars, while the glass is 
held close to them, or the edge of a card or sheet of paper, which is laid 
on the desk. Still greater accuracy may be obtained by using a card 
on which two lines are drawn, crossing each other at right angles; both 
principal meridians may in this way be found at once; the optical center 
then lies over the intersection of the lines. 
The spectacles should now be placed on the patient, and the position 
of these centers in relation to the pupil carefully noted. The patient is 
first asked to look across the room; the centers of the pupils should cor- 
respond with the dots on the glasses. Next, the patient is required to 
look at the finger of the surgeon held at 40 cm. distance, and it will be 
noticed that the centers of the pupils and the dots no longer coincide, 
but that the former have passed to the inner side of the latter. If the 
glasses are for distance or for constant wear, the space between the 
centers of the lenses should be the same as the interpupillary distance; 
if the glasses are for reading alone, the distance between the centers 
must be lessened. The ordinary reading distance being 40 cm., the 
visual lines converge to this point, and the farther the glasses are from 
the center of rotation, the nearer the centers should come to each other; 
therefore it is necessary to make the distance between the centers of the 
reading-glasses from 2 to 4 mm. less as compared with those of distance 
glasses, so that the visual lines may pass through these centers. Thus: 
The center of the pupil deviates inward about 1 mm. in fixing at a point 
40 cm. distant, as the pupil is 11 mm. in front of the center of rotation; 
a glass placed 13 mm. in front of this would require its optical center to 
be 1 mm. farther inward than the pupil-2 mm. in all. The two cen- 
ters should thus be 4 mm. nearer together in reading-glasses than in 
those for distance. 
Should glasses be ground with badly placed centers,-that is, too 
far apart or too close together,-the most unpleasant consequences 
may arise: obstinate diplopia, severe neuralgia, headache, and tendency 
to squint. 
The patient should observe some distant object while the inter- 
pupillary distance is measured during distant fixation, fixing his eyes 
on the finger-tip of the observer, held about 30 cm. from his eyes 
while the measurement is noted during convergence. There should 
be a variation of 2 mm. between these two measurements. If the differ- 
ence is greater than this, there is a probability that the patient has an 
insufficiency of convergence, and, in this case, the centers of convex 
glasses should be brought closer together; those of concave glasses 
placed farther apart. In order to ascertain the amount of deviation 
which is produced by decentering a spheric lens, see page 20. 
Reading-glasses should be tilted forward and placed about 5 mm. 
lower than those for distance, in order to conform with the depression 
of the visual line in reading. Spectacles are always to be preferred; but 
the prejudice of many patients in regard to spectacles will often have to 
be respected. The tilting forward of eye-glasses is rather an advantage SPECTACLES AND THEIR ADJUSTMENT 
157 
in reading, and in myopia the effect of this tilting is equivalent to a 
cylindric lens with a horizontal axis. This fact accounts for the prefer- 
ence shown by some patients for a simple concave spheric uncombined 
with a cylindric lens, in spite of the existence of a slight degree of astig- 
matism. 
When separate glasses are required for distance and reading, it is 
often very inconvenient to make the change from one to the other. The 
two glasses may be combined in the same frame by making the lower 
half suitable for reading and the upper half for distant vision (Franklin 
or split bifocals). Bifocal lenses, as already described, constitute a more 
suitable arrangement (see page 153). "Hook fronts" are very conve- 
nient for making a rapid change from reading to distant vision, or "half- 
hook fronts" may be employed. Occasionally, for special purposes, 
trifocal lenses are manufactured-that is, an upper segment correcting 
the distant vision and a lower segment correcting the close vision are 
cemented in a lens which corrects the intermediate vision. CHAPTER V 
DISEASES OF THE EYELIDS 
Congenital Anomalies.-Complete absence of the lids (ablepharia 
totalis), or their partial development {ablepharia partialis), is a rare 
anomaly. If the defect is of such a nature that the lids are wanting 
and the orbit divested of any covering for the globe, the condition is 
designated lagophthalmos, a name which also, and perhaps more prop- 
erly, has been given to a contracted state of the eyelids preventing their 
closure, independent of any muscular paralysis. 
Cryptophthalmos is a condition in which neither eyelid nor con- 
junctival sac is present, but the exterior integument passes in front of, 
and buries an eye more or less 
developed. 
Cleft eyelid {coloboma palpebroe) 
is a fissure, in appearance not un- 
like a harelip, which may be con- 
fined to the upper lid (its most 
common situation), but which also 
has been noted in the lower lid 
(when the upper lid of the same 
eye is always also involved), and 
even in the upper and lower lids 
on each side. The center of the 
cleft may contain an interven- 
ing membranous portion, either 
movable or pressed against the 
cornea (Fig. 81), or may be clear, so that the cornea fits exactly into it 
when the eyes are directed straight forward (Posey). 
Coloboma of the eyelids is most frequently associated with harelip 
and cleft palate; rarely with facial defects and other congenital anomalies 
in the eyeball. The deficiency may be remedied by a plastic operation. 
Symblepharon, or a cohesion, either partial or complete, between the 
eyelid and the ball, and ankyloblepharon, or a union between the margins 
of the lids, are unusual congenital anomalies. Sometimes only the 
middle portions of the lid-borders are attached by a filamentous band, 
or the outer angles of the lids adhere, and produce the defect known as 
blepharophimosis. 
Ectropion, or eversion of the edges of the eyelids, is a rare condition 
usually accompanied by increased size of the eyeball. Entropion, or 
inversion of the edges of the eyes, which in slight degree is said to be 
normal before birth, has been found associated with distichiasis, or the 
development of supplementary incurved eyelashes. 
Fig. 81.-Coloboma palpebrse and anoph- 
thalmos. 
158 CONGENITAL ANOMALIES 
159 
In congenital distichiasis, Kuhnt has demonstrated that the second 
row of lashes consists of fine hairs springing from the posterior part of 
the intermarginal area. Meibomian glands are wanting, and their 
Fig. 82.-Congenital distichiasis (from a patient in. the Philadelphia General Hospital). 
places are taken by the abnormal cilia. Occasionally the condition 
appears to be hereditary. 
The operations which are employed to rectify these conditions when 
of pathologic origin (see page 605) are also applicable here. 
Epicanthus is a striking congen- 
ital* anomaly giving rise to an appar- 
ent convergent strabismus, owing to 
the passage of a fold of skin from 
the inner end of the brow to the side 
of the nose, covering the internal 
canthus, its free concave border 
stretching outward. Thus the car- 
uncle, lacrimal punctum, and, in ag- 
gravated forms, a considerable por- 
tion of the area of the lids, are hid- 
den. Epicanthus generally is bilateral 
and is usually associated with ptosis 
(Fig. 83). The same condition in 
minor degrees is often seen in new- 
born children, and disappears with 
the subsequent development of the 
face and nose. A similar fold of skin 
at the outer commissure of the lids 
has been described, the so-called 
external epicanthus. True epicanthus may be hereditary, and the defect 
has been noted in several generations (von Hippel). 
Epicanthus may be remedied by excising a portion of the redundant 
integument from the bridge of the nose, and stitching together the 
opposed surfaces. 
Epitarsus is a somewhat wing-shaped duplicature of conjunctiva 
which passes from the fornix to be inserted near the lid border, and is so 
undermined that a small probe can be passed beneath it (Schrapringer). 
This anomaly is also described under the name congenital pterygium. 
Fig. 83.-Epicanthus and congenital 
ptosis (from a patient in the Children's 
Hospital). 160 
DISEASES OF THE EYELIDS 
Congenital ptosis consists in a drooping of the upper lid over the 
eyeball. It may be single or double, but never amounts to complete 
closure. In one variety there is an actual redundancy of the lid tissue; 
in the other the lid is thin and the skin stretched, owing to imperfect 
development or absence of the levator palpebrse. It may be caused 
by a nuclear and, rarely, by a cortical lesion. 
This anomaly is often associated with other vices of conformation, 
especially epicanthus, and with paralysis of the exterior ocular muscles, 
especially the superior rectus. It may be corrected by one of the opera- 
tions described on page 600. 
Congenital fistula of the upper lid has been reported. A super- 
numerary eyelid, presenting as a small growth at the inner canthus, has 
been described (J. L. Shoemaker and A. Alt). 
Edema of the lids in general terms is inflammatory or non-inflam- 
matory in origin. It may result from traumatism, the sting of insects, 
and is seen with severe inflammations of the conjunctiva, of the cornea, 
the uveal tract, and especially with infections of the globe, e. g., pan- 
ophthalmitis and in association with acute glaucoma. It is a common 
symptom of general conditions (renal or cardiac), and is conspicuous 
in thrombosis of the cavernous sinus, disease of the sinuses, especially 
of the ethmoid and antrum, and sometimes occurs in a fugitive, and 
not infrequently recurrent, form. The last variety has ben observed 
with migraine, at the time of the establishment of menstruation, and 
spontaneously without apparent cause. Some cases are analogous to 
urticaria. The eyelid is a common seat of angioneurotic edema. Some 
types of edema, non-traumatic in origin, have been called essential 
edemas. According to Trousseau, they are often arthritic in origin. 
A condition has been described characterized by great symmetric 
swelling of both eyelids which present the usual appearances of chronic 
edema, and to which Sir Anderson Critchett has given the name solid 
edema of the eyelids. The affection has been regarded as a recurrent 
lymphangitis of lupoid origin (Morris). Not infrequently the patients 
have a history of repeated attacks of erysipelas (Eyre). Persistent, 
non-inflammatory edema of the lids is sometimes observed in children 
following measles (Lawson and Sutherland). In rare instances lid 
edema is a late symptom of syphilis. 
Erythema of the lids appears in the form of a hyperemia, more or 
less diffused, under the influence of heat (sunburn), traumatism, and 
irritating poisons, or as symptomatic of a systemic disturbance. 
A passive hyperemia, in which the superficial veins of the lids are 
dilated and the tissue red and slightly swollen, commonly is the result 
of prolonged bandaging of the eye, and is seen in an active state asso- 
ciated with most of the inflammatory diseases of the cornea and con- 
junctiva. 
Urticaria, or hives, appears in the form of characteristic wheals 
associated with much tingling and burning sensation. 
Treatment.-This consists in removal of the cause and the applica- 
tion of a soothing lotion-lead-water or extract of hamamelis. BLASTOMYCOSIS OF THE EYELIDS 
161 
Erysipelas rarely attacks the eyelids as a primary affection, but 
spreads to them from the contiguous facial area. The chief danger of 
the affection in this region is its liability to infect the tissues of the orbit, 
producing compression of the central vessels of the retina and blindness. 
It may spread to the membranes of the brain and be fatal. The char- 
acteristic red, shining, and later brawny swelling, and the formation of 
cutaneous vesicles and small abscesses, are the symptoms which establish 
a diagnosis. 
Abscess of the lid (phlegmon) appears as a localized red eleva- 
tion, and is often a severe form of furuncle or hordeolum. The entire 
lid is hyperemic and the conjunctiva injected and often edematous. 
There are much pain, headache, and fever. This affection is provoked 
by injury, exposure, and disease of the orbit, and sometimes arises with- 
out ascertainable cause, especially in debilitated people and children. 
In rare instances it has been followed by thrombosis of the orbital veins 
and cavernous sinus and has terminated fatally. 
Treatment.-Pointing should be favored by hot, slightly carbolized 
fomentations or compresses soaked in boric acid solution. As soon as 
fluctuation is detected, or even earlier, a sharp knife may be thrust 
through the swelling, parallel to the muscle-fibers, and the contents 
evacuated; the cavity is to be kept clean with an antiseptic fluid. 
Furuncle of the lid is a localized inflammation of the skin and sub- 
cutaneous tissue, presenting symptoms analogous to abscess, which 
goes on to the formation of a central slough or "core." The surround- 
ing and overlying tissue may become gangrenous in subjects of poor 
nutrition. 
Malignant pustule, or specific anthrax, caused by the entrance of 
the Bacillus anthracis, and malignant edema, or a form of spreading 
gangrene, occasionally attack the eyelids. The former usually arises 
among persons whose occupation brings them in contact with diseased 
animals or decayed animal matter; the latter may follow an injury, 
influenza, the exanthemata, typhoid fever, whooping-cough, and ery- 
sipelas, but has also been described as an idiopathic affection. Some- 
times gangrene of the lids is metastatic in origin and occurs during py- 
emia. Noma of the, eyelids-that is, a symmetric gangrene of the lids 
and region of the lacrimal sac-has been described. 
Treatment.-According to the condition present, this should in- 
clude incision, promotion of the separation of the sloughs by hot com- 
presses steeped in boric acid solution, the use of the actual cautery 
to check the destructive tendency, and antiseptic lotions. 
Usually staphylococci and streptococci are present, but in some 
of these gangrenous processes diphtheritic bacilli have been found, and 
under such conditions serum therapy would be strongly indicated. 
Blastomycosis of the Eyelids.-Blastomycotic dermatitis, which 
may affect any portion of the body, has involved the eyelids in about 
one-fourth of the cases thus far reported (Casey Wood). The affection 
begins as a red papule and gradually extends until it forms a flat, wart- 
like growth with a red elevated margin. Dry crusts are apt to cover 162 
DISEASES OF THE EYELIDS 
its surface, and on their removal a bleeding rough surface is evident. 
Miliary abscesses are seen in the softened edges, from which and from 
the surface of the growth a mucopurulent discharge exudes. Although 
the conjunctiva may be injected, swollen, and granular, it is not involved 
further in the pathologic process. The disease is caused by an organ- 
ism belonging to the genus oidium, the spores of the fungus finding 
entrance owing to the injury of the skin surface. The affection may be 
mistaken for epithelioma, tuberculosis, or syphilis, and is differentiated 
by the clinical appearances and by an examination of the secretion from 
the miliary abscesses which will reveal the organisms. From the ocular 
standpoint the disease has been well described in this country by Casey 
A. Wood, W. H. Wilder, and Edward Jackson. 
Treatment.-This should consist of excision of the diseased areas, 
the application of the x-rays, and the internal administration of large 
doses of iodid of potassium. Ectropion may occur and may need a 
plastic operation for its relief (Wilder). 
Hordeolum, or stye, consists of a localized, suppurating inflam- 
mation of the connective tissue in the margin of the lid or of one of the 
glands of the follicles of the cilia (Zeiss's glands), and is almost always 
due to staphylococcus infection. This may remain a tender, circum- 
scribed swelling, which becomes invested with a yellow cap, indicating 
suppuration, or it may cause considerable pain, with edematous swell- 
ing of the entire lid and chemosis of the conjunctiva. It is known by 
the name hordeolum externum, to distinguish it from a hordeolum in- 
ternum, which is the result of suppuration of a Meibomian gland. 
Some persons are subject to a mild type of styes which appear in the 
form of superficial pustules along the margin of the lid. A characteris- 
tic feature of hordeolum is its tendency to recur, and a single stye, 
or several at a time, may appear again and again for many weeks. 
Recurring hordeola may be the starting-points of a chronic blepharitis. 
Driving in the cold or dust and the strain of uncorrected ametropia pre- 
dispose to this disorder. Frequent "attacks" of styes indicate derange- 
ment of health, and are especially associated with constipation and 
menstrual irregularities. Girls about the age of puberty are commonly 
affected. 
Treatment.-A stye sometimes may be aborted by the vigorous 
application of a hot boric acid lotion or an ointment of the red or yellow 
oxid of mercury; the same end is obtained by painting the inflamed sur- 
face with collodion. In the event of failure, suppuration should be en- 
couraged by repeated applications of small compresses steeped in hot 
water, and on the earliest appearance of pus a deep incision should be 
made through the base of the swelling, parallel to the edge of the lid. 
In persistent and recurring formation of styes treatment with bacte- 
rial vaccines controlled by determining the opsonic index has achieved 
excellent results. 
Exanthematous eruptions on the eyelid are found during the 
course of the eruptive fevers. The pustules of small-pox, if they appear 
upon the eyelids, form by preference at the commissures, and in con- HERPES ZOSTER OPHTHALMICUS 
163 
nection with the follicles of the eyelashes. The subsequent pitting from 
loss of tissue may cause considerable disfigurement. 
Sometimes a pustule declines to heal and forms a chronic post- 
variolous ulcer. Vaccine vesicles (vaccine blepharitis) may form on the 
lid-margins from accidental inoculation-e. g., with the finger-nail pre- 
viously in contact with a vaccine-pox or vaccine virus. The vesicles 
may develop into a severe ulcer, and the bulbar conjunctiva may be 
involved. 
Eczema of the lids, independently of that variety which is located 
upon the ciliary margin and which is one of the forms of blepharitis, 
may appear upon the general cutaneous surface of these structures, 
usually in association with its presence elsewhere on the face and scalp, 
and is seen in the erythematous, vesicular, and pustular varieties. 
Eczematous eruptions upon the lids are also associated with inflam- 
mations of the cornea and conjunctiva, and arise under the influence of 
prolonged bandaging. Atropin, when it produces conjunctivitis (see 
page 228), may cause an eczema of the lids and surrounding face. 
Treatment.-This depends upon the character of the eruption. 
If this is vesicular, a useful application is a drying powder composed of 
starch, oxid of zinc, and camphor; if crusts have formed, these should 
be removed with as little bleeding as possible and with the aid of an 
alkaline solution, maceration of the epidermis being avoided, and one of 
the following ointments employed: Plain oxid of zinc, or equal parts of 
oxid of zinc and vaselin to which 20 grains (1.3 gm.) of calomel have 
been added; or subnitrate of bismuth in an ointment. Itching is 
relieved by the application of lotio nigra followed by zinc ointment. 
If the disease assumes a chronic type, some preparation of tar (pix 
liquida or oil of cade) may be used. Good results follow the use of 
aristol ointment, both in subacute and chronic cases. 
As constitutional remedies, quinin, iron, and strychnin are recom- 
mended, and arsenic if the type is chronic. Proper regulation of diet, 
an occasional saline laxative, and good hygiene are important measures. 
Herpes zoster ophthalmicus is a specific infectious, and possibly 
contagious, exanthem (Van Harlingen) characterized by an eruption of 
vesicles, situated upon inflamed bases, over the area supplied by two of 
the three branches of the ophthalmic, or first division of the trigeminus 
-viz., the frontal, through its supra-orbital and supratrochlear branches, 
and more rarely the nasal nerve. 
Neuralgic pain, heat, and redness of the skin precede the vesicles, 
which, varying in size from a pin's head to a split pea, appear in dis- 
tinct crops or coalesce in irregular patches. At first they contain a 
clear yellow fluid, later becoming turbid, until at the end of a week or 
more they dry up, and the brown scabs drop off, leaving beneath decided 
and often disfiguring scars. 
The disease may be mistaken for erysipelas, from which it should 
be distinguished by the acute neuralgic pain and the formation of the 
vesicles in the course of a given set of nerves. 
Serious involvement of the eye itself, by the formation of blebs upon 164 
DISEASES OF THE EYELIDS 
the cornea, and by inflammation of the iris and ciliary body, is often 
associated with the disorder. More or less conjunctivitis is always 
present. The blebs on the cornea rupture and form ulcers, which leave 
permanent scars, and the iritis and cyclitis may pass on to a destructive 
inflammation of the deeper coats of the eye (ophthalmitis). Atrophy 
of the optic nerves and paralysis of the oculomotor and of the superior 
oblique have followed ophthalmic herpes; a form of parenchymatous 
keratitis which precedes by several days the cutaneous lesions of herpes 
has been reported (Terrien). Acute glaucoma and glaucoma secondary 
to cyclitis have been observed. 
Inflammation of the tissues of the eye is most apt to occur when the 
nasal branch is affected, and the vesicles extend to the tip of the nose, 
because from this branch, through the lenticular ganglion, arise the 
nerves supplying the iris, ciliary body, and choroid. This is not an in- 
variable rule, and destructive disease of the eyeball may appear even 
when the nasal branch is not involved. A severe and most intractable 
neuralgia often remains after the subsidence of the eruption. 
Herpes zoster ophthalmicus 
is more frequently seen among 
elderly people of feeble nutrition 
than among adults and young 
children, but the latter may be 
attacked even in the absence of 
constitutional depression. 
Treatment.-The disease runs 
an acute course and tends to 
spontaneous recovery in two or 
three weeks. Locally, anodynes 
are useful-lead-water and lau- 
danum, weak carbolic acid lotions, 
and preparations of belladonna. 
Ichthyol ointment is valuable. 
Desiccating powders (rice-starch, 
calomel, zinc oxid) are useful. 
Severe pain must be mitigated 
by opiates and morphin hypo- 
dermically, while the best consti- 
tutional remedies are full doses of quinin and iron, and later arsenic. 
Salicylate of sodium and aspirin are valuable, and McNab recommends 
ionic medication, with sulphate of quinin by means of the positive pole 
over the affected area. The postneuralgic pain may be relieved by 
croton chloral hydrate in doses of 5 to 10 grains (0.324-6.5 gm.) 
every four hours, and by the use of a mild galvanic current. If con- 
junctivitis, keratitis, iritis, or cyclitis arises, it requires the treatment 
directed to the relief of such conditions, which is detailed in the special 
sections devoted to their consideration. 
Herpes Facialis of the Lids.-Occasionally one or several groups 
of herpes vesicles develop upon the eyelids. The lesions usually appear 
Fig. 84.-Extensive coalescing herpes con- 
fined to the lower lid. BLEPHARITIS 
165 
in the form of a small cluster or a coalescent patch. The lid is swollen, 
reddened, and the disease gives rise to a burning and itching sensation. 
The lower lid is affected more commonly than the upper. 
Treatment.-The best application is ichthyol ointment, and under 
its influences the lesions rapidly disappear. The associated con- 
junctivitis should be treated with the usual applications-boric acid 
and argyrol. 
Blepharitis is the term applied to the various grades of subacute 
and chronic inflammation of the border of the eyelid, which, for clinical 
purposes, may be gathered into two groups-non-ulceralive and ulcerative 
blepharitis. The former may be studied under several subdivisions: 
1. Hyperemia of the Lid-border (Hyperoemia Marginalis; Vaso- 
motor Blepharitis) .-The margins of the lids have an unpleasant, slightly 
swollen, red appearance. Exposure to cold wind or any strain upon 
the accommodation causes a feeling of heat, followed by burning and 
lacrimation. The redness is caused by the passive congestion of the 
superficial blood-vessels. Scales or crusts are absent or but sparingly 
present. 
2. Simple Blepharitis (Seborrhea of the Lid-border; Blepharitis 
Ciliaris; Squamous Blepharitis).-This variety depends upon an abnor- 
mal secretion of the sebaceous glands, and results in the formation of 
scales and crusts situated on the margin of the lids at the bases of the 
eyelashes, or adhering to them, and may appear in either a dry or a 
moist form. Removal of the hardened sebum exposes the skin, shining, 
red, and occasionally abraded. There is usually slight conjunctivitis. 
An accompanying seborrhea of the eyebrows and scalp may be present; 
both lids are invariably affected, and the patients complain of burning, 
inability to perform close work, and some dread of light. 
Exposure to cold and dust and the use of the eyes quickly increase 
the congestion of the lids. If the disease is of long duration or is subject 
to frequent relapses, considerable thickening of the lid-margins is evi- 
dent, due to the inflammation surrounding the glands in the skin and 
tarsus. Crust formation on the lid-margins due to a deposit of dried 
conjunctival secretion may simulate blepharitis. In these circumstances 
removal of the scales will demonstrate that the underlying skin is normal. 
The second, or idcerative, form of blepharitis appears in several 
grades of severity as a special localization of- 
Eczema Upon the Lid-border (Blepharitis Ciliaris; Blepharitis 
Ulcerosa; Psorophthalmia; Lippitudo Ulcerosa; Tinea Tarsi; Sycosis 
Tarsi; Ophthalmia Tarsi, etc.). 
(a) Superficial Form (Marginal Eczema).-This resembles in general 
that variety which has been described as hyperemia of the ciliary mar- 
gin. The patient suffers from "weak eyes" and from frequent attacks 
of redness and soreness of the borders of the lids, associated with the 
formation of crusts, small pustules, and ulcers at the roots of the lashes, 
without, however, seriously interfering with their nutrition or growth. 
(6) Solitary Form (Blepharo-adenitis Ciliaris, a name given by Arlt).- 
This is characterized by the appearance of a circumscribed area of 166 
DISEASES OF THE EYELIDS 
thickening and redness of the lid-margin, upon which the cilia are 
matted together at their bases by the formation of thick yellow crusts. 
A single tuft of this kind may be present, or several on one lid-border; 
the process is frequently unilateral, in this respect being unlike the 
squamous forms, which are bilateral. Removal of the crusts evacuates 
a few drops of thin pus from the surface of the ulcer which lies beneath, 
and the cilia, which usually come away with the scab, have swollen and 
thickened roots. Spots of eczema at the nares and in the hair of the 
scalp may be present at the same time, as well as disease of the lacrimal 
passages. 
(c) Pustular Form (Blepharitis Ciliaris Ulcerosa) .-This manifests 
itself as an eczema of the lid-margins, in its worst types involving the 
four ciliary borders. Thick yellow crusts, which mat the eyelashes, 
form along the palpebral margins, covering deep ulcers which readily 
bleed, and which, often crater shaped, pass inward to the tarsus. 
The inflammatory process, if unchecked, seriously interferes with 
the nutrition of the lashes and the edges of the eyelid. The former be- 
come stunted, curled, misplaced (trichiasis), or drop out, and may be 
entirely absent (madarosis, tylosis). The latter assume a rounded shape, 
are swollen, reddened, thickened, slightly everted, and deprived of cilia 
(lippitudo, or "blear eye," hypertrophic blepharitis), and if the punctum 
lachrymale is displaced or closed, an overflow of tears adds to the dis- 
comfort of the patient. 
It is not always possible thus sharply to separate the various types 
of blepharitis, as they often shade one into the other; nor is it always 
safe to decide between those which arise from glandular hypersecretion 
and those which are due to eczema. After the cure of an ulcerative 
variety, small scales may form resembling the simple or squamous type, 
while the latter may also lead to, or be associated with, ulcerations. 
Terson suggests a classification of affections of the lid-margins from 
the dermatologic standpoint. He would distinguish two main groups, 
the suppurative and the squamous. The former, for the most part, 
includes affections of the hair-follicles and of the surrounding tissue- 
that is to say, either a folliculitis or a parafolliculitis. He regards 
ulcerative blepharitis as a process analogous to sycosis. The squamous 
form of blepharitis he classifies with seborrhea. 
Etiology.-In the majority of instances blepharitis is a disease of 
childhood, and is common near the age of puberty; the aggravated 
forms, especially those resulting in chronic changes in the ciliary mar- 
gins, are frequently seen in adults as the result of neglect. The malady 
may follow in the wake of an exanthem, particularly measles, and finds 
many subjects among anemic children of strumous or tuberculous habit, 
with blond hair and pale complexion. The usual presence of ametropia 
has led to the belief that this causes blepharitis (Roosa). There is no 
doubt that it aggravates and fosters the condition. In some families 
blepharitis is hereditary (Fuchs). 
Of considerable importance in the origin of this affection are in- 
flammations of the tear-sac, stricture of the nasal duct, and obstructive BLEPHARITIS 
167 
disease of the posterior nares, although it may be difficult, in individual 
cases, to decide whether the blepharitis has caused the closure of the 
lacrimal passages, or whether this has developed the blepharitis. 
Blepharitis is aggravated and excited by exposure to wind, dust, and 
heat, and by intemperate habits and loss of sleep. Finally, some in- 
stances appear to arise from an abnormal and probably congenital 
shortness of the lids (microblepharon), resulting in their insufficient 
closure during sleep (Fuchs). 
Staphylococci are found in the pustules. McNab has frequently 
discovered the Morax-Axenfeld bacillus in some varieties of marginal 
blepharitis. Stubborn varieties may depend upon eczema seborrhoicum 
of the face; rarely the trichophyton fungus is found (blepharitis tricho- 
phytica of Mibelli). According to Raehlmann, the Demodex folliculorum 
may cause the disease (blepharitis acaria). It is, however, a not uncom- 
mon inhabitant of the normal eyelid. Favus, in the form of dirty, 
yellowish-white crusts, occasionally appears upon the eyelids, and may 
be mistaken for blepharitis. Microscopic examination of the crusts 
would reveal the mycelium and the conidia. The invasion of the 
follicles of the eyelashes by the Trichophyton tonsurans, when the brow 
or beard is similarly affected, produces an appearance closely resembling 
severe blepharitis. 
Treatment.-This differs with the type of the disease, but in all 
cases the refraction of the eye should be ascertained and any anomalous 
condition corrected with suitable glasses. This will often cure an ordi- 
nary hyperemia of the lid-margin, but if it is not sufficient, in addition to 
soothing lotions, the daily use of a douche of water at a temperature of 
68° F., to which is added a little eau de cologne or alcohol, is serviceable. 
Stimulating salves do not yield good results in this variety, but the 
edges of the lids may be anointed with almond Q.il or vaselin. 
In the cases classified among the seborrheas all crusts and scales 
should be removed by means of alkaline solutions-bicarbonate or 
biborate of soda, gr. viij to fgj (0.52 gm. to 30 c.c.)-or with a 5 per 
cent, solution of chloral (Gradle), and one of the following ointments 
applied once or twice daily: yellow oxid of mercury, gr. j to 3j (0.065- 
to 3.885 gm.), zinc ointment, or the salve advised by Gradle milk of 
(sulphur and resorcin, 3 per cent.). 
Great care must be exercised to remove the crusts from all the 
ulcerated varieties, either with the lotions which have been mentioned 
or, after softening, with forceps, before the application of any salve. 
A satisfactory method is daily gentle scrubbing of the lid-margins 
with the lather of a good neutral soap. For this purpose special soaps 
(ophthalmic soaps) may be employed. Red or yellow oxid of mercury 
or dilute citrine ointment or ichthyol (2-10 per cent, of the ammoni- 
acal salt) may be applied to the lid margins. 
In chronic cases all loose cilia should be extracted with epilating 
forceps, and any deep ulcers should be touched with the point of a crayon 
of nitrate of silver, or penciled with a solution of the same drug, or 
treated with a mixture of corrosive sublimate in glycerin (1 : 100 to 1: 30 168 
DISEASES OF THE EYELIDS 
-Despagnet). In severe forms, or when it is desirable to try other 
remedies, diachylon ointment, 15 to 240 grains (0.972-15.5 gm.) of 
vaselin, boric acid ointment, 10 to 100 grains (0.65-6.5 gm.), or aristol 
ointment, 15 to 150 grains (0.972-9.72 gm.), will be found useful. Fri- 
denberg recommends expression of the lid-margins in order to remove 
the pathologic secretion from the glands and ducts. Picric acid (0.8-1 
per cent.) in glycerin (Fage), and sulphate of zinc, gr. ij to foj (0.13 gm. 
to 30 c.c.), if the Morax-Axenfeld bacillus is present (McNab), have 
been advised. Stubborn blepharitis has been successfully treated by 
ionic medication, after the manner of Wirtz. A | per cent, solution of 
sulphate of zinc is employed; special electrodes are required.1 
If the lacrimal passages are obstructed, they must be rendered 
patulous, and in all cases the anterior and posterior nares should be 
explored for disease. 
The constitutional remedies include iron, quinin, and, if struma is 
present, cod-liver oil and lactophosphate of lime, with iodid of iron or 
syrup of hydriodic acid. 
Blepharitis may be a mild affection and yield readily to treatment; 
or it may be stubborn, and require constant attention and frequent 
change in local measures to prevent deformities in the lid-margins. 
Phthiriasis (blepharitis pediculosa) occurs when the pediculus 
pubis or crab-louse forsakes its seat of predilection and finds a habitat 
among the eyelashes. The cilia appear sprinkled with a fine dark 
powder-the eggs of the parasites-which are usually found partially 
buried, head foremost, in the hair-follicles. There are some itching and 
redness. The affection in most instances has been observed in children. 
The lice may be removed by the application of blue ointment or a care- 
ful penciling with a strong bichlorid solution. 
Sporotrichosis of»the Eyelids.-This disease may attack the eye- 
lids in the form of a dermic granuloma with swelling of the preauricular, 
submaxillary, and cervical lymphatic glands (H. Gifford, Morax). 
Ulceration of the lid border and small abscesses of the lid skin may 
arise. Syphilis, tuberculosis, and blastomycosis must be excluded by 
cultivating the germ on maltose agar. The Sporothrix Beurmannii is the 
fungus which usually is the active agent. 
The treatment consists in local antisepsis and the administration of 
iodid of potassium. 
Syphilis of the Eyelids.-Syphilitic affections of the eyelids exist 
either as the primary sore or as secondary or hereditary manifestations. 
A chancre usually appears on the area included by the lid-borders and 
inner canthus, the tarsal conjunctiva and the culdesac (deBeck). 
The lesion, generally on one lid, but in rare instances bilateral, begins 
as a pimple, which gradually develops into a characteristic, somewhat 
saucer-shaped ulceration, with rather rounded edges and indurated base. 
The lymph-glands in front of the ear and at the angle of the jaw are 
enlarged. Contagion has often occurred by the application of the lips 
1 For details consult Klin. Monatsbl. f. Augenheilk., Nov.-Dec., 1908; also Ophthal- 
moscope, Jan., 1911, p. 18. TUMORS AND HYPERTROPHIES 
169 
or tongue of an individual suffering from mucous patches in the mouth- 
as, for instance, in the act of kissing; or by the filthy practice of attempt- 
ing to remove a foreign body with the tip of the tongue. Soiled fingers 
have also carried the contagion. 
It is possible to mistake the affection for a stye, suppurating chala- 
zion, ulcerated tear-sac, vaccine ulcer, or small rodent ulcer. In doubt- 
ful lesions a search for the Spirochaeta pallida should be made; the Was- 
sermann test should be applied. 
Treatment.-Locally, the ulcer may be dressed with black or yellow 
wash. As soon as the diagnosis is established, the ordinary antisyph- 
ilitic remedies should be exhibited, especially salvarsan or neosalvarsan. 
The lesions of secondary 
syphilis upon the eyelids re- 
quire no special description. 
Among the later manifes- 
tations gummas of the skin 
of the lid, which break down 
into ulcers,-so-called tertiary 
ulcers,-are described. 
A papular eruption may 
appear upon the eyelids of 
children the subjects of he- 
reditary syphilis shortly after 
birth. A form of blephari- 
tis, characterized by sharply 
ulcerated spots, has been 
described as the result of he- 
reditary syphilis, and in sub- 
jects of this dyscrasia absence 
and falling out of the eyelashes have been seen. The latter condition 
also arises during secondary syphilis. 
Tumors and Hypertrophies.-A variety of growths, cystic and 
solid, are found upon the eyelid and its border. Along the latter, warts 
or papillomas are common. These are benign, except when in elderly 
persons, through irritation, they may take on an epitheliomatous nature. 
They should be cut off and their bases cauterized. In place of the ordi- 
nary elevated wart (verruca) a flat variety of the growth, which in elderly 
persons may be pigmented, often develops (keratosis senilis pigmento- 
sus). Superficial wart-like processes situated upon the intermarginal 
area of the lids have been described by Birch-Hirschfeld (acanthosis 
nigricans). 
Small clear cysts, arising from Moll's glands, are common along the 
ciliary margin, often giving rise to considerable irritation. They 
should be punctured. 
A reddish, wart-like mass may occur at the mouth of a Meibomian 
gland-duct. This is to be treated like an ordinary wart. 
Angiomas (nevi) are usually congenital growths, and exist either as 
bright-red spots (capillary angiomas) or in the form of elevated, bluish, 
Fig. 85.-Extensive gumma of the upper and lower 
lid of the right eye. 170 
DISEASES OF THE EYELIDS 
somewhat tabulated, cavernous growths, which may assume large pro- 
portions and extend from the lid to the forehead and temple. These 
cavernomas become turgid, purplish in color, and apparently increase 
in size if the child cries. They should be dealt with early in their ex- 
istence, lest they spread into the orbit. In a patient under the author's 
care a tumor of this character extended to the apex of the orbit and 
involved the lacrimal gland. A tumor occupying the upper surface of 
the tarsus, soft in consistence and bluish in color, has been noted in the 
eyelids of babies. Clinically, it may be mistaken for a cavernoma, but 
examination after removal, which is usually accomplished without 
difficulty by an ordinary dissection, shows, as in Arnold Knapp's speci- 
men, that it is composed of open spaces containing blood, which are 
lined with large endothelial cells, similar cells occupying the interven- 
ing regions. Angiomas arising from the lymphatics are known as 
lymphangiomas; those which develop from the blood-vessels, as heman- 
giomas. Nevus pigmentosus, and moreover, as the starting-point of a 
malignant growth, has been observed on the eyelids. 
That operative interference should be practised which promises the 
least subsequent deformity to the lid. When small, capillary angiomas 
may be excised or cauterized with nitric acid; if of a larger variety, their 
blood-vessel structure may be destroyed with galvanocautery needles; 
or electrolysis may be tried, three gold-plated needles attached to the 
negative pole being inserted in various positions in the nevoid tissue, 
while the positive pole is attached to some distant point-for example, 
the arm. The seance should last from ten minutes to half an hour, 
according to circumstances. The application of carbon-dioxid snow 
has been efficient in the treatment of some angiomas. Radium has 
also been tried. It is possible sometimes to excise large cavernous 
angiomas, and if there is not sufficient skin to cover the defect imme- 
diately, to accomplish this subsequently by skin-grafting. Indeed, 
excision by an ordinary dissection, if it can be accomplished without 
serious loss of tissue, is a desirable method of treatment. In infants, 
however, the danger of shock and hemorrhage is great. 
Occasionally ulceration occurs in an angioma and is followed by 
serious hemorrhage. 
A disease characterized by an increase in the volume of the skin of 
the lid, which becomes folded and falls over its margin, but appears 
atrophic and may be transiently red, like the color of the cheek, has 
been described by Rohmer and others, and to it the name angiomegaly 
has been given. It symmetrically affects the upper lids, and has been 
attributed to a structural or functional anomaly of the vascular system. 
Cutaneous horns (fibroma; molluscum fibrosum) occur as connective- 
tissue new growths, either sessile or pedunculated, sometimes asso- 
ciated with numerous similar tumors elsewhere on the body. A cornu 
cutaneum may grow from the margin of the lid (Fig. 86). 
Neuromas of the plexiform variety occur on the eyelids, and neuro- 
fibromatosis accompanied by optic neuritis has been observed, and with 
hydrophthalmos on the corresponding side. Lipomas, which are prob- CHALAZION 
171 
ably extensions from the orbit, are benign growths which may be re- 
moved by careful dissection. Ptosis lipomatosis, at one time attributed 
to an accumulation of fat in the connective tissue of the upper lid, 
causing it to droop and its covering fold to hang over the palpebral 
border, is due to relaxation of the fascia connecting the skin with the 
tendon of the levator. Fat hernias of the upper lid have been described 
by Schmidt-Rimpler as the result of a congenital extension of the 
orbital fat through a defect in the orbicularis muscle. 
Rare forms of benign tumors 
are adenoma of the sweat-glands 
and their follicles, adenoma of the 
Meibomian glands (Knapp), papil- 
loma of the ciliary border, enchon- 
droma of the tarsus, and myoma 
of the orbicularis (Schnaudigel). 
Hypertrophy and ossification of 
the tarsus have been reported 
(Herbert). 
Fig. 86.-Cornu cutaneum of the upper 
eyelid (from a patient in the Jefferson Medi- 
cal College Hospital). 
Fig. 87.-Neuroma of the right upper 
eyelid and adjacent temporal region (from 
a patient in the Philadelphia General Hos- 
pital). 
Xanthelasma (xanthoma) is a connective-tissue new growth, with 
fatty degeneration, usually seen in the form, of narrow, semicircular 
patches, most common upon the upper eyelids, although all four lids 
may be affected. The patches are yellow or buff colored, and on a 
level with the surrounding skin or slightly raised above it. 
Excision, if this may be performed without producing ectropion, is 
the simplest method of treatment, but often yields unsatisfactory results, 
inasmuch as the xanthelasma reappears in the region of the excision. 
Electrolysis has also been recommended and often produces good 
results. High-frequency currents applied to the plaques by means of a 
special electrode are advised by Bordier. The application of trichlor- 
acetic acid to small xanthelasma patches has been commended, and 
recently the application of radium has been recommended by Schindler. 
Chalazion (Meibomian Cyst; Tarsal Tumor).-This is a small tumor 
due to a chronic inflammation of a Meibomian gland and the tissue 
which surrounds it. The growth begins by retention of the secretion 
of the Meibomian gland, followed by a peri-adenitis and destruction of 
the tarsal cartilage, with passage of the tumor toward the conjunctiva 172 
DISEASES OF THE EYELIDS 
(internal chalazion) or to the skin (external chalazion). Usually the 
process is a chronic one; sometimes it assumes an acute nature, and 
there is inflammatory reaction (see also hordeolum internum). A chala- 
zion may form in the excretory duct of a Meibomian gland, and then 
projects in a nipple-like body from the edge of the lid. Chalazia may 
be single or multiple, and in severe cases recurrences may be frequent 
until a chronic infection of the Meibomian glands and alteration of the 
tarsal cartilages take place. To this condition Weymann has given the 
name tarsadenitis Meibomica. In association with nasal ozena an 
affection of the Meibomian glands has been described in which they 
become chronically inflamed, and pus, containing the ozena bacillus, 
exudes from their ducts. 
Cause.-The cause of chalazia is not known, although Deyl and 
Hala maintain that they represent an infectious, bacterial process, the 
active bacilli being identical with xerosis bacilli. They may be asso- 
ciated with inflammation of the border of the lid and stoppage of the 
duct of the gland. Individuals affected with these growths not infre- 
quently have ametropic eyes, especially when there is a tendency to 
recurrence in crops, like styes. They are more common in adolescence 
than in youth, childhood, or in old age. 
Symptoms.-The tumor grows slowly, unless it is of the acute 
type, and forms a firm swelling attached to the tarsus. The skin usually 
is freely movable over it; on the conjunctival surface a discolored patch 
marks its position. Suppuration may take place in the growth. 
A so-called acute chalazion may be mistaken for an external stye, 
from which it is to be distinguished by the more circumscribed charac- 
ter of the inflammation, and by the fact that the stye points in the edge 
of the lid; and a chronic chalazion for a sebaceous cyst from which it 
may be differentiated by the firmness of its attachment to the tarsus. 
A chalazion, a small sarcoma of the lid, and even a beginning glandular 
carcinoma have been confounded. 
Pathologic Anatomy.-A microscopic examination reveals a col- 
lection of cells, the majority of which are of the small round variety, 
having their origin in the acini of the Meibomian glands. Sometimes 
large multinuclear (giant-) cells are evident, though inoculation experi- 
ments have shown that these are not tuberculous in type. The central 
part of the growth later undergoes a mucoid or colloid degeneration, 
and a cavity appears, which is filled with a cloudy fluid. There is no 
true capsule, and there are consequently no characteristics of a true cyst. 
Treatment.-An ointment-2 grains (0.13 gm.) yellow oxid of 
mercury to 1 dram (3.9 gm.) of vaselin or lanolin-persistently rubbed 
into the skin over a chalazion will occasionally cause it to disappear, 
but usually it is necessary to remove it, according to the method 
described on page 599. The eyes of patients who suffer from chalazia 
are usually ametropic and suitable glasses should be adjusted. 
The malignant growths which appear upon the eyelids are sarcoma, 
cylindroma, carcinoma in the form of epithelioma or of rodent ulcer, and 
lupus. SARCOMA 
173 
Sarcoma occurs as a primary tumor in both upper and lower lids, 
about 80 cases being on record, and usually is seen in children. The 
recorded cases have been analyzed by Wilmer, Veasey, Friedenwald, 
Shumway, and the author. According to Veasey, the youngest subject 
of lid sarcoma was seven months old and the oldest seventy-six years. 
At first the growth is slightly elastic, and the skin moves over it freely, 
but the tendency is to rapid growth, ulceration, and involvement of the 
orbit. The tumor may attain large proportions. In a patient under 
the care of J. Chalmers Da Costa and the author the weight of the 
Fig. 88.-Sarcoma of lid (from a patient in the University Hospital). 
neoplasm was 247 grams. The various types of sarcoma (myxosarcoma 
being frequent) have been seen in this region, both pigmented and non- 
pigmented, and the tumor has been known to follow a contusion. 
Cylindroma, somewhat allied to sarcoma, but less malignant, com- 
posed, microscopically, of hyaline cylinders, occurs at times in the 
eyelids of adults, and is of slow growth. 
An early removal of the tumor is urgently indicated, but in spite of 
operation there may be recurrence or metastasis. Radium has been 
successful in some instances (Callan, Abbe). 174 
DISEASES OF THE EYELIDS 
Lymphomas occur in the lids and orbits in patients suffering from 
leukemia. They are often symmetric. They cannot be distinguished 
histologically from round-celled sarcomas. Lymphoma of the lower 
lid may be part of a general lymphomatosis (Coats). 
Carcinoma of the eyelid often appears in the form of rodent ulcer 
(Jacob's ulcer), which is a type of epithelial cancer, being, according to 
F. H. Montgomery, practically a superficial carcinoma of the tubular 
variety. It is characterized by slow ulceration and non-involvement 
of the neighboring lymph-glands, and is usually seen in elderly persons. 
The growth begins as a pimple, over which a crust appears. Gradu- 
ally an ulcer forms, which slowly spreads with indurated and elevated 
Fig. 89.-Destruction of eyeball and orbital tissues by a rodent ulcer: five years between 
the two stages (from a patient in the Philadelphia General Hospital). 
edges, and, if unchecked, involves all the tissues and destroys the eye- 
ball. Often many years elapse before the ulcer attains any considerable 
size. The most common point of origin is the inner end of the lower lid. 
The slow growth and absence of lymphatic involvement, together 
with the age of the patient, suffice to distinguish rodent ulcer from a 
tertiary syphilitic sore. 
It may be confounded with lupus, but the latter occurs in younger 
subjects, is more inflamed and less indurated, the ulcerations proceed 
from many points, and are generally associated with lupus elsewhere in 
the body. 
Epithelioma with the ordinary clinical characteristics may attack the 
eyelid, and is one of the commonest tumors of this region. It usually CARCINOMA 
175 
begins at the lid margin, and is more frequent on the lower than on the 
upper lid. It not infrequently is situated at the outer commissure and 
involves both lids (Fig. 90). Microscopically, it consists chiefly of a 
downgrowth of the interpapillary pro- 
cesses of the rete. The epithelial 
plugs often contain "cell-nests." Ac- 
cording to Ginsberg, a certain num- 
ber of growths recorded as epithe- 
liomas are really endotheliomas (Fig. 
91). Glandular carcinoma, having its 
point of origin either in the Meibomian 
or in Krause's glands, may also occur 
in this region. 
Treatment.-Certain local remedies, 
as aristol, chlorate of potassium, and 
injections of pyoktanin, have been 
recommended. If the disease is ad- 
vanced, Canquoin's paste, chloracetic 
acid, scraping, and the actual cautery 
have been employed to check the 
ulceration. 
In recent years great advances in the treatment of the various 
malignant growths of the eyelids have been made, especially in the 
application of the a-rays. 
Fig. 90.-Epithelioma of the eye- 
lid (from a patient in the Jefferson 
Medical College Hospital). 
Fig. 91.-Epithelioma of eyelid encroaching on eyeball (from a patient in the Philadelphia 
General Hospital'). 
At the author's request Dr. Henry Pancoast, Professor of Rontgen- 
ology in the University of Pennsylvania, has prepared the following- 
directions, which will be found useful: 
An important consideration in x-ray applications in the neighbor- 
hood of the orbit is the possible injury to the eye that may result from 
the exposures. Ulceration and opacity of the cornea, severe conjunc- 176 
DISEASES OF THE EYELIDS 
tivitis, edema of the conjunctiva and lids, and optic neuritis have been 
noted. The eye should always be carefully protected. 
Epitheliomas involving the lids are frequently troublesome and 
obstinate, because there is a tendency to allow too little exposure to the 
rays lest the eye be damaged, or sufficient treatment cannot be given 
on account of the danger of injuring the ocular coats. If the growth 
overlies the eyeball, cocain may be introduced, and then a hard-rubber, 
ivory, or metal eye spatula may be inserted under the lid. All the sur- 
rounding healthy parts should be covered by an impenetrable protect- 
ive. The quality and quantity of rays used are most important. 
The tube should be soft, such a one which has a resistance equal to 1 or 
1| inches of spark-gap, and it should be placed as near to the area as 
possible. A current of 1 to 3 milliamperes may be used in the secondary. 
With the aid of a mechanical spring-interrupter the average duration 
of each exposure should be from five to ten minutes. On account of 
the latency of .r-ray effects many operators advise giving the exposures 
in series. Four or more applications are made on successive days, and 
then an interval of several days follows before the next set of exposures 
is given. With such a technic the necessary number of applications 
does not entail much danger to the eye. At the same time it should 
be borne in mind that preliminary partial or complete excision 
should be performed when it is not inconsistent with good cosmetic 
results. 
Although, according to Pancoast, excellent results have been ob- 
tained in many instances in the treatment of epitheliomas of the eye- 
lids by the use of Rontgen rays, the results from radium he believes 
are preferable and more certain, and the latter agent can usually be 
employed to better advantage and with greater safety to the eye. 
The reaction to radium in the unprotected bulbar conjunctiva is very 
severe and the eye should, therefore, be adequately protected against 
the less penetrating beta rays. This can readily be accomplished 
when the application is made near the palpebral margin by inserting 
a piece of metal such as a Snellen clamp between the lid and the eye, 
after cocainization. Such treatment results in a minimum loss of 
tissue, and any resulting deformity can be corrected subsequently 
if necessary. Papillomas may be removed in the same manner. 
Lupus vulgaris is a cellular new growth composed of variously 
shaped, reddish tubercles, which usually terminate in ulceration and 
extensive cicatrization. As this disease commonly appears on the face, 
it may also involve the eyelids. 
The process begins in youth, often before puberty, and is slow in 
its course. The ulcers are apt to start from a number of points which 
coalesce; their edges are soft, and the discharge is offensive. Syphilitic 
ulcers, on the other hand, are deeper, more excavated, with harder 
margins, and their course is more rapid. Tuberculosis of the lid and 
tarsus is usually secondary to conjunctival tuberculosis; rarely it is 
primary and may simulate the clinical picture of chalazion (von Hippel). 
Treatment.-Local application of caustic paste, erasion with a TARSITIS 
177 
curet and the actual cautery have been employed, and injections of 
tuberculin have been recommended. 
Lepra.-Leprosy attacks the eyelids very frequently. According 
to Lopez, two-thirds of those affected with this disease suffer from lesions 
in this region. These consist of anesthetic patches of color slightly 
different from that of the surrounding integument, tubercles, loss of 
the eyelashes and eyebrows, and ectropion and entropion, the former 
occurring with extraordinary frequency. 
Xeroderma Pigmentosum.-According to Greeff, the ocular 
affections in this disease are found both on the skin of the lids and the 
mucous membrane of the eye; more rarely on the cornea. The earliest 
evidences of the disease appear on the face, and particularly on the lids. 
After certain irritative symptoms, an atrophic process develops with 
areas of pigmentation, and even in the early stage of the disease the 
cilia fall out and disappear. Later, elevations of a warty appearance 
develop, the epithelial processes of which extend inward and become 
true carcinomas. The disease may occur in childhood as well as in 
adult age, and it is interesting that even in youth carcinoma may de- 
velop. L. W. Dean has reported favor- 
able results from the use of cocoa butter 
locally and injections of autoserum. 
Thorium has been tried. The carcino- 
matous tumors may be removed if they 
are not too numerous. 
Elephantiasis arabum, a chronic 
hypertrophic disease of the skin and 
subcutaneous tissue, has appeared in the 
upper eyelid in consequence of an injury, 
but may also be congenital. According 
to Cirincione, a distinguishing feature of 
true elephantiasis of the lids is that at 
least two lids are involved, and generally 
four of them. Repeated attacks of ery- 
sipelas have etiologic importance. Ele- 
phantiasis telangiectodes, or that disease 
which consists in a hypertrophy of the 
skin and connective tissue, together with fatty tissue and distended 
vessels, occurs in the upper eyelid as a congenital affection. 
Tarsitis, or inflammation of the tarsus, is usually syphilitic in origin, 
and presents great thickening of the tarsus, owing to diffuse gummatous 
infiltrations (Fig. 92). It may also be due to tuberculosis and to tra- 
choma. As a rule, it is chronic in course; an acute form has been de- 
scribed. The disease may resemble a chronic marginal blepharitis, 
with the formation of crusts and ulcers at the mouths of the hair- 
follicles, but differs from the latter condition by the presence of con- 
siderable thickening and induration of the tarsus. Alteration of the 
tarsus, owing to chronic infection of the Meibomian glands, may 
arise, and has been referred to. Suppurative tarsitis has occurred; 
Fig. 92.-From a photograph 
of a patient with syphilitic tarsitis 
under the care of Dr. Randall, in 
the Children's Hospital. 178 
DISEASES OF THE EYELIDS 
the author has recorded one case of this character apparently due to 
influenza. An ulcerative variety due to syphilis has been described 
(Morax). ' 
Treatment.-If syphilitic, tarsitis is amenable to the ordinary 
remedies; if not, much the same treatment described in connection with 
chronic blepharitis is applicable, especially the use of resolvent oint- 
ments. 
Blepharospasm, or an involuntary contraction of a portion or the 
whole of the orbicularis palpebrarum, appears as either a clonic or a 
tonic cramp. 
The former variety may consist merely in a twitching of a few 
fibers of the muscle, most commonly in the lower lid, very annoying, 
and often the cause of undue alarm. It arises from the strain of ame- 
tropia, prolonged eye use, and deficient amplitude of accommodation. 
It also occurs in a severe and intractable form, and occasions much dis- 
comfort and conjunctival irritation. 
The treatment comprises the prescription of glasses and a general 
tonic. In stubborn cases fluidextract of gelsemium will occasionally 
afford relief. Conium internally, and the extract locally, have been 
recommended. In recent times hypodermic injections of 80 per cent, 
alcohol at the emergence of the facial nerve have been tried and satis- 
factory results have been reported. 
Children are often affected, especially during their early school 
years, with undue winking of the eyelids, associated at times with 
jerky movements of the facial and other muscles. This form of nervous 
disorder was designated by Weir Mitchell habit chorea.1 Almost 
invariably, blepharitis, follicular and phlyctenular conjunctivitis, and 
errors of refraction and heterophoria are exciting causes. Long-con- 
tinued blepharospasm, especially in children with phlyctenular con- 
junctivitis, may give rise to lid-edema, due to pressure of the contracted 
orbicularis on the palpebral veins. Suitable glasses and appropriate 
local remedies, together with the exhibition of Fowler's solution, will 
usually bring about a cure. 
Tonic cramp of the orbicularis follows the introduction of foreign 
bodies into the eye, the presence of inflammations of the cornea and con- 
junctiva, and fissures at the angles of the lids, and depends upon irri- 
tation of the peripheral trigeminal filaments. 
More rarely a persistent lid cramp occurs, without obvious cause, 
and is unrelieved for weeks and even months. When the eyes are 
finally opened, there may be temporary blindness, without correspond- 
ing ophthalmoscopic changes; or permanent loss of vision, with gross 
lesions in the eye-ground. 
The treatment demands the removal of any peripherally exciting 
cause-fissure, foreign bodies, phlyctenules, etc. Hypodermic injec- 
tions of morphin have been used to control the trigeminal irritation, 
and in severe cases section of the supra-orbital nerve has been performed. 
Conium and gelsemium in the form of the fluidextract may be tried. 
1 Gowers gives the name "habit spasm" to the same affection. BLEPHAROCHALASIS 
179 
They should be pushed to the point of tolerance. The hypodermic use 
of alcohol has been referred to. 
Ptosis {blephar optosis) is that condition in which the upper lid 
droops entirely or partially over the eyeball, and cannot be voluntarily 
raised. It is either congenital (see page 160) or acquired by reason of 
the development of fatty or other accumulations in the connective tissue 
of the lid {pseudoptosis, see page 171), or it arises from paralysis of the 
oculomotor nerve, and in rare instances from lesion of its cortical center 
{paralytic ptosis). Ptosis also occurs as the result of injury of the levator. 
In some cases of unilateral congenital ptosis, usually on the left side, 
while the eyelid cannot be voluntarily raised, it is elevated when the jaw 
is moved during eating (contraction of the levator in association with 
the external pterygoid) (see also Ocular Palsies). 
Fig. 93.-Ptosis with edema of tissues, the result of laceration of the lid. 
It is convenient to make reference in this place to other associations 
in muscle action. Thus, there may be contraction of the orbicularis 
with movements of the jaw, contraction of the levator with abduction 
and adduction, and, as reported by Zentmayer, contraction of the 
frontalis with abduction. 
Treatment.-The medicinal treatment of ptosis calls for the exhibi- 
tion of those remedies which control the supposed cause of the palsy- 
mercury and iodids in syphilis, salicylic acid in rheumatism. 
The surgical treatment will be found on page 600. 
Blepharochalasis, or relaxation of the skin of the lid, due to 
atrophy of the intercellular tissue, has been described by Fuchs and other 
writers. The skin of the lid is thin, much wrinkled, and its superficial 180 
DISEASES OF THE EYELIDS 
veins are dilated. The condition may be remedied by excising appro- 
priate portions of the relaxed tissue and uniting the cut edges with 
sutures. 
Lagophthalmos, or an inability to close the eyelids, is either 
paralytic or non-paralytic, and usually results from paralysis of the 
facial nerve, as in Bell's palsy, but also occurs in tumors of the orbit, 
exophthalmic goiter, and staphyloma. The highest grade of lagoph- 
thalmos appears as a congenital defect (see page 158). Paralysis of 
the orbicularis has been described as a hysteric phenomenon, but it is 
doubtful if in these circumstances it really has been observed. Orbicu- 
laris palsy may follow an injury, and the author has seen bilateral paral- 
ysis of the orbicularis after fracture of the base of the skull, with only 
slight involvement of the lower facial area. Failure of the lids to come 
in contact with the globe at the outer canthus has been recorded as a 
congenital condition. 
The chief danger of the affection is ulceration of the cornea from 
exposure, rendered all the more certain should disease of the trigeminus 
also exist. 
Treatment.-In paralytic lagophthalmos the primary cause of the 
affection must be treated: in the non-paralytic varieties, and in any 
form in which the vitality of the cornea is threatened by its exposure, 
the operation of tarsorrhaphy may be employed (see page 603). 
Symblepharon,1 or a cohesion between the eyelid and the ball, 
may be complete or partial, acquired or congenital (see page 158). 
The most usual causes are in- 
juries, especially burns with 
acids or lime. Symblepharon 
also follows diphtheritic con- 
junctivitis, trachoma, pem- 
phigus, and occasionally puru- 
lent conjunctivitis; but the 
shortening of the conjunctival 
sulcus, which occurs by a 
species of drying of the con- 
junctiva, presently to be de- 
scribed, must not be con- 
founded with a true symbleph- 
aron. The attachment may be 
merely slight bands between 
the conjunctival surface of the 
lid and ball, or, in the more 
complete cases, the cornea may 
also be involved in the cicatricial union, and vision be seriously dis- 
turbed. The lower lid is most usually involved in the process; the 
upper may also participate (Fig. 94). 
Ankyloblepharon, or that condition in which the borders of the 
Fig. 94.-Symblepharon, the sequel of pur- 
ulent conjunctivitis (from a patient in the Phila- 
delphia General Hospital). 
1 Symblepharon really belongs to diseases of the conjunctiva, but is conveniently 
inserted in this place. ALOPECIA OF THE EYELIDS 
181 
two lids have grown together, may be congenital or acquired, and, like 
the preceding affection, partial or complete. 
The same causes which originate symblepharon are here active, and 
varieties are described in which the union takes place not by a growing 
together of the lids, but by the organization of a membrane, the result 
of croupous conjunctivitis. 
Blepharophimosis is the name given to that condition which 
arises through a contraction of the outer commissure of the lids, and 
results in shortening of the palpebral fissure. 
It is commonly seen in cases of long-standing conjunctivitis with 
irritating secretions; for instance, in chronic conjunctivitis and in some 
of the forms of granular lids. 
Treatment.-After an injury, or during the course of a local dis- 
ease, likely to result in one of these complications, scrupulous care must 
be exercised to avoid it. The formation of granulation tissue may be 
broken up with a probe, and it has been advised to place a piece of gold- 
beater's skin or the thin skin from the inner surface of an egg-shell 
(Coover) between the lid and the ball to prevent adhesions. 
The surgical treatment of these affections is described on page 
604. 
Trichiasis; Distichiasis.-Trichiasis is that affection in which the 
lashes are misplaced and turn inward against the eyeball; distichiasis is 
that condition in which incurved rows of supplementary cilia are de- 
veloped from the intermarginal part, close to the opening of the tarsal 
glands. 
The most usual causes of trichiasis are chronic inflammations of the 
lid-borders-blepharitis and granular conjunctivitis.1 Distichiasis, in 
rare instances, is congenital, or develops about the age of puberty. 
The cilia rubbing against the cornea produce constant irritation, and 
may lead to ulceration. 
Treatment.-If not too numerous, the lashes having a faulty direc- 
tion should be removed with cilium forceps, and when they grow again, 
the procedure repeated; their reappearance may sometimes be prevented 
by destruction of the hair-follicles by galvanopuncture. Other opera- 
tions consist of strangulation of the roots of the incurved lashes by a sub- 
cutaneous ligature, excision, and the various modifications of single 
and double transplantation of the entire ciliary border (see chapter on 
Operations). 
Alopecia of the eyelids, the loss of the lashes depending upon the 
fact that the patient, usually a hysteric girl, systematically pulls out 
the cilia, has been described by H. Gifford. The author has seen several 
cases. Sudden turning gray of the eyelashes has been recorded by 
Hirschberg after phlyctenular disease, and has occurred in sympathetic 
ophthalmia and iridocyclitis. Premature grayness of the cilia, sometimes 
temporary, has also been reported. 
1 Raehlmann believes that trichiasis hairs, or "false cilia," are developed from the epi- 
thelial covering of the lid-margin in consequence of marginal blepharitis, the result of 
granular conjunctivitis. 182 
DISEASES OF THE EYELIDS 
Entropion, or inversion of the lid, like trichiasis, is most com- 
monly caused in an organic form by granular lids, and also follows 
essential shrinking of the conjunctiva and diphtheritic conjunctivitis. 
Entropion and trichiasis are often associated. 
Two other varieties of entropion are described-muscular and 
bulbar. The former is sometimes present at birth from undue develop- 
ment of the orbicularis, and also occurs in a spasmodic type, under the 
influence of conjunctivitis, keratitis, and foreign bodies; the latter is a 
falling-in of the lids when the eyeball is shrunken or absent. 
Treatment.-The spasmodic varieties will usually subside if the 
exciting cause can be removed. In temporary entropion the lid may 
be painted with flexible collodion, which, by its contraction, draws out 
the inverted border, or, having everted the lid, it may be held in place 
with a longitudinal strip of plaster which is fastened to the cheek. The 
organic varieties of the disorder require one or other of the operations 
described on page 607. 
Ectropion, or eversion of the lid with exposure of the conjunctival 
surface, is either partial or complete. The disorder is divided into the 
Fig. 95.-Ectropion of the upper lid, 
the result of an injury to the brow and sub- 
sequent caries of the margin of the orbit 
(from a patient in the Philadelphia General 
Hospital). 
Fig. 96.-Ectropion of the lower 
lid, the result of a wound from the tine 
of a fork (from a patient in the Children's 
Hospital). 
acute or muscular and the chronic form, or that which results from 
organic changes. 
Acute ectropion usually occurs in children with conjunctivitis and 
in diseases of the cornea with blepharospasm, when the lids, during 
examination, become everted and remain so until replaced. One form 
of partial muscular ectropion is produced by facial palsy. 
The common causes of the second, or chronic, form of ectropion are 
wounds, especially such as are caused by dog-bites, by laceration of the 
lid by a sharp instrument, by burns and subsequent cicatricial contrac- 
tion, by chronic inflammatory conditions of the ciliary margin, by ulcera- 
tion of the lids as in lupus, and by caries of the orbital border and malar 
bone. The lower lid is more frequently involved than the upper, but 
ectropion is also seen in the latter position. 
Treatment.-This varies with the type and degree of the ectropion. 
In the spasmodic forms simple replacement of the everted lids suffices; MILIUM 
183 
in slightly marked grades, with some eversion of the lacrimal punctum, 
the canaliculus should be partly slit, and, if necessary, the nasal duct 
Fig. 97.-Ectropion of the lower lid, 
caused by caries of the malar bone (from a 
patient in the Philadelphia General Hos- 
pital) . 
Fig. 98.-Ectropion of the upper lid 
from syphilitic periostitis of the orbit (from 
a patient in the Philadelphia General 
Hospital). 
should be probed. The organic types of the disorder require a plastic 
operation for the relief of the deformity (see chapter on Operations). 
Certain diseases of the eyelids are 
comprised in a group of functional 
disorders of the sebaceous and sweat- 
glands. 
Seborrhea, or that disorder of the 
sebaceous glands during which their 
secretion is altered and forms an oily 
coating on the skin, sometimes ac- 
companied with crusts and epithelial 
scales, is also seen upon the eyelids. 
It is usually associated with a similar 
process in the scalp and eyebrow', and 
when specially localized upon the cili- 
ary margins creates one of the forms of 
blepharitis already described. 
Treatment.-Proper hygiene, cod- 
liver oil, iron and arsenic, removal 
of the accumulated sebum by fre- 
quent washings, and the application 
of sulphur and mercurial ointments 
comprise the most efficient methods of 
treatment. 
, Milium.-Milia, or small yellowish elevations, consisting of an 
accumulation of sebum within the distended but closed sebaceous glands, 
Fig. 99.-Ectropion of the lower 
lid following lupus. The scar on the 
cheek is faintly seen (from a patient 
in the University Hospital). 184 
DISEASES OF THE EYELIDS 
are common upon the eyelids. They often develop about the age of 
puberty. 
They are caused by improper care of the skin, and may be con- 
nected with general constitutional disturbances, dyspepsia, and consti- 
pation. They should be opened with a knife or needle and the con- 
tents evacuated. 
Molluscum contagiosum (molluscum sebaceum) is a disease 
of the sebaceous glands (according to some authors, of the rete muco- 
sum) characterized by the appearance of rounded papules, about the 
size of a pea, and of a waxy color. The eyelids are a favorite situation. 
The disorder occurs chiefly among ill-nourished children, is believed 
by many to be contagious, and may arise as an epidemic in homes and 
asylums. According to some observers, the affection is caused by a 
parasite belonging to the class coccidia, and really is a form of contagions 
epithelioma. Muetze's investigations indicate that the "molluscum 
corpuscles" are the result of a degeneration of the epithelial cells caused 
by the contagion, the nature of which is uncertain. 
Fig. 100.-Dermoid cyst of the eyebrow. 
Treatment.-Each molluscum should be incised and its contents 
forced out. 
Ephidrosis (hyperidrosis), or an increased flow of sweat, has in 
rare instances been observed as a local disorder of the sweat-glands of 
the eyelids. In cases of unilateral sweating of the face the lids neces- 
sarily participate. Retention cysts of the sweat-glands, in the form of 
round, sharply circumscribed elevations, have been observed by von 
Michel. 
Chromidrosis (seborrhoea nigricans), or the formation of a variously 
colored secretion from functionally disordered sweat-glands, is sometimes 
located upon the eyelids. It then receives the name of palpebral chromi- 
drosis, and consists of a bluish-black discoloration, usually upon the 
lower lid, which is somewhat oleaginous and can be wiped away. 
It is probably genuine in rare instances; in others it is believed to 
be either a fraud practised by hysteric subjects or due to the deposit INJURIES OF THE EYELIDS 
185 
of dust upon the surface of the skin affected with seborrhea. Young 
women are usually those affected. 
The treatment should consist in general invigorating methods cal- 
culated to remove anemia, debility, or nervous disturbances. Locally, 
lead-water and glycerin are recommended. 
Sebaceous cysts occur in the eyelids, most frequently in the outer 
part, and also in the eyebrow. In the latter situation they sometimes 
are deeply seated, tightly adherent to the periosteum, and may extend 
some distance into the orbit. Dermoid cysts are also found in this 
region. Their removal by an ordinary dissection is usually unattended 
with difficulty. 
Injuries of the Eyelids.-Incised, lacerated, punctured, and con- 
tused wounds, edema, emphysema, and ecchymosis of the lids are the 
ordinary results of accidents and injuries. 
Wounds.-The type of a wound depends largely upon the char- 
acter of the implement which has inflicted it, and may vary from a 
simple and superficial incision to a deep cut which penetrates the tissues 
of the lid and injures the structures of the eyeball. In like manner a 
laceration may be small and unimportant, or may be so extensive as 
to tear the eyelid from its attachments. Incised wounds in the line 
of the direction of the fibers of the orbicularis result in the least visible 
scar, owing to the absence of gaping. Such injuries are often inflicted 
by broken glass (a broken spectacle lens, for example) or china, by a 
knife or other sharp instrument, and by a thin sliver of metal. 
Treatment.-Accurate approximation of the edges of the wound 
should be secured with catgut or silk sutures. Even considerable lacer- 
ation may heal with very little deformity. 
Edema usually occurs as the sequel of a blow, owing to the loose 
connective tissue of the eyelids, which readily admits of distention (see 
also page 160). 
Treatment.-The application of evaporating lotions, for example, 
dilute lead-water and laudanum, associated, if the swelling is great, 
with a pressure bandage, is a measure which will afford relief. 
Emphysema of the lids is observed when a fracture of the orbit 
permits air to escape into the cellular tissue through a communication 
thus produced with the ethmoidal or frontal sinus. A soft swelling, 
crackling to the touch, is the result, which increases in degree when the 
patient blows his nose and forces the air through the fissured bone. 
The eyelids may participate in the emphysema of the neck and face some- 
times seen after tracheotomy or after stab-wounds of the chest. 
Ecchymosis of the lids, or a collection of blood in the connective 
tissue, in its simplest variety constitutes the familiar "black eye," the 
common result of a blow. A gradual absorption of the effused blood 
takes place, requiring a week or longer for its completion, but the skin 
may retain its black-and-blue stain for a greater period of time. 
Ecchymosis may be due to fracture of the base of the skull, and 
may be associated with emphysema if a fracture has involved the 
frontal or ethmoidal cells. 186 
DISEASES OF THE EYELIDS 
Treatment.-Emphysema will gradually subside without local treat- 
ment; if the swelling is severe, it has been recommended to prick the 
tissues and allow the air to escape. 
Ecchymosis should be treated with frequent applications of cold 
water, lead-water and laudanum, or diluted white extract of hamamelis. 
If discoloration remains for a long time, the "eye may be painted." 
The practice of applying leeches or incising the swollen lid and sucking 
out the contained blood is to be condemned. 
Foreign Bodies in the Eyelids.-Fragments of glass, shot, pieces 
of iron or steel, portions of wire, particles of stone, and splinters of wood 
may penetrate the tissue of the eyelids and occasionally remain unde- 
tected for long periods of time. They may become encysted or, as the 
result of infection, give rise to a lid abscess. If the foreign body is com- 
posed of iron or steel it may be removed by means of a magnet. 
Burns of the eyelids are commonly inflicted with hot water, caustics 
(lye and lime), acids, or are caused by the explosion of powder. 
The first agent produces the ordinary vesication, and the treatment 
should consist in the application of oil, while the pain may be materially 
relieved by using locally a lotion of carbonate of soda or, better, the 
moistened powder itself. 
Burns caused by the other materials are especially dangerous on 
account of the almost invariable involvement of the cornea and con- 
junctiva (see page 239). Immediately after a powder burn all loose 
powder should be removed, and, if possible, each grain picked out of 
the skin with a fine needle, or, according to Edward Jackson, destroyed 
by touching it with a fine electrocautery needle. The application for 
ordinary burns may then be used. Peroxid of hydrogen has also been 
employed to remove powder grains, and is most efficient. It may be 
applied in full strength or in a solution of 3 parts to 1 part of glycerin. CHAPTER VI 
DISEASES OF THE CONJUNCTIVA 
Congenital Anomalies of the Conjunctiva.-In addition to 
dermoid tumors (see page 233) certain thickenings of the conjunctiva 
of congenital origin have been reported. The latter resemble pterygia 
and extend between the fissures of the lid (Strawbridge). If necessary, 
excision could be performed (see also Epitarsus, page 159). 
Hyperemia of the conjunctiva (dry catarrh; hyperoemia palpe- 
braris) is characterized by an injection of the vessels, chiefly of the pal- 
pebral conjunctiva, but rarely affecting the ocular expansion of the 
membrane. The posterior conjunctival vessels (System I) are involved, 
but not to the same extent that they are in conjunctivitis. Both an 
acute and a chronic form exist. 
Causes.-The strain of ametropia furnishes a large contingent of 
these cases, while others arise when the refraction error is insufficiently 
or improperly corrected. Beginning presbyopia, especially in those per- 
sons who are disinclined to use glasses, and hyperemia of the conjunctiva 
are often associated; it also occurs with incipient cataract and slight 
opacities of the cornea, as the result of the effort to obtain clear images. 
Local irritants, as dust, foreign bodies, misplaced cilia, calcareous 
concretions, tobacco-smoke, cold winds, etc., are common causes, and 
the abuse of alcohol originates many cases. The condition may also 
arise in the eyes of those much exposed to bright light, to great heat- 
for example, in iron foundries and among workers in a-ray rooms. 
Patients with prominent eyeballs are more liable to hyperemia than 
those whose eyes are more deeply placed. 
Nasal catarrh, lacrimal obstruction, and marginal blepharitis are 
frequently accompanied by chronic hyperemia of the conjunctiva, which 
is much aggravated by the establishment of an acute coryza or "hay- 
fever." 
Finally, certain acute hyperemias, which may be recurrent, appear 
in the form of vasomotor disturbances, and arise under the influence 
of metabolic disorders, especially gout. Hyperemia of the conjunctiva 
also occasionally occurs in anemia and chlorosis in place of a pallid 
membrane, and may be associated with trigeminal neuralgia and 
migraine. Chronic conjunctival congestion has been attributed to 
gastro-intestinal auto-intoxication (J. F. Shoemaker). 
Symptoms.-Direct inspection reveals the congestion of the vessels, 
not sufficient to produce the velvety appearance seen in conjunctivitis 
and unaccompanied by any discharge. Swelling of the conjunctival 
follicles may be present, especially if the hyperemia is of long standing. 
There are photophobia, some lacrimation, a hot, stinging sensation 
187 188 
DISEASES OF THE CONJUNCTIVA 
aggravated by the use of the eyes, which readily "water" and grow un- 
comfortable, especially in artificial light. 
Treatment.-This requires the correction of refractive error. Re- 
moval of exciting local causes and attention to the anterior and poste- 
rior nares are necessary. Patency of the canaliculi and of the lacrimal 
passages should be secured. 
Locally, boric acid, gr. x to foj (0.65 gm. to 30 c.c.), or biborate of 
soda, gr. v (0.324 gm.), camphor water, foj (30 c.c.), and distilled 
water, f5j (30 c.c.), may be applied. More active astringents, as 
alum, tannin, and zinc, are sometimes employed, and stimulating 
drops, as equal parts of tincture of opium and water or boric acid 
solution, to which a few drops of alcohol have been added, are useful. 
Nitrate of silver is not advisable; argyrol (10 per cent.) is sometimes 
useful. Douching the eyes with hot or cold water is a valuable adju- 
vant. Temporary blanching of the conjunctiva may be secured with 
adrenalin (1 : 10,000) and preparations of suprarenal extract, but they 
are not advisable as frequent or constant applications. If there is 
reason to suspect any general trouble-for example, gout-this must 
receive attention. 
Conjunctivitis.- The conjunctiva is liable to various grades and 
types of inflammation which have certain symptoms in common: (1) 
Photophobia, not constantly present in all varieties, but commonly 
seen at some time during the course of the disease; (2) increased and 
usually altered secretion; (3) a changed appearance in the membrane, 
varying from a general injection of the blood-vessels and slight velvety 
opacity to the development of special pathologic products or the forma- 
tion of false membrane. 
The generic term conjunctivitis (ophthalmia of the older writers) 
is applicable to this entire group of diseases. Although bacteriologic 
examinations have given rise to a classification of conjunctivitis which 
has been recommended in place of the older arrangement, our knowledge 
is not yet sufficiently exact to make it expedient to banish entirely 
descriptions based upon clinical appearances. It should be remem- 
bered that the normal conjunctiva always contains bacteria, a number of 
varieties having been isolated. Comparatively few of them should be 
classified as at all pathogenic (Weeks); but non-pathogenic bacteria may 
become harmful if the tissues in which they exist are bruised or irritated 
(Randolph). According to Axenfeld, the xerosis bacillus and non-viru- 
lent, or only slightly virulent, Staphylococcus albus are practically always 
present in the normal conjunctiva; other organisms occasionally found 
are Staphylococcus pyogenes aureus and albus, pneumococcus, Streptococ- 
cus pyogenes (rare), diplobacillus and influenza bacillus (uncommon), 
Bacillus subtilis, and sarcinoe. 
Simple Conjunctivitis (Catarrhal Conjunctivitis or Ophthalmia).- 
This is an inflammatory disease of the conjunctiva, characterized by 
congestion, loss in the transparency of the palpebral conjunctiva, some 
dread of light and spasm of the lids, and a discharge sufficient only to 
glue the lids in the morning, or freer and mucopurulent. SIMPLE CONJUNCTIVITIS 
189 
Causes.-The etiology is made evident by observing certain varieties: 
Associated conjunctivitis is seen with eczema, facial erysipelas, im- 
petigo contagiosa, nasal catarrh, bronchitis, and constitutional dis- 
orders like typhoid fever and rheumatism. In acne rosacea conjunctivitis 
minute nodules form at the limbus; moderate irritation supervenes; sub- 
sidence takes place, but recurrence is frequent. The condition resembles 
somewhat phlyctenular conjunctivitis. It arises in adults who are the 
subject of acne rosacea. General as well as local treatment (dusting 
with calomel) is required. Exanthematous conjunctivitis, which accom- 
panies or follows measles, scarlet fever, and small-pox, may be included 
in this list. In the conjunctivitis of epidemic meningitis McKee has 
found the meningococcus. This conjunctivitis is an early symptom, 
and McKee thinks the bacteria may be found in the conjunctival 
secretion before they can be recovered from the cerebrospinal fluid. 
Mechanical conjunctivitis results from exposure to wind, dust, and 
traumatism (toxic conjunctivitis, see page 228). 
Symptomatic conjunctivitis may arise from the strain of ametropia, 
and is analogous to ordinary hyperemia. 
Micro-organisms (staphylococci, streptococci, pneumococci) are pres- 
ent in severe types and explain the contagion; neglected hyperemias 
and the presence of follicular granulations increase the susceptibility 
to infection, and scrofulous subjects are peculiarly liable to the disease. 
Occasionally a stubborn conjunctivitis is encountered from the secre- 
tion of which pure cultures of staphylococci may be obtained, and which 
therefore, has been called Staphylococcus conjunctivitis. McKee has 
described a variety of mucopurulent conjunctivitis due to a new patho- 
genic organism which somewhat resembles the influenza bacillus. A 
comparatively mild form of conjunctivitis is due to the Micrococcus 
catarrhalis, and is often accompanied by rhinopharyngitis. Conjunc- 
tivitis may also be caused by the presence of the meningococcus, Bac- 
terium coli (Axenfeld), ozena bacillus, and Bacillus subtilis (Gourfein). 
Symptoms.-The secretion is at first watery, and, by running over 
the edge of the lids, may excoriate the surrounding skin, which shows 
injection of its superficial veins. In certain individuals the lids, espe- 
cially along their palpebral margins, are slightly edematous. 
The secretion soon becomes mucous or mucopurulent, and, according 
to the grade of the inflammation, gathers in a slightly frothy material 
only at the commissural angles, or is more freely secreted. 
There are a general hyperemia and loss in the transparency of the 
tarsal conjunctiva, in which the posterior conjunctival vessels (System I) 
are concerned, and later of the fornix, caruncle, and semilunar folds. 
Although vision is not usually affected, some secretion may be ad- 
herent to the cornea and produce the same haziness in sight that would 
be present on looking through a dirty glass; and artificial lights, which 
are most uncomfortable at all times, appear fringed with colored borders. 
Photophobia may be entirely absent, or exist in marked degree in 
those varieties which complicate measles, or which are associated with 
the development of small superficial ulcers on the cornea. All ages of 190 
DISEASES OF THE CONJUNCTIVA 
life are liable to catarrhal conjunctivitis, but the majority of cases are 
seen in children and young people. 
Prognosis and Duration.-The prognosis is perfectly good, and the 
process will usually subside in a few days. One or both eyes may be 
affected. 
Acute Contagious Conjunctivitis {Acute Mucopurulent Conjunc- 
tivitis; Epidemic Conjunctival Catarrh; "Pink Eye"; Koch-Weeks' Bacillus 
Conjunctivitis).-This form of conjunctivitis may be classified as the 
severe and epidemic type of the variety of conjunctival affection just 
described. By some writers it is considered as a distinct disease. 
Etiology.-The majority of cases are caused by a small bacillus 
discovered independently by Koch in the acute conjunctivitis of Egypt, 
and by Dr. John E. Weeks in New York, and studied by Morax and 
others in Europe. This bacillus resembles that of mouse-septicemia, 
and measures 1 to 2 y in length and about 0.25 y in breadth. It is 
often associated with a clubbed bacillus (xerosis bacillus). It stains 
readily with ordinary anilin dyes. Some observers have maintained, 
but have not demonstrated, that the Koch-Weeks' bacillus and the 
influenza bacillus are identical, and that acute contagious conjunctivitis 
is a manifestation of influenza. The disease may occur at any age, ex- 
cept perhaps during the first few days of life, and is widespread over the 
world. It is commonest in warm and changeable weather (the fall and 
spring), is markedly contagious, and will pass rapidly from one member 
of a household to another. 
Symptoms.-The period of incubation is about thirty-six hours, 
and the disease begins with the symptoms of a mild catarrhal con- 
junctivitis, but usually on the third day develops into a severe form of 
conjunctivitis, in which the entire conjunctiva is deeply injected and 
small hemorrhages may be observed {hemorrhagic catarrhal conjunctivitis), 
the swelling of the conjunctival membrane being noticeable in opaque 
velvety layers, especially in the region of the retrotarsal fold. Some- 
times the bulbar conjunctiva is chemotic, sometimes brightly injected. 
The lids are glued together in the morning, and occasionally they are 
decidedly swollen and edematous; the eyes are hot and heavy, and feel 
as though they contained sand. The secretion is at first thick and ropy, 
and may be gathered into long strings of mucopus. Later, in some 
cases, the discharge becomes distinctly purulent. The acute stage lasts 
from four to ten days, and recovery may be expected in about two weeks. 
Toward the end of the disease, or in what may be known as the subacute 
stage, the retrotarsal folds are swollen and the papillary body is enlarged. 
Follicular hypertrophy is at times also observed, and if care is not taken 
the affection may last for a long time. Both eyes are almost always 
involved, sometimes simultaneously and sometimes one a day or two in 
advance of its fellow. Corneal complications are rare, but occasionally 
occur (Morax, Shumway). Hypopyon has been observed (Morax). 
Diagnosis and Prognosis.-The actual diagnosis depends upon 
microscopic examination and the finding of the specific micro-organism, 
but the clinical signs are very striking, particularly the character of the INFLUENZA-BACILLUS CONJUNCTIVITIS 
191 
secretion, with its tendency to gather in yellowish masses toward the 
inner canthus. If the disease is known to be epidemic at the time, or if 
it is shown to have passed from one member of the family to another, the 
diagnosis becomes still more certain. 
The prognosis is good in the majority of the cases, although relapses 
and recurrences are common, and one attack does not create immunity. 
The affection through neglect, however, may prove exceedingly trouble- 
some, and tends to attack all members of a household, a fact which, in 
asylums and similar institutions, may prove of serious import. 
Pneumococcus Conjunctivitis.-This form of conjunctivitis, due 
to the Frankel-Weichselbaum diplococcus (pneumococcus), was orig- 
inally described by Parinaud and Morax, and was supposed by them 
to be an affection of early childhood; indeed, it is more common in 
children than in adults, but no age of life is exempt. While it is not as 
contagious as the Koch-Weeks' bacillus conjunctivitis, its contagious 
nature is well established, and it may be transferred from one eye to 
another, from one person to a second, and as Gasparrini, Harold Gifford, 
Veasey, the author, and a number of other observers have noted, may 
appear in epidemic form, although not so extensively or frequently as 
the Koch-Weeks' conjunctivitis. According to Axenfeld, it is more 
prevalent in northern countries and in cold months of the year than 
other forms of mucopurulent conjunctivitis. Very rarely it is asso- 
ciated with pneumonia; a coryza may accompany or precede it. 
Symptoms.-Usually it begins as an ordinary conjunctivitis, the 
conjunctiva being reddened and secreting a rather thin mucopurulent 
discharge, in which small flocculent masses float. The upper lid is 
edematous and pinkish in color, the lashes lightly matted, and later the 
discharge becomes thicker and more purulent, and sometimes resembles, 
in severe cases, that found in purulent conjunctivitis. Small subcon- 
junctival hemorrhages may appear. The clinical manifestations of 
this form of conjunctivitis are often difficult to distinguish from Koch- 
Weeks' bacillus conjunctivitis. According to Gasparrini, in pneumo- 
coccusconjunctivitis a fine pellicle of fibrin can be wiped from the everted 
upper tarsus, which is not met with in Weeks' bacillus conjunctivitis. 
Generally the disease lasts from six to ten days, and the prognosis is 
favorable; rarely corneal complications have been noted; occasionally 
iritis develops, due to absorption of the toxin, without implication of the 
cornea (Axenfeld). 
Influenza=bacillus Conjunctivitis.-This form of conjunctivitis, 
due to the influenza bacillus (Pfeiffer's bacillus), has been especially 
studied by Zur Nedden, Morax, Jundell, and, in this country, by Arnold 
Knapp. Clinically, the manifestations of the disease are not severe; it 
is characterized by a copious, thin discharge, and affects chiefly the con- 
junctiva of the lids and retrotarsal folds. The majority of cases have 
occurred in young children and infants, in whom it is more severe than 
in adults, who are rarely attacked. Although the local disease presents 
a favorable prognosis, and usually disappears in from ten to fourteen 
days, it may be associated with rhinotracheitis, dacryocystitis, and 192 
DISEASES OF THE CONJUNCTIVA 
inflammation of the middle ear. Arnold Knapp has described a 'pseudo- 
membranous form of influenza bacillus conjunctivitis of great severity, 
which may cause perforation of the cornea. 
Swimming=bath Conjunctivitis.-This form of conjunctivitis is 
encountered not infrequently among those who frequent public baths. 
In many instances the symptoms are analogous to those which occur in 
catarrhal conjunctivitis, although the discharge is less abundant. Often 
the bulbar conjunctiva is coarsely injected. In two local epidemics of 
this disease in two large schools equipped with swimming-pools inves- 
tigated by the author the micro- 
organism found was in one in- 
stance the pneumococcus, and 
in another an unidentified ba- 
cillus. Sometimes the affection 
resembles acute trachoma, and 
Paderstein has been able to 
demonstrate "inclusion bodies." 
Diplobacillus Conjunctiv= 
itis (Morax-Axenfeld Bacillus 
Conjunctivitis, Angular Conjunc- 
tivitis, Subacute Conjunctivitis). 
-This form of conjunctivitis, 
due to a diplobacillus 2 to 3 p 
in breadth, often occurring in 
chains, was originally described 
by Morax and by Axenfeld 
abroad, and later was studied 
by Harold Gifford in this 
country. 
Symptoms.-One variety of the disease is insidious in character, 
and runs a rather tedious course, during which the main symptoms are 
redness and slight induration of the edges of the lids, particularly of 
the commissural angles, and congestion of the neighboring conjunctiva. 
In other words, the signs are those of a blepharoconjunctivitis. The 
abnormal secretion is grayish white and not abundant, and has a tend- 
ency to adhere to the reddened lid margins and to gather in small 
masses at the angles, especially the inner one. This clinical manifes- 
tation is so constant that it is well-nigh characteristic, and if there is 
any doubt, the diagnosis is readily established by finding the bacillus 
in the secretion. Occasionally these manifestations give place to an 
acute form, or the inflammation may be confined to the conjunctiva 
without special participation of the lid angle, or the disease may resemble 
an acute conjunctival catarrh with swelling. According to McKee, it 
may vary from a mild hyperemia of the conjunctiva to a severe muco- 
purulent conjunctivitis. Morax-Axenfeld conjunctivitis may attack 
persons of all ages, but is more common in adults than in young persons. 
It is widely distributed over the world. It may arise at any season, 
but is said to be more frequent in summer than during cold weather. 
Fig. 101.-The diplobacillus of Morax and 
Axenfeld (from a preparation by Dr. Harold 
Gifford). DIPLOBACILLUS CONJUNCTIVITIS 
193 
McKee, however, found the greatest number of cases in January. 
Diplobacillary conjunctivitis may be accompanied by a nasal catarrh, 
and the diplobacilli are found in the nasal secretion. 
Ordinarily the disease lasts from six weeks to six months, but if 
improperly treated may remain for much longer periods of time. Its 
duration is readily shortened by proper treatment. It may be asso- 
ciated with follicular and phlyctenular conjunctivitis, and corneal 
complications may arise, either in the form of superficial infiltrations or 
deep ulcers, from which the bacillus may be cultivated {diplobacillary 
keratitis). Iritis without corneal implication has been observed 
(Ernest Thomson). Occasionally these ulcers are complicated with 
hypopyon and iritis (L. Paul). Petit has isolated a bacillus closely 
allied to the Morax-Axenfeld organism which can produce a conjunc- 
tivitis like the one just described, and is also capable of originating 
hypopyon-keratitis. 
The Bacillus pyocyaneus sometimes causes a conjunctivitis which 
yields to zinc sulphate (Brown Pusey). 
Treatment of Conjunctivitis.-(a) Simple Conjunctivitis.-This 
consists, first, in search for the cause and the alleviation of associated 
conditions. The patient must be removed from the influence of dust, 
cold winds, tobacco-smoke, and the like; the under surfaces of the lids 
should be examined for foreign bodies, and their borders for misplaced 
cilia. In the earlier stages cold compresses are agreeable and suitable; 
sometimes frequent bathings with hot water are more acceptable. At 
first a solution of boric acid, as collyrium or spray-gr. x to f 5 j (0.65 
gm. to 30 c.c.) is useful. The eyelids and ciliary margins should be 
frequently washed with water and Castile soap. 
As soon as the discharge becomes mucous or mucopurulent and the 
velvety opacity of the conjunctiva forms, a stronger solution of boric 
acid, to which a few grains of common salt may be added, is advisable; 
and the everted lids may be painted with a solution of nitrate of silver, 
gr. v-x to f 5 j (0.324-0.65 gm. to 30 c.c.), and suitably neutralized. 
In place of nitrate of silver, protargol (5-20 per cent.) and argyrol 
(10-25 per cent.) are frequently employed. In mild cases one or two 
applications a day are sufficient, the drug being dropped into the con- 
junctival sac and allowed to spread freely over the inflamed membrane. 
Argentamin (2-5 per cent.) and largin (10 per cent.) are also recom- 
mended. In severe types, with a considerable discharge, bichlorid of 
mercury (1 : 8000-10,000) and cyanid of mercury (1 : 2000) are valuable 
collyria. 
Other preparations which have found favor are alum, gr. iv-viij 
to f 5 j (0.26-0.52 gm. to 30 c.c.), sulphate of zinc, gr. ij to f 5 j (0.13 
gm. to 30 c.c.), which may be suitably combined with boric acid, 
biborate of sodium, gr. iv-viij to f 5j (0.26-0.52 gm. to 30 c.c.), per- 
oxid of hydrogen, Panas' fluid, creolin (1 per cent.), and other anti- 
septic collyria. Should the thickening of the retrotarsal folds prove 
stubborn, after the acute symptoms have subsided, these may be 
touched with an alum crystal or a solution of tannin and glycerin. 
13 194 
DISEASES OF THE CONJUNCTIVA 
Atropin is not usually necessary unless a corneal ulcer complicates 
the affection. 
The eyes may be protected with smoked glasses, but in no circum- 
stances should they be bandaged or be covered with poultices of tea- 
leaves (which of themselves may produce conjunctivitis-"tea-leaf con- 
junctivitis"), bread and milk, scraped potatoes, and the like. It should 
be remembered that meddlesome domestic medication of this sort may 
change a simple conjunctivitis into a serious and purulent inflammation. 
At the outset a laxative, followed by full doses of quinin, is indicated; 
any associated disease of which the conjunctivitis may be a symptom- 
e. g., rhinitis-requires the usual treatment. Proper hygiene, fresh air, 
strict cleanliness, and protection from contaminated towels, etc., are 
evident indications. 
(6) Acute Contagious Conjunctivitis.-The treatment does not 
differ from that which has already been described in connection with 
simple conjunctivitis. Weeks recommends bichlorid of mercury (1: 
10,000) as a collyrium. Usually argyrol and protargol are prescribed, 
and they may act efficiently, but it is a mistake to permit patients 
themselves to use these preparations for long periods of time. As 
Risley has aptly said, they may originate a new set of conjunctival 
catarrhs, and give rise to a troublesome, tumid, hyperemic condition of 
the conjunctiva; also they may stain the membrane. Applications of 
nitrate of silver, in the usual manner, to the everted lids are useful. 
Iced compresses afford relief during the height of the affection. In 
place of the ordinary collyria, chlorid of zinc, 1 grain (0.065 gm.) to 
the ounce (30 c.c.), is highly commended; sulphate of zinc, gr. ij to 
f gj (0.13 gm. to 30 c.c.), is also valuable. 
(c) Pneumococcus Conjunctivitis.-In this affection the treatment 
already described in the preceding paragraphs is efficient. Sulphate of 
zinc drops are especially useful. 
(di) Influenza-bacillus Conjunctivitis.-1The usual collyria and anti- 
septics are advisable. Zur Nedden recommends nitrate of silver (1.5-2 
per cent.), oxycyanid of mercury (1 : 1500), and iced compresses. 
(e) Diplobacillus Conjunctivitis.-In this disease the preparations of 
zinc are practically specifics. They may be employed in the form of the 
sulphate (0.5-2.5 per cent.) or the chlorid (0.2 per cent.). Nitrate of 
silver, argyrol, and protargol, in contradistinction to their valuable action 
in other varieties of conjunctivitis, are of no use. Todd recommends 
sozoiodolate of zinc (1-2 per cent.) and ichthyol ointment (10 per cent.). 
Catarrhal Epidemic Conjunctivitis (Catarrh with Swelling; Epi- 
demic Catarrh).-Certain systematic writers, notably Saemisch and 
Schmidt-Rimpler, although they consider this disease to be a form of 
acute conjunctival catarrh, give it a separate description on account of 
certain distinguishing features, namely, swelling not only of the lid 
margin, but of the entire lid itself, which seems to be increased in volume 
and is reddened, together with tumefaction, infiltration, and marked 
hyperemia of the retrotarsal folds. The secretion is considerable in quan- 
tity, mucopurulent in character, and often mixed with small fibrinous CONJUNCTIVITIS NEONATORUM 
195 
masses. Both eyes are usually affected, and persons of any age may be 
attacked. It has appeared with especial frequency among scrofulous 
children, especially if they are also the subjects of exanthematous dis- 
ease of the face. The secretion should be considered as distinctly con- 
tagious, and the disease has appeared in the form of small epidemics. 
Sometimes it has been the sequel of influenza. In the secretion, pneu- 
mococci, staphylococci, and streptococci have been found. The treat- 
ment should include thorough irrigation of the conjunctival sac with 
bichlorid of mercury (1 :8000), cyanid of mercury (1 : 1500), or a satu- 
rated solution of boric acid. The swollen and inflamed retrotarsal folds 
may be treated with applications of 1 to 2 per cent, solutions of nitrate 
of silver in the usual manner, or in their place protargol and argyrol may 
be employed. 
Exanthematous Conjunctivitis.-This form of conjunctivitis 
has been briefly referred to in connection with catarrhs of the conjunc- 
tiva, and is particularly noteworthy as part of the manifestations of 
measles, scarlet fever, and small-pox. The disease may not only ac- 
company these exanthems, but often arises prior to their eruption. 
Small-pox pustules sometimes develop on the conjunctiva. Occasionally 
the conjunctivitis of measles assumes a very severe type, so severe that 
it may resemble a blennorrhea, and Fuchs has noted under these con- 
ditions a suppurative inflammation of the Meibomian glands. The 
investigations of Schottelius indicated that staphylococci and strepto- 
cocci are active in the conjunctivitis of measles, streptococci being 
especially common in fatal cases. 
Among the chronic exanthemata of the conjunctiva, acne rosacea 
is important (see also page 189), and in this disease minute nodules 
may form with marked irritation near the limbus. The conjunctiva 
may also be implicated in pityriasis, psoriasis, and herpes iris. Its 
involvement in syphilis, pemphigus, lupus, and lepra is elsewhere de- 
scribed. 
Treatment.-The treatment of exanthematous conjunctivitis does 
not differ from that of the catarrhal form of the affection and its varie- 
ties. Fuchs recommends the local application of calomel as especially 
valuable in acne rosacea of the conjunctiva. 
A very rare form of conjunctivitis or conjunctival disease is 
"squirrel plague conjunctivitis," described by Derrick Vail and 
Robert Sattler, due to an infection with the Bacillus tularense, iden- 
tified by McCoy and Chapin as the germ of squirrel plague. In Vail's 
patient the symptoms were: intense chemosis, mucoid secretion, en- 
larged preauricular glands, and deep yellow necrotic ulcers in the 
palpebral conjunctiva. 
Purulent conjunctivitis (acute blennorrhea of the conjunctiva') occurs 
in three specific forms: in the newborn (ophthalmia neonatorum), in 
young girls (occasionally boys), and in adults (gonorrheal conjunctivitis 
or ophthalmia). 
Conjunctivitis Neonatorum (Ophthalmia Neonatorum).-This is 
an inflammation of the conjunctiva, characterized, in its usual form, by 196 
DISEASES OF THE CONJUNCTIVA 
great swelling of the lids, serous infiltration of the bulbar conjunctiva, 
and the free secretion of contagious pus. 
Causes.-The affection is most frequently caused by the introduc- 
tion into the eye of the infecting material from some portion of the 
genito-urinary tract of the mother at the time of or shortly after 
birth. The majority of cases (60-70 per cent.) are associated with a 
special micro-organism-the gonococcus of Neisser. Exceptionally, in- 
oculation occurs in utero, owing to the penetrating power of the gono- 
coccus or to infection after rupture of the membranes (antepartum con- 
jiinctimtisf 
Many observers have demonstrated that ophthalmia neonatorum 
is not always gonorrheal in origin, but may be produced by various 
kinds of micro-organisms-pneumococcus, streptococcus, diplobacillus, 
Bacterium coli, and Staphylococcus albus, aureus, and citreus. It is 
possible that some forms of conjunctivitis neonatorum are really types 
of influenza-bacillus conjunctivitis. According to Stephenson, next to 
the gonococcus the pneumococcus is the commonest organism found 
with ophthalmia neonatorum. Inclusion-blennorrhea of the newborn is 
referred to elsewhere (see page 203). 
Inasmuch as the gonococcus is not invariably present, two forms of 
the disease have been distinguished-a severe type, caused by the 
gonococcus, with a tendency to increase in severity and invade the 
cornea; and a milder type, non-specific, with a tendency to recover. 
Hence, a virulent vaginal discharge is not necessary to produce this 
condition, except in intense degree, and it probably may arise from the 
contamination of any mucopurulent discharge during birth, and from 
injudicious intra vaginal antisepsis with strong solutions of mercuric 
chlorid. Careless bathing of the child after birth and the use of soiled 
towels and sponges are fruitful sources of infection. Contact with the 
lochial discharge may originate the disorder, although inoculation with 
healthy lochia has failed to produce the disease. 
The exact time of inoculation has not been determined. Infection 
is more likely to occur in face presentations and during retarded labors. 
Boys are attacked more frequently than girls. The disease is said to 
be more common during summer months in cold climates; in hot coun- 
tries, during the spring and autumn. 
Symptoms.-Conjunctivitis neonatorum usually begins on the 
third day after birth, but may set in as early as from twelve to forty- 
eight hours after inoculation, or, when it is the result of a secondary 
infection from soiled fingers, sponges, or clothes, be delayed to a much 
later date. Late gonococcic infections have been explained by Crede- 
Horder on the assumption that the Neisser organisms do not find their 
way directly into the conjunctival sac during birth, but may be hidden, 
for example, in Meibomian glands. Non-gonorrheal cases do not usually 
arise until after the fifth to the seventh day. Almost always both eyes 
suffer, the one being earlier and frequently more decidedly affected than 
its fellow. 
Four stages of the disease are common, but as these vary in different CONJUNCTIVITIS NEONATORUM 
197 
cases, and more or less rapidly shade one into the other, no very sharp 
lines need be drawn. 
A slight redness of the conjunctiva, with a trifling discharge in the 
corner of the eye, is rapidly succeeded by great, cushion-like swelling 
of the lids, with intense chemosis and congestion of the conjunctiva, 
accompanied by severe pain and discharge. The surface of the swollen 
lid is hot, dusky red, and tense; the upper lid overhangs the lower, and 
at first can be everted only with difficulty. The discharge, which in the 
beginning is slightly turbid, soon changes to a yellow or greenish-yellow 
pus, and is secreted in great quantities. 
If the lids are everted during the first day or two of the disease, the 
conjunctiva will be found to be swollen, red, and velvety, and that 
upon the eyeball intensely injected; upon the surface easily detached 
Fig. 102.-Conjunctivitis neonatorum (from a patient in the Philadelphia General Hos- 
pital). 
flakes of lymph are found; later, the conjunctiva becomes rough and of a 
dark-red color, spots of ecchymosis appear, or it is succulent and bleeds 
easily. Marked chemosis and infiltration of the ocular conjunctiva 
succeed, forming a hard rim; at the bottom of the crater-like pit thus 
produced the cornea may be seen. The thick, cream-like discharge 
increases, and either flows out from beneath the overhanging upper lid 
on to the cheek or is packed up in the conjunctival culdesac (Fig. 102). 
Sometimes false membrane forms and covers the tarsal conjunctiva; 
indeed, the appearances may be exactly like those of a membranous 
conjunctivitis. 
The lids now may lose much of their tense character, and can be 
more easily everted; the conjunctiva is puckered into folds and papilla- 
like elevations, and the discharge contains an admixture of blood and 
serum. Gradually the disease declines, and in from six to eight weeks 198 
DISEASES OF THE CONJUNCTIVA 
the discharge ceases. The relaxed palpebral conjunctiva is thick and 
granular, looking like the granulation tissue which surrounds wounds. 
The ocular conjunctiva is also thickened, and positive cicatricial changes 
may remain. 
The chief risk is destruction of the vitality of the cornea, the danger 
of which is materially increased if this membrane becomes lusterless, 
dull, and hazy within the first day or two of the disease, and the gono- 
coccus is freely present in the discharge. Frequently small oval ulcers 
form near the limbus, either transparent or surrounded by an area of 
cloudy infiltration, which rapidly increase in size; or larger areas of ulcer- 
ation develop in a more central situation. In many mild cases the cornea 
escapes without harm. The changes which take place in the cornea are 
due in part to strangulation of its nutrient vessels by the swollen tissue, 
but largely to direct infection by the discharge. Corneal lesions do not 
usually occur in eyes if the discharge is free from gonococci. 
After the formation of a corneal ulcer, either its healing and regen- 
eration of the corneal tissue takes place or else perforation occurs. 
The result of perforation will depend upon the amount and character 
of the destruction of the corneal tissue. If the ulcer is central and per- 
forates, the aqueous humor escapes, the lens is pressed forward against 
the posterior surface of the cornea, and the opening becomes closed with 
lymph. Restoration of the anterior chamber follows, and the lens re- 
turns to its proper position, carrying with it upon the anterior capsule 
a little mass of lymph. Thus the formation of a pyramidal cataract 
results (see page 404). Fuchs maintains that in the formation of opaci- 
ties following corneal suppuration the lens epithelium is rarefied by 
destruction of the cells; later there is proliferation of the remaining cells 
and capsular cataract results. 
Perforation of an ulcer peripherally situated, especially below, is 
followed by adhesion of the iris to the opening. The aqueous escapes, 
and, as the iris and the lens fall forward, the former becomes entangled 
in the perforation and is fixed by inflammatory exudation. The adhe- 
sion is either on the posterior surface or in the cicatrix, and the resulting 
dense white scar receives the name adherent leukoma. 
If the region of the scar is bulged forward because it is unable to 
resist the intra-ocular tension, anterior staphyloma results. Extensive 
sloughing of the corneal tissue, with total prolapse of the iris, matting 
together of the parts by exudation, and protrusion of the cicatrix con- 
stitute a total anterior staphyloma. 
Finally, perforation may be followed by inflammatory involve- 
ment of the ciliary body and choroid, and the rapid destruction of the 
eye through panophthalmitis, or a slower shrinking of the tissues, with 
atrophy of the bulb. Dense opacity occasionally appears in the cornea 
during convalescence, and may go on to ulceration or clear up perfectly. 
It may arise with great suddenness, and, should it occur in the lower 
half of the cornea, a deep indentation, owing to the pressure of the 
margin of the lid, is likely to occur. 
The appearance of the conjunctiva differs materially in different CONJUNCTIVITIS NEONATORUM 
199 
cases. Its surface may be covered over not merely with easily detached 
flakes of lymph, but with a gray, false membrane. More rarely a deep 
infiltration develops, like that seen in diphtheritic conjunctivitis. 
Restlessness, fever, and other constitutional disturbances are 
sometimes present, and synovitis of the knee and wrists may arise, of 
the same character as arthritis occurring in adults during gonorrhea. 
Rhinitis, infection of the lacrimal gland, meningitis, endocarditis, and 
general septicemia have been reported as complications of ophthalmia 
neonatorum. In rare instances pneumococcus conjunctivitis neona- 
torum may be associated in the second week with inflammation of the 
knee-joint (Stephenson). 
Conjunctivitis neonatorum does not always follow this course, be- 
cause the term is made to include affections of the conjunctiva in the 
newborn other than the types just described-mild catarrhal con- 
junctivitis, hyperemias, and that variety which, according to Noyes, 
presents the character of a granular, rather than of a purulent, con- 
junctivitis, and which may continue for weeks without danger of cor- 
neal complication. Occasionally a gonococcal conjunctivitis pursues 
the course of a simple conjunctival catarrh (Groenouw). Furthermore, 
as Saemisch has said, purulent conjunctivitis may develop in newborn 
children not due to the gonococcus (see also page 196), but caused either 
by other virulent bacteria or by non-bacterial agents. Necessarily the 
manifestations are less violent than those of gonococcal origin, and for 
these varieties the name acute blennorrhagic conjunctivitis neonatorum 
has been suggested. 
Some hyperemia of the conjunctiva, with a little yellowish dis- 
charge in the corners of the eye and slight swelling of the lower lid, is 
common in babies for a few days after birth. 
Diagnosis.-The onset and character of the typical disease, its 
symptoms and course, render a mistake in regard to its nature practically 
impossible. Close attention should be given to what at first appears to 
be a trivial inflammation in the eyes of a newborn child, because a viru- 
lent and destructive inflammation may follow with great rapidity. 
Bacteriologic examination of the secretion is essential, and the findings 
will determine the true character of the disease. 
Prognosis.-This is always grave in gonorrheal cases, but with 
competent medical attendance, if the eye is seen while the cornea is still 
clear, except in diphtheritic types, in those with inherent malignancy 
(Randall), or where depreciation of nutrition or intercurrent illness 
diminish the resisting power of the child, the majority of cases should 
be brought to a successful termination. Hence the attendants of new- 
born children should be compelled to seek medical advice as soon as 
conjunctival trouble appears, for delayed or improper treatment means 
sloughing of the cornea, when no form of medication can do more than 
relieve the violence of the inflammation, which, after it subsides, leaves 
the child with sight hopelessly marred, perhaps destroyed. The prog- 
nosis of the mild types is favorable. 
Prophylaxis.-The present high standard of scientific midwifery 200 
DISEASES OF THE CONJUNCTIVA 
includes such cautious antisepsis during labor that the risk of con- 
tamination is distinctly less than in former times, but still some pre- 
ventive method should be employed. 
The eyes of those children who have passed through a birth-canal 
knowm to be infected, or from which the suspicion of infection cannot 
positively be eliminated prior to birth, may be treated according to 
the method of Crede, which is as follows: As soon as the head is born 
the lids are carefully cleansed, parted, and two drops of a 2 per cent, 
solution of nitrate of silver are instilled into each conjunctival sac. 
Small cold compresses are then laid upon the lids and renewed at suit- 
able intervals. Occasionally severe reaction follows-conjunctival 
hyperemia or catarrh (the so-called "silver catarrh''), and even hemor- 
rhage from the conjunctiva and corneal haze. Hence it is not necessary 
to employ this method in all cases, and even in those in which it is indi- 
cated a 1 per cent, solution of nitrate of silver is sufficient. Wherever 
infection, or the suspicion of infection, can be excluded, milder measures 
-for example, washing the eyes and flushing them with a saturated 
boric acid solution-are sufficient. In place of a 2 per cent, solution of 
nitrate of silver a 1 : 500 solution may be used. Other materials recom- 
mended are aqua chlorini (Schmidt-Rimpler), sophol (5 per cent.) 
(von Herff, R. M. Williams), bichlorid of mercury (1 :5000), carbolic 
acid (1 per cent.), and the newer silver salts, especially argyrol (25 per 
cent.) and protargol (10 per cent.). The last-named remedies are not 
to be trusted in the management of eyes which have been exposed to 
gonorrheal infection. The value of Crede's method is so firmly estab- 
lished that it should not be neglected if the birth-canal is known to be 
infected with gonorrhea, or if the suspicion of infection cannot be ex- 
cluded. In its place a 5 per cent, solution of sophol has been highly 
recommended. Axenfeld advises its use "instead of the formerly em- 
ployed Crede's silver drops." With this drug the author has had no 
experience. The hands of the mother, nurse, and child should be 
searched for sources of infection, and, if gonorrhea is known to exist in 
the mother, the child should be isolated. Conjunctivitis neonatorum 
should be listed as a reportable disease, and laws should be enacted to 
this effect, and these laws should be rigidly enforced, and it should be 
possible to provide the affected children with expert attention at their 
homes or, even better, with hospital accommodations. The distribu- 
tion by health boards of circulars of advice to midwives and mothers 
and of tubes containing the chosen prophylactic, to those who are 
qualified to use it (preferably a 1 per cent, solution of nitrate of 
silver), should be required (F. Park Lewis, J. Clifton Edgar, and F. F. 
Wesbrook). As ophthalmia neonatorum is the cause of fully 8 per 
cent, of blindness in this country, all efforts to check the ravages of 
this disease cannot too strongly be emphasized. 
Treatment.-If the type is mild, the applications described under 
simple conjunctivitis are indicated; if severe, three conditions demand 
attention: the inflammatory swelling of the lids, the state of the con- 
junctiva, and the corneal complications. CONJUNCTIVITIS NEONATORUM 
201 
1. During the earlier states, when the lids are tense and the secretion 
lacking in its later creamy character, in addition to absolute cleanliness, 
local application of cold is a useful agent in a certain number of cases. 
This should be applied in the following manner: Upon a block of ice 
square compresses of gauze are laid, which, in turn, are placed upon the 
swollen lids, and as frequently changed as may be needful to keep up a 
uniform cold impression. This is far preferable to the use of small 
bladders containing crushed ice; indeed, the use of ice is not advisable. 
The length of time occupied with these cold applications must vary 
according to the severity of the case. Sometimes they may be used 
almost continuously, and sometimes every three or four hours for twenty 
minutes at a time. Standish and other surgeons deny the value of the 
use of cold in this manner, believing that it adds to the danger of corneal 
complications. This is entirely contrary to the author's experience. 
It must be emphasized, however, that it requires a good deal of 
experience to know when to use and when not to use cold, and not all 
cases are suited to its application. Hot fomentations have been ad- 
vised, especially where corneal complications exist, or the surface of 
the conjunctiva is covered with a gray film. These are applied with 
squares of antiseptic gauze wrung out in carbolized water of a temper- 
ature of 120° F., and frequently changed. The author, basing his 
opinion on a large experience in the Philadelphia General Hospital, 
doubts their efficiency. 
2. Constant removal of the discharge must be practised. 
The lids are to be gently separated, the tenacious secretion wiped 
away with bits of moistened lint or absorbent cotton, and the con- 
junctival sac gently but freely irrigated with an antiseptic fluid. For 
this purpose a saturated solution of boric acid (which is feebly anti- 
septic, but very cleansing and slightly astringent) or one of corrosive 
sublimate, 1 grain to 1 pint-0.065 gm. to 480 c.c. (strong solutions 
should not be used, because they may injure the corneal epithelium 
and cause ulceration), may be employed. Special and ingenious forms 
of lid irrigators have been devised, but are unnecessary and often 
harmful. The cleansing process must be repeated at least every hour, 
day and night, and, if necessary, much more frequently; but all manip- 
ulations must be most gentle and all caution not to injure the delicate 
structures of the eye must be maintained. 
3. The application of one of the salts of silver. 
Until comparatively recent times nitrate of silver was almost uni- 
versally employed, a drug combining the properties of an astringent and 
a superficial caustic. Its germicidal power, however, is not of much 
avail, as this is quickly impaired by contact with the tissue proteins. 
Once a day the palpebral conjunctiva and retrotarsal folds should be 
brushed over with a solution, 10 grains (0.65 gm.) to the ounce (30 
c.c.) their surfaces first having been carefully freed from any adherent 
discharge, and afterward all excess of the drug washed away with a 
solution of common salt, and this washing continued until a clean red 
surface is secured, when the lids may be returned to their proper posi- 202 
DISEASES OF THE CONJUNCTIVA 
tion, their margins greased with vaselin, and some of the lubricant 
introduced within the conjunctival culdesac. Great care must be 
exercised that the corneal epithelium shall not be injured. Ulceration 
of the cornea does not alter the treatment described. As long as the 
discharge is abundant the use of the caustic is indicated, and it may 
be employed from the very beginning of the disease unless the con- 
junctiva is covered with a false membrane, which would prevent its 
access to the conjunctival folds. 
Within the last few years protargol and argyrol have largely replaced 
nitrate of silver in the treatment of ophthalmia neonatorum in the prac- 
tice of many surgeons, and for noteworthy reports on their efficiency we 
are largely indebted to Myles Standish. His routine treatment is as 
follows: The edges of the lids are washed with a solution of boric acid 
once in half an hour, and they are anointed with vaselin to prevent them 
from sticking together. A solution of protargol or argyrol is instilled 
freely between the lids at intervals of from every hour to once in four 
hours. This fluid sinks to the bottom of the culdesac and floats to the 
surface the pus and mucus, which can readily be removed with a very 
slight amount of manipulation. Protargol has been used in strengths 
varying from 10 to 40 per cent., the 10 per cent, solution yielding the 
best results. Of argyrol, a 25 per cent, solution proved to be satis- 
factory. Henry D. Bruns recommends a 10 per cent, solution of argyrol 
to be used freely every half-hour until pus secretion is checked. Then 
he applies in the usual manner nitrate of silver (0.2-1.0 per cent.) once 
a day. Many other surgeons, both here and abroad, employ these drugs 
in a similar manner. According to Stephenson, in gonorrheal ophthal- 
mia neonatorum a 25 per cent, solution of argyrol painted once or twice 
a day over the conjunctiva, exposed for that purpose by eversion of the 
lids and carefully dried from adherent discharge, with the frequent use 
by instillation of the 25 per cent, or of a weaker solution, represents a 
method of treatment more promptly efficacious than any other with 
which he is acquainted. 
The author's experience is in accord with the good results ascribed 
to the methods of using argyrol just described, only in so far as the com- 
paratively mild cases of ophthalmia neonatorum are concerned in which 
this drug achieves good results, not because its action is more efficient 
in controlling the disease than that of nitrate of silver, but because it is 
more easily applied, is less irritating, and has a marked detergent effect, 
driving the secretion before it. In a number of cases the argyrol treat- 
ment will not be sufficient, and nitrate of silver must be used, especially, 
as Bruns recommends, in addition to or after the use of argyrol. The 
author is entirely unconvinced that argyrol should replace nitrate of 
silver, although he practically employs it as part of the treatment in 
suitable cases.1 Protargol possesses no advantages over nitrate of silver. 
1 The author is well aware that many surgeons deprecate the use of nitrate of silver 
in these circumstances. George Derby, for example, thinks the reaction in gonorrheal 
conjunctivitis is too great to permit its use and that its bactericidal power cannot assail 
the deep-seated gonococci. He prefers mild remedies, e. g., argyrol. E. B. Heckel reports 
excellent results from constant irrigation alone with iced physiologic salt solution. PURULENT CONJUNCTIVITIS IN YOUNG GIRLS 
203 
At the first appearance of corneal haze one drop of a 0.5 per cent, 
solution of atropin is to be dropped into the eye two or three times daily. 
During corneal complications Darier recommends a collyrium contain- 
ing dionin, pilocarpin, and cyanid of mercury. 
Persistent swelling of the conjunctiva is sometimes treated by scari- 
fication. Division of the outer commissure to relieve pressure is not 
suited to young infants, although it may be indicated in adults. 
If one eye alone is affected, suitable protection for the sound eye 
should be provided. This may be accomplished by antiseptic bandag- 
ing of the uninflamed organ (Buller's shield is difficult of application in 
infants). 
The attendants must be impressed with the fact that upon their 
faithful carrying out of directions, and upon their unremitting care, 
much, if not all, of the hope of bringing the case to a successful termina- 
tion depends. The attendants must further be impressed with the con- 
tagious nature of the pus; all bits of rag and pledgets of lint used in the 
treatment must be destroyed, and after each treatment the hands of 
those engaged must be thoroughly washed and disinfected with a 
solution of bichlorid of mercury. 
Many other remedies have been used in the treatment of conjuncti- 
vitis neonatorum; for example, those mentioned on page 193: carbolic 
acid (0.5 to 2 per cent.), iodoform and iodoform ointment (4 per cent.), 
aqua chlorini, cyanid of mercury (1 : 1500), permanganate of potassium 
(1 : 5000), used in copious irrigations, formaldehyd (1 : 5000), and argen- 
tamin (2 per cent.). Darier suggests a 3 per cent, solution of ichthargan 
if protargol loses its effect. Blenolenicet salve has been recommended 
(Adams, Scheuermann), and sophol in 5 per cent, solution (Von Herff). 
Antigonococcus serum has been tried and good results have been 
reported. These remedies do not seem to possess virtues which should 
make them replace those which have been more fully described. 
Inclusion=blennorrhea of the Newborn.-In certain varieties of 
conjunctivitis neonatorum, usually non-gonorrheal and for the most 
part benign in nature, the Giemsa stain will reveal in the secretion "epi- 
thelial inclusions," that is, clusters of small granules, colored violet or 
dark blue, which cap the nucleus like a cowl. According to Axenfeld, 
this "inclusion-blennorrhea" is frequently unilateral, the retrotarsal 
fold is tumid, and if the disease lingers long a granular condition of 
the conjunctiva supervenes. After its subsidence sometimes delicate 
cicatricial tissue remains. Corneal complications are not in evidence. 
Whether these "inclusions" are the cause of this disease is not known 
(see also page 217). 
Purulent Conjunctivitis in Young Girls.-Occasionally young 
girls are the subjects of vaginitis, which in severe forms is associated with 
a purulent discharge, and in hospitals and asylums has occasionally 
assumed the form of an epidemic among the inmates. In a certain per- 
centage of these cases gonococci are present in the discharge, and the 
disease- may be conveyed to the eye by the fingers, or gain entrance into 
the conjunctival sac from discharge adherent to bed-linen, sponges, etc. 204 
DISEASES OF THE CONJUNCTIVA 
There results a purulent conjunctivitis, with symptoms closely re- 
sembling those of ophthalmia neonatorum, although usually the mani- 
festations are less violent, and the corneal complications less likely to 
occur than in the gonorrheal conjunctivitis of adults. To this disease 
the name ophthalmoblennorrhea, or gonoblennorrhea, of young girls has 
been given. The treatment should in all respects conform to that 
which has been described in connection with ophthalmia neonatorum. 
If properly treated, the prognosis is good. 
Gonorrheal conjunctivitis (pundent ophthalmia; acute blennorrhea 
in adults') usually can be traced to its source of contagion from an 
acute gonorrhea or a gleet, by contact with soiled fingers or linen, or 
from an eye affected with this form of conjunctivitis. 
The same micro-organism described in connection with gonorrheal 
ophthalmia neonatorum is active in gonorrheal conjunctivitis, the 
diplococci being found within the cells; later they penetrate the epi- 
thelium and enter the lymph-spaces in the subconjunctival tissue. 
Symptoms.-The first symptoms appear from twelve to forty-eight 
hours after inoculation, and resemble those already recited in connec- 
tion with the same disease occurring in the newborn (see page 196). 
The vitality of the cornea is in constant danger, and involvement 
of this membrane may arise during the height of the attack or later, 
and when convalescence apparently is established. This consists in 
ulcers, small and large, either central or peripheral; in the latter position 
they often exist as grooved rings or small clean-cut lesions without infil- 
tration, hidden by the swelling of the surrounding conjunctiva, and very 
prone to perforate. A more or less dense opacity may follow ulcera- 
tion or arise independently of this condition. 
If perforation occurs, all the phenomena described on page 198 will 
ensue, and even without perforation, iritis, cyclitis, and disease of the 
deeper structures of the eye may develop and defeat the possibility of 
obtaining good vision. 
Gonorrheal conjunctivitis reaches its climax in about ten days and 
then gradually subsides in from one to two months; or it may pass into 
a chronic type and be one of the forms of chronic blennorrhea, in which 
there is general redness of the palpebral conjunctiva, with hypertrophy 
of its superficial layers and some thickening of the papillae. 
Diagnosis.-This is readily made from the history of the case, and, 
above all, by an examination of the secretion for the gonococci. 
Prognosis.-The prognosis is always grave, even more so than in 
conjunctivitis neonatorum. Fully developed gonorrheal conjunctivitis 
rarely recovers without some corneal involvement, and only too often 
the eye is hopelessly marred. Arthritis, endocarditis, and septicemia 
may arise as complications (see also page 199). 
Treatment.-This includes the same principles and practice de- 
scribed in connection with ophthalmia neonatorum (see page 200), but 
requires certain modifications suggested by the adult age of the majority 
of the patients. 
If the swelling of the lids is so great that their pressure threatens Plate II. 
Fia.I 
Fia.U 
Fia.R 
Fig. HI 
Fig. I.-Discharge from right eye in a case of purulent conjunc- 
tivitis; gonococci numerous in cells (Stephenson). 
Fig. II.-Bacillus of Weeks in pure culture (from a photograph) 
(Weeks). 
Fig. III.-Conjunctival secretion from acute contagious conjunc- 
tivitis ; polynuclear leukocytes with the bacillus of Weeks ; P, Pha- 
gocyte containing bacillus of Weeks; immers. TC-, oc. iii (Morax). 
Fig. IV.-Secretion from a case of conjunctivitis, showing pneu- 
mococci; immers. TV, oc. iii (Morax). GONORRHEAL CONJUNCTIVITIS 
205 
to destroy the cornea, the outer canthus may be divided (canthotomy). 
This acts in a twofold manner, by relieving pressure and by depleting 
the engorgement through the loss of blood occasioned by the incision, 
which should be made with a scalpel, cutting the tissues from without 
down to the bone as far as the margin of the orbit, but leaving the con- 
junctiva uninjured. Repeated incisions of the hard rim of chemotic 
conjunctiva which surrounds the cornea will also relieve pressure, and 
in some circumstances is a most useful procedure. In desperate cases 
some operators (Critchett, Fuchs) have not hesitated to split the lid 
vertically and stitch the divided portions to the brow, restoring them 
by a plastic operation after the disease has subsided. Cold may be 
applied with compresses in the manner already described, or continu- 
ously with Leiter's tubes. Certain experienced surgeons, as has 
already been mentioned in connection with ophthalmia neonatorum, 
doubt the value of cold applications. The author believes that in 
gonorrheal conjunctivitis in adults, during the early stage, cold is not 
only most agreeable to the patient, relieving pain and irritation, but of 
distinct value in checking the inflammatory process and the movement 
of the bacteria. Not all cases are suited to cold, and it is not always 
right to use the cold continuously; but, as is well maintained by Weeks, 
it may be used for periods of twenty minutes to half an hour every 
three or four hours, thus obtaining the therapeutic value of the cold 
and avoiding the danger of depressing the nutrition of the cornea. 
Local applications include the antiseptic lotions previously given 
(see page 202), in addition to which may be mentioned a drug which the 
author can highly recommend, namely, permanganate of potassium, 
1 : 2000-5000, used copiously, a pint at a time, in continuous irrigation 
after the manner of Kalt. These irrigations should be performed three 
or four times a day, according to the severity of the case and the quan- 
tity of the discharge. Nitrate of silver should be employed in the 
manner described on page 201. In place of this drug argyrol and 
protargol have been much employed. According to Standish, pro- 
targol seems to act somewhat better in the gonorrheal conjunctivitis 
of adults than argyrol. If either of these drugs is used it should be 
applied in the manner already described (see page 202). In the opinion 
of the author, argyrol, if used at all, should be employed only as an 
adjuvant in the treatment of gonorrheal conjunctivitis, and not to the 
exclusion of nitrate of silver, which, he is satisfied, will always hold a 
high position in the therapy of this disease in adults. With subcon- 
junctival injections in the treatment of serious cases of gonorrheal 
ophthalmia, as, for example, they have been recommended by Hirsch, 
who uses a solution of oxycyanid of mercury, 1 : 5000, to which acoin 
is added, the author has had no experience. Neither has he faith in 
the value of peroxid of hydrogen diluted to 3 per cent., which has 
been recommended in the treatment of this disease, nor has he had an 
opportunity of testing the value of blenolenicet ointment. The treat- 
ment of this disease with antigonococcus serum does not appear to have 
been satisfactorv. 206 
DISEASES OF THE CONJUNCTIVA 
On the appearance of any of the types of corneal ulceration atropin 
drops should be instilled with sufficient frequency to maintain mydriasis 
and subdue ciliary hyperemia; indeed, it is a wise precaution to employ 
this mydriatic from the beginning of the disease. Eserin has also been 
recommended, or the combined action of eserin and atropin, obtained 
by using the former drug during the daytime and the latter at night. 
In the majority of instances atropin will secure the best results. Iodo- 
form freely dusted upon the ulcer is of service, and other measures men- 
tioned on page 253 must be considered. Dionin is recommended by 
Darier. 
If an ulcer threatens to perforate, paracentesis (see page 619) 
through its floor will diminish the intra-ocular pressure, and may pre- 
vent or lessen the extent of prolapse of the iris. A substitute for this 
operation is the use of the actual cautery or an application of pure car- 
bolic acid, and should be preferred. If perforation has taken place, 
excision of the prolapsed iris, sometimes recommended, is not without 
danger, as this procedure may open a way for the entrance of infecting 
material to the deeper structures of the eye. The final outcome of the 
case will depend upon the extent of corneal involvement and the ultimate 
treatment of the remaining leukoma, staphyloma, or shrunken ball will 
require, according to circumstances, iridectomy, abscission, eviscera- 
tion, or enucleation. 
Often the patients are debilitated, and supporting treatment is indi- 
cated, namely, quinin, iron, strychnin, and milk-punch. If there is con- 
stipation, calomel and saline laxatives should be administered. The 
pain, which is often severe, may be allayed with morphin or opium. 
In place of morphin, codein may be employed. It is a mistake, in the 
serious forms of this disease, to depend alone upon local measures. 
The treatment of a chronic conjunctivitis, the sequel of an acute 
attack, depends upon the degree of thickening in the mucous membrane, 
but is usually best managed by careful exposure of the thickened con- 
junctiva and applications of nitrate of silver, tannin and glycerin, and 
the occasional use of the alum or sulphate of copper stick. A col- 
ly rium of boric acid, bichlorid of mercury, or sulphate of zinc may be 
used. 
Prophylaxis.-Patients suffering from gonorrhea should be warned 
not only of the great danger of infecting their own eyes, but the eyes 
of those around them. Inasmuch as a very minute quantity of urethral 
discharge, and even where this is the product of a chronic disease- 
gleet, for example-may produce acute conjunctivitis, these precau- 
tions become the more necessary. 
As usually one eye alone is affected, it is a matter of great importance 
to secure the other eye from contact with the secretions. This may be 
done by sealing it with an antiseptic bandage, the edges of which are 
made tight by fastening along them strips of gauze painted with flexible 
collodion, or by the application of Buller's shield. The latter consists 
of a watch-glass fitted in a square piece of rubber adhesive plaster, which 
is carefully applied to the brow, temple, lower margin of the orbit and NON-SPECIFIC PURULENT CONJUNCTIVITIS 
207 
nose, and should be secured with additional strips to prevent the en- 
trance of discharge.1 The inner margin should be sealed with collodion, 
as a contamination is most likely to occur at this point, and inefficient 
application increases, rather than diminishes, the danger. 
All the precautions which have been stated in regard to the care 
of conjunctivitis neonatorum apply with equal and even greater force 
to the present disease. In a number of instances the surgeon in attend- 
ance has been contaminated. 
Metastatic Gonorrheal Conjunctivitis2 {Gonorrheal Epibulbar 
Conjunctivitis-Heerfordt).-This is an inflammation of the mucous 
membrane of the eye due to the gonococcus which is carried from the 
urethra to the conjunctiva through the medium of the circulation; 
or it may be caused by the gonotoxin. According to W. Gordon M. 
Byers, whose definition has just been quoted, it may occur as the initial 
symptom of a generalized infection, appear simultaneously with the 
other manifestations-for example, ar- 
thritis-follow the outbreak of inflam- 
matory symptoms elsewhere located, or 
be the only expression of a systemic 
gonorrhea. 
The disease is almost invariably bi- 
lateral, is more common in men than 
women, and resembles a catarrhal con- 
junctivitis with some swelling of the 
mucous membrane and redness of the 
lids. Small ulcers of the cornea may 
form. According to Heerfordt, it may 
assume the form of phlyctenular con- 
junctivitis. Iritis, iridocyclitis, and 
uveitis may follow this inflammation, 
just as they are seen associated with 
gonorrheal rheumatism. Endogenous 
gonorrheal keratitis, occurring before or 
after arthritis, has also been described, but the etiologic relation of 
gonorrhea in this regard is doubtful (Elschnig). Relapses occasionally 
occur; the average duration of the disease is about two weeks. The 
diagnosis rests upon the presence of gonorrhea, the absence of the 
gonococcus, and the ordinary bacteria of conjunctivitis in the secretion. 
The treatment of this affection demands the same remedies useful 
in ordinary conjunctivitis. Heerfordt advises massage with an oint- 
ment of yellow oxid of mercury and a lotion of copper sulphate (0.25 
per cent.). 
Nonspecific Purulent Conjunctivitis.-Purulent conjunctivitis, 
not gonorrheal in origin, may be caused by the secretion of diphtheritic 
Fig. 103.-Application of Buller's 
shield. 
1 Care should be taken to provide a watch-glass of the ordinary form, not one with a 
concave center. 
2 Some surgeons apply the name gonorrheal ophthalmia to this affection, and reserve 
the term gonorrheal conjunctivitis for the disease which is caused by a specific urethral 
discharge. 208 
DISEASES OF THE CONJUNCTIVA 
conjunctivitis, and occasionally by granular lids. As has been noted, 
the manifestations of Koch-Weeks' bacillus conjunctivitis and pneu- 
mococcus conjunctivitis are not infrequently so violent and the secre- 
tion so profuse and purulent that they might be classified among puru- 
lent inflammations of the conjunctiva. (See also page 195.) It should 
further be remembered that a catarrhal conjunctivitis, by neglect or 
injudicious external applications-for example, poultices-may be 
aggravated into an inflammation in all particulars resembling gonor- 
rheal conjunctivitis. Infection from the nares and pneumatic sinuses 
can also cause severe inflammation of the conjunctiva, associated with 
much purulent discharge. The treatment is exactly that which has 
been described in connection with other forms of acute conjunctivitis. 
The best results follow the free irrigation of the conjunctival sac with a 
saturated solution of boric acid or bichlorid of mercury (1:10,000), and 
the use of argyrol, protargol, and nitrate of silver in the usual manner. 
If properly treated, corneal complications are uncommon. 
Croupous or Pseudomembranous Conjunctivitis (Plastic, 
Membranous Conjunctivitis').-Of this disease, two varieties may be 
considered. The first is an inflammation of the conjunctiva, character- 
ized by a soft, usually painless swelling of the lids, a membranous exuda- 
tion upon the conjunctiva, and a scanty, seropurulent discharge. 
Causes.-The affection in its pure form is rare. It is never found 
among the newborn, and rarely among adults, the majority of cases 
occurring in early life-i. e., between first half year and the seventh 
year. 
The contagiousness of the disease has not been established; no 
definite cause is known, although some relation exists between this dis- 
order, scrofula, and eczema. Patients affected may at the same time 
be suffering from a croupous inflammation of the respiratory tract. 
Some authors regard the affection as a mild diphtheria. Non-virulent 
Ldffier bacilli, staphylococci, and diplococci have been found in the 
secretion. Croupous conjunctivitis may also be due to the pneumo- 
coccus, the diplobacillus, the Bacterium coli, and the Koch-Weeks 
bacillus. Influenzal bacillus membranous conjunctivitis has been de- 
scribed (see page 191). 
Symptoms.-These begin with an acute conjunctivitis, succeeded 
by swelling of the lids, which remain soft and pliant, and usually not 
painful to the touch. In a few days there is a deposit of a characteristic 
false membrane composed of coagulated fibrin, rather translucent and 
porcelain-like in appearance, beginning upon the retrotarsal folds, coating 
the inner surfaces of the lids, but not invading the bulbar conjunctiva. 
It may readily be removed without loss of the conjunctival tissue, and 
shows beneath a granular and somewhat bleeding surface. It is quickly 
reproduced. The cornea, except in severe cases, escapes. 
Healing takes place in from ten to thirty days, except in those in- 
stances where the membrane is formed again and again, and the course 
of the disease may continue for months and even years, constituting the 
recurring form of pseudomembranous conjunctivitis. DIPHTHERITIC CONJUNCTIVITIS 
209 
Diagnosis.-The disease may be confounded with conjunctivitis 
neonatorum and diphtheritic conjunctivitis. From the former it is dis- 
tinguished by the absence of profuse purulent discharge and the age of 
the patient; from the latter, by the soft swelling of the lids, the super- 
ficial character of the membrane, and absence of virulent Klebs-Lbffler 
bacilli. 
Treatment.-This should include the application of ice compresses, 
frequent removal of the discharge with a solution of chlorid of sodium 
or chlorate of potash, and later the cautious use of nitrate of silver 
(Knapp), or of argyrol and protargol. As in many instances it is diffi- 
cult to exclude diphtheritic infection, the administration of diphtheria 
antitoxin should be ordered in doubtful cases. 
The second variety of membranous conjunctivitis is due to strepto- 
cocci, is rapid in development, and is associated with swelling of the lids 
and much discharge, and may quickly destroy the cornea. It occurs 
in children in connection with measles, scarlet fever, and influenza; but, 
according to Morax, may appear independently of febrile complications 
and may accompany impetigo. The prognosis is most unfavorable not 
only to eyesight, but also to life. The disease is often mistaken for 
diphtheritic conjunctivitis (it is sometimes called streptococcus diph- 
theria of the conjunctiva). Microscopic examination will decide the diag- 
nosis. The treatment already detailed is indicated. According to 
Axenfeld the use of streptococcal serum is to be recommended. 
Membrane-forming conjunctivitis, not strictly to be classified with 
either of the foregoing types, has several times been referred to. Thus, 
membrane formation may be noted as an intercurrent condition in 
several varieties of conjunctivitis-for example, in gonorrheal conjunc- 
tivitis, pneumococcus and Weeks' bacillus conjunctivitis, trachoma, 
and exanthematous conjunctivitis. Membranes may also form in the 
conjunctiva as the result of chemical, mechanical, and thermic irritants. 
It is especially noteworthy after certain injuries of the conjunctiva- 
for instance, lime-burns. 
Diphtheritic Conjunctivitis.-The deep-seated or necrotic variety 
of this disease is characterized by a board-like, very painful swelling 
of the lids, a scanty seropurulent or sanious discharge, and exudation 
within the layers of the tarsal conjunctiva, which spreads to the ocular 
conjunctiva, and by pressure destroys the nutrition of the cornea. 
Causes.-In addition to the Klebs-Loffler bacilli, which cause 
the disease, other micro-organisms, for example, streptococci, staphy- 
lococci, and non-virulent xerosis bacilli, are usually present in the dis- 
charge (Uhthoff). The disease, which is contagious, may originate 
from a similar case, or arise in the course of a purulent conjunctivitis. 
It has occurred, though rarely, with conjunctivitis neonatorum. At 
times it appears in connection with eczema of the face and borders of 
the lid, and is an occasional accompaniment of some acute illness, for 
example, scarlet fever or measles, the diphtheritic type of the inflam- 
mation being ingrafted upon the conjunctiva. The disease has been 
seen during epidemics of diphtheria, and may be part of a process which 
14 210 
DISEASES OF THE CONJUNCTIVA 
passes from the nose to the conjunctiva, or may be due to direct inocu- 
lation with the diphtheritic poison. 
It is commonest between the ages of two and eight, and is unusual in 
young infants. In certain localities in the south of France and the north 
of Germany the disease was formerly frequent. It is usually stated 
that the disease is comparatively rare in America and England; but 
Sydney Stephenson records a percentage of 1.25. This author regards 
conjunctival diphtheria and croupous conjunctivitis as one and the same 
disease. 
Symptoms.-The patches appear in a discrete or confluent form; 
the lids are swollen with a characteristic, painful, board-like hardness. 
The false membrane is of a dull, grayish appearance, and is torn off with 
difficulty, and carries with it parts of the conjunctiva. If the process is 
deep, the subjacent structure is pale, infiltrated, and when cut into may 
be anemic and lardaceous. If the diphtheritic inflammation has been 
ingrafted upon a case of purulent conjunctivitis, the abundant secretion 
ceases, or becomes irritating and sanious. 
Sloughing of the cornea is almost inevitable in severe cases, and 
rapid destruction of this membrane may take place in twenty-four 
hours; even in mild cases ulcers may be expected. 
Restlessness, fever, alimentary derangements, and nervous phe- 
nomena are usual constitutional disturbances, and the disease may be 
followed by loss of knee-jerk and paresis of various parts of the body. 
Albumin may be present in the urine, and occasionally diphtheritic con- 
junctivitis proves to be fatal (Stephenson). 
Diagnosis and Prognosis.-This disorder is distinguished from the 
previous disease by the characteristic board-like infiltration of the lids 
and the bacteriologic examination, and has nothing in common with the 
flakes of false membrane sometimes seen in purulent conjunctivitis, 
from which it is further separated by the character of the discharge and 
by bacteriologic examination. The prognosis, as may have been in- 
ferred, is unfavorable, although with modern treatment more cases 
are cured without impairment of vision than formerly was possible. 
Occasionally, even if the diphtheritic membrane is only slightly de- 
veloped, rapid necrosis of the cornea ensues. 
Treatment.-The eyes should be frequently cleansed with warm 
boric acid solution or bichlorid of mercury solution (1 : 8000) and atro; 
pin drops should be instilled. Iodoform salve (or powder) may be 
freely applied within the conjunctival sac; indeed, vaselin itself is effi- 
cient in these circumstances. 
Internally, quinin, iron, and mercury have been recommended; 
but the greatest reliance should be placed upon diphtheria antitoxin, 
which should be promptly administered exactly as it is in ordinary 
faucial diphtheria. At the first dose, 1500 to 2000 units of antitoxic 
serum may be injected into the lateral abdominal wall, and repeated 
in ten or twelve hours, according to the severity of the symptoms. 
The sound eye may be covered with a bandage or Buller's shield. 
The patient should be isolated. PHLYCTENULAR CONJUNCTIVITIS 
211 
In addition to the deep-seated, necrotic variety of diphtheria of the 
conjunctiva, the disease, according to Uhthoff, Sourdille, Elschnig, and 
Morax, may assume a benign aspect and a superficial pseudomem- 
branous form. Why virulent diphtheritic bacilli sometimes cause a 
superficial and sometimes a deep intersitial type of the affection has not, 
according to Uhthoff and Coppez, been determined. The former author 
also describes a simple catarrhal conjunctivitis in association with diph- 
theritic bacilli. 
Phlyctenular Conjunctivitis {Phlyctenular Ophthalmia; Scrofulous 
Ophthalmia; Eczema of the Conjunctiva) .■-This is a form of inflammation 
of the conjunctiva, characterized by the appearance of one or more 
grayish elevations, situated chiefly upon its bulbar portion in the imme- 
diate vicinity of the cornea. Less, frequently the phlyctenules appear 
upon the tarsal conjunctiva, those on the 
lower lid being of firmer consistence than 
those on the bulbar conjunctiva (Schiele). 
Causes.-The disease is believed to 
be of constitutional origin, and its sub- 
jects are often tuberculous and badly 
nourished children. Errors of diet, un- 
wholesome foods, and the abuse of tea 
and coffee act as predisposing causes. 
It often follows the exanthemata, es- 
pecially measles. Infectious rhinitis is 
always present, and usually the sub- 
maxillary and cervical glands are swollen, and there is eczema of the 
lip and nares. There is a distinct clinical association between this dis- 
ease and eczema. It is possible that the active micro-organism is the 
Staphylococcus pyogenes aureus or albus, which is found beneath the 
epithelium of the affected conjunctiva, but an endogenous origin of the 
disease cannot be wholly excluded. That the disease is a true tubercu- 
losis is disputed by Axenfeld. 
Symptoms.-The disease occurs in a single and a multiple form; 
the pimples or phlyctenulse lie near the corneal margin or directly upon 
it, and are usually from 1 to 3 mm. in diameter. 
If the elevations are large, yellow, and contain purulent material, 
the disease has been called pustular ophthalmia. 
In any circumstances it is accompanied by dread of light, injected 
blood-vessels, and increased lacrimation. The conjunctiva may be 
transparent, or the disorder associated with a mucopurulent conjuncti- 
vitis. After the exanthemata this association is common. 
In the multiple form, numerous minute phlyctenules may be scat- 
tered over the entire conjunctiva, and are accompanied by decided 
general red injection, irritation, and photophobia. The disorder sub- 
sides in from ten days to two weeks. 
Treatment.-Locally, mild antiseptic collyria, especially lotions of 
boric acid, are useful. Much irritation indicates atropin drops and the 
Fig. 104.-Phlyctenular conjunc- 
tivitis (Children's Hospital). 212 
DISEASES OF THE CONJUNCTIVA 
occasional instillation of holocain to relieve the photophobia. The eyes 
may be protected by colored glasses. 
After the acute symptoms have subsided the best results are obtained 
by introducing the yellow oxid of mercury, 1 grain to 1 dram (0.065- 
3.885 gm.), into the conjunctival sac or by dusting into it calomel, pro- 
vided the patient is not taking iodid of potassium, otherwise a reaction 
between the potassium iodid in the tears and the calomel occurs, with 
the ultimate formation of double iodids, which are caustics {calomel 
conjunctivitis"). Applications of borobismuth ointment to the nasal 
eczema are recommended by Schiele, who also speaks favorably of such 
antiseptic powders as gallicin, iodogallicin, and bismuth oxyiodid tan- 
nate. Linear cauterization of the fornix has been advised in severe cases. 
An excellent regulation treatment is a mild course of mercurial 
laxatives. Simple diet, good air, exercise, and internally, quinin, iron, 
arsenic, and cod-liver oil, complete the therapeutic measures. 
Phlyctenular conjunctivitis is so closely allied to phlyctenular 
keratitis that the separation of the two affections is purely artificial, and 
this account is a preface to the description of the more exact disposition 
and relation of the phlyctenules, which appears on page 242. 
Vernal Conjunctivitis (Fruehjahr's Catarrh, Saemisch; Phlyctoena 
Pallida, Hirschberg; Periodic Hyperplastic Conjunctivitis, Wicher- 
kiewicz; Fibroma of the Limbus; Spring Conjunctivitis).-This form of 
conjunctival disease is characterized by photophobia, stinging pain, 
considerable mucous secretion, the formation of flat granulations in 
the palpebral conjunctiva, and a hypertrophy of the conjunctiva sur- 
rounding the limbus of the cornea. 
Causes.-Definite information in regard to the cause of this disease 
is lacking. It is possible that some specific micro-organism exists 
which has not yet been isolated. Although frequently the disorder 
returns in the early spring and subsides in the fall and winter, cases 
may occur in any month of the year, and its designation, spring catarrh, 
is not a good one, because the affection is in no sense a catarrhal one, 
and it does not necessarily occur in the spring. It is most frequent 
between the ages of five and fifteen, but occasionally occurs in ad- 
vanced adult life and in very young children, even those but a few 
months of age. According to Posey's investigations, it is more fre- 
quent in males in the proportion of 85 to 15 per cent. It may accom- 
pany the disease known as hay-fever. Some writers decline to consider 
vernal conjunctivitis a distinct disease, but look upon it as a hyper- 
trophic form of chronic conjunctivitis. In a few instances it appears 
to be hereditary, and Meyerhof describes a familial development of 
vernal conjunctivitis. At times there appears to be a congenital dis- 
position to the disease. 
Symptoms.-The affection begins like an ordinary conjunctivitis 
and is almost always bilateral; a few unilateral cases are on record. 
There are photophobia, more or less mucous secretion, circumscribed peri- 
corneal injection, and the formation at the limbus of small, gray, semi- 
transparent nodules, which swell up and overlap the edge of the cornea. VERNAL CON.JUNCTIVITS 
213 
Three varieties of the disease are described-the limbus, palpebral, 
and mixed forms. The conjunctiva of the bulb is injected, that of the 
lids is slightly thickened and of a dull, pale color, as if brushed over with 
a thin layer of milk. This milky film seems to be the most constant 
symptom of the disease, and is to be observed before the granulations 
appear on the inner surface of the lids. When they appear in typical 
form, these granulations cover the tarsal conjunctiva, are flattened, 
and contain deep furrows between them. In the colored race there is a 
brownish pigmentation of the scleral base of the hypertrophied masses 
(Burnett). 
The disease may be distinguished from trachoma by the flattened 
appearance of the granulations, the absence of infiltration and pannus, 
and the history of recurrence at special seasons of the year. Elschnig 
calls attention to an arrangement of the blood-vessels of the tarsal con- 
junctiva which he considers peculiar to spring catarrh. The normal 
vascular distribution is replaced by innumerable small vessels arising 
perpendicular to the conjunctival surface. Mixed forms of spring 
catarrh and trachoma have been described (May, Meyerhof). 
The pathologic histology of the lesions has attracted much attention 
in recent years. According to Axenfeld, who has elaborately investi- 
gated this disease, the primary lesions arise in the subconjunctival 
tissue, followed by proliferation of the epithelium. An accumulation of 
plasma cells takes place, succeeded by a homogeneous sclerosis of the 
connective tissue. Elastic tissue is abundant. The milky appearance 
of the surface of the conjunctiva is due to subepithelial hyalin thicken- 
ing. Eosinophils are frequent in the conjunctiva and occur in large 
numbers in the secretion. There is no essential difference between the 
tarsal and palpebral manifestations of the affection, unless future in- 
vestigations should confirm the assertion of some observers that in the 
bulbar proliferations the epithelial changes take precedence. 
The prognosis of the disorder is not unfavorable, except in so far 
as relapses are concerned, which make its course a long one, sometimes 
lasting from eight to ten years, or even longer. Usually the activity 
of the process begins to subside after it has existed for six or seven years. 
Slight opacity of the cornea may result. 
Treatment.-During the height of the attack the eyes may be pro- 
tected with dark or yellow-tinted glasses. Cold compresses afford some 
relief. Weak astringents and antiseptic lotions, such as have been 
recommended for ordinary conjunctivitis, are useful. The application 
of boroglycerid to the everted lid is sometimes valuable, and the sys- 
tematic use of a preparation of suprarenal extract, or of adrenalin 
chlorid (1 : 10,000), to which a 1 per cent, solution of holocain is added, 
is of service. Axenfeld suggests the application of a solution of sulphate 
of quinin, and Elschnig advises the instillation of a watery solution of 
ichthyol (1 to 2 per cent.). Salicylic acid ointment (1 per cent.) is 
recommended, and massage with yellow oxid ointment may be tried. 
Electrolysis has been employed, and brossage has been advised by L. W. 
Fox. Exuberant granulations and limbus hypertrophies may be ex- 214 
DISEASES OF THE CONJUNCTIVA 
cised. According to Wicherkiewicz, a collyrium of antipyrin (10 per 
cent.), and instillations of 2 or 3 per cent, of protargol are efficient. 
Starr, in Buffalo, and Allport, in Chicago, have recommended the 
arrays in the same manner as they are applied in trachoma, and have 
reported favorable results. Abbe and other surgeons have advised the 
application of radium, and have recorded notable successes. There is 
some evidence to show that the internal administration of arsenic is 
of advantage. Associated intranasal inflammation should be treated. 
Change from a warm to a cool climate is of service. 
Follicular Conjunctivitis (Follicular Ophthalmia; Conjunctivitis 
Follicularis Simplex; Trachoma Folliculare; Folliculosis; "School Fol- 
licles") .-This affection is characterized by the presence of small pinkish 
prominences in the conjunctiva, for the most part in the retrotarsal 
folds, and usually arranged in parallel rows. The descriptive term "con- 
junctivitis" may be applied to the affection if the signs of inflammation 
are associated with it; if the latter are absent, the term folliculosis of 
the conjunctiva is more appropriate. 
Causes.-The disease arises under the influence of poor hygienic 
surroundings, especially in pauper schools, where it may appear as an 
aggravated epidemic, but it is frequently seen in mild form, especially 
among children during their school years, particularly if they are the 
subjects of anemia and chlorosis. Indeed, in so large a percentage of 
school children can tumefaction of the conjunctival lymph-follicles be 
found that the name school-folliculosis has been suggested by Greeff. 
Evidently refractive errors are the exciting cause of many of these 
cases. Enlargement of the follicles may also be caused by local irri- 
tants and some medicaments-for example, atropin (see page 228). 
Much difference of opinion exists as to whether folliculosis should 
be placed in a separate category from granular conjunctivitis, or 
whether it should be regarded as an early stage of the latter disease. 
Although transitional forms apparently exist, the evidence, clinically 
at least, warrants the belief that this affection is distinct from granular 
lids, because folliculosis occurs where trachoma is unknown, and be- 
cause the follicles disappear without leaving a trace of their existence or 
producing scar tissue in the conjunctiva. Histologically, however, 
there is no decisive difference between fresh follicles and fresh trachoma 
bodies. It would seem, as Greeff insists, that folliculosis may arise 
under the influence of various excitants, and in this sense is a symp- 
tom and not a distinct disease. 
Symptoms.-The children-for it mostly occurs in children and 
young people-complain of slight dread of light and inability to con- 
tinue at close work, and inspection reveals numerous round elevations 
in the conjunctiva, chiefly along the fornix, which are tumefied lymphatic 
follicles. The color of the follicles varies from nearly white to a decided 
pink. After their disappearance the conjunctiva regains its natural 
state. 
If with the enlarged follicles inflammatory symptoms are combined, 
the disease is a true follicular conjunctivitis; the lids are swollen, GRANULAR CONJUNCTIVITIS 
215 
reddened, and their margins streaked with secretion, which, at first 
thin, may become more purulent and quite abundant. In certain cir- 
cumstances the disease resembles the condition termed "swelling with 
catarrh" (see page 194), except that the development of the follicles is 
much more evident. The inflammatory form of the affection may 
assume a more chronic type, with special development of the follicles in 
the fornices, and only secretion enough to stick together the lids in the 
morning. 
The disorder is to be distinguished from granular lids by observing 
that the small bodies are neither so large as true granulations nor so 
highly colored as hypertrophied papillae; that the mucous membrane is 
not affected more deeply than the lymphatic follicles; and that cicatricial 
changes are not present. 
The prognosis is good in so far as the fate of the mucous membrane 
is concerned, but the disorder is troublesome and will often last for 
months, and, under imperfect hygienic surroundings and in crowded 
asylums, may prove to be a stubborn affection. 
Treatment.-Locally, boric acid, either alone or made up with a 
few minims of alcohol to one ounce of water, weak bichlorid solutions, 
and occasional applications of boroglycerid or tannin and glycerin are 
useful. A salve of | grain (0.0324 gm.) of sulphate of copper to the 
dram (3.885 gm.) of vaselin has been highly extolled. If there is 
much secretion, the usual treatment of conjunctivitis is required, 
especially silver and its various salts. 
Refractive error should be corrected because ametropia aggravates 
the disorder. In stubborn cases, especially in asylums, expression of 
the swollen follicles with suitable forceps should be performed (see 
page 617). 
Granular Conjunctivitis (Gramdar Lids; Trachoma; Egyptian 
Ophthalmia; Military Ophthalmia').-This is a disease of the conjunctiva 
in which this membrane loses its smooth surface, owing, in the language 
of Saemisch, to an inflammatory infiltration of its adenoid layer, asso- 
ciated with the development of follicles ("granulations") and enlarge- 
ment of the so-called papillary layer. After absorption and metamor- 
phosis of the inflammatory material, cicatricial changes are found. 
Causes.-Formerly it was the custom to separate this disease into 
two forms-acvte granulations, or acide gramdar conjunctivitis, and 
chronic granulations, or chronic gramdar conjunctivitis, and certain sys- 
tematic writers-for example, Saemisch-continue this distinction. 
In so far as the author's observations are concerned, they lead him to 
agree with those who maintain that the so-called acute trachoma, at 
least in the majority of cases, represents an admixture of ordinary 
granular lids and acute conjunctival catarrh. An attack of acute 
conjunctivitis may precede the development of trachoma. According 
to MacCallan, in Egypt, the acute symptoms are most often caused by 
the Morax-Axenfeld bacillus, the Koch-Weeks bacillus, and the gono- 
coccus. Greeff, however, seems to have proved by inoculation that 
there is an acute trachoma which may develop in a few days. 216 
DISEASES OF THE CONJUNCTIVA 
Granular conjunctivitis may arise apparently under the influence 
of poor hygienic surroundings, and in institutions where the inmates 
are crowded together the disease may readily spread. 
It has been stated that certain individuals, especially of lymphatic 
constitution, are predisposed to granular lids, but, although its subjects 
are often pale and anemic, because they live in badly ventilated homes, 
there is no known constitutional disorder which causes the disease, as it 
may attack those who are in perfect health. Personal susceptibility 
to the disease varies. Racial predisposition has been maintained, the 
Mongolian race being especially liable to the affection; but, according 
to Axenfeld and Boldt, marked racial predisposition is doubtful. In 
Egypt and the eastern countries an admixture of trachoma and pur- 
ulent ophthalmia is very prevalent. Trachoma is generalized through- 
out Egypt, affecting about 95 per cent, of the population (MacCallan). 
According to MacCallan, children in Egypt are usually infected dur- 
ing the first two years of life. It may develop in the newborn as the 
result of infection during delivery, inasmuch as trachoma of the genital 
passage occurs. It is exceedingly common among the poorer classes 
in Ireland and Russia, and Jews of the lower social grades are very 
prone to be affected. The Indians of our own country are frequently 
attacked, while pure negroes are almost exempt. The exemption of 
the negro, however, is denied by Minor. Trachoma is widely dis- 
tributed through certain regions in the Middle West and western 
portions of the United States. 
Among the immigrants to our country-Poles, Jews, Russians, 
Hungarians, and Italians-the disease is common, and occasions much 
anxiety among those whose duty is concerned with the inspection of 
these foreigners. The determining factor, however, is not so much con- 
nected with racial predisposition as with the uncleanly habits and un- 
hygienic surroundings of those who are the subjects of the affection. 
The geographic distribution of trachoma has attracted much atten- 
tion, and it has been found that the dwellers in certain regions of the 
earth where the climate is damp are readily affected, while it has been 
maintained that an altitude of 1000 feet confers comparative im- 
munity from the disease and facilitates its cure. Trachoma, however, 
occurs in mountainous regions, for example, in our own country among 
the Indians as well as among white settlers.1 A climatic predisposi- 
tion is doubtful. 
Bacteriology of Trachoma.-Transference of the morbid material 
from a trachomatous conjunctiva to another eye may result not only 
in a purulent conjunctivitis, but in a disease like the one from which it 
came. In this sense the disease is specifically contagious, although the 
affection is not conspicuously contagious by secretion inoculation 
(Axenfeld). There is no proof that trachoma is caused by micro- 
organisms of the bacterial group or by blastomycetes. 
Halberstadter and Von Prowazek, working in Java, and Greeff, 
1 According to Burnett, trachoma occurs at an altitude of 4700 feet. Van Millingen 
denies the influence of altitude and an immunity for certain races. GRANULAR CONJUNCTIVITIS 
217 
Frosch, and Clausen, in Germany, discovered in the discharge and 
follicle contents of trachoma very small granules, resembling diplo- 
bacteria. They are surrounded by a zone (hence called by Prowazek 
chlamydozoa}, and occur either isolated or grouped together within 
the cell next to the nucleus (see also page 203). They increase in 
number, and gradually occupy almost the entire protoplasm of the 
cell which is destroyed, and they are set free in the secretion. Certain 
small bodies are seen in the protoplasm of the cells and outside of the 
cells, and they almost always accompany the "inclusions," and are 
called "Lindner's initial bodies." The Prowazek bodies are found in 
fresh, untreated trachoma, less easily in granular lids of long standing. 
Their exact nature is unknown, although, according to Axenfeld, they 
probably are neither cell-products, metamorphosed gonococci (Herzog), 
nor the products of mucoid degeneration. They are so seldom present 
in other conjunctival disease that their detection is highly significant. 
Their absence, however, does not exclude trachoma. They an? usually 
Fig. 105.-So-called trachoma bodies-epithelial inclusions (Axenfeld). 
known as "Prowazek or Prowazek-Halberstiidter bodies or corpuscles," 
and they have also been found in ophthalmia neonatorum (Heymann) 
(see page 203), in their early stage in the normal conjunctiva, and in 
some forms of chronic conjunctivitis (Erdmann). 
Pathology and Varieties of Trachoma.-The pathognomonic appear- 
ance and essential element of the disease trachoma are. the "granula- 
tions," or "trachoma bodies," or follicles.1 
Two views have been held-the one that the trachoma bodies have a 
special pathologic character; the other that they are derived from the 
lymphatic follicles, which, although poorly developed, are probably 
present in the natural human conjunctiva, and some authors declare 
that these follicles and their changes originate all the anatomic and 
clinical qualities of trachoma. Although it may not be possible to dis- 
tinguish in the early stages trachoma bodies from enlarged lymphatic 
1 It should be remembered that the word "granulations" refers to the characteristic 
feature of trachoma, and not to surface granulations which may form during the course of 
the disease. The Prowazek bodies are also called "trachoma bodies" by some authors, 
for example, by Greeff. 218 
DISEASES OF THE CONJUNCTIVA 
follicles, there is a difference in the nature of the two conditions, and 
for the most part the "unitarian standpoint" with reference to trachoma 
has been abandoned-that is, the theory that all follicles in the conjunc- 
tiva represent trachoma. Certainly so-called "benign follicles" exist 
which disappear without a residue of lesions (see page 214), and, on the 
other hand, an infection with follicular formation arises which subsides 
after a long period of time and leaves cicatrices (see page 219). Be- 
tween these two forms are the "border-line" cases which are difficult to 
classify. The onset of trachoma may be preceded by a Koch-Weeks 
bacillus conjunctivitis in which Prowazek bodies can be found. Some 
authors deny that trachoma is a specific disease, believing that it is the 
pathologic expression of the reaction of the conjunctiva to various 
irritants (Walker). 
Fig. 106.-Trachoma of the retrotarsal fold: a, Follicle; b, diffuse infiltration; c, Henle's 
gland with goblet-cells; d, lymph-vessel filled with leukocytes (X 30) (Holden). 
The following varieties of chronic trachoma have been recognized 
by systematic writers: 
1. Papillary trachoma, in which the trachoma bodies or follicles are 
sparsely present and hidden from view by hypertrophied conjunctival 
papillee, or, more accurately, pseudopapillse. The blood-vessels are 
enlarged, and there is marked increase in the number of lymphoid cells. 
The development of the follicles in the adenoid layer lifts above them the 
thickened epithelium. This form is sometimes spoken of as chronic 
trachoma. 
2. Follicular trachoma, in which the presence of the "follicles" or 
trachoma bodies is the chief characteristic. These bodies are round col- 
lections of lymphoid cells which may possess an incomplete capsule, 
and which, as before stated, are elaborately developed in the adenoid 
layer of the conjunctiva. Some authors consider follicular conjunctivitis 
(see page 214) a variety of this type. Systematic writers have differ- 
entiated the following cellular elements in the trachoma follicle: lympho- 
cytes, which form the chief constituent of the peripheral zone; mono- 
nuclear leukocytes, which compose the chief portion of the follicle; 
phagocytes, which are found among the leukocytes; and certain acces- GRANULAR CONJUNCTIVITIS 
219 
sory elements-for example, multinuclear cells, etc. Beneath the fol- 
licles are dilated lymph-vessels, and blood-vessels may extend into the 
follicles. The lymphadenoid tissue surrounding the follicles is infil- 
trated with leukocytes. Some of the cells of the follicles are discharged 
or absorbed; others are converted into connective-tissue fibers, which, 
by their contraction, produce the changes described on page 220. 
According to Parsons, the invariable termination of trachoma in cica- 
trization is brought about by absorption of the contents of the follicles 
and proliferation of the connective tissue of the conjunctiva, it being 
doubtful if the elements of the follicle can themselves form fibrous tissue. 
In one form, designated by Knapp noninflammatory follicular 
trachoma, the spawn-like granulations develop in the conjunctiva with- 
out evidence of inflammation, and have been regarded as analogous to 
nasopharyngeal adenoid hypertrophies. 
3. Mixed trachoma, in which the follicles or bodies lie among hyper- 
trophied and inflamed papillae, but are not hidden by them. This 
type is sometimes described as diffuse or complicated trachoma. 
Fig. 107.-Follicular trachoma (Johnson). 
Fig. 108.-Typical granular lid and beginning 
cicatrization, with pannus (Berry). 
4. Sclerosing trachoma (Knapp), in which, after an initial stage of 
ordinary granulations, leathery (fibrous), flattened excrescences develop 
in the upper tarsal and retrotarsal conjunctiva. 
5. Cicatricial trachoma, in which atrophy and scar tissue are mani- 
fest-"the end stage of uncured cases" (Knapp). 
Although the separation of granular lids into these varieties is con- 
venient from the clinical standpoint, such a separation cannot be main- 
tained on histologic grounds. Indeed, Saemisch maintains that the 
terms "papillary" and "follicular trachoma" should be avoided, as the 
first corresponds with blennorrhea, and the second with follicular con- 
junctivitis. He also deprecates the name "mixed trachoma," and be- 
lieves the disease should be divided into simple granular conjunctivitis 
and granular conjunctivitis in the stage of cicatrization. 
Symptoms.-The "granulations or follicles" often appear without 
antecedent inflammation, and so insidiously that their real nature is for 
a time unknown to the patient. They usually develop in the form of 220 
DISEASES OF THE CONJUNCTIVA 
grayish-white, semitransparent bodies, which vary in size according to 
their stage of development, and which, from fancied resemblances, have 
been called "sago-grain" or "vesicular" granulations. They may be 
disseminated or arranged in parallel rows, and have sometimes been 
likened to the appearance of frog's spawn (follicular trachoma). The 
granulations are, for the most part, confined to the palpebral conjunc- 
tiva, and the upper retrotarsal fold, which is a favorite location, should 
be well exposed during the examination. Occasionally granulations 
are found upon the caruncle and semilunar folds. 
The mucous membrane is pale or yellowish red, unevenly rough, 
and contains the trachoma bodies, or.follicles, which have a more or less 
deep situation and fill up the tissue. If they have not followed an 
acute process, there are few or no irritative manifestations and little 
discharge-perhaps only sufficient to glue together the lids. As time 
goes on the closely packed masses compress the true conjunctival tissue 
and its circulation, and a superficial vascularity of the cornea may 
appear. This stage may last for months and be subject to numerous 
variations. 
In the next stage vascularity is increased, the follicles grow larger, 
soften, and their contents are forced out by the pressure of the sur- 
rounding infiltrations, forming, in association with the hypertrophied 
conjunctival papillae, red protuberances (hypertrophied pseudopapillae). 
This period is associated with strong irritation and mucopurulent or 
purulent secretion, photophobia, local pain, and corneal complications. 
During the time of fatty degeneration and softening, which by some 
authorities is deemed a process of ulceration, fresh follicular (granular) 
eruptions take place, in turn to go through the same changes which 
their forerunners have undergone. The mucous membrane now has a 
flesh-red appearance; it is with difficulty that the "granulations" are 
distinguished from the papillae, and, indeed, they are united with them, 
forming variously shaped diffuse or isolated protuberances. Sometimes 
resorption of the follicles, which can take place at any stage, appears 
to occur by retrogression without softening. Usually degenerative 
changes in the cells take place. Fusion and softening of the closely 
packed follicles may be followed by hyaline degeneration, giving rise 
to a gelatinous appearance, which is sometimes designated gelatinous 
trachoma. 
In the final stage cicatrization begins, and gray-white scar-lines 
appear, intersecting the remains of the old "granulations." When these 
cicatrices lie parallel to the ciliary borders, they present, on eversion of 
the lid, a typical appearance1 (Fig. 108). 
By a gradual process of cicatrization of the old. "granulations" 
and successive new crops, a chronic induration and diffuse scar tissue 
results (cicatricial trachoma). This being firmly attached to the 
tarsus, which itself has undergone softening through a lymphoid infil- 
1 It is convenient to thus divide the disease into three stages, as Raehlmann has done, 
but it is not always possible to separate sharply each stage by symptoms or appearances 
peculiar to itself. GRANULAR CONJUNCTIVITIS 
221 
tration, contracts, and the deformities of the lid and its border, so com- 
mon in this disease, result. The fibroid induration of the mucous mem- 
brane affects all portions, and there may be almost entire obliteration of 
the conjunctival sulcus, or the membrane may undergo a species of 
drying up, to which the name xerosis has been applied. Individuals 
with granular lids, in the stage of thickening of the mucous membrane, 
have an almost characteristic sleepy look, peering uncertainly through 
narrowed palpebral fissures, caused by the ptosis-like droop of their 
indurated eyelids. 
In so-called acute granular conjunctivitis the lids are swollen, the 
conjunctiva reddened, the conjunctival pseudopapillse hypertrophied 
and elevated by the underlying lymphoid infiltration, while between are 
found the yellowish, round "granulations." The dread of light is in- 
tense, and in forcible separation of the lids scalding tears gush out, and 
later mucopurulent discharge appears. Still later, vascularization and 
ulceration of the cornea may develop. As before stated, many authors 
are disinclined to regard these manifestations as a special form of 
trachoma, but consider them to be a mixture of granular lids and 
catarrh; acute exacerbations of chronic trachoma are common. 
Sequelae of Granular Lids.-The most important results of long- 
standing granular lids are trichiasis, distichiasis, and entropion, con- 
ditions already described (see page 181), atrophy and shrinking of the 
conjunctiva from cicatricial changes (see page 230), cloudiness and ul- 
ceration of the cornea, and pannus. 
Pannus may be looked upon as a form of vascular keratitis, which 
always begins in that portion of the cornea covered by the upper lid, 
but which, in severe cases, may involve its entire surface. It depends 
upon the formation of new blood-vessels between the corneal epithelium 
and Bowman's membrane, associated with collections of round cells. 
It may be composed of only a few vessels (ptannus tenuis'), or be thick, 
fleshy (pannus crassus), and bulging in appearance. If softening and 
ulceration occur, the true corneal tissue is invaded. 
It is sometimes taught that pannus is mechanical in origin and is 
caused by the friction of the granulations. According to Raehlmann, 
however, it should not be considered as a simple traumatic irritation, 
but as a follicular process, with the formation of lymphoid infiltration, 
analogous to the same pathologic condition in the conjunctiva; in short, 
pannus is to be regarded as a special implantation of the trachoma 
process in the layers of the cornea. Mutermilch believes that pannus 
does not depend upon roughness of the conjunctiva, but upon the de- 
struction of living epithelium, and where this is regenerated, the pannus 
subsides. Extensive and deep ulceration may complicate pannus, which, 
in turn, may lead to the development of iritis; or the cornea may become 
entirely opaque; or, finally, the ulceration may be followed by perfora- 
tion of this membrane and staphylomatous bulging. 
Diagnosis.-This usually presents no difficulties. An examination 
of fresh material should reveal the Prowazek-Greeff granules, but, as 
has already been pointed out, the presence of these bodies, while highly 222 
DISEASES OF THE CONJUNCTIVA 
significant, is not sufficient to establish a diagnosis; i. e., their absence 
does not exclude trachoma. The disease is made evident by direct 
inspection of the everted lids unless the associated swelling of the pap- 
illae is so great as to obscure the "granulations," especially in the forms 
of papillary trachoma. Hypertrophied conjunctival papillae, chronic 
blennorrhea, and surface granulations must not be mistaken for trach- 
oma. The clinical distinctions existing between trachoma and fol- 
licular conjunctivitis have been pointed out. Great care should be 
exercised in the inspection of immigrants, and those undoubtedly 
trachomatous should be deported. All suspected persons, and 
all those in whom the diagnosis is uncertain, should be isolated 
and detained until the exact nature of their conjunctival trouble is 
ascertained. 
Prognosis.-In the best circumstances, granular lids, when well 
established, is a tedious disease, and greatly endangers the vision of the 
patient. Relapses are frequent, and at any time the disorder is likely 
to assume an intense inflammatory action. Its contagious character 
renders the affection especially dangerous in schools and in any insti- 
tution where large numbers of inmates are gathered together. The dis- 
charge, even when present in slight degree, is readily conveyed from one 
subject to another by the careless use of towels and common utensils. 
Great caution is necessary in such circumstances to prevent a disastrous 
epidemic. 
Treatment.-The treatment of chronic granular lids includes the 
application of caustics, astringents, antiseptics, and certain so-called 
specific remedies, operative procedures, and general medication. 
Local applications of astringent and caustic preparations are used 
to cause absorption of the "granulations," but these should not be of 
such strength as to produce cicatricial changes more harmful than the 
original malady. 
A variety of substances has been employed; indeed, it is safe to 
assert that there is scarcely an antiseptic or caustic agent the use of 
which is permissible in ocular disorders that has not been tried in 
the effort to alleviate the symptoms of this disease. If granular con- 
junctivitis is associated with much discharge in the sense of mucopuru- 
lent secretions, the ordinary antiseptic and slightly astringent lotions 
are useful, and should be freely employed to irrigate the conjunctival 
culdesac. Those which serve the best purpose are saturated solutions 
of boric acid, bichlorid of mercury (1 : 5000 or 1 : 10,000), and cyanid 
of mercury (1 : 1500). 
Formerly, during the stage of conspicuous lymphoid infiltration and 
decided follicular eruption, without the presence of much discharge, the 
direct application to the everted lids of strong solutions of bichlorid of 
mercury (1 :300 or 1 : 500) were much employed, and at one time the 
author was impressed with their value, but in recent years has practi- 
cally discontinued them. 
In the stage of softening of the granulations and swelling of the 
conjunctival pseudopapillse, associated with mucopurulent and purulent GRANULAR CONJUNCTIVITIS 
223 
discharge, in addition to flushings with the antiseptic solutions already 
mentioned, nitrate of silver is of value, employed in the manner already 
described (see page 201). Generally it is not necessary to use a solu- 
tion stronger than 2 per cent. Instead of nitrate of silver, argyrol and 
protargol in the usual strengths may be employed. In this stage 
solutions of permanganate of potassium (1 : 3000 and 1 : 5000) have been 
advocated, while stronger solutions (1 : 1000) have been applied directly 
to the everted lid. 
At one time sulphate of copper was almost universally employed in 
the treatment of trachoma, and the author is convinced that it still 
occupies a useful place in the management of this affection. Where the 
eruption of new granulations is associated with beginning cicatricial 
metamorphoses of old crops and their surrounding tissue, this remedy 
is of value. The crystal of sulphate of copper should be smooth and 
carefully applied to all portions of the affected areas, especially to the 
retrotarsal folds, and the treatment followed by washing the surface 
with cold water. It is a painful remedy, and in sensitive patients there 
is no objection to cocainizing the eye. In order to render sulphate of 
copper painless, it has been suggested to fuse it into a crayon composed 
of this drug, orthoform, holocain, and gum tragacanth. Sulphate of 
copper, dissolved in glycerin (5 per cent, solution) is a most useful 
application. 
In place of sulphate of copper, copper citrate (cuprocitrol), originally 
recommended by F. R. Von Arlt, has found favor with some surgeons. 
It may be employed in a 5 or 10 per cent, ointment, which is introduced 
well in the conjunctival sac, and gentle but thorough massage used im- 
mediately afterward. 
During the later stages of trachoma, in order to hasten the absorp- 
tion of remaining granulations and perhaps to prevent the tendency to 
xerosis, boroglycerid (30-50 per cent.) is a useful remedy, applied in the 
usual manner with a cotton mop. In mild cases, or after an impression 
has been made with stronger caustics, a favorite astringent is tannin 
and glycerin, 30 to 60 grains to 1 ounce (1.95-3.9 gm. to 30 c.c.), or the 
everted lids may be touched with an alum crystal. Among the many 
additional remedies which have been tried in this affection the following 
may be mentioned: Liquid carbolic acid, liquor potassa, beta-naphthol, 
hydrastin, iodoform, or aristol (in powder or salve), an ointment of the 
yellow oxid of mercury, calomel, iodid of silver, ichthargan (2 to 3 per 
cent.), itrol in powder, ichthyol, and cyanid of mercury (1 : 500), which 
is energetically rubbed by means of a tampon of cotton wool over the 
granular surface. 
Granular lids are liable at any time to develop acute symptoms: 
increased discharge; exacerbation of pannus, with clouding and ulcera- 
tion of the cornea; hyperemia of the iris, and acute pain in the brow 
and temple. Usually severe local applications must be discontinued, 
and the treatment instituted which is applicable to acute conjunctivitis, 
and which need not be here repeated. Hot compresses are often agree- 
able, and the pupils should be dilated with a solution of atropin or 224 
DISEASES OF THE CONJUNCTIVA 
scopolamin. In this stage and, indeed, in other stages, especially if 
pannus is present, it would seem that dionin is of some value. 
The x-ray treatment of trachoma has occupied a very large share of 
attention within the last few years, and has been recommended by 
Mayou, Stephenson, Walsh, and other surgeons. 
The author's experience with this method of treatment is too limited 
to render an expression of opinion from him of value. In the few cases 
in which he has used it and seen it employed the results were indifferent, 
certainly not any better than those obtained by ordinary therapeutic 
agents or operative procedure. With improved technic, and particu- 
larly with the ability to measure the exact dosage of the rays, it would 
seem that the method offers a fair prospect of success, and should 
be given the fullest trial. Radium has also been used in the treat- 
ment of trachoma, but Charles H. May, who has studied the action 
of this substance in this respect, concludes that the results obtained 
are not so favorable as those secured with sulphate of copper. Carbon- 
dioxid snow has also been employed; applications for a few seconds 
once a week at first, later the time may be increased to twenty seconds. 
Stephenson and Walsh also recommend the application of the 
high-frequency current through a vulcanite electrode applied to the 
upper lid in the treatment of severe trachoma. 
Operative Procedures.-These include the various methods for re- 
moving the granulations: Scarification of the conjunctiva; abscission 
of the granulation; excision of the retrotarsal fold or of a strip of the 
infiltrated fornix; removal of a part of the tarsal conjunctiva at the same 
time that the strip of infiltrated fornix is excised (the so-called combined 
excision); extirpation of the tarsus (Kuhnt's extirpation) and squeezing 
or rolling out the trachoma follicles with suitable instruments, espe- 
cially with Noyes', Knapp's, or Kuhnt's forceps. Removal of the gran- 
ulations by means of a curet or stiff brush, and then rubbing into them 
strong solutions of bichlorid of mercury or cyanid of mercury (grattage, 
brassage), are measures that have been much employed. Grattage is 
performed by D. H. Coover with strips of sterilized sand-paper. The 
methods of applying the various operative procedures are described on 
page 617. 
Of the methods just enumerated, expression of the follicles with 
suitable forceps, particularly in the so-called follicular forms of trach- 
oma, is the most satisfactory, although both simple and combined 
excision of the infiltrated fornix sometimes yields exceedingly satis- 
factory results. Some surgeons, notably Mr. George Lindsay Johnson, 
recommend electrolysis in the treatment of trachoma. 
Treatment of Trachoma with Pannus.-If the pannus is limited in 
degree, it requires no special treatment, as it will disappear with the 
absorption of the granulations; but if it is extensive, and especially if 
associated with ulceration, special treatment should be directed toward 
its cure. This includes the local remedies which are appropriate for a 
vascular keratitis, namely, an antiseptic lotion, the various mydriatics, 
and occasionallv dionin. GRANULAR CONJUNCTIVITIS 
225 
Inveterate pannus, without ulceration of the cornea, at one time was 
treated by the production of a violent conjunctivitis, characterized by 
the formation of a somewhat clinging false membrane, with a 3 per cent, 
infusion of jequirity, painted upon the everted lids. This method was 
introduced by de Wecker to substitute the old-fashioned inoculation of 
the conjunctiva with blennorrheic pus. It has also been advised to apply 
the same drug in fine powder, a little at a time, exactly upon the portions 
of the granulations to be absorbed. The author has not been favorably 
impressed with jequirity. It has been recommended in this country 
by Cheatham and Sweet in recent years. 
Since the introduction into ophthalmic practice of jequiritol and 
jequiritol serum by Roemer, these substances have been much employed 
in the treatment of trachoma. Jequiritol is an extract made from the 
seed of the abrus precatorius. It is used in a sterile solution mixed with 
50 per cent, glycerin, so that an exact dose can be given without evil 
effects, which was not possible with abrin or the old infusion. Accord- 
ing to Casey A. Wood, who has published directions for its application 
according to Roemer's method, it should be used as follows: The drug 
comes in four different degrees of strength. A single drop of No. 1 is 
instilled into the conjunctival sac by means of a capillary tube. If no 
severe reaction follows, the dose must be daily increased until a typical 
jequiritol inflammation develops. Occasionally no reaction occurs 
until No. 2 is used, when the acute inflammation is finally induced, and 
subsides in a few days. Subsequently the eye will endure a still stronger 
dose. Immunity is obtained after a number of inflammatory attacks, 
and at last the strongest dose produces no effect. If twenty-four hours 
after the employment of a dose the inflammation appears to be too 
severe, several drops of the jequiritol serum should be instilled into the 
eye frequently during the day. According to Hoor, jequiritol is indi- 
cated in old trachomatous pannus with cicatrized and degenerated con- 
junctiva. It is contraindicated in purulent processes of the cornea, in 
recent opacities, and in fresh trachomatous pannus. In spite of all care 
certain complications may arise-for example, edema of the lids, pain, 
facial eczema, and suppuration of the lacrimal sac. Evidently jequir- 
itol is not without danger, and should be restricted to the cases already 
described. 
The operation of peritomy, which consists of an excision of a ring of 
conjunctival tissue surrounding the cornea, has been much practised for 
the relief of severe pannus. Another method is to scrape away the 
opaque and vascular areas in the cornea with a small knife (Gruening). 
If the palpebral fissure becomes contracted by cicatricial changes, or if 
during inflammatory periods in trachoma the lids dangerously com- 
press the cornea, the operation of canthoplasty affords relief. 
General Medication.-It is a mistake to depend solely upon local 
measures for the relief of granular conjunctivitis, for, although the dis- 
ease has no proved consitutional origin, its subjects give frequent evi- 
dence of malnutrition, and are sometimes affected with tuberculosis. 
Hence, in addition to every advantage that fresh air-if possible, at a 
15 226 
DISEASES OF THE CONJUNCTIVA 
high elevation-good food, and pleasant hygienic surroundings can 
give them, iron, cod-liver oil, hypophosphite of lime, arsenic, and, in 
short, a general tonic regimen should be ordered. Suitable attention 
to the alimentary tract is important. 
Parinaud's Conjunctivitis {Infectious Conjunctivitis; Septic Con- 
junctivitis; Lymphoma of the Conjunctiva [Goldzieher]).-This rather rare 
form of conjunctival affection was first accurately described by Parinaud 
in 1889, and has in recent times been the subject of very extended 
researches, particularly by Chaillous in France, and Gifford, Verhoeff, 
and G. S. Derby in this country. According to the last-named authors, 
the disease has been observed only in the temperate zone, and occurs 
a little more frequently in the autumn than at other seasons. The 
sexes are about equally affected, and all ages seem liable to it, the 
youngest patient recorded being one and a half years of age and 
the oldest fifty-nine. More commonly it is a unilateral than a bi- 
lateral disease; indeed, only a very few times have both eyes been 
affected. 
The chief symptoms are the following: Swelling of the lid, usually 
most marked in the upper lid, hyperemia and edema of the bulbar con- 
junctiva, and a moderate mucopurulent discharge. The characteristic 
conjunctival lesions consist of large, reddish, semitransparent polypoid 
vegetations, small yellowish granules, erosions, and superficial ulcers. 
Sometimes the conjunctival growths are pedunculated. Very rarely 
corneal changes in the form of keratitis have been described. Glandular 
involvement usually takes place simultaneously with or very soon after 
the development of the ocular disease. In a few instances it has pre- 
ceded them. Most often the preauricular glands are affected; more 
rarely the retromaxillary, the parotid, the submaxillary, and the cervi- 
cal. Occasionally acute tonsillitis has been noted. The disease may 
last from one to five months. 
So far, investigations have failed to isolate any of the known micro- 
organisms as a causative agent of this disease, although McCrae found 
in one case a bacillus which resembled the Klebs-Loffler bacillus, which 
he regarded as the probable excitant of the ocular inflammation. Sin- 
clair and Shennan have isolated two varieties of white staphylococci 
from the necrotic areas in one case. Parinaud believed that the disease 
was of animal origin, and Hoor maintains that in the majority of cases 
there is a history of an opportunity of animal contagion; but Verhoeff 
and Derby regard this theory, at present at least, as unsubstantiated. 
Recently Verhoeff has found in the lesions of this affection a filamentous 
organism classified as a leptothrix, which he regards as the cause of the 
disease. There may be difficulty in distinguishing the disease from 
tuberculosis of the conjunctiva, and to reach a definite diagnosis it may 
be necessary to inoculate the anterior chamber of a rabbit's eye with a 
fragment of the suspected tissue. Microscopic examination of the ex- 
cised tissue reveals cellular infiltration, consisting of lymphoid and 
phagocytic cells and marked cellular necrosis. 
The treatment recommended includes the ordinary antiseptic col- CHRONIC CONJUNCTIVITIS 
227 
lyria, nitrate of silver, or the newer silver salts, applications of sulphate 
of copper, and excision of the granulations. The injection of antidiph- 
theritic serum has been tried, and Sinclair and Shennan have instituted 
vaccine treatment, but the patient did not remain under observation 
for a sufficient time to demonstrate the value of the method. 
Sporotrichosis of the conjunctiva has been reported by Morax, 
Cruchandeau, Gifford, and others. Thickening of the lid, nodular 
swelling of the conjunctiva, superficial yellowish ulcers, and adenopa- 
thy were present. (See also page 168.) 
Chronic conjunctivitis (chronic ophthalmia}, the result of an acute 
blennorrhea, has been referred to on page 206. 
As an independent disorder, and assuming more the type of a hy- 
peremia, it is a common disease in elderly persons. There are hy- 
peremia, thickening of the papillary layer of the tarsal conjunctiva, 
swelling of the caruncle, soreness of the edges of the lids, and slight 
mucopurulent discharge. Often the bulbar conjunctiva is notably 
injected. Chronic conjunctivitis due to hypersecretion of the Mei- 
bomian glands (conjunctivitis meibomiana} and to "insufficiency of the 
eyelids," so that they close only with effort and remain open during sleep, 
is described by Elschnig. The latter may result in a form of xerosis of 
the conjunctiva (tyloma conjunctiva, Saemisch). A chronic conjuncti- 
vitis of moderate severity with only slight injection and traces of ab- 
normal secretion in the commissural angles has been called conjunctivitis 
sicca, and is especially aggravating on awakening. It is to this affec- 
tion that the so-called "morning ptosis" is usually due, the patient 
being unable to open the eyes except with the help of the fingers, which 
elevate the lid. The relation of the diplobacillus to chronic and sub- 
acute conjunctivitis has been described (see page 192; see also Hyper- 
emia of the Conjunctiva, page 187). In association with chronic 
conjunctivitis and chronic ciliary blepharitis delicate flame-shaped 
marginal keratitis may arise, the lesions having their bases at the 
limbus and their apices advanced about one-third way across the 
cornea (W. T. Holmes Spicer). 
Treatment.-Cleanliness, with antiseptic lotions, the application 
of "lapis divinus," an alum crystal, or glycerol of tannin, gr. x to fgj 
(0.65 gm. to 30 c.c.), are useful local measures. Aqueous solutions of 
suprarenal extract (8 per cent.) or adrenalin chlorid (1 : 10,000) will 
temporarily dissipate the congestion, but the author has not been 
able to persuade himself that they are curative in their action. The 
puncta lachrymalia should be examined, and if they are closed, they 
should be dilated and the lacrimal passages irrigated with an Anel 
syringe, and the nasal chambers should be carefully treated. Refrac- 
tive error, which may keep up congestion, requires correction. For 
conjunctivitis meibomiana emptying of the Meibomian glands is recom- 
mended (Elschnig, Fridenberg). Boric acid in lanolin (2 per cent.) is 
useful if the conjunctival surface is too dry. If the Morax-Axenfeld 
bacillus is present, solutions of zinc sulphate or chlorid should be used 
(see page 194). 228 
DISEASES OF THE CONJUNCTIVA 
Egyptian and military conjunctivitis are terms which have at 
different times been loosely used to describe all forms of conjunctival 
inflammations occurring in crowded barracks and similar institutions, 
which assumed an epidemic tendency, pursued a more or less chronic 
course, and hence included varieties of acute and chronic blennorrhea 
and mucopurulent conjunctivitis, in addition to those cases which 
possessed as a fundamental diagnostic symptom "granulations" of the 
conjunctiva, and which eventuated in the formation of cicatrices. 
Lacrimal conjunctivitis is really a form of chronic conjunctivitis 
depending upon obstruction of the lacrimal passages and the frequently 
associated blepharitis, and in the discharge of which streptococci are 
found. The eyelids are inflamed upon their borders, the cilia gathered 
in little tufts by the formation of small pustules at their bases, the 
conjunctiva is injected and tear-soaked, and there is a somewhat gummy 
discharge. This form of conjunctivitis may be complicated, according 
to Parinaud, with hypopyon and iridocyclitis. 
The treatment requires that the lacrimal passages shall be rendered 
patulous, in addition to the ordinary remedies suitable for chronic con- 
junctivitis and ulcerated blepharitis. 
Lithiasis conjunctivae is a troublesome condition caused by a cal- 
careous degeneration of inspissated secretion in the acini of Meibomian 
glands. It is more commonly seen in elderly people than in young sub- 
jects, especially if they are gouty. On everting the lids, numerous 
small, yellowish-white concretions will be seen distinctly gritty to the 
touch. These act like so many foreign bodies and produce considerable 
irritation and pain. 
Each concretion should be removed with a fine needle, the conjunc- 
tiva having first been rendered insensitive with cocain. 
Toxic conjunctivitis is a name suited to those forms of conjunctival 
inflammation caused by certain chemicals, by insects, and by the pro- 
longed use of the mydriatics (notably atropin) and the miotics. 
Atropin conjunctivitis occurs at all ages, but is commonest in old 
persons. Sometimes it will appear after only a few drops of the solution 
have been used, but usually not until the drug has been employed for a 
long time. It has been attributed to impurities in the drug, to the ex- 
istence of free acid, to the presence of a fungoid growth, and to idiosyn- 
crasy. In a number of instances arthritic history has been obtained 
(Collins). The disease usually appears in the form of follicular granu- 
lations, sometimes associated with much swelling of the lid and eczema 
of the surrounding tissue. (See also page 214.) 
Eserin, hyoscyamin, duboisin, and homatropin less commonly cause 
this affection, and the same disorder has been reported as the result of 
the prolonged use of cocain. 
Conjunctivitis occurs among those who work in anilin dyes, and from 
chryosphanic acid, when this has been used as an ointment in skin 
affections, and may be caused by artificial fertilizers. Chrysarobin 
conjunctivitis (photophobia, lacrimation, and blepharospasm) may, 
according to Igersheimer, be associated with gray deposits in the cornea, CONJUNCTIVITIS NODOSA 
229 
resembling superficial punctate keratitis. Podophyllin coming in con- 
tact with the eye may produce intense congestion, edema of the lids, and 
infiltration of the cornea (C. Chiari). 
Conjunctivitis caused by caustics, acids, and other strong irritants 
is elsewhere considered. Workers with a-rays are subject to a severe 
and at times intractable form of conjunctivitis (see page 507). Con- 
junctivitis may follow the stings of flies and other insects, and has been 
described as due to the presence of larvae in the conjunctival sac (larval 
conjunctivitis). Parasitic conjunctivitis due to one of the groups of the 
higher fungi has been reported by A. J. Smith, C. M. Hosmer, J. T. 
Carpenter, Jr., and W. C. Posey. Violent conjunctivitis may be caused 
by the venom of certain serpents, by eel-blood, and contact with as- 
carides. Some persons quickly acquire a sharp conjunctivitis if they 
come near horses, for example, in driving, or if they stroke the fur of a 
cat or work among certain flowers, notably the primrose, or if plant 
hairs gain entrance to the conjunctival sac. 
The treatment in general demands the removal of the cause, and in 
atropin conjunctivitis applications of tannin and glycerin and of an 
alum crystal are useful. In some instances the author has found a 1 
per cent, solution of creolin of service. A bland ointment for the 
irritated cutaneous surface and the ordinary antiseptic lotions are indi- 
cated. 
Conjunctivitis Nodosa (Ophthalmia Nodosa; Pseudotuberculosis of 
the Conjunctiva [Wangenmann]).-This disease is caused by the irritation 
of caterpillar hairs which have lodged in the conjunctiva, cornea, or iris, 
and was first described in 1883 by Pagenstecher. In addition to con- 
junctival congestion and pericorneal injection, the disease is character- 
ized by a number of grayish or yellowish semitransparent nodules, which 
are located in the conjunctiva and episclera, the most usual situation 
being the ocular conjunctiva between the lower border of the cornea and 
the fornix. In a case studied by the author and E. A. Shumway, 
27 such nodules could be differentiated, those directly in the center of 
the collection being somewhat confluent and assuming a crescentic 
and circular appearance. The lesions strongly suggest tubercle of the 
conjunctiva; and, indeed, the disease is called pseudotuberculosis of the 
conjunctiva by some authors. The center of each nodule usually con- 
tains a caterpillar hair, and is surrounded by round cells, giant cells, 
and externally by spindle cells and a capsule. It is not definitely decided 
whether the irritation is a mechanical one, or whether it is due to some 
constituent of the hairs. Not only is the conjunctiva affected, but the 
hairs may penetrate the cornea, enter the iris, and there form the nodules 
which have been described. It is probable that they may even reach 
the choroid. The disease is generally caused by certain species of 
caterpillar, particularly Lasiocampa, or Bombyx (B. rubi, B. pini), 
Liparis (L. monacha, L. dispar), etc. In the case studied by the author 
and Dr. Shumway the hairs of the Spilosoma virginica were identified. 
This subject has recently been elaborately studied by Teuschlaender 
and by Parker in this country. The treatment should consist in excision 230 
DISEASES OF THE CONJUNCTIVA 
of the conjunctival nodules and the ordinary remedies for conjunctivitis. 
A somewhat similar disease, clinically resembling trachoma, has been 
described by Markus as the result of the implantation of plant hairs. 
Xerophthalmos (atrophy of the conjunctiva; xerosis) is the name 
employed by systematic writers to describe a dry, lusterless, and 
shrunken appearance of the conjunctiva, and is recognized under two 
forms-parenchymatous and epithelial. 
The former type results from cicatricial changes which involve the 
deep layers of the conjunctiva; the sulcus is obliterated, and the lids, 
in severe cases, are attached to the eyeball, while the cornea is opacpie. 
The surface of the conjunctiva of the lids is smooth, dry, and almost 
leathery to the touch. Granular lids, diphtheritic conjunctivitis, pem- 
phigus, and essential shrinking of the conjunctiva are the causes of the 
disorder. 
Treatment is of no avail, but some comfort may ensue by instilling 
glycerin and wTater or by the local use of an emulsion of cod-liver oil. 
In the epithelial type the exposed ocular conjunctiva becomes dry 
and has a lack-luster appearance; cheesy flakes form, and the mem- 
brane is greasy and thrown into folds. A short bacillus (xerosis bacillus) 
has been found in the secretion of these cases, but its pathogenic char- 
acter is doubtful. This form of xerosis sometimes occurs in epidemics, 
associated with night-blindness, and is seen among people of poor 
nutrition-for instance, during prolonged fasts-or among those whose 
eyes have long been exposed to sunlight. It is also one of the symp- 
toms of keratomalacia in infants. According to Stephenson, the dis- 
ease is not rare. Night-blindness is not always present, but usually 
there are signs of torpor of the retina, with contraction of the visual 
fields and reversal of the red and green fields (see also page 506). 
The treatment demands a nutritious diet, a soothing collyrium, dark 
glasses, and removal from the surroundings which have caused the 
difficulty. 
Amyloid disease of the conjunctiva is a rare disorder, in which 
pale, yellowish masses appear chiefly in its palpebral portion. It has 
been supposed to arise from granular conjunctivitis, but, according to 
Raehlmann, the growths are independent of trachoma. 
Extirpation is the proper mode of treatment. Their structure is 
analogous to lymphoid tumors in which a hyaline degeneration may be 
found, and which, in all probability, is an antecedent condition (Raehl- 
mann, Kubli). The diagnosis can be made with certainty only by sub- 
mitting the tissue to the iodin test. Herbert has described hyaline or, 
as he prefers to call it, colloid degeneration of the conjunctiva. 
Conjunctivitis Petrificans.-In this rare disease, described by 
Leber in 1895, a number of irregular white, opaque spots appear in the 
conjunctiva, which are slightly elevated above the surface and covered 
by epithelium. The surrounding conjunctiva is reddened and some- 
what inflamed, and any portion of it may be affected, and in advanced 
stages the disease may spread to the bulbar conjunctiva and the tissue 
of the lids. The disease may assume a recurring as well as a spreading ABSCESS OF THE CONJUNCTIVA 
231 
nature, and in any event is a chronic one, and may last for months or 
even years. Nothing is known of the etiology of the disease, the white 
spots consisting of deposits of lime associated with an organic base. 
All cases thus far reported have occurred in young females. Recently 
Sidler-Huguenin observed a case of this character in a hysteric girl 
who produced the lesions by putting lime into the conjunctival sac. 
It did not differ from the type ordinarily described. 
Pterygium is a peculiar, fleshy growth, consisting of hypertrophy 
of the conjunctiva and subconjunctival tissue. One or both eyes may 
be affected. Its most usual situation is at the inner side of the eyeball, 
corresponding to the course of the internal rectus muscle; more rarely 
it develops at the outer, and very exceptionally at the upper or lower, 
part. When the fan-shaped expansion arises from the semilunar fold 
and caruncle, it converges as it ap- 
proaches the cornea, the center of 
which it rarely passes. 
The growth is uncommon in young 
subjects, the average age, according 
to Fuchs, being about forty-eight, al- 
though it often develops at a much 
earlier period of life. According to 
Robert Thompson, of Australia, and 
John McReynolds, of Texas, in their 
regions the affection is not infre- 
quently encountered in young sub- 
jects, Thompson's youngest patient 
being only fifteen years old. The theory advanced by Arlt, that ulcera- 
tion at the margin of the cornea should be regarded as the primary 
cause of the affection, is no longer tenable. According to Fuchs, ptery- 
gium is a development of a pinguecula, and like it, save in exceptional 
cases, belongs to the so-called senile changes in the eye. As the ptery- 
gium develops, the characters of the pinguecula disappear. Exposure 
to dust, smoke, wind, and heat is the exciting cause, according to 
McReynolds, who has often seen pterygia both at the inner and the 
outer canthus. Pseudopterygia may result from blennorrhea, burns, 
or erosions of the corneal surface, the thickened conjunctiva becoming 
attached to the corneal lesion. 
The treatment consists in excision, transplantation, strangulation 
by means of ligatures, or evulsion (see page 614). 
Pinguecula is a small, yellowish elevation situated in the con- 
junctiva near the margin of the cornea, and usually at the inner side. 
It has the appearance of fatty tissue, but is a hyaline degeneration of the 
connective-tissue fibers of the subconjunctival tissue, and should be 
regarded, according to Fuchs, as the first stage in the development of a 
pterygium. It may be excised or destroyed with the actual cautery. 
Abscess of the conjunctiva is a rare condition, in which a local- 
ized area of suppuration appears in the subconjunctival tissues. It 
may develop in children of greatly depressed nutrition, and is sometimes 
Fig. 109.-Large pseudopterygium, 
the result of a lime-burn. 232 
DISEASES OF THE CONJUNCTIVA 
the sequel of a wound. Ulcers of the conjunctiva are occasionally seen 
and may be severe enough to destroy the tarsus (Cailloud). Widmark 
and T. Harrison Butler have described a form of conjunctival disease 
characterized by congestion of the inferior tarsal conjunctiva and of this 
membrane in the lower epibulbar expansion. Part or all of the affected 
area stains with fluorescein. Slight stippling of the cornea may be 
present. Brow pain and occipital headache may precede the inflam- 
mation. Massage with a 1 per cent, ointment of yellow oxid of mer- 
cury, according to Butler, is the best application in the treatment of 
Widmark's conjunctivitis. 
Ecchymosis of the Conjunctiva.-This is an extravasation of 
blood beneath the conjunctiva sclerse, the meshes of the connective tissue 
being filled with blood-clot, and occurs as the result of an injury, or from 
some violent, straining effort-e. g., during a paroxysm of whooping- 
cough or a convulsive seizure. It may arise without obvious cause, 
especially in elderly persons, and has been seen in young girls at the 
time of the menstrual epoch. Its occurrence during severe conjunctival 
inflammations has been described. Recurring subconjunctival hemor- 
rhages are important indications of chronic nephritis and arteriosclerosis. 
They also occur in diabetes. Ordinarily, subconjunctival hemorrhage 
will subside by absorption and requires no treatment. 
Chemosis (edema) of the conjunctiva occurs where the connective- 
tissue layer is distended with serum, and is often associated with an 
inflammatory exudation. It is generally a symptom of some other dis- 
ease-for example, acute conjunctivitis, choroiditis, iritis, sinusitis, or 
orbital cellulitis. Angioneurotic edema of the conjunctiva, with swell- 
ing and hyperemia, may appear without any apparent cause and with 
marked suddenness. In paralysis of the external straight muscles the 
overlying conjunctiva is often decidedly edematous, and may be an 
early symptom of this condition. Chemosis of the conjunctiva follow- 
ing the use of iodid of potassium has been reported by the author, and 
it may succeed a general outbreak of urticaria. 
Treatment.-The swollen tissues may be incised and an astringent 
lotion prescribed. 
Emphysema of the conjunctiva consists in a distention of the 
connective-tissue spaces with air, and occurs under the same condi- 
tions which occasion this accident when it involves the eyelids. 
Lymphangiectasis of the conjunctiva is a development of small 
blisters in the conjunctiva, filled with semitransparent fluid, and usually 
gathered together in masses. These are situated superficially, and 
readily move with the conjunctiva over the subjacent tissue. An inter- 
ference with the natural lymph flow and consequent distention of the 
lymph-spaces is the probable explanation of their appearance. The 
affection is said to be most frequent in children, but may occur at any 
age. Spontaneous disappearance is the common outcome, but, if need 
be, the small blisters may be incised. 
Syphilis of the Conjunctiva.-Chancres may develop on the 
upper or lower culdesac, and even upon the ocular conjunctiva, as TUMORS AND CYSTS OF THE CONJUNCTIVA 
233 
primary affections, and not only as extensions from the lids. A few 
instances of soft chancre have been described. 
As manifestations of general syphilis, ulcerated papular syphilids 
and gumma of the conjunctiva have been recorded. Mucous patches 
occasionally develop on the conjunctiva. Finally, there is a type of 
inflammation called syphilitic conjunctivitis, which appears as a stub- 
born catarrh, or in the form of granulations similar to trachoma follicles, 
in an anemic and rather colloid-looking conjunctiva. The disease is 
not amenable to local treatment, but disappears under antisyphilitic 
remedies. Conjunctival lesions in hereditary syphilis are uncommon; 
papular syphilids and gummas have been described. 
Tumors and Cysts of the Conjunctiva.-As congenital forms, 
translucent cysts, angiomas, cavernous angiomas, lymph-angiomas, 
dermoid growths (see page 284), and pigment spots have been de- 
scribed. Moles of the conjunctiva are usually deeply pigmented (occa- 
sionally they have a gray or pinkish color); rarely they spread over the 
tissue without involving the deeper layer. Angiomas may be situated 
on the palpebral conjunctiva, the bulbar conjunctiva, the fornix, or 
the plica. Usually congenital in origin, they may arise in later life. 
A nevus may be the starting-point of a sarcoma. Pigment spots, after 
healing of variolous pustules, have been described. Noevus pigmentosus 
also occurs (Wintersteiner) and may give rise to sarcoma. Pigment 
patches on the ocular and palpebral conjunctiva have been observed- 
melanosis of the conjunctiva (Randolph). In a patient under the care 
of the author there was marked bilateral pigmentation in both con- 
junctival sacs, with patches of pigment in the semilunar folds and 
caruncles. He was one of a family with this peculiarity, which had 
existed in a number of generations. 
Cysts of the conjunctiva may appear in the bulbar conjunctiva, in the 
palpebral conjunctiva, and in the fornix. Parsons describes the fol- 
lowing varieties: Retention, lymphatic, traumatic, parasitic, and con- 
genital cysts. This materially simplifies Cirincione's elaborate classi- 
fication. Retention cysts, often seen in the region of the retrotarsal 
folds, are small, oval, clear bodies. They develop in new-formed glands 
as the result of inflammation, in the so-called Henle's glands, and more 
rarely in Krause's glands. They may also arise from the accessory 
lacrimal gland. Lymphatic cysts appear in the bulbar conjunctiva, 
and represent dilatations of lymphatic vessels (lymphangiectasis and 
lymphangioma (see page 232). Usually multiple, they occasionally 
appear as isolated, yellowish cysts. Traumatic cysts arise as the result 
of a conjunctival wound or injury, and sometimes are implantation 
cysts-that is, through the wound epithelium from the skin, cilia, etc., 
gains entrance, degenerates, and produces the cyst. Parasitic cysts 
are usually due to the presence of a cysticercus, and appear as large, 
yellowish vesicles. A white spot in the wall may indicate the situation 
of the embryo. Filariae may also cause conjunctival cysts. To a 
growth situated near the corneal margin, semitranslucent in color, and 
often of congenital origin, Parinaud gave the name dermo-epithelioma. 234 
DISEASES OF THE CONJUNCTIVA 
For this title Oatman preferred the name "epithelial cystoma of the 
conjunctiva," as he believed it represented a transitional stage in the 
development of the epithelial cyst. 
Among the benign tumors, dermoids (see page 284), lipoma, fibroma, 
osteoma, granuloma, adenoma, hemangioma, and papilloma have their 
habitat upon the conjunctiva. Lipomas and lipomatous dermoids are 
found (see Fig. 114) between the superior and the external rectus. Fibro- 
mas are either hard or soft, and appear in the form of polypi. Soft fibro- 
mas occur chiefly in the fornix or palpebral conjunctiva, and are often 
highly vascular. Hard fibromas are less common, and arise from the 
palpebral conjunctiva or caruncle. Bone formation usually occurs 
betwen the margin of the cornea and the commissure. Papillomas 
Fig. 110.-Epibulbar lipoma (from a 
patient in the University Hospital.) 
Fig. 111.-Papilloma of the conjunctiva 
(from a patient in the Philadelphia General 
Hospital). 
are either pediculated or sessile, and histologically resemble the struc- 
ture of the papillae. They may arise from the conjunctiva or plica, 
and are often multiple. Ordinarily benign, they may undergo car- 
cinomatous degeneration and infiltrate the eyelids (Risley and Shum- 
way). Papillomas have been confounded with masses of granulation 
tissue arising from wounds-e. g., after strabismus operations and 
with angiosarcomas. Adenomas may originate on the conjunctival 
surface of the lids from Krause's and Moll's glands, and from the 
Meibomian glands. They may develop into malignant growths- 
adenocarcinomas. 
Treatment.-Usually the growths described can be readily excised, 
and the edges of the wound may be united with fine sutures. In simple 
cysts, cutting away the anterior wall is generally sufficient to cause a 
cure. Nevi have been treated with applications of ethylate of sodium TUMORS AND CYSTS OF THE CONJUNCTIVA 
235 
(Snell). The removal of papillomas should be thorough, as they have a 
tendency to undergo carcinomatous degeneration. 
The malignant growths include epithelioma and sarcoma. 
Epithelioma may occur as a primary growth upon the ocular con- 
junctiva, especially at the limbus cornese, and rarely appears before the 
fortieth year of life. Commonly situated at the outer side, it may also 
appear on the nasal side, and in rare instances has surrounded the 
entire cornea (peribulbar epithelioma'). 
The epitheliomatous or carcinomatous growth usually first mani- 
fests itself as a small, reddish elevation surrounded by injection. Gen- 
erally the growth is slow; its base is broad and attached to the under- 
lying tissue; rarely a large fungous mass is formed. The tumor is com- 
posed of proliferating masses of epithelium which proceed from the 
fig. 112.-Sarcoma of corneoscleral 
junction (from a patient in the Jefferson 
College Hospital). 
Fig. 113.-Section of eyeball (see Fig. 112) 
with sarcoma of corneoscleral junction. 
surface epithelium, and are separated into alveoli by a connective-tissue 
stroma. As a rule, the substantia propria of the cornea is infiltrated, 
and if the growth involves the eyeball, it does so along the perivascular 
and perineural lymph-sheaths. Conjunctival epithelioma may be pig- 
mented (melanocarcinomai). 
Sarcoma of the conjunctiva arises at the limbus (epibulbar sarcoma), 
its subjects generally being past middle life, in the form of a reddish- 
white or brownish-black growth, usually overlapping the cornea, but 
not often involving its structure. Both pigmented and unpigmented 
varieties occur, the former being the more frequent. The tumors may 
grow rapidly and reach a large size. They are composed of round and 
spindle cells, and may have a markedly alveolar arrangement (alveolar 
sarcoma')', sometimes the cells are distinctly epithelioid in type (endo- 236 
DISEASES OF THE CONJUNCTIVA 
thelioma). Epibulbar sarcomas may develop from collections of pig- 
mented cells on the conjunctiva ^pigment spots, melanomas'). Rarely 
they invade the interior of the eye. Sometimes they are multiple. Sar- 
comas of the palpebral conjunctiva and fornix and diffuse melanotic 
sarcomas have been recorded. Angiosarcomas of the conjunctiva arise 
from a proliferation of the adventitia of the blood-vessels, and in their 
growth, like fibromas, they thrust the epithelial covering in front of 
them. They have been mistaken for papillomas. 
Prognosis and Treatment.-Epitheliomas vary in malignancy; but 
they tend to recur even when superficial. Occasionally it may be 
proper to remove the growth, with the expectation of saving the eye- 
ball; but if it is involved, complete removal of the globe is indicated. 
Epibulbar sarcomas have been removed and the eyeball preserved; but 
Verhoeff and Loring regard them as highly malignant, inasmuch as 
there is a history of recurrence in fully 80 per cent, of the cases, and 
recommend that the eyeball should be removed at once. Excision of 
Fig. 114.-Lipomatous dermoid of the con- 
junctiva: eye turned up and in. 
Fig. 115.-Sarcoma of the conjunc- 
tiva (from a patient in the Philadelphia 
General Hospital). 
these growths is sometimes practicable in the early stages without 
sacrificing the eyeball. 
Lepra.-According to Lopez, the chief alterations in the conjunc- 
tiva produced by leprosy are anesthesia, inflammation, pterygia, and 
tubercles. The anesthesia of the conjunctiva probably determines the 
chronic conjunctivitis, which is common. Pterygia are frequently 
observed, and are caused by the action of external irritants upon the 
ocular conjunctiva, which has become insensitive under the influence 
of the disease. 
It is convenient in this place to refer to the effect of leprosy upon the 
cornea, in which the lesions are frequent and varied. The tubercles 
which form in the conjunctiva are apt to attack the corneoscleral 
margin, but may involve the cornea exclusively. A late manifestation 
of the disease is an inflammation of the cornea known as leprous keratitis, 
which somewhat resembles interstitial keratitis. 
Lupus occurs as a primary disease, or extends to the conjunctiva TUBERCLE OF THE CONJUNCTIVA 
237 
from the surrounding integument. It appears in the form of red, granu- 
lar patches placed upon an ulcerated base. As the same microbe is the 
cause of lupus and tuberculosis, any difference existing in the two dis- 
eases occurring in this situation must rest upon the clinical appearances, 
the lupus spot showing healing in one direction and active ulceration in 
another. Those cases in which the disease has spread from the lid to 
the conjunctiva have especially been classified as lupus. 
Tubercle of the conjunctiva occurs as a primary and as a second- 
ary affection. 
Primary tuberculosis of the conjunctiva is rare, but a certain number 
of instances are upon record in which there was an absence of evidence 
of tuberculosis elsewhere, and in which there was no reappearance of 
the disease locally, or in distant organs, after its removal. Villard 
maintains that in 60 per cent, of the cases he has analyzed no initial 
tuberculous lesion was discovered, and therefore he does not believe in 
its endogenous origin. 
As a secondary affection it has usually appeared in association with 
nasal and laryngeal tuberculosis. 
According to Eyre, who adopts Sattler's classification, the disease 
may appear in one or other of the following manifestations: (1) One or 
more miliary ulcers which usually caseate; (2) grayish or yellowish sub- 
conjunctival nodules which resemble the sago granules of trachoma; (3) 
florid hypertrophied papillse and rounded, flattened outgrowths of granu- 
lation tissue; (4) numerous pedunculated cock's-comb excrescences; 
(5) a distinctly pediculated tumor. The ulcers have uneven and 
slightly raised edges, and their floors have yellow or sometimes a larda- 
ceous appearance. 
There are thickening of the lids, dark-red swelling of the conjunc- 
tiva, considerable discharge, and occasionally tumefaction of the tear- 
sac. The preauricular and submaxillary lymphatic glands of the same 
side are enlarged. Pain is not considerable unless the ulceration in- 
volves the bulbar conjunctiva and cornea or extends to the lids. 
The disease should be distinguished from trachoma, epithelioma, 
and syphilitic ulceration. 
Diagnosis.-In any suspected case the real nature of the affection 
may be decided by excising a portion of the diseased tissue, submitting 
it to microscopic and bacteriologic examination, or by submitting the 
patient to a test with tuberculin, or by implanting a portion of it in 
the anterior chamber of a rabbit's eye. It is not always possible to 
demonstrate the presence of tubercle bacilli. 
In trachoma the lymph-glands are not involved and the discovery of 
the Prowazek bodies (see Fig. 105) would tend to establish the diag- 
nosis. 
Epithelioma is excluded by the age of the subjects, tuberculosis 
almost invariably occurring in young persons; that is, those under the 
thirtieth year of life. 
Prognosis.-This depends upon whether the disease is primary or 
secondary. In order to prevent general infection it is important to 238 
DISEASES OF THE CONJUNCTIVA 
eradicate the local lesion. Sight may be destroyed by involvement of 
the cornea. 
Treatment.-The diseased tissue may be removed with a knife or 
curet; the galvanocautery has been recommended. The subsequent 
treatment should include the use of a collyrium of bichlorid of mercury, 
and iodoform or aristol powder. Injections of tuberculin TR are ad- 
visable, and, according to Ormond and Eyre, represent a treatment far 
superior to incision and scraping. Stephenson suggests the trial of the 
x-rays. Axenfeld uses a 50 per cent, solution of lactic acid in the treat- 
ment of conjunctival tuberculosis; after its application the eye is irri- 
gated with a saline solution. 
Pemphigus of the conjunctiva is a rare affection, characterized 
by the formation of bullse, associated with pain and lacrimation, and, 
after succeeding attacks, degeneration and cicatrization of the con- 
junctiva. Instead of vesicles on the inflamed area, membranous exuda- 
tions, grayish-white in color, may form. According to Michel, the dis- 
ease may be confined to the conjunctiva, or it may attack not only the 
conjunctiva, but also the mucous membrane of the nose, mouth and 
pharynx, and the skin. 
The course of the disease, which tends to recur from time to time, is 
destructive to the nutrition of the conjunctiva, and later to the cornea. 
The former undergoes cicatricial change, and may grow fast to the ball; 
the latter becomes opaque and staphylomatous. 
Under the name essential shrinking of the conjunctiva, a condition of 
atrophy, contraction, and gradual disappearance of the conjunctival 
culdesac has been described, during which the free borders of the lids 
become fixed to the ball and the cornea becomes dry and opaque. 
This probably is a form of pemphigus, but has also been recorded as an 
essentially distinct process. According to Pergens, essential shrinking 
of the conjunctiva may be produced by trachoma, psoriasis, xeroderma 
pigmentosum, ichthyosis, and lupus. 
Treatment.-This is practically unavailing. Applications of glycerin 
and water and other emollients have been employed with the hope of 
keeping the conjunctiva moist, and x-rays (Neeper) and thiosinamin 
(Melville Black) have been advised. Rabbits' conjunctiva and human 
conjunctiva have been transplanted, but usually without beneficial 
results. The internal administration of arsenic has been recommended. 
Injuries of the Conjunctiva.-(a) Foreign Bodies.-A small 
particle of coal, ash, or dust is easily removed if lodged upon the lower 
portion of the conjunctiva; but if it finds its way beneath the upper 
lid, and is situated far back under the retrotarsal fold, it may not come 
into view when the lid is everted unless the fold is pushed into promi- 
nence. If the foreign body is attached to the tissues it may be necessary 
to dislodge it with the point of a needle or with a spud. Cocain or 
holocain will render this operation painless. 
(6) Wounds.-These may be part of a serious injury involving 
the lid or deeper structures of the eye; more rarely they occur as simple 
lacerations, confined usually to the bulbar portion. In suitable cases, AFFECTIONS OF THE CARUNCLE 
239 
after proper cleansing, the lips of the wound should be drawn together 
with a few sutures. 
(c) Bums.-These are commonly inflicted with lime (mortar or 
quicklime), molten metals, powder, and acids, and are especially serious 
because of the deformity which the subsequent contraction is likely to 
produce, or on account of the development of a symblepharon (see page 
180). Ulceration of the cornea, hypopyon, and even panophthalmitis 
may result. The prognosis of such injuries is always grave. 
All foreign substances must be removed at once, and if lime has been 
the injuring agent, this is best accomplished by forcible irrigation of the 
conjunctival sac with clean water. Schmidt-Rimpler, however, prefers, 
in these circumstances, thorough cleansing of the eye with oil intro- 
duced with a syringe into the culdesac. For acid burns an alkaline 
lotion is usually recommended. The subsequent treatment consists in 
the instillation of olive or castor oil, and atropin drops, to prevent sec- 
ondary iritis if the cornea is much inflamed; atropin may be incorpo- 
rated with liquid vaselin and placed in the culdesac. Powder grains 
are frequently embedded in the conjunctiva; they cannot be picked from 
their beds; usually the larger ones can be excised. 
Affections of the Caruncle.-The caruncle and semilunar fold 
may be swollen in conjunction with a general inflammation of the con- 
junctiva, but also may undergo localized enlargement and inflammation, 
to which the name encanthis has been applied, and which is subdivided 
by systematic writers into an acute or inflammatory and a chronic 
variety. The process may go on to the formation of a minute abscess. 
Swollen caruncles are commonly found in patients with eye-strain, 
especially with imperfect amplitude of convergence. The small body 
is red, elevated, and angry looking, and injected vessels run from it 
toward the cornea in the interpalpebral space. This condition might 
be designated symptomatic or functional encanthis. 
In like manner, temporary irritation of the structure is caused by the 
lodgment upon it of a foreign body, or by the presence of misplaced cilia 
which rub against it. The caruncle should be carefully examined when 
patients complain of irritation, lacrimation, and inability to use their 
eyes with comfort. 
The excessive development of the hairs normally placed upon the 
caruncle is called trichosis carunculae. 
A number of tumors situated upon and growing from the caruncle 
have been recorded; in two instances the growth proved to be an ade- 
noma (Prudden and Schirmer). Primary sarcoma (Veasey, Snell) and 
carcinoma of the caruncle (malignant encanthis) have been described. 
Papilloma, dermoids, nevus, fibroma, lymphangioma, epithelioma, cyl- 
indroma, angiosarcoma, and lymphosarcoma have also been reported 
(V. Berl). 
Treatment.-Local irritations of this body may be relieved by the 
direct application of a mild astringent like alum, or soothed by touching 
it with tincture of opium. Foreign bodies, stiff hairs, and misplaced 
cilia must be extracted. A tumor should be removed by excision. 240 
DISEASES OF THE CONJUNCTIVA 
Argyria Conjunctivae {Argyrosis').-Long-continued application of 
solutions of nitrate of silver to the conjunctiva may be followed by a 
brownish discoloration of this membrane. For this reason it is inadvis- 
able to allow patients to use at home even a weak collyrium of this drug. 
The same discoloration follows the injudicious use of protargol, argyrol, 
and largin; indeed, these drugs produce the stain more quickly than 
nitrate of silver, even, it is said, after a few weeks of their employment. 
The coloration is due to staining of the elastic fibers; the epithelium is 
free from pigment. Argyrosis from nitrate of silver is practically irre- 
mediable, although the use of dionin is said to decrease its intensity 
(Lebensohn). Argyrosis from argyrol decreases after a discontinuance 
of the drug (Krauss). A collyrium of iodid of potassium (0.5 per cent.) 
may be tried. A yellowish-brown discoloration of the conjunctiva, 
known as siderosis conjunctivae, due to the prolonged use of sulphate of 
iron, has been reported. CHAPTER VII 
DISEASES OF THE CORNEA 
Under the general term keratitis are included divers forms of in- 
flammatory affections of the cornea, to which, according to the type, 
certain well-marked stages belong; cellular infiltration in the layers of 
the cornea going on either to absorption or to the formation of pus; loss 
of the substance of the cornea lying over the infiltrated area, and the 
development of an nicer; loss of the transparency of the superficial 
corneal layers over an infiltrated area, which has been converted into 
pus and created an abscess, with the final destruction of these layers by 
the development of the abscess; the appearance of vessels in the cornea; 
and the process of repair after loss of substance, or the period of cica- 
trization. 
Certain associated and subjective symptoms may be present in all 
forms of corneal inflammation. Among the former the most notable 
are the congestion of the vessels of the circumcorneal area; involvement 
of the iris and ciliary body in the severe types of the affection, with the 
added signs of iritis and the development of exudation in the anterior 
chamber. The subjective symptoms include diminution of vision, pain, 
photophobia, excessive lacrimation, and blepharospasm. 
Although it is customary to divide the many types of corneal in- 
flammation into suitable groups, it is by no means possible to refer the 
disease in each instance to one or other of these divisions. 
Phlyctenular Keratitis or Keratoconjunctivitis {Eczema of the 
Cornea).-This disease is characterized by the formation of single or 
multiple phlyctenules on some portion of the cornea, and is accom- 
panied by dread of light, excessive lacrimation, and blepharospasm. 
Causes.-The disease is commonly seen in so-called scrofulous sub- 
jects, rarely before the first year of life, most frequently in children 
before the age of puberty, and less commonly in adults. It often is 
secondary to phlyctenular conjunctivitis or is associated with it (see 
page 211). Enlarged lymphatic glands, prominent and swollen lips, 
and diseases of the joints and bones may be present. 
This form of keratitis is in close connection with obstructive (adenoid 
vegetations) and inflammatory diseases of the nasal passages, and an 
infectious rhinitis is a constantly associated disorder, which, in turn, 
determines an eczema about the nares. Indeed, the clinical association 
between this disease and eczema is intimate, and eczema of the face 
and scalp is frequently an accompanying condition. The affection often 
follows in the wake of measles or other acute exanthemata, and is dis- 
tinctly under the influence of climate, being aggravated in warm and 
moist weather. Tuberculosis of the lymphatic glands is present in 
16 
241 242 
DISEASES OF THE CORNEA 
fully one-half of its subjects, and the evidence is daily increasing that 
phlyctenular keratitis is closely connected with tuberculosis and prob- 
ably caused by it. A large number of the subjects of phlyctenular dis- 
ease (88 per cent., G. S. Derby, Stock) react to tuberculin-a suggestive 
fact, although it does not prove that tuberculosis is the cause of the 
disease. Phlyctenules not infrequently have developed as the result of 
the Calmette reaction and have also followed subcutaneous injections 
of tuberculin. 
Staphylococcus pyogenes aureus and albus are present in the epi- 
thelium of the affected regions; but these organisms are usually not 
found in any number in fresh phlyctenules. Tubercle bacilli have not 
been discovered (L. Muller). The exact cause of the ocular lesions, or 
phlyctenular eruption, has not been determined. 
Symptoms.-The phlyctenules, which consist in the early stage of 
minute subepithelial collections of round cells, appear upon the cornea 
usually at or near the corneoscleral junction. They vary in size from a 
poppy-seed to a millet-seed; their tops, at first gray, speedily grow 
yellow, break down, and form superficial ulcers. They are accompa- 
nied by decided local congestion, increased lacrimation, and photo- 
phobia. 
The palpebral conjunctiva, always hyperemic, may remain trans- 
lucent and bathed in tears, or the disorder may be complicated with 
mucopurulent conjunctivitis. 
When the photophobia is severe, the child buries its head deeply in 
the bed-clothes; the lids are spasmodically closed, rendering inspection 
of the eye difficult, at times well-nigh impossible. The dread of light 
and the blepharospasm are probably due to direct irritation of the 
corneal nerves, as Iwanoff found the cellular infiltration situated along 
their course. , 
The pustule, when it breaks down, forms a phlyctenular ulcer. 
This may remain at its original seat near the margin, or creep toward 
the center of the cornea (migratory pustule}, followed by a bundle of 
thickly crowded blood-vessels, and form a special type of corneal in- 
flammation, known as fascicular keratitis. The blood-vessels, when 
the ulcer heals, disappear, but a stripe of opacity remains. 
Under the name phlyctenular marginal keratitis a variety of this 
disorder exists, characterized by the development of numerous phlyc- 
tenules along the rim of the cornea, giving rise to a process which 
may cease here, or which, by further invasions, may produce vascular 
ulcers. 
More dangerous than any of the other varieties is the formation of a 
single pustule, just at the corneal border, which speedily ulcerates and 
is surrounded by a yellow area of infiltration, with a strong tendency to 
perforate. 
If these inflammations recur constantly, the cornea becomes clouded, 
uneven from loss of epithelium, and covered with numerous superficial 
vessels, the whole forming the so-called phlyctenular pannus. 
Sometimes in the middle and deep layers of the cornea extensive PHLYCTENULAR KERATITIS OR KERATOCONJUNCTIVITIS 
243 
gray or yellow opacities may form, which may suppurate with large 
loss of tissue, or go on to resorption. These are the so-called deep 
scrofulous infiltrations. 
Pathology.-The efflorescence or phlyctenule consists of a collection 
of lymphoid cells, lying between Bowman's membrane and the epi- 
thelium, by the softening of which, as before described, the superficial 
cells are discharged, and an open, ulcerating surface is exposed. By 
further degeneration the entire nodule disappears, and the loss of sub- 
stance is rapidly replaced with epithelium. 
Diagnosis.-This presents no difficulties, direct inspection render- 
ing the nature of the disease evident. 
Prognosis.-The course varies greatly; in mild cases healing takes 
place with only a slight loss of substance, and the resulting scar is 
scarcely discernible. 
Not so with the severe forms, in which there has been decided loss 
of substance and a distinct scar-tissue remains, or in which deep ulcera- 
tion with perforation occurs, or where constantly recurring vascular 
ulceration leaves an uneven and roughened surface. In children of 
the tuberculous type, especially if their surroundings are unfavorable, 
phlyctenular keratitis is exceedingly intractable. 
Treatment.-In order to make a thorough application of the local 
remedies the child's head should be taken between the surgeon's knees 
and the lids separated, while the attendant holds the hands and body; 
the cornea will usually roll out of sight, but gradually may be coaxed 
into view. Sometimes a lid-elevator is useful, and a few whiffs of ether 
or chloroform may be necessary. 
If much secretion is present, boric acid or physiologic salt solution 
should be employed, and atropin drops should be instilled with suffi- 
cient frequency to maintain mydriasis. Cocain, judiciously used, will 
allay the photophobia, but its continuous application where corneal 
ulcers exist is to be deprecated. Holocain is sometimes useful; dionin 
occasionally seems to act unfavorably in phlyctenular keratitis. An 
ointment of the yellow oxid of mercury, gr. j to 3j (0.065-3.885 gm.), 
either with or without the addition of atropin, may be employed, or 
calomel be dusted into the conjunctival sac, provided no form of iodin 
is being exhibited (see page 212). The eyes should be protected with 
goggles, and the child encouraged not to bury its head in the bed- 
clothes (see also page 251). 
Douching the eyes with cold water will subdue the dread of light, 
and touching the ulcerated external commissure, which almost invariably 
exists in these cases, with a crystal of bluestone, as Koller has suggested, 
helps to relieve the blepharospasm. In severe cases the ulcerated fissure 
may be incised, or the lids may be forcibly separated. No doubt this 
acts by stretching or rupturing a few fibers at the commissural angle, and 
relieves the spasm in the same manner as a similar manipulation is 
efficacious in fissure of the anus. 
The best possible hygienic surroundings must be obtained, with 
fresh air and wholesome food. Cod-liver oil, iron, especially syrup of the 244 
DISEASES OF THE CORNEA 
iodid of iron, syrup of hydriodic acid, quinin, often suitably given with 
pepsin, and arsenic are the most acceptable internal remedies. 
The urine should be examined in all these cases; and scrupulous 
attention to the condition of the alimentary canal is an important factor 
in the treatment. 
If rhinitis is present, a powder composed of equal parts of pulver- 
ized camphor, boric acid, and subnitrate of bismuth is useful (Augag- 
neur), especially if the parts are thoroughly cleansed with Dobell's 
solution before its insufflation into the nasal chambers; powdered iodo- 
form may be used in like manner, but its odor is objectionable, hence 
nosophen is preferred by many surgeons, and borobismuth ointment is 
recommended. The affected mucous membrane may be painted with 
compound tincture of benzoin or sprayed with permanganate of potas- 
sium (1 :5000). In obstructive postpharyngeal and nasal affections 
(hypertrophies, adenoid vegetations) the diseased areas must be treated 
according to the methods of intranasal surgery. A patulous condition 
of the lacrimal passages should be secured. 
In stubborn forms of recurring vascular ulcer and deep ulceration, 
especially in the fascicular type, the use of the actual cautery in the 
manner later described is productive of excellent results, or the ulcer 
may be touched with trichloracetic acid. In general terms, the treat- 
ment of severe types of phlyctenular ulcer is the same as that recorded 
on pages 252-254. In phlyctenular pannus peritomy is sometimes a 
useful procedure, and canthoplasty may be necessary. 
After healing, provided the condition of the cornea permits it, any 
refractive error should be corrected. The best results in the treatment 
of phlyctenular disease are secured if its subjects are treated like other 
cases of tuberculosis-viz., after the patient is instructed as to general 
living, proper food, etc., he is visited in his home by one of the class- 
workers in the social service of the hospital, and is shown how to live 
and helped to carry out all directions. This method, advocated by 
George Derby, the author has followed with satisfaction in his hospital 
patients. 
In general terms, phlyctenular inflammation of the cornea, which has 
just been described, is a circumscribed, usually superficial keratitis, 
and is known under a variety of synonyms-lymphatic, scrofulous, 
vesicular, fascicular, and pustular-and where it appears in adults as- 
sumes the form of a simple corneal infiltration. It furnishes the great- 
est number of ulcers of the cornea which are found in early life, and also 
a large group of those ulcers which are of primary origin-i. e., where 
the disease starts in the cornea, the remainder of the group being caused 
by injury, abscess, depressed nutrition, etc. The entire series is in con- 
trast to secondary ulcers-i. e., where the disease follows as the result 
of a severe inflammation of the conjunctiva-e. g., purulent, diphtheritic, 
or granular conjunctivitis. 
The remaining inflammations of the cornea are divided by system- 
atic 'writers into ulcerative and non-rdcerative inflammations. 
Ulcers of the Cornea.-If the stage of infiltration fails to termi- ULCERS OF THE CORNEA 
245 
nate in absorption and there is destruction of the overlying corneal tissue, 
an ulcer results Surrounding the area of necrotic tissue is a clear space, 
and beyond this a ring of infiltrating leukocytes which come from the 
vessels at the edge of the cornea. In favorable cases this necrotic tissue 
is thrown off, the surrounding cornea clears, the ulcer is covered by a 
proliferation of the epithelium, and the loss of substance is replaced by 
connective tissue derived from the fixed cells of the cornea. Where 
the process is progressive, successive layers of the cornea become in- 
volved, the iris and ciliary bodies are infiltrated, and hypopyon forms 
(see page 247). If the ulceration is not checked, the cornea perforates, 
and inclusion of the iris may result in staphyloma (see page 259). If the 
iris does not prolapse, the perforation may be closed with a tissue pro- 
Fig. 116.-Perforating ulcer of the cornea with incarceration of iris (from a photomicro- 
graph). 
duced by proliferation of the posterior lining endothelium. Bowman's 
and Descemet's membranes are never reproduced. 
In addition to those which have been described with phlyctenular 
keratitis, corneal ulcers may be gathered into several groups: 
1. Simple ulcer appears in the form of a small, superficial, gray lesion, 
associated with slight pericorneal vascularity, and results from the 
rupture of a phlyctenule ("pimple ulcer") or from trauma. 
An ulcer, which, from its situation, is called small central ulcer, 
may develop as a gray or gray-white opacity in the center of the 
cornea, and is not accompanied with much vascularity or dread of 
light. The elevation is slightly cone shaped until the whitish top 
breaks down into a shallow depression. 246 
DISEASES OF THE CORNEA 
Usually single, this form of ulcer may be multiple, and tends to 
recur. It is seen in young chilren who have been poorly nourished and 
are of a so-called strumous habit. While healing generally occurs with 
promptness, a permanent opacity may remain, which, from its central 
situation, may seriously impair vision. If neglected, and in patients 
of poor nutrition, this ulcer occasionally forms an abscess of the cornea, 
or changes its type and develops into the following variety: 
2. Purulent or deep ulcer consists of an area of yellowish (purulent) 
infiltration, surrounded by a zone of hazy cornea, round or irregular in 
shape, centrally excavated, and with a tendency to travel inward toward 
perforation, but not to extend in a lateral direction. Like all severe 
types of corneal ulceration, it may be associated with inflammation of 
the iris and the formation of pus in the anterior chamber; if perforation 
takes place, an adherent scar or leukoma results. 
This ulcer is either primary from injury, and sometimes contains 
a foreign body as its nucleus, or is secondary to a violent grade of 
conjunctival inflammation. The subjective symptoms are pain, brow- 
ache, congestion, and sometimes, though not necessarily, photophobia. 
3. Indolent ulcer (absorption ulcer) occurs under several forms: (a) 
Shallow central ulcer, with slightly turbid base, unattended with any 
considerable pain or photophobia, essentially chronic in its course, and 
healing finally with a faintly opaque facet (faceted ulcer). 
(b) Excavated or gouged-out ulcer, often seen in children, most trouble- 
some because it is rebellious to treatment, has its seat near the corneal 
margin. It may be entirely overlooked on account of the absence of con- 
gestion, and because in appearance it is a small, punched-out excavation 
with transparent bottom, and free from any opaque surrounding. The 
floor of the ulcer loses its translucency when healing is about to take 
place, and a few vessels of repair pass to its margin. 
(c) Reparative ulcers are seen when, as occasionally occurs in the 
course of the healing of an ordinary corneal ulcer, this loses its turbidity 
and assumes a clear, facet-like appearance. These are similar to the 
absorption ulcers which occur primarily, and which, unattended with 
injection and with local symptoms, may, none the less, extend inward 
and perforate the cornea. 
Indolent ulcers, in general terms, depend upon some failure in the 
nutrition of the cornea due to nervous disturbance. They are found 
in anemic and scrofulous subjects, and are seen in cases of chronic 
trachoma. 
4. Infected or Sloughing Ulcer (Purulent Keratitis).-Ulcers without 
vessels of repair, which spread widely from one border and readily 
become complicated with hypopyon and iritis, and which are often 
the result of a trifling injury, usually affect elderly persons and those 
whose nutrition is depressed. 
The most important type of these is the acute serpiginous or creeping 
ulcer of Saemisch. In the beginning a nearly central gray area forms, 
which ulcerates; its margins are sharp, and one, assuming the form of an 
elevated curve, is more decidedly opaque or yellow than the others, and ULCERS OF THE CORNEA 
247 
is known as the arc of propagation. Immediately behind it, the ulcer 
with its gray floor seems deeper than the portion next to the corneal 
margin. 
The surrounding cornea is opaque, and the lesion spreads rapidly, at 
the same time growing deeper; iritis, iridocyclitis, and hypopyon ensue, 
and perforation and extensive sloughing of the cornea are likely to occur. 
Usually the patient complains of severe brow-pain and the eye is in- 
tensely tender. Vision is reduced to mere light perception. In other 
cases, while the local lesion is severe, the subjective symptoms of in- 
flammation are almost absent. Kipp calls attention to certain types of 
infected ulcer from the margin of which straight, or nearly straight, lines 
diverge in all directions obliquely through the parenchyma of the deep- 
est layers, their ends being connected by intermediate striae. They 
may be due to folds in Descemet's mem- 
brane or to cell infiltration. Their pres- 
ence indicates a favorable prognosis. 
Hypopyon, to which reference has just 
been made, may be seen with both small 
and large ulcers, and consists of a collec- 
tion of pus in the anterior chamber, vary- 
ing in extent from a mere line to a quantity 
which well-nigh fills the chamber. 
This appears as a yellow mass at the 
bottom of the anterior chamber, and is 
bounded above by a horizontal margin. 
If the collection is fluid, its position will 
shift with movements of the head; if it is 
tenacious, no movement can be observed. 
The pus is caused by an aggregation of 
leukocytes derived from the vessels about 
the periphery of the cornea and from 
those in the inflamed ciliary body and iris, 
the endothelium of which is cast off. In 
other words, the pus in hypopyon does not come from the cornea. 
Sometimes Descemet's membrane is ruptured without perforation of 
the cornea, and the pus in the cornea and in the anterior chamber 
is in direct connection. 
The combination of ulcer of the cornea and pus in the anterior cham- 
ber has received the name hypopyon keratitis, which generally is limited 
to the type described as infective or creeping ulcer. 
Causes of Infected or Sloughing Ulcers.-The investigations of Uht- 
hoff and Axenfeld have demonstrated that-(1) Typical serpiginous 
ulcer of the cornea with hypopyon is nearly always caused by the pneu- 
mococcus (Frankel-Weichselbaum capsulated diplococcus); this micro- 
organism may frequently be found in these ulcers in almost pure cul- 
tures. These ulcers are also occasionally caused by the diplobacillus 
of Morax and Axenfeld (diplobacillary ulcers'), the bacillus of Petit, the 
Bacillus subtilis (Zur Nedden), and the streptococcus. (2) Sloughing 
Fig. 117.-Infected ulcer of 
the cornea, with hypopyon-hy- 
popyon keratitis (modified from 
Haab). 248 
DISEASES OF THE CORNEA 
ulcers not typically serpiginous are caused by infection with staphylo- 
cocci, streptococci, and by mixed infection. Occasionally pneumococci 
originate ulcers which are not characteristically creeping. (3) In addi- 
tion to the micro-organisms mentioned, the following bacteria, according 
to Uhthoff, have been found to be the cause of various forms of infected 
ulcer: Pfeiffer's capsulated bacillus, Bacillus pyogenes foetidus, Bacte- 
rium coli, Bacillus pyocyaneus, diplobacillus, pneumobacillus, ozena 
bacillus, tubercle, and lepra bacillus. Other unidentified varieties have 
also been found, and corneal ulceration has also been ascribed to strepto- 
thrix (De Bernardinis). 
Infected ulcer due to Bacillus pyocyaneus, as a rule, is a malignant 
process. Preceded by superficial keratitis a deep lesion develops, with- 
out the crescentic shape of the serpiginous ulcer and containing pus, 
chiefly in its center. The diagnosis depends upon a bacteriologic ex- 
amination. 
5. Mycotic Keratitis (Keratomycosis Aspergillind)-In a small per- 
centage of cases of sloughing keratitis the infection is due to a mold- 
Aspergillus fumigatus-the fungus, as a rule, finding entrance through a 
corneal abrasion from injury. The ulcer has a dry appearance and has 
been compared to a grease-spot; it is surrounded by a gray or yellow 
line, and the enclosed area ultimately exfoliates. Hypopyon and iritis 
may be present; sometimes the lesions assume the form of a simple cor- 
neal infiltration resembling fascicular keratitis. Ellett has reported a 
corneal ulcer in which he found Aspergillus nigricans. According to 
Morax, mycotic corneal affections may be due to the Verticillium 
graphii. 
The various micro-organisms come from the conjunctiva, the ciliary 
borders, the nares, the lacrimal passages, and from external contami- 
nated surroundings. An injury to the cornea from a chip of stone, a 
chestnut-bur, beard of wheat, or the like may become infected, and 
be the starting-point of these dangerous forms of corneal ulceration. 
Typical serpent ulcer is rare in children, whose corneas appear to with- 
stand pneumococcal infection. 
6. Abscess of the cornea consists of a purulent infiltration in the 
deeper layers of this membrane, over the center of which, in the early 
stages, the epithelium is unbroken and prominent, but later, discolored 
and slightly sunken. 
The corneal zone immediately surrounding it is hazy. The margins 
of the collection are thicker and more prominent than its middle; pus 
is seen in the anterior chamber; the aqueous humor is turbid and the iris 
inflamed. 
Generally the lesion grows more yellow, notches laterally, bulges 
forward, and finally bursts, leaving a more or less ragged ulcer covered 
with tenacious pus, and pursuing a course similar to or identical with 
that described under sloughing or infected ulcer, of which, indeed, 
abscess is the first stage. The causes are identical with those described 
in connection with infected ulcer; occasionally a definite cause cannot 
be ascertained. ULCERS OF THE CORNEA 
249 
7. Infected Marginal Ulcer.-According to Zur Nedden, this form 
of corneal disease consists of a 1 to 2 mm. long oval ulcer, running parallel 
to the limbus, with only a slight diffuse infiltration in its vicinity, the 
rest of the cornea being normal. Sometimes several superficial infiltra- 
tions develop, which may unite with the original ulcer and form a 
sickle-shaped lesion; exceptionally the cornea is completely surrounded. 
In other cases the multiple infiltrations do not coalesce. The infection 
is believed to be due to a specific micro-organism, to which Zur Nedden 
gives the name "bacillus of infected marginal ulcer." The prognosis is 
good; hypopyon rarely forms. 
8. Exanthematous Keratitis.-Most violent forms of suppurative 
keratitis occur during the convalescent stages of small-pox, though 
pustules rarely form upon the cornea. Abscess of the cornea occasionally 
accompanies scarlet fever, influenza, measles, typhoid fever, typhus 
fever, and pyemia, and in these cases has been regarded as metastatic, 
the pathogenic material having been conveyed through the blood, and 
not as coming from without, as in the more usual examples. Schirmer's 
investigations indicate, however, 
that the so-called variolar ab- 
scess of the cornea, which has 
hitherto been considered an 
endogenous infection, arises by 
penetration of the virus from 
without. 
9. Ulcus rodens is the name 
which was applied by Mooren 
to a creeping ulcer which begins 
at the upper edge of the cornea 
as a superficial lesion, separated 
from the healthy portion by a 
gray, opaque rim, which is under- 
mined. The deeply undermined 
conjunctival edge of the ulcer is 
a striking feature of the disease. 
The extent of the undermining 
may reach 4 to 5 mm. from the 
border of the cornea (Randolph). 
Mooren's ulcer may be associated with an ulcer of the sclera (Parsons). 
Although vessels may pass to a rodent ulcer and cicatrization apparently 
begin, it relapses quickly and progresses forward, until the whole cornea 
has been traversed and sight is destroyed. The cornea is not usually 
perforated in this disease, which is a rare form, sometimes bilateral, 
attacking adult and depressed subjects. The process may last from two 
to ten months and even longer. It is called by Nettleship chronic 
serpiginous ulcer and Mooren's ulcer. The cause of the disease has not 
been discovered. 
Fuchs has described keratitis marginalis superficialis, that is, a super- 
ficial variety of ulceration, which he has encountered in middle-aged 
Fig. 118.-Mooren's ulcer (from a patient 
in the University Hospital). 250 
DISEASES OF THE CORNEA 
persons, and which proceeds somewhat unevenly from the corneal 
border, so that the margin is indented toward the corneal center and 
framed in a gray line. The conjunctiva may be attached to it in the 
form of a pseudopterygium. The lesion differs from ulcus rodens 
because it is more superficial and less undermined. It may last for 
long periods of time and is subject to relapse. 
10. Circular ulcer (marginal ring ulcer, annular ulcer) occurs in the 
form of a deep groove at the corneal margin, which gradually progresses 
until it may entirely girdle the cornea and cut it off from its nutri- 
tion. Photophobia, injection, lacrimation, and other irritative symp- 
toms are not prominent, but perforation of the cornea and prolapse of 
the iris are common. The disease is seen in debilitated subjects. 
Another variety of ring ulcer is formed as the result of a marginal 
phlyctenular keratitis (see page 242), probably by the coalescence of a 
number of small foci. Ring ulcers are also seen in catarrhal and puru- 
lent conjunctivitis, and in the latter condition may prove especially 
dangerous if they are hidden by the chemotic conjunctiva. 
11. Dendriform ulcers (keratitis dendritica; ulcerans mycotica; fur- 
row-keratitis; keratite idcereuse en sillons etoiles) are forms of keratitis 
which appear in branch-like ramifications, having a superficial situation, 
with slight knob-like swellings at the end of the branches. The cornea 
may be insensitive and fluorescein will stain not only the lesions, but the 
cornea exclusive of them (Verhoeff). The inflammation manifests 
itself in two forms. 
In one, from the beginning, the symptoms include photophobia, 
lacrimation, strong bulbar injection, swelling of the upper lids, and 
absence of the epithelium over the furrow-formed ramifications-an 
implantation of the process in the deeper corneal layers. 
In the other the disease assumes a subacute or torpid character, with 
practical absence of severe irritative symptoms and loss of the cover- 
ing epithelium-a limitation of the lesion to the superficial layer. In 
the first form the opacity is confined to the axis of the furrows; in the 
second, to the border. After healing, the scars have the same general 
configuration which was present during the stage of ulceration. The 
disease occurs in both sexes, and occasionally is seen in children. 
The cause is not definitely known. The disease is attributed by C. J. 
Charles to a terminal nerve lesion, and by Verhoeff, who classified it with 
neuropathic affections of the cornea, to disturbance of the nerve-supply. 
Fuchs thinks some cases may arise from febrile herpes of the cornea 
(see page 264) by the increase and coalescence of the small blebs. 
A keratitis in which the lesion consists of a peculiar, narrow, ser- 
piginous, superficial ulcer, with lateral offshoots, like the skeleton of 
veins in a lanceolate leaf, usually accompanied with photophobia and 
lacrimation, and sometimes ushered in with severe supra-orbital neural- 
gia, has been attributed to malaria. It is a form of dendritic keratitis 
and has been well studied by Kipp and by Ellett. 
12. Exhaustion ulcer (keratomalacia) may appear as an extensive 
ulceration in the center of the cornea, or as a ring abscess at its circum- ULCERS OF THE CORNEA 
251 
ference. The tissue speedily is converted into a slough, which drops 
out, and an extensive perforation results. 
In other instances the sequel is described as a species of atrophy of 
the cornea, which is converted into a whitish, flattened plate (Schmidt- 
Rijnpler). 
One or both corneee may be affected, and the usual cause is exhaustion 
after acute illness or after prolonged diarrhea or dysentery. A similar 
softening and sloughing of the cornea may be the result of ophthalmia 
neonatorum (see page 198), or cataract incisions which have become 
septic, and xerotic keratitis (see page 262). 
13. Tuberculous Keratitis (Tuberculosis and Tuberculous Ulcer of the 
Cornea).-Tuberculous lesions of the cornea almost always arise by 
reason of an extension of this disease from the uveal tract, including the 
pectinate ligament, and manifest themselves either as tuberculous 
nodules or as a diffuse parenchymatous keratitis (see also page 266). 
Primary tuberculous ulceration (Greeff) and tuberculous nodes in the 
corneal periphery (Bach) have been described which later push their 
way into the cornea. The lesion not uncommonly has a distinct tri- 
angular form (see Fig. 130). A variety of abscess of the cornea, without 
any healing tendency, which by some authorities has been regarded as a 
tuberculous process, has been observed in scrofulous children. 
Prognosis of Ulcers of the Cornea.-This necessarily depends upon 
the character and situation of the corneal lesion, but even in the mildest 
forms some corneal opacity or irregularity of the corneal epithelium will 
remain (see page 258). If bacteriologic investigation should reveal the 
presence in the ulcerated area of pneumococci or of a mixed infection, the 
prognosis is serious, and at once the measures described in paragraph (b), 
page 253, should be instituted in the hope that the spread of infection 
may be prevented. In severe forms of suppurative keratitis the prog- 
nosis is most unfavorable, although active treatment will sometimes be 
followed by surprisingly good results. 
Treatment of Ulcers of the Cornea.-It is not possible to lay down 
definite rules for the treatment of all forms of corneal ulceration-this 
must be governed by the exigencies of each case; but certain principles 
are common to the various types. 
Acute Stage: Pain and Photophobia.-These should be relieved by 
the plans already suggested in the treatment of phlyctenular keratitis. 
In simple ulcers, atropin, a lotion of boric acid, and dark glasses will 
usually suffice, and prompt cure often follows an application directly 
to the ulcer of nitrate of silver (1 per cent.). 
Cocain will relieve photophobia temporarily, but its continuous use 
in corneal vdceration is positively harmful. Holocain, on the other hand, 
is of distinct value, as was pointed out by Hasket Derby, especially if 
applied directly to the ulcerated surface. If a corneal ulcer is ac- 
companied with much dread of light, the methods described under 
phlyctenular keratitis may be employed. Dionin (2 to 5 per cent.) 
is of marked service. 
Whenever corneal ulceration is associated with conjunctivitis, the 252 
DISEASES OF THE CORNEA 
inner surfaces of the lids may be brushed over with a solution of nitrate 
of silver, gr. ij-v to §j (0.13-0.32 gm. to 30 c.c.), or protargol (5 to 20 
per cent.), or argyrol (10 to 25 per cent.) may be freely instilled. The 
last-named drug is not without danger, as it may cause a permanent 
brown stain at the seat of the ulcer. The culdesac should be care- 
fully cleansed with a boric acid solution, a collyrium of bichlorid of 
mercury (1 : 8000), or cyanid of mercury (1 : 2000). 
Subacute and Torpid Stage.-After the subsidence of the acute symp- 
toms, or where the ulcer from the beginning is torpid, local stimulation 
should be secured with an ointment of the yellow oxid of mercury, gr. j 
to 3j (0.065-3.885 gm.). Finely powdered calomel dusted into the 
eye is also of excellent repute. In like manner iodoform or aristol, in 
salve or powder, may be tried. Eserin has been recommended instead 
of atropin in small sluggish ulcers. 
Deep and Sloughing Ulcers.-It was a universal and is still a common 
practice to instil a solution of atropin, because of its anodyne effect and 
because it lessens the liability to iritis. The solution should be sterile, 
as otherwise a simple ulcer may be infected and pass into a -sloughing 
condition. 
In some cases eserin is employed, because it stops the migration of 
white blood-corpuscles, or promotes absorption through dilatation of 
the ciliary vessels, or limits the sloughing process. Furthermore, 
abnormal intra-ocular tension is lowered by the action of the drug. 
The strength of the solution may be from | to 1 grain (0.0162-0.065 
gm.) to the ounce (30 c.c.), the latter being unnecessarily active in 
most cases. One or two drops of the eserin solution should be in- 
stilled from three to six times daily; and as, under its influence, con- 
gestion of the ciliary body and iris may ensue, as well as brow-pain, 
these complications should be counteracted by using a few drops of 
the atropin lotion at night. Deep ulcers near the margin are those 
most suited for the eserin treatment. The author, after considerable 
experience, is persuaded that eserin in corneal ulceration has a very 
limited sphere, and that atropin is almost invariably the better drug. 
Schiotz and Gunnufsen have noted rise of tension in some cases of 
serpiginous ulcer of the cornea, and think that if it is present mydriasis 
should be avoided, lest it increase the danger of glaucoma. Atropin, 
eserin, or pilocarpin may be used in conjunction with dionin, if this 
drug is indicated, to produce an analgesic or lymphagogue action. 
Pain is relieved and the process of repair encouraged by the fre- 
quent application of hot compresses (see page 201), and by the use of 
dionin, which may be employed in solution or as an ointment. Hot 
water (150° F.) dropped directly upon the ulcer is recommended by 
Lippincott. The culdesac and lacrimal passages must be irrigated 
frequently with antiseptic collyria-a saturated solution of boric acid, 
bichlorid of mercury (1 : 10,000), aqua chlorini, or cyanid of mercury 
(1 : 2000). 
1. Impending Perforation.-When a perforation of the cornea is 
liable to occur by extension of the ulcer, a dry antiseptic compressing ULCERS OF THE CORNEA 
253 
bandage should be applied, removed when the necessary local applica- 
tions are made, and again reapplied. Long-continued use of the 
bandage may be followed by eczema of the lids. This should be treated 
by dusting the parts with calomel or nosophen. Catarrh of the con- 
junctiva and dacryocystitis contraindicate the use of the bandage unless 
the danger of perforation is imminent. If dacrocystitis persists in spite 
of ordinary treatment, the lacrimal sac should be excised (see page 682). 
If bulging forward of the floor of the ulcer indicates that perforation 
threatens, the intra-ocular tension should be lessened by paracentesis 
of the cornea. This operation is described on page 619. It may be 
necessary to repeat the operation on several days. Intense pain will 
often be thus speedily relieved and healing rapidly result. 
2. Idle Spread of Local Infection.-If, in spite of such treatment, the 
corneal ulcer continues to spread, either in the form of a lesion creeping 
across the face of the cornea or by passing inward through its layers, 
the process must be stopped by one of several means: (1) Scraping with 
a curet; (2) the direct application of a suitable chemical which combines 
the properties of a germicide and a caustic; (3) the actual cautery. 
(a) The ulcer may be curetted with a sharp spoon (under a boric 
acid spray-de Wecker), all the sloughed material removed, the edges 
penciled with a sublimate solution (1 :2000), iodoform dusted upon its 
surface, and a dry sterile bandage applied. Mules advised softened 
iodoform wafers. 
(b) The chemical substances commonly employed are nitrate of 
silver, carbolic acid, nitric acid, trichloracetic acid, tincture of iodin, 
and formaldehyd. The first, in the strength of 10 to 20 grains (0.65- 
1.3 gm.) to the ounce (30 c.c.), is applied directly to the seat of 
ulceration (care being taken to avoid the surrounding cornea) by 
means of a probe on which has been twisted a thin band of absorbent 
cotton, or the point of a pencil of lunar caustic may be gently pressed 
against the sloughing tissue. Carbolic acid (liquid) may be employed 
in the same manner as the silver solution; or tincture of iodin, or a 
caustic solution of formaldehyd (1 : 50), or trichloracetic or nitric acid. 
Of these substances, carbolic or trichloracetic acid have given the 
author the greatest satisfaction. Absolute alcohol applied directly to 
the ulcerated surface is sometimes of great value. Prior to the ap- 
plication of these caustics the ulcerated area should be stained with 
a solution of fluorescein (see page 50). 
(c) The actual cautery may be either a small Paquelin or galvano- 
cautery; when neither of these is at hand, a knitting-needle or platinum 
probe, heated red hot in the flame of a Bunsen burner, will suffice. 
The edge and floor of the ulcer should be gently but thoroughly burned. 
Usually one cauterization is sufficient, but in the event of failure to 
destroy all the sloughing material, the operation should be repeated on 
the following day (see also page 620). Cocain or holocain render the 
operation painless, but there is no objection to general anesthesia in 
nervous patients. 
If the surgeon is careful to touch only those portions involved in the 254 
DISEASES OF THE CORNEA 
ulcerated process, the resulting scar will not be greater than would have 
been the case had the ulcer secured cicatrization without such treatment. 
Fluorescein will show the extent of the ulcer and mark out the area to 
be cauterized. 
The actual cautery may be used to check the advance of sloughing 
ulcers, although recent improvements in ocular therapeutics have 
rendered the use of this agent less frequently necessary than in former 
times. In rodent ulcer (to which it should be applied early and thor- 
oughly) it is one of the few means that is efficacious, and it is also 
indicated in cases of fascicular keratitis. 
Abscess and Hypopyon.-The pus should be evacuated. If the ab- 
scess is unbroken, its anterior wall may be incised with a delicate knife, 
and the subsequent treatment conducted on the principles laid down for 
sloughing ulcers. If there is hypopyon, paracentesis of the cornea or 
Saemisch's section (see page 620) may be practised. Subsequently 
iodoform may be dusted upon the cornea and a bandage applied, to be 
renewed at suitable intervals. 
The antiseptic and specific treatment of ulcers have to a great degree 
replaced the operation of Saemisch, and in many instances absorption 
of the products of a hypopyon-keratitis will follow the non-operative 
treatment already described. 
Perforation.-If perforation of the cornea and prolapse of the iris 
occur, the vigorous use of atropin or eserin, according as the lesion has a 
central or peripheral situation, aided by gentle effort at reiiosition with 
a probe, a compressing bandage, and rest in the recumbent posture 
represent measures which are sometimes followed by success. 
In the event of failure, or in any event, if the prolapse is a large one, 
the iris may be drawn forward through the aperture and excised close 
to the cornea. After excision the aperture may be covered with a con- 
junctival flap taken from the bulbar conjunctiva, twice as large as the 
original opening, into which it is gently inserted with a probe. A firm 
compressing bandage, not to be disturbed for three days, is applied. 
This method, which can be recommended, is said by its author, Gamo 
Pinto, to secure a flat cicatrix, often without any attachment of the 
iris, although anterior synechia usually results even from the smallest 
perforation. Conjunctival flaps, formed according to the technic of 
Kuhnt, may be useful in these circumstances. If the prolapse has 
been large, a more or less complete staphyloma is apt to follow in spite 
of vigorous bandaging and the use of eserin or atropin. An early iridec- 
tomy may prevent this catastrophe. 
Other Methods of Treating Corneal Ulcers.-(a) Dionin.-The value 
of dionin in the treatment of corneal ulcer is unquestioned and has been 
referred to. It would seem that occasionally, in addition to its lympha- 
gogue and analgesic action, it has a positive effect in stimulating corneal 
regeneration. Immunity is quickly established, and therefore, as a 
rule, it should be used for three days and then discontinued for two or 
three days, or until its application is again followed by the dionin reac- 
tion. The strength of the solution may vary from 1 to 10 per cent., ULCERS OF THE CORNEA 
255 
according to the indications, a good average general strength being 5 per 
cent. Dionin may be combined with atropin, eserin, holocain, and 
cocain, according to the indications, bnt, in the experience of the 
author, furnishes better results if employed in a separate solution, and 
the.other drugs, also in separate solution, are used either before or 
after its application. Occasionally its action seems to be enhanced 
by the addition of adrenalin, although adrenalin itself is not a remedial 
agent of satisfaction. Powdered dionin or dionin in salve may also be 
used. With its employment by subconjunctival injection, as recom- 
mended by some surgeons, the author has no experience. Its advan- 
tageous effects are distinctly enhanced by the use of a 2 per cent, solu- 
tion of holocain. 
(6) Serum Treatment.-Romer, believing that 95 per cent, of infected 
so-called serpent ulcers are caused by the Frankel-Weichselbaum diplo- 
coccus, has, with the aid of the chemist Merck, developed a serum 
(pneumococcus or antipneumococcus serum) which he advises in the treat- 
ment of this form of corneal disease. The serum may be used subcu- 
taneously and also subconjunctivally, and may be instilled into the con- 
junctival sac. Romer himself doubts the value of the subconjunctival 
injections. Subcutaneously from 3 to 5 c.c. of the serum may be 
employed, and the results thus far reported indicate that occasionally 
it seems to facilitate the cure of beginning ulcers, but in large, well- 
developed ulcers it is ineffectual (Zur Nedden). Complications have 
been reported-for example, myocarditis and decided febrile reaction 
are said to have followed the injections (Zeller). With this method 
of treating corneal ulcers the author has had no experience. According 
to Axenfeld, this serum possesses curative properties, but, as prepared 
at present, its action is not sufficiently certain to allow it to replace 
other methods. Recently Romer has advocated autoserotherapy in 
the treatment of hypopyon keratitis. The serum obtained from a 
blister in the patient's arm is injected beneath the conjunctiva, the 
dose being 1 c.c. 
The antistreptococcus serum or vaccine has also been employed in 
streptococcal infections, but apparently it, like the antipneumococcus 
serum, should be regarded as supplementary to other forms of treat- 
ment. Of staphylococcus serum-therapy too little is known to deter- 
mine its influence on the eye (Axenfeld). In place of Romer's serum, 
antidiphtheritic serum has been employed with success (Darier, Zim- 
mermann, Fromaget) in the treatment of severe corneal ulceration. 
Good results have also followed the use of Deutschmann's serum (yeast 
serum in the dose of | to 1| c.c. in children, and 4 to 8 c.c. in 
adults), according to reports by Deutschmann, Von Hippel, and others. 
In Axenfeld's clinic its effects were negative. In the author's expe- 
rience bacterins prepared from the micro-organisms responsible for cor- 
neal ulceration have proved to be of surprising value in the treatment of 
infected ulcer of the cornea. These bacterins (or vaccines) have been 
prepared for him by Dr. B. A. Thomas from patients in the University 
Hospital. The dose has varied from 50,000,000 to 300,000,000. Such 256 
DISEASES OF THE CORNEA 
bacterins represent a therapeutic measure which should receive careful 
attention and trial. 
Hypopyon keratitis has also been treated by means of applications 
of pyocyanase, prepared from cultures of the pyocyaneus bacillus. 
(c) Subconjunctival Injections.-Naturally, subconjunctival injec- 
tions, so satisfactory in certain diseases of the eye, have been tried in 
corneal ulcers. At one time bichlorid of mercury was chiefly employed, 
but, largely owing to Mellinger's investigations, this gave place to phys- 
iologic salt solution, which seemed to act equally well. There is a 
certain amount of evidence, however, that in infected corneal ulcers 
cyanid of mercury is the better agent. Of this drug, 10 to 20 minims 
(0.6-1.25 c.c.) of a 1 : 4000 solution may be injected beneath the con- 
junctiva; its use, in these circumstances, is strongly urged by Col. 
Henry Smith. There is no objection, but, on the whole, rather ad- 
vantage in adding chlorid of sodium to the solution. Of the bichlorid 
of mercury solution, Dufour has recently recommended injections of 
1 : 2000 if the ulceration is active, and 1 : 3000 to 1 : 10,000 if the 
infection is not very robust. Acoin added to the solutions employed 
in subconjunctival injections is said to diminish the pain. It should 
be used in a 1 per cent, solution, one-third of which is added to two- 
thirds of the solution employed. 
(d) Additional Local Measures.-Reference to the value of iodoform 
directly dusted upon corneal ulcers has already been made. In its 
place xeroform or nosophen may be used. Sometimes these remedies 
are employed in the form of an ointment, as are also iodid of potas- 
sium, iodol, and europhen. Iodoform introduced into the anterior 
chamber after paracentesis in the form of rods, which is so highly recom- 
mended in infected wounds of the cornea by some surgeons, is not a 
useful procedure in hypopyon keratitis. Absolute alcohol applied di- 
rectly to an ulcerated surface is occasionally of great value. The anilin 
dyes, in the form of blue and yellow pyoktanin, at one time regarded with 
favor, in the opinion of the author are valueless. lodin-vasogen is rec- 
ommended in infiltrated and spreading ulcers in 0.6 per cent, solution, 
and ariol dusted on the surface of an ulcer after the application of the 
actual cautery is recommended by Fischer. If bacteriologic examina- 
tion should reveal the presence of the diplobacillus in the corneal ulcer 
(diplobacillary ulcer), the preparations of zinc should be used (sulphate, 
chlorid, or salicylate in 1 to 5 per cent, solution) and applied directly to 
the lesion. Zinc preparations are also useful in pneumococcus ulcer, 
and Morax has tried rabbit's bile with indifferent success. Recently 
ethylhydrocuprein (optochin) has been strongly advocated in the 
treatment of pneumococcic ulcers of the cornea. It may be applied 
directly to the ulcer in a strength of from 1 to 2 per cent, by means of a 
cotton swab held in place for a minute and repeated as required, or used 
in a watery solution every hour, or employed in the form of an ointment, 
combined with atropin. Decided improvement has been noted as early 
as the third or fourth day, and even earlier. At first its application 
causes much burning pain, which may be checked with holocain. Some ULCERS OF THE CORNEA 
257 
reports of its value are enthusiastic; others express disappointment. 
Purulent keratitis has been successfully treated by zinc iontophoresis.1 
Darier recommends scarlet red in the treatment of infected ulcers (5 per 
cent, ointment in an aqueous solution), and Haass urges pellidol and 
azodolen, derivatives from scarlet red, in 2 per cent, ointment in the 
management of corneal lesions with loss of epithelium. The application 
of radium has been advocated by Lawson and McKenzie. In Mooren's 
ulcer of the cornea the use of the actual cautery has received high 
commendation. H. Lewis Jones has achieved success by using zinc 
ions. Covering the ulcerated area with conjunctival flaps has been 
tried; the author has employed this method once with only temporary 
success. Thermotherapy has been employed by Weekers in ulcers of the 
cornea by means of a platinum filament at a low degree of incandescence, 
which is held over the surface of the ulcer for one minute without 
touching it. 
(e) Associated Conditions.-The treatment of conjunctivitis com- 
plicating ulcer of the cornea in nowise differs from that suited to 
ordinary cases. An ulcer should always be carefully examined for the 
presence of a foreign body, which may be covered by a small slough, while 
misplaced cilia are fruitful sources of corneal irritation and may hinder 
the prompt healing of ulcers. They should be removed with epilating 
forceps or destroyed by galvanopuncture. 
The lacrimal passages should be explored and, if strictured, rendered 
patent, while irrigation of the lacrimal canal with a 4 per cent, solution 
of boric acid, or 1 : 8000 solution of bichlorid of mercury, or 10 to 20 
per cent, solution of protargol or argyrol, is of material aid in the treat- 
ment of infected ulcers, because this passage is commonly the seat of 
unhealthy secretion. If the tear-sac contains pus it should be excised. 
At the same time the nasopharynx and the accessory sinuses need 
exploration and treatment of diseased conditions. 
The teeth should always be examined, and, if faulty, the patient 
turned over to a competent dentist. The frequent relation of carious 
teeth and pyorrhea alveolaris to corneal ulceration is well established, 
and the irritation of a new dentition in young children has been found 
to be the cause of abscess or ulcer of the cornea. In brief, the entire 
cephalic mucous membrane (Harrison Allen) should be explored, because, 
in one or other of its component parts, it may be the seat of disease, 
which, even if it is not the cause of the coexisting corneal ulceration, 
is none the less responsible for retardation in the healing process. 
Some corneal ulcers appear to have been caused by disease of the 
accessory sinuses, especially the ethmoid sinuses, and by purulent 
rhinitis. 
Constitutional Treatment.-The patient, other things being equal, 
should not be secluded in a dark room, but, with eyes properly pro- 
tected with goggles, go out into the fresh air every day. The diet must 
1 For the method of applying this remedial agent, see Traquair's article on "The 
Treatment of Purulent Keratitis by Zinc Iontophoresis," Ophthalmic Review, vol. xxx, 
1911, p. 1. 258 
DISEASES OF THE CORNEA 
be nutritious and easily digested; tea, coffee, candies, and pastries 
should be forbidden. 
If scrofulosis is present, cod-liver oil, lactophosphate of lime, and 
iodid of iron or syrup of hydriodic acid are indicated; anemia is best 
treated with the tincture of the chlorid of iron or with the carbonate of 
iron; any suspicion of malaria requires the use of quinin and arsenic. 
The syphilitic taint, which may be present without being the direct 
cause of the ulcer, indicates the iodids, and mercury, especially in the 
form of the bichlorid. If ulcers of the cornea occur in gouty or so-called 
rheumatic subjects, citrate of lithium, mineral waters, iodids, colchicum, 
salicylic acid, salol, etc., are indicated. Thyroid extract has been used 
by the author and Veasey in stubborn non-ulcerative keratitis, and this 
drug has recently again been recommended by Radcliffe. In tubercu- 
lous ulceration of the cornea (see page 251) important results are achieved 
by the administration of tuberculin (see page 318). 
A very strict inquiry into the condition of the alimentary canal 
should never be forgotten. In children, calomel is a useful laxative; in 
older patients, the salines and saline waters are often necessary. 
The urine should be carefully examined for albumin and sugar, and 
for the products which indicate imperfect assimilation. The influence 
of enterogenous auto-intoxication must be eliminated. 
A very important element in the successful management of cases of 
sloughing ulcers, especially in subjects of depressed nutrition, is the 
maintenance of proper circulation; strychnin and digitalis are often 
indicated. Severe pain may be alleviated by opium or morphin in 
suitable cases; the drug also has a favorable influence upon the ulcera- 
tion. Codein also serves a useful purpose. 
Results of Corneal Ulceration.-Opacities more or less permanent 
follow almost all ulcerations of the cornea. If the opacity is slight, it is 
spoken of as a nebula or macula; if dense, as a leukoma. An old corneal 
macula possesses a good reflecting surface, which serves to distinguish it, 
as Haab points out, from a recent inflammatory infiltration, which has 
a dull surface. 
It is evident that upon the position of the opacity in the cornea 
depends its influence upon vision. The more central it is or, rather, the 
more directly it encroaches upon the pupillary region, the greater will be 
the disturbance of direct vision. Inequalities in the curvature of the 
cornea distort the retinal images and are fruitful sources of irregular 
astigmatism. 
Where perforation has followed ulceration and the iris has re- 
mained entangled in the aperture, the attachment is called an anterior 
synechia; the corneal scar to which the iris is fastened receives the name 
adherent leukoma (Fig. 119). An eye thus afflicted may become quiet 
and retain, either with or without operative interference, useful vision; 
but may also be subject to recurring attacks of inflammation, and may 
originate sympathetic irritation or inflammation in the fellow eye. It 
may also become the subject of glaucoma. 
The distention of a cicatrix, to whose inner surface the iris is attached, ULCERS OF THE CORNEA 
259 
constitutes a corneal staphyloma, which is called total if the entire 
cornea is involved, partial if only a portion is included, and racemose 
if perforations have occurred at various points. 
The mechanism of the development of staphyloma is, briefly, as 
follows: A perforation takes place, and the iris falls forward and at- 
Fig. 119.-Adherent leukoma, the result of perforating corneal ulcers (from a patient in 
the Philadelphia General Hospital). 
taches itself to the opening, or protrudes through it, becoming fixed 
there by the lymph thrown out in the process of repair. The scar tissue 
which remains fails to withstand the intra-ocular tension, and that por- 
tion of the cornea is pushed forward beyond its normal limits, forming 
a pouch-like deformity. 
Fig. 120.-Beginning staphyloma of cornea following perforation of infected ulcer. 
The protrusion may flatten down, and under the influence of fresh 
inflammation bulge forward again, or may extend between the palpebral 
fissures and prevent the lids from closing (consult Fig. 121). Staphy- 
lomas, the result of ulceration, are more or less opaque, because they 260 
DISEASES OF THE CORNEA 
represent the scar tissue which has formed after the rupture of the 
membrane. Corneal staphylomas, which are not opaque and have not 
formed under the influence of an inflammation, also occur, and will 
presently be described. Thick corneal scars and staphylomas may 
Fig. 121.-Complete staphyloma of the 
cornea. 
Fig. 122.-Section of an eyeball with com- 
plete staphyloma of the cornea. 
undergo retrogressive metamorphosis with the deposition of hyaline 
masses and lime particles in them. Purulent ulcers may develop and 
perforate the lesion; they may even cause panophthalmitis and subse- 
quent atrophy of the eyeball. Ulcers thus formed were named by Arlt 
atheromatous ulcers. The condition is also 
called scar keratitis, and, according to 
Fuchs, is due to entrance of bacteria 
through the diseased and feebly resisting 
epithelium (see also page 414). Anterior 
synechiee and adherent leukoma may also 
occur, according to Von Hippel, from 
internal ulcer, without suppuration of the 
anterior corneal layers. Later the eye 
may become staphylomatous. 
If after inflammation of the cornea, 
with loss of its superficial layers, the in- 
tra-ocular pressure causes the remaining 
lamina to bulge forward into an opaque 
elevation, the condition is called kerectasia. 
This differs from an ordinary partial staph- 
yloma because there has been no perfora- 
tion, and the iris tissue is not involved in 
the process. 
If all the layers of the cornea down to the posterior elastic lamina are 
destroyed, and this protrudes through the opening in a small, trans- 
lucent, hernia-like pouch, surrounded by a rim of opaque cornea, it is 
known as a keratocele. 
An orifice remaining after a wound or, more commonly, because of 
Fig. 123.-Staphyloma of 
cornea, with hypertrophy of the 
cicatricial tissue. ULCERS OF THE CORNEA 
261 
the failure of an ulcer to heal is designated fistula of the cornea. It may 
last for a long period and stubbornly resist efforts at cure. It has been 
recommended to touch the mouth of the fistula with a point of lunar 
caustic, and even to pare the edges and introduce a corneal suture. A 
cicatrix of horny nature growing from the cornea has been reported by 
Arnold Lawson, and he thinks the epithelium covering cicatrices may 
not infrequently become cornified. 
Treatment of the Results of Corneal Ulceration.-Satisfactory results 
follow massage of the cornea. The massage movements should be made 
in a circular and radial manner over the cornea, through the closed lids, 
after the introduction of a small piece of the yellow oxid of mercury 
salve into the conjunctival culdesac. Some irritation accompanies the 
method, but may be allayed by the occasional use of a collyrium of boric 
acid and cocain. Instead of yellow oxid of mercury salve an ointment of 
dionin may be used. In place of finger massage, vibration massage, intro- 
duced by Maklakow, may be employed. An Edison electric pen, the 
point being armed with a small ivory ball, is employed. The vibration 
rate varies from 200 to several thousand a minute. Subconjunctival 
injections of physiologic salt solution may aid in the absorption of 
corneal opacities following keratitis, and similar injections of magnesium 
sulphate and sodium sulphate have been recommended. Thiosinamin 
in |-grain (0.0324 gm.) doses and gradually increased has been em- 
ployed in the treatment of opacities of the cornea. The author has 
tried the remedy without satisfactory results. Other methods of treat- 
ing corneal scars are as follows: A 5 per cent, solution of a mixture of 
equal parts of thiosinamin and antipyrin (J. Galezowski); an eye-bath 
of ammonium chlorid, one to three teaspoonfuls to a cupful of boiled 
water (Pick); and injections of a 15 per cent, solution of fibrolysin, 
which is a compound of thiosinamin and salicylate of sodium, the dose 
being | to 2 cm. 
Alleman revived the use of galvanism for the removal of corneal scars, 
and reported favorable results. A suitably prepared electrode is con- 
nected with a battery, the cathode being applied directly to the anes- 
thetized surface of the cornea, and the anode to the soft tissues of the 
cheek. Usually a current of from 1 to 1| milliamperes gives the best 
results. The seance lasts at the beginning of the treatment for one min- 
ute, and is gradually increased to three or four minutes. Great care 
should be taken not to produce too much reaction. Sulzer recom- 
mends electrolysis and phototherapy in the treatment of corneal opacities. 
Vision may be improved by an iridectomy for new pupil, and the 
appearance of the eye by tattooing the cornea with India ink if the 
corneal leukoma is dense. Attempts have been made at transplantation 
of rabbit's cornea for the relief of dense central opacities. Some recent 
efforts at corneal transplantation have met with encouraging results, 
especially if a circle of clear cornea can be removed from a freshly enu- 
cleated eye and transferred to the opening made in the leukomatous 
cornea. Von Hippel's trephine is a useful instrument for this opera- 
tion. 262 
DISEASES OF THE CORNEA 
The treatment of staphyloma in the first place is preventive, and 
those measures already described in connection with impending per- 
foration of the cornea, and perforation after its establishment, are indi- 
cated-namely, a compressing bandage and the use of eserin or, in some 
circumstances, atropin. If, in spite of this, the bulging continues, para- 
centesis of the anterior chamber or an iridectomy opposite the clearest 
part of the cornea may be performed. Indeed, an iridectomy to pre- 
vent the formation of staphyloma is often useful while the corneal scar 
is still flat, especially if the tonometer indicates any rise of tension. If 
the disease has been so extensive that a complete and unsightly staph- 
yloma has formed, which is the seat of pain and a source of danger to 
the fellow eye, excision of the globe is indicated, or one of the various 
substitutes for the operation of enucleation (see page 636). 
Keratomalacia (Xerotic Keratosis-a name also applied to kera- 
titis e lagophthalmo-Necrosis Comece; Infantile Ulceration of the 
Cornea, with Xerosis of the Conjunctiva).-This disease is characterized 
by dryness of the conjunctiva and destructive ulceration of the cornea, 
and usually appears in infants during the first year of life. According 
to Stephenson it is especially liable to arise about the eighth month, but 
may develop from the third to the twentieth months. 
Cause.-It occurs only in anemic, badly nourished individuals. 
It has been seen accompanying meningitis, measles, and variola, and 
among children with diarrhea, enteritis, tuberculosis, syphilis, and those 
who are inmates of homes whose surroundings are unhygienic. Bacilli 
have been found, but the special microbe, if it exists, has not been cer- 
tainly isolated. In a few cases the Spirochaeta pallida has been found 
(Stephenson). The disease is not a common one. A somewhat similar 
condition has been described in the eyes of negro children in the South 
(Kollock). 
Symptoms.-In the beginning there are conjunctival congestion 
and lacrimation, but the peculiarity of the disorder is the development 
of the appearances described under Epithelial Xerosis (see page 230), in 
connection with the corneal lesions. A gray haze, rapidly turning into 
ulceration, appears in the cornea, followed by inflammation of the iris 
and the formation of hypopyon. Perforation of the cornea and destruc- 
tion of the eyeball may result. Both eyes, as a rule, are affected, one 
earlier than the other. 
The prognosis is very unfavorable; the patients usually die (accord- 
ing to Stephenson the disease is fatal in 50 per cent, of the cases) of the 
wasting disease which has occasioned the trouble, or of an intercurrent 
pneumonia. In some cases streptococci have been found in the local 
lesions, and foci of these micrococci scattered throughout the body. 
Treatment.-This resolves itself, besides the ordinary treatment 
of severe corneal ulceration, into the administration of the internal 
remedies which are indicated by the general state of the patient. 
Neuroparalytic keratitis is the name applied to an ulceration of 
the cornea which arises when this structure becomes anesthetic, because 
it is severed from the influence of the trigeminus. KERATITIS E LAGOPHTHALMO 
263 
Causes.-Disease of the Gasserian ganglion, or its removal for 
trifacial neuralgia, disease of the nuclei of the fifth pair, periostitis of the 
orbit, syphilitic deposits, and fracture of the skull may cut off the tri- 
geminal influence and cause the affection. 
The corneal lesion has been ascribed to a trophic change; to the less- 
ened power of resistance which the cornea in its insensitive condition 
presents to external injuries; to the irritation of the fifth nerve by the 
lesion; to micro-organisms; and to increased evaporation from the sur- 
face of the cornea. 
Wilbrand and Saenger dismiss the traumatic theory and believe 
that some trigeminal fibers from the first branch remain and carry the 
irritation, which is finally concerned with the development of the dis- 
ease. Such irritations, according to Verhoeff, might readily cause an 
acid reaction and, if sufficiently long continued, originate the lesions. 
Hence, in the language of Parsons, the disease is probably due to irrita- 
tive changes in and about the degenerating nerve. 
Symptoms.-The keratitis begins in the true corneal tissue, and 
spreads peripherally until the central necrosis or slough separates, and 
perforation of the cornea with prolapse of the iris occurs. The anterior 
chamber may contain pus or pus mixed with blood. Beyond and 
around the central abscess the corneal tissue is comparatively clear, 
especially in a margin of 2 to 3 mm. in width, but in the periphery there 
may be secondary foci of infiltration, closely connected with inflamma- 
tion of the neighboring conjunctiva. The surface of the cornea and 
conjunctiva is anesthetic. The intra-ocular tension is diminished. 
There may be considerable pain and irritation or these symptoms may 
be absent. 
The prognosis is unfavorable, and in spite of treatment destructive 
inflammation often results, although occasionally the keratitis subsides 
without the formation of purulent material. The center of the cornea, 
however, is flattened and presents a dense scar at the termination of the 
disease. 
Treatment.-The usual treatment of corneal ulcers is necessary, 
and the affected eye should be excluded from the influence of external 
irritants, either by a carefully applied antiseptic bandage or by a Buller's 
shield, or, better, by stitching together the lids. The same operation is 
indicated as a prophylactic measure preceding removal of the Gasserian 
ganglion. At least, the eye should be covered with a protecting shield, 
such as has been devised by W. W. Keen. Experimental evidence 
indicates the propriety of preventing evaporation by keeping the eye in a 
moist atmosphere. 
Keratitis e Lagophthalmo (Keratitis of Desiccation; Keratitis 
Xerotica-Feuer).-This affection arises because the cornea is exposed, 
owing to defective closure of the lids (see also pages 180 and 584). As 
the result of this exposure there is desiccation of the corneal epithelium, 
which becomes fissured and in places exfoliates. Thus, a pathway for 
microbic invasion is opened, and ulceration and suppuration occur. 
The usual causes of this affection are: proptosis of the eyeball, as in ex- 264 
DISEASES OF THE CORNEA 
ophthalmic goiter (see page 583) and exophthalmos (see page 592); 
paralysis of the orbicularis, as in facial palsy (see page 180); and long- 
continued illness associated with defective closure of the lids. 
The treatment consists in protecting the cornea by a suitable bandage 
or shield, or in some cases by stitching the lids together (see page 604). 
Herpetic Keratitis {Herpes of the Cornea).1-The corneal lesions 
associated with herpes zoster ophthalmicus have been described on page 
163. The present disease consists of a vesicular eruption upon the cor- 
nea, which breaks down and forms an ulcer, characterized by a denuda- 
tion of epithelium not unlike that produced by injury. 
Causes.-Horner described herpes of the cornea with whooping- 
cough, intermittent and typhoid fever, and, in general terms, with those 
affections in which herpes of the lips and nose is found. It is seen in 
acute and subacute disease of the posterior nares and pharynx, and also 
in affections of the respiratory apparatus generally (pneumonia, bron- 
chitis), and may follow or be associated with influenza. 
Symptoms.-The disease begins with the symptoms of catarrhal 
conjunctivitis followed by a series of transparent vesicles upon the 
cornea, which have been compared to a string of small beads. The 
vesicles are placed in a circle, or run in a diagonal or irregular line 
Fig. 124.-Showing various shapes and positions of herpes ulcers (Haab). 
across the cornea. They speedily rupture and leave an open patch, 
deprived of epithelium, which is anesthetic and has irregularly serrated 
margins, upon which the remains of vesicles may be seen. The lesions 
are easily shown by fluorescein, which may also produce a deep or super- 
ficial coloration of those portions of the cornea apparently unaffected. 
The sensation of the cornea is diminished. 
The progress of repair is slow, and is often interrupted by the reap- 
pearance of fresh vesicles. The disease may be complicated with pus in 
the anterior chamber and iritis. Pain in the eye and brow, photo- 
phobia, lacrimation, and a gritty sensation are the subjective symptoms. 
Treatment.-This consists in relieving the general condition; usually 
quinin in full doses is indicated, and salicylate of sodium is a most 
valuable remedy. During the stage of irritation, atropin, holocain, 
warm compresses, and dark glasses are needed. Dionin is of signal 
service. After the formation of the ulcer the treatment is conducted 
on general principles. A pressure bandage is of advantage, and in 
many cases an application of tincture of iodin is promptly successful. 
It may be repeated as often as required. Occasionally the application 
1 This term, as Horner observed, is often incorrectly used as synonymous with phlyc- 
tenular keratitis. VASCULAR KERATITIS 
265 
of carbolic or trichloracetic acid or the actual cautery may be needed to 
subdue stubborn ulcers of this character. 
Rosacea Keratitis.-Usually in women at or about the fortieth 
year of life, but sometimes at an earlier period, in association with acne 
rosacea, there may develop a form of keratitis. The manifestations 
vary. There may be lacrimation, blepharospasm, blepharitis, bulbar 
injection, and the development of a grayish-white, vascularized corneal 
infiltration with small circular ulcers, as in Holloway's patient; or 
small marginal ulcers and infiltrations may arise (Erdmann; see also 
page 189). The treatment of the coexisting acne rosacea is important. 
The eye lesions are favorably influenced by the usual lotions, by scopol- 
amin-mydriasis, and especially by holocain. 
Keratitis bullosa in many instances is a symptom and not a 
separate disease, inasmuch as it consists of the formation of one or more 
small blebs of short duration (keratitis vesiculosa), or of larger blebs of 
more enduring existence (keratitis bullosa), upon the cornea of an eye 
the subject of iridocyclitis, interstitial keratitis, or glaucoma. 
Cause.-This affection formerly was attributed to a mechanical 
effect due to increased intra-ocular tension. Probably under the 
pathologic conditions existing an interepithelial edema takes place, 
the fluid penetrating from the anterior chamber through the changed 
and unresisting endothelial cells, or coming from the capillary network 
of the corneal limbus. This edema causes the epithelial cells to de- 
generate and loosen their hold on Bowman's membrane, and they are 
raised in the form of bullse. Sometimes, in addition to epithelium, the 
walls of the bullae are composed of a homogeneous membrane. Occa- 
sionally moderately large vesicles form upon a cornea otherwise normal, 
and in one reported case malaria was believed to be the chief factor in 
their causation. 
Symptoms.-In addition to the formation of the blebs, there are 
burning pain, photophobia, injection of the bulbar conjunctiva, and rup- 
ture of the vesicles, leaving an abrasion which may go on to ulceration, 
and its infection may produce sloughing of the cornea, and even panoph- 
thalmitis. There is a strong tendency to recurrence, and with each new 
formation of vesicles the violent inflammatiory symptoms are repeated. 
Treatment.-This consists in puncture of the blebs and suitable 
local measures, according to the causative disease. Holocain, dionin, 
and sometimes pilocarpin are useful. In severe cases iridectomy and 
even enucleation may be needed. The recurrent character and the 
remissions which have been described have suggested the use of anti- 
periodic doses of quinin; and these have been given with good results. 
The second group of corneal inflammations, a description of which 
follows, is the non-ulcerative, and includes a variety of affections free from 
ulceration. 
Vascular keratitis is a superficial vascularity and opacity of the 
cornea, and is seen in pannus caused by granular lids (see page 221) 
and in phlyctenular pannus the result of many relapses of phlyctenular 
keratitis (see page 242). 266 
DISEASES OF THE CORNEA 
Another form of vascular keratitis is characterized by the formation 
of two opposite vascular areas at the upper and lower margins of the 
cornea, which approach each other until the vascularization is complete. 
The disease is met with in young adults and in unhealthy, scrofulous, 
and underfed children. The second eye usually is attacked, and, as 
was pointed out by Carter, the character of the disorder indicates a 
perverted action of the nerves which govern the areas affected, and 
places it in analogy with herpes. 
Symptoms.-These begin insidiously with slight intolerance of 
light, preceding the appearance at the upper margin of the cornea of a 
crescent of closely arranged blood-vessels, which, as they advance, push 
before them a border of corneal opacity. Simultaneously the same 
appearances become manifest at the lower margin. Between the 
vascular areas the cornea is grayish white in color, or it may assume 
an appearance which suggests a purulent infiltration of the layers. 
Clearing begins at the borders, and the whitish opacity which re- 
mains leaves the center last of all. All cases must be regarded 
with anxiety, as the lesions do not always entirely disappear (compare 
page 270). 
Treatment.-Local irritants are contraindicated. Atropin, dionin, 
and warm fomentations in the early stages, and later a salve of the yellow 
oxid of mercury or calomel are useful. The best internal treatment is 
a prolonged course of iron and bichlorid of mercury. Iridectomy for 
new pupil may be necessary, and the convex side of the vascular crescent 
may be touched with the galvanocautery, or a free peritomy may be per- 
formed. 
Parenchymatous Keratitis {Interstitial, Syphilitic, Inherited, 
Specific, and Diffuse Interstitial Keratitis; Anterior Uveitis').-This is a 
diffuse keratitis in which a chronic inflammation of the whole thickness 
of the cornea takes place, until, usually without ulceration, but always 
with superficial or deep vascularization, the cornea in severe cases 
passes into a condition of universal thick haziness. 
Causes.-The majority of cases of interstitial keratitis are due to 
inherited syphilis, the evidence of which is present in 60 per cent, of 
them. In a comparatively small percentage of cases (2 to 10 per cent., 
according to Stephenson's investigations) acquired syphilis is the etiologic 
factor. Next to syphilis, tuberculosis furnishes the largest contingent 
of cases of interstitial keratitis (about 10 per cent.). This disease may 
also be caused by rachitis, scrofula, malaria, myxedema, trypanosomi- 
asis, leprosy, the climacteric, and depressed nutrition. It is occasion- 
ally seen in animals and may be the result of trauma. Its causation 
by syphilis, tuberculosis, leprosy, and trypanosomiasis has been proved 
not only in clinical, but in histologic, bacteriologic, and experimental 
investigations. 
It is most frequently observed between the ages of five and fifteen 
years (most frequent between six and twenty-Hoor), occasionally 
as early as the third year, but rarely after the thirtieth year. A few 
cases are on record as late as the sixtieth year of life. The disease is PARENCHYMATOUS KERATITIS 
267 
more frequent in females than in males, occurring in the former espe- 
cially at the periods of second dentition and of puberty. 
Interstitial keratitis appears to have been aggravated by the de- 
velopment of menstruation, and also to have undergone improvement 
by establishment of the menstrual molimen. It is probable that the 
affection occasionally arises in utero, and a congenital form of interstitial 
keratitis, not differing in appearance from the ordinary or postnatal 
form of the disease, has been described (Randolph). It has been pro- 
duced in animals by inoculation of the eye with syphilitic material, and 
in human beings it has followed a chancre on the lid or conjunctiva 
(10 cases, according to J. T. Carpenter). Fuchs has observed in some 
cases of interstitial keratitis that in shape the cornea is a vertical ellipse. 
In general terms he believes that an oval cornea is more frequent in 
persons with inherited syphilis and in those who are likely to acquire 
interstitial keratitis than it is in other patients. It does not follow, 
as he points out, that be- 
cause the cornea is oval the 
patient has inherited syphilis. 
Symptoms.-The lesions 
begin either in the center or 
at the margin of the cornea. 
In the first instance, after a 
few days of slight ciliary 
congestion and watering, a 
faint cloudiness appears. 
The spots of haze, if care- 
fully examined, will be found 
to be interstitial opacities, 
composed of round cells-that is, within the structure of the cornea 
itself and not on either surface. 
In two or three weeks they spread until the whole cornea is in- 
vested with a diffuse haziness, veiling or completely hiding the iris, 
except, perhaps, through a narrow rim at the margin of the cornea. 
The steamy surface has often been compared to ground glass. Care- 
ful inspection will reveal that the opacity is not uniform, but contains 
saturated whiter spots scattered through it, which have been described 
as "centers of the disease." There are always at this stage ciliary con- 
gestion and some pain and dread of light. Blood-vessels derived from 
the ciliary vessels are thickly set in the layers of the cornea and produce 
a dull red color-"the salmon patch of Hutchinson." These patches 
may be small and crescent shaped, or large and sector-like. In one 
type (referred to on page 266) the vascularity creeps from above and 
below until the entire cornea is cherry red. If the disease begins at the 
margin of the cornea, areas of cloudiness appear at different portions of 
it, and gradually from all sides approach the center until the general 
haziness is complete. Owing to the formation of vessels, the limbus 
becomes red and swollen at those portions which correspond to the 
marginal opacities, giving rise to an appearance which has received the 
Fig. 125.-Vessel formation in the cornea after in- 
terstitial keratitis (Hirschberg). 268 
DISEASES OF THE .CORNEA 
name "epaulet-like swelling." It is most often seen in the upper cor- 
neal margin. 
The subjective symptoms of irritability and photophobia are more 
pronounced in strumous children who are at the same time syphilitic. 
Ulceration rarely occurs, but none the less ulcers of discoverable size 
are sometimes present, and hypopyon and an appearance resembling an 
Fig. 126.-From a photograph of a patient in the Children's Hospital, the subject of in- 
herited syphilis and interstitial keratitis. 
accumulation of pus in the layers of the cornea have been reported. 
Iritis and the formation of posterior synechiae are not uncommon, in one 
form the iritis being associated with deposits on the posterior layer of 
the cornea and the formation of anterior synechiae. Inflammation of 
the ciliary region is occasionally encountered; secondary glaucoma and 
shrinking of the eyeball may follow. 
In the course of time, varying in accordance with the treatment, PARENCHYMATOUS KERATITIS 
269 
the eye begins to clear, usually from the periphery. Perfect recovery 
of the transparency must be rare, although the remaining haze may be 
slight. Years after an attack of interstitial keratitis minute vessels, 
nearly straight, branching at acute angles and short bends, may be 
detected in the cornea. These appearances have been especially de- 
scribed by Nettleship and Hirschberg, the latter observer stating that 
the vessel formation never subsides entirely, and he has seen this con- 
dition, with the aid of a corneal loup, thirteen years after an attack. 
In addition to the complication of iritis and inflammation of the 
ciliary body, more or less retinitis is very apt to be present. Dissem- 
inated choroiditis, and even optic neuritis and retinal hemorrhage, 
have also been observed; indeed, it is not uncommon to find, far for- 
ward in the eye-ground, areas of choroiditis (anterior choroiditis) not 
only in the diseased, but also in the unaffected eye (see also page 
351). The presence of the vessels and the deposits in the retina and 
choroid after the disease has subsided may be utilized for the diagnosis 
of inherited syphilis. Secondary glaucoma may develop, with deep 
cupping of the disk. Periods of rise of tension during the course of 
interstitial keratitis are not uncommon, and must be carefully guarded 
against, using eserin or by paracentesis of the cornea. 
The subjects of typical forms of this disease often present a remark- 
able combination of physical defects. The dwarfed stature, the coarse, 
flabby skin, the sunken nasal bridge, the scars at the angle of the mouth 
and also of the nose, the malformed permanent teeth, in which the 
central incisors have vertically notched edges (Hutchinson's teeth), 
indelibly stamp the inheritance of the patient. This character of teeth 
is present in between 20 and 30 per cent, of the cases. Indeed, it has 
been seen as frequently as 31 times in 48 cases. The presence of deaf- 
ness, cicatrices in the pharynx, chronic periostitis of the tibia, synovitis 
of the knee-joint (symmetric or unilateral), and indurated lymphatic 
glands further emphasize the syphilitic taint. Not only are the differ- 
ent forms of Hutchinson's teeth frequently evident, including the peg- 
shaped milk canine, but also the defective first permanent molars de- 
scribed by Fournier and Darier, and the "sloped molar" of Gifford. 
The interstitial keratitis of acquired syphilis is usually a late second- 
ary or a tertiary event. It may be circumscribed or diffuse, and is 
more apt to be unilateral than the variety due to inherited syphilis. 
Its evolution is relatively more rapid, and it is more promptly amen- 
able to treatment. Usually it appears in adults between the twentieth 
and fiftieth year of life; exceptionally it has been seen in children (see 
also page 267). 
Diagnosis.-The course of the disease is usually quite typical, 
and the associated symptoms characteristic. The tension of the eye- 
ball and the age of the patient in most instances help to exclude primary 
glaucoma, while the history and character of the inflammation differ- 
entiate it from old corneal maculae and from the diffuse infiltration of 
the cornea which is sometimes seen as the result of injury. Wasser- 
mann's test should always be made, and, to distinguish between cases 270 
DISEASES OF THE CORNEA 
due to syphilis and tuberculosis, the reaction of the patient to tuber- 
culin or to Von Pirquet's test should be tried. 
The presence of the minute straight vessels is good evidence of 
former interstitial keratitis. These vessels must be distinguished from 
those which remain after pannus from granular lids. According to 
Hirschberg, in the latter condition they are more superficial and pass 
into anterior conjunctival vessels. There are well-formed anastomoses, 
the broader veins are accompanied by finer arteries, and there are pecu- 
liar ramifications of the small deep vessels. The vessels seen in corneal 
scars after ulceration are confined to these cicatrices. The rest of the 
cornea is free. 
Certain atypical cases of interstitial keratitis have been described, 
namely, forms in which the opacities are stripe-like; others in which 
they are ring-like; others presenting the appearance of pus in the layers 
of the cornea, the so-called abscess forms; others in which there is a com- 
bination of interstitial keratitis and keratitis punctata, and that form 
which is spoken of as central annular interstitial keratitis, especially de- 
scribed by Vossius, and usually seen in individuals under the age of 
twenty, and for which a definite cause has not been found. The variety 
which begins as a marginal vascular keratitis has been described. Cor- 
neal ulceration is uncommon, but is occasionally encountered. 
Prognosis.-From six to eighteen months are usually consumed in 
the development of the various stages of the disease. The second eye 
is almost certain to be attacked in from a few weeks to two months; 
even active medication may not prevent the involvement of the second 
eye. In rare instances the interval is many months, even a year; it 
may be delayed from five to six years. The patient or his friends must 
be warned of this fact. 
A return to perfect transparency is unusual. The vessel formation 
in the cornea probably never subsides entirely, but even long-continued 
opacity in the course of time may markedly lessen, and reasonable 
vision be restored. The occasional onset of deep-seated inflammation 
of the ciliary region, and the fact that after the cornea has cleared evi- 
dences of former choroiditis, retinitis, or disease of the optic disk, with 
glaucomatous cupping, may be discovered, must not be forgotten in 
rendering a prognosis. 
Relapses are frequent (18 to 22 per cent, of the cases, according to 
Hoor), not only of the corneal disease, but of the complications found 
in the iris and retina. Von Szili suggests that the causation of relapses 
may be due to anaphylaxis, to which he also, in part, attributes the de- 
velopment of the disease after traumatism. It has been taught by some 
observers that the disorder is more severe now than in former times. 
Pathology.-The principal changes occur in the deeper layers of 
the substantia propria of the cornea, and consist essentially of dense 
infiltrations of these areas. Newly formed blood-vessels are seen in 
the posterior and middle layers, and there may be nodular collections 
of lymphocytes (Fuchs). Some authorities distinguish between primary 
and secondary interstitial keratitis, the latter being associated with PARENCHYMATOUS KERATITIS 
271 
inflammation of the uveal tract. Leber regards the disease as always 
secondary to a uveitis, and this view is strengthened, according to 
Parsons, by reason of the frequency with which anterior choroiditis 
can be found ophthalmoscopically in the less affected eye, and by such 
microscopic examinations which have been made. Some authors 
(Von Hippel, Elschnig, Stock) believe that this parenchymatous kera- 
titis is primary-i. e., that the corneal disease is the direct result of the 
general infection. Other observers (Stephenson) ascribe the corneal 
disease to an extension of the process from the uveal tract; that is, in 
syphilitic cases, the spirochetes, arriving from this area, proliferate in 
the corneal tissue. Referring especially to syphilitic interstitial kera- 
titis, two views in regard to the nature are maintained, either that it is 
due to the direct action of the spirochetes which have been found in the 
cornea (Von Hippel, Clausen, Igersheimer), or that it is an indirect 
manifestation of syphilis, i. e., a para- or meta-syphilitic affection. 
Von Hippel, in some histologic investigations, found nodules in the 
cornea containing epithelioid and giant cells. Injections of tuberculin T. 
cause a local reaction in some of the cases, which suggests a tuberculous 
nature of the process. 
Anaphylactic keratitis has been produced by Wessely, Von Szili, and 
Arisawa which closely resembles human interstitial keratitis. Thus, 
Wessely obtained these results by injecting 2 drops of sterile horse 
serum between the lamellae of one cornea, followed in fourteen days 
by a similar injection between the lamellae of the other cornea. Von 
Szili and Arisawa produced opacity and vascularization in a cornea 
sensitized fourteen days previously by means of an injection into the 
auricular vein. It is not impossible that interstitial keratitis should 
be regarded as an anaphylactic phenomenon. Thus, Derby, Walker, 
Igersheimer, and Schoenberg reason that the spirochetes or their toxins 
may sensitize the cornea during extra- or intra-uterine life. If later, 
during childhood, a new amount of latent syphilitic virus enters the 
previously sensitized cornea, keratitis results. 
Treatment.-All irritating applications are harmful. Atropin, to 
maintain mydriasis, prevent iritis, and allay inflammation, should be 
systematically employed, unless rise of tension appears, when it must 
be discontinued. Dionin is of distinct service. The frequent use of 
hot fomentations is useful, and tenderness in the ciliary region will be 
relieved by a leech applied to the temple. The eyes may be protected 
from dust and light by goggles or a dark shade. 
A long-continued course of mercury is indicated. The most satis- 
factory method of administration in the earlier stages is by inunctions, 
1 dram (3.885 gm.) of the ointment rubbed into the skin once or twice 
a day, according to circumstances. Mercury with chalk, 1 grain (0.065 
gm.) three times a day, is highly recommended. Subconjunctival in- 
jections of bichlorid of mercury have been advocated, but in the 
author's experience have proved an unsatisfactory method of admin- 
istering mercury in this disease. Similar injections of cyanid of 
mercury have been employed. Injections of saline solutions are 272 
DISEASES OF THE CORNEA 
often of decided advantage. L. Webster Fox advises subconjunctival 
injections of sodium saccharinate (1 to 3 per cent.). Some surgeons 
recommend that mercury be given in the form of hypodermic injec- 
tions. An experience with this plan of treatment has not caused the 
author to abandon the usual methods of administration. 
During the time the inunctions are being employed, cod-liver oil 
may be exhibited; later, bichlorid of mercury is a valuable remedy, and, 
as many of the patients are anemic, this is advantageously combined 
with the tincture of the chlorid of iron. Arsenic is useful, and atoxyl 
is highly recommended by Stephenson in doses of 0.25 to 0.50 gram, 
injected beneath the muscles of the back once or twice a week. A 
course of tonic treatment, nourishing diet, exercise, and healthful sur- 
roundings are necessary; in short, all measures are indicated which 
elevate the standard of the patient's general health. Indeed, it is 
most important to treat the subjects of this disease most carefully from 
the dietetic standpoint. Injections of tuberculin T. in those cases de- 
pending upon tuberculosis have proved to be efficient. They should 
be administered according to the methods described on page 318. 
Much difference of opinion exists as to the value of salvarsan and 
neosalvarsan in the treatment of interstitial keratitis of luetic origin. 
In the author's experience this form of medication is most valuable, 
and in syphilitic patients it quickly causes a subsidence of the irritative 
phenomena. The injections of neosalvarsan are given at intervals of 
one to two weeks; usually small doses are employed. During the 
intervals the medication should consist in mercurial inunctions, iodid 
of potassium, or mixed treatment. The dose of salvarsan must be 
regulated according to conditions and symptoms; usually each dose 
should be 0.4 gram. Sometimes 0.2 gram will suffice. 
When all irritation has subsided, clearing of the remaining opacity 
is facilitated by the use of a salve of the yellow oxid of mercury, to- 
gether with massage of the cornea, or by the local use of a solution of 
iodid of potassium. Subconjunctival saline injections may facilitate 
the absorption of the corneal opacities. Iridectomy, if the tension rises 
and glaucoma threatens, may be necessary; it is evident that it should 
be employed for new pupil if a stubborn central opacity remains. 
Keratitis Punctata Syphilitica {Keratitis Punctata Vera [Mauth- 
ner]; Keratitis Interstitialis Punctiformis Specifica [Hock]; Keratitis 
Punctata Profunda [Fuchs]).-This form of keratitis was originally de- 
scribed by Mauthner, and is characterized by the appearance of cir- 
cumscribed, pin-head sized grayish spots in the parenchyma of the 
cornea; episcleral injection is usually wanting. The iris is not involved, 
the overlying cornea appears transparent, and the dots may arise 
quickly and disappear rapidly without leaving a trace. They probably 
indicate a gummatous infiltration of the cornea. This disease is a rare 
manifestation of syphilis in its later stages, and should be treated with 
the usual antisyphilitic remedies. 
Keratitis punctata is characterized by a precipitate of opaque 
dots, generally arranged in a triangular manner, upon the posterior KERATITIS SUPERFICIALIS PUNCTATA 
273 
elastic lamina of the cornea (Descemet's membrane-hence also called 
descemetitis). The overlying cornea, is hazy, its surface at times slightly 
uneven. This affection is always secondary to disease of the iris, ciliary 
body, choroid, or vitreous, and hence is a symptom and not a specific 
disease. It will be fully considered elsewhere (see page 323). 
Keratitis Profunda (Central Parenchymatous Infiltration; Circum- 
scribed Parenchymatous Keratitis).-This form of keratitis is charac- 
terized by the formation of a grayish opacity in the deeper layers of the 
cornea, sometimes without severe irritative symptoms and unassociated 
with ulceration. 
The cause is not always discoverable; sometimes alcoholic excess, 
cold, rheumatism, and malaria may originate the disorder; it undoubt- 
edly may develop from an injury. W. T. Holmes Spicer believes that 
overeating and drinking, and their results in the individuals or in their 
descendants, in the form of gout and rheumatism, with defective in- 
testinal functions, are responsible for the majority of the cases. It is 
probably an expression of gastro-intestinal auto-intoxication in some 
cases. An acute interstitial keratitis in association with mumps has been 
described. 
The following is Fuchs' description of this disease: The gray 
opacity, usually in the center, is covered by the superficial corneal 
layers, which are hazy and stippled, but not absorbed. Close examina- 
tion (with a loupe) of the corneal opacity resolves this into individual 
points, spots, or gray interlacing stripes. The deposit slowly absorbs 
without ulceration, and commonly with only slight vesicle formation, 
and leaves the cornea clear, or permanent opacity may remain. Symp- 
toms of inflammation may or may not be present; there is hyperemia of 
the iris. The duration of the disease is from one to twelve months, 
the average duration being about three months. Spicer thus sum- 
marizes the symptoms of deep keratitis: Moderate ciliary congestion, 
moderate vascularization, but no salmon patch, opacification of the 
cornea, either as a central disk or a peripheral cone, an appearance under 
loupe examination of fine striated lines, and edema of the cornea. 
Fluorescein causes the deepest parts of the cornea to take on a stain. 
He believes that the true seat of the disease is in the nutrient blood- 
vessels. 
The treatment requires atropin, dark glasses, and, later, yellow oxid or 
similar salve to aid resolution. Dionin and subconjunctival injections 
of salt or cyanid of mercury may be tried. The constitutional treatment 
is most important, and is governed by the probable cause. 
Among the more uncommon forms of corneal inflammation the fol- 
lowing may be mentioned: 
Keratitis Superficialis Punctata (Keratitis Subepithelialis Cen- 
tralis; Keratitis Maculosa; Noduli Cornea; Relapsing Herpes Cornea).- 
This disease appears in several forms, just as it has been described under 
several names, either different types of the same disorder or closely 
analogous manifestations. 
Generally it begins with the symptoms of a sharp conjunctivitis in 274 
DISEASES OF THE CORNEA 
which the secretion is watery, while at the same time there is catarrhal 
disease of the respiratory tract. In two or three days numerous small 
punctiform or linear spots appear, not immediately beneath the epi- 
thelium, but below Bowman's membrane. The overlying cornea is 
slightly hazy, and the epithelium above the spots a little elevated, the 
foci being more numerous near the center of the cornea than at the 
periphery. The cornea intervening between the spots is somewhat 
hazy, and contains small points and gray lines radiating hither and 
thither, comparable to the fine fissures in ice. The disease is tedious 
and may last for months. It occurs in young individuals, usually is 
bilateral, and is unaccompanied by loss of epithelium, ulcers, iritis, or 
hypopyon. 
Stellwag described foci of large size, most commonly in the periphery. 
This type of the disease begins with pain in the brow, and the iris may 
be involved (nummular keratitis). It is analogous to interstitial forms 
of keratitis. In his cases the duration was much shorter, cure having 
been effected in two weeks. 
The anatomic nature of the spots is uncertain; by some observers 
they have been believed to be enlarged and opaque corneal corpuscles, 
or lymph-spaces filled with opaque matter. The disease may be asso- 
ciated with catarrhal affections of the upper air-passages. It has been 
observed in association with menstrual disorders (Bosser), but its 
exact nature is unknown. Verhoeff's investigations lead him to regard 
the affection as a neuroparalytic keratitis, with the causal lesion in the 
ciliary ganglion. The infiltrations beneath Bowman's membrane he 
attributes to the action of pyogenic diffusible toxic substances arriving 
at nerve terminals. The disease differs from herpes in the absence of 
vesicle formation and herpes of the face, in its bilateral character, and 
in the great number of corneal spots or foci. 
The treatment should be directed to the mucous membrane of the 
nasopharynx as well as to the eye. Locally, during the state of irrita- 
tion, atropin is indicated, and later yellow oxid salve. Holocain and 
dionin are of service. Full doses of quinin would seem to be called for, 
and it has been recommended to use the constant current along the 
region of the distribution of the supra-orbital nerve. 
Keratitis Marginalis Profunda.-Under this name, which is here 
used in a sense quite different from that employed on page 242, Fuchs 
has described a rare form of keratitis in which a yellowish-gray zone of 
opacity, immediately joining the sclera, pushes into the clear cornea, 
accompanied by severe inflammatory symptoms, and occupies about 
one-half of the corneal circumference. The vessels of the limbus cover 
the opacity; in several weeks these and the inflammatory symptoms 
subside, leaving a rim of infiltration somewhat like an arcus senilis, 
save only that it joins the sclera directly and is not separated from 
it by a stripe of clear cornea. The disorder is unaccompanied by 
ulceration. 
It should not be mistaken for the angular corneal opacity, which 
appears in connection with scleritis, and which is known as sclerotizing GRILL-LIKE KERATITIS OR CORNEAL OPACITY 
275 
keratitis (see page 290); it differs from it in the absence of any preceding 
scleritis. The disorder occurs in elderly subjects. 
Keratitis Disciformis (Keratitis Annularis et Disciformisf- 
According to Fuchs, this is an individual type of ring-like or disk-like 
keratitis. It has also been described by Grunert. It should be dis- 
tinguished from the annular keratitis of Vossius (see page 270). The 
disease is found in persons in middle life, and appears frequently after 
slight epithelial defects, whether these are caused by injury or by 
herpes of the cornea. It is characterized by a delicate gray disk which 
occupies nearly the middle of the cornea, and which is separated from 
its transparent margin by an intensely gray, sharply marked border. 
The superficial layers of the cornea are smooth and unirritated. In the 
course of the disease, which lasts usually for several months, small 
ulcers may appear, and under most circumstances there is a decided 
opacity after the subsidence of the disease. Fuchs thinks that this 
disease has a position between serpiginous ulceration and the flat, disk- 
shaped ulceration after herpes of the cornea. All three depend upon an 
infection of the cornea which gains entrance through a breach in the 
epithelium. The difference depends upon whether there is a deep or a 
superficial involvement of the tissue, which, in its turn, depends probably 
upon the character of the bacteria. Peters emphasizes the connection 
between this form of keratitis, corneal erosions, and serpent ulcer, 
and believes that all three depend upon a nervous lesion affecting the 
corneal epithelium, followed by edema of the tissue. Verhoeff contends 
that the disease is neuropathic in origin. Schirmer has described cir- 
cumscribed parenchymatous keratitis, exactly resembling keratitis disci- 
formis, due to infection with vaccine virus. The treatment may include 
atropin, hot compresses, and the local application of absolute alcohol, 
but it has not been followed by encouraging success. Dionin may be 
tried. 
Grill=like Keratitis or Corneal Opacity (Gittrige Keratitis, 
Biber, Haab); Nodular or Guttate Opacities of the Cornea (Groe- 
nouw, Fuchs); Family Punctate Degeneration of the Cornea 
(Fehr).--Grill-like corneal opacity, known also under the name of 
trellisecl and lattice-form opacity of the cornea, was first described by Biber 
and Haab, and has been well investigated by Freund. The last-named 
author gives to these opacities the following characteristics: They 
constitute a hereditary disease which appears first after the age of 
puberty, in the form of gray, superficially placed spots in and around 
the center of the cornea, which lie beneath the epithelieum and lift it 
into a position of distinct unevenness on the superficial layers of the 
cornea, and by diffuse corneal opacity which, examined with a loupe, is 
seen to be composed of a grill-like network with radial opacities. The 
peripheral borders of the cornea are free from disease. 
Nodular or guttate opacities of the cornea were first described by 
Groenouw and later investigated by Fuchs. According to these authors, 
the disease consists in the development of numerous small, rounded, or 
irregular gray opacities in the cornea, especially within the pupillary 276 
DISEASES OF THE CORNEA 
area. Between the larger opacities lie much smaller, dust-like gray 
points. The epithelium is slightly raised by the larger nodes, and, 
therefore, there is a certain slight irregularity of the corneal surface. 
Almost all of the cases have occurred in men, and they were not found 
to be associated with any constitutional disease. In some of the 
patients a history of previous corneal inflammation was obtained. 
Reticular opacities and interstitial punctate opacities are names also 
suggested for this disease. 
With the name "family punctate degeneration of the cornea," 
Fehr has described a punctate opacity of the cornea which may affect 
several members of one family, and which begins about the tenth or 
twelfth year of life, progressing steadily until toward middle life. The 
cornea presents a diffuse gray appearance, and is strewn with white 
spots and dots of various shapes in the center, while the periphery 
remains comparatively clear. With a strong lens the diffuse opacity is 
seen to be composed of minute points, by the condensation of which 
the larger opacities are formed. The corneal surface is smooth, reflects 
evenly, and has normal sensibility. Although this corneal condition 
differs somewhat from the two previous ones just described, it evidently 
is analogous, as Fehr points out, to them, and he suggests that these 
lesions probably represent three different types of the same affection, 
for which he proposes the name "family punctate or spotted degenera- 
tion of the cornea." 
These various processes represent a degeneration rather than an 
inflammation, and the opacities are probably due to deposits of hyalin 
material in the deeper layers of the corneal epithelium and in Bowman's 
membrane. There may also be a mucoid substance produced by de- 
generation of the corneal lamellae. Nodular opacities of the cornea 
(Groenouw) are regarded by Wehrli as a form of chronic tuberculous 
disease of the anterior layers of the cornea {lupus of the cornea). Treat- 
ment is absolutely unavailing. 
Marginal Degeneration of the Cornea.-This is probably 
similar to, if not identical with, the furrou'-keratitis of Schmidt-Rimpler, 
and has been well studied by Fuchs, George Coats, and a number of 
observers. It occurs in middle-aged or elderly persons in whom usually 
an arcus senilis becomes wider and the cornea in the area of the arcus 
grows thin. A groove or gutter forms; this gives way before the intra- 
ocular tension, and a marginal ectasia is developed. The symptoms of 
irritation are mild; sometimes the lesions are unilateral, sometimes bi- 
lateral. In Zentmayer's patient the grooves encircled the margin of 
the cornea of each eye except for an arc about 15 degrees down and in. 
Whether the process is degenerative or inflammatory has not been de- 
cided. Terrien has tried the application of the actual cautery for its 
relief. 
Epithelial Dystrophy of the Cornea.-According to Fuchs, this 
degenerative disease of the cornea affects only elderly persons, being 
more common in women than in men; it has also been noted in associ- 
ation with tabes dorsalis by Fuchs. The corneal sensibility diminishes, RIBAND-LIKE KERATITIS 
277 
a diffuse opacity of the cornea develops in the pupillary area, associated 
with marked alterations in the epithelium, the surface of which is uneven 
and shows blebs or small dark spots. While the epithelium is the chief 
site of the lesion, there is also stippling in the deeper layers of the cornea. 
There may or may not be increased intra-ocular tension. In two 
patients studied by the author the disease began in one, a man, eighteen 
years after a successful cataract extraction, and in the other, a healthy 
woman, without apparent cause. All the typical symptoms recorded by 
Fuchs were present. Treatment is said to be unavailing, but in one of 
the author's patients the persistent use of dionin, associated with the 
internal administration of biniodid of mercury, seemed to check the 
process. 
Filamentous Keratitis.-This somewhat unusual condition is 
characterized by the development of small threads or filaments of tissue 
on the cornea, which usually appear after abrasions or wounds (traumatic 
filamentous keratitis'), or herpes, or occasionally without apparent cause 
(spontaneous filamentous keratitis). The tags have a bulbous extremity 
and are often twisted like a rope. They start from small vesicles by the 
formation of a slender pedicle, and are composed of epithelial cells, 
more or less degenerated, and sometimes especially elongated. Torsion 
of the filaments is due to the movement of the eyelids. A number of 
them may be found in a single cornea; thus, in a case reported by Zent- 
mayer, fifteen to twenty of these filaments in various stages, some as 
clear vesicles attached to the cornea by a short pedicle, others as fila- 
ments 5 mm. in length with a bulbous extremity, were noted. They 
may speedily disappear, or persist, or recur after removal. Locally, 
holocain is of service. 
Riband=like keratitis (primary opacity of the cornea; transverse 
calcareous -film of the cornea; keratitis trophica; keratitis petrificans 
[Suker]) appears, as was pointed out by Nettleship, in two forms: 
In the one, usually in elderly people, the exposed part of the cornea 
is invaded in a transverse direction by a smooth subepithelial opacity, 
oval in shape, which can be chipped off, and is composed of an incrusta- 
tion of lime-salts. Hyalin deposits also appear in the cornea. There 
is no ulceration and no change in the overlying epithelium. The opacity 
is sharply limited and the remainder of the cornea is clear. The dis- 
order almost invariably is symmetric, and is situated upon the exposed 
cornea, although deposits like the transverse band may also be found in 
other parts of the cornea. A margin of the cornea at each end is free. 
Gout and excess of uric acid in the blood have been suggested as consti- 
tutional causes, a suggestion strengthened by the occasional occurrence 
of insidious iritis, glaucoma, and hemorrhagic retinitis. It may be 
mistaken for the opacity which occurs from the injudicious use of salts 
of lead. 
In the other type of the affection a horizontal band of opacity, 
grayish-brown in color, crosses the corneae of eyes which have long been 
blind from iridocyclitis, sympathetic ophthalmia, and glaucoma. Here 
the stripe is less uniform, less sharply defined, and consists of a roughened, 278 
DISEASES OF THE CORNEA 
transverse opacity. The calcareous nature of the other type may be 
wanting. As it occurs in the lower third of the cornea, or that part 
exposed when the eye is rolled up, and in an eye with impaired nutrition, 
the affection has been considered trophic in its nature. According to 
Best, the deposits are composed of lime and connective tissue. Hyalin 
globules are often present. 
Blood=staining of the Cornea.-This phenomenon has been 
observed in cases of hyphemia and increased intra-ocular tension. 
The cornea assumes a smoky or rust-colored tint, except at its periphery, 
the clear portion being sharply separated from the cloudy area, which, 
however, is usually more pronounced in its center. The appearances 
closely resemble those of an amber-colored lens dislocated into the 
anterior chamber. With the microscope numerous granules (probably 
hematoidin) are found deposited in the substantia propria, which, ac- 
cording to Griffith, have entered the corneal tissues by endosmosis in a 
state of solution. The lesions have been studied by E. T. Collins, 
Vossius, Weeks, and J. Griffith; according to the observations of Collins 
and the author, it requires at least two years for the stains to disappear. 
Arcus senilis (gerontoxori), or a circle of fatty degeneration of the 
substantia propria just within the margin of the cornea, is, as its name 
implies, almost invariably found in old persons. A true arcus is always 
separated from the adjacent sclera by a thin stripe of clear cornea. 
Occasionally a genuine example of this affection appears to have been 
noted in children (Hansell). An arciform opacity, the result of ulcer- 
ation, may be mistaken for arcus senilis. The nature of the fatty 
material in arcus senilis has not been determined (Parsons). 
The affection requires no treatment, and 
its presence appears not to interfere with the 
healing of wounds; for example, in cataract 
extraction. 
Senile degeneration' in the form of scle- 
rosis and atrophy of the corneal margin, which, 
according to Fuchs, may arise in connection 
with arcus senilis, has been described on 
page 276. 
Corneal pits (dellen) have been described 
by Fuchs, usually at the temporal margin of the cornea. They exist in 
the form of small saucer-like depressions, and may arise in association 
with swelling, inflammatory or otherwise, of the neighboring conjunc- 
tiva, or spontaneously. They last from a few hours to several days. 
Conical Cornea (Keratoconusf-This consists of a cone-shaped 
bulging forward of the cornea, and is rarely congenital. It has been 
observed in several members of the same family. Usually stated to 
be more common in women than in men, some recent statistics do not 
confirm this assertion. It occurs most frequently between the ages 
of fifteen and thirty years; rarely it is seen in children. Its exact cause 
is unknown. Exhausting illness, menstrual disturbance, and espe- 
cially chronic dyspepsia may be associated with the development of 
Fig. 127.-Conical cornea. CONICAL CORNEA 
279 
conical cornea, the immediate cause being a disturbance in the relation 
of the intra-ocular pressure to the resistance of the cornea. Minute 
clefts in Descemet's membrane may appear, and pulsation of the 
cornea synchronous with each impulse of the heart. In the study of 
keratoconus Von Hippel has applied Abderhalden's test and found a 
disturbance of glandular secretion, an observation which has also been 
made by Siegrist. 
The cone is transparent in most instances; occasionally its apex is 
slightly opaque. The bulging slowly progresses, but does not rupture 
or ulcerate. After years it comes to a standstill. One or both eyes 
may be involved, commonly the latter, the second eye being affected 
some time after its fellow. The eye becomes myopic and highly astig- 
matic. Slight forms of conical cornea may be overlooked unless the 
shadow-test is employed and the characteristic reflections observed, 
or a Placido disk is used (see page 50), or the cornea is studied with 
the ophthalmometer and the distortion of the images of the mires is 
investigated. 
Treatment.-Although no form of glass or no optical apparatus 
may avail in advanced cases, a careful trial should always be made with 
spherocylindric lenses, and frequently their employment in unusual 
combinations will markedly improve visual acuteness. The refraction 
should be frequently investigated and the lenses changed according to 
existing conditions. The tendency for the cone to alter and increase in 
size seems to be lessened by the persistent use of eserin or pilocarpin. 
The strength of the solution need not be greater than to | grain 
(0.0054-0.0108 gm.) to the ounce (30 c.c.). The administration of 
thyroid extract has been advised. 
Properly perforated black disks-that is, forms of artificial iris- 
are recommended by L. Webster Fox for the relief of conical cornea. 
If the apex of the cone appears to be thinning, a weak solution of 
sulphate of eserin and a compressing bandage are indicated. 
In advanced cases an operation is advisable, having for its object 
the substitution of a contracting cicatrix for the tissue at the apex of the 
cone, which shall diminish the excessive curvature. Several plans are 
suggested: (1) Cutting off a small, superficial flap and subsequently 
cauterizing the surface, associated with repeated paracentesis of the 
cornea, and later a small iridectomy for optical purposes; (2) cutting off 
the flap and drawing the edges of the wound together with delicate 
sutures; (3) cutting from the apex of the cone a small disk with a tre- 
phine; (4) multiple punctures with fine needles; (5) obtaining the de- 
sired loss of substance by the application of a galvanocautery. If the 
resulting scar is directly central, an iridectomy for optical purposes 
will usually be required; but if the apex of the cone is eccentric, as it 
often is, iridectomy will not be required. Elschnig advises that the 
galvanocautery shall be applied at a dull-red heat to the apex of the 
cone, and this area connected with the nearest point of the corneal 
limbus by a superficially cauterized band. Optical iridectomy, accord- 
ing to this author, is not necessary. 280 
DISEASES OF THE CORNEA 
Hydrophthalmos (Hydrophthalmos congenitus; Keratoglobus; Mega- 
locornea; Buphthalmos; Glaucoma congenitum).-In this affection there 
is slow bnt progressive enlargement of the eye in all its diameters; the 
cornea is flattened, the pupil dilated and sluggish, the iris atrophic 
and sometimes tremulous, the sclera thinned and of a bluish color, 
and the anterior chamber deepened; the tension is raised. In the course 
of time the cornea may become cloudy (keratoglobus turbidus), although 
this is not always the case (keratoglobus pellucidus). The papilla may 
be deeply cupped. Fissures in Descemet's membrane may arise and 
appear as lines of grayish color with double contour, visible to the 
corneal microscope. 
The affection appears at birth or shortly afterward, and its incipient 
stages are believed to be intra-uterine. The precise cause is not accu- 
rately determined. Buphthalmos is more frequent in negroes than in 
white children, perhaps, as Zentmayer suggests, on account of the greater 
frequency of congenital syphilis among them. It has been ascribed to 
an intra-uterine iridokeratitis with increased intra-ocular tension; in 
other words, a form of congenital glaucoma. Pyle divides the disease 
into two classes: true hydrophthalmos, depending upon congenital 
defective development of the cornea, iris, or filtration channels, and 
hydrophthalmos secondary to fetal intra-ocular inflammation. 
The prognosis is unfavorable; the affection usually progresses to 
blindness. Iridectomy has been practised sometimes with a good result, 
more often with poor success; some favorable results from repeated 
sclerotomies have been reported; indeed, Haab states that if these pro- 
cedures are begun early enough, infantile glaucoma can be cured. 
Corneoscleral trephining has been recommended; the author has ob- 
served one apparently beneficial effect from this procedure. Eserin 
or pilocarpin should be tried. 
Injuries of the Cornea.-Traumatic Keratitis.-These comprise: 
(1) Foreign bodies; (2) erosions; (3) wounds, and (4) burns and scalds. 
Foreign bodies, as particles of sand, cinders, fine splinters of iron, 
and bits of emery, may either lodge upon the epithelium or become em- 
bedded in the substance of the cornea. If they are sharp, like a splinter 
of iron or small thorn from a chestnut-burr, they may partially pene- 
trate the membrane. 
The pain of even a minute foreign body is considerable; the eye 
waters and grows red, and the source of irritation is commonly referred 
to the under surface of the upper lid, although the intruder may be 
directly upon the center of the cornea. 
To remove an embedded foreign body a drop of a 4 per cent, solution 
of cocain or a 2 per cent, solution of holocam is instilled, the upper and 
lower lids are held apart with the thumb and forefinger of the surgeon's 
left hand, while with the right hand he takes a carefully sterilized needle, 
or a spud, and lifts the body from its position with as little injury as 
possible to the cornea. The area should afterward be inspected by 
means of a 2-inch lens and oblique illumination. In any case in 
which the operator is not sure that he has removed the foreign sub- INJURIES OF THE CORNEA 
281 
stance he may resort to the fluorescein method described on page 50. 
If the substance has been iron or emery, a small, rust-like spot will 
often remain. Powder grains may be removed by touching them with 
a fine galvanocautery point (E. Jackson). 
If the spicule has partially penetrated, it may be necessary to pass 
a broad needle through the cornea behind it to secure a surface against 
which to work, and to prevent the manipulations from pushing it entirely 
through the cornea and into the anterior chamber. 
After the removal of the foreign body, the resulting irritation may 
be allayed by a drop of atropin; the use of a bandage for a few days 
will facilitate the healing of the ulcer. Disinfection of the conjunctival 
cul de sac with a bichlorid lotion (1 :8000) or one composed of cyanid 
of mercury (1 :2000) is important. If in the attempt to remove the 
foreign body much abrasion of the cornea has occurred, great care should 
be exercised to prevent infection. Darier recommends a collyrium of 
cyanid of mercury which contains dionin. 
Among oyster-shuckers a form of keratitis is prevalent (oyster- 
shuckers' keratitis), caused by small particles of oyster shells striking 
the cornea and producing ulcers. Randolph has shown that the disease 
depends upon the irritating chemical ingredients in the shell, and not 
upon micro-organisms. It is best treated by atropin and mild anti- 
septic lotions, and a 2 per cent, solution of holocain in physiologic salt 
solution. Kerato-iritis, the result of a bee-sting, has been reported 
(Huwald), and also from the action of antipyrin (Inouye). 
Erosions.-A superficial loss of epithelium caused by the contact of 
a sharp body, for example, a finger-nail, in itself may be insignificant, 
but may lead, through septic infection, to a severe ulceration, particu- 
larly if the injured eye is exposed to the discharge from an inflamed 
lacrimonasal duct. 
The treatment consists of the instillation of an antiseptic lotion, for 
example, bichlorid of mercury (1 :8000), and the use of atropin and 
holocain, with a compressing bandage to immobilize the lids until 
healing takes place, provided no septic discharge is present. 
Relapsing Traumatic Keratitis Bullosa {Relapsing Erosion of the 
Cornea; Traumatic Keratalgia) .-In general terms the symptoms of this 
affection are these: Some time-several weeks or several months-after 
an abrasion of the cornea by a finger-nail, a twig, or similar object, the 
patient experiences, almost always on awakening in the morning, some 
difficulty in opening the eye, followed, when the lid is raised, by marked 
foreign-body sensation, decided epiphora, flushing of the eyeball, and 
sharp neuralgic pain. Each movement of the lid is painful, and the 
"attack" continues from one-half hour to several hours, when, usually 
by afternoon, the symptoms subside and the eye is again apparently 
normal. Careful examination during the continuance of the irritative 
signs just described will reveal on the cornea a small ruptured vesicle, 
or a larger blister or bulla, or sometimes simply an erosion of the super- 
ficial epithelium, without indications of vesicle or bulla. Occasionally 
the only lesion to be detected is the scar or macula caused by the original 282 
DISEASES OF THE CORNEA 
injury, without loss of epithelium. These attacks may recur at short 
or long intervals, for weeks, months, and even years. 
Treatment.-The ordinary treatment of corneal ulcer is indicated, 
and the author has been especially satisfied with the action of holocain 
(2 per cent.), persistently and frequently used. A pressure bandage 
and massage with a salve of yellow oxid of mercury may be tried. A 
drop of liquid vaselin instilled at bedtime is useful. 
Wounds of the cornea naturally divide themselves into non-penetrat- 
ing and penetrating, and differ in character according to the instrument 
which has inflicted them. 
Non-penetrating wounds partake of the nature of erosions, and, like 
them, may be in themselves of minor importance, but may result in 
sloughing ulcers through microbic infection. 
The treatment already described is applicable. 
A penetrating wound allows the escape of the aqueous and renders 
incarceration and prolapse of the iris liable, with all the possibilities de- 
scribed in connection with perforating ulcers. The wound may injure 
the lens and cause traumatic cataract, or involve the ciliary region and 
cause sympathetic inflammation, or become infected and originate a 
sloughing keratitis or a panophthalmitis. 
After a perforating wound of the cornea the eye should be thor- 
oughly disinfected, the iris, if prolapsed, replaced if possible, and eserin 
or atropin instilled, according to the situation of the injury. If replace- 
ment is not possible, and usually it is not, the prolapsed portion should 
be seized with iris forceps and excised. In either event the subsequent 
treatment requires rest, disinfection of the conjunctival cul de sac, and 
a carefully applied antiseptic compressing bandage. Care must be 
taken to ascertain whether a foreign body has lodged within the anterior 
chamber or within the deeper portion of the globe. z-Ray examination 
may be necessary. 
The tendency to traumatic iritis may be combated by the frequent 
use of cold compresses, and the instillation of an atropin solution. 
In severe corneal wounds, involving the iris, lens, and ciliary body, the 
question of enucleation or evisceration must be decided. Gaping 
wounds of the cornea may be closed with fine silk sutures or, according 
to de Wecker, covered with conjunctiva, which is dissected loose in such 
a manner that it may be united over the cornea by a purse-string suture. 
After the corneal wound has united, the conjunctival covering is re- 
moved and restored to its original position. Kuhnt's conjunctival 
flaps may also be used. 
Bums and scalds are produced by the contact of acids, lime, molten 
metal, and hot water or steam, and the general management of such 
cases does not differ from that of similar accidents to the conjunctiva, 
which necessarily is involved (see page 239). 
Sometimes the burn may be superficial and the whole surface epi- 
thelium be changed into a white scum, which presents a most alarming 
appearance. The destroyed tissue, however, is speedily replaced by a 
new layer of epithelium. Burns with slaking lime and molten metal TRAUMATIC STRIPED KERATITIS 
283 
are liable to result in disastrous consequences, and may be followed by 
sloughing keratitis and even panophthalmitis, and if the burns are 
located at the limbus, elevation and intra-ocular pressure may develop 
(Kummell). Allport and Rochester have advantageously used intra- 
muscular injections of cacodylate of sodium in the treatment of corneal 
opacity following a lime burn. Ammonia burns of the eye are of serious 
import, and even where the injury originally seems to be comparatively 
slight, there may develop later rapid necrosis of the cornea, with 
exudation in the anterior chamber, followed by blindness. There is 
a certain similarity between carbolic acid burns and those caused by 
ammonia, but the ultimate prognosis is, according to Stieren, less 
gloomy. 
Severe corneal and conjunctival burns have been caused by ex- 
ploding golf-balls, so-called "zodiac" and "water-core" balls, containing 
caustic contents, e. g., barium sulphate, sodium hydrate, soap, free 
alkali, and zinc chlorid. The treatment of burns and scalds has already 
been described (see page 239). 
All the various forms of corneal injury cause more or less severe 
inflammation, properly classed under the general term traumatic kera- 
titis, and possesses in greater or less degree the cardinal symptoms of 
keratitis-pain, lacrimation, photophobia, and disturbance of vision. 
Peripheral Annular Infiltration of the Cornea (Ring Abscess 
of the Cornea).-This condition is characterized by an infiltration of the 
cornea, the exudation being distributed in a zone concentric with the 
corneal margin. At first the ring is gray, but rapidly becomes yellow, 
its inner edges being somewhat less well defined than its outer; in 
almost all cases panophthalmitis is the ultimate result. The condition 
most commonly follows perforating wounds of the cornea, especially if 
caused by chips of metal, and operations, for example, cataract ex- 
traction. Rarely is it seen after perforating corneal ulcers and in 
metastatic ophthalmitis. It has been well studied by Fuchs, and 
recently by Morax. Bacteria enter the anterior chamber through a 
wound and there proliferate, and by their products give rise to an 
infected iridocyclitis and keratitis, by which the cornea is attacked from 
the rear. Leukocytic infiltration in the form of a ring follows, which is 
itself amicrobic. Hanke believes he has found the specific bacillus, 
but Morax maintains that so-called ring abscess cannot be explained by 
the presence of any one specially determined microbe, but by the pro- 
liferation of certain microbes in the anterior chamber, among which he 
is willing to admit Hanke's bacillus. 
Traumatic Striped Keratitis (Keratitis Striata).-This condition 
may arise after incised wounds of the cornea, and in its most perfect 
manifestation, after cataract extraction (see page 667), and especially 
after expression of the lens in its capsule (see page 660). The gray 
strise, which should be studied with a loupe, are disposed perpendicularly 
to the wound, and stretch toward the opposite margin of the cornea. 
They cause no irritation, and the appearance does not materially com- 
plicate the treatment of the wound which gives rise to them. These 284 
DISEASES OF THE CORNEA 
stripes do not represent a cellular infiltration, but depend upon folds in 
Descemet's membrane. Usually they disappear within a week of their 
development. 
Obstetric Injuries of the Cornea.-These injuries may be due to 
prolonged labor or to forceps pressure. They have been particularly 
well studied by Ernest Thomson and Leslie Buchanan, who classify 
them as diffuse temporary opacities due to edema, and permanent linear 
opacities, which extend vertically, obliquely, or horizontally across a 
whole or a part of the cornea, and which are caused by rupture of the 
posterior elastic lamina of the cornea. In several cases of the edema- 
tous variety studied by the author the opacity gradually but entirely 
disappeared. Doubtless some of the scars of the cornea, known as 
"congenital leukomas," have been caused by birth injuries. The 
author has investigated a few cases of high unilateral irregular corneal 
astigmatism evidently due to the same cause. 
Fig. 128.-Dermoid of the cornea 
(from a patient in the Philadelphia General 
Hospital). 
Fig. 129.-Dermoid of the corneo- 
scleral junction, which on section showed 
a gland inclusion (from a patient in the 
University Hospital). 
Tumors and Cysts of the Cornea.-Tumors of the cornea are 
rare. The following have been described: fibroma, papilloma, myxoma, 
dermoids, sarcoma, epithelioma, and endothelioma. True fibromas 
have been reported, but usually they are scar-fibromas, that is, they 
are hyperplastic scars. A myxomatous degeneration of such a scar is 
the probable origin of the so-called corneal myxomas. The papillomas, 
which have been examined, in most instances have arisen at the limbus 
and invaded the cornea. A few primary sarcomas, even in children, 
have been described, and Parsons has investigated one endothelioma. 
According to this authority, nearly all of the cases of so-called epithe- 
lioma of the cornea are growths beginning in the limbus at the position 
where the conjunctival changes into corneal epithelium. This was the 
condition of affairs in several specimens examined by the author. 
Dermoid tumor is a congenital growth, and sometimes is associated 
with other anomalies of the lid and eyes. Strictly limited to the cornea, 
it is most uncommon; generally it occurs as a firm, hemispheric, yel- 
lowish-white growth, lying partly upon the cornea and partly upon the CONGENITAL ANOMALIES OF THE CORNEA 
285 
conjunctiva. The apex, often paler than the rest of the growth, is 
covered with short hairs. These, however, occasionally grow to an 
unusual length, and have been seen protruding through the fissure of 
the lids and hanging down upon the cheeks. If undisturbed, the tumor 
may slowly enlarge, and has been reported to have attained the size 
of a walnut. Bilateral dermoids have been recorded. 
These dermoids have been ascribed by Van Duyse to the remains 
of amniotic adhesions, and by Remak to invagination of the ectoderm. 
Microscopically, the growth represents the structure of the skin and its 
appendages. 
Teratoid tumors may be situated at the corneoscleral junction, 
rarely, if ever, on the cornea, or upon the outer half of the sclera, or 
upon the bulbus in the neighborhood of the caruncle. They contain, 
as a rule, acinotubular glands, fatty tissue, smooth and striated muscle- 
fiber, hyalin bodies, and cartilage. 
Corneal cysts, according to Oatman, occur in two principal forms- 
epithelial and lymphatic. The first variety is the more common; it 
usually arises from the epithelial layer of the conjunctiva, which is 
ingrafted on the cornea. Cysts following injury of the cornea have been 
ascribed to the proliferation of surface epithelium which has been 
carried into the corneal stroma. They are, therefore, implantation 
cysts. Oatman doubted this pathogenesis, and explained them by 
assuming that a proliferation of superficial epithelium lines the wound 
with epithelial cells, and the mass thus produced, separated from con- 
nections with the surface, takes on an active growth and forms the cyst. 
True lymphatic retention cysts may result from dilatation of the corneal 
canals and spaces. Corneal cysts may be cured by excising a piece of 
their walls. 
Congenital Anomalies of the Cornea.-Microphthalmos is that 
condition in which the entire eye remains in a more or less rudimentary 
state, and in which the cornea is too small in all its diameters. Pure 
cases of microphthalmos, according to Manz, are very rare; usually 
one or other of the component portions of the globe is wanting. Numer- 
ous theories have been advanced to explain their etiology-incomplete 
closure of the fetal ocular cleft (Arlt), fetal illness in orbita (Wedl and 
Boch), intra-uterine sclerochorioretinitis (Deutschmann). The affec- 
tion has also been ascribed to the influence of heredity. 
Megalophthalmos has been described on page 280. 
Sclerophthalmia or sclerosis is that condition in which the opacity of 
the sclerotic encroaches upon the cornea in such a manner that only the 
central portion remains transparent. It is due to an imperfect differ- 
entiation of the cornea and sclera at an early period of fetal life. It may 
be symmetric, and affect only the upper half of the cornea. 
Congenital opacities of the cornea are seen in the form of milky spots 
which may clear up in later life, or as leukomas. Usually the iris is 
dimly visible through the clouded tissue. These opacities are due either 
to intra-uterine inflammation or to an arrest of development (see also 
Birth Injuries, page 284). 286 
DISEASES OF THE CORNEA 
Congenital anterior staphyloma of the cornea appears in the form of 
a true staphyloma, and is a rare affection. The abnormality depends 
not so much upon a malformation or an arrest of development as upon 
a fetal inflammation, which, according to Pincus, takes place in the 
second half of fetal life. They have been well studied by J. Herbert 
Parsons, who holds that the lesions develop in exactly the same manner 
as they do when they take place after birth. Treacher Collins, how- 
ever, thinks failure of the development of the anterior chamber may be 
the original cause in some cases. Peters ascribes the condition to de- 
fective development of Descemet's membrane, and Von Hippel to 
internal ulcer of the cornea. Heredity probably plays some role in this 
and similar affections of the cornea. Congenital staphyloma of the 
cornea associated with dermoid formation has been reported. 
Congenital melanosis or pigmentation of the cornea may appear in the 
form of a vertically oval area of brownish color in the center of this 
membrane. The affection is more common in women than in men. 
It has been ascribed to an abnormal development of the uveal tract 
(Krukenberg). The lesion has been well studied in this country by 
Dr. T. B. Holloway, and he has described peripheral pigmentation of the 
cornea in association with symptoms suggesting multiple sclerosis; 
some of the patients have cirrhosis of the liver. Congenital familial 
flatness of the cornea (cornea plana), according to Ruel, is characterized 
by flattening of the anterior portion of the eyeball in such a manner that 
the curvature of the cornea passes directly into the curve of the sclera 
without the formation of an angle. In Ruel's patients the corneas were 
diffusely opaque. CHAPTER VIII 
DISEASES OF THE SCLERA 
The sclera, constituting four-fifths of the covering of the globe of 
the eye, and being in intimate relationship with the choroid and ciliary 
body, is subject to inflammations peculiar to itself, and to changes in- 
dicative of disease of these subjacent structures. Its close connection 
with the cornea associates the latter membrane in some phases of its 
diseases, and its union with the iris through the pectinate ligament 
establishes an anatomic connection, just as there often is a pathologic 
relation. The overlying bulbar conjunctiva necessarily participates in 
scleral inflammation. 
The inflammations affect (1) the episcleral tissue (episcleritis) and 
(2) the sclera itself (scleritis), and hence are superficial or deep. They 
further are acute or chronic, diffuse or circumscribed. 
Episcleritis occurs in the form of small, dusky red, subconjunctival 
swellings or nodes, which usually appear in the ciliary region on the 
temporal side of the cornea, though patches may occur in any portion 
of the zone. 
The conjunctival vessels over the patch are coarsely injected, and 
movable with the somewhat edematous conjunctiva. The episcleral 
vessels show a dusky congestion which is immovable. The elevation 
is back shaped; sometimes tender to pressure and sometimes not, and 
there may or may not be much irritation and pain. In some cases 
of phlyctenular disease of the corneal margin it is difficult to decide 
between this affection and episcleritis; what appears to be a patch 
of the latter may develop into the former. 
The disease runs a subacute course, reaching its height in about 
three weeks, then gradually disappears, and leaves a somewhat dull 
area of discoloration marking its former position. Relapses are frequent, 
both at the original seat or in new spots on the sclera, and these recur- 
rences may happen again and again for months and even years. The 
cornea and uveal tract easily participate in the inflammation. 
Cause.-Episcleritis and episcleral nodes, either solid or moderately 
soft in texture, are more frequent in women than in men in the author's 
experience. Patches of episcleritis of the character described occur in 
the eyes of those who are much exposed to the weather. In other cases 
superficial scleritis is caused by rheumatism, gout, tuberculosis, men- 
strual derangements, and enterogenous auto-intoxication, and also 
appears without discoverable cause. Well-marked episcleral (not 
conjunctival) congestion or episcleritis occurs in connection with dis- 
ease of the accessory sinuses. 
287 288 
DISEASES OF THE SCLERA 
In these forms of superficial scleritis the prognosis is good so far as 
sight is concerned, because deeper and adjacent structures are unin- 
volved, but unfavorable on account of the recurrences. 
Treatment.-This consists in the use of atropin to allay pain and 
prevent any tendency to iritis, warm antiseptic collyria, and hot com- 
presses. Dionin is of distinct service. In the chronic types eserin and 
pilocarpin, f to | grain (0.0162-0.324 gm.) to the ounce (30 c.c.) of 
water, have a beneficial influence, provided no iritis is present. Sub- 
conjunctival injections of salt solution are useful, and similar injec- 
tions of salicylate of sodium (2 per cent.) and of hetol (cinnamate of 
sodium) have been recommended (Pfliiger). Massage with a salve of 
the yellow oxid of mercury is indicated in chronic cases, and it has 
been recommended to scarify the tumefaction, scrape it away with a 
sharp curet, or cauterize it repeatedly, in a superficial manner, with 
the actual cautery. These cauterizations are often followed by ex- 
cellent results. Internally, salicylic acid and iodid of potassium are 
needed in rheumatic cases, and good results follow diaphoresis with 
pilocarpin or the Turkish bath. Menstrual and uterine disorders must 
be rectified, and the influence of intestinal sepsis eliminated. If a 
tuberculous taint is discovered, injections of tuberculin are of service. 
Any error of refraction or anomaly of the external eye muscles should 
be corrected. 
Fugacious Periodic Episcleritis.-This name has recently been 
applied by Fuchs to a variety of relapsing episcleritis characterized by 
the appearance of one or more patches of episcleral injection or edema, 
of violaceous hue, lasting from two to eight days, and reappearing again 
at intervals of several weeks or even months, to go through the same 
course. The duration of the affection is usually about one year; it 
occurs most frequently in adults. Gout and rheumatism are asso- 
ciated constitutional conditions. The same affection was described 
some years ago by Swan M. Burnett under the name of "Vasomotor 
Dilatation of the Vessels," and by Jonathan Hutchinson with the title 
"Hot Eye." The treatment is the same as that already recommended 
for episcleritis. 
Scleritis may appear in the form of a diffuse, bluish-red injection, 
occupying the entire exposed portion of the sclera, very painful, unat- 
tended with secretion, save some increase in lacrimation, and liable to 
be mistaken for conjunctivitis or iritis; or in the form of circumscribed 
patches, of violaceous tint, situated in the ciliary region, and somewhat 
resembling in appearance the forms of superficial or episcleral elevations 
just described, being, however, less sharply defined, so that the whole 
zone may be involved, but in unequal degree. Spicer calls attention to 
crescentic areas of infiltration in the cornea, separated from the patch 
of scleral inflammation by a band of clear cornea. In many cases of 
diffuse deep scleritis, hard, whitish nodules develop in the inflamed 
tissue (nodular scleritis). Overgrowth of the infiltrated tissue may 
produce diffuse or circumscribed areas, which are called hyperplastic 
scleritis. The chief distinction between the superficial and deep forms SCLERITIS 
289 
of scleral inflammation is the almost invariable tendency of the 
latter to affect other portions of the eye-the cornea and uveal 
tract. 
Pathology.-In episcleritis the infiltrating cells are found either in 
the superficial layers around the conjunctival vessels or in the deepest 
layers. The vessels are dilated, extravasations of blood are found, and 
often spots of necrosis and giant cells. Usually the choroid and sclera 
are infiltrated and edematous. 
The causes of deep scleritis are exposure to cold, rheumatism, 
gout, scrofula, vasomotor changes, and disturbances of the sexual 
apparatus, especially anomalies of menstruation. Young adults are 
most frequently attacked. The so-called gummatous scleritis, in which 
the patches are yellowish brown and translucent, is due to syphilis; 
and gonorrhea, if it is associated with synovitis, may cause the dis- 
order. Deep scleritis is also seen 
in the subjects of congenital 
syphilis and tuberculosis. The 
trial of tuberculin in scleritis will 
often be followed by a general 
as well as a local reaction. Ex- 
cised nodules may show epithe- 
lioid cells and giant cells, but no 
tubercle bacilli. Tuberculous scle- 
ritis is probably due to an infec- 
tion derived from the aqueous 
arising from the filtration angle 
(Verhoeff). Finally, types of 
scleritis (sclerokeratitis) unasso- 
ciated with any definite cause 
or diathesis are seen in young 
and middle-aged subjects, most 
commonly women, whose nutri- 
tion is depressed, and who may 
or may not have a tuberculous 
disposition or inheritance. Scle- 
ritis may be a metastatic inflam- 
mation, the original focus of infection being at some distant part of 
the body, for example, a rectal abscess, a felon, or a purulent sinusitis 
(Dupuy-Dutemps). 
Deep scleritis usually attacks both eyes, runs a chronic course, and 
may affect the iris (leading to closure of the pupil), ciliary body, choroid, 
vitreous (causing opacities), and the cornea. In prolonged cases of the 
disease dark scars remain after absorption of the products of the in- 
flammation, which are unable to resist the intra-ocular pressure, and 
form elevations (ectasia sclerse). Sometimes the whole anterior portion 
of the sclera becomes bluish or slaty colored, is misshapen and elongated, 
and the cornea, which appears small, is poorly differentiated from it on 
account of the haziness of its margins. 
Fig. 130.-Tuberculous sclerokeratitis, 
showing scleral nodules and characteristic 
triangular corneal infiltration (from a patient 
in the University Hospital). 290 
DISEASES OF THE SCLERA 
Sclerokerato=iritis (Scrofulous Scleritis; Anterior Choroiditis').- 
This name is applied to the complicated scleritis referred to in the pre- 
vious paragraph, and is characterized by chronicity, relapses, and in- 
volvement of the cornea and iris. 
Beginning with a deep scleritis of the ciliary zone, the adjacent cornea 
becomes opaque and sometimes ulcerates; the iris is inflamed, posterior 
synechiae form, and pain and congestion may be severe. After weeks the 
symptoms subside, the characteristic discolored area marks the former 
scleral disease, and haziness in the cornea indicates the seat of previ- 
ous inflammation in this membrane. Relapse takes place, with fresh 
scleritis, new corneal involvement, renewed iritis, or iridochoroiditis, and 
vitreous changes, and so on, until after many months, it may be, the 
disease comes to an end, leaving the sclera discolored and bulged, the 
cornea covered with patch-like opacities, the iris bound down with ad- 
hesions, the vitreous filled with opacities, and the eye practically de- 
prived of vision. 
Sclerotizing keratitis, referred to on page 274, is the name applied 
to a patch of opacity in the deeper corneal layers, usually triangular in 
shape, with its base toward the patch of scleritis, which is its origin. 
After the cure of the scleritis, a white or yellowish-white opacity remains 
directly in contact with the sclera. Instead of a single patch of this 
character, several small triangular areas may arise in the circumfer- 
ence of the cornea as the result of scleritis. 
Treatment.-The treatment of scleritis and sclerokerato-iritis de- 
pends upon the type and stage of the disease and the presence or ab- 
sence of definite cause. Locally, atropin, hot compresses, cocain, holo- 
cain, dionin, and boric acid lotion, and in painful cases leeches to the 
temple are suitable. Pilocarpin is valuable if iritis is not present. 
The eyes should be carefully protected with goggles. After the sub- 
sidence of acute symptoms massage may be tried. The use of the 
actual cautery has been mentioned. Subconjunctival saline injections 
are useful. 
In rheumatic cases salol, the salicylates, the alkalis, and iodid of 
potassium are the most available remedies; in gout, carefully regulated 
diet, mineral waters,-Buffalo, Poland, etc.,-citrate of lithium, and 
colchicum, especially in the form of colchicin, and change of climate 
are useful. Cod-liver oil, iodin, iron, and sweats with pilocarpin, 
grain (0.00648 gm.) hypodermically, are also indicated. The diapho- 
retic measures are proper in any case, other things being equal, and, 
in place of pilocarpin, an electric cabinet or Turkish bath may be the 
means of creating diaphoresis. In syphilis, bichlorid of mercury, 
inunctions of mercurial ointment, and neosalvarsan are efficacious. 
Indeed, mercury is generally advantageous as a means of altering 
the nutrition of the part and preventing exudation into the uveal 
tract. Disorders of menstruation should always be corrected. Finally, 
in subjects with depressed nutrition, quinin, arsenic, and a general 
tonic regimen are required. Because many cases of scleritis are due 
to tuberculosis a tuberculin treatment (see page 318) is often indi- STAPHYLOMA OF THE SCLERA 
291 
cated, and may be followed by most satisfactory results. Tests with 
tuberculin should always be made; a positive reaction will follow in a 
number of instances. 
Annular Scleritis (Brawny Infiltration of the Sclera).-To this 
severe form of scleritis, which invariably affects the whole region around 
the cornea, J. Herbert Parsons, G. Derby, and Verhoeff have recently 
called renewed attention. Unlike ordinary scleritis, which usually 
attacks young adults, this affection is a disease of advanced age or, at 
least, of middle life. Both eyes are usually affected, though not to an 
equal extent. The disease is essentially chronic, and subject to periodic 
exacerbations and remissions. Verhoeff believes that syphilis is an im- 
portant etiologic factor, although this cause is doubted by Schodtmann, 
who first described the disease. Gilbert has ascribed it to gout. The 
prognosis is most unfavorable, many of the eyes having been lost. 
The corneal margin is the essential site of the infiltration, from which 
region it spreads on both sides into the surrounding tissues, overlapping 
the cornea on the one side and extending as far as the equator of the 
eyeball posteriorly on the other. The swelling is usually gelatinous 
and succulent and has a brownish-red color. In addition to the in- 
volvement of the cornea, the uveal tract, especially the anterior part 
of the choroid and the ciliary body, are inflamed. 
Posterior Scleritis.-In this affection, as described by Fuchs, the 
symptoms are edema of the lid, exophthalmos, conjunctival chemosis, 
and ophthalmoscopically the appearance of detachment of the retina, 
or of a gray cloudiness over the affected area. After the subsidence of 
the inflammation changes in the retina remain. Secondary iridocyclitis 
may arise. According to Coats, the disease depends upon blocking of 
one of the larger ciliary arteries and consequent infarction of the inner 
layers of the sclera, choroid, and retina. 
Staphyloma of the sclera has been divided by systematic writers 
into anterior, equatorial, and posterior staphyloma, according to the 
situation of the lesion. Posterior staphyloma is detected with the 
ophthalmoscope in a highly myopic eye (see page 131). 
It is evident that all bulging of the sclera depends upon a disturbance 
between the resistance of the sclera and the intra-ocular tension, but it 
is not evident in all cases whether the process which originated the 
trouble began in the underlying tissue or in the scleral structure itself. 
There may be a general enlargement of the scleral coat, for example, 
in hydrophthalmos (see page 280); or one or more darkly tinted swell- 
ings in the ciliary region may arise, one sometimes occurring in ad- 
vance of each rectus tendon; or, finally, the staphylomatous swelling 
may exist at the equator in the region of the vena vorticosa. 
The following causes may originate scleral staphyloma: Chronic 
glaucoma, old kerato-iritis and closure of the pupil, inflammation of the 
ciliary body, thinning of the scleral coat by repeated attacks of inflam- 
mation, tumors, and wounds closed by non-resisting scars. 
Treatment.-A single scleral staphyloma may not destroy vision. 
If the intra-ocular tension is increased, an iridectomy is indicated. 292 
DISEASES OF THE SCLERA 
If the eye is useless, enucleation or one of its substitutes may be 
necessary. 
Abscess and ulcers of the sclera are exceedingly uncommon. 
Abscess in the scleral tissue may result from an infected wound and 
has been seen in connection with certain specific and contagious dis- 
eases-e. g., glanders. Metastatic scleral infection has been recorded 
(see page 289). 
Ulcer of the episcleral tissue has been described in association with 
tuberculosis. A tumor, gumma, or tubercle of another region of the 
eye may break down and ulcerate into the sclera. 
Tumors of the sclera are rare growths. The following have been 
described: Fibroma, fibrochondroma, enchondroma, and osteoma. 
Primary sarcoma, if it exists, must be rare; recently a case has been 
recorded; secondary sarcoma, carcinoma, and glioma have been reported. 
Gumma of the sclera has been de- 
scribed, and tubercle may invade it 
from the uveal tract. A few scleral 
cysts have been recorded. Small 
primary scleral growths may be dis- 
sected from their beds, and the 
wounds closed with conjunctival su- 
tures (Fig. 131). 
Injuries of the Sclera. - 
Wounds of the sclera may be caused 
by a sharp implement (knife, scis- 
sors, broken glass, etc.) or foreign 
body (chip of iron or steel, bullet, 
etc.), or they may result from a blow 
on the bulbus on the inner side and 
above, rarely downward and out, 
causing rupture of the sclera, usually 
found 3 mm. from, and concentric 
with, the corneal margin (T. Collins). The rupture may be exposed 
through a rent in the conjunctiva, and is then said to be "compound," 
or it may be concealed by the conjunctiva, which is untorn. Indirect 
ruptures of the sclera occur in the vicinity of the cornea and are more or 
less concentric with it, because here, due to the presence of Schlemm's 
canal and the penetrating anterior ciliary veins, there is an area of poor 
resistance. A blow may also rupture the cornea. Corneal tears, accord- 
ing to L. Muller, are more common in young people than scleral ruptures. 
If the wound has perforated the sclera, two complications are liable 
to be present: loss of a portion of the contents of the globe and injury 
to the inner coats, and the introduction into the eye of septic material 
which will cause destructive inflammation. 
Symptoms.-A perforating wound of the sclera, if sufficiently large, 
causes loss in the tension of the globe, hemorrhage into the vitreous, or, 
it may be, into the anterior chamber, and the appearance of dark tissue 
in the wound, representing, according to its situation, portions of the 
Fig. 131.-Cyst of the corneoscleral 
junction (Philadelphia General Hos- 
pital) . FOREIGN BODIES 
293 
choroid or ciliary body; a bead of vitreous is likely to present. A 
small perforating scleral wound may be hidden by the overlying con- 
tused and swollen conjunctiva. Usually the intra-ocular tension is 
lower than normal. Rupture of the sclera is commonly associated 
with grave lesions in other portions of the eye-separation of the 
retina and extensive tears in the choroid and iris. 
Prognosis.-This depends upon (1) the extent and situation of the 
wound and amount of escape of vitreous; (2) the presence or absence 
of septic material upon the implement or body which inflicted the in- 
jury; (3) whether a foreign body has remained within the globe; and (4) 
the character of the foreign body which may have entered. It is evi- 
dent that even a trifling perforating wound, unattended with loss of 
vitreous or prolapse of the inner coats, may be a point of entrance of 
infection. 
Treatment.-Having carefully ascertained that no foreign body is 
within the globe, the eye should be disinfected with a solution of bi- 
chlorid of mercury (1 : 5000), and the edges of the wound, after all foreign 
substances have been removed, penciled with a stronger solution of the 
same drug (1 : 2000) or with a 5 per cent, solution of iodin. The over- 
lying conjunctiva is next drawn together with several fine sutures. The 
eye is closed with an antiseptic compressing bandage and the patient is 
put to bed. Iced compresses are an advantage during the early stages 
of the treatment. At the end of forty-eight hours the wound may be 
inspected and the dressings renewed. In larger wounds the sutures 
(sterile silk or catgut) are passed directly through the sclera by some 
surgeons, care being taken to avoid the choroid, but the author agrees 
with Snell that usually scleral sutures are not necessary, conjunctival 
sutures being sufficient; the sutures may be removed at the end of a 
week if the healing has progressed favorably. Some surgeons advise 
the introduction of iodoform before the application of the bandage. In 
some instances, in spite of kind healing of the scleral wound, there are 
subsequent detachment of the retina, vitreous change, and shrinking 
of the eyeball, but apparently hopelessly injured eyes may be saved by 
careful aseptic surgery. 
In the event of a scleral wound being extensive, with much loss of 
vitreous and collapse of the coats, especially if the ciliary body is in- 
volved and sight practically gone, or if the endeavors to remove the 
foreign body have been unsuccessful, enucleation should be performed 
to avoid the dangers of sympathetic inflammation in the fellow eye. 
Foreign Bodies.-If the wounding substance has been small-e. g., 
a chip of steel, a splinter of gkss, a particle of dynamite cap, or a bullet- 
endeavor should be made to ascertain whether this has penetrated the 
globe and remained within it, or has passed entirely through the eyeball 
and buried itself in the tissues of the orbit. Foreign bodies may be 
embedded in any of the structures of the eye and are frequently found 
in the vitreous. If loose, they tend to gravitate to the lowest part of 
the vitreous and rest upon the posterior part of the ciliary body (T. Col- 
lins). Double perforation of the eye is not uncommon as the result of a 294 
DISEASES OF THE SCLERA 
bullet wound or one caused by the explosion of a dynamite cap, but 
less frequent if the foreign body is a chip of iron or steel. In rare in- 
stances the perforation of the posterior scleral wall has been discov- 
ered with the ophthalmoscope, but since the introduction of z-ray ex- 
amination the diagnosis is rendered comparatively easy, and the radio- 
graphs should show whether the foreign body has passed entirely 
through the posterior scleral wall or is embedded partly within and 
partly without the scleral covering. According to Leber, perforating 
injuries of the eye with pieces of copper may result in purulent inflam- 
mation merely by the chemical action of the metal; if microbes are 
proved to be absent by culture experiments, an attempt to remove the 
body may be made, and, if successful, the eye saved, even if inflamma- 
tion has begun. Foreign bodies may be tolerated for long periods of 
time, with good vision, in the background of the eye, but can never 
be trusted unless they are small and the accompanying lesions trifling; 
in other circumstances they are liable to cause degenerative changes. 
However, small fragments of glass have remained for years within the 
globe without creating untoward symptoms. 
Unfortunately, blood in the vitreous and anterior chamber, or opacity 
of the lens, is apt to obscure the media to such a degree that ophthal- 
moscopic examination is not of much service; but if the media are clear, 
this method may be the means of detecting the foreign body. Air 
bubbles in the vitreous are suggestive, but not pathognomonic of a 
foreign body in the globe. An attempt at locating the body may be 
made by observing the situation of the wound, the condition of the cap- 
sule of the lens, the probable direction which the foreign substance 
took on making its entrance, by a search for points of tenderness and 
for a scotoma in the field of vision. If there is any doubt, a skiagraphic 
examination should be undertaken, and in the majority of instances 
(pieces of wood excepted) the Rontgen rays will readily reveal the 
presence and position of the foreign body. Of the various methods 
devised for this purpose, the one elaborated by W. M. Sweet, in the 
opinion of the author, is most satisfactory. The method of McKenzie 
Davidson and Dixon's modification of the Sweet method are also 
excellent. 
Having satisfied himself of the presence and position of a non- 
metallic foreign body within the globe, the surgeon may attempt to 
extract it through the original wound with delicate, carefully disin- 
fected forceps, or through a new wound made in the most favorable 
situation. But in some instances a small fragment of sterile glass, for 
example, difficult or almost impossible to reach had better be allowed 
to remain rather than to make matters worse by the frequent introduc- 
tion of instruments into the vitreous chamber in the effort to extract.it. 
If the foreign body is composed of iron or steel and its presence 
cannot be detected on account of opacities in the media, a diagnosis 
may be made, as was first suggested by T. R. Pooley, with the magnetic 
needle. Useful instruments have been constructed on this principle by 
Asmus and Hirschberg, and are known as sideroscopes, with which a FOREIGN BODIES 
295 
properly protected magnetic needle is brought near different portions 
of the eye in succession, and any deviation of the needle carefully 
noted. Where the deviation is greatest there is reason to suspect the 
foreign body exists. A large magnet may also be employed for diag- 
nostic purposes, the dislodgment of the foreign particle giving rise to a 
localized spot of pain or point of bulging, but great care must be exer- 
cised in attempting this procedure, as sudden movement of the foreign 
body may cause serious intra-ocular lesions, hemorrhage, tearing of 
the iris, etc. Moreover, as has been pointed out by Hirschberg, the 
absence of pain when the eye is approached by the magnet does not 
surely exclude the presence of a foreign body. 
Fig. 132.-Foreign body in the vitreous. 
The most satisfactory method in a doubtful case, and where the 
media are so obscured that ophthalmoscopic examination is impossible, 
is the employment of the a-rays, which, if properly used according to 
Sweet's method (see Appendix, page 692), have, in the author's expe- 
rience, never failed to give exact information of the position of the 
foreign substance. When this has been determined, the body should 
be extracted with the electromagnet. In former times it was much 
the practice to introduce the extension point of a magnet, for example, 
the Hirschberg model, either through the original entrance-wound or 
through one made for that purpose, as far into the vitreous as was neces- 
sary to attract the splinter of iron or steel from its position. Naturally, 
the disadvantage of this procedure is the introduction of an instrument 
into the vitreous chamber, and hence the value of the so-called giant 296 
DISEASES OF THE SCLERA 
magnets, notable among which is the Haab model. If, however, a per- 
fectly accurate localization has been made, for example, by the Sweet 
method, there is usually very little difficulty in making a very small 
incision with a Graefe knife through the sclera at that point which near- 
est approaches to the position occupied by the particle of metal. To the 
lips of this wound the extension point of a magnet of sufficient power may 
be applied, which almost invariably attracts the body to its point. It is 
to be noted that the instrument is not introduced within the vitreous, 
but placed against the lips of the wound, which afterward is closed 
in the usual manner and the treatment already recommended in con- 
nection with scleral wounds is instituted. Instead of this procedure, 
the various giant magnets may be employed to draw the body from 
its position in the posterior portion of the eye, around the lens into 
the anterior chamber, from which it is readily removed by a small 
hand magnet through a suitably placed corneal incision. This is the 
method especially advocated by Haab, and which is fully described 
on page 642. Of the great value of this method there can be no 
doubt, especially if it is not possible to utilize the x-rays for diag- 
nostic purposes, in which circumstance it is the only proper pro- 
cedure, but if the foreign body can be accurately localized by the 
Rontgen rays, according to Sweet's method or any other satisfactory 
method, and the position of the body found to be such that a small 
incision may be made directly over it, or in its immediate neighbor- 
hood, through which it is drawn by a magnet (the Sweet model has 
proved most satisfactory), without the introduction of the instrument 
into the vitreous, the results are just as good as those which follow 
the withdrawal of the foreign body by means of a giant magnet. 
Direct extraction in these circumstances presents no greater danger 
than the other method, and in many instances a danger not so great, 
and such accidents (and there are now many of them on record) of 
intra-ocular hemorrhage, sudden tearing of surrounding tissues, espe- 
cially of the iris, and the like, are avoided. Haab, however, strongly 
condemns the extraction of steel or iron from the interior of the eye 
through a scleral incision, and his opinion in this respect is shared by 
many surgeons. Thus, Charles Goulden examined the records of 118 
extractions of metallic foreign bodies from the eye, and found that the 
worst ultimate results occurred if the body entered through the sclera 
or if it was removed by scleral puncture. The author's experience, 
on the other hand, with direct extraction of magnetic particles in the 
manner described after x-ray localization, has been most favorable. 
Modifications of the Haab magnet, less powerful, but also less bulky, 
have been devised by Lippincott, Johnson, Sweet, Parker, and others. 
Other giant magnets are those, for example, devised by Volkmann and 
Hirschberg, and Mellinger has designed the Innenpol magnet, in which 
the patient's head is placed within a large electric coil, and the passage 
of the current magnetizes both the foreign body in the eye and the iron 
instrument held in front of the eye to attract it. 
If infection has already begun when the patient is seen, and the CONGENITAL PIGMENTATION OF THE SCLERA 
297 
condition of the eye is not so hopeless that immediate enucleation 
is necessary, various methods have been tried to check the purulent 
process. If, for example, the wound of entrance has been through the 
cornea, and the anterior chamber contains pus, this may be evacuated, 
and, as Haab recommends, small rods of sterilized iodoform, one or two, 
according to circumstances, may be introduced within this chamber. 
He also, in like manner, introduces these rods directly into the vitre- 
ous if infection has begun in that region, and reports successes. This 
method of intra-ocular disinfection has been sharply criticised-Krause, 
for example, believing that iodoform, either in the form of powder or 
rods, is unable to influence favorably beginning infection, but that, on 
the contrary, of itself it may produce pathologic changes, and repre- 
sents a method inferior to other well-known procedures for the relief 
of infected wounds-for example, that of Schirmer, who brings the 
patient under the influence of mercury by inunctions. The author 
has tried the iodoform method in several cases with indifferent success, 
and prefers the use of mercury, especially calomel, in repeated, properly 
guarded, doses. Drainage of the anterior chamber, expression of the 
lens, and thorough irrigation of the posterior chamber with salt solution 
have seemed to be of service in a few cases in the author's practice. 
Constant iced compresses are of value. Van Millingen has suggested 
the trial of endocular cauterization in these circumstances-that is, 
the introduction into an infected scleral wound of a galvanocautery 
point, if necessary, even into the vitreous, and the cauterization of all 
surrounding tissue. 
Prognosis.-This is always grave, but by means of the methods 
just detailed many eyes have been saved, and some with useful vision. 
The important point is to operate as soon as possible after the accident 
-i. e., before the foreign substance has become incarcerated in the 
tissues and covered with lymph. Coppez and Gunsberg maintain that 
the prognosis is more favorable with those bodies which are situated 
in the vitreous than with those entangled in the ciliary body or 
choroid. Goulden's results have been referred to (see page 296). If 
judicious efforts have failed to extract a foreign body from the interior 
of the eye, or if infection has proceeded beyond the reasonable hope of 
recovery, enucleation or evisceration usually is necessary. 
If a particle of iron remains for some time in the eye, there is a 
deposit of iron pigment in its tissues which gives rise to a condition 
known as siderosis bulbi, characterized by a peculiar greenish-yellow or 
yellowish-brown discoloration of the iris and cornea, and a circle of 
brown dots beneath the capsule of the lens. The pigmentation may be 
due to the iron derived from the foreign body (xenogenous pigmentation) 
or to hemosiderin derived from blood (hematogenous pigmentation). 
Sometimes the iris regains its original color after removal of the foreign 
body and, occasionally, even if it remains within the eye. 
Congenital pigmentation of the sclera (melanosis sclera) occurs 
both in spots and as a more diffuse discoloration. The spots are more 
common in the upper portion, and may be associated with pigment 298 
DISEASES OF THE SCLERA 
changes in the iris and choroid. Pigment spots in the sclera have been 
observed in certain diseases-e. g., Addison's disease-and sometimes 
are exactly symmetric, situated near the margin of the cornea. 
Blue sclerotics may be associated with inherited syphilis and 
exhibit a remarkable hereditary transmission. In addition to the 
leaden color of the sclera, there may be conical cornea and congenital 
opacity of the cotnea, that is, embryotoxon. Harman traced in five 
generations of one family 55 members, of whom 31 showed this con- 
genital peculiarity. Transmission occurs through affected mothers. 
Persons with blue sclerotics are peculiarly liable to bony fractures. CHAPTER IX 
DISEASES OF THE IRIS 
Congenital Anomalies.- Heterochromia, or the condition in which 
the color of one iris is different from that of the other, is a peculiarity 
which may be without pathologic significance, but in many instances 
the signs of cyclitis in the lighter colored eye are evident, and this eye 
is liable to cataract formation. It has been referred to on page 53. 
Corectopia, a term applied to an eccentric position of the pupil, is not 
to be confounded with cases of true coloboma of the iris, presently to be 
described. The grade of corectopia may vary from a slight increase of 
the normal eccentric position of the pupil below and to the inner side, 
to those cases in which the whole pupil is displaced toward the border 
of the cornea. The latter variety is a very unusual phenomenon. 
This complete shifting of the normal position of the pupil has been 
ascribed either to an essential malformation or to the result of a fetal 
iritis. Both eyes may be affected symmetrically, and several members 
of the same family may present the defect. 
Fig. 133.-Polycoria. 
Fig. 134.-Persistent pupillary membrane: (1) Pupil con- 
tracted; (2) pupil dilated (Wickerkiewicz). 
Polycoria, or a multiplicity of pupils, is a rare anomaly. The ab- 
normal pupil or pupils may be situated in the immediate neighborhood 
of the normal pupil, separated from one another by a narrow band of iris 
tissue, or the increased number of pupils may be the result of crossing 
strands of persisting pupillary membrane (Fig. 133). An opening which 
exists at the ciliary margin of the iris has been described, and is prob- 
ably due to a congenital iridodialysis. 
Persistent pupillary membrane results from an incomplete resolution 
of the membrane which covers the anterior surface of the lens during 
fetal life, and which usually disappears in the seventh month, although it 
may remain as late as the end of intra-uterine life, and even in the first 
month after birth. 
Accurately speaking, the pupillary membrane is a specialized por- 
tion of the capsulopupillary covering. The name of pupillary mem- 
299 300 
DISEASES OF THE IRIS 
brane alone is applicable to those cases in which threads attached to the 
small circle of the iris pass diametrically or cord-wise across the pupil, 
to be inserted elsewhere in the corona (Fig. 134). Usually the fibers 
proceed from the anterior surface of the iris across the pupil, either 
singly or in groups of three or more strands. Sometimes the fibers 
remain separated; sometimes they grow together in front of the anterior 
capsule or unite in the form of a variously colored plaque, adherent to 
the capsule of the lens (capsulopupillary membrane). Persistent pu- 
pillary membrane is more common in one than in both eyes; of 68 
cases observed by Stephenson, 13 were bilateral and 55 unilateral. 
Capsulopupillary tags are not infrequently mistaken for the synechiae 
due to iritis; indeed, the association of the two has been observed. No 
difficulty, however, should arise, because the normal action of the pupil 
is not impeded by the presence of these vestigial anomalies. The appear- 
ance is not often detected until some other disorder calls for an oph- 
thalmoscopic examination, because vision is not seriously or at all im- 
Fig. 135.-Bilateral coloboma of iris, upward and outward, and cataract (University 
Hospital). 
paired. Oblique illumination or examination with a loupe or corneal 
microscope will readily demonstrate the remains of pupillary membrane. 
Coloboma of the iris is a fissure of this membrane which in a general 
way resembles an artificial pupil made by iridectomy. The anomaly 
is more frequent in both eyes than in a single eye. Where the defect is 
unilateral, the anomaly is usually found on the left side. The situation 
of the fissure is generally downward or downward and inward. Excep- 
tions to this rule have been observed; indeed, numerous atypical forms 
have been recorded, the defect being placed outward, inward, upward, 
down-and-out, up-and-in, and up-and-out. 
The coloboma may extend across the whole iris {complete coloboma), 
or stop at a certain distance from the ciliary margin (incomplete colo- 
boma). In addition, the so-called pseudocoloboma is described, which 
may be looked upon as a form of heterochromia of the iris, or indicates 
the last remains of the ocular fissure which is tending toward closure, 
and which appears as a small stripe, somewhat granular, and differen- 
tiated from the rest of the iris by its brighter color. In "bridge colo- IRITIS 
301 
boma" the borders of the cleft are united by a narrow pigmented or 
colorless band of fibers. 
Coloboma of the iris, often hereditary, is frequently associated 
with similar defects in the choroid, and also with microphthalmos, 
congenital cataract, fissure of the eyelids, lips, and palate. It has 
been attributed to an arrest of development, the result of incomplete 
closure of the choroidal fissure; but Lang and Treacher Collins believe 
that the defect is caused by a partial abnormal adhesion or late sepa- 
ration of the lens and cornea, the iris failing to develop in that portion 
of the area which is involved. If the abnormal adhesion or late sepa- 
ration is complete, irideremia results. 
Irideremia, or congenital absence of the iris, occurs both in a partial 
and a complete form. 
Total congenital irideremia is almost invariably bilateral. It is 
frequently associated with other anomalies of the globe-partial or 
complete cataract, dislocation of the lens, nystagmus, strabismus, de- 
partures from the normal curvature of the cornea, or annular opacities 
in its periphery and atrophy of the optic nerve. In a majority of in- 
stances there is a marked hereditary tendency. 
Congenital ectropion of the uvea consists in a round mass of dark 
color projecting from the margin of the pupil, bending around to the 
anterior border of the iris. A similar formation is proper to the eye 
of the horse and is frequently seen in the cow. This appearance has 
sometimes been described as a papilloma of the iris; it is not, however, 
a neoplasm, but a congenital ectropion of the uvea. 
Cysts, nevi* and atrophies of the iris occur as congenital defects, and 
congenital aplasia of the anterior layers of the iris has been observed. 
Hyperemia of the iris is associated with several acute affections 
of the eye, for example, acute trachoma, purulent conjunctivitis, kera- 
titis, scleritis, inflammations of the uveal tract, and traumas, and is a 
precursor of inflammation. Hence it is a symptom and not a disease 
of the iris. 
Hyperemia of the iris is recognized by change in color, a blue iris 
becoming greenish; a brown iris, a reddish brown; by contraction of the 
pupil, which dilates sluggishly or not at all, to the changes of shade and 
light, and is slowly affected by a mydriatic, the effects of which are 
much less permanent than in the healthy iris; and by slight pericorneal 
injection. 
The treatment consists in the management of the disease which has 
caused the hyperemia, and especially in the instillation of atropin. 
Iritis.-Under the general term iritis are included various types 
of inflammation of the iris. 
Causes.-Iritis may depend upon constitutional disorders, infections, 
toxins, and traumatism, or upon disease in other portions of the eye. 
Hence, it is usually stated that iritis is either primary or secondary. 
In point of fact, however, it is. doubtful if the term "primary iritis" 
should be retained, inasmuch as iritis is probably never primary, but 
always secondary, in that it is one of the manifestations of the action 302 
DISEASES OF THE IRIS 
of a toxin or an infection. To those cases of iritis which apparently 
originate independently of injury, or of an ocular or constitutional 
disorder, the name idiopathic was formerly applied, a term which 
should be eliminated, although, unfortunately, we are un'able always 
to decide what exactly is the causative factor in each case. Iritis 
is also divided, according to its supposed etiology, into syphilitic, 
rheumatic, gouty, gonorrheal, diabetic, tuberculous, scrofulous, septic, auto- 
toxemic or toxemic, cachectic, traumatic, and sympathetic iritis. 
Symptoms.-1. Change in the color of the iris, in addition to loss of 
its natural luster and obscuration of the characteristic striated appear- 
ance. 
2. Pericorneal injection, due to congestion of the non-perforating 
branches of the ciliary vessels (System II), producing the fine pink zone 
surrounding the cornea known as "ciliary congestion," or the "cir- 
cumcorneal zone." In severe cases there may be distention of the 
posterior conjunctival vessels, and slight chemosis of the conjunctiva 
(see also page 49). 
Fig. 136.-Various forms of posterior synechiae: A, Single attachment; B, multiple 
attachment forming the so-called "ace-of-clubs" pupil; C, irregular annular attachments 
(Sichel). 
3. Miosis, or contraction of the pupil, due partly to hyperemia and 
spasm of the sphincter, and partly to irritation of the peripheral nerve 
filaments. The reaction of the pupil to the influence of light and myd- 
riatics is diminished or lost. In a certain number of cases, according to 
Herbert, there is slight dilatation of the pupil as compared with the un- 
affected eye. This primary dilatation of the pupil, with preservation 
of its reaction, is a noteworthy symptom in so-called rheumatic iritis 
(Kriickmann; see also page 310). 
4. The formation of posterior synechiae, or attachments between the 
layer of pigment covering the posterior surface of the iris and the cap- 
sule of the lens. They are demonstrable by the instillation of a myd- 
riatic, which will produce an irregular dilatation of the pupil, certain 
portions of the pupillary margin of the iris being held back by some- 
what tongue-shaped projections attached to the lens-capsule, and may 
be readily studied by means of oblique illumination or with a loupe. 
The tags protruding into the pupil space usually have a brownish color. 
The attachments may vary in size, firmness, and number; being 
either narrow and thread-like, broad and dense, single or multiple, or IRITIS 
303 
even extending all around and pinning down the margin of the iris in 
an annular manner (annular posterior synechiae). In association with 
the synechiae there may be an exudation of false membrane covering the 
whole pupillary space (pupillary membrane). 
5. Irregularities in the surface of the iris, due to local swellings, accu- 
mulations of exudation, deposits of fibrin, or the formation of nodules. 
6. Haziness of the cornea or deposits upon its posterior surface. 
According to Friedenwald, the cornea is affected in every case of iritis, 
that is, there are deposits on Descemet's membrane or infiltrations in 
the substantia propria. The former are constant, the latter occa- 
sional. 
7. Changes in the character of the aqueous humor-(1) Slight or con- 
siderable turbidity; (2) pus; (3) blood; and (4) occasionally exudation. 
In addition to the symptoms just detailed there are subjective signs 
more or less peculiar to iritis. 
1. Pain.-This is situated first in the eyeball, and is known as 
"ciliary pain," and second, in the brow and temple, sometimes quite 
sharply defined in the distribution of the supra-orbital nerve, very 
severe, throbbing, and stabbing in character, and with marked increase 
in severity during the night. Occasionally the nasal and infra-orbital 
regions are the painful areas. Pain in the teeth is not uncommon. 
2. Disturbance of Vision.-This is in direct proportion to the amount 
of cloudiness which has occurred in the media. Decided impairment of 
visual acuteness denotes extension of the disease to the ciliary body or 
deeper structures. 
During iritis, transient myopia and astigmatism are commonly present. 
Especially in the plastic types of the disease, even after full pupillary 
dilatation, an increase in the refractive power is demonstrable. Although 
there are changes in the corneal curvature, according to the late C. A. 
Oliver the bulk of the ametropic change in such cases is due to perver- 
sion of the lens action from spastic accommodation (Koller) as the result 
of ciliary irritation. 
3. Tenderness of the Globe.-This is often present in uncomplicated 
iritis, but if severe, it suggests inflammation of the ciliary body. 
4. Photophobia and Lacrimation.-These symptoms vary consider- 
ably in degree, being almost or quite absent in some varieties, and 
severe in those of acute and violent onset. 
5. Malaise, fever, nausea, and marked depression occasionally are 
experienced by the patient, the last often being the result of prolonged 
pain and insomnia. 
Diagnosis.-The salient symptoms of iritis just detailed are suffi- 
cient for the purpose of diagnosis; nevertheless, it is not uncommon to 
find a case of iritis mistaken for some other external inflammation, 
and the table on page 304 may be found useful. 
A diffuse scleritis somewhat resembles in its color the zone of peri- 
corneal injection more or less characteristic of iritis, which, indeed, may 
be a complicating symptom of this disease. Acute glaucoma bears some 
resemblance to acute iritis (for the distinguishing points see page 385. 304 
DISEASES OF THE IRIS 
Iritis. 
Simple Conjunctivitis. 
Phlyctenular Conjunctivitis. 
1. Severe brow pain, 
Feeling of foreign body 
Acute general irrita- 
worse at night. 
in the eye. 
tion. 
2. Dim vision. 
Vision usually unim- 
Vision impaired by cor- 
paired, unless secretion is 
very abundant. 
neal involvement. 
3. Fine pericorneal in- 
Coarse conjunctival in- 
Diffuse injection, with 
jection. 
jection. 
special lines of vessels 
running to phlyctenules. 
4. Absence of secre- 
Mucopurulent dis- 
Free lacrimation. 
tion; some abnormal lacri- 
mation. 
charge; flakes of lymph. 
5. Sluggish or immo- 
bile pupil. 
Pupil unaffected. 
Pupil unaffected. 
6. Iris discolored. 
Iris unchanged in color. 
Iris unchanged in color. 
7. Abnormal reaction 
Normal reaction to myd- 
Normal reaction to myd- 
to mydriatic. 
riatic. 
riatic. 
8. Severe photophobia 
Severe photophobia ab- 
Severe photophobia and 
exceptional. 
sent in simple cases. 
blepharospasm. 
9. Conjunctiva usually 
Conjunctiva opaque, 
Conjunctiva translu- 
translucent; occasionally 
velvety, and at times 
cent, bathed in tears. 
chemotic. 
chemotic. 
10. Tenderness on pres- 
sure. 
Tenderness not marked. 
Tenderness not marked. 
11. Posterior syne- 
chiae. 
No synechiae. 
No synechiae. 
Course, Complications, and Prognosis.-An iritis may pursue an 
acute course, reaching its termination in four to eight weeks, or be 
chronic from its onset and last, in a slow and insidious inflammation, 
for long periods of time. The termination of an iritis may be entirely 
favorable. The inflammatory adhesions disappear, and the iris regains 
complete mobility, only a few traces of iris pigment being seen on the 
capsule of the lens. On the other hand, more or less complete attach- 
ment causing distortion and inequality of the pupil (consult Fig. 136) 
may remain; or deposits of exudation may directly occlude the pupil 
and lie upon the capsule of the lens; or the tissue of the iris may show 
areas of atrophy and exhibit a bleached or grayish aspect. 
The binding down of the iris throughout the whole extent of its 
pupillary edge, although the pupil itself remains clear, is denominated 
exclusion or seclusion of the pupil; if the pupil is filled in with opaque 
inflammatory deposit, the term occlusion of the pupil is applied. With 
extensive or annular synechise the angle of the anterior chamber be- 
comes obliterated, the iris, owing to the exudation behind it, is bulged 
forward except around its pupillary margin, which is bound down, so 
that a crater-like depression is evident, and the appearance denominated 
iris bombe is developed. This leads to ncreased tension, secondary 
glaucoma, and even shrinking of the vitreous, detachment of the retina, 
and atrophy of the eyeball unless the communication between the ante- 
rior and posterior chambers of the eye is restored by operative measures 
(Figs. 137 and 138). Repeated attacks of iritis, as well as chronic 
inflammation of the iris, may cause atrophy of the tissue. In these cir- 
cumstances the color of the iris is gray, the markings of its surface 
disappear, dilated blood-vessels and reddish patches appear, small holes 
develop in its tissue, the pupil margin is thin, and its tissue is friable IRITIS 
305 
(Fig. 139). A form of progressive atrophy of all layers of the iris has been 
described (C. A. Wood, Harms, Zentmayer, and the author). Periods 
of increased intra-ocular tension are evident and the eyes become glauco- 
matous. Wood did not consider that glaucoma was an essential part 
of the affection, although it was the end process in his patient. The 
anatomic examination revealed, in addition to glaucoma and iris 
atrophy, a fibrinoplastic cyclitis. 
Fig. 137.-Exclusion and occlusion of pupil 
with exudation behind iris, following gummatous 
iritis; compare with Fig. 138 (from a patient in 
the Philadelphia General Hospital). 
Fig. 138.-Exclusion and occlu- 
sion of the pupil. The iris is adher- 
ent by its entire pupillary margin to 
the lens. The posterior chamber (/i) 
is thus made deeper, the anterior 
chamber (i>) shallower, especially 
where the root of the iris (a) is 
pressed against the cornea. The 
retinal pigment is beginning to sepa- 
rate at s. The pupil is closed by an 
exudate membrane, o. In the lower 
part of the anterior chamber there is 
matter (p) precipitated upon the pos- 
terior surface of the cornea. The 
cortex of the lens has become cata- 
ractous (r); the nucleus (k) is un- 
altered (Fuchs). 
Fig. 139.-Atrophy of iris (from a patient in the 
University Hospital). 
The following tissues of the eyes may become involved during the 
course of an iritis: The cornea {keratitis punctata); the ciliary body 
{iridocyclitis}; the crystalline lens {cataract, especially cataracta accreta, 
in which the iris and lens are fastened together); the choroid {irido- 
choroiditis}; the vitreous {exudation into the vitreous, hyalitis}; and the 
optic nerve and retina {hyperemia or neuroretinitis}. With these facts 
in mind, and with the tendency of certain types of the disease to relapse, 
a prognosis must be guarded, but in uncomplicated iritis, seen early 306 
DISEASES OF THE IRIS 
and properly treated, a perfect result may be obtained in the large 
majority of cases. Relapses of iritis are often attributed to posterior 
synechiee, but, as Fuchs points out, are not due to them, but to the 
continuance of the cause of the affection. 
Pathology.-Systematic writers at one time were accustomed to 
divide iritis into three varieties: plastic, parenchymatous, and serous 
iritis. A more accurate classification from the pathologic standpoint 
is acute, chronic, purulent, and nodular iritis. In general terms, in iritis 
it may be said that the iris is thickened and infiltrated with round cells, 
which are collected either along the line of the vessels or in circum- 
scribed nodules. The vessel walls are thickened and small hemorrhages 
occur in the tissue. The exudation in the anterior chamber consists of 
round cells, mixed with fibrin and pigment granules. In many cases 
the inflammatory products are completely absorbed, but should they 
become abundant, they organize, forming a layer of connective tissue 
which covers the iris and binds it to the lens, occluding the pupil in the 
manner already described. The exudation in the iris likewise organizes, 
and the atrophic iris shows obliterated and thickened vessels, clumping 
of pigment granules, and an entire absence of iris-stroma. Purulent 
iritis due to infection with micro-organisms is followed by panophthal- 
mitis. This infection may come from without, as it occurs, for example, 
in perforating injuries, and is called exogenous infection; or from within, 
as, for example, in metastatic processes, and is called endogenous infec- 
tion. In nodular iritis the nodes are formed of aggregations of lympho- 
cytes. It is often difficult to distinguish between the varieties of iritis 
from the histologic standpoint, as they merge one into the other. If 
the exudation is poor in cells and fibrin, and the iris tissue shows cellular 
infiltration, there is serous iritis (not to be confounded with the cyclitis 
clinically called serous iritis); if the exudation is rich in fibrin but poor 
in cells, and the iris tissue markedly infiltrated, there is fibrinous iritis; 
if with an exudation rich in cells and fibrin there is extensive infiltration 
of the iris tissue, with mononuclear and multinuclear leukocytes, there 
is purulent iritis (Ginsberg). 
Treatment.-The description of the treatment is reserved for the 
subsequent sections devoted to the particular consideration of the 
various types of iritis which follow. 
Iritis and Its Types.-In the acute form of the disease the salient 
symptoms of iritis already recorded (see page 302) are present. Not 
only may the ordinary attachments form between the iris and the cap- 
sule of the lens, but a plastic exudation may cover the pupil-space with 
a false membrane, and the adhesions between the iris and the lens- 
capsule may be unusually firm and unyielding. To this form of iritis 
the descriptive term plastic is sometimes applied. In some cases a 
gelatin-like mass is deposited in the anterior chamber, and its appear- 
ance has been compared to that of a dislocated lens in the same posi- 
tion (fibrinous or spongy iritis}. In various forms iritis is seen in- 
1. Syphilis-Syphilitic Iritis.-The percentage of patients with 
syphilis who acquire iritis during the course of the disease varies from IRITIS AND ITS TYPES 
307 
0.42 to 5.37, according to the different authorities, but among cases of 
iritis, syphilis has been found to be the cause in from 30 to 60 per cent. 
(Alexander). In other words, syphilis is usually regarded as the most 
common cause of iritis. It may appear between the second and the 
ninth month after the initial lesion, or may be delayed until the eight- 
eenth month. Occasionally it arises at a very late period in syphilis 
-that is to say, during the period of so-called tertiary manifestations, 
either as a primary iritis, as a relapse, or in one of the forms presently to 
be described. The lesions are due to the influence of syphilitic virus, 
that is, to the lodgment and activities of the Spirochaeta pallida, which 
has been found in the aqueous humor of an eye with acute syphilitic 
iritis (Zur Nedden, Stephenson). 
The clinical manifestations of syphilitic iritis vary. They may be 
those of ordinary acute iritis without lesions, which of themselves do 
not justify the diagnosis of syphilis, and syphilis as the etiologic 
factor can be established only by the history of the case, by the 
Fig. 140.-Papules in syphilitic iritis 
(from a patient in the Philadelphia General 
Hospital). 
Fig. 141.-True syphilitic iritis with 
large nodes in iris; about seventh month 
of the disease. 
therapeutic test, or by the serum reaction of Wassermann. Accord- 
ing to Kriickmann, an early manifestation of syphilis in the iris, 
which may appear in the sixth week after primary infection, is 
roseola, characterized by overfilling of superficially placed vessel loops, 
which arise and disappeared quickly. The color is bright red in con- 
trast to the copper tint of the skin eruption. Roseola may in later 
stages be the forerunner of papules. Localized sphincter lesions 
always suggest the influence of syphilis (Kriickmann), and with the 
development of papules a form of iritis appears which yields charac- 
teristic, if not pathognomonic, signs of its origin. In the inflamed 
iris there appear one or more yellowish, reddish-yellow, or reddish- 
brown nodules, varying in size from a hemp-seed to a small pea, 
situated at the pupillary or ciliary border, or occasionally between 
the two in the iris tissue, although Fuchs maintains that they do not 
arise in the midbreadth of the iris. They vary in number from one 
to four, the intervening tissue being comparatively unaffected, and 
belong, in spite of their resemblance to gummas, with which at one 
time they were confused, to a comparatively early period of syphilis- 308 
DISEASES OF THE IRIS 
that is, to the period indicated in the previous paragraph. Under the 
influence of treatment they are gradually absorbed without leaving very 
marked scars, although a certain amount of atrophy of the iris tissue on 
close examination will be found marking their former situation. This 
form of iritis is sometimes called true syphilitic iritis or syphilitic paren- 
chymatous iritis. It is also known under the terms iritis papulosa, or 
condylomatosa.1 These' names have originated because the small 
nodules in the iris have been compared to papular syphilids and con- 
dylomata, inasmuch as they belong in the same stage of syphilis with 
these manifestations. They clearly differentiate themselves from 
gumma, not only by the date of their appearance, but because they do 
not caseate or break down and suppurate. 
Even where these distinct nodules are not present in syphilitic iritis, 
careful examination of the iris will frequently show localized discolored 
swellings in the edematous iris tissue, and usually broad and thick 
synechiee, formed by a union of the iris tissue with lens-capsule, and not 
merely an adhesion of the posterior epithelium, and, as Fuchs has shown, 
microscopic investigation indicates that these nodules are always pres- 
ent, but are sometimes so small that they have not sufficiently elevated 
the iris tissue to reveal their presence to ordinary clinical methods of 
examination. To this form of iritis the name syphilitic or luetic fibrinous 
iritis is sometimes given. 
The disposition and character of the papules which develop on the 
iris as the result of syphilis have been particularly studied by Kriick- 
mann, who among the early varieties describes superficial and deep- 
seated small iris-syphilids, the chief situation of the latter being in the 
vessels system of the sphincter and its immediate neighborhood, and 
medium-sized papules which develop under the anterior stroma layer. 
The papules of an early stage of syphilis often have a reddish color, 
while those of later periods of the disease are yellow or grayish yellow 
and more decidedly circumscribed, owing tQ the absence of edema. A 
rare manifestation is the eruption of the papules in a group formation. 
Gummatous iritis or, more properly, gumma of the iris occurs, appear- 
ing, according to Alexander, almost constantly at the ciliary border. 
The lesion is solitary, of the size of a pea or small nut, and grows toward 
the ciliary body, disappearing through fatty degeneration, leaving be- 
hind a permanent scar, or atrophy of the iris. Such a manifestation, 
strictly localized in the iris, is extremely rare. It appears, if at all, in the 
so-called tertiary period of syphilis, or that period in which gummas in 
other organs are found. 
In syphilitic iritis both eyes are attacked, one a little later than its 
fellow; occasionally the onset is simultaneous. The course usually is 
acute, and after thorough cure relapses are not common. Sometimes 
the disease assumes a subacute type, or may be so prolonged in its course 
and complications as to justify the term chronic iritis. 
1 Kruckmann objects to the term "iritis condylomatosa" because there is no accurate 
comparison to be made between condyloma of the skin and the papules of the iris in 
syphilis. IRITIS AND ITS TYPES 
309 
Acute iritis of the so-called plastic type is rare in newborn infants 
of syphilitic heritage, but has been described in children with inherited 
syphilis, from the second to the fifteenth month. Acute iritis in children 
in the first months of life, and also in later childhood years, usually is 
the result of hereditary syphilis. A late manifestation appears in the 
form of an iridocyclitis of the so-called serous type, the involvement of 
the entire uveal tract being evident by the manifestations of the signs of 
uveitis, which are elsewhere described. 
Treatment.-The most important local drug in this as in other forms 
of iritis is atropin sulphate, gr. iv to f 3 j (0.26 gm. to 30 c.c.), several 
drops of the solution to be instilled in the conjunctival culdesac every 
three or four hours. Mydriasis should be maintained until all ciliary 
irritation has subsided and during the period of changes in the refractive 
power of the eye (see page 303). 
Pain is relieved and at the same time congestion is diminished, 
thus rendering the mydriatic action of the atropin more certain, by 
leeching the temple-one to three Swedish leeches being applied near 
the line of the hair, or blood is drawn by an artificial leech. In the 
absence of a regular Heurteloup, this may be accomplished by making 
an incision in the temple with a scalpel and using a small cupping-glass, 
to which a piston is attached for exhausting the air. Should atropin 
not be tolerated, hyoscyamin, scopolamin, or duboisin may be substi- 
tuted (see page 117). 
The constant use of atropin leads to disagreeable dryness of the 
throat. This may be obviated in part by compressing the tear-duct after 
each application. It may be relieved by giving the patient a gargle 
made of equal parts of iced water and a strong decoction of coffee. 
Pain is further relieved by the application of moist or dry heat; the 
latter is best made by means of cotton batting which is held before a 
fire and then laid upon the affected eye, to be replaced by a freshly 
heated mass as soon as cooling occurs, or with a Japanese stove or hot 
box. Moist hot applications are more efficient if a pad of surgical gauze 
is steeped in the following solution: Acetate of lead, 5j (3.9 gm.); pow- 
dered opium, oss (15.5 gm.); boiling water, Oj (473.11 c.c.) (Randolph). 
Dionin in 5 to 10 per cent, solution is valuable on account of its lympha- 
gogue and analgesic action, which is increased by the addition of a 
2 per cent, solution of holocain. With the use of high-frequency currents 
for the relief of the pain of iritis the author has had no experience. 
The best constitutional treatment is some form of mercury, either 
the protiodid, blue mass, or calomel, given, as in syphilis generally, 
just short of the point of salivation, and continued for many weeks even 
after all acute symptoms have subsided. Inunctions of unguentum 
hydrargyrum are advantageously employed, preceded by a hot bath or 
diaphoresis with the aid of a hot chamber. If inunctions are properly 
given they represent a most satisfactory method of administering 
mercury, and usually 3j (3.9 gm.) of the ointment may be daily rubbed 
into the skin. Hypodermic or, rather, intramuscular injections of 
mercury, particularly mercuric chlorid or salicylate of mercury (of 310 
DISEASES OF THE IRIS 
mercuric chlorid the dose may be from A to | grain-0.00405-0.008 gm.; 
of salicylate of mercury, | grain-0.0324 gm.), are strongly advocated 
by some surgeons. 
In syphilitic iritis salvarsan produces the most favorable results, 
and under its influence the lesions disappear with astonishing rapidity. 
If the Wassermann test is positive, other things being equal, a dose of 
0.6 gram should be given intravenously (in women 0.4 gram is usually 
sufficient). At the expiration of three weeks, the Wassermann test 
being still positive, this dose may be repeated. During the intervals 
mercury or iodid of potassium should be administered. 
Clinical trial of neosalvarsan indicates that it equals salvarsan in 
efficiency and that it is less toxic. In arsenic content 0.6 gram of sal- 
varsan is equivalent to 0.9 gram of neosalvarsan. The injections may 
be given at comparatively frequent intervals, the dose being regulated 
according to circumstances and effects, as often as once in ten days or 
two weeks. 
In old syphilitics with much cachexia, in whom a plastic iritis im- 
properly treated in the early period has relapsed, it is not always wise or 
possible to induce active mercurialization. For them bichlorid com- 
bined with the tincture of iron is a suitable remedy. Subconjunctival 
injections of bichlorid of mercury (2 to 4 drops of a 1 : 2000 solution) 
are efficient, but painful. Acoin added to the injection relieves the 
pain. In place of the bichlorid solution one of cyanid of mercury 
(1 : 5000) is now advised by Darier. Equally good results are obtained 
with 5- to 15-minim (0.3-0.92 c.c.) injections of physiologic salt solution 
if there is not too much circulatory stasis. The injections may be given 
every second or third day, and should be followed by light massage of 
the eyeball. Usually they are not necessary if active constitutional 
treatment (salvarsan, mercury) has been carefully carried out. 
2. Rheumatism-Rheumatic Iritis.-According to Kriickmann, rheu- 
matic iritis is apt to begin with conjunctival hyperemia or a non-bac- 
terial conjunctivitis; at first, in some cases, there may be mydriasis 
with preservation of the pupil reflexes and congestion of some of the 
radially placed larger iris vessels, followed by a sudden increase of the 
iris injection and the appearance of pericorneal injection, pupil immo- 
bility, fibrous exudation into the superficial stroma layer, and fine de- 
posits on the posterior surface of the cornea. The vitreous remains 
clear. 
The association of iritis with acute rheumatism (acute rheumatic 
fever), however, must be exceedingly uncommon, if it ever occurs. 
Indeed, as Kriickmann maintains, the so-called rheumatic iritis must 
be sharply separated from those iritic involvements which follow or 
accompany acute joint rheumatism, and which depend upon metas- 
tasis of staphylococci or streptococci proceeding from purulent processes 
in the joints. Paine and Poyton have isolated a diplococcus which 
they regard as the specific cause of rheumatic fever, and with which 
experimentally they were able to produce an iridocyclitis which was 
regarded as a true rheumatic iridocyclitis. In so far as acute rheuma- IRITIS AND ITS TYPES 
311 
tism is concerned these observations have been confirmed by Rosenow, 
whose investigations also indicate that muscular rheumatism (see 
below) may be due to a closely related streptococcus. 
Because the relation of rheumatism to the development of iritis is 
a vague one, and because the general "rheumatic" conditions-myalgia, 
joint lesions, etc.-may be toxic in origin, T. Harrison Butler suggests 
that the ocular manifestation should be denominated autotoxemic or 
toxemic iritis, and that the term "rheumatic" should be abandoned. 
3. Autotoxemic Iritis {Iritis with Disorders of Nutrition or Constitu- 
tional Disorders).-Notably between the ages of twenty and fifty, 
but also at later periods of life, either coincident or not with affections 
which are usually classified as chronic rheumatism, chronic joint rheu- 
matism, or muscular rheumatism-i. e., myalgia manifesting itself as 
lumbago, pleurodynia, or pain in various groups of muscles (usually 
classified by systematic writers as "constitutional diseases" or "dis- 
eases of nutrition")-iritis is not uncommon. In Butler's statistics this 
type of iritis or iridocyclitis constitutes 6 per cent. It varies consider- 
ably in the aggressiveness of its symptoms. Not uncommonly these 
are severe, with much pericorneal injection, acute pain, greater usually 
than in syphilitic cases, and tenderness of the globe. Frequently only 
one eye is affected; the inflammation rarely is simultaneously sym- 
metric. The second iris may be affected in like manner after a longer 
or shorter interval. From the subjects of this form of iritis, if none 
of the various types of polyarthritis or myalgia is present, a history of 
such an affection can usually be obtained; sometimes the history de- 
velops the fact that the patient has suffered from sciatica, or crural, 
musculospinal, and other forms of neuritis. 
Relapses are frequent, in this particular differing from syphilitic 
plastic iritis, and a patient once having had an attack of this type of 
iritis (often in its manifestations an iridocyclitis) is liable at intervals 
of months or even years again to be attacked. If treatment is begun 
early, even in recurring attacks, perfect cure may be expected. 
The frequent relapses of some varieties of the affection have given 
rise to the term recurrent iritis. 
A form of iritis exists, aptly called quiet iritis (Hutchinson), in which 
there is no pain or ciliary congestion; it is practically non-adhesive, 
the only subjective symptom being the progressive dimness of vision, 
which leads to its discovery, and which is caused by so-called chronic 
rheumatism or inherited arthritic tendency in a majority of cases, but 
which may also depend upon syphilis. A variety of quiet iritis in which 
the lesions are said to be confined to the posterior layer of the iris has 
been described by Grandclement under the name "Uveite irienne." 
It occurs usually in women during the period of uterine activity; fre- 
quently its subjects are anemic. Grandclement failed to associate it 
with any local or general malady. 
A severe and sometimes destructive form of iritis may accompany 
arthritis deformans. There is a variety of iritis characterized by warty- 
looking translucent excrescences at the pupil margin, generally occur- 312 
DISEASES OF THE IRIS 
ring in women, to which Doyne has given the name guttate iritis. (Com- 
pare this section with pages 324-326.) 
With two constitutional diseases or disorders of nutrition iritis or 
iridocyclitis is not infrequently associated, namely, gout and diabetes. 
Gouty iritis, as it is usually called, occurs in the subjects of gout, 
irregular gout (often referred to with questionable accuracy as gouty, 
lithemic, or uric acid diathesis), and in the members of gouty families. 
It probably depends upon the defective nitrogen metabolism which 
underlies gout, although this origin is not accepted by some authors. 
It tends to relapse, to attack one eye at a time; the superficial layers 
of the iris are especially affected. It may precede a gouty attack else- 
where in the body. A form of iritis, insidious in character and de- 
structive in tendency, almost invariably associated with disease of 
the vitreous, occasionally occurs in children of gouty parents. These 
children, according to the late Mr. Hutchinson, have a peculiar square- 
ness of build, heavy features, florid complexions, and feebleness of cir- 
culation in the extremities. Less frequently iritis (sometimes puru- 
lent), sometimes associated with fibrous deposits in the pupil space 
and with hemorrhage in the anterior chamber, develops in the sub- 
jects of diabetes; it is ordinarily described as diabetic iritis. Its fre- 
quency among diabetics has varied from 1.5 to 5 per cent. 
Treatment.-The use of atropin in the manner already described 
is of paramount importance. For it scopolamin, gr. ij to foj (0.13 
gm. to 30 c.c.), may be substituted, or the two drugs may be com- 
bined. Leeches and moist and dry heat will help to relieve the pain, 
and, at the proper stage, subconjunctival injections of salt solution. 
Much comfort often results from the administration at night of Hny 
grain (0.00065 gm.) of hyoscin, but morphin or codein, if given at all, 
must be administered with great caution lest the patient form a drug 
habit. Rubbing the brow with an ointment of mercury and bella- 
donna is of some service. Dionin (5 per cent.) and holocain (2 per 
cent.) act well in relieving pain. 
Much reliance may be placed upon salicylic acid, salicylate of sodium, 
salicylate of strontium, and aspirin; of these remedies, salicylate of sodium 
is the best; indeed, it relieves the pain of any form of iritis. It should 
be exhibited in full doses, 60 to 80 grains (3.9-5.2 gm.) during the 
first twenty-four hours, and afterward the amount gradually lessened. 
The tendency to recurrence requires preventive treatment in the 
form of regulated diet, the use of mineral waters, and proper attention 
to change of clothing, according to the vicissitudes of the climate. A 
course of treatment at some establishment connected with the various 
medicinal springs is of great benefit. In all forms of iritis, especially 
in the autotoxemic types, the nasopharynx, the tonsils, the accessory 
sinuses, and the buccal mucous membrane should be carefully ex- 
amined for focal infection, which may be the cause of the toxemia 
of which the patient is the subject as well as of the iritis (see also 
page 324). Intestinal putrefaction may be present and must be 
corrected. IRITIS AND ITS TYPES 
313 
If the iritis assumes a chronic type, or if there has been exudation of 
lymph or involvement of the ciliary body, mercury and iodid of potassium 
may be exhibited. After the inflammatory signs of iritis have thor- 
oughly subsided and the eye is quiet, the refractive error should be 
thoroughly corrected and the glasses worn constantly, because there is 
no doubt that this plan of treatment distinctly checks the tendency to 
relapse. 
Should gout be determined to be the underlying cause, the usual 
treatment of this affection-dietetic and medicinal-is indicated, in 
addition to the local measures. Medicinal springs treatment is 
especially valuable. The subjects of gout must be treated on general 
principles. 
4. Gonorrhea-Gonorrheal Iritis.-This is a form of iritis (often a 
severe iridocyclitis), chiefly plastic in character, does not necessarily 
coincide with nor immediately follow the gonorrheal attack; an arthritis 
of the knee, or sometimes of the ankle, intervenes; sometimes arthritis 
and iritis occur at the same time, and sometimes the iritis precedes the 
arthritis. Brailey has seen it assume a gelatinous type. This disease 
is much more common than has usually been supposed, and there may 
be a long interval between the acquisition of the gonorrhea and of the 
iritis-frequently several years and even as long as thirty years. The 
blood should be examined for a complement-fixation reaction, and the 
posterior urethra for gonococci. It should be remembered that an 
ordinary iritis in a person with syphilis may be due to a gonorrhea from 
which he has also suffered. In many instances so-called rheumatic 
iritis is really gonorrheal in origin; indeed, William Lang believes that 
the gonococcus is the most frequent cause of plastic iritis. The affec- 
tion is due to the influence of the gonococci and their toxins on the iris. 
The presence of these micro-organisms in the anterior chamber has 
been demonstrated (Sidler-Huguenin). The disease is attended with 
severe pain, in addition to the usual symptoms of iritis, and its chief 
manifestations are in the superficial layers of the iris. It may relapse 
with each new attack of gonorrhea. 
Treatment.-The local use of atropin, etc., is indicated. If the 
urethra is inflamed, this must receive attention. Iodid of potassium 
may be tried, and mercury, if there is much exudation. Relief will 
follow profuse sweats by means of pilocarpin given hypodermically 
or with the aid of an ordinary hot chamber or cabinet; indeed, these 
remedies are of great value in other varieties of stubborn iritis. Sub- 
conjunctival injections of salt and of cyanid of mercury have been 
advocated, and dionin in the usual manner may be employed. Excel- 
lent results, in the author's experience, follow the administration of 
gonococcic vaccine (Neisser bacterin). Large doses are tolerated: 
50,000,000 to 100,000,000 organisms may be injected at intervals of 
three to seven days. Even larger doses are advocated by William 
Lang (200,000,000 to 500,000,000 at intervals of a week). John 
Weeks, however, thinks smaller doses (2,500,000 to 50,000,000) produce 
equally good results. 314 
DISEASES OF THE IRIS 
Iritis Secondary to Mucous Membrane Infection.-Iritis 
(more often iridocyclitis or uveitis) caused by infection of mucous 
membranes is of frequent occurrence. The primary source of such 
infection most frequently is a chronic septic process in the mouth 
(pyorrhoea alveolaris), in the teeth (tooth-root abscesses), in the tonsil, 
in the nasopharynx, in the accessory nasal sinuses, in the stomach and 
intestines, in the urethra (see page 313), in the uterine cavity, the 
prostate, and in the skin (boils, furuncles, etc.). 
Treatment.-In all cases of iritis and iridocyclitis the regions named 
must be carefully searched for disease and persistently treated if it is 
present. The usual local ocular treatment is indicated. Vaccine 
therapy (usually the staphylococcus is the active organism, but others 
may be potent) may be efficient. (For additional information, see pages 
327, 328.) 
In malaria a periodic iritis with hypopyon has been described, and 
somewhat analogous to this is another periodic iritis, or iridocyclitis, 
which has been seen before each menstrual period (iritis catamenalis), 
perhaps due to abnormalities in the uterine discharge. Fuchs reports 
severe iridocyclitis in association with general alopecia. A relation 
between nephritis and iritis has been described. Sometimes plastic 
iritis of moderate grade is found in elderly persons for which no cause 
can be found; to these types of iritis formerly the name "idiopathic" 
was applied. 
Scrofulous iritis occurs usually in children and young persons 
of scrofulous habit. In some respects it resembles inherited syphilitic 
iritis. Nodules of lardaceous appearance may also form. Tuberculous 
iritis is described on page 317. 
Infectious disease iritis is seen in association with recurrent 
fever, variola, pneumonia, pertussis, parotitis, tonsillitis, herpes zoster, 
cerebrospinal meningitis, influenza, dysentery, typhus and typhoid 
fever, and a purulent iritis, as the result of embolism, occurs in the 
course of septicemia after puerperal fever, and in pyemia. 
The management of such cases depends upon general principles, 
the free use of quinin and stimulants being appropriate in purulent iritis. 
Traumatic iritis occurs as the result of an injury, either acci- 
dentally inflicted or due to an operation-e. g., cataract extraction.1 
In this category are placed, also, those cases of iritis which follow discis- 
sion of the lens and which depend upon swelling of the cortical material 
and infection conveyed through the wound. The iritis excited by 
foreign bodies-for instance, metallic particles-embedded in the iris 
has been ascribed to a chemical as well as to infective action. 
Treatment.-The usual local measures are advisable. Iced com- 
presses are advantageous, and the internal administration of mercury 
and the salicylates is indicated. 
Sympathetic iritis (see page 333). 
1 Spongy iritis (see page 306) is occasionally seen after cataract extraction (Knapp). 
Plastic iritis has been ascribed to the action of st"rong solutions of eserin (eserin iritis'); 
but it is doubtful if the drug could produce such an effect in a healthy eye. CHRONIC IRITIS 
315 
Secondary iritis, independently of the fact that in a certain sense 
all types of iritis are secondary, may depend upon exogenous sepsis, 
for example, that which results from an infected corneal wound (see 
Traumatic Iritis) or upon exogenous toxemia, for instance, that which 
proceeds from an infected corneal ulcer (see page 306). 
Scleritis of the deep variety is often associated with iritis. More 
rarely the primary disease begins deep in the eye-e. g., in detachment 
of the retina. The presence of intra-ocular tumors, vitreous exuda- 
tions, or retinal hemorrhages may occasion a secondary iritis. 
Serous Iritis.-At one time it was the custom to describe a form 
of iritis characterized by a serous or, more commonly, a seroplastic 
exudation, deepening of the anterior chamber, slight dilatation of the 
pupil, haziness of the cornea and aqueous humor, and a precipitate of 
opaque dots upon the posterior surface of the cornea, generally arranged 
in a triangular manner, with the apex pointing upward, with the term 
serous iritis, or serous iritis and keratitis punctata (see page 323). Both of 
these terms are inappropriate, the one indicating purely a symptom of 
a disease, and the other an unproved pathologic condition. For a full 
consideration of this matter, see page 323. 
Chronic Iritis.-Any type of iritis may assume an acute, subacute, 
or chronic course; if the last, no additional symptoms occur, but those 
ordinarily present are modified by the chronicity of the stages. 
In addition to the chronic type of an ordinary iritis there remains 
to be described one which has received the name plastic iridochoroiditis, 
because of co-existing disease of the choroid and vitreous, leading to the 
formation of a secondary cataract. This disease occurs in adults, often 
without assignable cause, is symmetric, and proceeds steadily in a tend- 
ency destructive to the nutrition of the eye (see also page 326). 
The treatment of the latter condition is unsatisfactory, alteratives, 
tonics, and operative measures often meeting with indifferent success. 
Operative Treatment in Iritis.-Paracentesis of the cornea may be 
needed to reduce continued elevation of tension in some forms of iritis, 
and has been advised as a therapeutic measure in some varieties of 
iridocyclitis. Should inflammation of the iris and hypopyon exist, the 
treatment already described (see page 254) is required. 
Iridectomy is often recommended for the relief of recurrent iritis, 
or in an iritis which refuses to heal completely, some ciliary injection 
and irritability remaining. Those cases which present the least change 
in the iris, in which the aqueous humor is clear and the tension is not 
subnormal, are most likely to yield a good result. Iridectomy in recur- 
rent iritis does not insure the patient against future attacks, and repre- 
sents a method of treatment which, in the author's experience, usually 
is most unsatisfactory. 
In chronic iritis, however, circular posterior synechiae and bulging 
of the iris are important indications for the operation. Determined 
rise of tension and threatening glaucoma, in any circumstances, furnish 
imperative reasons for its performance. According to the late Mr. 
Nettleship, keratitis punctata, chronic thickening of the iris with very 316 
DISEASES OF THE IRIS 
extensive attachments, the existence of myopia, a tendency to spon- 
taneous bleeding, and hypopyon render the operation less desirable; 
if the tension is below the normal, the operation may be followed by 
bleeding and shrinking of the eyeball; occasionally, even in these cir- 
cumstances, excellent results are achieved. If, however, a map of the 
visual field, sometimes obtainable only with a small point of light, 
indicates extensive deep disease, the chances of operative success are 
notably lessened and the operation may be contraindicated. 
An iridectomy is performed to secure one or all of three ends: (1) 
Prevention of recurring attacks; (2) re-establishment of the communi- 
cation between the anterior and posterior chambers of the eye, and 
thereby improvement in nutrition and aversion of threatened glaucoma; 
(3) improvement in vision by the substitution of an artificial pupil for 
one that has been occluded or excluded. 
Fig. 142.-Cyst growing from posterior sur- 
face of the iris advancing into the anterior 
chamber (from a patient in the University 
Hospital). 
Fig. 143.-Cyst of the iris following 
traumatism (from a patient in the Uni- 
versity Hospital). 
That portion of the iris should be selected for excision which is least 
changed and least bound down by adhesions. 
Posterior synechiae remaining after the acute symptoms of iritis 
have subsided have been regarded as a cause of relapse or recurrence, 
and, although this has not been proved (compare with page 306), 
several operations have been devised for severing such attachments, to 
which the general term corelysis has been applied. 
Tumors of the Iris.-Cysts.-Cysts having transparent, delicate 
walls lined with pavement epithelium {serous cysts; retention cysts') 
may be congenital or may develop in the iris as the result of an injury. 
They are due to closure of the mouth of an iris crypt and its distention 
with the retained fluid. Cysts formed by a separation of the two layers 
of the pigmented retinal epithelium at the back of the iris {cysts of the 
retinal epithelium) are due, according to Treacher Collins, to interfer- 
ence with the lymph-current of the iris. Multiple cysts may develop TUMORS OF THE IRIS 
317 
on the posterior surface of the iris (Pagenstecher, Fuchs, Wintersteiner). 
Such a cyst may have a brownish color and be mistaken for a malignant 
tumor. A parasitic cyst-that is, one due to cysticercus in the iris-has 
been reported. Implantation of a cilium, or of superficial epithelium, 
in the anterior chamber may be the starting-point of an epithelial, pearl- 
like tumor {pearl-cysts or cholesteatoma), essentially cystic, with a lining 
of laminated epithelium and semisolid contents of degenerated epi- 
thelial cells and fat-globules (F. R. Cross and E. T. Collins). Traumatic 
cysts, which owe their origin to the intrusion through a wound of corneo- 
conjunctival epithelium, which proliferates, are divided by J. Meller 
into iris-cysts proper, which are situated entirely within the iris tissue, 
iris-chamber cysts, which are situated partly in the iris and partly in the 
anterior chamber, and wall-chamber cysts, which are so situated that the 
iris forms only part of their boundary wall. 
A cyst may be minute, or grow and fill the anterior chamber; both 
eyes may be affected, and some instances of multiple iris-cysts are on 
record (see page 316). A cyst may cause iridochoroiditis by pressure. 
An attempt should be made to remove it through an incision, the 
growth and surrounding iris being seized, drawn out, and excised. 
Tubercle of the Iris {Tuberculous Iritis).-In a certain number of 
persons, usually between the ages of five and twenty-five (Pechin), 
small, grayish-red or yellowish nodules develop at the margin of the 
pupil or at its ciliary border, bearing great similarity in their external 
appearance to miliary growths {disseminated miliary tubercle of the iris). 
The nodules are usually 2 to 3 mm. in diameter, and may be situated 
close to the anterior surface of the iris or deep in its stroma. Two 
terminations have been observed: the growths may develop slowly and 
finally be absorbed and disappear, posterior synechiae remaining at 
their points of origin {attenuated tubercle of iris, Leber); or successive 
developments of new nodules may lead to a plastic inflammation of the 
iris and ciliary body, and involvement of the cornea {keratitis punctata), 
and cause perforation at the corneoscleral junction, and shrinking of the 
eyeball. In these circumstances tubercle of the iris appears in the form 
of an iritis. In some cases of tuberculous iritis the nodules are ill- 
defined, being situated within the inflamed and thickened iris. 
Tubercle of the iris also occurs in a confluent or conglomerate form, a 
yellowish nodule growing from the periphery of the iris, covered, it may 
be, with smaller bodies. The tendency of this growth is to increase, to 
perforate the eye, and to cause a general dissemination of tubercle. 
The average age of persons affected with primary tuberculosis of 
the iris is twelve years; one or both eyes may be affected, more com- 
monly the former. Although the patients may present no other signs 
of tuberculosis, this, and in a fatal form, may become a sequence. 
Sometimes the affection of the iris is secondary to the general disease. 
Bacilli and giant-cells may be found in these growths, proving their 
true nature, or the diagnosis must rest upon the results of inoculation 
of a rabbit's or guinea-pig's anterior chamber with a fragment of the 
suspected tissue, or upon tests with tuberculin, either by means of 318 
DISEASES OF THE IRIS 
subcutaneous injection or cutaneous vaccination. For diagnostic pur- 
poses Koch's old tuberculin may be used in gradually increasing doses, 
beginning with 1 mg. and with two-day intervals increasing to 5 mg. 
Treatment.-Removal of a tubercle of the iris is almost always 
unsuccessful, except in some varieties of attenuated tuberculosis. 
Hence, if the disease is attacked from the operative standpoint, enuclea- 
tion has been recommended. Before radical surgical procedures are 
adopted there should be a thorough trial of the therapeutic value of 
tuberculin. Von Hippel, using tuberculin T. R., begins with the dose 
of -5^ mg., and gradually increases to mg., and even to mg. 
In some cases the dose is further increased from | mg. to f; i. e., 1 mg. 
by | mg. at each injection. A bouillon filtrate of tuberculin obtained 
from the Saranac Laboratory, with the initial dose of 0.0001 mg., is 
recommended by G. S. Derby. The author's results with tuberculin 
as a therapeutic agent have been most satisfactory. He has also used 
with satisfaction tuberculin "Old." The five dilutions contain respec- 
tively 1 : 1000 mg., 1 : 100 mg., 1 : 10 mg., 1 mg., and 10 mg. The 
dose of each dilution is 2 mg., and is progressively increased until 20 
minims are injected. Following this, the next series is begun. The 
introduction of iodoform into the anterior chamber has been tried. 
Sarcoma of the iris is rare as a primary growth. It has been well 
studied in this country by Veasey, and more recently by C. A. Wood 
and Brown Pusey. Iris sarcoma is more common in the latter half of 
life-that is, after thirty years-than at an earlier period, although a few 
cases have been reported in the first decade of life. Females are more 
often affected than males; the lower half of the iris is the primary seat 
of the growth in a large percentage of the cases. A few instances of 
bilateral iris sarcomas are on record. The first stage of the tumor's 
growth is slow, and may last for months and even years; in the second 
and later stages there is rapid increase in size, with pain, hemorrhage, 
etc., and, finally, rupture of the globe. Usually the tumor is pigmented; 
rarely a leukosarcoma of the iris develops. Histologically, small round 
and small spindle cells are the predominating forms. The growth must 
be differentiated from melanoma, tubercle, and gumma. A few iris 
sarcomas have been successfully removed by iridectomy (Thorington); 
but Wood and Pusey are emphatic in their advice that the globe shall 
be enucleated as soon as the diagnosis is certainly established. 
Melanoma of the iris is a dark tumor, developed from the pigment 
stroma of the iris, and although commonly passive and innocuous, is 
occasionally the precursor of sarcoma. Melanomas also occur at the 
pupillary margin of the iris, where they develop from the retinal pig- 
mented cells. 
Rare forms of iris tumor are vascular growths (nevi), leprosy nodules, 
and myomas. It is more than doubtful if primary carcinoma of the 
iris occurs; it may develop as a secondary growth, as also may glioma. 
Injuries to the Iris.-Wounds.-An incised wound limited to the 
iris does not necessarily produce serious results. It will be followed by 
blood in the anterior chamber, which in course of time is absorbed. INJURIES TO THE IRIS 
319 
Wounds, however, are rarely limited to the iris, but having penetrated 
the eyeball through the cornea or ciliary region, may cause sympathetic 
irritation, or injure the lens and produce traumatic cataract. 
In the first instance atropin, to secure physiologic rest of the iris, 
and a compressing bandage will lead to a speedy cure; in the other in- 
stances the extent and position of the wound will determine the neces- 
sity for enucleation or for the treatment applicable to traumatic iritis. 
Foreign Bodies.-A foreign body may penetrate the cornea and 
lodge in the iris, or, having partially penetrated the cornea, may be 
pushed through it in the efforts at dislodgment and become entangled 
in the iris. * 
An opening is made with a broad needle or narrow keratome at the 
corneoscleral junction, eserin having been previously instilled, and a pair 
of forceps passed into the wound, with which the body is seized, or a 
small loop of platinum wire may be slipped beneath the fragment, by 
means of which it is withdrawn. If this is not possible, the piece of iris 
Fig. 144.-Iridodialysis and partial cataract; pupil dilated. 
in which the substance is entangled may be drawn through the wound 
and excised. If the body is composed of steel or iron, it can be dis- 
lodged with a magnet. 
Blows upon the eye may cause the following lesions: 
Iridodialysis is a rupture of the ciliary attachment of the iris (liga- 
mentum pectinatum). By this means an opening is produced compar- 
able to a false pupil; it may be detected by the red reflex which shines 
through the artificial aperture, usually somewhat semilunar shaped, 
situated in the periphery of the iris at the corneoscleral margin (Fig. 144). 
This may be quite small or involve more than half the circumference. 
The injury may produce other lesions-for example, cataract. 
In a few instances reattachment of the ruptured fibers has taken 
place under the favoring influence of atropin, which should be vigor- 
ously instilled. Ordinarily the lesion is permanent and, if small, occa- 
sions little trouble, although there may be diplopia. Pain, some dread 
of light, and hemorrhage into the anterior chamber are the immediate 
sequences of such an accident. 320 
DISEASES OF THE IRIS 
Rupture of the sphincter produces mydriasis and minute notchings 
of the pupil border. According to some authorities the not uncommon 
dilatation of the pupil (traumatic mydriasis) which follows a blow is 
always accompanied by such a lesion. The condition is not altered by 
treatment. Rupture of the continuity of the iris membrane by concus- 
sion is very rare (Harlan). 
Displacement of the iris occurs under three forms: (1) Retroflexion, 
or a folding back of a portion of the iris upon the ciliary processes, 
usually accompanied by a partial dislocation of the lens; (2) anteversion, 
or turning upon itself of the detached portion of the iris, so that the 
under or uveal surface is exposed; and (3) aniridia, or complete detach- 
ment of the iris from its insertion, so that it lies in the anterior chamber, 
or even under the conjunctiva. An injury severe enough to produce 
this condition usually is attended with other serious lesions of the 
remaining structures of the eye. 
ANOMALIES OF THE ANTERIOR CHAMBER 
1. Alterations in its Depth.-Physiologically, the anterior cham- 
ber is shallower in infancy and old age, and diminishes in its middle 
depth during the act of accommodation. 
Pathologic deepening of the anterior chamber occurs in luxation or 
absence of the lens, in some cases of cyclitis, and is present in conical 
cornea and certain forms of staphyloma. 
Pathologic shallowing of the anterior chamber occurs in chronic 
iritis with bulging forward of the iris, in glaucoma, and in the later 
stages of growths of the interior of the eye. Its depth is also lessened 
when there is diminution of the secretion of aqueous humor, in long- 
standing inflammation of the uveal tract with detachment of the 
retina. 
2. Alterations in its Contents.-These may consist in mere 
turbidity of the aqueous, as in iritis, keratitis punctata, and glaucoma, 
or there may be a positive collection of pus, several times referred to 
under the name of hypopyon, and commonly seen in sloughing ulcers 
of the cornea and purulent inflammations of the iris and ciliary body. 
Finally, blood collects in the anterior chamber, a condition which 
receives the name hyphemia. This follows injury to the iris, and occurs 
in tumors of the eye, hemorrhagic glaucoma, and in severe forms of 
iritis and cyclitis. It is also seen in hemophilia and splenic leukemia 
(Sorger). Blood-staining of the cornea may cause a peculiar smoky 
hue, resembling a lens luxated into the anterior chamber (see also 
page 411). 
3. Foreign Bodies and Parasites.-A foreign body penetrating 
the cornea may lodge upon the iris or fall into the anterior chamber. 
This may be a fragment of iron or steel or a particle of glass. Some- 
times a cilium passing through a wound obtains entrance into the 
anterior chamber; if it remains long enough, it causes a cystic tumor 
(implantation cyst). TUMORS AND CYSTS OF THE ANGLE OF THE ANTERIOR CHAMBER 
321 
The two parasites described in this situation are Cysticercus and 
Filaria sanguinis hominis. In all these instances the intruder should 
be removed by an operation. 
4. Tumors and Cysts of the Angle of the Anterior Chamber.- 
According to Parsons, endothelioma is the only primary growth of the 
angle of the anterior chamber. A tumor of this character, its cells 
Fig. 145.-Cilia in the anterior chamber after wound of corneoscleral junction. 
being derived from the pectinate ligament, has been described by Hanke. 
Tubercle, gumma, sarcoma, and glioma occur as secondary deposits 
in this region. Cysts, derived from a congenital cystic growth of the 
ciliary epithelium, may develop in the anterior chamber (Holmes Spicer, 
R. A. Greeves). CHAPTER X 
DISEASES OF THE CILIARY BODY AND SYMPATHETIC 
IRRITATION AND INFLAMMATION 
Cyclitis and Iridocyclitis.-Under the general term cyclitis are 
included various types of inflammation of the ciliary body. The close 
anatomic connection of the iris, choroid, and ciliary body makes dis- 
eases limited strictly to the last structure exceedingly uncommon, just 
as in many instances inflammations primary in the iris or choroid also 
involve the ciliary body. 
Hence if the iris and ciliary body are associated in pathologic changes, 
the term iridocyclitis is applicable. 
The symptoms which in general lead to the diagnosis of cyclitis or 
iridocyclitis are the following: Edema of the lid, injection of the cir- 
cumcorneal or ciliary zone, neuralgic pain, and tenderness on pressure. 
Change in the aqueous humor, which grows turbid; precipitates of ex- 
udation in grayish-brown points upon the posterior layer of the cornea, 
and at times hypopyon; exudation in the posterior chamber, attaching 
the under surface of the iris to the lens-capsule in a complete posterior 
synechia, the retraction thus produced causing a deepening of the ante- 
rior chamber; exudation into the vitreous causing opacities, especially 
in its anterior layers; and alterations in the tension of the globe, which 
may be increased or decreased. 
The general symptoms of pain, photophobia, lacrimation, etc., are 
present in the acute types of the disease, and vision is seriously im- 
paired according to the amount of the exudation in the pupillary space 
and vitreous. 
To those cases characterized by especially severe ciliary pain and 
marked pericorneal injection, dilatation of the veins of the iris and de- 
cided retraction of its periphery by reason of the plastic nature of the 
exudate in the ciliary body, the descriptive name plastic cyclitis is often 
given. The tension may be high or low, according to the grade of the 
inflammation and the character of the process. The disease may in- 
volve the choroid, and the vitreous may be filled with opacities. If 
the pain is comparatively slight and the pericorneal injection less 
marked, while deepening of the anterior chamber, primary slight 
dilatation of the pupil, turbidity of the aqueous, and decided precipita- 
tion of dots on the posterior surface of the cornea ("keratitis punctata") 
are conspicuous features, the descriptive name serous cyclitis is sometimes 
applied. With these phenomena fine vitreous opacities, inflammation 
of the iris and choroid, narrowing of the anterior chamber, increased 
tension, and secondary glaucoma may be associated. 
322 UVEITIS, OR SEROUS CYCLITIS 
323 
Purulent cyclitis is characterized by intense ciliary pain, great peri- 
corneal injection, and edema of the conjunctiva and the upper lid. The 
vitreous contains large opacities, and a noteworthy feature is the forma- 
tion of hypopyon, which may disappear and reappear again in a few 
days, its reappearance sometimes being signaled by a fresh exacerbation 
of intense pain. The iris and choroid commonly are included in the 
inflammation. 
Pathology.-As already noted, systematic writers at one time were 
accustomed to divide cyclitis into plastic, serous, and purulent cyclitis. 
The objections to a classification of this character have been recorded 
in connection with iritis (see page 306). In general terms, inflamma- 
tion of the ciliary body may be acute, suppurative or purulent, and 
chronic. In addition to the infiltration of the iris and exudation in the 
anterior chamber, there are round-cell infiltration of the ciliary body, 
much more intense in the vascular ciliary processes than in the ciliary 
muscle, and lines of exudation into the posterior chamber and the 
vitreous. The retina, choroid, and nerve are also involved in a varying 
degree. Later the exudations organize and contract, producing atrophy 
of the ciliary body, proliferation of the pigment layers, and stretching 
of the processes toward the posterior pole of the lens. The exudations 
contain newly formed vessels, the lens becomes cataractous, and if the 
inflammation has been intense, the retina is detached and atrophy of the 
entire eyeball results. If the ultimate result of cyclitis is phthisis bulbi, 
the pathologic process has been a chronic plastic cyclitis, with an exuda- 
tion rich in fibrin which has gradually changed into fibrous tissue. 
Prognosis.-Cyclitis under vigorous treatment, begun early, may 
subside; but the prognosis is always grave, because the disease is 
liable to originate glaucoma, and in the purulent type, or in the 
plastic variety which has become purulent, tends to produce atrophy 
of the iris and choroid and, as described above, phthisis bulbi. 
Shrunken balls of this character are often tender, readily become 
inflamed, and may produce sympathetic ophthalmitis; this is particu- 
larly true if the original inflammation has been a cyclitis of the plastic 
type, which probably remains in a chronic state. 
Causes.-As already stated, primary and uncomplicated disease of 
the ciliary body is rare. The affection usually is part of a process which 
involves the choroid or iris, and, therefore, the same conditions and 
affections which cause iritis (see page 306) may originate cyclitis. A 
full consideration of the factors concerned with disease of this region will 
be found on pages 324 and 325, and also in the section devoted to Dis- 
eases of the Iris. 
Injuries are common causes of cyclitis, and the inflammation may 
follow operations upon the globe-e. g., cataract extraction. 
The treatment of cyclitis is practically identical with that of iritis, 
and, therefore, the directions need not be repeated. 
Uveitis, or Serous Cyclitis {Descenietitis; Aquo-capsulitis; Kera- 
titis Punctata; Serous Iritis).-In this disease the clinical as well as the 
pathologic manifestations are chiefly concerned with the uveal tract. 324 
DISEASES OF CILIARY BODY AND SYMPATHETIC IRRITATION 
The inflammatory process either affects the whole tract or, first con- 
fined to one part of it, is liable to extend to one or both of the other two 
parts; sometimes it remains confined to the part first attacked. 
Causes.-In general terms, the causes of uveitis may be septic or 
toxic. A certain number of cases depend upon so-called constitutional 
diseases or disorders of nutrition-for example, chronic rheumatism, 
gout, arthritis deformans, and diabetes; on specific infectious diseases- 
influenza, syphilis, gonorrhea, tuberculosis, and specific fevers; on dis- 
eases of the blood-for instance, anemia; on auto-intoxications, particu- 
larly enterogenous auto-intoxication; on areas of chronic sepsis in 
the pelvic region, urethra, the prostate and seminal vesicles, the 
intestines, the rhinopharynx and accessory sinuses, gums (pyorrhoea 
alveolaris, tooth-root abscess), the tonsils, the pharyngeal ring, and 
the skin (furuncles). (See also page 314.) 
Stock's investigations, both from the clinical and the experimental 
standpoint, indicate that tuberculosis is a frequent cause of chronic 
uveitis. Hence, tests to determine the presence of tuberculosis should 
not be neglected in the study of this affection, and the serum reaction 
of Wassermann should be utilized to establish the presence or absence 
of syphilis as an etiologic factor. Undoubtedly gonorrhea is a cause of 
importance. In what manner these various ailments and conditions 
create an inflammation of the uveal tract has not been positively deter- 
mined, but it is not unreasonable to assume that the disease manifes- 
tations represent an effort on the part of the uveal tract to expel from 
its tissues some toxin of bacterial or other origin, precisely as certain 
forms of dermatitis originate in an effort of the skin to eliminate a 
poisonous agent. Syndey Stephenson maintains that inasmuch as 
many inflammatory affections of the iris and ciliary body are due to 
microbic infection, there exist good grounds for believing that the 
proximate cause of all cases of endogenous iridocyclitis is the excretion 
by the ciliary body of the micro-organisms and their products. As 
already pointed out (see page 314), and quoting Stephen Mayou, it 
may be said that non-suppurative inflammation of the uveal tract is 
often due to pyogenic organisms of diminished virulence, for example, 
Starphylococcus albus, derived from the distant foci of infection, which 
have been named. 
Symptoms.-In large measure the symptoms of this condition 
have been described on pages 272 and 315, and in the paragraphs 
relating to the various types of cyclitis. In other words, the mani- 
festations vary considerably, and one description does not apply to 
all types. 
The following symptoms are often present, and when grouped to- 
gether are characteristic: There are moderate deepening of the anterior 
chamber, at the beginning slight dilatation of the pupil (or, at least, an 
uncontracted pupil), haziness of the cornea and aqueous humor, and a 
precipitate of opaque dots upon the posterior elastic lamina of the 
cornea, generally arranged in a triangular manner with the apex point- 
ing upward. There is slight pericorneal injection, and at first no great UVEITIS, OR SEROUS CYCLITIS 
325 
tendency to form synechiae. It is not uncommon to find the tension 
somewhat higher than normal, at least in the earlier stages of the dis- 
ease; later it diminishes. With the formation of posterior synechiae, 
if they are at all extensive, secondary glaucoma may develop. The one 
fairly constant clinical sign, which in a certain sense is characteristic, 
Fig. 146.-Uveitis, early stage; large dots 
irregularly placed (magnified). 
Fig. 147.-Uveitis; large dots on corneal 
surface (magnified). 
is the manifestation which gave rise to the name "punctate keratitis" 
-namely, a deposit of variously sized and colored dots, arranged usually 
in a triangular manner on the posterior layer of the cornea. In this 
connection, however, it should not be forgotten that this so-called 
descemetitis, in some form or other at least, is practically always present 
in all varieties of iridocyclitis, al- 
though not necessarily in the tri- 
angular-like manner which has just 
been described. The deposits on 
the posterior surface of the cornea 
may be fine and dust-like, or large 
and drop-like. To the last-named 
variety the term "mutton-fat" is 
often applied. The deeper layers 
of the cornea may be infiltrated 
(keratitis profunda; see also page 
303), and the iris may contain 
thickenings and nodules, especially 
in the tuberculous types of the 
disease. 
Not only are the evidences of involvement of the iris and ciliary 
body present, but in most cases careful examination of the choroid will 
reveal lesions in its tissues. They may be vague, and comprise only 
the so-called choroidal congestion, or appear far out in the periphery 
in patches of acute choroiditis, sometimes in large zonular areas of 
acute plastic choroiditis, and sometimes so far forward that ophthal- 
moscopic examination does not reveal their presence. The vitreous 
usually contains fine, floating opacities, or, in severe cases, coarse, 
Fig. 148.-Uveitis, showing punctate 
deposits on cornea and cross-hatching 
(magnified). 326 
DISEASES OF CILIARY BODY AND SYMPATHETIC IRRITATION 
web-like opacities, and occasionally hemorrhages. The visual field 
examination will often reveal, even in the absence of rise of tension, 
irregular contractions, and, not uncommonly in the earlier stages of 
the disease, scotomas. The visual acuteness may be greatly decreased, 
owing to exudations in the vitreous and the deposits on the cornea, 
while in some of the milder cases it is scarcely reduced below the 
normal, and the patients are conscious only of ocular disease because 
of slight local discomfort and muscse in their field of vision. 
There are so many manifestations of this disease that it is not 
practicable to attempt an exact classification. In general terms, it may 
be said that sometimes the signs are chiefly those of punctate keratitis 
or descemetitis; that a senile form of the disease is not uncommon, 
unassociated with acute symptoms or involvement of the iris, with 
only a few spots on the posterior surface of the cornea, and with a 
certain amount of flaky vitreous opacity, choroiditis in active mani- 
festation being absent, although there may be a certain amount of 
irregularity of the retinal circulation; that occasionally a marked 
descemetitis is the chief sign of a decided choroiditis or choroido- 
retinitis, often of obscure origin; that a chronic uveitis may develop 
in the iris, less commonly in the ciliary body, with or without punc- 
tate deposits in the cornea, insidious in character, more frequently 
encountered in young women than in men or in children; and that, 
finally, the disease may be recurrent and assume a type to which 
the author has ventured to give the name malignant uveitis, and which 
terminates in secondary glaucoma, cataract, and often in blindness. 
With these cases of malignant uveitis may be described those to 
which the names iridochoroiditis, cyclitis with disease of the vitreous and 
keratitis punctata, and chronic serous iridochoroiditis have been given. 
They have been divided into two forms, according as the affection is 
primary in the iris or in the choroid. In the first instance, there are 
mild iritis, insignificant pain, and ciliary congestion, deepening of the 
anterior chamber, and spots on the posterior layer of the cornea; inflam- 
mation continues, relapses take place, exudation occurs behind the iris, 
while its pupillary margin is bound down so that the surface is irreg- 
ularly bulged forward, and if the pupil is not too much occluded, the 
ophthalmoscope will reveal many flocculi in the vitreous. The tension 
may now rise and the eye pass into secondary glaucoma. 
In the other type the process passes from behind forward, beginning 
with patches of choroiditis, which increase in extent and depth; the 
nutrition of the vitreous is impaired and opacities form, the lens is 
altered and pushed forward, the iris becomes embodied in a plastic in- 
flammation, with narrowing of the anterior chamber and a loss of 
vision. As the disease of the uveal tract continues, the lens becomes 
opaque, the eyeball softens, the retina may be detached, and, finally, 
phthisis bulbi occurs. In addition to the causes already mentioned, 
the affection, which is common in young adults, and usually symmetric, 
has been attributed to prolonged work, associated with loss of sleep 
and defective nutrition. UVEITIS, OR SEROUS CYCLITIS 
327 
Pathology.-The deposits on the posterior surface of the cornea, 
which are so conspicuous a symptom of this disease, and which have 
given rise to the name punctate keratitis, may be very fine or of medium 
size, and sometimes large and greasy-looking, in which circumstances 
they are known in England as "mutton-fat deposits." They are de- 
rived chiefly from the ciliary body, as Fuchs originally demonstrated, 
and also, in lesser degree, from the iris. An exudation of lympho- 
cytes occurs upon the surface of the ciliary body, the lymphocytes 
pass into the anterior chamber and are precipitated on the posterior 
surface of the cornea (Fuchs). Their cyclitic origin has been strongly 
maintained by E. Treacher Collins, especially after his discovery of the 
so-called glands of the ciliary body. In other words, according to him, 
this disease may be regarded as primarily a catarrhal inflammation of 
these glands. Their secretion, he maintains, becomes augmented, 
causing increase in the aqueous humor and deepening of the anterior 
chamber. The aqueous is altered in character, contains leukocytes, 
pigment cells, and fibrin, and these formed elements gravitate and are 
deposited upon the lower portion of the posterior face of the cornea. 
Some authors-for example, Hill Griffith-have asserted that the dots 
on Descemet's membrane are formed in the choroid and set free in the 
vitreous, are carried by the nutrient currents of the eye and deposited 
on the back of the cornea. His view, as he himself points out, would 
necessitate the admission that the suspensory ligament is permeable to 
solid particles. Histologic investigation of the eyes affected with this 
disease indicate that in general terms there is a chronic cyclitis, in which 
the anatomic changes do not materially differ from those found in or- 
dinary types of cyclitis. Groenouw has demonstrated round-celled 
infiltration of the iris, of the deeper layers of the corneal border and the 
ciliary body, with collections of round cells on the posterior layer of the 
cornea and on the ciliary processes. In his investigations the choroid, 
retina, and optic nerve were normal, but other observers have found 
them affected, as necessarily would be the case in so far as the choroid 
is concerned, where the ophthalmoscopic evidences of choroiditis are 
present. In later stages of chronic uveitis there is an overgrowth of 
the epithelium of the ciliary body. This epithelial hyperplasia, de- 
scribed by Fuchs, is, according to him, characteristic of some cases of 
chronic uveitis. Harms' investigation of the pathologic anatomy of 
chronic iridocyclitis with deposits on Descemet's membrane indicates 
that the inflammation of the uveal tract is limited largely to the anterior 
segment of the eyeball, the deeper parts being much less affected. 
The pigment found in the deposits on the posterior surface of the cornea 
arises probably in part from degenerated red corpuscles, and largely 
from the uveal tract. In some grave types of iridocyclitis, leading to 
retinal detachment and atrophy of the eyeball, Fuchs found lesions 
resembling exogenous endophthalmitis, and believes they are caused 
by a virulent toxin or by bacteria conveyed by metastasis. 
Treatment.-This depends upon the character of the disease or 
the type which it assumes. In the absence of increased intra-ocular 328 
DISEASES OF CILIARY BODY AND SYMPATHETIC IRRITATION 
tension, mydriatics are indicated, either atropin or scopolamin. With 
increased tension the mydriatic must be suspended and occasionally 
a miotic may be needed, or paracentesis of the anterior chamber 
may be performed. Dionin is of distinct advantage, and it may be 
combined with the atropin or eserin, according to indications. Pilo- 
carpin diaphoresis is sometimes admirable in its effects. If for any 
reason the drug is not well borne, a similar physiologic action may be 
obtained by sweats induced in a Turkish bath, or with the aid of an 
ordinary cabinet. Subconjunctival injections are exceedingly valuable 
-either ordinary physiologic salt solution or cyanid of mercury. Mer- 
cury, preferably by inunction, even in non-specific cases, should be ex- 
hibited. It may also be given by the mouth in the form of the protiodid. 
In syphilitic cases the indications for mercury are evident, and salvarsan 
and neosalvarsan (see page 310) should be employed. lodid of potas- 
sium, iodid of sodium, and iodid of lithium are important alterative 
remedies, and in acute cases, especially those associated with great 
pain and decided cyclitis, full doses of salicylate of sodium or of aspirin 
render signal service. Naturally, the indications furnished by the prob- 
able etiologic factors must be given due consideration, and, therefore, 
iron, arsenic, bichlorid of mercury, syrup of hydriodic acid, and similar 
remedies should be administered. With atoxyl in this disease the 
author has had no experience, but he has seen marked benefit follow 
the administration of Donovan's solution. The administration of 
tuberculin in the manner already described (see page 318) is followed by 
excellent results, and should certainly have full trial if the reaction to 
tuberculin is positive. Mayou has successfully treated uveitis with 
staphylococcic vaccine where the staphylococcus has been obtained from 
the anterior chamber by paracentesis, and tests have demonstrated 
that neither tuberculosis nor syphilis is the etiologic factor. The 
author's investigations indicate that in a certain number of cases of 
uveitis, especially of an insidious and relapsing type, so-called enterog- 
enous auto-intoxication bears a relation to the disease, even if it is not 
a causal one in the sense that a toxin formed within the metabolism is 
the exciting agent, and treatment should include a carefully selected 
diet and intestinal antisepsis. Indeed, the association of intestinal 
sepsis with this disease is often an intimate one. The important rela- 
tion of focal infections in the rhinopharynx, the teeth, and the accessory 
sinuses to this affection has been referred to, and these regions should 
be thoroughly explored and treatment ordered according to the find- 
ings. The investigation of the teeth should include an a:-ray examina- 
tion. As Allen J. Smith and Barrett have found that the Endameba 
buccalis is one of the factors in the production of pyorrhoea alveolaris, 
emetin has been used with success in relieving the oral sepsis, and thus 
indirectly may help in the cure of a uveitis caused by it. After the 
acute symptoms have subsided, in the opinion of some authors massage 
of the eyeball is desirable, and galvanism has been advocated. S. Lewis 
Ziegler believes that electric treatment shortens the course of uveitis. 
He advises the application of the positive pole. In some types of SYPHILIS OF THE CILIARY BODY 
329 
malignant uveitis the administration of thyroid extract has achieved 
encouraging results (Bordley). 
If as the result of this disease firm posterior synechiae block the com- 
munication between the anterior and posterior chambers, this should 
be reopened by a broad peripheral iridectomy, which, if the lens is 
opaque, may be combined with its extraction. Even in eyes in which 
softening has begun, provided the field of vision still remains intact, 
good results will sometimes follow a successful iridectomy. If at any 
time during the course of the disease rise of tension should develop and 
iridectomy should not be admissible, either paracentesis of the anterior 
chamber or posterior sclerotomy may be tried. Tapping the anterior 
chamber has been advised as a therapeutic measure, even if the tension 
is not elevated, and in a few cases in which the author has put this ex- 
pedient to the test it has apparently been of benefit to the patients. 
The fluid from the chamber should be examined for the Spirochaeta 
pallida, tubercle bacilli, and for pyogenic organisms. From the latter 
vaccines can be prepared if the treatment advocated by Mayou is to be 
tried. 
In recent times a few reports indicate that radium has served a 
useful purpose in relieving the pain and facilitating the absorption of 
inflammatory products in chronic uveitis (C. H. Williams). 
Injuries of the Ciliary Body.-The danger attending perforating 
wounds of the sclera has been described on page 292; this danger is 
doubly increased if the wound occurs in any portion of a zone, | inch 
wide, surrounding the cornea, a region commonly called the "dangerous 
zone," after the late Mr. Nettleship's apt description. In addition to 
the damage inflicted by the wound the risk of acute and suppurative 
cyclitis and of sympathetic inflammation is present. 
Treatment.-After a penetrating wound in this region two courses 
are open to the surgeon-an attempt to save the eye, or immediate 
enucleation. If an attempt be made on the side of conservatism, the 
plan discussed under scleral wounds (see page 293) should be followed; 
if not, enucleation or one of its substitutes will be required (see page 636). 
Syphilis of the Ciliary Body.-Syphilitic affections of the ciliary 
body may exist either in a diffuse infiltration of granulation tissue and 
inflammatory exudation or in tumor formation-that is, in syphiloma 
of the ciliary body, to adopt the term advised by Ewetzky, who has 
thoroughly studied this subject. According to him, the symptoms of 
syphiloma of the ciliary body manifest themselves chiefly in the form 
of a severe iridocyclitis, with hazy cornea, or an intense parenchyma- 
tous vascular opacity of this structure. Keratitis punctata may be a 
prominent symptom, and sometimes hypopyon is present. The tumor 
formation in the ciliary region may extend completely around the 
cornea, and perforation usually takes place through the sclerotic or into 
the anterior chamber. The color of the tumor is often yellow, and 
when caseous degeneration sets in there may appear in the anterior 
chamber the products of the degeneration of the tumor, which give rise 
to the appearance of hypopyon. The largest number of cases occur 330 
DISEASES OF CILIARY BODY AND SYMPATHETIC IRRITATION 
between the twentieth and the fortieth years of life, and more men than 
women are affected. Only rarely is inherited syphilis a cause of this 
condition. In those cases due to acquired syphilis, a large percentage 
has appeared in the early stage of the systemic affection. 
A number of cases of gumma of 
the ciliary body have been recorded, 
but on pathologic grounds it is 
probably impossible to distinguish 
between papules and gummas, and, 
therefore, Ewetzky's term syphiloma 
is appropriate. Some writers de- 
scribe precocious gummas of the cilia ry 
body as early tertiary lesions, but 
Ewetzky does not believe that they 
should be separated into a special 
group. The condition must be dif- 
ferentiated from syphilitic growths 
of the conjunctiva which are mov- 
able; from syphiloma of the scle- 
rotic, which is usually unassociated 
with iridocyclitis, and from melanotic sarcoma and tuberculosis of 
this region. The treatment does not differ from that which has been 
advised in connection with syphilitic diseases of the iris, and full doses 
Fig. 149.-Gumma of iris and ciliary 
body. 
Fig. 150.-Microscopic section of gumma of iris and ciliary body (see Fig. 149): 
I, Remains of lens; c. p.^atrophied ciliary processes; g, gummatous growth involving base 
of iris and ciliary body, containing in its center a cyst, c. 
of mercury and iodid of potassium are the most important therapeutic 
agents, especially if used in conjunction with salvarsan and neosalvarsan 
(see page 310). SYMPATHETIC IRRITATION AND SYMPATHETIC INFLAMMATION 
331 
Tumors of the Ciliary Body.-Primary sarcoma of the ciliary body 
is a rare disease. Usually the growth is pigmented, although a few 
cases of leukosarcoma have been described. The sarcoma may not 
seriously impair the function of the eye in its earlier stages, when the 
tumor appears as a brown mass behind the iris, rarely in the angle of the 
anterior chamber. Later the growth exhibits the four stages which 
are common to all intra-ocular tumors. The tumor may be composed 
of round, spindle, or mixed cells, and, according to Groenouw, the 
prognosis is better than in sarcoma of the choroid. Sometimes sar- 
coma of the ciliary body assumes a flat and infiltrated character, to 
which the name ring or annular sarcoma has been given. This is a 
comparatively rare manifestation, only about 8 cases being on record 
(Alling and A. Knapp). The ciliary body may also be invaded by 
sarcoma from the choroid or iris. 
Other growths which have been noted in this region are epithelial 
hyperplasias and innocent tumors of the ciliary epithelium (Fuchs), 
which, occurring in elderly persons, arise from the unpigmented layer 
at the summit of a ciliary process. An unusual pathologic condition 
found by Fuchs in an eyeball atrophic after iridocyclitis is a neuroma 
of a ciliary nerve. Adenomas have been described and, very rarely, 
primary carcinoma, myoma, and myosarcoma. For those tumors of the 
ciliary'epithelium which represent the embryonic retina Fuchs proposes 
the name diktyoma. A tumor of this character has been described by 
Verhoeff with the title teratoneuroma embryonale. Metastatic carcinoma 
and secondary glioma have been recorded. 
As an extension of the disease from the iris or choroid, tubercle of 
the ciliary body may appear, and leprosy nodules have been reported, as 
have also a few cysts. 
Senile degeneration of the ciliary body occurs, and atrophic changes in 
this structure are met with after cyclitis. According to Parsons, 
calcification and ossification of the ciliary body itself are rare. Nearly 
always there are sequels of ossification in the choroid. 
SYMPATHETIC IRRITATION AND SYMPATHETIC INFLAMMATION OR 
OPHTHALMITIS 
These terms are applied to affections in which one eye is implicated 
in a morbid process as the result of disease or injury to the other. For a 
long time it was taught that they represented two essentially different 
conditions; but in recent years a number of authorities have concluded 
that this distinction should no longer be maintained-that, in other 
words, sympathetic irritation should be regarded simply a moderate 
degree of sympathetic inflammation. Schirmer, however, continues 
to insist on the essential difference of the tw'O affections, and, on clinical 
grounds at least, and in the light of present knowledge, it seems wise to 
agree with his contention. 
It is customary to describe the eye which is implicated as the result 
of disease or injury of its fellow as the sympathizing eye, and the one 332 
DISEASES OF CILIARY BODY AND SYMPATHETIC IRRITATION 
affected by the disease or injury which causes the irritation or inflam- 
mation the exciting eye. 
Conditions Producing Sympathetic Affections.-Generally one or 
other of the following conditions is present: 
(1) Wounds of the ciliary region which set up a traumatic irido- 
cyclitis or uveitis, especially if associated with incarceration of the 
underlying tissue in the scar, as well as wounds of the eyeball elsewhere 
located. The ciliary region is the zone previously described by the term 
borrowed from Mr. Nettleship, "dangerous zone." Traumatisms prob- 
ably cause over 80 per cent, of the cases of sympathetic inflammation. 
(2) Foreign bodies in the eye. (3) Perforating wounds or ulcers of the 
cornea in which the iris has become incarcerated, or scars involving the 
ciliary body. (4) Operations upon the eye-extraction of cataract, 
sclerotomy, iridodesis, iridectomy, discission, and reclination. (5) 
Luxation, wounds, and calcification of the lens. (6) Intra-ocular tumors, 
e. g;, sarcomas (Fuchs, Meller), especially if associated with iridocyclitis 
(Schirmer). (7) Ossification and calcification of the choroid and ciliary 
body. (8) Pressure of an artificial eye or incarceration of the stump 
of the optic nerve in scar tissue, after the operation of enucleation, and, 
in rare instances, implantation of an artificial vitreous in Tenon's cap- 
sule or in the scleral cup (Mules' operation). 
According to O. Schirmer, there is no sound evidence that herpes 
zoster ophthalmicus, glaucoma, symblepharon, intra-ocular cysticercus, 
subconjunctival rupture of the globe (without associated iridocyclitis), 
or spontaneous inflammation of one eye can cause sympathetic oph- 
thalmitis, although sympathetic irritation may, no doubt, arise in 
consequence of any of these conditions. Meller has reported some 
cases of sympathetic ophthalmia, the exciting eye having acquired 
inflammation spontaneously, that is, without injury, but in each in- 
stance iridectomy had been performed on the eye originally attacked. 
Whether eyes which are, or have been, the subjects of purulent panoph- 
thalmitis can produce sympathetic inflammation is disputed. This 
relationship has been recorded (Alt,1 Schirmer, Ahlstrom, Zentmayer). 
According to Ruge, even in these eyes the real exciting cause was a 
fibrinoplastic inflammation. 
Sympathetic irritation, according to some authors, should be 
regarded as a functional disturbance-that is, a sympathetic neurosis. 
It presents a series of symptoms, comprising photophobia, lacrimation, 
blepharospasm, defective or impaired accommodation, lessened visual 
acuteness or amblyopia, inability to perform close work, neuralgic pain 
through the distribution of the supra-orbital nerve, tenderness on pres- 
sure over the ciliary region, photopsia, contraction of the field of vision 
(fatigued visual field), and hyperemia of the eye-ground. 
1 It is stated that eyes which are, or have been, the subjects of purulent panophthal- 
mitis do not excite sympathetic ophthalmitis, and generally in suppuration of the cornea 
and its sequels and in panophthalmitis and the phthisis bulbi which it causes, this compli- 
cation is not to be apprehended (Fuchs). Alt, however, in his analysis of more than 100 
cases, found 13 eyes enucleated for sympathetic iridochoroiditis, the other having been 
lost by purulent panophthalmitis. SYMPATHETIC INFLAMMATION 
333 
The tendency of this condition is to recur, and in this sense it may 
last for weeks, or even for months and years. It disappears entirely 
with the removal of the exciting eye or of the exciting cause. Those 
authors who decline to regard this affection as one which should be 
separated from sympathetic inflammation believe that its origin is 
infective,' and that the character of its manifestations is due to a 
small or intermittent dose of the toxin. 
Symptoms in the Eye Exciting Sympathetic Irritation.-An eye so 
injured or diseased that it is liable to produce the condition described 
in the preceding paragraph is liable, during the course of the irritation, 
to attacks of congestion in the ciliary region, photophobia, tenderness 
on pressure, lacrimation, and neuralgic pain. Sympathetic irritation 
may also be induced by minor lesions-for example, retained foreign 
bodies in the conjunctival cul-de-sac. 
Sympathetic inflammation (sympathetic ophthalmitis; infective 
cyclitis, transferred ophthalmitis [Oliver]) occurs in several forms, some- 
times arising in the wake of an attack of irritation, sometimes coexist- 
ing with it, but frequently without any premonition or association of 
this character. It has been stated that marked oscillation of the iris 
often occurs when a sympathetic irritation is about to give place to 
an inflammation. H. S. Gradle believes that marked lymphocytosis is 
present if the injured eye is of such a character that it may produce 
sympathetic ophthalmia. The diagnostic and prognostic value of the 
test is disputed by Neumann and Franke. 
With or without warning, sympathetic ophthalmitis or, as it may 
be called, sympathetic or infective uveitis, because the uveal tract is 
especially involved, presents itself: 
1. As an iridocyclitis (uveitis fibrinosa sympathetica, Schirmer), 
plastic or malignant-i. e., an inflammation characterized by pain, pho- 
tophobia, pericorneal congestion, discoloration of the iris, closure of 
the pupil by exudation around its margin and behind the iris, which is 
plastered to the capsule of the lens, cyclitis, narrowing of the anterior 
chamber, effusion into the vitreous, involvement of the choroid, opacity of 
the lens, detachment of the retina, and finally shrinking of the eyeball. 
According to Schirmer, ophthalmoscopic changes are frequent in the 
early stages of sympathetic uveitis, in the form of a choroidoretinitis, 
the outlines of the papilla being hazy, the retina edematous, and the 
retinal veins dilated and tortuous. 
2. As a serous iritis, more accurately a serous iridocyclitis (Panas), 
or serous iridochoroiditis (de Wecker), or serous sympathetic uveitis 
(Schirmer), causing turbidity of the aqueous, deepening of the anterior 
chamber, punctate opacities on the posterior layer of the cornea, slight 
rise in tension, moderate ciliary injection, opacity in the anterior layers 
of the vitreous, some involvement of the ciliary body and choroid. Not 
infrequently, if not in all the cases, papilloretinitis coexists with the 
uveitis. This process under proper treatment may cease and recovery 
result; but often it may pass into, or be the forerunner of, a malignant 
uveitis, with all its evil consequences. 334 
DISEASES OF CILIARY BODY AND SYMPATHETIC IRRITATION 
3. As a papilloretinitis (sympathetic papilloretinitis, Schirmer), 
which as a coexisting condition in uveitis has been noted. Sometimes, 
however, according to Schirmer, it constitutes the primary affection; 
that is, the uvea is not associated in the inflammation. This neuritis 
is of moderate grade, the disk is not prominent, its borders are veiled 
and surrounded by grayish retinal opacity; the veins are swollen and 
tortuous, and occasionally small hemorrhages are present. 
A choroiditis caused by sympathetic inflammation has been described 
a number of times, notably by Hirschberg, Caspar, Haab, and A. Dalen. 
The lesions somewhat resemble the spots of disseminated choroiditis 
due to syphilis, and appear, especially in the periphery of the eye-ground, 
in the form of small yellowish-red areas, with central pigment dots. 
According to Dalen, the disease is a chorioretinitis, and not a pure 
choroiditis. A peculiar distribution of small yellowish-white flecks or 
nodes, lying behind the retinal vessels, often grouped and without pig- 
mentation, has been described; they probably lie within the choroid. 
Choroiditis in the primarily affected eye has been recorded (Hirschberg, 
Heerfordt). 
4. Other manifestations of sympathetic ophthalmitis have been 
reported, for example, a simple atrophy of the optic nerve, but the exact 
relationship of such a condition to a sympathetic affection has not been 
proved. In this connection reference should be made to the so-called 
sympathetic amblyopia described by Nuel, which, according to this 
author, begins at a much later period than true sympathetic ophthalmia 
-that is, at a period later than one or two months after the traumatic 
iridocyclitis has occurred. At first there is only a vague amblyopia, 
with obscurations; later visual acuteness is much reduced and the field 
of vision contracted, and should the amblyopia attain a decided degree, 
there may be a slight neuritis or pallor of the papillomacular bundle, 
or a perivasculitis. The affection may continue for months or even 
years, with alternate improvements and aggravations. Nuel explains 
it by assuming the presence of a neuritis caused by a hyperplasia of 
the interstitial tissues. Deafness has been observed. 
There is no good evidence to show that cataract, conjunctivitis, 
keratitis, or scleritis are manifestations of that affection to which the 
name "sympathetic" is ordinarily applied. 
A premonitory symptom of great importance, and one which should 
always be searched for in cases in which sympathetic irritation or inflam- 
mation is likely to take place, is an almost characteristic tenderness in 
the ciliary region, frequently in a circumscribed spot, which may be 
picked out with the end of a probe. When this is pressed upon, the 
patient shrinks from the touch in a peculiar and striking manner. 
Sometimes an exactly similar tender spot is found in the ciliary region 
of the exciting eye. Biehler and von Hippel have demonstrated that 
fluorescein will color the endothelium of the cornea in certain uveitic 
inflammations when the superficial layers of the cornea are still intact 
and when ordinary examination fails to reveal these early changes. 
Alberti suggests the use of this test in cases of suspected but not yet SYMPATHETIC INFLAMMATION 
335 
manifest sympathetic inflammation. A. Maitland Ramsay and A. W. 
AI. Sutherland have observed, using Bjerrum's method (see page 81), 
spindle-shaped enlargement of the blind-spot as a sign of active conges- 
tion of the optic disk, and suggest this examination as an important aid 
in determining the onset of trouble passing from an eye with an infected 
injury to the fellow eye. Von Hippel has applied Abderhalden's test in 
cases of sympathetic ophthalmia; in these patients a positive biologic 
reaction to uveal tissue was obtained, but the reaction is not specific 
for sympathetic ophthalmitis. 
In view of the prominence which the metastasis-theory of sympa- 
thetic ophthalmitis has attained in recent times, and to which reference 
is made on page 338, the general symptoms of this condition are of im- 
portance. The presence of meningitis has been suspected, but never 
demonstrated. Severe headache, however, rise of temperature, de- 
lirium, and deafness have been reported, and it is of the utmost 
importance to submit patients who are suffering from sympathetic 
ophthalmitis to the fullest investigation from the general standpoint. 
Romer and the author have urged that the blood of patients with sym- 
pathetic ophthalmia should be carefully examined for micro-organisms. 
Lymphocytosis, as described by Gradle, has been referred to. 
Symptoms in the Eye Exciting Sympathetic Ophthalmitis.-Pre- 
ceding the development of any of the types of sympathetic ophthalmitis, 
the exciting eye usually presents obvious iritis or iridocyclitis, congestion, 
and alteration in the tension; but the local manifestations in the exciting 
eye may not be characterized by pain, and consequently may escape 
attention, and although necessarily the vision is disturbed, the eye 
need not be a blind one. Indeed, there are no phenomena in the exciting 
eye which may be designated as characteristic, and Schweigger was un- 
willing to recognize a clinical picture peculiar to the sympathizing eye. 
The period of incubation, or that period of time between the recep- 
tion of the injury or disease in the exciting eye and the development 
of inflammation in the sympathizing eye, varies considerably, in the 
majority of cases being from three to six weeks. Exceptionally the 
disease begins as early as the fourteenth day and has been postponed as 
late as twenty years, in Alt's collection one case being stated to have 
occurred as late as sixty years after the exciting disease. The maximum 
interval is, however, difficult to state with accuracy. 
Sympathetic irritation may arise within a very few days after the 
reception of an injury. It has occurred within the first forty-eight 
hours. 
Pathology.-In so far as sympathetic irritation is concerned, if this 
is to be considered as a condition distinct from sympathetic inflamma- 
tion, no information in regard to pathologic changes can be given, be- 
cause, to all intents and purposes, they do not exist, or, if they exist, op- 
portunity to detect them has not been afforded. It is usually considered 
to represent a neurosis, and the exciting eye to have conveyed through 
the medium of the ciliary nerves the irritation-phenomena which are 
manifest in the sympathizing eye. It is to be noted, however, that the 336 
DISEASES OF CILIARY BODY AND SYMPATHETIC IRRITATION 
exciting eye, in these circumstances, may present exactly the pathologic 
changes which in other circumstances produce a true ophthalmitis in 
the fellow eye, and, therefore, the belief of many authors that the two 
are identical is not to be disregarded. 
The pathologic anatomy of eyes which produce sympathetic ophthal- 
mitis, that is to say, exciting eyes, has been thoroughly investigated, 
while that of the eyes which have become inflamed as the result of an 
infective cyclitis of the fellow eye, that is, sympathizing eyes, has not 
received much attention, for the simple reason that the opportunities of 
examination are rare. In so far, however, as they have gone, in general 
terms it may be stated that the lesions are identical; in other words, 
the same conditions are present in the exciting and the sympathizing 
eye. 
Schirmer has summarized the lesions in uveitis which produce 
sympathetic ophthalmitis somewhat as follows: All three portions of 
the uvea contain disseminated foci of small round cells, associated with a 
high grade of inflammation, characterized by a diffuse infiltration of the 
entire tissue with similar small cells. After the disappearance of the 
inflammation the uveal structure is destroyed and atrophied, and sub- 
stituted by a pigmented connective tissue poor in vessels. Upon the 
surface of the iris and ciliary body there is a rich fibrinous exudation, 
with a strong tendency to organization, but the choroid fails to exhibit 
a similar exudative process. 
Fuchs' investigations have thrown a new light on the pathologic 
anatomy of sympathetic ophthalmitis. He found in the uvea of exciting 
eyes a dense infiltration of lymphocytes, and in many cases in the 
midst of this infiltration collections of epithelioid cells, often with giant 
Fig. 151.-Traumatic iridocyclitis. Diffuse infiltration of the iris and ciliary body. SYMPATHETIC INFLAMMATION 
337 
cells between them. This infiltration may be present only in certain 
spots in the form of isolated nodules in the iris, ciliary body, or choroid, 
or the uvea may be wholly or at least largely occupied by the process. 
Indeed, the infiltration may make its way into the sclera, which becomes 
permeated with scattered nodules. In so far as the different tissues of 
the eye are concerned and their implication in this process, the iris is the 
least affected, the ciliary body is always involved, and usually the 
choroid is more infiltrated than other portions of the uvea, especially 
in its posterior portion. A fibrinoplastic uveitis not infrequently com- 
plicates this proliferative uveitis of sympathetic inflammation, but Fuchs 
does not regard this as an essential factor in the process, because it may 
be absent in typical cases. Bacteria were not demonstrated in the 
nodules, but Fuchs does not doubt that the affection is produced by 
bacteria, which, instead of causing an acute suppuration, originate a 
chronic proliferation, and this inflammation has the property of being 
transmitted to the second eye through the circulation. 
Fuchs' observations have been confirmed by Lenz, Kitamura, E. V. 
L. Brown, and a number of other observers. Huge, however, denies 
that the anatomic conditions found in an eye exciting sympathetic 
ophthalmitis are characteristic, and while he does not doubt that there 
is a mixed infection in many cases, he holds to Schirmer's view that there 
is a pure sympathetic plastic exudation. Meller concludes that such 
marked specific changes cannot always be found in the exciting eye as 
would justify a diagnosis, but such insufficiency of histologic findings does 
not alter the view that there is in the first eye a specific morbid process 
similar to that by which the ophthalmia of the second eye is produced 
and which is distinctly different from posttraumatic inflammations. 
Now, while it may be too much to say that proliferative uveitis is pathog- 
nomonic of sympathetic ophthalmitis, there seems no doubt, to use the 
language of E. V. L. Brown, that it is the essential anatomic condi- 
tion present in the eye which causes sympathetic inflammation of its 
fellow. 
Pathogenesis of Sympathetic Ophthalmitis.-Formerly it was almost 
universally thought that this disease was due to a reflex action through 
the ciliary nerves, and on this theory the name "sympathetic" was 
applied. The exact nature of this grave malady is not known, although 
the older hypotheses have largely been abandoned for the theory of 
infection. 
According to Deutschmann, the inflammation is a progressive proc- 
ess in the continuity of the tissue of one eye to the other by way of the 
optic nerve apparatus, and is of bacterial origin; hence, a migratory 
ophthalmitis. Deutschmann's researches have, however, not been con- 
firmed (Gifford, Mazza, Randolph, Limbourg, Levy, and Greeff), and 
"the migration theory is still a hypothesis" (Greeff). The ciliary nerve 
theory, in a modified form-i. e., that disturbances of nutrition and in the 
circulation, caused by irritation of the ciliary nerves in the "exciter," 
create the inflammation in the "sympathizer"-has been maintained 
by Schmidt-Rimpler. Romer's investigations, however, have utterly 338 
DISEASES OF CILIARY BODY AND SYMPATHETIC IRRITATION 
set aside the possibility of accepting the ciliary nerve theory in any 
form. Bellarminoff and Selenkowsky believe that all cases of sympa- 
thetic disease may be explained by the action of a toxin which is pro- 
duced by the bacteria which have entered the primarily affected eye, and 
which reach the other eye by means of the lymph and diffusion streams. 
Brown Pusey suggests as an explanation of sympathetic ophthalmitis 
that the cells of the injured eye, probably those of the ciliary body and 
iris, give rise to a cytotoxin, which, having a selective affinity for corre- 
sponding cells in the other eye, there sets up an inflammation. A pre- 
cisely similar theory has been propounded by Golovine. Motais, al- 
though frankly stating that he has no clinical evidence to support him, 
and that as yet no experimental researches are at hand to lend aid to his 
hypothesis, maintains that the anastomoses between the veins of exit 
of the eyes constitute the most probable paths for the transmission of 
sympathetic ophthalmitis; and even so great an authority as Leber 
believes that this view should receive consideration. Romer regards 
sympathetic ophthalmitis as a metastasis, the metastatic infection pro- 
ceeding by way of the blood-streams, and thus brings himself in accord 
with views originally expressed by Berlin. This infection is ascribed 
to some form of micro-organism which is pathogenic for the eye alone 
and does not affect the body generally. The metastasis theory, accord- 
ing to Romer, most satisfactorily explains all of the phenomena of so- 
called sympathetic ophthalmitis, and is entirely consistent with the 
results of modern bacteriologic research. Moreover, it has now received 
confirmation from the anatomic standpoint, especially by Fuchs' re- 
searches. 
The micro-organisms which excite sympathetic ophthalmitis have 
not been isolated; indeed, they have not been seen, and, therefore, it 
may be assumed that they are distributed in invisible form by the intra- 
ocular fluids throughout the eye, and the condition represents, as 
Parsons puts it, a generalized endogenous infection by invisible organ- 
isms. Attempts have been made by Raehlmann with the "ultramicro- 
scope" to detect these bodies, and, according to his report, he has met 
with success. It would seem, however, that his researches require 
considerable confirmation, and Zur Nedden's rod-like bacillus, which 
"seemed to fulfil the conditions demanded of the exciter of sympathetic 
ophthalmia," has not been proved to be the potent agent in this 
respect. 
While the prevailing theory is that in sympathetic ophthalmia the 
infection enters the eye through a wound or other pathway, J. Meller 
has advanced an endogenous theory. According to him some part of the 
body other than the eye is the port of entry for the specific organism 
which has an elective affinity for uveal tissue, and attacks that of the 
diseased eye because its resistance is lowered, the damage having oc- 
curred from a wound or a toxic iridocyclitis. Gradually sympathetic 
inflammation arises, which leads to metastasis to the other eye. E. V. L. 
Brown believes that this theory explains those cases in which in the 
primary eye neither wound nor other opening can be found. SYMPATHETIC INFLAMMATION 
339 
Recently Elschnig has maintained that in the development of 
sympathetic ophthalmia two factors are necessary: anaphylaxis of uvea, 
on account of tissue disintegration, the chief role being taken by the 
pigment, and an anomalous condition of the organism, for example, 
nephritis, diabetes, auto-intoxication, etc. Naturally, this theory of 
the existence of anaphylactic uveitis has met with much opposition, but 
recently has acquired some advocates, for instance, A. Jess, who admits it 
explains certain clinical facts better than the bacterial hypothesis, to wit, 
the period of incubation, and Cramer, who observed a second attack 
of sympathetic ophthalmia coincident with alopecia and whitening of 
the eyebrows. This he believed was an anaphylatic reaction of pigment 
origin. 
Treatment.-The most important consideration is prophylaxis, or, 
in other words, the management of the eye originally affected. This 
depends upon the character and situation of the wound or upon the 
stage of the disease, and upon the amount of vision possessed by the 
injured or diseased organ. 
In the section devoted to Treatment of Wounds of the Sclera (see 
page 293) the method is described by which eyes seriously wounded 
may be saved. Schirmer believes that, the treatment of injured eyes 
should include full doses of mercury, and the author can confirm the 
therapeutic value of this remedy in this respect, as well as the value of 
large doses of salicylate of sodium. 
It may sometimes happen, where every advantage of nursing and 
careful watching is at hand, that eyes may be saved which would be 
sacrificed in other circumstances. The attempt requires the gravest 
thought before it is undertaken, because the onset of sympathetic oph- 
thalmitis may be insidious, and when once begun treatment rarely fully 
removes the structural changes which have taken place. The propriety 
of operating must be determined by regarding the following rules, which 
are modified from those given by Schirmer and Swanzy, and represent 
the published experiences of the best authorities. 
Enucleation, or one of its substitutes, should be performed on- 
1. An eye with a wound so situated as to involve the ciliary region, 
and so extensive as to destroy sight immediately, or to make its ultimate 
destruction by inflammation of the iris and ciliary body reasonably 
certain. 
2. An eye with a wound in this region already complicated by severe 
inflammation of the iris or ciliary body, even if sight is not destroyed; 
or an eye containing a foreign body which judicious efforts have failed 
to extract, and in which severe iritis is present, even if sight is not 
destroyed. 
3. An eye the vision of which has been destroyed by plastic iridocy- 
clitis, or one which has atrophied or shrunken, provided there are tender- 
ness on pressure in the ciliary region and attacks of recurring irritation; 
or without waiting for signs of irritation. 
4. An eye the sight of which has been destroyed, even though sympa- 
thetic inflammation has begun in the sympathizing eye, in the hope of 340 
DISEASES OF CILIARY BODY AND SYMPATHETIC IRRITATION 
removing a source of irritation, and thus rendering treatment to the 
second eye more effectual. 
5. An eye in which the wound has involved the cornea, iris, or ciliary 
region, either with or without injury to the lens, and in which persistent 
sympathetic irritation in the fellow eye has occurred, or in which there 
have been repeated relapses of sympathetic irritation. 
6. An eye either primarily lost by injury or in a state of atrophy, 
associated with signs of sympathetic irritation in the fellow eye. 
It is universally conceded that the enucleation of an eye (^preventive 
enucleation) primarily injured, the visual function of which cannot be 
restored, is the surest way of preventing sympathetic ophthalmitis. 
It is to be remembered, however, that even a very early enucleation does 
not necessarily prevent sympathy in the fellow eye, because the infective 
process may have begun before the operation, and may not develop for 
several weeks. It has occurred fifty-three days after the enucleation 
of an eye injured twenty days prior to its removal (Stephenson), and 
C. B. Welton has collected 28 cases of this character, the shortest inter- 
val between the injury and the enucleation being nine days and the 
longest two months. In place of enucleation, evisceration has been 
practised, but this operation has been followed by sympathetic inflam- 
mation. Resection of the optic nerve (neurectomy) does not provide 
absolute security, but if the patient declines enucleation, it may be used 
as a substitute. 
If sympathetic inflammation has begun, the rules just quoted are not 
applicable, and enucleation must not be performed if there is any vision 
in he exciting eye, which in the end may prove to be the more useful 
organ. The treatment already recommended for iritis and iridocyclitis 
is applicable. 
In the treatment of the sympathetically affected eye operation 
usually has no place. Both iridectomy and sclerotomy have been ad- 
vised, but it is better to await the subsidence of acute symptoms before 
attempting any surgical interference unless the intra-ocular tension is 
inordinately raised, when scleral incision may be practised or iridectomy 
with or without the removal of the lens. 
The general treatment consists in confinement in a darkened room 
(moderate exercise with eyes well protected is permissible in subjects 
failing for lack of it); complete functional rest of the eyes and atropin 
or scopolamin locally, provided there is no rise of tension and no atropin 
irritation; and leeches to the temple if the inflammation is florid. 
Dionin (5 per cent.) should be used. Mercurial inunctions are impor- 
tant, and free diaphoresis, either with pilocarpin or by vapor baths, has 
been advised; in debilitated patients tonics and alteratives are advisable. 
The value of sodium salicylate, advocated by Gifford in the treatment of 
sympathetic ophthalmitis, is great, at least 60 to 100 grains (3.9-6.5 gm.) 
a day should be exhibited, and even larger doses are sometimes well 
borne; but, inasmuch as the treatment must continue for long periods of 
time, the doses must be regulated strictly according to the results 
achieved. Gifford believes that most patients will be able to take daily SYMPATHETIC INFLAMMATION 
341 
1 grain (0.065 gm.) of sodium salicylate for each pound of weight. 
While this drug cannot prevent sympathetic uveitis, its use during trau- 
matic iridocyclitis seems to render the sympathetic affection less virulent 
than otherwise would be the case, and in this respect is the superior 
of mercury. Stock recommends benzosalin in the treatment of sympa- 
thetic ophthalmia, and Gifford has found atoxyl to be useful, and recently 
has advised large doses of atophan, 40 to 60 grains (2.6-3.9 gm.) a day. 
The administration of salvarsan has been tried and favorable results have 
been reported. Bernheimer reports good results in one case from the in- 
jection of tuberculin. Intra-ocular injections of bichlorid of mercury, in 
the opinion of the author, should not be employed, although they have 
been highly endorsed. Subconjunctival injections have been recom- 
mended. The author's experience with them in this disease has not 
been encouraging. G. S. Derby and H. N. Pratt conclude, from their 
own experience and that of Zur Nedden, that the blood-serum of an 
individual with sympathetic ophthalmia may be of curative value when 
injected into another patient with the same disease. Not less than 
1 ounce (30 c.c.) of the serum was used. 
Under such treatment the affected eye will recover with useful 
sight, pass into atrophy or phthisis bulbi, or grow quiet, with the forma- 
tion of complete annular adhesions of the iris to the capsule of the lens, 
which has become cataractous. 
To improve vision under the last-named condition, iridectomy and 
iridotomy have been tried, but the results are usually unfavorable. 
Extraction of the cataractous lens, with iridectomy, also presents serious 
difficulties. For those cases in which a transformation of the iris, lens, 
and capsule into a tough, opaque, and inelastic tissue has occurred, Mr. 
George Critchett practised the following operation: The patient is 
placed under the influence of an anesthetic, a speculum is introduced, 
the globe is fixed, and a fine cutting needle is introduced through the 
cornea, its point being directed to the center of the capsule. This struc- 
ture is penetrated by making a rapid rotary movement, on the principle 
of a gimlet. A second needle is introduced from the opposite side and 
the points separated from each other, the result being a rent in the 
center of the capsule and the escape of the soft lens matter. The opera- 
tion must be repeated at proper intervals until a clear pupil has been 
obtained. It is suited to young eyes, although it may succeed in adults, 
as in one case in the author's practice. Care should be taken to avoid 
wounding the iris. With this operation the author has achieved gratify- 
ing success. 
The prognosis of sympathetic ophthalmitis is essentially grave, 
although Alberti's statistics indicate that it is not as unfavorable 
as in former times, probably owing to modern antiseptic methods, and 
also that its manifestations are not so malignant.. Useful vision may be 
retained, especially after sympathetic choroiditis (E. V. L. Brown). Com- 
plete and permanent recovery may sometimes occur; but the patient can- 
not be considered cured until at least a year has elapsed. Eyes in 
which papillitis is the manifestation of the sympathetic disease, and 342 
DISEASES OF CILIARY BODY AND SYMPATHETIC IRRITATION 
which, according to Schirmer, never begins after removal of the exciting 
eye, are cured by enucleation of the originally injured eye, not imme- 
diately, like sympathetic irritation, but in the course of several weeks. 
More frequently, especially in the forms, which appear as an irido- 
cyclitis or iridochoroiditis, the sight of the eye is lost and the organ 
shrinks. Excepting the cases of pure papillitis, those varieties which 
appear as a serous uveitis, and which retain this character of inflamma- 
tion, afford the most satisfactory prognosis. It is extremely important 
to warn patients of the grave nature of this malady, and if an attempt 
is made to save an eye injured in the manner already described, it must 
be done with the full understanding of the serious risks which are under- 
taken, and the patient must be kept under constant observation. CHAPTER XI 
DISEASES OF THE CHOROID 
Congenital Anomalies.-Two striking congenital anomalies occur 
in connection with the choroid: 
1. Coloboma of the choroid is a large defect in the choroid, almost 
always in its lower part, and often associated with a similar vice of con- 
formation in the iris. 
Examined with the ophthalmoscope the deficient area appears as a 
glistening, pearl-colored patch, often irregular on its surface, owing to the 
development of several protrusions and corresponding intervening de- 
pressions, and bordered by an irregular pigment line. In some cases the 
retina may be recognized as a translucent veil covering the defect, and 
the retinal vessels occasionally pass into the depression; in others the 
retina is absent, and the defect will be represented in the visual field by a 
scotoma. The coloboma may include the optic-nerve entrance, either 
partially or completely, or may be separated from it by a bridge of 
healthy choroid. It may be confined to the area around the disk, or pass 
downward as far as it can be followed, and be connected with a similar 
defect in the iris, from which it is separated by a band of choroid tissue. 
Sometimes several defects are present in the same eye-ground. Imperfect 
closure of the fetal cleft (choroidal fissure) is the usual explanation of this 
condition. Some choroidal defects resembling coloboma apparently 
depend upon an intra-uterine choroiditis. According to E. T. Collins 
and W. Lang, all colobomas of the choroid may be explained by assuming 
that they are due to an abnormal adhesion of the retina to the meso- 
blast, which may take place either before or after the closure of the fetal 
cleft. 
In addition to coloboma in the usual situations, similar defects have 
been described in the macular region {macular coloboma, see Fig. 160) and 
the nasal half of the eye-ground (B. A. Randall and the author), and for 
these defects, which do not involve the optic disk, Lindsay Johnson has 
proposed the name extrapapillary coloboma. Atypical coloboma of the 
choroid may also be situated upward and outward and probably in any 
part of the choroid. It is due to failure in the formation of blood-vessels 
in the inner part of the mesoblast surrounding the secondary optic 
vessel (Collins and Mayou). A striking developmental abnormality is 
one in which the entire choroid except a small area in the region of the 
macula is absent. To this condition the name choroideremia has been 
given. Both eyes are affected; the patients are night-blind (Nettleship). 
2. Albinism, or a congenital want of pigment in the choroid and iris, 
is a deformity met with both in a complete and incomplete form. It 
depends upon a failure of pigment in mesoblastic tissue surrounding the 
343 344 
DISEASES OF THE CHOROID 
secondary optic vesicle and in the outer layers of the secondary optic 
vessel (Collins and Mayou). 
The iris has a pink or pink and yellow appearance, due to the reflec- 
tion of light from its own blood-vessels and from those of the choroid, 
which, in the most pronounced forms of the defect, can be seen with the 
ophthalmoscope down to their finer branches. The anomaly is most 
marked in early childhood, is almost invariably associated with lack of 
pigmentation in the hair, and is accompanied by nystagmus, am- 
blyopia, and high grades of refractive defects. Usually these eyes are 
photophobic. In many instances albinism has been observed in several 
members of the same family, and seems to be hereditary. Semi-albinism, 
Fig. 152.-Congenital defects in the choroid; one large coloboma in the usual situation 
with two smaller areas between it and the disk. 
especially in the periphery of the fundus, is sometimes observed in infants 
and may persist in adult life. 
Hyperemia of the Choroid.-An actual hyperemia could be 
demonstrated only by finding a real distention of the vessels of the cho- 
roid, which usually are invisible, and the congestion of the choroid, de- 
scribed with myopic or asthenopic eyes, and as the result of exposure 
to bright light and heat, is more often a figure of speech than a proved 
pathologic condition. 
In eyes subjected to prolonged strain, the result of uncorrected ame- 
tropia, certain changes in the normal appearance of the fundus arise 
which are usually described under the vague term "choroidal disturb- 
ance." We may, perhaps, assume hyperemia where the nerve-head 
presents distinct redness, which is imperfectly differentiated from the CHOROIDITIS 
345 
unduly flannel-red appearance of the surrounding choroid, or where the 
choroid, instead of exhibiting its usual uniform red color, has changed 
into what has been denominated a "woolly choroid," with faint dark 
areas in the periphery, indicating the interspaces between the choroidal 
vessels, and more or less pronounced retinal striation surrounds the disk. 
This is a familiar picture in many cases of "eye-strain," and where the 
ophthalmoscope reveals, in addition to the other signs already described, 
an appearance as if fine pigmented grains had been scattered over the 
fundus, especially its central regions, the name "miliary choroidoretinitis" 
has been applied to it by Theobald. Similar lesions may follow' exposure 
to great heat and light, and may be seen in the eyes of puddlers, etc. 
Treatment.-In this condition, often associated with the subjective 
symptoms of aching eyes, some intolerance of artificial light and distinct 
asthenopia, the eye should be atropinized, dark glasses should be worn, 
and after the irritable condition of the fundus has sufficiently subsided 
a proper correction of the refractive error should be ordered. Internally, 
small doses of iodid and of bromid of potassium serve a useful purpose. 
Choroiditis.-Under the general term choroiditis are included 
various types of inflammation of the choroid. 
Causes.-Choroiditis, like iritis, may depend upon constitutional 
disorders, infections, toxins, and traumatisms, or upon disease in other 
portions of the eye. Choroiditis is often classified according to the 
probable etiology-for example, syphilitic, tuberculous, traumatic, etc., 
choroiditis. (Compare with pages 301, 302.) 
Symptoms.-Certain symptoms, for the most part revealed only by 
the ophthalmoscope, are present: 
1. Alteration in the uniform dull-red surface of the eye-ground 
caused by (a) the absorption of the pigment epithelium; (6) patches of 
pale-yellow color with ill-defined boundaries due to exudation (recent 
choroiditis); (c) patches of white color due to exposure of the underlying 
sclerotic (atrophic choroiditis); and (d) patches of black pigment, vari- 
ously shaped, scattered over the fundus, and usually bounding the spots 
of atrophy (pigment heaping). 
2. Absence of external manifestations indicative of the deep-seated 
disease, except where acute and purulent forms, in which the diseased 
process is not localized in the choroid, are accompanied by injection, 
chemosis of the conjunctiva, etc. 
3. Changes in the transparent media (lens, vitreous) by the formation 
of opacities, as a secondary result of the choroidal disease. 
Subjective symptoms peculiar to choroiditis do not exist. 
Pain usually is not present except in purulent forms, and in such 
varieties as may be complicated with iritis. 
Disturbance of vision is in direct relation to the situation of the 
lesions and the amount of atrophy. If the choroidal disease is periph- 
eral, visual acuteness may be unaffected; if atrophic patches occupy the 
macular region, sight may be greatly diminished or practically obliter- 
ated. It is remarkable, however, that even in extensive diffuse choroid- 
itis good vision may still be present. If the disease has caused second- 346 
DISEASES OF THE CHOROID 
ary changes in the vitreous or lens, these add to the depreciation of 
visual acuteness. 
Scotomas, both positive and negative, may be present. Contrac- 
tion of the field of vision in certain types of choroiditis, and especially if 
secondary atrophy of the optic nerve has occurred. The displacement 
of the retinal elements overlying the diseased choroidal areas causes 
metamorphopsia; sometimes objects appear smaller than they really are, 
micropsia; sometimes larger, macropsia. In the early stages of choroid- 
itis the patients are much annoyed by subjective symptoms of light- 
i. e., photopsies. 
Diagnosis.-This is readily made by observing with the ophthal- 
moscope the appearances briefly summarized in paragraph 1 of the gen- 
eral symptoms. 
Inasmuch as choroiditis, in the large majority of cases, is compli- 
cated with retinitis, it is difficult to decide whether the pigment lies in 
the choroid or retina. If the pigment mass is covered by a retinal vessel, 
and at the same time is situated in a deeper layer than this, its position is 
judged to be in the choroid; if the retinal vessel is covered by the pigment 
mass, and the latter is situated more anteriorly, its position is assumed 
to be in the inner surface of the retina, to which spot it has wandered 
through secondary involvement of the retina. Pigment characterized 
by a "lace-like pattern," or resembling bone-corpuscles, is always in the 
retina (Nettleship). A commingling of these positions in the same eye- 
ground is common. 
Course, Complications, and Prognosis.-A choroiditis may be sudden 
in onset and pursue an acute course; for example, an acute choroiditis at 
the posterior pole of the eye resulting in a permanent myopia (see also 
page 129) or purulent forms of the disease. 
More commonly the course of choroiditis is slow and chronic. Begin- 
ning with exudation or hemorrhage, it passes by slow stages through the 
period of absorption, atrophy, and pigment accumulation. It is by the 
last signs that a former choroiditis is recognized, and the changes are 
called "old choroiditis" or "choroidoretinitis." 
The following structures are liable to become involved during the 
course of a choroiditis: The retina, which from its intimate association 
with the choroid through the pigment epithelium probably does not es- 
cape in any instance, and in many the association of disease is so close 
that we apply the term choroidoretinitis or retinochoroiditis; the optic 
nerve (choroiditic atrophy); the vitreous (vitreous opacities); the crystal- 
line lens (posterior polar cataract)-, the iris (iridochoroiditis); and the 
sclerotic (scleroticochoroiditis). 
The prognosis in choroiditis is always grave, and although careful 
treatment may preserve sight, in many instances great depreciation of 
vision and even blindness may ensue. Necessarily the prognosis as to 
vision depends upon the position of the disease and its relation to the 
macula. 
Pathologic Anatomy.-In non-purulent forms of choroiditis collec- 
tions of round cells are gathered in the choroid, especially along the ves- DEEP CHOROIDITIS 
347 
seis between this membrane and the retina, and hemorrhagic extravasa- 
tions may be seen. Organization of this round-cell exudation causes 
atrophy of corresponding portions of both choroid and retina, union of 
the two membranes, disappearance of the pigment layer of the retina 
except at the edges of the lesions, where it is proliferated, and wandering 
of the pigment cells into the retina along the lines of the vessels. In 
purulent choroiditis there is a dense cellular infiltration of the choroid, 
rapid involvement of retina and vitreous, panophthalmitis, and subse- 
quent phthisis bulbi. 
As already stated, choroiditis may be acute or chronic, and at one 
time was classified, according to the pathologic conditions, into plastic, 
serous, and purulent forms. 
For the present purpose choroiditis may be divided into superficial 
and deep choroiditis, and a well-recognized classification may be adopted 
which places all forms under one of two heads: (1) Nonsuppurative 
exudative choroiditis and (2) suppurative choroiditis and iridochoroiditis. 
Treatment.-This, in general terms, demands perfect rest for the 
affected eye, protection from glaring light, and the administration of 
remedies indicated by the cause of the choroiditis. Further details will 
be reserved for the sections devoted to the several varieties of choroiditis. 
Superficial Choroiditis (Epithelial Choroiditis).-Instead of the 
general dull-red appearance of the eye-ground, the larger vessels may 
be manifest as rather broad, reddish, or yellowish-red stripes, which 
traverse the fundus in an interlacing manner, and between which are the 
dark intervascular spaces, many of them having a lozenge-shaped appear- 
ance. This is due to the absorption of the pigment epithelium and the 
capillary layer which lies just beneath it. 
In certain instances it is physiologic, and is commonly seen in the 
periphery of eye-grounds, often by preference occupying a space down 
and in from the disk. 
It may be universal, the only portion of the eye-ground escaping 
being the region directly confined to the macula, and it then presents 
a striking picture to the ophthalmoscope. The larger vessels of the 
choroid-stroma pass in a sinuous manner across the eye-ground, bringing 
out into distinct relief the pigmented connective-tissue cells of the 
choroid proper which lie between them (consult Fig. 161, page 356). 
The atrophy is superficial and of itself does not disturb vision. Such 
appearances are seen in myopia; in "stretching eyes," when hyperopic 
refraction is diminishing or passing into myopic refraction; in glaucoma; 
and sometimes are associated with retinal disease-for example, pig- 
mentary degeneration. 
Deep Choroiditis.-1. Diffuse Exudative Choroiditis.-This occurs 
in an acute and in a chronic form-i. e., the chronic form represents the 
ophthalmoscopic appearances commonly observed after subsidence of 
the acute process. 
In the early stages of acute choroiditis the diseased areas are repre- 
sented by yellowish-white, sometimes greenish-gray, exudations, which 
may be diffuse, circumscribed, or disseminated, and which shade gradu- 348 
DISEASES OF THE CHOROID 
ally into the surrounding eye-ground, or which may be fringed with 
pigment, small eroded areas, and hemorrhages. 
Fig. 153.-Acute choroiditis with wide-spread, fog-like exudations. 
Later these areas of exudation undergo absorption and metamorpho- 
sis, and some of the following conditions are present, which may be 
named chronic choroiditis: In- 
stead of the normal red of the 
eye-ground the ophthalmoscope 
reveals white or yellowish-white 
plaques, sometimes separated 
by partly normal choroid, more 
often running into one another 
until a huge expanse of exposed 
sclera is visible throughout the 
fundus. 
The white patches appear 
speckled because numerous pig- 
ment masses of black color are 
collected upon them, irregular 
in form, sometimes gathered in 
lumps, sometimes assuming vari- 
ously shaped groups. They lie 
beneath the retinal vessels for 
the most part, although usually 
pigment will be found collected upon these retinal vessels showing the 
participation of the retina in the process (choroidoretinitis, Fig. 154). 
Fig. 154.-Diffuse exudative choroiditis with 
choroidoretinitis (E. von Jaeger). DEEP CHOROIDITIS 
349 
In other patches the atrophy has not been sufficient to expose the 
glistening white sclera, and there will be found the lesions of super- 
ficial choroiditis, namely, band-like, orange-yellow, or light red vessels, 
freely anastomosing with each other, and, between them, the pigmented 
epithelium. In still other spots yellowish exudations are evident, which 
represent the earlier stages of the process already described. In these 
circumstances all the stages from yellowish extravasation to complete 
atrophy are visible. 
2. Disseminated Choroiditis.-Another form which may be looked 
upon, according to a classification adopted by some authors, as the cir- 
cumscribed variety of the type just described, is that which is known as 
disseminated choroiditis. 
In this type, usually beginning in the periphery, but gradually 
approaching the center of the eye-ground, numerous round or oval 
spots surrounded by black margins are found. The white center of the 
spot is the exposed sclera; the black margin, the altered pigment. 
Instead of a white center there 
may be a single black mass, 
in its turn encircled by a yel- 
lowish ring. Where the spots 
assume a punched-out look, as 
if a sharp instrument had cut 
out the tissue down to the 
sclera, the margins of the inci- 
sion being bordered with pig- 
ment, the appearances are char- 
acteristic. 
These spots of disseminated 
choroiditis vary greatly in num- 
ber. There may be only one or 
two, or the eye-ground may be 
dotted over with them. Be- 
tween the spots the choroidal 
tissue is comparatively healthy. 
The earlier stages of such spots 
consist in small, yellowish or greenish-gray exudations, which gradually 
absorb, leaving the atrophic marks which have just been described 
(Fig. 155). 
Vitreous opacities are often present, either faint and floating, or 
large, string-like, and membranous. There may also be cataract at the 
posterior pole of the lens. 
The optic nerve may become affected in the later stages of deep 
choroiditis and undergo a species of atrophy to which the name choroiditic 
atrophy has been applied. The edges of the disk are slightly hazy, the 
color a reddish yellow, and there is contraction of the retinal vessels. 
Disseminated and other forms of choroiditis are often associated with 
secondary pigmentation of the retina, and the pigment patches not uncom- 
monly resemble those seen in pigmentary degeneration of the retina. 
Fig. 155.-Disseminated choroiditis 
(de Wecker). 350 
DISEASES OF THE CHOROID 
These pigmentations are especially noteworthy in forms of disseminated 
choroiditis due to syphilis. 
3. Circumscribed Plastic Choroiditis (Localized Exudative Choroiditis; 
Choroiditis with Descemetitis').-Areas of choroiditis are not infrequently 
encountered in young persons and young adults-that is, from fifteen 
to thirty years of age-which ophthalmoscopically do not differ mate- 
rially from those types already described, except in their circumscribed 
character. Usually there is a large, bluish-white patch of effusion, gen- 
erally denser in its center and thinning off at its margin into the healthy 
fundus. The diseased area may be close to the disk (Hill Griffith), near 
or at the macula, or in the periphery (Friedenwald). The early exuda- 
tive stage is followed by erosion and atrophy, but the course is compara- 
Fig. 156.-Disseminated choroiditis and optic neuritis with retinal hemorrhages 
in a syphilitic patient in the Orthopedic Hospital. The choroiditis is of long standing, 
the neuroretinal lesions a fresh implantation. 
tively benign, and, unless the macular region is involved, there is no 
distinct depreciation of central vision. Not uncommonly keratitis 
punctata (descemetitis) and vitreous opacities accompany the condi- 
tion (see also page 325). Not infrequently rise of intra-ocular tension 
may be present and an attack of acute glaucoma may be precipitated, 
especially if a mydriatic is employed. 
Plastic choroiditis near the disk may give rise to an appearance 
similar to that of optic neuritis. One variety described by Jansen has 
been named by him retinochoroiditis juxta papillaris; its position is 
interpreted in the visual field by a scotoma which joins the blind-spot. DEEP CHOROIDITIS 
351 
4. Anterior Choroiditis.-To this condition reference has been made 
in the description of parenchymatous keratitis (see page 269). The 
lesions are situated far in the periphery, and may exist as a special form 
of disease, or result from an extension backward of affections of the iris 
and ciliary body. 
Causes.-The cause of deep choroiditis, either diffuse or dissemi- 
nated, is acquired syphilis in a great number of cases, and the disease 
appears from six months to two years after the initial infection. Some- 
times it is postponed to a much later period (tertiary period). Opacities 
in the vitreous are common in syphilitic choroiditis. Although certain 
choroidal lesions have been looked upon as especially characteristic of 
syphilis, it is not safe to attempt to make a diagnosis of syphilis simply 
by the appearances of any of the varieties of choroiditis. Diffuse 
syphilitic choroiditis depends upon a filtration of the toxin of syphilis, or 
perhaps a dissemination of its active agent (Spirochaeta pallida) through- 
out the tissue of the choroid. If the deposit of the toxin remains local- 
ized the circumscribed varieties of the affection arise. Disseminated 
choroiditis, choroidoretinitis, and secondary pigment degeneration of 
the retina are seen in children the subjects of hereditary syphilis. Cho- 
roiditis due to acquired syphilis usually affects both eyes. The Wasser- 
mann test should be applied to all cases of choroiditis. 
A disseminated choroiditis (hereditary choroiditis') affecting both 
eyes is occasionally encountered as a family disease independently of 
syphilis and associated with disorders of the central nervous system 
(Hutchinson), and familial chorioretinitis has been observed. Patches of 
choroiditis are found in the eyes of children born with cataract. 
A choroiditis quite indistinguishable from the forms described may 
result from an injury (traumatic choroiditis). As the result of concussion 
injuries of the globe pigmented choroiditis may arise in the form of 
scattered areas of variously shaped pigment masses, usually of small 
size, sometimes granular, interspersed with small erosions and spots of 
atrophy. 
Many cases of choroiditis, especially of the disseminated variety, as 
well as of the diffuse and localized exudative manifestations, are due 
to tuberculosis (tuberculous choroiditis). This etiologic factor can be 
demonstrated by tuberculin injections, which are followed by local reac- 
tion. 
Choroiditis has also been ascribed to disturbances of nutrition, 
metabolic disorders, nephritis (albuminuric choroiditis), diseases of the 
liver (ophthalmia hepatica), anemia, chlorosis, acute infectious diseases, 
and to infections arising from the nasopharynx, accessory sinuses, and 
the teeth (pyorrhoea alveolaris). In acute plastic choroiditis the follow- 
ing etiologic factors have been reported: acute tonsillitis, oral sepsis, 
intestinal toxemia, auto-intoxication, typhoid fever and other infectious 
fevers, and pneumonia. Gradle suggests that the infecting material 
from the accessory sinus or other focus of infection may gain access to 
this region through the posterior ciliary vessels. (For additional causes, 
see page 324.) 352 
DISEASES OF THE CHOROID 
The prognosis is always grave if the process is an extended one and 
the macula involved; it is best in the syphilitic cases and in some forms 
of acute plastic choroiditis, in which the results of treatment are most 
satisfactory. 
Treatment.-This depends upon the cause. If it is syphilis, inunc- 
tions of mercurial ointment should be prescribed, to be followed by iodid 
of potassium, or the mercury may be given by the mouth in the form of 
the protiodid, or by the hypodermic method. Later, a prolonged course 
of bichlorid of mercury combined with tincture of iron is advisable. 
Saharsan and neosalvarsan in the later states of choroiditis have not 
seemed to the author to be of much value; in acute forms their action is 
more satisfactory (compare page 310). Subconjunctival injections have 
been recommended. They may be composed of bichlorid of mercury 
(1 :2000-4000), cyanid of mercury (1 :5000), or physiologic salt solution. 
Pilocarpin sweats may be tried, and in non-syphilitic cases their effect 
is sometimes strikingly favorable; in old cases strychnin and the galvanic 
current have been advised. If tuberculosis is the suspected or definitely 
established cause, tuberculin should be administered (see page 318). 
Certain cases of intra-ocular tuberculosis (choroiditis'), especially charac- 
terized by chronicity of the lesions, are distinctly amenable to this 
treatment. AH close work must be forbidden; the eyes should be pro- 
tected with dark glasses. Should a mydriatic be employed in the treat- 
ment of acute choroiditis, its effect on the intra-ocular tension must be 
carefully watched and frequent tonometric tests are advisable. Dionin 
is of service; also subconjunctival injections. Naturally, general 
medication should be governed by the probable etiologic factors, and 
what has been written on page 328 applies to the disease now under 
discussion, and in acute choroiditis, especially of the circumscribed 
variety, great care should be exercised in a search for focal infection, 
particularly in the buccal mucous membrane. 
Central choroiditis is the name applied to choroiditis confined 
to the region of the macula; its manifestations are numerous. 
There may be an irregular patch of exudation, semi- or completely 
atrophic, and bounded by pigment. This is recognized objectively by 
the ophthalmoscope, and subjectively by a scotoma in the field of vision. 
Occasionally the area consists of an epithelial atrophy, either with a well- 
marked border, somewhat irregular in outline, or with a border less 
sharply marked, and with pigment distributed over the surface of the 
defect. Sometimes the lesions consist of areas of yellowish exudation, 
interspersed with small round and linear pigment masses and dot-like 
hemorrhages. Kipp calls especial attention to hemorrhagic central 
retinochoroiditis in non-myopic eyes, characterized by an oval or round 
area, surrounded by hemorrhage. 
Again, the macula may be occupied or surrounded by a large white 
patch, the rest of the eye-ground being normal. Occasionally the area 
is entirely circular and the deep vessels exposed, or they may be atrophied 
and converted into white lines (sclerosis of the choroidal vessels). Pigment 
is usually absent. To these types of choroidal change the same senile CENTRAL CHOROIDITIS 
353 
areolar atrophy of the choroid is usually applied. Extensive sclerosis 
of the choroidal vessels, which are apparently converted into white lines, 
with some pigmentation in the periphery of the eye-ground, but with 
normal disks and retinal vessels, has been reported as a family disease, 
that is, it may occur in several members of the same family. A form of 
choroiditis especially described by Forster is known as choroiditis areolata, 
and affects the region of the disk and the macula. The spots are numer- 
ous, but larger than those in disseminated choroiditis. Their centers 
may be white, and are usually black rimmed and sometimes undermined. 
Occasionally the macula is covered with a greenish or grayish plastic exu- 
date, of various shapes, often surrounded by a rim of hemorrhage and 
later by a zone of erosion or atrophy-probably a late stage of plastic 
choroiditis (see page 350). 
Fig. 157.-Central atrophic choroiditis; on the temporal side of the disk there is a 
semi-atrophic area-the so-called conus (from a patient in the Philadelphia General 
Hospital). 
In the same region there is observed another variety of the disease, 
first described by Tay and Hutchinson as central senile guttate choroiditis, 
marked by the appearance of numerous white, glistening dots, somewhat 
resembling the earlier stages of albuminuric retinitis (Nettleship) and 
always symmetric, though sometimes an interval of time elapses before 
the implication of the second eye. The white spots are due to colloid 
degeneration and calcareous formations in the choroid, and are asso- 
ciated with secondary involvement of the retina. Occasionally the 
macular region contains an oval or circular patch of dense grayish-white 
or yellowish-white tissue, which lies beneath the retina and seems to be 
in the choroid, and which, according to Nettleship, belongs to this group 
of central senile choroidoretinitis. Usually there are contraction of the 
field of vision and negative scotoma. Large areas of colloid change may 354 
DISEASES OF THE CHOROID 
also occur without disturbance of vision (verrucosities of the choroid), 
Fig. 158. 
It is important, if possible, to recognize all forms of central choroiditis 
before a cataract operation is performed. They may be suspected if 
there is imperfect central fixation for light, but really can be positively 
determined only while the cataract is still incipient and the ophthal- 
moscopic examination is possible. 
Causes.-Central choroiditis of inflammatory type may be caused 
by syphilis and also by blows upon the eye. Chronic atrophic choroiditis 
in this region is seen in myopia, and Gould has described macular cho- 
roiditis as the result of uncorrected ametropia and insufficiency of the 
internal recti muscles, even in non-stretching eyes (ametropic choroiditis). 
Nettleship believes that central senile choroidoretinitis, in its various 
manifestations, depends chiefly upon disease of the posterior ciliary 
arteries, either the trunks themselves or the branches which perforate 
Fig. 158.-Colloid change in the macular region. 
the sclerotic near the optic nerve, and that any affection of the retina 
itself is secondary. 
Treatment.-In the syphilitic variety the usual remedies are indi- 
cated. In types connected with refractive error the best possible cor- 
rection should be given and absolute eye-rest enjoined. In the senile 
varieties, both the ordinary and the guttate types, treatment appears 
to have no influence. 
Unclassified Forms of Choroiditis.-Besides the diseases of the 
choroid which have been described others appear which cannot be def- 
initely classified: 
Large patches of atrophy not located in special portions of the 
choroid, resulting probably from the absorption of former hemorrhages, 
or, perhaps, tuberculous areas; hemorrhagic choroiditis occurring, as 
pointed out by Hutchinson, especially in young men, and resulting in 
numerous spots of atrophy which are not readily distinguished from those UNCLASSIFIED FORMS OF CHOROIDITIS 
355 
of the syphilitic variety; yellowish or other spots of choroidal disease, 
which have been attributed to the action of intense light or the glare 
Fig. 159.-Central cone-shaped lesion in choroid, surrounded by lines of edema (patient 
in the University Hospital). 
Fig. 160.-Macular coloboma (compare with Fig. 157). 
of heat; slight macular changes in the form of small yellowish or maroon- 
colored spots, sometimes with a few scattered pigment granules in the 
immediate vicinity of the fovea, which do not affect vision and are 356 
DISEASES OF THE CHOROID 
unnoted by the patient. These have been attributed by some authors 
to the influence of abnormal refraction, but are sometimes seen in associ- 
ation with transient albuminuria, and probably represent small spots 
of degeneration due to vascular disease, perhaps of the short posterior 
ciliary arteries which supply the region of the macula. 
Myopic Choroiditis.-Atrophy of the choroid, commonly of a 
local character, occurs in severe or, as it has sometimes been called, 
malignant myopia, and is observed either in connection with or sur- 
rounding the nerve-head. It is caused by the elongation which occurs 
at the posterior pole of the eye, and receives the name posterior staphy- 
loma; if the disk is entirely sur- 
rounded by the area of atrophy 
the name annular posterior 
staphyloma or circumpapillary 
atrophy is suitable (Fig. 161). 
The term scleroticochoroid- 
itis posterior is also applied 
to this variety of choroidal 
change, just as anterior sclerot- 
icochoroiditis is the name given 
to the inflammatory affection 
which attacks circumscribed 
portions of the anterior part 
of the choroid, with corre- 
sponding portions of the scle- 
rotic, and which, in aggravated 
instances, may give rise to 
staphylomatous bulging and 
gradual loss of vision by opac- 
ity of the vitreous and cornea 
(see page 291). Hirschberg 
objects to the term "myopic 
choroiditis," as he believes the lesions are mechanical and not inflam- 
matory in origin. 
Semi-atrophic and atrophic crescents (often inaccurately called "conus") 
also appear at the outer margin of the disk in astigmatic eyes, and in 
eyes undergoing change owing to the distention of their coats from too 
close work aggravated by imperfectly or improperly corrected errors of 
refraction. In hyperopic and emmetropic eyes narrow white crescents, 
usually at the temporal side of the disk, are often evident. These are the 
so-called scleral crescents. 
In the macular region in myopia there may be very decided semi- 
atrophic or atrophic patches having the general characteristics of the 
spots already described, and greatly interfering with vision. The proc- 
ess begins in the form of small rents which gradually coalesce into an 
atrophic patch. In like manner this area may be involved by a hemor- 
rhage in progressive myopia, which after absorption leaves impaired 
vision, owing to the damage of the overlying retina. The vessels of the 
Fig. 161.-Myopic choroiditis. The cut 
illustrates posterior staphyloma-the white 
area surrounding the nerve: atrophic choroiditis 
in the macula-the white patch bordered by pig- 
ment in the central part; and general exposure of 
the choroidal vessels by absorption of the retinal 
pigment epithelium. SUPPURATIVE CHOROIDITIS AND IRIDOCHOROIDITIS 
357 
choroid are exposed by maceration and absorption of the retinal pig- 
ment epithelium, causing the appearance described under superficial 
choroiditis (see Fig. 161, and also page 347.) 
Suppurative Choroiditis and Iridochoroiditis.-Acute iritis 
occasionally becomes complicated with inflammation of the choroid 
(see page 305), and a chronic type of iridochoroiditis, which tends to loss 
of vision and shrinking of the eyeball, has been described (see pages 315 
and 326). 
The present disease, however, is distinguished by a suppurative 
process between the retina and choroid, which extends into the vitreous 
and spreads into the entire uveal tract. 
Symptoms.-There are edema of the lids, chemosis of the conjunctiva, 
haziness of the cornea, inflammation of the iris and ciliary body, and, it 
may be, hypopyon. If there is sufficient transparency of the media, 
a mass of exudation may be seen behind the lens in the vitreous, giving 
rise to a yellowish reflection when viewed by transmitted light {pseudo- 
glioma, destructive ophthalmitis; see also page 414). At first the tension 
may be raised and the anterior chamber is shallow; later the tension is 
lowered. 
In addition to these objective symptoms there are severe brow-pain, 
tenderness of the globe, loss of vision, and constitutional symptoms, as 
chill and fever. 
The ultimate result depends upon whether the disease remains local- 
ized in the uveal tract and vitreous, or spreads to all the tissues of the 
eyeball. In the former case the inflammatory symptoms subside, the 
pain lessens, the intra-ocular tension is lowered, and the eyeball gradu- 
ally shrinks. 
In the latter case the inflammation spreads, the edema of the lids 
and chemosis of the conjunctiva are intense, the pain severe, and the 
constitutional symptoms-fever, chills, nausea, and vomiting-are very 
marked. The inflammation involves Tenon's capsule and causes pro- 
trusion of the globe, which is pressed against the swollen lids until these 
can scarcely be separated on account of the swelling and edema. Finally, 
rupture of the sclera or sloughing of the cornea occurs, the purulent mat- 
ter finds a vent, the pain subsides, and in about six weeks the ball is soft, 
sightless, shrunken, and free from pain. The second outcome of purulent 
choroiditis is known as panophthalmitis, and the ultimate result is 
phthisis bulbi. 
Causes.-Suppurative choroiditis, or iridochoroiditis, may be caused 
by the introduction of pathogenic microbes in the same manner as in 
purulent cyclitis-that is, the infection comes from the outside. It is, in 
short, an exogenous infection. In these circumstances it may arise 
as the result of perforating wounds and injuries; operative wounds which 
have become infected-for example, cataract extraction, sloughing ulcers 
and abscesses of the cornea, and prolapse of the iris and thinned cystoid 
corneal cicatrices, those, for example, which are created by corneo- 
scleral trephining, a diminutive aperture having formed, permitting the 
entrance of micro-organisms. 358 
DISEASES OF THE CHOROID 
Suppurative choroiditis may also be caused by embolism from a 
microbic area, and produces the condition which is known as metastatic 
ophthalmitis. From the etiologic standpoint, following Axenfeld's classi- 
fication, metastatic ophthalmitis may result from puerperal pyemia, 
which is its most frequent cause; from surgical pyemia, which in- 
cludes all cases which arise from injury, operations, and local puru- 
lent areas,' even where the last-named conditions are non-traumatic, 
but have an internal origin, and have their situation in the mucous 
membrane of the digestive, pulmonary, and urinary organs (Groenouw); 
from cryptogenetic septicopyemia, that is, the point of entrance of the 
infection has not definitely been determined, and, finally, from in- 
fectious diseases, particularly pneumonia, influenza, measles, scarlet 
fever, diphtheria, and small-pox. The disease may also result from 
cerebrospinal meningitis, basic meningitis, dysentery, bronchitis, 
whooping-cough, inflammation of the umbilical vein, and thrombosis 
of the orbital veins. It may be bilateral or unilateral, and the puerperal 
cases usually develop during the first two weeks of the disease, but may 
be detained until the seventh week. Ulcerative endocarditis is a fre- 
quent complicating factor. 
Pathology.-Examination of eyes in which suppurative choroiditis 
has occurred shows the presence of a thick purulent infiltration of the 
choroid, involvement of the overlying retina, and sometimes conversion 
of the entire vitreous into a purulent material. In the metastatic vari- 
ety of the affection the septic masses enter into the capillaries of the eye. 
Sometimes the retina is exclusively or, at least, first affected, later the 
uveal tract is also involved. 
Fuchs' investigations of the anatomic changes in inflammation of 
the choroid and those which result from infection of the vitreous indi- 
cate that the inflammation spreads to the inner lining of the vitreous, 
especially to the pars ciliaris retinae and to the retina itself. Purulent 
retinitis results, and the choroid is seriously involved where the inflamed 
retina remains in contact with it. To this process he gives the name 
endophthalmitis septica. 
Streptococci, staphylococci, and sometimes Frankel-Weichselbaum 
pneumococci have been found, and in many cases of panophthalmitis not 
necessarily metastatic in origin special bacilli are present, some of which 
have been determined to have pathogenic significance. This is particu- 
larly true after injuries of the eye, and in a number of instances those 
organisms have been found to which Haab has given the name pan- 
ophthalmitis bacilli, and which belong to the group of the "hay bacilli." 
Prognosis.-This is most unfavorable, and almost invariably a 
shrunken eyeball is the result of the inflammation. A few cases of re- 
covery from suppurative iridochoroiditis following cerebrospinal men- 
ingitis have been recorded. The termination of destructive ophthal- 
mitis in children is usually not fatal, but a few deaths have occurred, 
generally from meningitis (see also page 414). In bilateral cases of 
puerperal metastatic ophthalmitis the mortality is exceedingly high, only 
a few authentic cases of recovery being on record. TUMORS OF THE CHOROID 
359 
Treatment.-In the early stages antiphlogistic treatment may be 
of service in robust cases-blood-letting from the temple, a sedative fever 
mixture, with sufficient morphin to relieve pain, and locally, frequently 
changed ice compresses. In later stages hot fomentations are better, a 
square of lint soaked in heated bichlorid solution being applied to the 
eye;, and internally, opium and quinin in full doses are indicated. If 
there is much pain before spontaneous rupture has occurred, a free in- 
cision into the sclerotic will bring relief. The methods of treatment to 
prevent the spread of septic processes after injury have been described on 
page 296. 
Surgeons differ in regard to the advisability of enucleating the globe 
during the acute stages of panophthalmitis, some operators declining to 
perform excision in such circumstances, in the belief that meningitis is 
liable to follow, while others do not recognize this danger. 
Fig. 162.-Leukosarcoma of choroid, showing at (a) constriction which marks where 
choroidal capsule was ruptured and where retina became adherent, being pushed forward 
with growth of upper part of tumor (6), which assumes a mushroom shape. At (c) cho- 
roidal origin of growth is seen. 
The author does not hesitate to enucleate an eyeball in which there 
is suppuration if the surrounding orbital tissues are not yet involved 
in the process; but agrees with Pooley that where the process has reached 
a great height, where there is purulent infiltration of the orbital tissues, 
and where the affection has begun posteriorly, as in some varieties of 
septic iridochoroiditis, the operation of enucleation is surrounded by 
dangers. In a certain number of cases it has been followed by menin- 
gitis. Therefore under these conditions evisceration is preferred. But 
even after evisceration there may be a great accumulation of inflamma- 
tory products behind the scleral cup, and to these a vent must be given. 
Tumors of the Choroid.-The most frequent neoplasm of the 
uveal tract and, for the present purposes of description, of the choroid 
is sarcoma. Most commonly it appears as a pigmented growth (melano- 
sarcoma); more rarely (1 in 8, according to W. C. Rockliffe) without 
pigment (leukosarcoma). 
Sarcoma of the choroid, according to E. Pawel, is most frequent 
between the ages of fifty and sixty. A good many cases, however, occur 360 
DISEASES OF THE CHOROID 
at an earlier period than this, but the disease is rare under the twentieth 
year. Men are more frequently affected than women, and the left eye, 
according to some statistics, is more apt to be involved than its fellow. 
Pathology.-The growth usually is circumscribed, and has a spheroid 
form as long as the choroidal capsule remains unbroken: Sometimes it 
assumes a cake-like shape, and occasionally the form of a mushroom. 
Rarely, there is diffuse sarcomatous infiltration of the choroid. 
Sarcoma of the choroid is al- 
most invariably a primary growth; 
but the choroidal coat may be, 
Fig. 163.-Macroscopic appearance of 
a pigmented choroidal sarcoma-flattened 
growth or so-called cake-like form. One 
extrascleral nodule. 
Fig. 164.-1, Pigmented flat sarcoma; 
2, cyst of retina; 3, detachment of retina 
in portion of eye opposite to position of 
tumor. 
though very rarely, affected by a metastasis occurring from a tumor 
in some other portion of the body-for example, the mediastinum 
(A. V. Meigs and the author). 
The tumor develops from the outer layers of the choroid, and grows 
inward, detaching the retina. The cells are round or spindle formed, or 
occasionally of a large endothelioid type, provided they develop from the 
endothelial linings of the lymph-spaces. They are usually pigmented, 
the density of the pigmentation depending upon the participation of the 
choroidal stroma cells in the proliferative process. Usually there are 
many broad vessels around which the cells may be grouped. Intra- 
ocular sarcomas may undergo necrosis owing to the death of groups of 
cells at a distance from blood-vessels from insufficient oxygenation. 
Toxins are liberated which devitalize the surrounding cells (Fuchs). 
In the second stage secondary glaucoma occurs, and occasionally plastic 
iridocyclitis appears and results in atrophy of the globe. A tumor may 
grow in a phthisical eye, and, as Leber has pointed out, an eye which is 
the seat of a growth may become phthisical and the tumor itself cease 
to grow for a time. Coppez divides the primary new growths of the 
choroid into-(1) Interfascicular endotheliomas which develop from the TUMORS OF THE CHOROID 
361 
endothelial cells of the lymph-spaces; (2) peritheliomas (angiosarcomas) 
which arise from the perithelial cells of the blood-vessels; (3) sarcomas 
of various characters which grow from the proper cells of the choroid 
and the adventitia of the blood-vessels. Alveolar sarcomas, also called 
endotheliomas or intravascular angiosarcomas, are rare as compared 
with perivascular sarcomas of the choroid. It is probable that in these 
alveolar types the greater mass of the tumor is formed by the proliferation 
of endothelial cells. 
Diffuse sarcomas of the choroid are classified by Parsons into two 
subgroups-flat sarcomas and ring sarcomas. They are characterized by 
an infiltrating tendency, as opposed to the formation of a definite tumor. 
They exhibit large round or polygonal cells, alveolar or plexiform ar- 
rangement, hyaline and myxomatous degeneration, and extension along 
the perivascular lymph-spaces. According to Parsons, they should be 
Fig. 165.-Pigmented sarcoma at a; retina 
detached and folded. 
Fig. 166.-Leukosarcoma at a; retina de- 
tached. 
considered as endotheliomas, and they spring from the lining cells and 
proliferate in the spaces which they line. The onset of glaucoma is early 
in diffuse sarcoma. 
Parsons has also called attention to certain anomalous sarcomas of 
the choroid which bear a microscopic similarity to organizing blood-clot 
and are of comparatively low malignancy. According to him, if they are 
not excised, they shrink, and represent the tumors before referred to 
which have been found in phthisical eyes. Destructive hemorrhage may 
occur in choroidal sarcomas, as has been specially pointed out by Verhoeff. 
Hemorrhages of this character may be responsible for the sudden attacks 
of glaucoma which are often seen in choroidal sarcoma. Occasionally 
sarcomas of the choroid may take their origin in melanomas, just as they 
do in the iris and ciliary body. A good example of such an origin has 
been reported by the author and E. A. Shumway. The smallest sar- 362 
DISEASES OF THE CHOROID 
comas on record have been described by Fuchs (in one instance the 
growth being between 0.7 and 0.8 mm. in the horizontal and vertical 
diameters), and Shumway and the author have also observed a very 
small sarcoma of the choroid (4.4 mm. in the anteroposterior diameter 
and 0.9 mm. in thickness). 
Symptoms.-The life history of a sarcoma of the choroid has been 
divided by systematic writers into four periods: The first, the quiet 
period; the second, the inflammatory period; the third, the extra-ocular 
period, or that stage when the growth bursts through the scleral bound- 
ary; and fourth, the period of metastasis. 
In the first stage the disease resembles a detachment of the retina, 
this membrane being pushed forward by the underlying elevation, the 
whole being surrounded by a serous effusion. Beneath this retinal 
covering the browmish mass may sometimes be recognized, covered by 
irregular choroidal vessels, except in the non-pigmented varieties. If 
the growth is situated far forward, it is sometimes possible to examine 
it by means of oblique illumination through a dilated pupil. There is a 
corresponding defect in the field of vision, and the sight of the affected 
eye is diminished in accordance with the situation of the tumor. Should 
this be peripheral, the central vision at this stage may not be seriously 
affected. The first stage usually lasts from six to twelve months, but 
rarely may be prolonged to five years. Occasionally sarcoma of the 
choroid produces symptoms resembling tenonitis (Kipp and the 
author). 
In the next period of the history of this growth, or the inflammatory 
or glaucomatous stage, symptoms of increased tension which depend upon 
alterations in the angle of the anterior chamber arise: pain in the brow, 
anesthesia of the cornea, shallowing of the anterior chamber, and dila- 
tation and tortuosity of the perforating episcleral vessels. Ophthalmo- 
scopic examination is no longer possible, the localized detachment of the 
retina becomes general by increased serous effusion, the lens may become 
cataractous, and a severe iridocyclitis may supervene. 
As the growth continues, the sclera is ruptured and the surround- 
ing tissues are involved (fungus state or stage of episcleral tumors'). 
It may pass backward into the brain, or secondarily affect the optic 
nerve, but more commonly the last, or metastatic stage (stage of generali- 
zation), develops; distant organs are attacked by growths of similar 
histologic character, the liver far more frequently than other organs, but 
also the spleen, intestines, and even the lungs. Metastasis to the liver 
need not necessarily be delayed until the tumor has burst, at least 
visibly, through the scleral boundary. The most extensive secondary 
sarcoma of the liver which has come under the writer's notice developed 
from a small sarcoma of the choroid, in which there was no external 
manifestation, but in which a few fragments in the orbital tissues 
appeared to be of suspicious nature after the removal of the eye. 
Diagnosis.-It is necessary to differentiate sarcoma of the choroid 
from glioma of the retina. To this reference will be made in a future 
section. TUMORS OF THE CHOROID 
363 
In the early stages choroidal sarcoma may be mistaken for idiopathic 
detachment of the retina and detachment of the choroid. In retinal 
detachment there is usually a history of sudden onset, and the ophthal- 
moscope may reveal undulations of the folds of the detached retina with 
the movements of the eye, vitreous opacities, and signs of choroiditis. 
Moreover, the field is frequently less sharply defective than in choroidal 
sarcoma. Parsons, impressed with the fact that early detachment of 
the retina occurs in many cases of sarcoma of the choroid, urges in all 
instances of apparently simple detachment of the retina that a most 
careful search for tumor should be made by the methods already de- 
scribed, and especially by transillumination of the sclerotic (diaphanos- 
copy), by means of which the most satisfactory results are obtained. 
Various instruments have been designed, notably those of Leber, Sachs, 
and Wiirdemann. The eye having been cocainized, the point of the 
instrument is passed over all areas of the exposed sclera. In the ab- 
sence of a growth the red glare in the pupil remains undisturbed and 
bright; if a growth exists, the passage of the light is obstructed as the 
point of the instrument is placed over the region beneath which it is 
situated, and the pupil remains dark. In order to detect tumors situ- 
ated far posteriorly, Lancaster has mounted a small Tungsten lamp at 
the end of a flexible copper tube attached to a posterior flashlight battery. 
Through an incision in the conjunctiva and capsule of Tenon the lamp 
can be carried behind the eyeball and its posterior segment thus trans- 
illuminated. The value of ophthalmodiaphanoscopy in these circum- 
stances has been described on page 110. 
Choroidal detachment is rare, the history is different from that of 
sarcoma, and the characteristic vessels of the choroid can usually be 
recognized beneath the vessels of the retina. 
Too much reliance cannot be placed upon the tension of the eyeball 
as a distinguishing sign between sarcoma and retinal detachment, be- 
cause intra-ocular tension may be unaltered in each instance, although, 
as C. Devereux Marshall has shown, it is probably never diminished 
(as it often is in retinal detachment) in undoubted cases of choroidal 
sarcoma, while it may be reduced in cases of sarcoma of the ciliary 
body. 
In the stage of increased pressure the disease is to be distinguished 
from glaucoma by observing the suddenness of the onset of inflammatory 
symptoms-in the latter disease without antecedent history of poor 
vision-and the fact that in the glaucomatous eye there are remissions 
in the acute symptoms, and that the tension is somewhat amenable to 
the miotics. 
Prognosis.-Removal of an eye for choroidal sarcoma results in a 
cure in from 25 to 30 per cent, of the cases, although statistics on this 
point vary greatly. Hirschberg's published statistics may be briefly 
summarized as follows: Local recurrence, 2.5 per cent.; metastasis, 41.5 
per cent.; cure, 56 per cent. He points out that statistics show a steady 
improvement in so far as permanent recovery after enucleation for 
sarcoma of the choroid is concerned. His own earlier operations yielded 364 
DISEASES OF THE CHOROID 
only 35 per cent, of recoveries. Metastasis to internal organs is the 
most usual cause of death and generally takes place within two years 
after operation. The stage at which enucleation is performed does 
not certainly influence the occurrence of metastasis, although, as 
Hirschberg maintains, operation at the very earliest stage should 
be urged. It is usually stated that very vascular and round-celled 
sarcomas are more fatal than other varieties. Prognosis is better in 
young than in aged subjects. Local recurrence is much less frequent 
than metastasis; it is prevented by prompt removal of the eye. If 
there is no recurrence or metastasis within four years after enucleation 
of the eye, this complication becomes unlikely, although exceptions to 
this rule have occurred, and metastasis has been noted even after seven 
years. 
Treatment.-From what has been said it is evident that the only 
treatment is prompt enucleation. The optic nerve should be severed as 
far back in the orbit as is possible. It may be necessary to remove the 
entire contents of the orbit. The treatment of choroidal sarcoma by 
radium has not yielded satisfactory results. 
Rare forms of tumor of the choroid are the following: Cavernous 
angioma, telangiectatic sarcoma, adenoma, and enchondroma. Angiomas 
of the choroid (about 21 are on record) may occur in connection with 
nevi of the face. 
Carcinoma of the Choroid.-The tumor (a comparatively rare 
growth, about one-third being bilateral) is of rapid development and 
generally appears as a flat growth in the neighborhood of the macula. 
In the majority of instances it represents a metastasis from a carcinoma 
of the mammary gland (39 times in 64 cases collected by Suker and Gros- 
vener); the primary neoplasm has also been situated in the lungs, pleura, 
stomach, liver, thyroid, mediastinal glands, suprarenal gland, prostate, 
and ovary. 
Tubercle of the Choroid.-Tubercles appear in the choroid as 
yellowish-white spots, varying in size from 1 to 1.5 mm., occasionally 
larger, and usually, though not necessarily, associated with similar 
growths in the meninges (tuberculous meningitis). Repeated examina- 
tion is required for their detection, and even then they may escape obser- 
vation, owing to their diminutive size (choroidal dust}. The facility of 
their detection has been much enhanced since the introduction of 
electric ophthalmoscopes. They have been frequently found in post- 
mortem examinations. 
Tubercles, known as miliary tubercles, are distinguished chiefly by 
their color, which has been described as of a dull yellowish white in the 
center, encircled by an ill-defined rose-colored area (Horner). Usually 
there are no pigmentary changes in the immediate neighborhood, but 
pigment bodies may surround the nodules if they are prominent (Bach). 
They are situated usually near the optic disk or in the macular region, and 
vary in number from three to six or many more. 
Instead of the miliary growth, a single large tuberczdous tumor may 
appear and progress, producing the same destructive changes as a sar- INJURIES OF THE CHOROID 
365 
coma. It may be associated with a similar one in the brain.1 Accord- 
ing to Zur Nedden, the age of patients suffering from tuberculous tumor 
of the choroid has varied between one and a half and sixty-two years, 
although the age of childhood has furnished by far the greatest percent- 
age. The condition must be differentiated from glioma of the retina 
in the young and sarcoma of the choroid in adults. The evolution of 
conglomerate tubercle of the choroid is usually more rapid than that of 
tumor. Scleral involvement and perforation generally occur early in 
the disease. Choroidal tuberculosis is rarely primary. Other signs of 
tuberculosis will usually be found in the general system. Occasionally 
in eye-grounds otherwise normal, and in patients in good health, isolated 
areas of choroidal atrophy with or without pigment heaping, or large 
patches of dense, slightly elevated pigment are seen, which probably 
represent healed tuberculous lesions-the so-called obsolescent tubercles 
or tuberculous areas. 
Fig. 167.-Rupture of the choroid on the temporal side of the disk and pigmented 
traumatic choroiditis (see page 351) on the nasal side (from a patient under the care of 
Dr. Randall in the Children's Hospital). 
Treatment.-Miliary tubercles of the choroid do not require any 
treatment directed to the eye itself, the vision of which may not be 
seriously affected. If a single large choroidal tumor is recognized, 
and the patient's general condition permits it, enucleation to avert 
general tuberculosis would seem to be a proper procedure. Instead of 
surgical procedures, injections of tuberculin (T. R.) have been employed 
by von Hippel and others with encouraging results, and should be given 
full trial (see also page 318). 
Injuries of the Choroid.-Wounds of the Choroid.-Necessarily, 
in a perforating wound of the sclera, the choroid is also lacerated or 
1 Chronic choroidal tuberculosis is characterized by optic neuritis, optic atrophy, 
hemorrhages (tuberculous inflammation), and a diffuse, yellowish-white discoloration, 
occupying a considerable area of the eye-ground, within which are round, yellowish-white 
spots. Michel describes tuberculous granulation tumors of the choroid, which begin with 
the appearance of retinal detachment, and later cause abscess in the vitreous and shrinking 
of the eye. 366 
DISEASES OF THE CHOROID 
incised, and no description other than that already given in this con- 
nection is required. 
Foreign Bodies in the Choroid.-A penetrating foreign body may 
lodge in the choroid; the treatment described on page 293 is applicable. 
Rupture of the Choroid.-The most important injury to which the 
choroid is subject, and which follows a blow upon the eye, is rupture. 
This generally manifests itself in a sickle-shaped crescent, commonly on 
the temporal side of the disk, rarely on the nasal side, and which very 
seldom extends in a horizontal direction. The rupture may be single or 
multiple, and sometimes is composed of several branches. The immedi- 
ate effect of the blow is a hemorrhage preventing distinct observation. 
After its disappearance the fissure is evident to the ophthalmoscope as a 
yellowish-white stripe bordered with some disturbed pigment (Fig. 167). 
The ruptures usually run concentrically with the papilla. 
They may be either complete or incomplete, and may or may not 
be associated with breakage of the overlying retina. In rupture con- 
fined to the choroid, the retinal vessels pass over it. If the retina has 
also given way there is apt to be more hemorrhage than without such 
accident, and no retinal vessels are observed crossing the choroidal 
separation. Associated with choroidal rupture there may be a rupture 
of the sphincter of the iris (Duane and the author). 
The ultimate effect on vision depends upon the size and situation 
of the rupture. At first there is very considerable disturbance of sight, 
partly due to effusion and partly to injury of the iris, sometimes as- 
sociated with blood in the anterior chamber. This slowly clears away, 
and very good vision may result provided the change in the eye-ground 
has not been extensive. A deterioration of vision may occur a long 
time after such an injury owing to secondary changes in the optic nerve. 
Treatment.-The pupil should be dilated with atropin; if there is 
much pain, a leech or two should be applied to the temple, a pressure 
bandage adjusted, and the patient put to bed. These measures suffice 
to encourage the absorption both of the blood and of the serous effusion. 
Hemorrhage into the Choroid.-In the section on Unclassi- 
fied Forms of Choroidal Disease variously shaped hemorrhages which 
appear in this membrane, and which by absorption give rise to atrophic 
spots, have been described. In like manner there may be hemorrhage 
from the choroid, the result of a blow. A choroidal hemorrhage may be 
distinguished from one situated in the retina by noticing the more diffuse 
character of the extravasation and the fact that the retinal vessels pass 
over it, but the diagnosis is difficult. 
Detachment of the Choroid.-This is a comparatively rare 
clinical condition, although not infrequently found in enucleated, 
shrunken eyes. It may be spontaneous or traumatic, partial or complete. 
The detachment may be caused by blood, serum, a layer of lymph, or a 
new growth. Cases following cataract extraction, iridectomy for glau- 
coma, iridosclerectomy, and corneoscleral trephining (see page 634) are 
not very uncommon. The detached choroid protrudes as a dark mass 
into the vitreous, and the anterior chamber is shallow or obliterated. ESSENTIAL PHTHISIS BULBI 
367 
It is caused by the passage of the aqueous humor through a rent in the 
attachment of the ciliary body beneath the choroid. The prognosis is 
favorable. 
Meller, who has carefully studied the subject, classifies detachment 
of the choroid thus: Early postoperative detachment, innocent in char- 
acter; late postoperative detachment, following trauma or occurring 
without cause; spontaneous detachment, either innocent, resembling 
postoperative separation, or malignant, causing blindness. If the retina 
is detached with the choroid the prognosis is most unfavorable. 
Ossification of the Choroids-This is occasionally found in eyes 
long blind and shrunken from destructive iridochoroiditis. The forma- 
tion of bone occurs in the inflammatory tissue, and may be recognized by 
palpation in the form of an irregular plate, spicule, or complete shell. 
Calcareous degeneration is common in eyes of this character. The eye- 
ball should be enucleated. 
Atrophy of the eyeball is a condition characterized by diminu- 
tion in the size of and alteration of the shape of the globe, caused by 
contraction of inflammatory exudations-for example, those formed in 
the uveal tract. It should be sharply distinguished, as Fuchs points out, 
from phthisis bulbi, which results from a suppurative inflammation (see 
page 357) and is associated with rupture of the sclera and partial evacu- 
ation of the ocular contents. The former may give rise to sympathetic 
irritation; the latter usually, but not always, is harmless. 
Essential phthisis bulbi (ophthalmomalacia) is the name applied 
to a condition of the eye characterized by hypotony (softening) and dim- 
inution in its size which is unrelated to inflammation. There may be 
photophobia, pain, miosis, and partial ptosis. An intermittent variety 
has been described. It may follow injury and be connected with disease 
of the sympathetic. CHAPTER XII 
GLAUCOMA 
Glaucoma is the name applied to several varieties of a disease of 
which increased intra-ocular tension is the most characteristic sign. 
Varieties of Glaucoma.-Systematic writers are accustomed to divide 
glaucoma into (1) primary glaucoma, or that form which arises independ- 
ently of clinically evident antecedent disease of the eye, and (2) secondary 
glaucoma, or that form which occurs as the sequel of a pre-existing ocular 
disease, often an inflammation of the uveal tract. 
The primary variety of this disease has been divided into (1) acute 
congestive glaucoma (acute inflammatory glaucoma); (2) subacute con- 
gestive glaucoma ("glaucoma irritatif," chronic inflammatory or conges- 
tive glaucoma); (3) chronic non-congestive glaucoma (simple glaucoma, 
glaucoma simplex, chronic non-inflammatory glaucoma). 
For clinical purposes it is convenient to retain these varieties of 
glaucoma and their descriptive names, but it should be distinctly re- 
membered that in a certain sense the divisions are artificial, because an 
acute glaucoma may cease to have its congestive character and take on 
the signs which are ordinarily supposed to indicate the chronic variety of 
the disease, and the so-called glaucoma simplex may at any stage of its 
career develop symptoms of an acute progress, and lose its non-inflamma- 
tory or, more accurately, non-congestive character. 
Symptoms.-The following is a syllabus of the symptoms common 
to the disease glaucoma, although all of these symptoms are not con- 
stantly present in each variety. 
1. Rise in intra-ocular tension, or increased hardness of the eyeball. 
Formerly variations in tension of the ocular tissue, in part determined 
by the rise of intra-ocular pressure, were graded from T? ("stiffened 
sclera") to T + 3 ("stony hardness"). Intermediate degrees were ex- 
pressed T + 1 and T + 2. 
Since the introduction of satisfactory tonometers, particularly the 
instrument of Schiotz, the crude estimation of the impressibility of the 
eyeball by means of finger palpation has only an historic interest. The 
use of the tonometer is described on page 87; it measures the state of the 
tension of the ocular tissue, which is determined in part by the intra- 
ocular pressure. 
2. Change in the Size and Shape of the Pupil and Mobility of the Iris.- 
The pupil may be round, oval or egg shaped, semidilated, or expanded 
to its fullest limit; the iris is sluggish in movement or entirely inactive. 
In simple glaucoma abnormal pupillary symptoms may be absent. 
The pupillary space sometimes transmits a greenish reflex (hence the 
name given by the older writers) from the surface of the lens. The dila- 
368 VARIETIES OF GLAUCOMA 
369 
tation of the pupil is explained by paresis of the ciliary nerves or by con- 
striction of the vessels of the iris. Partial atrophy of the lesser circle of 
the iris, which may lead to permanent dilatation of the pupil, is not un- 
common after acute attacks of increased tension (Hirschberg). 
3. Loss of the Transparency of the Cornea.-The cornea somewhat 
resembles the appearance of glass, the surface of which has been dulled 
by being breathed upon. This haziness is marked in the congestive 
types of glaucoma, but is absent or only slightly present in the simple 
varieties. If the cornea is carefully examined, the cloudiness will be 
found more decided in the center, and will resolve itself into very numer- 
ous closely aggregated points, the whole presenting a stippled or "needle- 
stuck" appearance. Iritis and iridochoroiditis may produce a similar 
appearance. The condition has been attributed to an edema of the cor- 
nea. Loss of corneal transparency with increased intra-ocular tension, 
such as may be caused, for example, by external pressure on the eye, is 
due, according to v. Fleishl, to the corneal fibers becoming doubly re- 
fracting. 
4. Change in the Depth of the Anterior Chamber.-This symptom varies 
from an almost imperceptible shallowing to a complete obliteration. 
During the course of glaucoma the lens system and peripheral portion 
of the iris are pushed forward, and this causes the depreciation in the 
depth of the anterior chamber. 
5. Change in the Normal Appearance of the Iris and Turbidity of the 
Aqueous and Vitreous.--The same edema which affects the cornea may 
also cause loss in the characteristic markings of the iris, so that its pattern 
becomes indistinct, especially in congestive forms of glaucoma. The 
veins of the iris may be dilated and tortuous; small hemorrhages are 
sometimes visible. Opacities in the media also are liable to form, and the 
lens itself may become cataractous. 
6. Alterations in the Conjunctival and Episcleral Vessels.-In acute 
glaucoma there are usually general hyperemia and often edema of the 
conjunctiva, but in chronic inflammatory and sometimes even in simple 
glaucoma there are marked enlargement and tortuosity of the episcleral 
venous branches (see System II, page 49). 
7. The Excavation of the Nerve-head and the Surrounding Yellowish 
"Halo," or "Glaucomatous Ring."-Under the influence of the increased 
intra-ocular pressure the most impressionable portion of the eye-the 
intra-ocular end of the optic nerve-gives way, and the glaucomatous 
cup is produced. According to Knies, congestion and edema of the nerve- 
head precede cupping, and according to Brailey and Edmunds, actual 
neuritis appears in advance of increased tension. The author and Gas- 
parrini have seen glaucomatous excavation of the papilla follow retro- 
bulbar neuritis. Wahlfors denies that increased intra-ocular tension 
alone is sufficient to cause cupping of the nerve-head, inasmuch as it 
requires a pressure of 135 mm. of mercury to produce such an excava- 
tion, and in glaucoma the rise rarely exceeds 100 mm. According to him, 
atrophy of the choroid is an important factor in this respect, because the 
resistance of the lamina cribrosa is thus reduced, owing to interference 370 
GLAUCOMA 
with the vessel-bearing tracts which pass from the surrounding choroid 
into the nerve-trunk and branch in the anterior layers of the lamina. 
According to Schnabel, the excavation in the nerve-head in glaucoma is 
not due to increased intra-ocular tension, but to a form of degeneration of 
the optic nerve-fibers, which causes their complete disappearance and 
the formation of small cavities, both anterior and posterior to the lamina 
cribrosa (cavernous atrophy of the optic nerve). Lacunar atrophy of the 
optic nerve has also been observed in myopia without hypertony. 
Axenfield has witnessed retrogression of a glaucomatous excavation, 
complete retrogression being rare, but the partial variety is not un- 
common. This observation indicates that the excavation is due to 
increased intra-ocular pressure and that the position of the lamina crib- 
rosa in glaucoma is not a constant one. 
Fig. 168.-Excavations in nerve-head: 1, Physiologic; 2, atrophic; and 3, glaucomatous 
excavations (Randall). 
The cupping of the optic disk is seen with the ophthalmoscope, and 
its depth is measured according to the directions given on page 107. 
It is also recognized by employing the parallax test with the indirect 
method as follows: The optic nerve is found in the usual manner by the 
inverted image, and the object lens moved from side to side. The entire 
eye-ground apparently moves with the motions of the lens, and the 
bottom of the excavation also seems to move in the same direction, but 
at a much slower rate. The contrast in the rate of the two movements 
is in a direct ratio with the depth of the excavation. 
The cup varies from one beginning to be pathologic to a fully formed 
excavation. In the latter instance the excavation is complete to the 
scleral margin, and its edges are abrupt; the vessels are crowded to the Plate III, 
The fundus of an eye with chronic glaucoma. VARIETIES OF GLAUCOMA 
371 
nasal side, bend sharply over the margin, and are lost to view behind the 
border of the cup, reappearing in fainter color at its bottom. 
The papilla is encircled by a yellowish ring due to atrophy of the 
surrounding choroid. 
It is important to distinguish between a large physiologic cup, an 
excavation due to atrophy of the optic nerve, and the glaucomatous cup. 
A physiologic excavation is partial and formed in a normally tinted 
nerve-head; an atrophic excavation is complete, shallow, and formed in 
a nerve-head of abnormal whiteness, owing to its loss of capillarity; and a 
glaucomatous excavation is complete, deep, and often of greenish hue. 
The microscopic appearances of a nerve-head containing a deep glaucoma 
cup are shown in Fig. 169 (consult also Fig. 168). 
Fig. 169.-Section of optic nerve-head containing a deep glaucomatous excavation, 
the so-called kettle-shaped excavation: r, Retina; ch, choroid; s, sclera; c, cup, or excava- 
tion, pushing back lamina cribrosa. 
The descriptions thus far given apply to typical forms of each variety 
of excavation. Sometimes it is a matter of considerable difficulty to 
decide between them, especially between an atrophic and a glaucomatous 
excavation where the latter is shallow; or between a physiologic excava- 
tion and glaucoma, where the former is associated with primary optic 
nerve atrophy. A diagnosis must then be based upon an examination of 
the other symptoms, particularly the field of vision. 
8. Vessel Pulsation on the Surface of the Disk.-(a) The Veins.- 
There is often marked venous pulse, especially at the dark knuckles of 
the veins as they bend over the margin of the excavation, but this is a 
common ophthalmoscopic appearance in healthy eyes (see page 102), 
and hence cannot be utilized as a diagnostic symptom. 
(6) The Arteries.-Pulsation of the arteries is a rare appearance 
except in aortic regurgitation, and therefore may be regarded as an im- 
portant indication of increased intra-ocular tension, in high degrees of 372 
GLAUCOMA 
which it is a striking symptom, the arterial trunks on the surface of the 
disk showing rapid alternate filling and collapse. It is usually, but not 
always, confined to the disk. The cause of spontaneous arterial pulsa- 
tion resides in the resistance to the passage of the blood through the 
vessels, a resistance which, in turn, depends partly upon increased ten- 
sion and partly upon spasmodic contraction of the vessels themselves. 
In cases of glaucoma in which this pulse is not spontaneously visible it 
may be induced by slight pressure upon the globe. 
In addition to the objective signs of glaucoma just described, certain 
subjective symptoms are more or less constantly present. 
1. Pain.-In acute attacks the pain is a severe neuralgia of the tri- 
geminal distribution, and often, in violent congestive cases, an intense 
agony associated with great depression, pallor of the countenance, nausea 
and vomiting. In subacute attacks there is a less marked similarly 
located pain. In chronic cases there may be only a general feeling of 
discomfort, a sense of fulness, occasional shoots of neuralgia, or attacks 
described by the patient as "headache." 
2. Alteration in the Sensibility of the Cornea.- Anesthesia of the cornea 
varies from a slight depreciation in its sensitiveness to an entire loss of 
sensation, as complete as that produced by cocain. Sometimes the 
anesthesia is not uniform over the surface of the cornea, but exists in 
spots or segments. It is due to the edema of the structure, which presses 
upon the filaments of the corneal nerves. 
3. Alterations in Central Visual Acuteness.-This symptom varies 
considerably, and in chronic cases excellent sharpness of sight may be 
preserved for a long time. It is important to remember this, because it 
is not safe to depend upon central vision as a guide of the rate of progress 
of a chronic glaucoma. In each attack of subacute glaucoma the vision 
quickly fails, and gradually is recovered as the attack passes away. 
Each recurrence leaves a more permanent impression. In acute glau- 
coma a characteristic symptom is the sudden loss of vision, which in a 
few hours may be reduced to a light perception, and in certain malignant 
types rapidly becomes extinct. 
4. Alteration of the Refractive Poiver of the Eye and Diminution of the 
Amplitude of Accommodation.-The former depends upon the change 
in the shape of the cornea, and the latter upon the effect of pressure 
upon the ciliary nerves. Alterations in the curvature of the cornea tend 
to produce an astigmatism "contrary to the rule" (see page 139), hence 
this is an important event in chronic glaucoma and in periods preceding 
its development. Diminished power of accommodation is evidenced 
by the desire of patients to change their reading-glasses to such as are 
stronger than the degree of refractive error or age of life would warrant. 
5. Alteration in Peripheral Vision, or the Field of Vision.-A careful 
map of the field of vision in glaucoma is indispensable, and the restric- 
tions present themselves in several forms: (a) The most usual and typical 
variety is partial or complete loss of the nasal field or of the upper or 
lower quadrant of the nasal side; (6) concentric restriction of the entire 
field; (c) restriction so constituted that the remaining field assumes an VARIETIES OF GLAUCOMA 
373 
oval or trowel shape; (d) sectional defects, often of the superonasal area; 
(e) loss of the entire field except a patch on the temporal side; (/) the 
formation of scotomas, which may be central, paracentral, annular, or 
peripheral (Figs. 170-178). 
Fig. 170.-Field of vision of right eye 
in a case of subacute glaucoma. Loss of 
the nasal half and concentric restriction of 
the preserved field. 
Fig. 171.-Field of vision of right eye 
in a case of chronic glaucoma, showing 
concentric restriction of the field. 
The contraction of the color-fields is usually proportionate to that of 
the form-field, but this rule meets with exceptions. Under the influence 
of operative measures or miotics very decided improvement in the extent 
of the visual field may take place. 
The tendency of the visual field is to contract progressively as the 
disease advances, and finally all portions are obliterated except a small 
Fig. 172.-Field of vision in right eye in 
case of chronic glaucoma, showing sectional 
defect (superonasal quadrant). 
Fig. 173.-Field of vision of left eye in 
chronic glaucoma. Trowel-shaped patch 
preserved chiefly on the temporal side. 
part upon the temporal side, which also disappears in the ultimate blind- 
ness (consult Fig. 174). 
The contraction of the field of vision is an important index of the 
rate of progress in glaucoma, more important than depreciation of central 
vision; but it is not sufficient to trust to the periphery of the field for 
information. A search for scotomas is imperative. They must be found 374 
GLAUCOMA 
either by the method suggested by Bjerrum (see page 81) or by ordinary 
perimetric methods, when care is taken to investigate each meridian and 
suitable test-objects are employed under varying degrees of illumination. 
Doubtless, as Bjerrum has pointed out, these scotomas are the result 
of the destruction of the fibers of the papilla at the margin or sides of the 
Fig. 174.-From the same case as Fig. 
173, six months later; only a small patch of 
preserved field on the temporal side. 
Fig. 175.-Just beginning contraction 
of nasal field; scotoma extending from 
blind-spot in a semicircular manner up- 
ward and inward. 
excavation. They are topographically different from those which occur 
in simple optic-nerve atrophy, and may be utilized as a differential test 
between the two conditions, as Bjerrum has already suggested. This 
writer believes, and his observations have been confirmed by Meisling, 
Berry, Bonne, Sinclair, and other investigators, that a scotoma of this 
character is peculiar, in that wherever 
situated it is in direct continuity with 
the blind-spot. The scotoma may ex- 
tend from the blind-spot and pass in an 
arc above and below the fixation point to 
end at the nasal side of it, about the 
horizontal meridian, or the defective area 
may merge with the blind area commonly 
existing in the nasal part of the field. 
This visual defect is often called Bjer- 
rum's symptom. As Bonne points out, a 
small paracentral arciform scotoma is a 
common phenomenon, and to a break in 
the nasal field, whereby an alteration 
takes place in the boundary line of the 
field at the inner side from vertical to horizontal along the hori- 
zontal meridian, which it pursues for a varying distance before it 
again assumes a vertical or nearly vertical direction, he has given 
the name "nasal step." Central annular scotomas are demonstrable, 
and peripheral scotomas may be the forerunners of subsequent de- 
fects in the peripheral visual field (Figs. 177, 178). Scotomas may 
develop above and below the blind-spot and gradually coalesce with 
Fig. 176.-Annular scotoma in 
chronic glaucoma; moderate con- 
traction of the peripheral field. ACUTE GLAUCOMA 
375 
that spot, i. e., a sickle-shaped scotoma is produced. Such scotomas, 
it is said, may be found in the field of an unaffected eye, its fellow 
being glaucomatous (Seidel's sign). 
6. Iridescent Vision.-This consists of a definite ring surrounding 
artificial lights, which thus become invested with a colored halo ("halo 
vision"). First there is a dark band, followed by a concentric zone of 
prismatic colors, violet within and red without. 
This phenomenon has been attributed to various causes depending 
upon physiologic or physical effects. Experimental evidence tends to 
support the opinion that the cause resides in the cornea, and depends on 
alterations in its epithelium, the result of exaggerated pressure.1 
Subjective sensations of light are experienced at times by totally 
blind glaucomatous patients. The explanation is probably a mechanical 
one, and the sensation depends upon a dragging on the retina. In one 
Fig. 177.-Visual field of right eye in 
chronic glaucoma, showing the mechanism 
of the loss of the lower and inner portion of 
the field, preceded by a scotoma, which 
gradually extends. Scotoma represented 
by parallel lines; area of dull vision which 
subsequently is completely lost, by dots. 
Fig. 178.-Later stage of Fig. 177. 
The scotoma has extended, and the area 
of the visual field in which sight was only 
dulled, and which is represented by dots in 
the preceding figure, has become com- 
pletely dark. 
case noted by the writer, both eyes being blind from glaucoma, the 
patient declared "all things seemed to be a sea of red fire." 
The clinical varieties of glaucoma may now be described. 
1. Acute Glaucoma {Inflammatory or Congestive Glaucoma').-This 
type of the disease is suitably divided into two stages: 
(a) Period of Incubation, or Prodromal Stage.-This is characterized 
by sudden failure in the amplitude of accommodation, with a desire to 
resort to stronger reading-glasses; temporary obscurations of vision, 
either dim vision or quite complete loss of sight, lasting for many min- 
utes; attacks of foggy vision, due to increased intra-ocular tension, all 
things apparently being invested with a haze; and the phenomena of 
colored halos around artificial lights. There may be some periorbital 
1 According to Schweigger, halo vision occurs in mild attacks of iritis with slight de- 
terioration of vision. It may also be caused by a layer of mucus overspreading the cornea 
during chronic conjunctivitis. According to Myles Standish, the halo due to mucus has 
only the outer or red and yellow bands. The presence of blue in the halo may, therefore, 
be regarded as indicating increased intra-ocular tension. 376 
GLAUCOMA 
pain, the pupil is slightly dilated, and the cornea and the aqueous 
humor faintly turbid. The appearance of the optic nerve at this stage 
is not characteristic. 
These prodromes bear some relation to emotional excitement and 
insomnia, and may occur when the head is congested or after a full meal. 
After the eye regains its natural state, in a week or two the symptoms 
may reappear, again to subside and to be replaced by a fresh exacerba- 
tion or a true "glaucomatous attack." The incipient period of glaucoma 
may last one or more years. 
(b) Period of Attack, or the "Glaucomatous Attack."-This com- 
monly begins during the latter part of the night, sometimes preceded 
by prodromes, but sometimes without previous warning, and is char- 
acterized by violent pain in the head, so severe that it may induce 
nausea and vomiting. The face may be pallid, the extremities cold, or 
there may be flushing and general fever. The eyelids are swollen, the 
conjunctiva injected and sometimes chemotic, the cornea steamy and 
anesthetic, the pupil semidilated and motionless, the aqueous turbid, and 
the iris discolored. The tension rises very high, the tonometer registering 
80 mm. of Hg and higher, and vision is rapidly lost, often only light- 
perception remaining, and even this may be abolished. Sometimes the 
attack is bilateral, or only a few hours elapse before the second eye is 
affected. Again, the interval between the two attacks may last weeks, 
months, or even years. 
Gradually the symptoms pass away, with the exception of slight 
impairment in the mobility of the iris, some limitation of the field, and a 
little rise in tension. Blindness almost never occurs in the first onset. 
At this time characteristic ophthalmoscopic appearances are not present. 
After a number of attacks, examination of the eye-ground during a re- 
mission (the fundus is not visible during an attack) may reveal the 
characteristic cupping, the halo, and the arterial pulse. 
If the disease is unchecked, the eye passes into a glaucomatous state, 
with fixed and dilated pupil, discolored iris, greenish reflex from the lens, 
vitreous opacities, shallow anterior chamber, and hazy cornea. Vision 
is now gradually destroyed and the eye reaches the state of absolute glau- 
coma; the ball is stony hard, the iris atrophic, the lens cataractous and 
pushed forward, the anterior chamber obliterated, the sclera discolored, 
the episcleral vessels coarsely injected, the cornea opaque, or perhaps 
ulcerated. Finally, there is disorganization of all the structures of the 
eyeball, and the sclera gives way with the formation of staphylomas, or 
the eyeball slowly atrophies as the result of choroiditis, change in the 
vitreous, and detachment of the retina. Acute glaucoma, instead of 
pursuing this course, occasionally passes into a chronic inflammatory 
type. Spontaneous rupture of a glaucomatous eyeball occasionally 
occurs; at the same time there may be choroidal hemorrhage. 
Glaucoma fulminans is the name applied to an aggravated, rare 
form of the acute disease, in which the symptoms may be fully de- 
veloped in a few hours without a prodromal stage. There is no remis- 
sion, and the destruction of vision is swift and permanent. CHRONIC GLAUCOMA OR NON-INFLAMMATORY GLAUCOMA 
377 
2. Subacute or Chronic Congestive Glaucoma.-This type may 
or may not begin with the prodromal signs already described, or may 
be the sequel of repeated acute attacks. The eye gradually passes 
into a stage characterized by the constant presence of a series of symp- 
toms which are often described under the title chronic inflammatory or 
chronic congestive glaucoma. 
The cornea is deficient in transparency or positively steamy; there 
are marked tortuosity of the episcleral veins and some discoloration 
of the scleral tissue; the aqueous humor is turbid and the deeper media 
present opacities; ophthalmoscopic examination, when it is possible, 
reveals the cupped disk and pulsating vessels; the tension of the eye is 
raised; the pupil is semidilated, and the iris sometimes atrophic and 
sometimes not. Hence two types of chronic inflammatory glaucoma are 
described, one associated with degenerative changes in the iris and one 
without such association. 
The field of vision is either contracted upon the nasal side or a quad- 
rant of the field is darkened, or the other defects described on pages 
373-375 may be discovered. 
During the course of the disease acute or subacute attacks super- 
vene; that is, there are sharp ciliary pain, increased steaminess of the 
cornea, increased injection of the eyeball, sinking of the vision, exag- 
geration of the tension, and marked anesthesia of the cornea. The 
attack gradually subsides, but in a few days or w7eeks repeats itself. 
Sometimes instead of a subacute attack of this character, an acute con- 
gestive exacerbation occurs, in all respects resembling the disease just 
described, and like it ending in absolute glaucoma or in degeneration 
of the tissues of the eye. This disease may last from several months 
to a year. 
3. Chronic Glaucoma or Noninflammatory Glaucoma (Usually 
Known as Simple Chronic Glaucoma or Glaucoma Simplex).-This type 
of the disease is characterized by an absence of the signs of glaucoma in 
the anterior aspect of the eye, at least on ordinary inspection. By 
careful examination, slight steaminess of the cornea may sometimes be 
detected, with a little lack of transparency in the aqueous humor, So, 
too, there may be some undue tortuosity of the perforating branches of 
the episcleral plexus. In general terms, how'ever, there is an absence 
of congestive symptoms and there is no pain. The tension of the eye- 
ball is always increased at some period of the disease, but this symptom 
is not constantly present, or it may be present at one portion of the 
day and not at another. Observations with the Schibtz tonometer 
indicate that increased tension is almost always present, although its 
degree may be a minor one. The depth of the anterior chamber is not 
materially altered. The chronic simple variety of glaucoma sometimes 
resembles chronic congestive glaucoma and vice versa. If in the affected 
eye corneal involvement is made evident by nebulous vision, halos, etc., 
or, in other words, by irritative attacks, the case ceases to be one of 
simple glaucoma, and should be grouped with the chronic congestive 
types. 378 
GLAUCOMA 
Almost without exception both eyes are affected simultaneously or 
successively; but it is difficult to fix the exact date of the onset of this 
variety of glaucoma, because of the absence of pronounced prodromal 
symptoms which precede the other types of this disease. 
If both eyes are affected, the one is usually more advanced than the 
other, and the pupil is generally slightly larger on the side of the greater 
disease. In the later stages a greenish sheen from the pupil is often dis- 
tinct. The central vision may be good, and in the earlier stages of the 
disease, after the correction of any refractive error, may reach the normal 
standard. 
The media are clear, and the disease is detected with the ophthal- 
moscope by observing the characteristic cup in the nerve-head, the halo 
surrounding it, and the spontaneous arterial pulse, or its ready develop- 
ment by slight pressure. 
The field of vision gives important information, and it assumes one 
or other of the characteristics described on page 372 (see Figs. 170-178). 
The central color perception is good, and the contraction of the periph- 
eral color perception corresponds with that of the form-field. 
Simple chronic glaucoma sometimes assumes a subacute or an acute 
nature like that already described, but often continues throughout its 
course without aggressive symptoms, having simply the characters of 
optic-nene atrophy with excavation, from which it should be distinguished 
by the presence of increased tension and by the visual field phenomena 
which have been described (see page 373). 
Causes.-(a) Predisposing Causes.-Primary glaucoma is rare before 
the fortieth year; not 1 per cent., according to Priestley Smith, begins 
earlier than the twentieth year. Glaucoma, generally unilateral, may 
occur in children, and juvenile glaucoma usually begins between the ages 
of fifteen and twenty; its prodromal period is of long duration. There 
may be a hereditary tendency to glaucoma, and, according to Nettle- 
ship, if the disease appears in more than one generation, it develops at 
an earlier age than in the preceding generation. Jews, Egyptians, and 
Brazilian negroes are said to be peculiarly liable to the disease. The 
glaucomatous eye is usually hyperopic, although Priestley Smith's 
statistics do not indicate a striking preponderance of this refractive 
state. There is a relation between smallness of the cornea and glau- 
coma. The average horizontal diameter of the normal cornea is 11.6 
mm.; of the glaucomatous cornea, 11.1 mm. (P. Smith). Story's meas- 
urements yield an average of 11.9 mm. A large lens is a predisposing 
factor, and small eyes, in which the lens may be disproportionately large, 
are more liable to the disease than normal globes. 
(6) Exciting Causes.-Glaucoma may be excited in eyes predisposed 
to the disease by worry, insomnia, bronchitis, cardiac disease, syphilis, 
gout, influenza, and neuralgia of the fifth nerve. Sometimes it follows 
injury and hemorrhage into the uveal tract, and traumatic glaucoma 
may be caused by a contusion of the globe without rupture of its 
coats. It has been stated that at corresponding ages usually there is 
higher average blood-pressure in glaucomatous subjects than in non- CHRONIC GLAUCOMA OR NON-INFLAMMATORY GLAUCOMA 
379 
glaucomatous subjects, and that arteriosclerosis and, therefore, increased 
blood-pressure are exciting causes of glaucoma. This contention is 
disputed by many observers, for example, H. Sattler, Freeland Fergus, 
H. C. Craggs, and C. G. Taylor. Overuse of ametropic or improperly 
corrected eyes, by causing uveal congestion, may bring on glaucoma 
in an eye predisposed to the disorder. The influence of strain upon the 
accommodation was explained by Snellen as follows: In the young eye, 
during accommodation for a near point, the diameter of the lens is 
reduced to about the same extent as that of the contracting ciliary 
muscle. The circumlental space remains about as wide as it was 
before, and the zonula remains tense as before. But the conditions are 
quite different in advanced life, when the elasticity of the lens is lost; 
the ciliary muscle contracts, but the form and size of the lens remain 
unchanged. The ciliary process is thereby pressed against the lens 
and the zonula slackened; hence the necessity of correction of refractive 
errors as a preventive measure. In a number of instances instillation of 
mydriatics has caused glaucoma. Acute glaucoma appears to be more 
frequent in winter than at other seasons of the year (Geisler). 
Should a patient between his fiftieth and sixtieth year desire to 
change his reading-glass frequently, or use one stronger than is suited 
to his age or the condition of the refraction of his eye, there is reason to 
apprehend the onset of glaucoma. On the whole, the disease is slightly 
more common in women than in men. Those symptoms which have 
been described as prodromes are distinctive in themselves, and acquire 
an importance greater than any probable predisposition. 
Pathogenesis and Pathology.-Three kinds of fluid are recognized 
within the eyeball: the blood within the blood-vessels, the lymph within 
the perivascular lymph-channels and the spaces in the uveal tract, and 
the intra-ocular fluid which is concerned with the nourishment of the 
vitreous and lens, supplies the aqueous chamber, and which, as was 
proved by Leber, proceeds from the epithelium of the ciliary body. 
It is probable that the lymph formation of the eye is produced in the 
ciliary body by a process of transudation, and not, as has been taught, 
by a process of secretion. 
The chief stream of the intra-ocular fluid thus derived proceeds over 
the lens and through the pupil into the anterior chamber, traverses the 
latter to reach the angle formed by the junction of the iris and cornea, 
passes through the meshes of the ligamentum pectinatum, and by diffu- 
sion and filtration is taken up by Schlemm's canal. From this canal 
the greater quantity of the fluid passes into the anterior ciliary veins, 
a part of it being absorbed and eliminated by the iris (Nuel, Benoit). 
Only a very small portion of the fluid flows backward through the 
vitreous and escapes by way of the perivascular lymph-channels in the 
optic nerve. According to Priestley Smith, it is doubtful if there is 
any continuous stream from the vitreous into the aqueous chamber, 
but the anterior hyaloid membrane and suspensory ligament are easily 
permeated by it, and in health any excess of fluid in the vitreous cham- 
ber escapes by the filtration angle in the manner already described. 380 
GLAUCOMA 
The pressure of the fluid regulates the outflow, so that when the afflux 
is increased a compensating increase of the efflux occurs (Snellen). 
The fluids of the aqueous and vitreous chambers are nearly identical 
in composition and contain about 95 per cent, of water, 1 per cent, of 
extractives and salts, and a minute quantity of albumin. The intra- 
ocular pressure, which is equivalent to that of a column of mercury 
25 mm. in height, is the same in the vitreous and the aqueous chambers, 
and preserves the shape and tension of the eyeball. If anything occurs 
to disturb its regulation, to quote Priestley Smith, "the pressure in 
the ocular chambers rises above the physiologic limits and we have 
the complex disturbance of function and structure called glaucoma." 
Fig. 179.-Photomicrograph of a specimen prepared by Dr. Brown Pusey. Communica- 
tion between Schlemm's canal (a) and scleral vein (6). 
What exactly are the factors potent in disturbing the regulation of 
pressure has never been satisfactorily determined, and numerous 
theories have been advanced. 
The theory which has been and is still widely maintained is that 
one which assumes a diminution in the outflow and, therefore, a reten- 
tion of fluid {retention theory). It obtained proper recognition when 
Knies and Weber demonstrated that in glaucomatous eyes, with shallow 
anterior chambers, there is an adhesion of the iris base to the periphery 
of the cornea, which prevents filtration at the angle of the anterior 
chamber and causes retention of the intra-ocular fluid (Figs. 180 and CHRONIC GLAUCOMA OR NON-INFLAMMATORY GLAUCOMA 
381 
181). This adhesion Knies regarded as an inflammatory process- 
that is, as a species of anterior iridocyclitis, while Weber considered it 
Fig.. 180.-Angle of the anterior chamber in a normal eye: c, Cornea; s, sclera; g, iris; 
c.b, ciliary body; l.p, ligamentum pectinatum; s.c, Schlemm's canal. 
Fig. 181.-Angle of the anterior chamber in long-standing absolute glaucoma: c, Cor- 
nea; s, sclera; j, iris; c.b, ciliary body; a.c, angle of chamber closed by adhesive inflamma- 
tion of the iris base to periphery of cornea, obliterating filtration area. 
to be secondary to the pressure induced by an abnormally swollen 
ciliary body. The fact that a mydriatic does harm to an eye predis- 
posed to glaucoma by dilating the pupil, rolling back the iris, and partly 382 
GLAUCOMA 
closing the filtration angle, and that eserin does good by contracting the 
pupil and drawing away the iris from this angle, indicates, as Snellen 
has pointed out, that the explanation of glaucoma is to be found not 
in an increase of secretion, but in a disturbance of excretion. 
Mydriatic glaucoma has also been ascribed to narrowing or closure 
of the iris crypts, an explanation which Priestley Smith declines to 
accept, for if it were correct, mydriasis should always be followed by 
rise of tension. 
According to Priestley Smith, obstruction of the circumlental space 
-i. e., the space between the margin of the lens and the surrounding 
structures-and consequent rise of pressure may follow increased size 
of the lens due to advancing years, unusual smallness of the ciliary 
area in hyperopia, or abnormal enlargement of the ciliary processes, 
and vascular disturbance which congests the uveal tract. It is possible 
that hypersecretion is sometimes concerned in the onset of glaucoma, 
and that serosity of the fluids plays a role in those forms which present 
a deep anterior chamber and wide filtration angle; but obstruction at 
this angle is part of the glaucomatous attack in the vast majority of cases. 
C. Hess points out that bulbous outgrowths may develop on the 
summits of the ciliary processes in the course of life. Individual differ- 
ences of the ciliary body are as important as differences in the size of 
the lens, and may have a distinct bearing on closure of the angle of the 
anterior chamber and the production of glaucoma. 
Laqueur and other observers think that glaucoma depends upon 
obstruction of the intra-ocular lymphatics, which find their way out 
with the vasa vorticosa, owing to rigidity of the sclerotic coat. Brailey 
described a chronic inflammation of the ciliary processes and iris periph- 
ery, with distention of the vessels, as the earliest lesion in glaucoma. 
Stilling taught that a hardening of the sclerotic surrounding the papilla, 
through which waste fluid escapes, leads to glaucoma, and Strokousky 
attributes glaucoma to an indurative scleritis. 
Evidently all retention theories assume that the cause of glaucoma 
depends upon an obstruction to the outflow of liquids from the eye 
occasioned by an interference with their escape through Fontana's 
spaces at the filtration angle, or through the perivascular lymph-channels 
in the posterior part of the eye, or through both of these exits; hence the 
fluid accumulates, the intra-ocular tension rises, and glaucoma results. 
In other words, upon the increased tension depend all the disturbances 
in the eye in this disease. 
But this explanation is far from satisfactory to many observers, 
and certain objections have been advanced. For example, it is main- 
tained that although adhesion of the root of the iris and blocking of 
Fontana's spaces are usually present in congestive glaucoma, it does not 
follow that this condition is the cause of the glaucomatous process; it 
may as w'ell be, indeed, it is more likely to be, a result of it. Moreover, 
while it is practically always present in the eyes with long-standing 
glaucoma, it may be absent in an early stage of the disease. But espe- 
cially is it true that this theory does not satisfactorily explain the CHRONIC GLAUCOMA OR NON-INFLAMMATORY GLAUCOMA 
383 
mechanism of so-called simple glaucoma, in which increased tension 
does not play a conspicuous role. 
Wahlfors believes that the search for the cause of simple glaucoma 
must be made in the choroid, and maintains that the primary lesion is 
an atrophic process in the choriocapillaris, leading to nutritional dis- 
turbances in the layer of the rods and cones, whereby the important 
symptoms of this variety of the disease, diminution of light-sense, 
defects in the field of vision, and excavation of the nerve-head (see 
page 369), can be explained. He explains glaucomatous increase of 
tension by assuming that paralysis of the muscular network of the 
choroid causes a slowing of the intra-ocular liquids, that the retarded 
flow permits the deposition of formed elements in the channels of exit, 
and that, therefore, there is a retention of the liquid; finally, the vense 
vorticosee are compressed by reason of the increased tension, and 
venous stasis is the result. According to the manner and activity with 
which these factors influence the eye, the various types of glaucoma are 
produced. 
Knies and other writers (see page 378), unable to reconcile any 
of the theories of glaucoma with the so-called simple variety of the 
disease, incline to separate it from the glaucoma class and place it 
among diseases of the optic nerve. In the present state of our knowl- 
edge, and keeping clearly in view the presence of increased tension, this 
does not seem advisable. Indeed, as Priestley Smith forcefully puts 
it, the nature of chronic and acute glaucoma is not essentially different, 
in that there is a close, though hidden, resemblance. "In both we find 
the predilection for small eyes; in both there is obstructive displacement 
of the iris-slowly established in the one case, rapidly in the other." 
Some authors explain this form of glaucoma by assuming a neuritis 
which blocks the lymph-channels in the optic nerve and its sheath, 
and which prevents the removal of effete matters which normally, to 
slight degree, occurs through these pathways, and thus causes in- 
creased tension and excavation. Hence the disease is sometimes called 
posterior glaucoma, to distinguish it from the other variety, anterior 
glaucoma. 
Priestley Smith believes that "typical chronic glaucoma depends 
on slowly increasing contact of the iris with the cribriform ligament, 
arising through enlargement or advance of the lens, and involving in its 
early stages no serious compression of the iris." 
W. Zimmerman considers that the primary cause of glaucoma de- 
pends upon a difference between the general blood-pressure and that of 
the eye. Parsons' experiments indicate that intra-ocular tension may 
passively respond to variations in the general blood-pressure, probably 
due to alterations in the volume of the intra-ocular blood-vessels, but it 
is uncertain that such passive changes are sufficient to account for glau- 
comatous attacks when these are apparently produced by excitement or 
emotion. 
The notable increase of the amount of albumin which LTribe Troncoso 
has found in the aqueous humor of glaucomatous eyes induces him to 384 
GLAUCOMA 
advance the theory that the symptoms which characterize glaucoma 
are best explained by its presence. The lesions in the blood-vessels 
which are found in glaucoma permit the passage of the albumin from the 
blood, and pathologic variations in the vitreous have also an impor- 
tant bearing on the glaucomatous process. Leber, however, who has 
reviewed Troncoso's work, has been unable to persuade himself that 
this author's views are correct. A. Knapp found in an eye with primary 
glaucoma an albuminous exudation which, by obliterating the anterior 
chamber through distention of the posterior chamber, produced the 
increased intra-ocular tension. 
Brown Pusey, experimenting with the increase and decrease of 
intra-ocular tension which may be induced by varying osmotic pres- 
sures, believes that on them depends the explanation of the primary 
cause of glaucoma. M. H. Fischer holds that glaucoma is due to an 
edema of the eyeball, the amount of water contained in the hydro- 
phylic colloids (chiefly the proteins) being increased by an augmenta- 
tion of the quantity of acid present in the organ. The ordinary exciting 
causes of glaucoma are responsible for this abnormal production or 
accumulation of acid. 
According to Thomas Henderson, the underlying predisposing and 
causal factor of glaucoma resides in a primary obstruction and closure 
of the pectinate ligament, or, as he prefers to call it, the cribriform 
ligament. This occlusion is the result of a sclerosis of the fibrous 
structure composing that filtration area which results, first, in a dimi- 
nution, and, finally, in a complete obstruction of the outflow through 
it, leaving the iris, with its crypts, as the only efferent channel for the 
lymph-streams. While this sclerosis is the fundamental cause in all 
cases of glaucoma, he admits a second and variable agent, vasomotor 
in nature, which determines the acute attacks of increased intra-ocular 
tension. Henderson's theory does not seem to Priestley Smith to be 
sufficient. Levinsohn, finding a striking deposit of pigment cells, 
derived from the cells lining the ciliary processes, in an eye with abso- 
lute glaucoma, suggests that this may be an important factor in the pro- 
duction of acute glaucoma. Kiischel believes that loss or disturbance 
of the elasticity of the supporting tissues of the eyeball is the cause of 
the various types of primary glaucoma. In all senile eyes this pro- 
duces the "glaucomatous disposition." 
Evidently all cases of glaucoma cannot be explained by any one 
theory, and the various clinical manifestations of the disease, as well as 
the results of treatment, indicate that sometimes one factor and some- 
times another is the more potent in its activities. Of those which 
have been described, obstruction of the circumlental space dependent 
upon increasing size of the lens due to advancing years, obstructive 
displacement of the iris slowly or rapidly established (Priestley Smith), 
alteration in the composition of the intra-ocular fluid, blocking of the 
efferent channels by edema and exudation, sclerosis or pigment deposi- 
tion, and vascular or vasomotor changes furnish the most satisfactory 
explanations of the various phases of glaucoma. CHRONIC GLAUCOMA OR NON-INFLAMMATORY GLAUCOMA 
385 
The pathogenesis of secondary glaucoma is easily understood, as the 
conditions which give rise to it-adherent leukoma, posterior synechiae, 
swelling and dislocation of the crystalline lens, tumors and cysts at the 
angle of the anterior chamber- readily obstruct the outflow of the intra- 
ocular fluid and occasion its retention. Moreover, in serous cyclitis 
(uveitis), in addition to the accumulation of inflammatory cells in 
Fontana's spaces, there is an excess of secretion, highly charged with 
albumin, from the inflamed ciliary body. Intra-ocular tumors and 
hemorrhagic retinitis (thrombosis of the central retinal veins) tend to 
increase the pressure in the vitreous and thus cause secondary glau- 
coma. 
As already pointed out, the apposition of the periphery of the iris 
to the cornea in primary glaucoma may at first be unassociated with 
inflammation; but if the apposition is long continued, proliferation of 
the endothelium of Descemet's membrane and the iris takes place and 
these two layers become adherent. Later the endothelium in large 
measure disappears, there is a round-celled infiltration of the deeper 
corneal layers and around Schlemm's canal, the tissue cells proliferate, 
and the iris becomes firmly bound down at its new position at the corneo- 
scleral junction. In the early stages of acute primary glaucoma the 
ciliary body and processes are engorged and swollen; later, and in long- 
standing cases, atrophy and shrinking occur. The changes in the choroid 
and their relation to the pathogenesis of the disease and the develop- 
ment of the excavation have been described. While there are no char- 
acteristic changes, as a rule, in the retina, in advanced cases atrophy of 
its elements are visible, and endo- and perivascular changes are evident, 
which may lead to hemorrhage. As already noted, edematous swelling 
and sometimes actual neuritis precede cupping of the nerve-head. Later 
there is backward depression of the lamina cribrosa and atrophy of the 
optic nerve-fibers. Alterations in the intrascleral passage of the venae 
vorticosse are sometimes discoverable, which depend upon proliferation 
of the endothelium in this position. 
Diagnosis.-It is of the utmost importance that glaucoma shall be 
recognized, if possible, in its very incipiency. The most usual prodromal 
symptoms are a frequent desire to change the reading-glasses, periods of 
obscuration of vision, and the halos surrounding the lamp-lights. 
The glaucomatous attack itself has frequently been mistaken for a 
"cold in the eye," for iritis,-and the disease has been aggravated by 
the instillation of atropin, which in almost all circumstances is con- 
traindicated,-for neuralgia, and for reflex ocular pain. The condition 
of the pupil, the diminished depth of the anterior chamber, and the 
increased tension of the globe are the symptoms which should prevent 
so fatal an error. As pointed out by Parisotti and Trousseau, ophthalmic 
migraine sometimes simulates glaucoma, inasmuch as it may be asso- 
ciated with increased intra-ocular tension, arterial pulsation in the 
fundus, and contraction of the visual field. 
The differential diagnosis of simple chronic glaucoma and atrophy 
of the optic nerve has been referred to and presents considerable diffi- 
25 386 
GLAUCOMA 
culty. The absence of constant increased tension in the simple form of 
the disease, or at least its doubtful presence, removes an important 
diagnostic point. Examination with the tonometer is of great impor- 
tance in these circumstances. Help may be obtained by observing the 
visual fields. In glaucoma the color-fields present a restriction corre- 
sponding with that of the form-fields, while in atrophy the peripheral 
color vision, especially for red and green, is markedly deficient. The 
diagnostic value of the shape of the field, and especially of the scotomas, 
notably Bjerrum's scotoma, has been described (see page 374). 
Examination of the light-sense is important. In glaucoma the 
"light minimum" is said to be deficient, but the "light difference" not 
far from normal; in pure optic-nerve atrophy there is imperfect ability 
to distinguish between different intensities of illumination ("light differ- 
ence"). In other words, according to Samelsohn, the light-perception 
power in glaucoma is much lessened, while the light-difference power is 
relatively not greatly interfered with; in optic-nerve atrophy the reverse 
is usually the case. Wahlfors, confirming observations made long ago by 
Mauthner and Forster, insists that reduction of the light-sense is one of 
the most frequent symptoms of simple glaucoma, and that night-blind- 
ness may first call the patient's attention to his eyes. Moreover, this 
reduced light-sense may exist for years before the real nature of the dis- 
ease is evident. 
It is an inexcusable error to confound the failing vision of chronic 
glaucoma with that of cataract, the greenish reflex of the lens, which 
may be seen in the pupillary space, being mistaken for an opacity of the 
lens. Eyes have been permitted to pass into blindness, and their 
possessors deluded with the hope that they were waiting for the ripen- 
ing of a cataract which never existed. An ophthalmoscopic examina- 
tion would settle the diagnosis at once. 
Prognosis.-Glaucoma does not tend to spontaneous cure, but, if 
unchecked, to blindness; hence the prognosis is unfavorable if proper 
treatment cannot be applied. Prognosis also depends upon the type 
of the disease and the stage of its development. Other things being 
equal, uncomplicated acute cases furnish the most reasonable hope of 
complete cure, and if a technically correct operation can be performed 
early, the result is usually satisfactory. In chronic cases much depends 
upon the amount of degenerative change in the tissues, and the prog- 
nosis must be guided by the state of vision, the extent of the field, and 
the condition of the iris. The effect of treatment upon the progress of 
glaucoma is included in the following section: 
Treatment.-In the majority of cases of glaucoma an operation is 
needed to check the disease. 
It may happen, however, that an operation is not at once possible or 
advisable, and hence the miotics should be quickly and thoroughly used. 
In the prodromal stage eserin salicylate or sulphate should be employed 
and will usually relieve the symptoms. In acute cases eserin, in a 
strength of from 1 to 4 grains (0.065-0.26 gm.) to the ounce (30 c.c.), 
acts favorably, and often with surprising rapidity, provided the pupil will CHRONIC GLAUCOMA OR NON-INFLAMMATORY GLAUCOMA 
387 
contract under its influence. Pilocarpin hydrochlorate, 2 to 5 grains 
(0.13-0.324 gm.) to the ounce (30 c.c.), may be substituted. Miotics 
act by drawing the iris away from the filtration angle, and, by con- 
tracting the pupil, cause widening of the spaces of Fontana and absorp- 
tion of the fluid; also iris-surface filtration is increased. A drop or two 
of the selected solution should be instilled every hour or two until relief 
is obtained; if this does not occur promptly, iridectomy or one of its 
substitutes should be performed. Arecolin in 0.5 per cent, solution 
has also been used; with this drug the author has had no experience. 
Dionin and adrenalin chlorid have been much employed in the treatment 
of acute glaucoma. The former (in 5 per cent, solution) often acts 
efficiently as a lymphagogue and analgesic; the latter (1 : 10,000) must 
be used with caution, as occasionally it increases the intra-ocular tension. 
It may be added to the solution containing the miotic. 
In addition to the use of eserin or pilocarpin during an acute attack 
the temple may be leeched, warm fomentation applied, and rest and 
relief from pain secured by the exhibition of morphin and chloral, the 
latter drug having some influence in reducing tension. Full doses of 
salicylate of sodium, however, act more favorably than any other con- 
stitutional remedy (Sutphen, Friedenwald); indeed, they are most 
useful in any form of glaucoma associated with pain. An interesting 
observation of Morax is that reduction of tension in glaucomatous eyes 
in syphilitic subjects has followed the injection of salvarsan. To 
lower intra-ocular tension Fischer and Thomas recommend subcon- 
junctival injections of sodium citrate (4.05-5.41 per cent, solution). 
Of these solutions, 5 to 15 minims (0.30-0.92 c.c.) are injected, and if 
the injections are frequently employed, the weaker of the two, diluted 
with 2 to 4 parts of physiologic salt, is employed. 
In chronic inflammatory (subacute) glaucoma, eserin (the sulphate 
or salicylate) or pilocarpin should be employed until it is decided what 
operation shall be done and when it shall be performed. The other 
remedies advised in the preceding paragraphs are also useful and should 
be used. 
There is much difference of opinion in regard to the value of miotics 
in the treatment of chronic, non-congestive glaucoma. In the opinion 
of some surgeons who deprecate operation in this form of glaucoma, they 
represent the chief therapeutic measure, while in the opinion of others 
they are practically without value. Neither of these extreme views is 
correct. That miotics can hold the disease in check for long periods 
of time cannot be doubted. They must be properly used, that is, the 
pupil must be kept contracted. For this purpose Posey prefers salicylate 
of eserin, beginning with a solution of Aj grain (0.00648 gm.) to the 
ounce (30 c.c.), and gradually increasing the strength until, if the drug 
has continued to act favorably, at the end of three years the solution 
has a strength of 3 grains (0.195 gm.) to the ounce (30 c.c.). The 
author prefers pilocarpin, as it is equally efficient and less irritating; 
the strength should usually be twice that of the eserin solution. Con- 
junctival irritation can generally be prevented if the solutions are always 388 
GLAUCOMA 
fresh and sterile, and if the conjunctival sac is frequently irrigated with 
a boric acid lotion. 
Massage of the eyeball is of distinct advantage; it may be followed 
by improvement in vision and deepening of the anterior chamber. 
Apparently it assists the action of the miotics. Usually it is not 
possible to employ it in acute glaucoma, but in simple glaucoma and in 
eyes with mild attacks it certainly temporarily lowers the tension. 
It may be applied by means of various instruments (see page 261), that 
is, vibration massage or with the help of suction cup (suction massage). 
Just as good results can be obtained by simple massage with the finger- 
tips. Unfortunately, the value of massage has been unduly magnified 
by irregular practitioners. It is useful only as an adjuvant to other 
well-recognized procedures, operative and medicinal. Strychnin and 
nitroglycerin should be given to patients with chronic glaucoma, espe- 
cially the latter drug if there is increased vascular pressure. High- 
frequency currents have been advised. 
Iridectomy, in the author's opinion, in most circumstances, con- 
tinues to be the most satisfactory operative procedure in the treatment 
of acute glaucoma. It should be performed early, in the prodromal 
stage if possible, while the excretory apparatus is still intact and before 
the root of the iris is welded to the cornea. General anesthesia should 
be induced before its performance, because the high tension of the 
eyeball somewhat nullifies the action of cocain. Much depends 
upon the exact position of the iridectomy, which is difficult of per- 
formance on account of the narrow anterior chamber, and no caution 
should be omitted which will secure perfect quiet on the part of the 
patient. 
In performing iridectomy for the relief of acute glaucoma the follow- 
ing directions should be borne in mind: If a keratome (Fig. 300) is 
employed, it should be entered through the sclerotic coat 2 mm. from 
the apparent border of the cornea, and, after the completion of the 
incision (see page 624), should be slowly withdrawn in order to prevent 
a sudden gush of aqueous humor, and a too rapid reduction of tension, 
which might be followed by intra-ocular hemorrhage. If the anterior 
chamber is shallow the iridectomy is usually more easily performed, 
and with better results, if a Graefe cataract knife (see Fig. 345) is em- 
ployed in the usual manner (see page 655). The excision of the piece 
of iris should be complete up to the periphery-i. e., up to the ciliary 
border-and no portion of the excised iris must remain in the angles of 
the wound (compare with page 390). This is a much more important 
matter than the excision of a large piece of the iris-for example, one- 
fifth of it-as is usually advised. A comparatively narrow technically 
correct iridectomy yields satisfactory results. If the tension is very 
high, preliminary scleral puncture, as advised by Priestley Smith and 
Gifford, is a useful procedure. It should be remembered that scleral 
puncture has been followed by intra-ocular hemorrhage (A. Knapp). 
A favorable result may be expected from iridectomy if the tension 
is lowered; an unfavorable one if this remains high. If there is a sudden CHRONIC GLAUCOMA OR NON-INFLAMMATORY GLAUCOMA 
389 
rise of tension a short time after the operation, accompanied by severe 
pain, there is reason to suspect intra-ocular hemorrhage. 
Section of the iris is often followed by an extensive hemorrhage into 
the anterior chamber. A prolonged effort to get rid of this blood should 
not be made lest the trituration produce cataract. The blood will 
absorb, although it may take many days and even weeks before this is 
entirely accomplished. 
The re-forming of the anterior chamber is sometimes delayed as long 
as a week. Occasionally a day or two after the operation there is some 
slight rise of tension in the eye, which is of temporary character. 
There is difference of opinion as to whether the eye should be ban- 
daged or not after operations of this character. The author believes 
that not only should a bandage be applied for the first few days to the 
eye upon which the operation has been performed, but also to the fellow 
eye; and that the one placed upon the affected organ should remain 
there until complete restoration of the anterior chamber has taken place. 
The eye which has not been operated upon should be kept thoroughly 
under the influence of eserin or pilocarpin during the course of the treat- 
ment, because it is well known, in acute glaucoma, that iridectomy may 
be followed by a speedy outbreak of the same disease in the opposite 
eye. In most instances the iridectomy should be placed directly up- 
ward, so that the overhanging upper lid may cover the coloboma. 
Should the primary iridectomy fail to reduce the tension permanently 
it may be necessary to reinforce it with a cyclodialysis or an anterior 
sclerotomy (see page 635). 
The author has expressed his faith in the efficacy of iridectomy in 
acute glaucoma. Col. Elliot and other surgeons decide in favor of 
corneoscleral trephining or other operations designed to establish 
permanent filtration in the acute as well as in the chronic forms of 
glaucoma. 
If the eye which has not been subjected to operation has a 
decidedly shallow anterior chamber, and if there is a history of pro- 
dromal glaucomatous phenomena, it should be submitted to opera- 
tion as soon as the iridectomy wound in the opposite eye has firmly 
healed, certainly before the patient passes from skilled observation, 
because it is practically certain that it will be attacked like its fellow. 
If the signs of impending glaucoma are not clear and the eye is never- 
theless suspected, the mydriatic test suggested by Edward Jackson, 
Harlan, and Brailey, which consists of the instillation of a solution of 
homatropin and noting whether it produces any rise in intra-ocular 
tension or pulsation of the vessels of the fundus, may be employed. 
Should the test be positive, it would seem proper to perform at once 
what Treacher Collins has called a preventive iridectomy, or, following 
Col. Elliot's advice, a corneoscleral trephining. If this is declined or 
deemed inadvisable, the patient should use daily a solution of a miotic 
(strong enough to keep the pupil contracted), and be provided with a 
stronger solution to be used in an emergency-i. e., during a sudden 
attack. If both eyes are affected, both should be operated upon, pro- 390 
GLAUCOMA 
vided the conditions are suitable, at proper intervals; sometimes in 
acute cases operation on one eye must immediately be followed by opera- 
tion on the other. 
One of the complications which may follow the operation of iri- 
dectomy in glaucoma is the formation of a bulging scar at the seat of the 
incision, sometimes called a cystoid cicatrix. This is especially true if 
due care has not been taken to free the angles of the wound from adher- 
ent iris. On the other hand, in severe cases, this very cystoid cicatrix, 
by permitting a filtering of the liquids, has been regarded as a favorable 
condition. In this connection the modern operations for the relief of 
glaucoma, by means of which a filtering area is produced, must be con- 
sidered. They are discussed on page 629. 
The treatment of chronic inflammatory (subacute) glaucoma is 
less likely to be followed by the brilliant results seen in acute cases; 
and many instances are on record in which after the performance of an 
operation, entirely correct in its technic, the disease has not been 
stayed, or malignant glaucoma (see page 390) has resulted. This is 
particularly true if degenerative changes have occurred in the iris. 
Nevertheless, iridectomy preceded, if necessary, by sclerotomy or one 
of its substitutes, that is, corneoscleral trephining or iridosclerectomy, 
will more often yield a satisfactory result than if medicinal measures 
are alone relied upon, and should be performed as early as possible. 
There is much difference of opinion in regard to the value of iridec- 
tomy in simple glaucoma (chronic non-inflammatory glaucoma), and 
some surgeons doubt the propriety of its performance in this disease, 
and depend upon miotics and certain internal remedies-for example, 
strychnin and nitroglycerin. Statistical information indicates that in 
a limited number of the cases of simple glaucoma submitted to iridectomy 
the results are immediately unfavorable-that is, the disease is not only 
not checked, but rapidly progresses to blindness; in a fair percentage of 
cases (15-45 per cent.) the disease remains stationary-that is, the 
iridectomy maintains the condition of vision which was present before 
the operation; in a certain number of cases there is temporary ame- 
lioration, but later slow advance of the disease-a rate of advance, 
however, that is slower than if operation had not been performed; in a 
comparatively small percentage of cases the operation is followed by per- 
ceptible and permanent improvement in vision. 
In a certain number of cases (Friedenwald has collected 24, 18 of 
them being women) a perfectly smooth iridectomy is followed by malig- 
nant glaucoma. The symptoms which usually appear one or twro days 
after the iridectomy are: marked increase in tension, obliteration of the 
anterior chamber, fixation of the coloboma, ciliary tenderness, chemosis 
of the conjunctiva, swelling of the lids, and rapid loss of vision. Hence 
the importance of following Schweigger's advice to operate in chronic 
glaucoma affecting both eyes, first upon the one with the more advanced 
disease, even if it is blind. If no complication arises, there is reason to 
hope that iridectomy on the fellow eye will be followed by a normal 
healing process. The treatment of malignant glaucoma consists in the CHRONIC GLAUCOMA OR NON-INFLAMMATORY GLAUCOMA 
391 
instillation of eserin, or posterior sclerotomy, and the administration of 
large doses of salicylate of sodium (Friedenwald). 
It is not entirely certain how iridectomy cures glaucoma. It has 
been suggested that this is accomplished by the removal of the por- 
tion of tissue which closes the angle at the anterior chamber; by the 
moderation of the blood-pressure in the iris (Exner); by the filtration 
of the fluids of the eye through the line of healing, which, for this reason, 
has been called the filtration scar; by the permanent drain which the 
cut surface of the iris affords, inasmuch as it is not closed by reparative 
processes (Henderson). The details of performing iridectomy and 
sclerotomy will be described in the chapter devoted to Operations. 
The operation of sclerotomy has been used as a substitute for iri- 
dectomy, but the weight of testimony in favor of the latter operation 
is sufficiently great not to make it a more desirable n^de of procedure 
than iridectomy except in selected cases. Every iridectomy which is 
peripherally situated, and in which the knife enters through the sclera 
some distance from the apparent border of the cornea, is in itself a 
sclerotomy. It is useful as a supplement to iridectomy if the tension 
is not reduced, and may be employed in old blind glaucomatous eyes to 
relieve pain. According to the late Dr. de Wecker, sclerotomy, fol- 
lowed later by iridectomy, which can then be performed more correctly 
owing to the improved state of the eye, is preferable to a primary 
iridectomy. 
In recent years a number of important and usually satisfactory 
operations have been devised for the purpose of maintaining a filtering 
cicatrix or area, and, in so far as our present knowledge enables an 
opinion to be formed, their permanent results, other things being equal, 
are much more satisfactory than the simple iridectomy of former times. 
Of these, the most important are Lagrange's operation, by means of which 
an iris-free filtering cicatrix is produced with a combined iridectomy 
and sclerectomy (see page 629), Herbert's wedge-isolation operation (see 
page 630), trephining the corneoscleral border (Fergus-Elliot operation, 
see page 632), and Holth's punch operation. The value of Heine's 
operation, or cyclodialysis (see page 635), in the treatment of glaucoma 
has been much discussed in the past few years; but it is evident that 
while it has its uses it cannot replace iridectomy or the operations just 
referred to. 
The operation of sympathectomy, or excision of the superior cervical 
ganglion of the sympathetic, for the relief of glaucoma has been per- 
formed a number of times. Little is heard of the operation at the pres- 
ent time, and evidently it has, very properly, failed to secure a per- 
manent place in ophthalmic surgery. 
For the relief of the pain of absolute glaucoma opticociliary neurotomy 
has been performed, and is still advocated by some surgeons. In the 
opinion of the author, enucleation or one of its substitutes is a better 
operation, but he also has had some excellent results with cyclodialysis 
and from corneoscleral trephining. In these circumstances, if the other 
eye shows any prodromal signs of glaucoma, it would seem proper that 392 
GLAUCOMA 
an iridectomy or a corneoscleral trephining should be performed in an- 
ticipation of the glaucomatous attack. 
Secondary glaucoma, or that form which arises in consequence 
of some pre-existing disease of the eye, may, like the primary variety, 
assume an acute or chronic type. 
It may follow inflammation of the iris and ciliary body with the pro- 
duction of extensive synechiae; serous cyclitis, ulcers of the cornea which 
have perforated and produced adherent cicatrices or staphylomatous 
bulging; swelling of the crystalline lens after needling; discission of after- 
cataract and, occasionally, primary extraction of cataract; dislocation 
of the lens; detachment of the retina, associated with severe hemorrhage; 
the growth of a choroidal sarcoma or other intra-ocular tumor; and 
choroidoretinitis, plastic choroiditis, or disease of the retinal vessels. 
Owing to injury the vitreous may pass forward into the anterior chamber, 
block the channels of exit, or press against the iris, and thus cause 
secondary glaucoma. Adhesion of the lens capsule to the cornea fol- 
lowing traumatism or cataract extraction not infrequently results in 
secondary glaucoma. 
In most of the instances mentioned there is no difficulty in diag- 
nosticating secondary glaucoma by the history of the case and the 
knowledge of the pre-existing disease. This is not so easy if the original 
trouble has been deep in the eye, for example, a sarcoma. In these 
cases the glaucoma is usually absolute. 
Treatment.-Secondary glaucoma, in general terms, requires the 
same treatment as the primary form of the disease, which must be modi- 
fied according to the surrounding ocular conditions. A dislocated lens, 
or a lens swollen after discission for cataract, should be removed. Abso- 
lute glaucoma associated with great pain, if there is any suspicion of 
intra-ocular growth, indicates excision of the globe. 
Hemorrhagic glaucoma is one type of secondary glaucoma in 
which numerous retinal hemorrhages appear as the result of thrombosis 
of the retinal vessels, or hyaline degeneration of their walls, or other 
causes likely to produce extravasation of blood (albuminuric retinitis). 
The tension rises and the character of the disease may be acute, sub- 
acute, or chronic. This condition should be sharply differentiated from 
primary glaucoma associated with retinal hemorrhages, although some- 
times it is exceedingly difficult to decide whether the glaucoma is second- 
ary to the hemorrhages, or whether the hemorrhages have been pro- 
duced by alterations in the tension of a glaucomatous eye. With the 
ophthalmoscope one may see the ordinary appearances of glaucoma and 
numerous retinal hemorrhages; or, in addition, there may be the lesions 
of the disease which has caused the hemorrhages and the glaucoma which 
followed them. Hemorrhage into the vitreous may occur, obliterating 
the fundus reflex; the cornea is steamy, the anterior chamber obliterated, 
the iris discolored, and the eyeball intensely injected and very hard. 
Iridectomy is not usually followed by good results in hemorrhagic 
glaucoma. It may lead to permanent blindness by fresh hemorrhagic 
exacerbations. If attempted it should be preceded by posterior scle- COMPLICATED GLAUCOMA 
393 
rotomy. Corneoscleral trephining has been tried. The results of ante- 
rior sclerotomy are more favorable than those of simple iridectomy. 
Tapping the vitreous alone may be followed by relief, and cautious 
paracentesis of the anterior chamber was advocated by Bull. If the 
pain becomes intense and blindness ensues, enucleation is required. 
General treatment is of importance, as the patients are usually the sub- 
jects of vascular disease and high arterial tension: the cautious use of 
cardiac sedatives, nitroglycerin, and strict regulation of the diet and mode 
of life. Locally, measures to relieve ocular congestion and the miotics 
may be employed; dionin and holocain often afford decided relief. 
Complicated Glaucoma.-Two kinds of complicated glaucoma 
are described which may be looked upon as varieties of the secondary 
form of the disease, namely, cataract with glaucoma and high myopia 
with glaucoma. In the former condition one eye alone is usually affected. 
It is to be distinguished from the lenticular opacity produced by abso- 
lute glaucoma. During the formation of cataract glaucoma may 
occur, due probably to swelling of the lens and lessening of the circum- 
lental space, and it is important to test frequently the intra-ocular 
tension of patients with developing cataract; preliminary iridectomy 
may be required. 
In high myopia with glaucoma the usual changes in the field of 
vision and the papilla are present. In addition to this there is more or 
less choroidal disturbance, which may itself be the cause of the glauco- 
matous condition. According to Hotta, the first change produced by 
the increased tension is an excavation of the nerve-head, and subse- 
quently an ectasia into the intervaginal space of the immediately sur- 
rounding sclera. 
Hydrophthalmos, or that disease of the eye which has been looked 
upon as a congenital glaucoma, has been described on page 280. CHAPTER XIII 
DISEASES OF THE CRYSTALLINE LENS 
Congenital Anomalies.-In addition to congenital cataract and 
congenital displacement of the lens, which are described on pages 411 
and 412, two anomalies require mention: 
1. Coloboma of the Lens.-This defect occurs usually with a similar 
defect in the iris and choroid. The normal, rounded margin of the lens 
is replaced by a straight margin in a horizontal direction or incurved. 
The amount of the defect varies from a slight indentation to about 
one-quarter of the lens substance. It is almost always situated in the 
inferior half of the lens. 
2. Lenticonus.-This is an abnormal curvature of the posterior sur- 
face of the lens or an anomaly of the nucleus (L. Muller), either unilateral 
and associated with lenticu- 
lar opacities, or without such 
association, and then usually 
bilateral. Anterior lenticonus 
also occurs. With the plane 
mirror a sharp red disk, sur- 
rounded by dark shadows, like 
an oil-globule in water, may 
be seen (Knapp). Congenital 
aphakia, in association with 
faulty development of the an- 
terior part of the globe, has 
been reported; it may also re- 
sult from the absorption and 
degeneration of a previously 
formed lens. 
Cataract.-Under the term cataract are included several types of 
an opaque condition of the crystalline lens, of its capsule, or of both 
these structures, which anatomically are distinguished by the titles 
lenticular, capsular, and capsulolenticular. 
Varieties of Cataract.- (1) Primary; (2) secondary to disorders in 
other portions of the eye; (3) symptomatic of a general malady or local 
injury. 
A cataract is either partial and stationary, or progressive and be- 
comes complete, and clinically is classified as senile, subdivided into 
nuclear and cortical; or, according to Axenfeld, subcapsular, supranuclear, 
and nuclear; juvenile or presenile; congenital, subdivided into complete 
or partial; secondary or complicated; traumatic; and after-cataract. 
Fig. 182.-Posterior lenticonus (from a patient 
in the University Hospital). 
394 CATARACT 
395 
Cataracts are also classified according to their consistence as hard, 
soft, or fluid, and sometimes are designated by their color as black, 
white, amber, etc. Although in many instances the precise division of 
cataract into special varieties may be unimportant, the following table, 
compiled from the classifications employed in various standard works, 
may be useful to the student as a resume of what has gone before: 
1. Lenticular. 
2. Capsular. 
3. Capsulolenticular. 
Anatomically 
1. Senile 
2. Juvenile or presenile. 
(a) cortical 
(b) nuclear 
general. 
(a) complete 
complete, 
congenital. 
Clinically 
3. Congenital 
(b) partial 
lamellar, or zonular, 
axial. 
pyramidal, or polar. 
anterior polar cataract, 
posterior polar cataract, 
complete cataract. 
4. Complicated or secondary 
5. Traumatic. 
6. After-cataract. 
Symptoms.-The following symptoms are present with more or less 
constancy in cataract, exemplified by the senile form of this disease: 
1. Change in Visual Acuteness.-The amount of depreciation of 
sight depends upon the situation and extent of the opacity, and some- 
times upon alterations in the refractive power of the lens. Thus there 
may be an increased refraction at the nucleus, causing myopia, often 
called 'prodromal myopia. In these circumstances distant vision is 
improved by concave lenses and reading becomes possible without the 
aid of convex glasses. This is the so-called "second sight," which in 
itself is strong presumptive evidence of the existence of cataract. In 
like manner the change in the lens may produce an irregular astigmatism, 
or an astigmatism "against the rule" may develop. 
2. Hyperemia of the Conjunctiva.-This is caused by the strain 
which the effort to see through a somewhat clouded lens produces. 
3. Pain and Photophobia.-These symptoms are not prominent; 
but sometimes, owing to the condition of disturbed choroid which com- 
monly is associated with cataract, patients complain of dull, aching 
pain or other asthenopic symptoms. Tinted glasses relieve the photo- 
phobia and permit slight dilatation of the pupil, which sometimes im- 
proves vision if the opacity is central. Pain, with rise of tension on 
account of swelling of the lens, occasionally occurs. Indeed, acute 
glaucoma may be caused by this swelling of the lens during the formation 
of cataract, and the state of the intra-ocular tension deserves close atten- 
tion in all patients with formed or forming cataract. 
4. Polyopia and monocular diplopia are occasionally the result of 
incipient cataract, and are due to the irregular astigmatism which the 
alterations in the lens have produced. 
5. The Anterior Chamber.-This may be normal in depth-the usual 396 
DISEASES OF THE CRYSTALLINE LENS 
condition; shallower than normal-indicating a swollen lens; or abnor- 
mally deep-a symptom of a small lens. 
6. The Pupil -This may be natural in appearance and the mobility 
of the iris entirely normal; but sometimes the effect of exclusion of 
light or of a mydriatic fails to induce a dilatation of the pupil. 
We speak of the "color of the pupil," and this varies in cataract 
according to the degree of maturity and the hue of the opacity. Hence 
in the unilluminated pupil no change is seen in its color in incipient cata- 
ract; but in a ripe cataract the pupillary space may appear dull, gray, 
and even white, according to circumstances. In examples of so-called 
"black cataract" the pupil is dark. The mere inspection of the pupil, 
however, without optical aid is not sufficient to ascertain the condition 
of the lens, which continues to increase in size even with advancing 
years, if it remains clear (Priestley Smith). But it becomes firmer, 
straw colored, and reflects more light. This creates a dull sheen in the 
pupil which may be mistaken for cataract. The yellowish tint of the 
lens in advanced life may modify the relative perception of colors, which, 
indeed, may be so pronounced as to create blue-blindness (C. Hess). 
Diagnosis.-From what has been said, it is apparent that the abso- 
lute diagnosis of cataract depends upon the use of the ophthalmoscope. 
Since the introduction of the ophthalmoscope, the catoptric test has 
fallen into disuse, although it may be employed to determine the presence 
of the lens and in the diagnosis of black cataract. 
This test is performed as follows: If, in a dark room, a lighted 
candle be moved before a healthy eye with dilated pupil, three images 
of the flame will be seen: two erect, formed by reflection from the 
convex cornea and anterior surface of the lens, the former producing the 
bright image and the latter the more diffuse; and one inverted, rela- 
tively clearer, from the posterior surface of the lens. If, now, the lens 
be opaque, the inverted image will be wanting, the deeper erect image 
also disappearing when the opacity involves the capsule, the corneal 
image being then alone visible. 
Before using the ophthalmoscope for the detection of cataract the 
pupil should be dilated, preferably with homatropin, cocain, or euph- 
thalmin. The examiner proceeds in the manner described on page 
99, and will detect in incipient cataract spots or streaks of opacity, 
often radiating from the periphery toward the center, which appear 
black from the interference with the reflection of light from the choroid. 
In like manner the nucleus may be seen to be hazy and the periphery 
clear, or the sectors of the lens are strongly marked. The beginning 
of cataract is also made evident by flaws in the lens, which have been 
compared to cracks in glass, and are known as "striae of refraction." 
If the entire lens is opaque, no portion of the pupillary space exhibits 
any red reflex from the fundus, although a lens which appears com- 
pletely cataractous through the undilated pupil may exhibit spots of 
incomplete opacification in the periphery recognized by the transmitted 
red glare when the pupil is dilated. The final examination with trans- 
mitted light should be made with a +16 D lens or with a corneal loupe. CATARACT 
397 
With oblique illumination (see page 51) the opacities, if incipient, 
appear as white or gray streaks and dots. 
When a progressive senile cataract is fully matured, its presence 
may often be detected without any special examination except in the 
instances already mentioned, but it is a matter of the utmost impor- 
tance to ascertain when this full maturity has been reached, or, in other 
words, whether the cataract is ripe. This is determined in the following 
manner: 
The patient being placed in the proper position, the pupillary space 
is illuminated. If the opacity is complete, the opaque lens, covered by 
its capsule, is level with the margin of the pupil, and there is no shadow; 
if not, the major portion of the opacity is at a level posterior to the plane 
of the pupil, or, in other words, a clear or partly clear space is present 
between the iris and the opaque portion, and a dark semicircle appears 
upon the opacity at the side from which the light comes. This is the 
shadow of the iris. Shining sectors or the transmission of a red glare 
Fig. 183.-Cortical cataract: 1, Section of lens, opacities beneath the capsule; 2, opaci- 
ties seen by transmitted light (ophthalmoscope mirror); 3, opacities seen by reflected light 
(oblique illumination) (modified from Nettleship). 
indicate immaturity, even if the shadow is absent. In hypermature 
cataract the shadow is visible, but the surface of the lens is flat. 
Development, Course, and Pathology of Cataract.-In progressive 
senile or, as it is sometimes called, simple cataract there is a period of 
growth from incipiency to full maturity which varies considerably, 
and ordinarily consumes from one to three years. Often the rate of 
increase is very slow, and immature cataract, especially of the cortical 
variety, may remain unchanged for many years. At other times the 
development of the disease is comparatively rapid. This slow progress 
of cortical senile cataract should be remembered, and the discovery of 
striae in the lens need not condemn the patient to rapid deterioration of 
vision. Indeed, certain lenticular opacities remain practically stationary 
for years. 
The opacities begin either equatorially-n. e., at the edge of the lens- 
or centrally-i. e., at the nucleus. In the former case the striae begin 
just beneath the capsule and are seen both in the anterior and poste- 
rior portions. Sometimes broad sector-shaped opacities form, or the 398 
DISEASES OF THE CRYSTALLINE LENS 
opacities may be narrow, or they may appear as delicate radiating lines. 
They gradually radiate toward the center (encroach on the pupil space), 
the nucleus becomes hazy and sclerosed, the cortical layers become 
opaque, and, finally, the cataract is complete. Cataract, other things 
being equal, is more prone to begin in the lowTer part of the lens than 
elsewhere. 
In the second variety the nucleus becomes hazy and the surrounding 
cloudiness always remains the most opaque portion of the cataract, 
which gradually spreads to the cortex (Fig. 184). Where diffuse 
clouding occurs first at the central portion of the lens, that is, in the 
layers immediately surrounding the nucleus, marked depreciation of 
vision is an early symptom. A frequent lesion is a disk of opacity in 
the posterior layers of the cortex, web-like in structure, or sometimes 
looking like a collection of minute bubbles and striae. This also causes 
marked disturbance of vision. 
To a ring of opacity near the equator of the lens and behind the 
iris, seen in old persons and frequently stationary for long periods of 
time, the name arcus senilis lentis has been given. 
Fig. 184.-Nuclear cataract: 1, Section of lens, central position of opacity; 2, appear- 
ance by transmitted light; 3, appearance by oblique illumination (modified from Nettle- 
ship) . 
Cataract may also begin as a more or less diffuse clouding or in the 
form of small dots, or blister-like bodies, scattered through the cortex, 
or located at either pole, or in opacities which, with transmitted light, 
resemble dark flocculent precipitates. In the last-named circumstances 
the advance is more rapid than where the striae are the first manifesta- 
tion. Instead of going on to maturity, a nuclear haze or a spear of 
opacity may remain stationary, or at least show no practical change 
for years. 
During the formation of cataract the following changes occur in the 
lens: First, there is a separation of the lens-fibers with a collection of 
fluid between them, which coagulates into drops-the spheres of Mor- 
gagni. Later there are swelling, clouding, and fatty degeneration of 
the cortical fibers and the formation in them of nucleated vesicular 
bodies. Ultimately there is disorganization of the fibers, and the 
lenticular tissue is changed into fat-drops, spheres of Morgagni, and 
albuminous liquid, and the cortex separates from the capsule, the CATARACT 
399 
liquor Morgagni collecting between them. The lens nucleus becomes 
sclerosed, but in other respects is not greatly altered. Paul Romer has 
studied the pathogenesis of cataract from the point of view of serum 
investigations, and believes it is possible that, as a result of the de- 
generative processes of old age, antibodies are liberated in the blood 
which possess a definite affinity for certain parts of the lens protoplasm. 
They, by uniting with corresponding receptors of the lens protoplasm, 
are able to damage the lenticular cells, just as blood-corpuscles are 
destroyed by the union with them of specific cytotoxins. 
Maturity may be succeeded by the stage of "overripeness" and the 
cataract gradually shrinks to a flat disk, or the liquefaction of the 
cortical matter permits displacement of the nucleus, a type which is 
known as Morgagnian cataract. Tremulousness of the iris is seen in 
overripe cataracts. Sometimes calcareous degeneration in the lens or 
its capsule may take place. 
The cataract, the development of which has just been described, is, 
for the most part, hard-i. e., the nucleus of the lens is large. Under 
the age of thirty-five all cataracts are soft-i. e., the nuclei are small 
or wanting, just as the lenses in which they develop have failed to attain 
the density which later they assume. 
Causes of Cataract.-1. Age of Life.-Cataract which becomes 
complete is especially frequent after fifty years; but, as Fuchs remarks, 
it cannot be regarded as a physiologic attribute of old age. It is a 
pathologic process, and age, while it is an important factor in its develop- 
ment, must often be regarded only as a predisposing cause. Occa- 
sionally total cataract without apparent constitutional disease is found 
in adolescents. The very beginnings of cataract, according to one 
observer, are not peculiar to old age, but appear between the twentieth 
and the thirtieth year as an equatorial cataract. 
2. Sea1.-This appears to have no decided influence, the sexes being 
about equally affected, unless it be in the zonular variety, in which a 
greater liability of females has been recorded. 
3. Disease.-Sugar has been found in the urine of about 1 per cent, 
of cataract cases, and the cataractous lenses of patients the subjects 
of diabetes mellitus at times contain sugar. According to Klein, 
posterior polar, combined with posterior cortical, cataract, unassociated 
with choroiditis, is significant of diabetes. Albumin is present in about 
6 per cent, of the cases, but the etiologic relation of nephritis to cataract 
has not been proved. Grilli's researches lead him to believe that cataract 
is caused by a species of dehydration of the lens, brought about by an 
insufficient elimination of solids by the kidneys, and a consequent rise 
of osmotic tension in the blood and aqueous humor. Doubtless, changes 
in the osmotic pressure of the fluids circulating around the lens, whether 
they are due to toxic causes or local disease, contribute to the formation 
of cataract, although Romer has shown that they may vary greatly 
without affecting the lens. 
Cataract has also been noted in connection with idiopathic fevers 
and allied diseases, with gout, malaria, influenza, rachitis, syphilis 400 
DISEASES OF THE CRYSTALLINE LENS 
(Bos), angiosclerosis, and especially atheroma of the carotid (Michel), 
epilepsy, and other convulsive seizures, meningitis (Bock), certain 
cutaneous affections (Mooren, Rothmund, Andogsky-dermogenetic 
cataracts'), with bronchocele, with hookworm disease (Calhoun), and 
sea-sickness (Weeks). As Becker has stated, however, a connecting 
link between constitutional maladies and opacities of the crystalline 
lens has not been established. The frequency with which lenticular 
opacities, either cortical or at the posterior pole, appear in eyes the 
retinal arteries of which show signs of degeneration (see page 453) is 
well known. The late D. W. Greene studied the relationship between 
increased blood-pressure and the formation of cataract, and believed 
that increased arterial tension exerted a certain influence in the causa- 
tion of lenticular opacities. It is possible that sclerotic changes in the 
nutrient vessels of the anterior uveal tract may aid in the development 
of lenticular degeneration. Schiotz has described a relationship between 
cataract and disturbances of internal secretion. 
4. Occupation.-Cataract is especially frequent among glass-blowers, 
and is attributed to the effect of the radiated heat and excessive per- 
spiration. In bottle-makers, cataract the lesions often consist of a dense, 
well-defined disk of opacity in the center of the posterior cortex, sur- 
rounded by smaller opacities. It is not improbable that additional 
investigations such as the author made years ago would show the same 
liability to cataract in puddlers and others exposed to intense heat; 
indeed, Cridland has observed in furnace-workers cataract resembling 
that which is frequent in glass-blowers, to which the name furnace- 
workers' cataract has been given. 
5. Heredity.-Remarkable examples of the influence of heredity 
in the formation of cataract have been published. It has been noted 
that the tendency is more marked in the child-bearing period, and that 
the transmission is through the female line; transmission through the 
male line only, however, has been recorded. All phases of this subject 
were elaborately studied by the late Kir. Nettleship. In both groups 
of acquired cataract, that is, senile and presenile or juvenile cataract, 
the transmission is almost always direct. Occasionally a generation 
is skipped. Referring to the frequency of inherited cataract, he found 
that women are somewhat more liable to familial acquired cataract than 
men. 
6. Toxic Agents.-Cataract has been produced artificially by poison- 
ing rabbits with naphthalin (naphthalin cataract), sodium nitrate, and 
other toxic agents. In addition to the cataract, there are changes in 
the retina and vitreous and also general disturbances. 
During epidemics of ergotism patients are at times affected with 
cataract (rapAanic cataract), the appearance having been noted almost 
exclusively in the convulsive type of this toxemia; hence it is not certain 
whether the lenticular opacity results from the poisoning by the ergot 
or on account of the convulsions. 
7. Traumatism.-Cataract may follow a direct injury to the lens, 
or be caused in an indirect manner-for example, by a concussion (con- CATARACT 
401 
cussion cataract"). To this category belong those cataracts which have 
followed a lightning-stroke. A number of examples are recorded, both 
double and single, partial and complete. In addition to the cataract, 
optic neuritis, optic atrophy, rupture of the choroid, iritis, iridocyclitis, 
miosis, mydriasis, and palsy of accommodation have been observed. 
Cataract may also be caused by a violent electric shock. 
8. Diseases of the Eye.-Cataract may be secondary to numerous 
acute and chronic affections of the eye-viz., iritis, iridocyclitis, irido- 
choroiditis, choroiditis, detachment of the retina, glaucoma, and diseases 
of the cornea, especially sloughing ulcers. The frequent coexistence of 
disturbance of the choroidal coat and incipient cataract has led to the 
opinion that while opacity of the lens (so-called senile) is a condition 
commonly seen in advanced life, it does not, in all probability, depend 
upon senile changes, but is originated in local pathologic states involv- 
ing the nutrition of the eye itself (Risley). 
9. Accommodative Strain.-Investigations show that a large majority 
of cataractous eyes are hyperopic and astigmatic, and it has been stated 
that the danger of cataract is increased where the astigmatism is against 
the rule and remains uncorrected. The evident prophylactic measure is 
the use of proper glasses. 
The etiology of cataract is by no means always clear, and often 
several factors are necessary to explain it; sometimes no direct cause 
can be assigned; frequently there are extra-ocular causes and the 
cataract results from nutritive disturbances. 
The following additional facts in regard to the clinical varieties de- 
serve attention: 
I. Senile Cataract (Simple Cataract; Gray Cataract").-1This, repre- 
senting the type of general cataract which develops after the fortieth 
year of life, is nuclear, cortical, or mixed in its origin. It may not 
appear before the sixtieth year. Its course from incipiency to full 
maturity has been described. 
The color usually is gray, and the nucleus, which itself does not 
become cataractous, but is hardened, may be recognized by its yellowish 
or brownish hue and its waxy appearance. 
If the nucleus is small and the surrounding cortex uniformly white, 
the cataract is comparatively soft; if the nucleus is large and the color 
of the cataract distinctly gray, yellowish, or brownish, it is hard. 
Instead of a gray or grayish-white color, the cataract may be yellow 
or amber, or the sclerosis of the nucleus extends to the cortical sub- 
stance, so that the whole lens is brownish and the pupil black (black 
cataract"). Sometimes there is opacity of the hyaloid membrane, which 
Fink calls hyaloid cataract. Occasionally cholesterin crystals may be 
found in cataracts, not only in the senile, but also in the juvenile 
variety. 
Senile cataract generally is bilateral, one eye being more affected 
than its fellow; but a cataract may attain maturity in one eye before 
the other lens is affected (unilateral cataract"). 
II. Juvenile cataract is a term descriptive of those opacities of the 402 
DISEASES OF THE CRYSTALLINE LENS 
lens which occur before the fortieth year of life. To such cataracts the 
name presenile is also given (Nettleship). 
In forms of cataract developed in early life the evidence of the in- 
fluence of heredity is often strong. 
General cataracts in young persons {complete cataract of young 
people) may arise without known cause or from one or other of the causes 
already recorded. These are bluish white, often have a sheen like pearl, 
and are soft. 
HI. Congenital Cataract.-This may appear as a complete or partial 
opacity of the lens. In the complete form the lens usually is white or 
bluish-white in color, densely opaque, and soft. The eye may be other- 
wise healthy, or there may be changes in the choroid, retina, optic nerve 
(congenital amblyopia), and sometimes vices of conformation, as 
coloboma, microphthalmos, and hydrophthalmos. Disturbances of 
nutrition during intra-uterine life, changes in the choroid, arrest of 
development, consanguinity of 
parents, and heredity have been 
invoked to explain its existence. 
There are several varieties of 
partial congenital cataract: 
(a) Zonular or lamellar cataract 
appears, as its name implies, in 
the form of an opaque layer sur- 
rounding the clear, but some- 
times cloudy, center of the lens, 
and is the most frequent form of 
partial congenital cataract. On 
the surface streaks of opacity are 
often evident, which may project into the clear cortex and are called 
"riders." Usually it is double, but may be unilateral, and is either 
congenital or forms in early infancy. The cataract is stationary in 
most instances, but occasionally becomes complete. 
If the center of the pupil is examined, a reddish point surrounded 
by a grayish halo will be observed. When the pupil is dilated with 
atropin and examined with the ophthalmoscopic mirror, the central 
dark zone will be apparent, surrounded by a reddish circle, due to the 
reflection from the fundus passing through the peripheral part of the 
lens, which remains clear. With oblique light the appearances may be 
as in Fig. 185. A rare type is several zones of opacity separated by 
zones of transparency. Patients with zonular cataract act like myopes, 
and the refraction of the eye may be myopic. Macular changes are 
not infrequent. 
The cause of lamellar cataract is not certainly known. In the 
congenital variety it is probably due to some developmental defect; in 
the variety arising in early infancy some fault in nutrition has occurred. 
Most often the subjects are rachitic, and present the teeth and cranial 
asymmetry peculiar to this affection. Peters considers tetany a more 
common cause than rachitis, and Hesse and Phelps emphasize the fre- 
Fig. 185.-Zonular cataract (after Spicer). CATARACT 
403 
quent association of zonular cataract and tetany-both are attributed 
to parathyroid insufficiency. A history of convulsions is common, and 
dental defects, which are present in the form of lines, furrows, or ter- 
races, may lie transversely across the incisors or canines. Anatomically, 
lamellar cataract consists of a narrow zone of degenerative change in 
the lens-fibers, situated be- 
tween the nuclear and cor- 
tical areas (Lawford). 
Cataract may develop in 
later life, that is, between the 
ages of twenty and fifty, 
in persons who suffer from 
tetanic spasms. These pa- 
tients may also suffer from 
loss of hair, necrosis of the 
nails, and chronic skin erup- 
tion. To such cataracts the 
name tetany cataract has been given, and they are apparently due to a 
toxin which affects epithelial structure (E. T. Collins). 
(6) Central cataract (central lental cataract) consists of a white opacity 
in the central part of the lens, due probably to faulty development at 
an early stage of intra-uterine existence. Sometimes vision is surpris- 
ingly good; at other times it may be poor, and defects of development 
in the eye may be present and nystagmus may develop. 
(c) Pyramidal Cataract- This is also known as anterior capsular or 
polar cataract, and consists of a small, well-defined, pyramidal-shaped or 
circular opacity due to hyper- 
plasia of the capsular epithe- 
lium and degeneration of the 
lens-fibers in that position. It 
probably arises in consequence 
of contact of the lens and 
cornea in fetal life, which 
causes an arrest of osmosis of 
nutritional fluid (E. T. Collins). 
Mules suggested that these cat- 
aracts may be cretified remains 
of the pupillary membrane. 
At the posterior pole of the 
lens an opacity similar to the 
one described may be found, known as a posterior polar or pyramidal con- 
genital cataract. It is caused by vestigial remains of the hyaloid artery 
at its lenticular attachment, or persistence of the part of the posterior 
vascular sheath of the lens, and, strictly speaking, is not a true cataract, 
that is, the changes are not in the lens. These opacities are sometimes 
separated into those which lie beneath the capsule and those which 
exist upon its surface. A small dot-like opacity of this origin, and 
which does not disturb vision, is quite common. 
Fig. 186.-Anterior polar cataract (after Nettle- 
ship). 
Fig. 187.-Posterior polar cataract seen by 
transmitted light (from a case of pigmentary 
degeneration of the retina). 404 
DISEASES OF THE CRYSTALLINE LENS 
(d) Punctate cataract is an unusual form of congenital lenticular 
change in which the opacities present themselves in the form of more 
or less fine points, occupying the center of the pupillary space. The 
cataract remains stationary for a long time. 
(e) Fusiform cataract is a rare variety characterized by an opaque 
stripe passing from the anterior to the posterior pole of the lens, some- 
times with offshoots, disposed like coral branches. It may be com- 
bined with zonular cataract. It is also known as axial or coralliform 
cataract, and is prone to occur in families. Nettleship's list contains 
the record of one family in which thirty members, in four generations, 
were known to be affected. Nettleship and Ogilvie have described a 
peculiar form of congenital family cataract in which a disk of opacity, 
"consisting of a single layer, always thin, but varying in transparency, 
is situated behind the nucleus, but well in front of the posterior capsule." 
Disk-shaped opacities behind the nucleus, often hereditary, are also 
termed "Doyne's cataract." 
IV. Complicated or Secondary Cataract.-This may be complete 
and arise in consequence of the various diseases of the eye enumerated 
on page 399. In iritis, for example, fibrinous exudations are attached 
to the lens-capsule, contraction occurs, the capsule is disturbed in 
its relation to the underlying lens-fibers, which are separated, and 
cataract forms. If this process is a limited one, the lenticular opacity 
may remain circumscribed. It may also be incomplete, and appears 
in the following varieties: 
(a) Anterior Polar Cataract.-In addition to the congenital variety 
of this opacity there is an acquired type, which arises in consequence 
of a perforating ulcer of the cornea-for example, in ophthalmia neo- 
natorum (see page 198). In infants' eyes it may follow ulceration of the 
cornea without perforation. 
(6) Posterior polar cataract, as a congenital variety, has been de- 
scribed ; but another form is the more or less star-shaped opacity, which 
is the commonest variety of complicated cataract, seen at the posterior 
pole of the lens in high myopia, vitreous disease, disseminated choroiditis, 
and pigmentary degeneration of the retina. It may remain stationary 
for a long time, disturbing vision in proportion to its density, or it may 
progress and become complete. Other forms of posterior polar lenticu- 
lar opacity, unconnected with evident disease of the ocular coats, 
are not infrequent. The opacity may be circular, irregularly star 
shaped, and resemble a small meshwork interspersed with dots and 
blebs. It may remain unchanged for long periods of time, or the 
remaining part of the lens may gradually become opaque. A similar 
appearance toward the anterior pole of the lens is sometimes visible; 
occasionally the opacity exists in both positions at the same time. 
A form of complicated family cataract has been described by Purt- 
scher and by Zentmayer. It occurs about the age of thirty in eyes with 
thin, bluish-white scleras, tremulous gray-brown irides, deep anterior 
chambers, contracted pupils, and a tendency to glaucoma after operative 
interference. CATARACT 
405 
V. Traumatic Cataract.-This is caused by direct injury to the lens 
by some penetrating substance which lacerates the capsule and then 
permits the entrance of the aqueous humor. (See also page 400.) The 
lens substance swells up, becomes opaque, and some of it may escape 
into the anterior chamber. Absorption takes place in about six weeks. 
This course represents the most favorable outcome of such an accident. 
In other cases there may be iritis, cyclitis, and secondary glaucoma, 
owing to swelling of the lens. 
Instead of going on to complete opacity, an injured lens, in some 
instances, presents a limited opacity, which remains stationary; in 
other instances this disappears, and in still others there is slow advance 
of the opacity. 
The opacity was explained by Marcus Gunn by the action of the 
sodium chlorid of the aqueous humor upon the globulin of the lens 
substance. This explanation, according to C. A. Clapp, is inconsistent 
with chemical facts. He believes that when "the lens-fibers are broken 
up they undergo autolytic changes." 
A more indirect mechanism of traumatic cataract is concussion 
(concussion cataract)-a blow upon the eye causing a slight rupture of 
the anterior or posterior capsule, followed by opacity, which may be- 
come general or retain a limited size for a long time. According to 
Nettleship, absorption of a complete concussion cataract is more un- 
common than where the lenticular opacity has followed a direct trauma, 
although the lens may gradually shrink in size. A ring-shaped opacity 
may appear on the surface of the lens after contusion of the eye, gener- 
ally in young eyes. This is a circular opacity, 3 to 4 mm. in diameter, 
concentric to the margin of the pupil, and of a brownish color. The 
lesion is sometimes called Vossius' ring, or contusion-lesion of the lens 
(Caspar). Vossius ascribes the lesion to pigment adherent to the cap- 
sule or to disturbance of the epithelium. It is, as it were, a cast of the 
iris margin and its pigment on the capsule. In several eyes studied 
by the author the lesion disappeared within a few weeks after the 
injury. 
VI. After-cataract.-This name has been applied to those changes 
which occur in the capsule of the lens remaining after the extraction of 
cataract. It is usually called secondary cataract. 
These changes may depend on proliferation and thickening of the 
capsular epithelium; on agglutination of the two layers of the capsule, 
the anterior part being so folded over that it has retained cortical mate- 
rial, which has thus been shut off from the dissolving action of the 
aqueous and remains as a membranous opacity; or upon new-formed 
tissue between the capsule layers or thickened elements from the 
anterior part of the vitreous. If there has been postoperative reaction, 
fibrinous exudation from the iris adds to the opacity. The name has 
also been given to the dense white membrane (membranous cataract) 
which is composed of deposits of lymph, and fibrinous and plastic exuda- 
tion, and to which the iris and even the ciliary processes are adherent, 
and which follows postoperative iridocyclitis. (Consult Fig. 354.) 406 
DISEASES OF THE CRYSTALLINE LENS 
VII. Capsular Cataract.-The name capsular cataract is applied to 
thickenings and proliferations of the capsular epithelium, and sometimes 
to subcapsular degeneration of the lens-fibers, which may be congenital, 
may follow inflammatory processes of the eye (corneal ulcer), and may 
occur in connection with other degenerations in overripe cataract. 
VIII. Capsulolenticular cataract is the name applied to opacity of 
the lens associated with thickening of the surrounding capsule, most 
commonly in the center of its anterior portion. 
Prognosis.-Incipient cataract in the form of striae in the anterior 
cortex need not doom the patient to rapid deterioration of sight, be- 
cause the existing vision is often maintained for long periods of time. 
Spontaneous disappearance of senile cataract has been reported. Ac- 
cording to Pyle, this may occur on account of ruptured capsule, dis- 
location, or degenerative changes; rarely the phenomenon has been 
observed, although the history of such etiologic relationship could not 
be obtained. 
Operation is generally deferred until the cataract is ripe. The sur- 
geon must ascertain whether the eye itself is in a healthy condition by 
attention to the following considerations: 
(a) The probable condition of the interior of the eye, if no data of oph- 
thalmoscopic examinations during the incipiency of the cataract are at 
hand. This is ascertained as follows: 
Place the patient before a lighted candle about 4 meters distant- 
the flame should be distinctly recognized. This gives evidence that the 
macular region is free from extensive disease, but does not exclude a 
small lesion. Next cause the eye under examination to fix the flame 
attentively, and move a second lighted candle radially through the field 
of vision. The flame should be recognized as soon as the rays strike the 
edge of the cornea, and the patient should be able to indicate the direc- 
tion in which it is coming. Thus the "light-field," or the "projection 
of light," is tested, and, if the answers have been accurate, "projection 
of light is good in all parts of the field." 
If the patient fails to appreciate the candle-flame in any portion of 
the field, coarse changes may be suspected-e. g., extensive* choroiditis, 
detachment of the retina, glaucoma, etc.; but it is not possible to detect 
a small area of central choroiditis by this means (see also page 353). 
The macular region should be investigated by requiring the patient 
to note the separation of two small centrally placed flames, or by 
causing him to look at the light through a small aperture in the center 
of a disk. Fluid vitreous, indicated by tremulousness of the iris, is an 
unfavorable sign. Should there be no light-perception, the cataract is 
an unsuitable one for operation except that in certain circumstances its 
extraction is justified in order to improve the patient's appearance. 
(6) The Probable Condition of the Refraction.--It may be impossible 
to ascertain this unless some record is at hand of an examination when 
the media were still clear. Some idea of the refraction is obtainable by 
examining the glasses which the patient may have used during his 
reading days. High myopia renders the prognosis less favorable; in- CATARACT 
407 
deed, the vision after operation in myopic cases, other things being 
equal, is not so good as that of hyperopes. 
(c) The Mobility of the Iris; Its Reaction to a Mydriatic.-This 
should be prompt and normal. Failure of iris reaction in either case 
may indicate imperfect conductive power in the optic nerve, or atrophy 
or other change in the iris. 
(d) The Age and General Condition of the Patient.-Advanced age 
alone does not militate, as much as it would seem likely to do, against 
successful cataract extraction. So, too, the extraction of diabetic 
cataract is often followed by good results; and even the presence of 
chronic Bright's disease, while a complicating circumstance, does not 
forbid the operation. Great feebleness, dementia likely to become 
worse with confinement, nasopharyngitis, advanced arteriosclerosis, 
eczema, cystitis, and chronic bronchitis are unfavorable conditions. 
According to Hansell, syphilis should be regarded as a dangerous com- 
plication. 
(e) The Condition of the Area of Future Operation and of Its Sur- 
roundings.-Disease of the lacrimonasal channels, trachoma, chronic 
conjunctivitis, and blepharitis contraindicate cataract extraction be- 
cause the wound is almost certain to become infected by the unhealthy 
discharges. In such circumstances a line of treatment later described 
must be instituted before operation. A matter of importance, not 
always attended to, is the state of the rhinopharynx. This should be 
reasonably healthy to secure the highest type of success. Eczema of the 
face or other regions of the body is a source of danger. Prior to cataract 
extraction a careful bacteriologic examination of the conjunctiva is im- 
portant. 
(/) The Type and Condition of the Cataract.-In making a prognosis 
the size of the nucleus and its position, the probable consistence of the 
cortex, the primary or secondary nature of the cataract, and its stage of 
maturity must be considered. Certain conditions (amblyopia) influence 
the prognosis in complete congenital cataract, and in the partial varieties, 
like the lamellar form, the eye may be defective in construction. In 
traumatic cataract the extent of injury to parts other than the lens must 
be regarded. 
Treatment.-This may be divided into the treatment of immature 
and of mature cataract. 
Drugs do not exist which can dissolve a growing cataract; and the 
use of electricity, which has been recommended, is of no value. Massage 
of the eyeball associated with the instillation of a mixture of glycerin 
and boric acid solution has been commended (Kalish). The author has 
failed to observe the slightest benefit from such treatment. 
1. The refraction should be carefully tested and that glass ordered 
which gives the most accurate vision. It may be necessary to make 
frequent changes in the correcting lenses to conform with the altera- 
tions in refraction brought about by the swelling of the lens. 
2. Congestion of the choroidal coat may be relieved by the exhibition 
of certain alteratives, among which the iodids of sodium and potassium 408 
DISEASES OF THE CRYSTALLINE LENS 
and syrup of hydriodic acid are the most suitable. The iodids may be 
combined with small doses of bromid of potassium or bromid of sodium. 
Subconjunctival injections of iodid of potassium have been recom- 
mended (Badal, von Pflugh); of their value the author has no knowledge. 
Dor advocates the treatment of cataract locally with a solution com- 
posed of 5 grams of desiccated sodium iodid, 5 grams of crystallized 
calcium chlorid, dissolved in 400 grams of distilled water. The solution 
should be applied for half an hour a day by means of a glass eye-bath. 
The daily instillation of a 1 per cent, solution of iodid of sodium or 
iodid of potassium has also been tried. Some observers report favorable 
results from the persistent use of dionin in solutions of gradually ascend- 
ing strength. Col. Henry Smith strongly recommends subconjunctival 
injections of cyanid of mercury (1 :4000-6000). The moderate use of 
the eyes may be permitted without danger of hastening the process of 
maturation. If the patient suffers from diabetes, nephritis, lithemia, or 
arteriosclerosis, suitable dietetic and medicinal measures should be 
employed. Drinking water freely is advised by Edward Jackson. 
3. Often comfort may be given and vision improved by keeping the 
pupil dilated with a weak mydriatic (if the opacity is central). Tinted 
lenses, which correct any existing refractive error, should be worn. In 
other cases a miotic is useful. 
If the vision of eyes suffering from cataract of the nuclear type is 
improved by mydriasis, this has been given as an indication for optical 
iridectomy, but is not a sufficient one unless the patient finds by observa- 
tion that the increased visual acuteness, as noted by test-type examina- 
tion, is also advantageous in pursuing his ordinary occupation. 
Artificial Ripening.-The exceeding slowness with which a senile 
cataract may progress often leaves the patient in a state of semiblindness. 
To remedy this, several methods have been proposed for hastening the 
process of ripening. 
Simple division of the anterior capsule; division combined with 
iridectomy (Mooren); division and external massage (Rohmer); iridec- 
tomy and triturating the lens-fibers by rubbing the cornea over the 
coloboma with a horn spoon (Forster's method); paracentesis of the 
cornea, and internal massage directly on the anterior capsule with a 
small spatula (Sasso and Ricaldi and B. Bettmann, of Chicago); and 
simple paracentesis of the cornea with external massage (T. R. Pooley, 
of New York, and J. A. White, of Richmond, an operation practised by 
the latter surgeon with much success). 
A discission, after the manner of Graefe, carried deep into the lens 
substance, was recommended by Schweigger as the only satisfactory 
method, especially before the fortieth year; and a preliminary capsu- 
lotomy has been advised and practised by Homer E. Smith (see page 669). 
He has reported excellent results, as have other surgeons who have 
followed his method. 
Treatment of Immature Cataract.-Some operators of extensive 
experience hold that the usual criteria of ripeness are erroneous in that 
period when accommodation is annulled by physiologic changes in the CATARACT 
409 
lens-that is, about the sixtieth year-and the lens may be extracted 
safely even if it is in part unclouded. It may also be done successfully 
at an earlier age. 
Many operators, following McKeown's advice, after the extraction 
of immature cataract resort to intracapsular irrigation and wash out 
tenacious cortical material with a suitably warmed physiologic salt 
solution. Indeed, irrigation of the anterior chamber forms part of the 
technic of all cataract operations in the hands of some surgeons. Suit- 
able irrigation apparatus has been designed by McKeown and by J. A. 
Lippincott. 
If the unripe material is not removed it may swell up and cause iritis. 
Therefore the safest plan is to wait for maturity; but if this is impossible 
or very undesirable, the author has been in the habit of extracting an 
unripe cataract in preference to performing a ripening operation. 
With irrigation of the anterior chamber the author's experience has been 
comparatively limited, but the testimony, constantly increasing, of its 
value in removing cortical material and aiding in a restoration of tone 
to the eye tissues, especially the iris, is so clear that evidently it repre- 
sents a procedure which should be considered in all suitable cases. 
According to Colonel Henry Smith, Derrick Vail, W. A. Fisher, and 
a few other surgeons, the best means of managing immature cataract is 
its extraction in the capsule by the so-called Indian or Smith method (see 
page 660). The stage of immaturity at which Smith advocates the ex- 
traction of immature cataract in the capsule is where the opacity has 
progressed so far as to unfit the patient for the performance of his ordi- 
nary duties. With this operation the author has had no experience. If 
the patient is unable to wait for maturity of the cataract, he has often 
successfully extracted an unripe lens after preliminary iridectomy, and 
recently has employed irrigation with normal saline solution to get rid 
of cortical remnants. In a few instances he has practised deep discis- 
sion or preliminary capsulotomy. 
Treatment of Mature and Complete Cataract.-Mature cataract 
recjuires an operation for its removal, differing according to the age 
of the patient and the consistency of the cataract. 
Hard cataracts, or those which occur after the fortieth year, are 
suitably removed either by-(a) simple extraction (extraction without 
iridectomy), (6) combined extraction (extraction with iridectomy), or 
extraction after preliminary iridectomy. 
In recent times extraction in the capsule, according to the Smith 
method, has been extensively tried. 
Soft cataracts, or those which occur before the thirtieth year, are 
suitably removed by-(a) linear extraction; (6) the needle operation, 
or that of solution by discission; and (c) the suction method. A soft 
cataract before the twenty-fifth year may be removed through a linear 
incision into the cornea, and a semifluid one by suction. Complete 
cataract of young people and complete congenital cataract are generally 
removed by discission, the latter variety of cataract being ready for 
operation after the completion of dentition. 410 
DISEASES OF THE CRYSTALLINE LENS 
According to E. Treacher Collins, a child should be ten months old 
before operating for congenital cataract. If the pupil is small and does 
not dilate with atropin, an iridectomy may first be necessary. In so- 
called disk-shaped cataract, that is, where an anterior polar one is set 
in a ring of clear or partially clear lens substance, an attempt should 
be made to dislocate it with a needle and let it fall into the anterior 
chamber. 
Treatment of Partial Congenital Cataracts.-Central, lental, and 
zonular cataracts are treated by iridectomy or by discission. The 
former procedure is better if, after dilatation with a mydriatic, there is 
sufficient improvement in vision to justify the manufacture of a new 
pupil or glasses do not improve vision. This should be made opposite 
to the clearest part of the lens. If this does not prove satisfactory, the 
lens may be needled or, finally, the entire lens may be extracted. 
Pyramidal, punctate, and fusiform cataracts are not generally amen- 
able to operative treatment. Discission or one of its substitutes is the 
method of operating applied to after-cataracts. 
Extraction of unilateral cataract will not usually give the patient in- 
creased visual acuteness because; owing to the inequality of refraction, 
the eyes will not work together. The operation may be performed 
(simple extraction) for cosmetic reasons, to avoid overmaturity in the 
opaque lens, and to improve the field of vision upon the affected side. 
If there is divergence, a subsequent tenotomy of the externus or ad- 
vancement of the interims may be necessary. 
The technic of performing the various methods of cataract extrac- 
tion, the dangers and accidents, will be described on pages 647-669. 
After a successful extraction or solution, and after sufficient time has 
elapsed to secure firm healing, a suitable pair of lenses should be ad- 
justed-one for distant vision and one for reading. 
Removal of the crystalline lens produces the condition technically 
spoken of as aphakia, and causes a high degree of hyperopia, in the emme- 
tropic eye corresponding to about 11 D. The degree of hyperopia will 
be diminished if the previous refraction has been myopic, and it is 
possible to produce emmetropia provided the former near-sightedness 
has been of such degree that the removal of the lens exactly neutralizes 
it (see also page 136). 
In ordinary circumstances the correcting lens for distant vision 
is about +10 D. For reading and similar occupation a lens having 
a focal distance of 25 to 33 cm. is added to the distance glass. 
In addition to the hyperopic refraction which follows cataract ex- 
traction, a certain amount of regular astigmatism is the result of the 
operation, due probably to failure of the wound to heal evenly on account 
of inaccurate coaptation of its edges, caused by the character of the in- 
cision or by some condition-for example, badly applied dressings- 
during convalescence. This astigmatism is generally "contrary to the 
rule," and is often higher during the first month or two after the extrac- 
tion, or until cicatrization is complete, than it is at a later period. 
Usually not more than 3 D remain permanently, but even 1 D should DISLOCATION OF THE CRYSTALLINE LENS 
411 
be sought out and corrected. Naturally, prolapse or incarceration of 
the iris causes a very high degree of astigmatism. 
Glasses should not be adjusted until all redness has disappeared from 
the eye, and they should not be worn constantly at first. It is wise to 
wait from six weeks to two months before ordering the glasses for con- 
stant use. 
The amount of vision obtained after a cataract extraction varies 
quite considerably. Perfect vision is frequently secured-i. e., 
but more often patients must be content with lower degrees, | or, 
according to some operators, of normal vision being considered 
sufficient to place the case within the category of successes. 
Acuteness of vision may be considerably raised by successfully 
dividing the capsule of the lens which remains behind, and some sur- 
geons perform this operation almost as the rule (see Operations). 
Fig. 188.-Spontaneous dislocation of lens into the anterior chamber of highly myopic eye 
(from a patient in the Philadelphia General Hospital. Drawing by Dr. Randall). 
Dislocation of the Crystalline Lens.-This may be congenital 
(ectopia lentis), and is due to a relaxation or absence of the zonula. 
The displacement ordinarily is incomplete, and really consists in a de- 
centration of the lens; but complete congenital luxation is also described. 
Congenital cases are usually symmetric, and generally the displace- 
ment is lateral, upward, or upward and outward. But in the course 
of time the lens may leave this position, owing to elongation of the 
zonular fibers, and be displaced downward and outward. Several 
members of the same family may be affected; for example, G. Griffin 
Lewis has reported hereditary ectopia lentis extending through six 
generations and involving sixteen individuals. Unilateral cases are 
also described. 
In addition to congenital dislocations, there are those due to disease 
of the eye-e. g., choroiditis, malignant myopia, etc.-and those caused 
by traumatism. Traumatic dislocation may also be incomplete or 
complete; if the latter, the lens may be dislodged from its normal position 412 
DISEASES OF THE CRYSTALLINE LENS 
backward into the vitreous, forward into the anterior chamber, or, 
through a wound, beneath the conjunctiva, and even under Tenon's 
capsule. 
Symptoms.-If the dislocation is partial, the margin of the lens 
may be seen as a dark line with the ophthalmoscope, the refraction of 
the eye will vary according to the point through which it is observed 
(i. e., through the lens or beyond it), the iris is tremulous from loosening 
Fig. 189.-Congenital dislocation of the crystalline lenses, up and out (patient in the 
University Hospital). 
of the suspensory ligament and lack of the support of the lens (irido- 
donesis), and monocular diplopia and impaired or absent power of 
accommodation are demonstrable. If there is complete posterior luxa- 
tion, the symptoms are much the same as when the lens has been removed 
by operation, and if the cause of the dislocation is trauma, the symp- 
toms of the injury-e. g., hemorrhage, etc.-may be present. 
Fig. 190.-Subconjunctival dislocation of the lens (from a patient in the Chester County 
Hospital). 
A dislocated lens usually becomes cataractous, and often causes 
intense pain and frequent attacks of iritis, or, by occluding the angle 
of the anterior chamber, may give rise to glaucoma. 
Treatment.-In partial dislocation an attempt should be made to 
secure the best vision with suitable glasses. Sometimes it is possible 
to remove an incompletely congenitally luxated lens by linear extraction 
following a discission. FOREIGN BODIES IN THE LENS 
413 
In complete luxation into the anterior chamber the lens may be 
removed by a simple corneal incision. For removal of a lens dislocated 
into the vitreous humor, provided it is producing irritation, a scoop 
introduced through a peripheral corneal incision may be employed, or 
the operation devised by the late C. R. Agnew may be attempted. In 
the latter, a double needle or "bident" is thrust into the vitreous humor 
far enough back to avoid wounding the iris, the handle of the instrument 
is depressed, the lens is caught and brought forward through the pupil 
into the anterior chamber, and removed in the ordinary way. Knapp 
prefers, in these circumstances, after thorough local anesthesia, to expel 
the lens by methodical external pressure through an upper corneal 
section, after removal of the speculum. He presses the edge of the 
under lid on the lower part of the sclera, directly toward the center of 
the eyeball. If this fails, he introduces a wire or metal spoon through 
the corneal section and the pupil, and extracts the lens in this way. 
The author has employed this method with satisfaction. 
If the lens has been dislocated beneath the conjunctiva, it should 
be extracted through a small incision made directly over it. 
After the successful removal of a dislocated lens the eye should be 
provided with cataract glasses. 
Foreign Bodies in the Lens.-Foreign bodies lodged in the lens 
usually cause general opacity. Occasionally the body is surrounded 
by a small opacity which remains localized, the remainder of the lens 
being clear. If a piece of steel or iron is embedded in the superficial 
layers, it may be dislodged with the electromagnet, and even from the 
deeper layers by the powerful magnet of Haab. If the lens is opaque 
the whole crystalline lens, with the foreign body in it, should be ex- 
tracted, lest the foreign body become displaced and disappear within 
the eye. If any difficulty is experienced in deciding the position of the 
foreign body, or whether a foreign body is really in an opaque lens, the 
Rontgen rays should be employed. A properly prepared series of skia- 
grams will practically always decide the question. CHAPTER XIV 
DISEASES OF THE VITREOUS 
Inasmuch as the vitreous after birth contains no blood-vessels and 
is not subject to inflammation, it has been contended that the term 
hyalitis is not correct. Straub, however, defends its use in that he be- 
lieves that irritants in the vitreous may produce chemotactic substances 
which attract leukocytes from the vessels of neighboring structures, and 
the process should be regarded as a true inflammation. 
Pus in the Vitreous (Abscess of the Vitreous).-This condition is 
caused by a penetrating injury, a foreign body, or a purulent choroiditis, 
for instance, a metastatic choroiditis after inflammation of the cord in 
newborn children, or after scarlet fever, erysipelas, relapsing fever, 
basic meningitis, cerebrospinal meningitis, etc. (see also page 358). 
Purulent collections in the vitreous may complicate the infectious 
diseases or may be caused by an infection which passes through an opera- 
tion scar from a few months to many years after apparent healing. 
Cystoid cicatrices are particularly dangerous in this respect. The 
entrance of bacteria may be facilitated by the presence of prolapsed 
iris tissue, thinness of the scar, a fistula, and insufficient nourishment of 
the cicatricial tissue. On experimental grounds a defect in Descemet's 
membrane appears to be necessary to permit the microbes to pass into 
the deeper tissue of the eye. Even when the scar is dense and there is 
no fistula, bacteria may enter (Dolganoff and Sokoloff). 
Symptoms.-If the cornea is clear, a yellowish reflex is seen shining 
through the pupillary space, there are retraction of the periphery 
of the iris and bulging of its pupillary border. Usually one or two 
synechiae are present and the tension is diminished. In addition to 
this, there may be a pericorneal zone of congestion connected with the 
inflammation of the iris and ciliary body. 
If the exudation in the vitreous is circumscribed, the symptoms 
at the first glance are not unlike those of glioma of the retina, and the 
name pseudoglioma has been given to this condition, especially as it is 
seen in children. It is, however, to be distinguished from a true glioma 
of the retina by the history of the case, the usual presence of the signs of 
iritis, the retraction of the periphery and bulging of the pupillary border 
of the iris, and the diminished tension of the globe. 
These cases of pseudoglioma or ophthalmitis are especially noteworthy 
as they occur in children and young subjects suffering from meningitis. 
There is purulent inflammation of the uveal tract, with deposits of exu- 
dation in the vitreous which give rise to the yellowish ^appearance 
which can be seen through the pupil. The retina is detached and the 
optic nerve inflamed. The affection has been attributed to an exten- 
sion of inflammation from the meninges along the optic nerve, but 
414 OPACITIES IN THE VITREOUS 
415 
Percy Flemming suggests that the meningitis and ophthalmitis is each 
the result of a pyemic process. The source of the pyemia may be 
middle-ear disease. Stephenson urges examination of the pus in the 
eye for the meningococcus (Diplococcus intracellularis meningitidis). 
This micro-organism is also responsible for some cases of purulent con- 
junctivitis (see also page 189). Among 43 cases of ophthalmitis there 
have been 7 deaths, 6 from meningitis (see also page 357). George Coats 
and J. Graham Forbes have carefully investigated the relation of the 
Meningococcus intracellularis to pseudoglioma, and believe that a causal 
relation may be established between this organism and this disease. 
Treatment.-If pus has once formed in the vitreous, in the manner 
just described, no medicinal treatment is of avail; the ball will shrink 
and enucleation is usually necessary. Intra-ocular injections of chlorin 
water have been recommended. 
If, during the earlier stages of this affection-for instance, during 
the course of a low fever-the discovery is made that fine flakes of opacity 
are beginning to appear in the vitreous, it is possible that a vigorous 
supporting treatment may save the eye from destruction (Hansell). 
Opacities in the Vitreous.-These are either fixed or moving, 
and vary considerably in shape, size, and somewhat in color. The 
opacities may appear in the form of membranes, bands, dots, threads, 
flakes, and strings; or, finally, the entire vitreous humor may give 
evidence of uniform loss of translucency, which on careful focusing 
resolves itself into a diffuse, dust-like opacity. 
The fixed membranous opacities usually are adherent by two or 
more points to the choroid, retina, optic disk, and sometimes to the 
ciliary processes, and even to the posterior capsule of the lens. They 
may exist as a membrane which crosses the vitreous and covers the optic 
disk, or as membranous bands running from before backward, and may 
be coarse, dense, and organized, or fine and more like a cobweb in texture. 
Method of Detection.-The examination of the vitreous is made after 
the manner described on page 99. 
The rapidity with which the bodies move depends upon the con- 
sistency of the vitreous humor; if this is normal, the movement is slow; 
if it is fluid or semifluid, the movement is correspondingly rapid. 
The different layers of the vitreous may also be examined for fixed 
opacities by means of the upright image in the ordinary way, by first 
finding the optic papilla, then gradually placing stronger and stronger 
convex lenses behind the sight-hole of the mirror until a + 16 D is in 
place, thus bringing everything into focus from behind forward. The 
observer's head must be close to the observed eye. 
The subjective symptoms of vitreous opacities depend entirely upon 
their amount and density. There may be little or no depreciation of 
central vision, or this may be diminished and even entirely obliterated. 
Patients frequently are conscious of black and gray spots before their 
eyes; sometimes these assume fantastic shapes, and not infrequently 
these shapes repeat themselves so constantly that the patient is able 
accurately to describe them. The same symptoms may appear where 416 
DISEASES OF THE VITREOUS 
there is no organic disease (see page 417). Alterations in the field of 
vision, pain, redness of the eye, or similar conditions will depend largely 
upon associated changes, and usually are absent if the vitreous alone is 
affected. 
Causes.-1. Refractive error, generally high degrees of myopia asso- 
ciated with changes in the choroid and posterior staphyloma. 
2. Diseases of the eye, chiefly cyclitis, iridocyclitis, uveitis, choroid- 
itis, and retinitis. 
The shape and character of the opacities vary with the condition 
which has caused them. In cyclitis and iridocyclitis inflammatory 
opacities are seen; in chronic and old-standing choroiditis flake-like or 
thread-like opacities are very common, especially in elderly people, and 
are probably due to hemorrhages having their origin in the choroid. 
In syphilitic choroiditis and retinitis, in addition to large, floating opaci- 
ties, there may be a diffuse mist which resolves itself into the so-called 
dust-like opacities (hyalitis punctata), and is almost characteristic of the 
disease which has caused the original inflammation of the choroid and 
retina. These dust-like opacities are either diffused throughout the 
entire vitreous chamber, or are situated in its posterior layers, or ante- 
riorly, in the neighborhood of the ciliary region. 
3. Injuries of the eye, which have caused a hemorrhage from the 
choroid or ciliary region. The origin of the opacity is an extravasation 
of blood. In the latter case, as has already been mentioned, suppuration 
of the vitreous may occur. 
4. Diseased Conditions of the System, Local or General.-Infectious 
diseases, wide-spread endarteritis; arteriosclerosis, gout, syphilis, tuber- 
culosis, malaria, portal congestion, anemia, and irregular or suppressed 
menstruation may be responsible for vitreous opacities; also the pro- 
longed action of arsenic. 
5. Absence of Apparent Cause.-Opacities of various shapes, often 
fine and thread-like, and commonly seen in old people, occur without 
evident disease of the uveal tract, retina, or optic nerve. Their pres- 
ence in some instances is without serious import. Sometimes the vitreous 
is studded with minute light-colored spheres; probably a congenital 
condition, named asteroid hyalitis by Benson. White, glistening spots in 
the vitreous have also been described as evidences of fatty degeneration. 
Prognosis.-This depends entirely upon the cause of the vitreous 
disease. If this has started in a purulent disease of the choroid or a 
purulent change in the vitreous has taken place, the prognosis is ex- 
ceedingly unfavorable, and the eye goes on to destruction. 
If the cause of the disease is syphilis or other constitutional condition 
amenable to treatment, satisfactory clearing of the vitreous may be ex- 
pected; even very dense opacities will disappear under proper treatment. 
When the opacities are due to hemorrhage, the absorption of the clot is 
not so likely to take place. Both hemorrhagic opacities and others are 
subject to relapses. 
Treatment.-In any case of vitreous opacity, provided the general 
fundus of the eye-ground justifies this, and there is reason to believe that HEMORRHAGE INTO THE VITREOUS 
417 
eye-strain in any sense is connected with its cause, suitable lenses should 
be ordered, but the use of the eyes at close ranges should be discouraged. 
In syphilitic vitreous disease the usual remedies are applicable. If 
the vitreous change depends upon an exhausted condition of the system, 
supportive measures are indicated. 
If the patient's condition warrants it, excellent results follow sweats 
induced with pilocarpin, or by means of Turkish baths or in an ordinary 
electric lighted cabinet. lodid of potassium and sodium are useful, 
as is syrup of hydriodic acid. 
If the disease which implicates the vitreous depends upon consti- 
pation and portal congestion, in addition to a regulated diet cholagogue 
laxatives should be administered. Anemia and menstrual irregularities 
are evident indications for treatment; in the former case the combina- 
tion of bichlorid of mercury with iron is useful. If there is an active 
inflammatory condition, blood-letting from the temple may be prac- 
tised; in fact, the treatment becomes that which is suited to the acute 
inflammation which has started the disorder. The use of the galvanic 
current has been warmly recommended by some surgeons in vitreous 
opacities. Elschnig has treated a certain number of eyes with vitreous 
opacities following hemorrhage by aspirating | c.cm. of vitreous and 
replacing it with normal saline solution. 
Muscae volitantes (myodesopia) are the black specks and motes 
often seen in the field of vision, especially if the eye is directed 
toward a bright surface. They follow the movements of the eye, and 
are especially annoying during the act of reading, as they float across 
the page. They do not actually interfere with vision. 
There is no true opacity of the vitreous, and the ophthalmoscope 
fails to detect in these instances opaque particles. They are probably 
due to the shadows thrown upon the retina by naturally formed elements 
in the vitreous bodies, perhaps the remains of embryonic tissue. Cor- 
puscles in the retinal vessels may be seen by looking through a dark- 
blue glass at a white cloud. They appear as small oval bodies. 
Although of no serious import, so far as sight is concerned, these 
muscse produce an amazing amount of annoyance in nervous and sensi- 
tive persons. Patients frequently maintain that they obscure an 
object, floating directly in front of it, and they assume exaggerated and 
fantastic shapes. They are often ascribed by the laity to disorders of 
digestion and torpidity of the liver, and are aggravated by the habit 
which their possessors form of searching for them. 
Treatment.-Eye-strain should be removed by the adjustment of 
suitable lenses, and a course of alterative tonics may be ordered. 
Hemorrhage into the Vitreous.-As has already been stated, 
many vitreous opacities result from hemorrhages from the vessels of 
the choroid, ciliary body, or retina. Hemorrhage into the vitreous may 
result from anemia, nephritis, diabetes, arteriosclerosis, myopia, and 
glaucoma. According to Ridley, if the hemorrhage arises from the retinal 
vessels, the hyaloid is usually detached and the blood lies between this 
membrane and the vitreous. If the ciliary body is the source of the 418 
DISEASES OF THE VITREOUS 
hemorrhage, it usually bursts through the hyaloid into the vitreous. 
Retinal detachment may occur, especially if the hemorrhage recurs on 
several occasions. Injury is a common cause of hemorrhage in the 
vitreous, and in such circumstances the entire chamber may be so filled 
with blood that it is easily detected in its natural color as a dark-red 
clot, sometimes being so dense that no reflex comes from the fundus. 
Finally, in certain cases, generally in young male adults, spontaneous 
hemorrhage into the vitreous occurs, together with hemorrhage in the 
retina. According to Eales, such patients are liable to constipation, 
irregularity of the circulation, and epistaxis. Hutchinson thinks that 
gout may be a cause in some cases. The investigations of Axenfeld and 
Stock indicate that an important etiologic factor in recurring intra- 
ocular hemorrhage in adolescence, as well as in proliferating retinal 
lesions and retinal periphlebitis (see also page 440), is tuberculosis, the 
active agent being a tuberculous toxin. The author has made some 
clinical examinations in confirmation of this statement. There is 
marked disturbances of vision depending on the density of the clot, 
which is likely to be imperfectly absorbed, and both in this form of 
vitreous hemorrhage as well as in others there may be repeated blood 
extravasation. To these frequently recurring hemorrhages into the vit- 
reous the term "malignant" has been applied. It is possible, as Coats 
suggests, that anomalies in the coagulability of the blood may account 
for many of these cases. 
Treatment.-This should consist in the administration of cardiac 
sedatives, laxatives, and later of iodid of potassium or sodium, accord- 
ing to the circumstances. If arteriosclerosis is present, the usual 
treatment of this condition is indicated. Sometimes instead of elevated 
there is lowered arterial tension. The administration of calcium salts 
to aid the coagulability of the blood is worthy of trial; coagulose and 
pituitrin may be administered and thyroid extract has been successfully 
employed. Injections of hemolytic serum have been tried, but with disas- 
trous results (Elschnig). Intravenous injections of human blood-serum 
have been used (A. E. Davis). Ligation of the carotid for recurring 
hemorrhage into the vitreous has been performed, and in a few in- 
stances with success. As in other vitreous changes, if the general con- 
dition permits it, a sweat-cure may be instituted, either by means of 
the Turkish bath or with pilocarpin. Enterogenous auto-intoxication 
should be corrected. Because of the relation of tuberculosis to this 
condition the advantages of tuberculin treatment should be considered. 
Synchysis (Fluidity of the Vitreous) .-This is a softened or fluid 
condition of the vitreous, which, as has already been implied, can be 
positively diagnosticated or, rather, assumed to be present only by 
noticing the rapid movement of particles of opacity contained within 
it during motions of the eye. Although tremulousness of the iris is 
sometimes seen where there is decided fluidity of the vitreous humor, 
this symptom does not prove its condition, but only a lack of support by 
the crystalline lens owing to relaxation of the zonula. The tension of 
the eyeball may be diminished. BLOOD-VESSEL FORMATION IN THE VITREOUS 
419 
It occurs in elderly people with disease of the choroidal coat and in 
high myopia. A fluid vitreous is a complication of serious import in 
cataract extraction. 
Synchysis scintillans is a term applied to a fluid vitreous which 
holds in suspension numerous scales of cholesterin which move with 
great rapidity across the ophthalmoscopic field and produce a striking 
picture, resembling a shower of brilliant crystals. Poncet has reported 
in this connection tyrosin and crystallized phosphates, but investigations 
seem to show that the appearance is due solely to cholesterin. 
The affection probably depends upon a choroiditis, and is said to 
be more common among alcoholic subjects and those with arthritic 
tendency or any serious disorder of nutrition. The affection is, however, 
clinically at least, seen in eyes which apparently are not diseased in 
Fig. 191.-New blood-vessel formation in the vitreous. 
other portions, especially in old people, and may be present in advanced 
degree without depreciation of visual acuteness. 
Treatment.-This does not appear to have any influence. Suc- 
cinate of iron has been recommended. 
Blood=vessel Formation in the Vitreous.-Occasionally cases 
are examined which present an entirely new blood-vessel formation in 
the vitreous in front of the entrance of the optic nerve (Fig. 191). 
Only a few vessels may be present or, in extreme cases, the entire 
disk is obscured by a congeries of contorted vessels, the whole forming 
an extensive vascular veil of anastomosing capillaries coming directly 
from the nerve-head and having no connection with the retinal vessels 
(Harlan). The vessels may owe their origin to vitreous and to retinal 
hemorrhages; in other cases the origin is probably of a specific nature 
(Hirschberg). The relation of tuberculosis to this and similar condi- 
tions has been described. 420 
DISEASES OF THE VITREOUS 
Foreign Bodies in the Vitreous.-These are usually chips of 
steel, splinters of glass, particles of gun-cap, or small shot. They 
may reach the vitreous by penetrating the sclera directly or by passing 
through the cornea and lens. The foreign body, if unremoved, may 
cause suppuration in the injured eye or sympathetic ophthalmitis in the 
fellow eye. The symptoms, diagnosis, and treatment of foreign bodies 
in the vitreous have been included with injuries of the sclera on pages 
293-297. 
Entozoa in the Vitreous.-Cysticerci in the vitreous are exceed- 
ingly rare except in Northern Germany, and here also, according to 
Hirschberg, their frequency in recent years has much diminished. 
Another parasite which has been seen in the vitreous, the removal of 
at least one specimen being on record, is the Filaria sanguinis hominis. 
Detachment of the vitreous is a condition which, of itself, would 
not create blindness; but because it produces detachment of the retina, 
it is a change of the gravest import. 
Traumatism, choroiditis, hemorrhages, intra-ocular growths, and 
staphyloma may cause it. The vitreous humor is said to be occa- 
sionally detached without change in its translucency, although opacities 
are usually present. Shrinking of the vitreous after a blow on the eye 
causes its hyaloid to be detached from the retina. In eyes removed 
after injury, stretching across the globe behind the lens, the so-called 
cyclitic membrane may be seen. 
Persistent Hyaloid Artery.-During fetal life the vitreous humor 
is traversed by the hyaloid artery, which is an extension of the central 
artery of the retina, and proceeds from the optic nerve to the posterior 
surface of the lens. The vessel passes through a channel having a. 
delicate membranous lining, known as the canal of Cloquet. Oblitera- 
tion of this artery begins at the end of the fifth month of gestation. 
Sometimes obliteration fails, and the most important congenital 
anomaly of the vitreous is evident-namely, the persistence of some 
vestige of the hyaloid artery. It may appear in the following'forms: 
A rudimentary strand attached to the disk; a strand attacned to the 
disk and a vestige also at the posterior surface of the lens; a strand 
passing from the disk to the lens; a similar strand containing blood; 
a strand attached to the lens alone; and a persistent canal (canal of 
Cloquet) without any remnant of the vessel. These are the most 
ordinary and well-recognized forms. 
In addition to this, shreds of tissue and membranes on the optic 
disk, masses resembling connective tissue, and small cystic bodies are 
probably remnants of this artery. Its role in producing posterior 
capsular cataract has already been described. The appearances are 
readily recognized by the ophthalmoscope, and require no further 
description than the names already given. 
This classification has been condensed from the admirable mono- 
graph of Dr. De Beck who has written a complete account of the anomaly. 
According to Uribe Troncoso, a free cyst developed from the ciliary proc- 
esses may give rise to the appearance of a vesicle floating in the vitreous. CHAPTER XV 
DISEASES OF THE RETINA 
Hyperemia of the Retina.-Although the capillary network of 
the retina, invisible in ordinary circumstances, may, under other con- 
ditions, become evident {capillary congestion), the presence of a con- 
gestion is inferred, not by any alteration in the appearance of the retina 
itself, but by changes in the surface of the optic disk, generally known 
by the terms increased redness or undue capillarity, and is associated 
with increase in the amount of the retinal striation which surrounds the 
papilla, so that its edges are veiled or slightly blurred. Such appear- 
ances are common in asthenopic and ametropic eyes, and in persons 
whose occupations expose them to the glare of artificial heat-e. g., 
puddlers. 
It is possible to speak with more confidence of a change in the 
caliber, course, color, and general size of the retinal vessels, provided 
more than the normal amount of blood finds its way into them and they 
are distended, tortuous, or positively lengthened. It is customary to 
describe the hyperemia as active if an increased amount of blood is sent 
to the retina, because the systemic circulation is unduly filled-e. g., 
in rapid action of the heart with fever, pneumonia, etc.-and as ijassive 
if the blood is not properly returned from the eye, for example, in com- 
pression of the retinal vein. In the last-named circumstance the veins 
are large, filled with dark blood, and often tortuous, while the arteries 
are unaffected or are smaller than usual. 
Among the general causes of a stasis-hyperemia may be mentioned 
mitral disease, emphysema, violent cough, convulsive seizures, or, in 
short, any cause which is likely to produce engorgement of the veins of 
the head and neck, and to prevent the emptying of their contents into 
the great venous channels of the chest. Increase in the diameter of the 
veins is much more frequent than increase in the diameter of the ar- 
teries, while, on the other hand, increase in the diameter of the arteries 
is uncommon as compared with a diminution of their caliber (Loring). 
Pathologic significance must not always be ascribed to apparent changes 
in the diameter of the veins, because eye-grounds are often crossed by 
large dark veins, the arteries being small by contrast, without definite 
local or general cause for the phenomenon. 
Ordinarily patients with hyperemia of the retina do not present 
characteristic symptoms, but if the condition is connected with ame- 
tropia there are ocular pain, photophobia, and lack of eye endurance. 
Treatment.-In hyperemia dependent upon errors of refraction the 
evident treatment is physiologic rest under the influence of atropin, 
421 422 
DISEASES OF THE RETINA 
and later a suitable correction with glasses. When the condition depends 
upon general causes, these furnish the indications for treatment. 
Anemia of the retina should be looked upon not as a disorder 
of this structure, but as a symptom of local pressure or of some cause 
situated within the general economy. 
The highest type of anemia of the retinal vessels is seen with stop- 
page of the circulation by an embolus or thrombus, and occurs in 
marked degree as the result of compression, in consecutive atrophy of 
the optic nerve. Other causes of anemia of the retina are general 
anemia, cerebral anemia, and syncope. 
Extreme narrowing of the retinal arteries is occasionally seen as the 
result of a vasomotor spasm-for example, in "sick headaches" and in 
true migraine. In these cases there may be temporary complete or 
partial (hemianopic) blindness. If the blindness approaches from 
above downward, the obstruction is in the retinal circulation, but if it 
assumes a lateral form, the cortical visual centers are probably affected 
(Priestley Smith). Impeded retinal circulation may be attributed to 
the high arterial tension which is known to be present in some cases 
of migraine. 
Under the name ischemia of the retina a condition is described in 
which, with complete blindness, there are pallor of the optic disks and 
extreme narrowing of the retinal blood-vessels. This has been seen in 
the collapse stage of cholera (Graefe), in whooping-cough (Knapp, 
Noyes), in erysipelas (Ayres), and under the influence of toxic doses 
of quinin and salicylic acid. 
Treatment.-The flagging circulation should be stimulated by digi- 
talis and strychnin. Nitrite of amyl has been employed in spasm of the 
retinal arteries. General anemia calls for its appropriate remedies. 
Hyperesthesia of the Retina.-This is characterized chiefly by 
the symptoms which indicate a supersensitive state of the retina-dread 
of light, lacrimation, blepharospasm, neuralgic pain, and imperfect eye 
endurance. 
Ophthalmoscopic changes may be practically absent, but in most 
instances those lesions will be detected which have been referred to 
under congestion, but which, adopting a name which was originally 
employed by Jaeger and later used by Loring, may be described as irri- 
tation of the retina. These are: undue redness of the nerve-head, veiling 
of its nasal edges, from which, and from those above and below, distinct 
striation of the retinal fibers are evident, while streaks of light tissue 
can be followed along the course of the larger vessels. The margins of 
the disk are veiled by this retinal striation, and although the physio- 
logic cup, or the "light spot," may be unchanged, the general sur- 
face of the disk seems to be covered with a delicate layer of edematous 
tissue. At the same time the choroid reveals changes similar to those 
described on page 344, or else is distinctly granular and macerated. 
Often the entire fundus fails to present a distinct ophthalmoscopic 
picture, and may be described by saying that the details of the eye- 
ground are not sharply seen with the aid of any correcting glass. ANESTHESIA OF THE RETINA 
423 
Causes.-Hyperesthesia and irritation of the retina are usually 
caused by errors of refraction and anomalies of muscle balance, espe- 
cially in neurasthenic and hysteric subjects. They also owe their origin 
to chronic headache, neuralgia, sexual abuses, prolonged fevers, pul- 
monary disorders, and exposure to bright light. In a series of cases 
which the author has reported, oxaluria appeared to be the source of 
trouble. 
In some instances of retinal irritation the cause seems to be de- 
pendent upon changes in the nasopharynx; for example, engorgement 
of the septum, associated with myxomatous and hypersensitive spots, 
vasoparetic and infiltrated turbinals, and secondary changes in the 
pharynx and larynx. Just as areas of hyperesthesia in these regions 
may be part of a general neurosis, so, also, they may be both directly 
and indirectly connected with a hyperesthetic condition of the retina, 
and the eyes will not grow comfortable until the nasal disease is cured. 
It is probable that retinal irritation may sometimes be the forerunner 
of organic change in the optic nerve (Loring). 
Treatment.-Spectacles are not a panacea, and although errors 
of refraction should always be neutralized, the correcting lenses alone 
do not suffice to relieve the symptoms. General tonics, rest, massage, 
and all measures calculated to overcome debility or existing neurosis 
are required. The nasopharynx should be explored. A thorough ex- 
amination of all organs should be instituted and treatment directed 
according to the findings. Retinal irritation is apt to be exceedingly 
stubborn. 
Anesthesia of the retina (neurasthenic or nervous asthenopia), like 
several other disorders of the retina just considered, should be regarded 
not as an affection peculiar to the eye, but as one of the symptoms of a 
complicated neurosis. Very often the condition described in the pre- 
ceding paragraph and the present affection are closely allied, and with 
neurasthenic asthenopia there may be marked hyperesthesia and irrita- 
tion of the retina. On the other hand, such appearances may be entirely 
absent. 
The subjective symptoms of this condition have been arranged by 
Wilbrand and others as follows: Headache, particularly throbbing in 
the brow and temples, occipital distress, pain in the back of the neck 
and spine, vertigo, muscee volitantes, defective accommodation, intol- 
erance of light, and improvement in vision in the dusk and through 
tinted glasses. Any attempt at concentrated vision is followed by a 
rapid disappearance from view of the object which is to be fixed. There 
are diminution of central vision, sudden attacks of obscuration of vision, 
processions of scotomas, visual hallucinations, lack of fixation of the 
optical memory images, persistent and confusing after-images, colored 
vision-for example, erythropsia-and a red appearance of the pages of 
a book, the letters of which seem to be green. 
In this affection peculiar alterations of the visual field, the so-called 
fatigue contractions, appear. The following forms have been described: 
The shifting or displacement type, originally investigated by Forster, 424 
DISEASES OF THE RETINA 
in which the visual fields differ according as the examination is con- 
ducted from the temporal side to the nasal, or from the nasal side to the 
temporal, the contraction being pronounced on the nasal side in the 
former, and on the temporal side in the latter; the exhaustion type of 
Wilbrand, in which the test-object is moved from the temporal side to 
the nasal, and from the nasal side to the temporal, several times in suc- 
cession, across the entire width of the perimeter-indeed, as often as 
the field continues to diminish; unstable concentric limitation-that is, a 
field which is constantly changing during examination; the exhaustion- 
spiral type, in which the tracing of the visual field appears coiled like 
a watch-spring, in consequence of its limits becoming concentrically 
smaller; and, finally, the recuperation-extension type, in which the re- 
stricted field may extend during rest or by a strong effort of will. 
The "oscillating field" described by Wilbrand and O. Koenig may 
also be found, in which the object disappears and reappears several times 
in the same meridian, and in which a similar oscillation occurs with 
colored test-objects. Such fields are not only encountered in so-called 
nervous asthenopia, but with the retinal exhaustion which is found in 
a variety of conditions. 
Patients thus affected are, for the most part, women, often the 
subjects of ovarian and uterine diseases, neurasthenia, hysteria, and 
chlorosis. It is not an uncommon affection in children between the 
ages of nine and fifteen, in whom, in addition to reduction of central 
visual acuteness, there is marked contraction of the visual field. Pure 
types of retinal asthenopia are also seen in men. 
Treatment.-This should include all suitable general measures, and 
not infrequently a "rest-cure," namely, rest with seclusion, forced feed- 
ing, massage, and electricity. 
Although tinted glasses are recommended, they are not always ad- 
visable, lest the affected eyes become too much accustomed to the dull 
light afforded through such protection. Any error of refraction should 
be corrected, but spectacles and treatment designed to relieve imbalance 
of the ocular muscles are usually not alone sufficient to cure these 
patients. It should be remembered, however, that errors of refraction 
are often the source of the trouble, and that they must always be thor- 
oughly and carefully corrected if good results are to be obtained. The 
neglect of this part of the treatment has been the origin of many cases 
of chronic invalidism. 
Cyanosis of the Retina.-This name is applied to an ophthal- 
moscopic picture seen in patients with congenital heart disease and 
general cyanosis. The vessels of the fundus are dilated, especially the 
veins, which may be greatly distended and tortuous. They carry blood 
much darker than is normal, and the arteries resemble in color the 
ordinary retinal veins. Small hemorrhages near the disk and larger ones 
in the macula may be present; sometimes vision is normal; sometimes 
it is greatly reduced. The ophthalmoscopic appearances of the affection 
were first described by H. Knapp; they have been studied and depicted 
in this country by Posey, H. H. Tyson, and T. B. Holloway. In RETINITIS 
425 
cyanotic 'polycythemia the veins of the fundus are greatly enlarged and 
are very dark colored; the arteries are not materially changed. Retinal 
hemorrhages may be present (E. Jackson, Parker). 
Retinitis.-Under the general term retinitis are included the various 
types of inflammation of the retina. 
Varieties and Causes.-Retinitis, like iritis and choroiditis, may 
depend upon constitutional disorders, altered states of the blood and 
blood-vessels, infections, auto-intoxication, toxins and traumatisms, or 
be due to an extension of a diseased process from an inflamed iris, 
ciliary body, or choroid-that is, the retinitis is either primary or 
secondary. Retinitis is often classified according to the probable 
etiology-for example, syphilitic, renal, diabetic, hemorrhagic, etc., 
retinitis. It is further divided, according to its character, into circum- 
scribed and diffuse, and was formerly separated, according to its sup- 
posed pathologic nature, into serous and parenchymatous retinitis. 
Pathology.-In the acute stage of retinitis the retina exhibits edema 
and infiltration with leukocytes and red blood-corpuscles. White areas 
are visible, due to fatty degeneration of both nervous and supporting 
tissues, varicosity and swelling of the nerve-fiber, and to masses of 
fibrinous exudation in the granular and nuclear layers. The blood- 
vessels are thickened, often obliterated, and the supporting tissue 
hypertropied. In the later stages of atrophy the retina consists of a 
connective-tissue network which contains many pigment cells; the ner- 
vous elements disappear, and the blood-vessels are converted into solid 
cords. In brief, as Ginsberg summarizes the matter, the changes which 
present themselves for consideration include edema and exudation, 
hemorrhage, and small-celled infiltration; proliferation of the neuroglia 
and the vessel wall connective tissue; degeneration of the retinal ele- 
ments, the vessels, and the neurogliar tissue; and pigmentation. 
Symptoms.-Certain objective and subjective symptoms are present 
in most of the forms of retinitis. 
1. Loss in the Transparency of the Retina.-This may manifest itself 
as a faint, diffuse haze, a circumscribed opacity and swelling, or as 
streaks of white infiltration, especially along the lines of the larger 
vessels. 
2. Areas of Exudation-These are an advanced stage of the con- 
dition just described. They appear as white spots, sometimes discrete, 
sometimes confluent, or as patches of bluish-gray, buff, or yellowish 
color. They should be differentiated from the shining white plaques 
due to atrophy of the choroid by their softer tone, their situation, and 
because there is an absence of accumulation of choroidal pigment. 
They may be present anywhere in the retina or localized in the macular 
region. 
3. Tortuosity of the Vessels and Change in Their Caliber.-The veins 
are darker than normal, unduly wavy in outline, or positively length- 
ened in their course. The arteries may not be materially changed, but 
the finer transverse branches are often very tortuous, and both sets of 
vessels are liable to displacement from their normal level as they cross 426 
DISEASES OF THE RETINA 
areas of thickening, or to partial obscuration by the puffy and infil- 
trated retina. Many vessels invisible in health become injected in 
retinitis and form a fine red striation, passing from the nerve-head. 
Pulsation of the vessels is readily induced by pressure. 
4. Hemorrhages.-These occur either in the fiber-layer or the 
deeper portions of the retina. The presence of retinal hemorrhage 
alone, however, does not indicate the existence of inflammation, as it 
may occur quite independently of retinitis. 
If the hemorrhage is in the nerve-fiber layer, it usually assumes a 
flame-shape, with frayed or feathery edges; if its situation is in the 
deeper layers, it has a cleaner-cut border and more rounded shape. 
5. Changes in the N erve-head.-More or less change in the optic 
papilla is present: undue redness, loss of the distinctness of its margins, 
obscuration by the swollen and puffy retinal fibers, or, finally, positive 
inflammation or neuritis. Atrophy of the disk is commonly present 
after severe retinitis. 
6. Pigmentation.--Black spots of pigment mark the situation of 
former retinal hemorrhages. Pigment in the retina, like hemorrhages, 
although in many instances a sequence of retinitis, is of itself not neces- 
sarily a symptom of inflammation of this membrane. 
The difference between pigment in the retina and in the choroid 
has been described on page 345. 
7. Atrophy of the Retina.--This, like atrophy of the choroid, may 
indicate a former hemorrhage or an area of inflammation. All the 
retinal layers, as well as the choroid, may be involved, exposing a 
white patch of sclera (atrophic choroidoretinitis), or only the superficial 
layers may be affected, and the spot may be marked by a permanent 
whitish or yellowish opacity. Contraction of the vessels and white 
tissue along their coats are often seen after retinitis. 
In addition to the ophthalmoscopic signs there are: 
1. Change in Visual Acuteness.-Central vision is diminished in 
direct proportion to the severity of the case and the situation of the 
inflammatory action. 
2. Change in the Field of Vision.-This may be irregularly or con- 
centrically contracted, or scotomas may appear in its center. 
3. Distortion of Vision.-This occurs under several forms: (a) Ob- 
jects appear to be reduced in size if the retinal elements are spread 
a*part (micropsia'); (b) objects appear to be increased in size if the retinal 
elements are crowded together (macropsia); (c) objects appear to un- 
dergo change in their contour or shape (metamorphopsia). Vertically 
placed parallel lines, on the one hand, appear to be bulged outward, and, 
on the other, to be bent inward. Fine parallel lines may appear wavy 
to a normal eye. Retinal metamorphopsia is often associated with a 
scotoma. 
4. Pain and Photophobia.-Acute pain is almost always absent, 
even in violent forms of retinal inflammation; indeed, it is much more 
likely to be present in the less pronounced grades. 
Usually the sensation is one of discomfort rather than of actual TYPES OF RETINITIS 
427 
pain. Photophobia may or may not be present. It is never a marked 
sign, although comfort ensues from the use of tinted glasses. 
The diagnosis of retinitis depends upon the essential symptom of 
the disease-opacity or loss of transparency in the retina. All the 
other symptoms which may be present-exudation, hemorrhages, pig- 
mentation, and atrophy-help to make up the clinical characteristics 
of the various types, but in themselves are not diagnostic of inflam- 
mation of this membrane. 
Much diagnostic aid is obtained by noting the effect of the disease 
upon vision, especially under the influence of diminished illumination, 
and when acuteness of sight fails quite out of proportion to the amount 
of the light reduction, the student should at once be upon his guard. 
Investigation of the light-sense in the manner already described (see 
page 66) is important. If the coarse changes detailed in the general 
symptom-grouping are present, the picture is readily interpreted. 
Course, Complications, and Prognosis.-The course of a retinitis, 
like any other inflammation, may be acute or chronic, and its progress 
of long or short duration. When the retina and choroid are simul- 
taneously inflamed, a common complication is change in the vitreous 
(vitreous opacities), and an almost constant association is inflammation 
of the optic papilla, leading to atrophy in prolonged cases (retinitic 
atrophy). 
The prognosis may be favorable, grave, or positively fatal, depend- 
ing upon the extent of the inflammation, its situation in the inner or 
outer layers of the retina, and the cause. Before giving a prognosis 
the surgeon must always attempt to estimate the extent of the permanent 
disability which is likely to remain in the form of atrophy of the mem- 
brane or secondary changes in the papilla. Other things being equal, 
the prognosis of syphilitic retinitis is the most favorable. 
Treatment.-This, in general terms, demands perfect rest for the 
inflamed organ, and therefore atropin mydriasis is often desirable. In 
sthenic cases, in the early stages, blood-letting from the temple has been 
recommended. 
The remedies most likely to afford relief are the various forms of 
mercury, iodid and bromid of potassium, pilocarpin, and electric-cabinet 
diaphoresis and Turkish baths. Special methods of treatment are re- 
served for the sections devoted to the several clinical varieties. 
Types of Retinitis.-As an introduction to the special varieties 
of retinitis which will presently be considered, it serves a useful clinical 
purpose to refer to two types of retinitis formerly described under the 
names serous and parenchymatous retinitis. The first type, also called 
retinitis simplex, diffuse retinitis, and edema of the retina, is a condition 
characterized by an infiltration, especially of the nerve-fiber and gang- 
lionic layer of the retina, causing opacity, together with hyperemia, 
most marked in the veins. 
The opacity varies from a delicate veiling to a decided gray-white 
opacity, most noticeable around the nerve-head, the margins of which 
are veiled or hidden. From this point the grayish opacity shades out 428 
DISEASES OF THE RETINA 
into the surrounding retina. The disk is not necessarily swollen: it 
may be simply hidden by the infiltrated tissue, or, if this is not 
marked, it is very red and its edges obscured by the radiation of 
finely injected capillaries from its margins. The veins are dark, fuller 
than normal, tortuous, and often partly covered by the swollen tissue; 
the arteries are not much changed in size, unless perchance they may be 
reduced in caliber by compression. Hemorrhages are rare, and exuda- 
tions in the macular region are uncommon. 
There are no external signs of this form of inflammation. Both 
direct and indirect vision are affected, the former being "foggy," the 
latter concentrically contracted. 
The second type, also called deep retinitis, includes those forms of 
retinitis in which, in addition to edematous infiltration, opacity of the 
retina, and venous hyperemia, there are pronounced cellular infiltration 
and structural change, leading finally to atrophy of the elements. 
Exudations of yellowish or gray color are visible, occurring in 
patches throughout the eye-ground, and often localized in a character- 
istic manner in the macula. Small hemorrhages are commonly present, 
and the morbid processes may attack the sheaths of the vessels, causing 
thickening and hypertrophy. 
There are no diagnostic external manifestations. Deeply seated 
pain of a dull, aching character may be present. Vision is often much 
disturbed, varying from a mere fogginess of the outlines of objects to an 
almost absolute loss of sight. Contraction of the field of vision and posi- 
tive scotomas are demonstrable, and the phenomena of distortion of 
objects are apparent. The disease may be circumscribed or diffuse, 
and localized in the external or internal layers, or affect both of these 
and also involve the choroid. 
The prognosis of the second variety is always grave, and although 
in certain cases absorption of the products is possible, compression and 
atrophy of the nervous elements must result in most instances. Inde- 
pendently of the fact that so-called serous retinitis may be the initial 
change of other forms presently to be described, it has been ascribed to 
cold, to undue light and heat, to toxins, infections, and to the influence 
of refractive error in eyes worked under the disadvantage of imperfect 
illumination. The other type depends, as a rule, upon various consti- 
tutional disorders, or occurs in association with other diseases of the eye. 
Partaking of the nature of one or the other of these forms there are 
certain clinical types: 
Syphilitic Retinitis.-The syphilitic forms of retinal inflamma- 
tion have been divided by Alexander into: (1) Choroidoretinitis ; (2) 
simple syphilitic retinitis; (3) retinitis with exudations; (4) retinitis with 
hemorrhages; and (5) central relapsing retinitis. 
The first form in the opinion of many authors is really a disease of 
the choroid, and the pathologic changes of cellular infiltration, exudation, 
atrophy, and proliferation of the pigment epithelium are found in the 
choroid, between the choroid and retina, and in the adjacent retinal 
layers. G. Nagel, however, points out that in specific retinochoroiditis. SYPHILITIC RETINITIS 
429 
there are changes in the retinal vessels-that is, a syphilitic endarteritis. 
The pigment changes are produced by wandering and proliferation of the 
retinal pigment. The choroid is markedly altered; sometimes the 
choriocapillaris completely disappears. In other words, the retinitis 
does not depend exclusively upon a choroiditis, nor does the contrary 
relationship hold good. 
The following signs are visible: Opacity of the vitreous, especially 
in the posterior portion, which resolves itself into fine points or dust-like 
particles, and stretches out to the periphery like a cloud; loss of trans- 
parency of the retina surrounding the nerve-head, which may be unduly 
hyperemic, and on account of the fine opacity in the vitreous may give 
the impression that it is swollen; numerous yellowish or white spots of 
Fig. 192.-Syphilitic retinitis. 
exudation bounded by pigment beneath the vessels of the retina in the 
periphery of the eye-grounds, and white spots in the macula; and, 
finally, occasional participation of the iris and posterior layer of the 
cornea. 
The subjective symptoms are: Depreciation of central vision, very 
marked in the later stages; night-blindness and great lessening of visual 
acuteness under weak illumination; irregular and concentric contraction 
of the visual field and the formation of ring scotomas as well as positive 
scotomas in the center of the field; and shimmerings, dancing spots and 
circles (photopsias), and distortion of objects in the form of micropsia 
and metamorphopsia due to separation of the rods and cones by the 
effusion. 430 
DISEASES OF THE RETINA 
In the second form there appears to be a localization of the disease 
in the retina, particularly its inner layers, and this tissue is, as Schobl 
expresses it, first, and often alone, selected by the syphilitic poison. 
The ophthalmoscope reveals a gray opacity surrounding the nerve 
entrance and stretching out in lines along the vessels; the papilla is dis- 
colored, cloudy, and has been compared to a yellowish-red, oval body 
seen through a covering of fog. The veins are darker than normal; the 
arteries usually are not materially changed. 
Other objective symptoms in syphilitic retinal disease are floating 
vitreous opacities, exudations along the lines of the vessels (retinitis 
with exudations, perivasculitis), and extravasations of blood, usually 
round in shape, attributed to disease of the vessel walls (endarteritis') 
or to the formation of thrombi (retinitis with hemorrhage). Hemorrhages 
in syphilitic retinitis, however, are of comparatively rare occurrence. 
According to Haab, syphilitic endarteritis is a comparatively rare 
disease, and may present the following lesions: Visible opacity of the 
walls of the arteries and rarely of the veins, so that the blood-columns 
of the diseased vessels are accompanied with lateral white lines; almost 
invisible disease of the vessel w'alls, manifesting itself, as in senile scle- 
rosis, by a narrow'ing of the blood-columns, and sometimes associated 
with extravasations of blood; an opacity corresponding to that caused 
by an obstruction of the central artery or one of its branches, and appear- 
ing as a gray-white or a milky area, with ill-defined edges, in which at 
times considerable hemorrhage may take place; and groups of circum- 
scribed white patches somewhat resembling those seen in albuminuria. 
Date of Occurrence.-Diffuse syphilitic retinitis may occur in con- 
genital and acquired syphilis. In the acquired form of the disease it 
appears from one to two years after infection, sometimes as early as the 
sixth month, and is found in about 8 per cent, of the cases (Alexander). 
One eye alone may be affected, but usually after several months the 
second eye is also involved. 
True retinitis must not be confounded with the so-called "retinal 
irritation" commonly seen in association with iritis, and the symptoms 
of which have been described under Hyperemia. Retinitis, however, 
may accompany or follow iritis. 
Course and Prognosis.-Although the onset of syphilitic retinitis 
may be sudden, the course is essentially chronic. 
The prognosis largely depends upon the stage at which treatment is 
begun and the vigor of the measures employed. Delayed or neglected 
treatment may lead to the grave consequences of extensive choroiditis, 
pigmentary degeneration in the retina, and atrophy of the optic disk. 
Even in favorable circumstances improvement may be temporary and 
many stubborn relapses occur. 
Treatment.-The same constitutional measures recommended in 
the treatment of syphilitic iritis (see page 309) are indicated, and, in so 
far as mercurials are concerned, should be vigorously employed. Con- 
cerning the value of salvarsan in syphilitic retinitis, it may be said that 
successes have been reported even in the presence of decided endar- HEREDITARY SYPHILITIC CHOROIDORETINITIS 
431 
teritis, and in the author's experience the use of 5ieosalvarsan in the 
manner already described has been followed by admirable results. 
Usually a mydriatic is advisable, and in any event dark glasses may 
be worn. 
Central relapsing retinitis {retinitis macularis) belongs to the late 
manifestations of syphilis, and appears in the form of a gray or yellow 
area in the macula, or as numerous small yellow or yellowish-white 
spots and pigment dots, or as a diffuse opacity of this region. The 
papilla and its surroundings are unaffected. It is a rare form of syph- 
ilitic retinitis, stubborn in its character, and prone to relapse. 
Hereditary Syphilitic Choroidoretinitis.-Various types of he- 
reditary syphilitic affections of the retina and choroid occur, and they 
Fig. 193.-Appearances of the eye-ground in hereditary syphilis (from a patient in the 
University Hospital). 
have been particularly well described and depicted by Haab and Sidler- 
Huguenin. Whether the primary seat of the disease in these cases is in 
the retina or in the choroid has not, in Haab's opinion, been definitely 
settled. According to these authors, some of the following types may 
be encountered: (1) The periphery of the eye-ground presents a some- 
what leaden color and contains black circular and triangular patches of 
pigment. The remainder of the fundus is thickly covered with reddish- 
yellow spots placed upon a dotted brownish-black surface. Occa- 
sionally these lesions are not extensive and cover only certain portions 
of the fundus, especially the periphery. (2) Chiefly in the periphery 
of the eye-ground roundish black foci of pigment, discrete and confluent, 
are evident, interspersed with linear and circular yellowish patches. The 432 
DISEASES OF THE RETINA 
lesions are not infrequently seen after the subsidence of interstitial kera- 
titis. (3) In place of gray and black lesions, whitish circular or con- 
fluent patches may be found in the periphery of the fundus. Some- 
times these types are mixed, and in some severe cases there are coarse 
choroidoretinitis, diseased retinal vessels, and atrophy of the optic 
nerve. There may be diminution of central vision, contraction of the 
field of vision, and night-blindness, symptoms which are absent in mild 
manifestations of the disease. 
Metastatic Retinitis (Septic Retinitis of Roth).-This term has 
been applied to an affection especially seen in surgical pyemia and puer- 
peral septicemia, and is characterized by small, circumscribed white 
spots near the papilla and in the macular region. Usually both eyes 
are involved, and numerous small hemorrhages may be seen. These 
spots are due to fatty degeneration of the capillaries and infiltration of 
the retinal fibers, caused by the infectious emboli in the vessels. Micro- 
organisms have been demonstrated in the lesions and in the retinal 
vessels. 
The spread of the inflammation to the uveal tract and the relation of 
this condition to purulent metastatic ophthalmitis (choroiditis) has been 
described on page 358. This condition is also sometimes called embolic 
panophthalmitis or endogenous ophthalmitis. 
An independent or primary suppurative retinitis may be caused by 
injury, that is, by a penetrating foreign body (see also page 294). 
Treatment.-The prognosis and treatment of suppurative retinitis 
does not materially differ from that recorded in connection with meta- 
static ophthalmitis. Occasional recoveries are recorded with preserva- 
tion of eyesight. 
Hemorrhagic Retinitis.-The presence of hemorrhages in the retina 
does not imply the coexistence of retinitis; only if signs of inflammation 
are added is the term "hemorrhagic retinitis" justified. 
In a typical case the appearances are as follows: Swelling of the 
papilla, its edges being clouded or hidden by an opaque infiltration 
of the surrounding retina; darkly tortuous and distended veins, but small 
arteries; and numerous hemorrhages, linear, flame shaped, irregular, or 
round in shape. 
The size, number, diffusion, and localization of the hemorrhages 
vary. Thus, they may be everywhere throughout the eye-ground, or 
grouped, especially in the macular region or around the papilla. If 
white spots are present as the result of degeneration after absorption of 
the blood, the appearances may closely resemble those seen in so-called 
albuminuric retinitis, which, indeed, may be one of the types of hemor- 
rhagic retinitis. 
Causes.-Hemorrhagic retinitis occurs with diseases of the heart 
and of the blood-vessels-e. g., hypertrophy, aneurysm, and end- 
arteritis; in suppressed menstruation; at the climacteric; and in a 
variety of general and local diseases, sometimes presenting types pres- 
ently to be described under special clinical designations. More rarely, 
retinitis with hemorrhages is caused by secondary syphilis. ALBUMINURIC RETINITIS 
433 
The hemorrhages may be due to rupture of retinal vessels whose 
coats have become degenerated-in other words, they depend upon 
endarteritis; but recent investigations show that in many cases, although 
the arteries may be diseased, there is even more extensive change in 
venous coats, and there may be thrombosis of the central vein. The 
disease is often monocular. The connection between degeneration of 
the blood-vessels and chronic inflammation of the inner layers of the 
retina is an intimate one. To all inflammation of the layers of the 
retina the term angiopathic retinitis is applied by Wildbrand and 
Saenger. (For further consideration of this subject, see Hemorrhage 
in the Retina, p. 451.) 
Prognosis.-This is unfavorable because the ocular condition may 
indicate a grave vascular or cardiac malady, and may be the forerunner 
of extravasations in vital centers. Sight may be seriously impaired. 
Secondary changes in the retina and optic nerve are likely to follow; 
glaucoma frequently results. 
Treatment.-The therapeutic measures must be governed by the 
general condition. F. R. Cross recommends subconjunctival blood- 
letting, and wet-cupping the temple has been advised. Often mercury, 
iodid of potassium, and iodid of sodium are indicated, with or without 
cardiac sedatives, and diaphoresis may be required. 
Albuminuric Retinitis (Renal Retinitis; Papilloretinitis; Retinitis 
of Bright's Disease).-Symptoms.-In a typical case, beginning in the 
macula or its immediate neighborhood, and continuing to be most 
numerous in this region, variously shaped and placed white spots appear. 
These at first may be small, discrete, and sharply separated, but later, 
or under other conditions, they form a somewhat star-shaped figure, the 
rays of which surround the fovea, but for the most part do not involve 
it. Occasionally, instead of a stellate arrangement, the white spots and 
lines, somewhat radially placed like spokes in a wheel, affect this neigh- 
borhood in part, but do not completely encircle it. 
At some distance from the papilla, and often surrounding it, larger 
yellowish-white or white spots are seen, which may coalesce and form a 
ring-shaped zone around the nerve-head broader than its own diameter. 
This striking, wide white area has been compared to snow, and desig- 
nated "the snowbank appearance of the retina." 
Other features, but, unlike the white spots, having no pathog- 
nomonic appearances, are the hemorrhages. They may be linear, flame 
shaped, or round, or mere flecks scattered here and there, and found 
with difficulty, or they constitute large, dark-red extravasations. More- 
over, they are not constant like the white spots, but at times disappear, 
leaving white marks which denote their former situation. Sometimes 
they occur in great numbers, like fresh explosions. To a certain extent 
they are indications of the violence of the disease. 
The blood-vessels may run over the white plaques, or may be buried 
in the swollen retina. Sometimes a vessel disappears beneath the infil- 
tration, to reappear at some distance beyond. The veins are dark and 
often tortuous; the arteries, as in other forms of retinitis, are not mate- 434 
DISEASES OF THE RETINA 
rially altered in size. In the later stages the vessels exhibit lack of 
transparency of their walls, in the form of white tissue along the sheaths, 
or they are actually converted into white strings. 
Finally, the optic papilla and its immediate surroundings may be 
intensely hyperemic, or a swelling of the nerve-head occurs, quite 
indistinguishable from that of optic neuritis, or choked disk, as it is seen 
in tumor of the brain. In any circumstances the edge of the papilla is 
clouded, but not necessarily swollen, the surrounding retina finely 
clouded, and traversed with numerous radiating injected lines, like those 
described in other types of retinitis. Quite commonly the changes in 
the papilla directly join the band of fatty infiltration already described, 
surrounding the end of the optic nerve. 
The chief, in fact the only, subjective symptom is depreciation of 
vision, which may vary from a slight and gradual impairment to com- 
plete blindness. It is a well-known fact that Bright's disease is often 
discovered by an ophthalmoscopic examination, the patient being 
ignorant of the fact that he is the subject of serious organic malady. 
The visual field may be altered according to the situation of the retinal 
lesions, and may contain blue-blind areas. According to Gerhardt, 
blue-blindness may be a sign of contracted kidney, and Simon main- 
tains that violet-blindness is not uncommon in connection with albu- 
minuric retinitis. 
Forms of the Disease.-Two varieties have been recognized-an 
inflammatory or exudative and a degenerative type. Often the two are 
combined. 
The former may be present as violent neuroretinitis from the begin- 
ning, or it may start as a degenerative type and assume inflammatory 
action. The latter begins without inflammatory changes, the white 
spots are small, often quite minute, and separated by comparatively 
normal areas, and the hemorrhages, if present, are inconspicuous, being 
confined largely to the nerve-fiber layer. The arteries are sclerotic,Cthe 
veins dark, and the disk, in the early stages, blurred and indistinct, but 
there is no peripapillary zone of white exudation and no macular figure. 
If hemorrhages are the most conspicuous feature of the disease, the term 
hemorrhagic is applied; if the changes are almost wholly confined to 
the optic papilla, the neuritic or papillitic type is developed. Samuel 
West draws a sharp distinction between degenerative and exudative 
albuminuric retinitis, and associates the former with granular kidney 
and the latter with parenchymatous nephritis. The exudative variety 
is inflammatory and probably toxic in origin; the degenerative depends 
on vascular changes. 
Often small hemorrhages and comparatively insignificant dots in 
the macula may be the signs of renal retinitis, and consequently of renal 
disease. Indeed, the so-called typical renal retinitis is not so frequently 
encountered as the less elaborately produced lesions of this affection. 
Among early signs of renal retinitis are changes in the capillary circula- 
tion, and dilatation and tortuosity of the small vessels around the macula, 
while the nerve-head assumes a congested, brick-red color. In every Plate IV. 
Albuminuric retinitis; star-shaped figure in the macula; the cir- 
culation in the distended veins impeded where the latter are crossed 
by the arteries which are undergoing sclerotic changes. ALBUMINURIC RETINITIS 
435 
case of retinal disease the urine should be frequently and thoroughly 
examined. 
Causes, Date of Occurrence, and Frequency.-While in general 
terms Bright's disease is the cause of the retinitis which bears its name, 
it most frequently occurs with chronic interstitial nephritis. It may 
also be caused by chronic parenchymatous nephritis, especially in the 
so-called inflammatory form. Naturally, the secondary contracted kid- 
ney, which is a sequence of large white kidney, may be associated with 
retinitis, and this is also true of amyloid disease of the kidney. The 
retinitis occurring with pregnancy is usually ascribed to albuminuria, but 
is probably due to the same substances which cause the albuminuria, 
the eclampsia, vomiting, etc., namely, toxemic products in the circula- 
tion. Retinitis may arise in the course of a scarlatinal nephritis. 
Usually both eyes are involved, but unilateral albuminuric retinitis 
is not a rarity (Knies), a certain percentage of cases maintaining monoc- 
ular retinal lesions until death. In another large percentage of cases the 
unilateral character of the affection is temporary, both eyes ultimately 
becoming affected. In general terms it is probable that the renal disease 
must be present for some months before retinal lesions appear. The 
age at which patients are attacked is usually stated to vary from thirty 
to sixty, the most prolific single decade, according to Nettleship, being 
from fifty to sixty. It is comparatively rare before the twenty-fifth 
year, but children and young persons are not exempt. 
About twice as many cases of renal retinitis occur in men as in 
women. If there is decided hyaline thickening of the retinal arteries, 
an early stage of granular kidney may be suspected, especially if the 
patient is comparatively young (Nettleship). The recorded percent- 
age of retinitis in renal disease varies from 9 to 33. In the author's 
experience fully 25 per cent, of patients with chronic Bright's disease, 
as he has examined them in general hospitals, have been affected by 
various forms of retinitis, but if these statistics should include not only 
the cases of so-called typical retinitis, but also those of comparatively 
insignificant lesions, consisting chiefly of alterations in the walls of the 
retinal vessels and blurring of the disk, this percentage would be con- 
siderably higher. 
Course, Pathology, and Prognosis.-The course of typical renal 
retinitis has been divided into the stage of hyperemia of the papilla, 
opacity of the retina, and hemorrhages; the stage of fatty degeneration; 
and the stage of retrograde metamorphosis and atrophy. 
The white spots may subside, but rarely disappear entirely, the 
macular changes being most permanent. Discoloration and atrophy of 
the papilla, contraction of the vessels and the formation of white tissue 
along their walls, and pigment changes in the retina finally result. 
The pathologic changes are found chiefly in the macular region and 
in a zone surrounding the nerve. The retina is thickened by the pres- 
ence of the so-called inflammatory edema and by hypertrophy of its 
nervous and supporting tissue. The glistening spots in the macular 
region are due to a fatty degeneration of the exudation and of the retinal 436 
DISEASES OF THE RETINA 
elements. Their star-shaped arrangement depends upon the oblique 
direction of the fibers of Muller in this position. Many fatty granular 
cells and deposits of coagulated fibrin are seen, particularly in the 
nuclear layers. Hemorrhages are present, but not necessarily a pro- 
nounced feature. In the early stages the vessels show thickening of the 
adventitia, and later pronounced hyaline change and proliferation of the 
lining endothelium. The nerve in many cases is swollen by the in- 
flammatory edema. The same causes which originate disease of the 
blood-vessels of the kidney originate also the alterations in the retinal 
vessels, and to these alterations the chief role must be ascribed in 
causing the various types of retinal lesions. Indeed, some authorities 
maintain that so-called albuminuric retinitis is entirely the outcome of 
disturbances in the circulation, that is, depends on arterio- and phlebo- 
sclerosis and their sequels. Sclerotic changes in the choroid vessels 
are also present. 
Detachment of the retina, hemorrhage into the vitreous, embolism 
and thrombosis of the vessels, extravasations into the choroid, and 
glaucoma may be complications of this affection. Detachment of the 
retina is not infrequent, and glaucoma may arise exactly as it does with 
retinal hemorrhages and retinal angiosclerosis. 
The prognosis, so far as vision is concerned, depends upon the extent 
of the lesions and of the involvement of the macula. In general terms 
it is unfavorable, although fair vision is often retained. Sometimes the 
exudations practically disappear. In so far as the life of the patient is 
concerned, albuminuric retinitis is a most unfavorable symptom, and 
many patients die within two years after its detection, and a consider- 
able percentage within the first year of its development.. There are, 
however, frequent exceptions to the rule, and the records show that 
patients have lived five, seven, and even a greater number of years 
after the retinal lesions have appeared, especially if they have been de- 
tected early and suitable treatment has been instituted. 
Albuminuric Retinitis in Pregnancy.-While the occurrence of 
albuminuria during pregnancy is not uncommon, varying, according to 
statistical reports, from 2 to 20 per cent., involvement of the optic 
nerve and retina, in the form of a neuroretinitis, to which the term 
albuminuric retinitis of pregnancy is usually applied, is much less fre- 
quent. The retinitis in this condition may gradually develop, occurs 
most frequently in primiparse, and generally in the second half of preg- 
nancy; exceptionally at an earlier period. The ophthalmoscopic signs 
of this retinitis may not differ from those which are caused by other 
forms of Bright's disease, and, in general terms, there is a wide-spread 
neuroretinitis with exudations and hemorrhages. The retinitis of 
pregnancy has been ascribed to a nephritis which is brought about by 
this condition, especially a fatty degeneration of the kidney epithelium, 
and also to toxemic products in the circulation (J. H. Fisher; see also 
page 435). It may also be caused by an acute nephritis which has 
developed during the pregnant period, and by an exacerbation of a 
pre-existing chronic nephritis during the same period. ALBUMINURIC RETINITIS 
437 
In the albuminuric retinitis of pregnancy the prognosis, in so far as it 
concerns the vision and the life of the patient, depends upon the dura- 
tion of gestation. With the termination of pregnancy the inflammatory 
deposits (the type most often is inflammatory) may subside and good 
vision may be restored, provided the process has not continued so long 
that the secondary changes already described have taken place. For 
this reason the induction of premature labor has been recommended as a 
therapeutic measure, and if the visual disturbances appear during the 
first six months of gestation usually the pregnancy should be terminated 
if sight is to be saved. 
Diagnosis.-In wide-spread albuminuric retinitis the changes de- 
tailed in the symptom-grouping are striking and in a sense character- 
Fig. 194.-Albuminuric retinitis of pregnancy. Colored patient in the University Hospital. 
istic, but the so-called typical cases are not as frequent as those in which 
the lesions are not so evident, and the significance of the retinal disease 
must be decided by general examination. Even so-called "typical" 
appearances have been observed in infections-for example, erysipelas 
and syphilis-independently of nephritis. Thus, Schieck has investi- 
gated a certain number of eyes with macular changes which were regarded 
as characteristic of nephritis, and yet the evidence of kidney disease was 
lacking; similar observations have been made by Wildbrand and Saenger, 
by Parsons, and by the author. 
Neuroretinitis from intracranial disease may simulate this affection, 
and often only by a careful study of the urine and the general symptoms 
the diagnosis can be established (see also page 479). The question be- 438 
DISEASES OF THE RETINA 
comes still more complicated if albuminuria is associated with brain 
tumor. 
In glycosuria and leukemia somewhat analogous appearances are 
found, and again, an examination of the urine, as well as that of the 
blood, may be necessary before reaching a diagnosis. 
The white spots are distinguished from plaques of choroidal atrophy 
by the absence of pigment heaping. The snowbank appearances differ 
from retained marrow sheath (see page 469) in that the latter stretches 
away from the margin of the disk, usually ending in a fan-shaped border, 
and is unaccompanied by the changes in the macula or by retinal edema. 
Fine lesions of the choroid in the macular region may be mistaken for 
somewhat similar retinal changes; but they are more scattered, more 
yellow in color, usually unassociated with distinct loss of vision, and less 
liable to assume a stellate or radial appearance. 
Treatment.-Local measures are practically of no avail. The 
case must be managed on the general principles suited to the form of 
kidney disease which is present. A proper remedy in most cases is iron, 
usually in the form of the tincture, and often advantageously combined 
with bichlorid of mercury. Decapsulation of the kidney has been 
tried without encouraging success. Harvey Cushing has recommended 
cerebral decompression, because he believes that increased intracranial 
tension is an important factor in the development of albuminuric 
retinitis. The author's single experience with this operation in these 
circumstances was disastrous. 
Diabetic Retinitis.-This occurs in several forms. It is always 
bilateral, but both eyes may not be affected at the same time. 
Hirschberg describes two varieties of diabetic retinitis-an exudative 
and a hemorrhagic form. In some cases of diabetic retinitis, either with 
or without hemorrhage, there are wide-spread areas of yellowish-white 
exudation and fatty change, and these lesions may arrange themselves 
in zone-like areas, above or below the macula, resembling the so-called 
circinate retinitis, and may be massed in the central region of the 
retina. They usually are late manifestations of diabetes, and are seen 
at a time when gangrene, carbuncle, hemiplegia, and other serious com- 
plications of this disorder arise. In any case of diabetes of long dura- 
tion retinitis is seldom absent, although it may sometimes be difficult 
to find the lesions, because they are situated in the periphery of the eye- 
ground. This is especially true if the complication of high myopia, or 
cataractous lens, is present. 
More commonly than in the retinitis of albuminuria, opacities and 
hemorrhages occur in the vitreous humor, and a condition analogous to 
proliferating retinitis may arise. To a collection of small white spots 
and hemorrhages irregularly arranged in the macular region and be- 
tween it and the disk the name central punctate diabetic retinitis has 
been applied. By some authors this appearance is considered typical 
of diabetes. The vital prognosis is unfavorable, but not nearly so 
grave as in albuminuric retinitis. 
To a striking ophthalmoscopic picture characterized by a very LEUKEMIC RETINITIS 
439 
light salmon color of the blood in the retinal arteries and veins, which 
are much enlarged, and by a somewhat light color of the general fundus 
the name lipemia retinalis has been given (Heyl). These appearances 
are ascribed to the presence of fat in abnormal amounts in the blood. 
No hemorrhages or exudations develop; in this respect it differs from 
leukemic retinitis. It is apt to occur in young diabetics and implies a 
grave prognosis. 
Treatment.-There is no local treatment of diabetic retinitis. The 
discovery of such a condition may lead to the finding of sugar in the 
urine, but more commonly the patient is already conscious of his dis- 
ease and is under medicinal and dietetic treatment. 
Fig. 195.-Diabetic retinitis; extensive white exudations in the macular region. 
Leukemic Retinitis.-The retinal changes seen in splenic leukemia, 
to which variety of the disease they are almost exclusively confined, 
affect both eyes, usually one more than its fellow. 
The most important ophthalmoscopic appearances are slight swelling 
of the papilla, pallor of its surface, veiling of its edges, and some opacity 
of the retina, especially along the lines of the vessels. The latter present 
a striking appearance. The veins are broad, distended, and of a some- 
what rose-red color; the arteries, in contrast, narrow and orange yellow, 
which color substitutes the ordinary fiery red of the choroid, the vessels 
of which, if they are visible, present a yellowish-red tint. 
Very prominent lesions are white spots with red borders, especially 
near the equator and in the region of the macula lutea. The spots 440 
DISEASES OF THE RETINA 
vary in size and are often somewhat elevated. They are due to a 
collection of lymph-corpuscles, and the red border to an extravasation 
of blood-corpuscles. 
On the other hand, retinitis associated with leukemia may not present 
characteristic appearances, but may consist simply of a diffuse opacity 
of the retina, or appear in the form of hemorrhagic retinitis. When 
the yellow spots which have been described develop in the macula they 
resemble the lesions produced by albuminuria. Indeed, albumin in 
the urine may be present with leukemia. In any doubtful case a careful 
blood examination will reveal the true nature of the disease. 
Proliferating Retinitis.-This affection is characterized by dense 
masses of bluish-white or white color, which are developed from the 
Fig. 196.-Proliferating retinitis in an early stage. Note the beginning formation of 
membranes extending from retina into vitreous. 
retina and stretch out into the vitreous humor. They often cover a 
considerable portion of the fundus and hide the papilla, which may 
with difficulty be seen through the intervening spaces. Sometimes the 
masses follow the course of the blood-vessels, which in part may lie 
beneath them, and in part pass over them; those which lie above the 
masses are occasionally newly formed blood-vessels. As complicating 
circumstances there may be detachment of the retina, opacity of, and 
hemorrhage into, the vitreous. 
According to Weeks, the essential of this disease is the production 
of membranes which extend from the retina into the vitreous humor, 
and a fibrinous exudation or hemorrhage must first occur before these RETINITIS CIRCINATA 
441 
membranes can be formed. This process and that of vascular growths 
in the vitreous (see page 419), as Marple has well shown, are identical. 
Two varieties of the affection have been described-syphilitic and 
traumatic-but, as Axenfeld has shown (see page 418), tuberculosis or 
its toxin may be the active agent. In these circumstances tuberculin 
injections should be given a trial. The disease is more common in young 
than in elderly subjects. Vision is greatly impaired, sometimes totally 
lost. 
Retinitis Circinata.-This name was applied by Fuchs to an 
affection characterized by a concentric aggregation of slightly raised 
white spots and lines around the macula. Sometimes the white spots 
surround the macula after the manner of a wreath; sometimes the 
arrangement is more like that of an ellipse, one end of which may touch 
Fig. 197.-Circinate retinitis (from a patient in the Jefferson Hospital). 
the edge of the optic disk, while the other extends beyond the macular 
region (Lawford). Fuchs regards the white patches as fibrinous exuda- 
tions which had taken place into the deeper layers of the retina, while 
de Wecker denied the special character of the disease, which he attrib- 
uted to fatty degeneration, the result of hemorrhages. Indeed, Amman 
has shown that the white spots are due to fatty cells clustered where 
hemorrhages have been. Hemorrhages may accompany the affection, 
and in one case (Fridenberg) there was a development of new-formed 
blood-vessels in the retina. The lesions have also been attributed to 
disease of the smallest macular vessels, especially the arteries (Oeller), 
and also to the results of a long-standing edema, the size of the circle 
varying according to the extent of the previous affection (Gunn). 
Sometimes the disease is essentially chronic and the appearance remains 
unchanged for years; sometimes it is slowly but surely progressive, and 442 
DISEASES OF THE RETINA 
rarely the ring of exudate may partly or entirely disappear. Such 
disappearance within one year has been noted by N. Bishop Harman. 
Central Punctate Retinitis (Retinitis Punctata Albescens).- 
This type of retinal affection was originally described by Mooren, and, 
according to him, is characterized by a great number of striae or spots 
scattered over the fundus, resembling in color the reflex of the sclera. 
The retinal vessels are not covered by the spots. The papilla is de- 
cidedly gray. While the peripheral field of vision is unaffected, in its 
center there may be either a relative or a positive scotoma. Vitreous 
hemorrhages have also been described, and in Hirschberg's cases, who 
calls the disease central punctate and striated retinitis, atheromatous 
changes in the vessels elsewhere in the body were found. Fuchs has 
called attention to the similarity of this disease to retinitis pigmentosa, 
inasmuch as it is either congenital or starts in infancy, affects several 
members of the same family, and may occur in the children of blood 
relations. Also, there may be night-blindness and contraction of the 
visual field. As John Griffith has pointed out, it should be regarded as a 
primary degeneration of the retina and choroid allied to pigmentary 
degeneration of the retina, and should not be classified as an inflamma- 
tory disease. Another type of chronic retinal degeneration is that to 
which Fuchs gives the name atrophia gyrata choroideoe et retina, also 
seen in the children of consanguineous marriages and associated with 
night-blindness. 
Treatment.-This consists in depletion from the temple, and iodid 
of potassium or other alterative of similar physiologic action. 
Retinitis Striata.-Occasionally light or yellowish-white stripes 
extending from the periphery toward the disk, and sometimes bordered 
by lines of pigment lying beneath the retinal vessels, are apparent to 
the ophthalmoscope. To this appearance the name retinitis striata has 
been given, and while the origin of the affection is not positively known, 
Holden contends that the stripes are the result of the metamorphosis of 
retinal hemorrhages, and in this respect are analogous to angioid streaks. 
On the other hand, it has been contended by L. Caspar that these 
retinal striations represent the final stages of spontaneously cured 
detachments of the retina. The author has published the case histories 
of two patients which appear to confirm this view of the origin of 
retinitis striata. 
Pigmentary Degeneration of the Retina (Retinitis Pigmentosa).- 
Although this affection is usually entitled retinitis pigmentosa, the 
phenomena of inflammation are absent, and it consists of a degeneration 
of the nerve tissue, associated with great contraction of the blood-vessels 
and the accumulation and deposition of pigment of well-nigh charac- 
teristic form in the substance of the retina. 
Symptoms.-The ophthalmoscopic appearances of a typical case are 
as follows: 
(a) Pigmentation.-The pigment masses frequently assume an ap- 
pearance resembling bone-corpuscles, and by the union of their processes 
suggest the Haversian canals. The resemblance of the pigment to bone- PIGMENTARY DEGENERATION OF THE RETINA 
443 
corpuscles is not always evident; the pigment deposits may be round 
and irregular and simulate the pigment spots of choroiditis, but unlike 
them they are situated in front of the blood-vessels and are in the inner 
layers of the retina. By preference, the pigmentary deposits are more 
marked on the temporal side. They begin in the periphery of the eye- 
ground, although not usually in the extreme periphery, often lying along 
the course of the main vessels, which may be in places encrusted by them, 
and gradually approach the papilla, the macular region remaining for a 
long time unaffected. A zone midway between the center and far 
periphery is the favorite seat of pigmentation. 
(6) "Wainscoted" Fundus.-A perfect picture of the appearance 
already described in connection with superficial choroiditis is visible on 
account of the absorption and decolorization of the retinal pigment 
epithelium and the exposure of the larger vessels of the choroid. The 
overlying retina is distinctly gray. 
(c) Contraction of the Vessels.-This is present in both systems. 
The vessels may be as thin as threads. Often their walls exhibit patches 
of opacity, and they are accompanied by fine white lines and covered 
here and there by pigment deposits. Not only are they greatly con- 
tracted, but they are apparently diminished in number. 
(d) The Changed Nerve-head.-The color of the papilla, according 
to the stage of the disease, is of a yellowish-gray, yellowish-red, or waxy 
tint. It finally becomes dull white and atrophic. Except a slight veil- 
ing, its edges are plainly marked. 
(e) Opacities of the Media.-Posterior polar cataract is frequently 
present, and in the later stages posterior cortical cataract. Opacities 
in the vitreous are uncommon. 
(/) Nystagmus.-Quite frequently a quick lateral oscillation of the 
eyeballs, or nystagmus, is present, especially in congenital cases. 
The subjective symptoms are: 
(a) Depreciation of Central Vision.-Visual acuteness may be but 
slightly affected in the earlier stages, although usually the perception 
of green and red is below the normal (Oliver). Indeed, reasonably good 
central vision may remain even when the disease is very wide-spread, 
but it finally sinks with the progress of the affection and, ultimately, 
blindness results, although this usually does not occur until the expira- 
tion of many years. 
(6) Contraction of the Field of Vision.-In the early stages of pig- 
mentary degeneration of the retina the field of vision may be nearly 
normal in extent, if the illumination is good, although much contracted 
if the illumination is reduced. Later, the field contracts concen- 
trically, according to the amount of degeneration, and the contraction 
may be so excessive that only a very small area of the field remains. 
In rare instances, even with extreme narrowing of the visual field, 
there is still moderately good central vision, and the patient may read 
by fixing a single word at a time. Finally, the contraction goes on to 
complete blindness. As the extreme periphery of the retina is often free 
from pigmentation in the earliest stages of the disease, when the equa- 444 
DISEASES OF THE RETINA 
torial region is already involved, the periphery of the visual field may 
be intact, but between it and the preserved central field there is a blind 
zone; that is, an annular or ring scotoma. According to M. L. Hepburn, 
the earliest manifestation of primary degeneration is this ring scotoma. 
At first it is incomplete and represents the loss of function in the inter- 
mediary zone of the retina. Later other portions of the retina degener- 
ate in regular order, the fixation point being the last to disappear. This 
is in accord with the author's experience. On the other hand, W. T. 
Shoemaker, as the result of his investigation of pigmentary degenera- 
tion of the retina in deaf mutes (17 cases), concludes that ring scotoma 
in this disease is a rare field defect. 
(c) Night-blindness.-Often this is the first symptom which calls 
attention to the case. The patient is uncertain in his movements and 
stumbles as soon as twilight begins, becoming quite helpless in the 
dark. Night-blindness is not always present, and in rare instances 
Fig. 198.-Ring scotomas in pigmentary degeneration of the retina. 
diminished light is a relief to the patient. Such a condition is due to 
retinal hyperesthesia. 
Atypical Varieties.-The pigment may be massed in the macular 
region; the central vision is much affected, and a scotoma appears 
around the point of fixation. In other instances the pigment is 
scattered all over the fundus in irregular masses, and is associated 
with clear, shining spots lying beneath the retinal vessels. Cases occur 
presenting the usual subjective symptoms, but without the accumula- 
tion of pigment-really forms of sclerosis of the retina without the forma- 
tion of pigment-and a few instances, associated with a broad peripheral 
zone of choroidal atrophy, have been described. Finally, in rare 
instances, retinitis pigmentosa may be complicated with chronic glau- 
coma, the retinal affection probably antedating the glaucoma (Bellar- 
minoff, Mandelstamm). Holloway has described pigmentary degen- 
eration of the retina in association with albuminuric neuroretinitis. 
Causes.-The disease is markedly hereditary. Simeon Snell has 
reported the history of this affection in five generations, 28 of the 67 PIGMENTARY DEGENERATION OF THE RETINA 
445 
descendants being affected. Consanguinity of the parents of the pa- 
tient has been found in a certain number of the cases; indeed, the dis- 
ease has been attributed to this cause alone. Nettleship's results are 
as follows: Heredity without consanguinity in 23.5 per cent., con- 
sanguinity without heredity in 23 per cent., and heredity combined 
with consanguinity in 3 to 4 per cent. Hereditary syphilis has been 
suggested as a possible cause of retinitis pigmentosa, but this etiology 
has not been proved. The affection is found among deaf mutes, idiots, 
and epileptics, and in this sense is connected with morbid states of the 
nervous system. Very often no cause can be assigned. The disease 
is either congenital or begins in childhood. According to W. T. Shoe- 
Fig. 199.-Pigmentary degeneration of the retina; marked exposure of vessels of choroid 
(from a patient in the University Hospital). 
maker, it is always congenital in origin, no matter how late its mani- 
festations are evident. 
Pathology.-The degenerative process begins in the outer layers 
of the retina, which becomes adherent to the choroid. -The rods and 
cones disappear, the blood-vessels are sclerosed, and their lumens 
contracted. Later the sclerotic process reaches the layer of ganglion 
cells and the nerve-fibers. There is a marked infiltration of pigment cells 
along the thickened vessels. The optic nerve atrophies and may con- 
tain hyaline masses similar to those in the lamina vitrea of the choroid. 
Wagenmann believes that the primary lesion is a sclerosis of the vessels 
of the choroid, and W. T. Shoemaker concludes that within the eyeball 
the primary tissue involved is the choroid. Gonin and Nettleship 
attribute the primary degeneration to deficient blood-supply owing to 446 
DISEASES OF THE RETINA 
obstruction to the blood-current in the choriocapillaris. The beginning 
of the disease has also been placed in the pigment epithelium. The 
affection is always bilateral. 
Diagnosis.-Retinitis pigmentosa may be distinguished from dis- 
seminated choroiditis by the difference in the pigmentation of the two 
diseases. 
Its differential diagnosis from certain types of pigmented retino- 
choroiditis seen in acquired syphilis is difficult, especially when the 
latter manifest themselves in the form of atrophy of the retina and a 
gathering of pigment spots, beneath which the exposed choroidal vessels 
are visible. In retinochoroiditis, however, the pigment spots do not 
have the characteristic form; they are much scattered, and do not follow 
or cover the blood-vessels; besides, vitreous opacities, which are com- 
paratively rare in pigmentary degeneration of the retina, are usually 
present. The visual field should lend aid in diagnosis, as in choroidal 
disease the characteristic feature is the patchy nature of the scotomas 
(M. L. Hepburn). 
A patient with night-blindness, or seen stumbling about during the 
twilight, should be subjected to a careful examination of the periphery 
of the eye-ground, if necessary, after dilatation of the pupil, because 
occasionally the pigment is confined to this region and might be over- 
looked by a careless observer. 
Course and Prognosis.-Pigmentary degeneration of the retina 
progresses steadily onward with ever-increasing contraction of the 
field of vision, until finally, usually by middle life, sight has been obliter- 
ated, with, perhaps, the exception of a slight eccentric preservation of 
the field. According to Nettleship, the age at which blindness becomes 
complete is variable, and, with rare exceptions, occurs only after the 
thirtieth to the thirty-fifth year of life; more usually after sixty years. 
The prognosis is, hence, nearly always unfavorable in all circumstances 
and in spite of all known endeavors to modify the course of the disease. 
Occasionally, when the pigment accumulation has advanced far over 
the retina, but the macula is still free, the disease remains stationary for 
long periods of time, and good vision within the narrow field continues. 
Treatment.-This is of little avail. Strychnin in full doses, espe- 
cially by the hypodermic method, has been recommended. If there is 
any suspicion of syphilitic taint, the usual remedies are indicated. 
Galvanism has been tried, and under its influence, it is stated, the pro- 
gressive contraction of the field of vision has been stayed, although no 
improvement in the acuteness of central sight was obtained. It cer- 
tainly should be given a trial in every case. 
Sometimes a peculiar pigmentation of the retina is encountered which 
has been mistaken for a type of retinitis pigmentosa, with which disease, 
however, it has no alliance. The pigment changes occupy a sector of 
the eyeground, and consist of collections of black or chocolate-brown 
spots, with a strong tendency to group formation. The spots may be 
round, oval, and often suggest diminutive bunches of grapes. This 
appearance was figured by Jaeger, has been described by Juler, Stephen- DETACHMENT OF THE RETINA 
447 
son, and others, and, quite recently, elaborately by Hoeg. It is doubt- 
less a congenital condition; the function of the eye is undisturbed. 
Detachment of the Retina (Ablatio Retinae; Amotio Retinae).- 
Idiopathic separation of the retina from the underlying choroid is due 
to an accumulation of a serous fluid between these membranes (serous 
detachment of the retina). 
Symptoms.-The student will observe, as he examines the various 
portions of the fundus with the ophthalmoscope (direct method), an 
alteration of refraction at the area of separation, the surface of the 
elevation thus produced being out of focus as compared with the rest 
of the eye-ground. Thus, if the general fundus is hyperopic, the de- 
tached portion will be more hyperopic, and require a stronger convex 
glass for the study of its surface; if it is highly myopic, a weaker concave 
glass, or, it may be, a convex lens. 
The normal color of the fundus is lost as the detached retina is 
approached, which appears as a gray or bluish-gray membrane stretch- 
ing forward into the vitreous, containing folds which give rise to a sheen. 
The intervening furrows present a greenish-gray reflex, and the whole 
oscillates with the movements of the eye if the underlying substance is 
fluid; if it is a solid, neither folds nor tremulousness are present. Rents 
in the detached retina, through which the choroid is visible, are often 
demonstrable. 
The retinal vessels rise over the separated portion, first lose the light- 
streak, and finally appear as dark, tortuous cords. They apparently 
are of smaller size than normal, and when followed backward they 
pass out of focus at the edge of the detachment, which is usually sharply 
marked from the normal fundus; indeed, there may be a yellowish border 
and occasionally accumulated pigment. The amount of discoloration 
of the detached area depends upon whether the case is recent or not, 
and upon the character of the underlying substance. In the earlier 
stages transparency is not lost, and the gray color, previously described, 
may not be present. 
The detachment, either partial or complete, may occupy any portion 
of the fundus, but commonly is found below, preceded, it may be, by a 
separation of the retina in the upper part of the eye-ground. These 
superior detachments may sag downward and bulge forward into the 
vitreous like a diminutive balloon. Sometimes the detachments are 
quite small, like a series of furrows, and at other times an almost circular 
circumscribed separation occurs. Finally, the subjective signs of de- 
tachment may bfe present without discoverable elevation of the retina, 
but over the area (which subsequently separates) there is complete loss 
of the light reflex from the retinal vessels (Loring). In these circum- 
stances the visual field should be mapped under reduced illumination. 
At first, owing to the small quantity of subretinal fluid, the detachment 
may be flat; occasionally it remains so, but usually it increases in 
extent and elevation. 
Unless the macular region is directly involved, vision is not obliter- 
ated, but there is always interference with sight. This may develop 448 
DISEASES OF THE RETINA 
suddenly. The field of vision is lost in an area corresponding to the 
detached retina, and the completely darkened portion is usually bor- 
dered by a zone of imperfect vision corresponding to an area of retina not 
yet separated, but elevated above its normal plane. If the retina is 
detached below, the upper portion of the visual field is obliterated; if 
above, the lower portion, and so on (Fig. 201). A retinal detachment 
just beginning may not be detected by a visual-field examination with 
a white test-object, but may be represented by a relative scotoma if the 
test-object is blue. 
The patients are conscious of distortion of objects (metamorphopsia); 
of floating spots before the eyes, due to the frequent presence of vitreous 
opacities; of an appearance like a cloud, due to the scotoma produced by 
the separated area; and of phosphenes, although the last cannot be 
elicited by pressure on the eyeball over the separated area. Should a 
Fig. 200.-Detachment of lower half of retina, which has floated forward. Disk and upper 
half of fundus dimly seen. 
patient with high myopia describe "attacks" of flashes of light, showers 
of sparks, or other types of photopsies, such symptoms are dangerously 
significant of impending retinal detachment. 
Causes.-The causes of retinal separation are: High (malignant) 
myopia; traumatisms and effusions of blood, preceded usually by 
hemorrhages into the vitreous or retina. More men'than women ac- 
quire simple detachment of the retina; myopic refraction most fre- 
quently is present, and the separation is more apt to occur in an eye in 
which the visual disturbance has rapidly developed. The condition 
often becomes apparent suddenly, especially after physical exertion; 
occasionally it develops gradually. 
Retinal detachment is also caused by intra-ocular tumors (sarcoma 
of the choroid) or subretinal parasites (cysticercus), tumors and ab- 
scesses in the orbit, and diseased conditions of the eye, as retinitis, DETACHMENT OF THE RETINA 
449 
cyclitis, iridocyclitis, etc. In iridocyclitis the detachment is often 
found only after removal of the shrunken globe, and is caused by con- 
traction during organization of strands of connective tissue attached 
to the retina. Separation of the retina may be congenital, due to syph- 
ilis, and it has been observed in several members of the same family 
(hereditary detachment of retina-Pagenstecher). Subretinal hemorrhage 
-the blood coming either from the retina or choroid-may produce the 
so-called hemorrhagic detachment of the retina, for example, in the sub- 
jects of arteriosclerosis, but also in anemia and chlorosis. In traumatic 
detachment of the retina the eye is usually, but not necessarily, myopic; 
the separation may immediately follow the injury or be delayed for 
weeks or even months (Galezowski). 
Fig. 201.-Various types of fields of vision in detachment of the retina. 
Mechanism.-Leber and Nordenson hold that the first process is a 
fibrillar change in the vitreous, which shrinks and occasions traction 
(retraction theory). This ruptures the retina, and the fluid from the 
vitreous cavity passes beneath it through the opening. The primary 
cause of the pathologic alteration in the vitreous is believed to be disease 
of the choroid and ciliary body. Greeff, Elschnig, and others, however, 
doubt if retinal detachment is caused by shrinking of the vitreous; detach- 
ment of the vitreous they regard as an artefact due to the action of fluids 
used in hardening the eyeball. Raehlmann explains the detachment by 
a diffusion theory, the conditions being analogous to transudations in 
other parts of the body. In some instances retinal detachment must 450 
DISEASES OF THE RETINA 
be explained by the presence of exudation or hemorrhagic extravasation, 
and in axial myopia of high degree the "mechanical theory" is applic- 
able-the separation of the retina being due to elongation of the eye- 
ball, fluidity of the vitreous, and hyperemia of the choroid. 
Diagnosis.-No difficulty arises in detecting a large detachment of 
the retina by attending to the symptoms already detailed. An exten- 
sive or complete detachment which floats far forward may be exam- 
ined by oblique illumination. If the vitreous is full of opacities, a 
study of the field of vision is useful. If the substance underlying 
the detached portion is fluid, there are usually diminished tension of 
the eyeball and the appearance of furrows in the separated tissue, which 
trembles with the movements of the eye, symptoms which are absent 
if a solid growth has caused the separation. Important diagnostic 
signs are the loss of the light-reflex of the vessels, and their dark color 
over the area of separation. They can be seen to regain the light- 
reflex in passing over the normal retina. It is important to submit all 
eyes with detachment of the retina to the transillumination test (see 
page 363). 
Prognosis.-This is very unfavorable, and many of the suggested 
means of treatment have proved unsatisfactory. In rare instances 
there is spontaneous reattachment of the retina. 
Treatment.-This should include rest in the prone position, a pres- 
sure bandage, preferably elastic, and pilocarpin sweats, the pupil of 
the affected eye being dilated with atropin, and lymphagogue activity 
stimulated by the use of a 5 per cent, dionin solution. Internally, 
the various iodids or small, frequently repeated doses of salicylate of 
sodium may be administered. 
Various forms of operative procedure have been attempted: scle- 
rotomy and, recently, trephining the sclera, thus evacuating the sub- 
retinal fluid; evacuation of the subretinal fluid by puncture and aspira- 
tion, and drainage by means of a gold wire; electrolytic puncture; incis- 
ion of the fibrous bands in the vitreous, followed by the injection of the 
vitreous humor of a rabbit (Deutschmann). Subconjunctival injec- 
tions are valuable. For this purpose de Wecker employed a solution 
composed of 3| parts of gelatin with 100 parts of physiologic salt solu- 
tion. Jocqs advocates injections of a saturated solution of salt in con- 
junction with scleral puncture, while Bourgeois recommends a 30 per 
cent, salt solution to which a few drops of a 5 per cent, solution of 
cocain are added, 1 c.c. of the fluid being injected. Subconjunctival 
injections of cyanid of mercury and of sodium chlorid are also advocated; 
they may be rendered painless by adding acoin to the solution. The 
author has secured a few favorable results with scleral puncture, fol- 
lowed by large (30 minims-1.9 c.c.) injections of physiologic salt 
solution, and has not found it necessary to increase the strength of the 
salt solution beyond 4 or 5 per cent. During the treatment the patient 
should remain in bed. Scleral cauterization, followed by subconjunc- 
tival saline injections, has been employed by Dor, and puncture of the 
eyeball with the galvanocautery has been advocated. With Deutsch- HEMORRHAGES IN THE RETINA 
451 
mann's operation (bisection of the vitreous and retina, with or without 
the intravitreous injection of animal vitreous) the author has had no 
experience. Deutschmann reports good results; some surgeons who 
have investigated the subject are not in favor of the operation. If the 
detachment is due to a tumor, the eye should be enucleated. For 
further consideration of this subject, see page 619. 
Hemorrhages in the Retina {Apoplexy of the Retina}.-The 
appearances of retinal hemorrhage have been described in the general 
symptom-grouping, and as they occur with so-called hemorrhagic 
retinitis (see page 432). 
Hemorrhages (unassociated with inflammation) may be in any of the 
layers of the retina, or, bursting through the limiting membrane, they 
may occupy the vitreous humor. By preference they are found along 
the course of the larger vessels; a favorite site is the macula. Hemor- 
Fig. 202.-Retinal hemorrhages (de Wecker and Masselon). 
rhages originating in the outer sheath of the optic nerve may appear 
at its margin and spread into the surrounding retina, although it does 
not follow that intrasheath hemorrhagic extravasations always follow 
this course. 
Hemorrhages of large dimensions and drop-like form usually mean 
an extravasation between the internal limiting membrane of the retina 
and the hyaloid membrane of the vitreous, and they come from a retinal 
vessel. These subhyaloid or preretinal hemorrhages tend to occur at 
the yellow spot more than at other parts of the fundus. Occasionally 
they assume a wedge-, bottle-shaped, or almost circular appearance, or 
they may have, as in an eye recently examined by the author, a long, 
roll-like form, and overlie the sweep of the retinal vessel; often they are 
semilunar in shape. Except as the result of traumatism they are exceed- 
ingly scarce in young children, but Harms has reported one case in a 452 
DISEASES OF THE RETINA 
child of four and one-half years. According to J. Herbert Fisher, the 
hemorrhage detaches the internal limiting membrane from the retinal 
layers, which are not invaded, and occupies the space thus formed. It 
may break into the vitreous. 
Causes.-Some of these have already been enumerated. The 
following resume, based upon the classification of Dimmer, may be 
added: 
(a) Hemorrhages caused by changes in the composition of the 
blood and the tissues of the blood-vessel walls: Pyemia, septicemia, 
ulcerating endocarditis; diseases of the liver, spleen, kidney, and 
atheroma of the vessels, and angiosclerosis of the retinal vessel; loss of 
blood (menorrhagia, hematemesis); anemia (simple and pernicious); 
hemophilia, purpura, and scurvy; diabetes and gout; tuberculosis; mala- 
ria and recurrent fever. In carcinoma of the stomach retinal hemor- 
Fig. 203.-Subhyaloid hemorrhage. 
rhages and white spots may resemble those seen in pernicious anemia. 
To this manifestation the name cachectic retinitis is sometimes applied. 
(6) Hemorrhages caused by disturbances in the circulation: Hyper- 
trophy of the heart and stenosis of the valves; thrombosis of the central 
vein of the retina, and embolism or thrombosis of the central artery; 
suffocation, compression of the carotid, and hemorrhages in the new- 
born, which are not infrequent; and the menstrual disturbances. 
(c) Hemorrhages caused by sudden alterations of the intra-ocular 
tension-e. g., after iridectomy in glaucoma-and by traumatisms. 
Among the latter may be classed retinal hemorrhages after large cuta- 
neous burns, and those which have followed compression of the thorax 
and neck and fracture of the skull. 
(d) Hemorrhages caused by certain toxic agents-e. g., phosphorus, 
chlorate of potassium, serpent virus. CHANGES IN THE RETINAL VESSELS AND THEIR WALLS 
453 
Prognosis.-This depends upon the extent and situation of the 
hemorrhages. They form an important prognostic guide of the disease 
which has caused them, and in elderly persons may be an indication of 
future hemorrhages into the brain. Glaucoma, detachment of the 
retina, and the formation of dense opacities in the vitreous humor may 
be complications. 
Treatment.-All use of the eyes must be forbidden. Locally, a weak 
solution of sulphate of eserin may be employed, especially in elderly 
people. Internally, the medication must be governed by the probable 
cause. Frequently cardiac sedatives, moderate diaphoresis, and later, 
alteratives, such as iodid of potassium, iodid of sodium, syrup of hy- 
driodic acid, and bichlorid of mercury, will be required. If the arterial 
tension is high, nitroglycerin should be administered. 
Fig. 204.-Extensive retinal vessel disease; periarteritis and periphlebitis. Right eye. 
Changes in the Retinal Vessels and Their Walls.-Certain 
changes in the retinal vessels due to vasculitis and perivasculitis are often 
seen. These are characterized by the appearance of white stripes along 
the vessels or, rather, the vessel walls become apparent by their con- 
version into whitish tissue, due probably to an infiltration of the adven- 
titia with lymph-corpuscles. This may be so extensive that the entire 
set of vessels is converted into a series of branching white lines. 
Such conditions may be due to various inflammatory diseases of 
the retina and optic nerve. Alterations in the retinal vessels are also 
caused by chronic nephritis and general arteriosclerosis, and present the 
following ophthalmoscopic appearances: 
1. Alterations in the course and caliber of the retinal arteries, mani- 
festing themselves as (a) undue tortuosity, which is not significant 
unless, to quote the words of Mr. Gunn, whose classification is fol- 
lowed, it is associated with other evidence of disease; (b) alterations in 454 
DISEASES OF THE RETINA 
the size and breadth of the retinal arteries, presenting, as it were, a 
beaded appearance. 
2. Alterations in the reflections from, and the translucency of, the 
walls of the retinal arteries, manifesting themselves (a) in increased 
distinctness of the central light-streak on the retinal vessel and an 
unusually light color of the entire breadth of the artery ("silverwire 
arteries"); (6) loss of translucency, so that it is impossible to see, as it 
is in the normal state, through the artery an underlying vein at the 
point of crossing; (c) positive changes in the arterial walls, consisting 
of whitish stripes, indicating degeneration of the walls or infiltration of 
the perivascular lymph-sheaths {perivasculitis). 
3. Alterations in the course and caliber of the veins, together with 
signs of mechanical pressure, manifesting themselves (a) in undue 
tortuosity, which, as in the case of the arteries, is not significant except 
in the presence of other disease; (6) alternate contractions and dilata- 
tions; (c) an impeded venous circulation where a diseased artery crosses 
it. The last is a sign of the utmost importance. Ordinarily, as an 
artery crosses the vein, as it may be seen by an examination of the 
normal eye-ground, there is no sign of pressure. If the walls of 
the artery are thickened by disease, it presses upon the vein, 
pushes it aside, or directly contracts its caliber, so that beyond 
the point of crossing there is an ampulliform dilatation, (d) Changes 
in the venous walls, precisely as they occur in the arteries, so that 
whitish stripes border the vessel, and are indications of degenera- 
tion in its walls. Often associated with this one may see varicosities. 
(See Plate V.) 
4. Edema of the retina, manifesting itself (a) as a grayish opacity, 
which may be present in the immediate neighborhood of the papilla, 
or in spots over the eye-ground and along the course of the vessels, 
looking like a fine gray haze, or in little fluffy islands far out in the 
periphery. 
5. Hemorrhages, manifesting themselves as linear extravasations 
along the course of the vessels, roundish infiltrations scattered over 
the fundus, or sometimes in a drop-like form. All these changes have 
been described by Raehlmann, Friedenwald, Hirschberg, the author, 
and many other observers, and were especially accurately recorded and 
classified by the late Mr. Marcus Gunn. 
The significance of these lesions is of serious import. In addition 
to their relation to nephritis, they may be the forerunners of vascular 
sclerosis of the brain or indicate the presence of disease of the cerebral 
arteries. Their subjects are liable to hemorrhage in the brain and all 
its consequences. In retinal angiosclerosis, the disease is probably 
primarily in the intima, according to Coats, and in arteritis new tissue 
forms which encroaches on the lumen of the vessel, sometimes suggesting 
a hyaline change. According to this observer, irregularities of vessel 
caliber are due to endothelial proliferation, and silverwire arteries to 
fibrosis. Endothelial proliferation of the main artery depends upon a 
circulating toxin. Plate V. 
Changes in the fundus in arteriosclerosis. EXUDATIVE RETINITIS 
455 
Angioid Streaks in the Retina (Retinal Pigment Strice').-These 
occur as dark, reddish-brown, sometimes almost black striae lying be- 
neath the retinal vessels. They give the impression of a system of 
obliterated vessels, as in a case recorded by the author, but are caused, 
according to Ward Holden, by the metamorphosis of hemorrhages 
diffused in a linear manner through the deep layers of the retina. Lister 
thinks they represent newly formed vessels which have penetrated 
inflamed tissue, and along which pigment deposits and other exudations 
are arranged. W. Zentmayer is inclined to regard the streaks as pig- 
mented vessels which are either of inflammatory or congenital origin. 
Coats suggests that the streaks arise along vessels, but that these vessels 
belong to the choroid rather than the retina. 
Fig. 205.-Angioid streaks in the retina; large central semicircular hemorrhage. 
Exudative Retinitis (Retinitis Hoemorrhagica Externa; Massive 
Retinal Exudation [Coats]).-In this form of retinal disease, particularly 
well described and studied by George Coats, the most conspicuous 
feature is a large, prominent yellowish-white circumscribed lesion, or 
smaller areas of yellow or white exudations lying beneath the retinal 
vessels. Coats has investigated several varieties of the affection, 
namely those without gross vascular disease, those with extensive 
vascular changes, and those with arteriovenous communication. Re- 
cently he has removed the last-named variety from his classification of 
massive retinal exudation. Of insidious onset and slow progress, the 
disease most often attacks young persons (average age about nineteen), 
and is more common among males than females. The patients are 456 
DISEASES OF THE RETINA 
usually in good health (anemia may be present), and their clinical and 
family histories do not yield information as to the etiologic factor. In 
late stages of the disease detachment of the retina, cataract, iritis, and 
glaucoma may develop. The affection depends, as Coats has shown, 
upon hemorrhages in the interretinal layers. A slow organization 
takes place with formation of cicatricial tissue masses. At first the 
choroid remains free from pathologic alterations, but there are border- 
line cases of the disease characterized by involvement of the choroid 
as well as the retina in the form of thickening and round-cell infiltration. 
Exudative retinitis is probably the result of local vascular disease; 
Fig. 206.-Massive retinal exudation. Left eye of a girl aged nineteen. 
ophthalmoscopically it has most often been mistaken for tuberculous 
choroiditis. 
Aneurysms.-Aneurysm of the central retinal artery is an extreme 
rarity. It has been seen as a spindle-shaped sac, pulsating synchron- 
ously with the heart. Miliary aneurysms, usually spindle shaped, have 
been noted in the small arterial twigs, and may be looked upon as sig- 
nificant of a similar condition of the vessels in other organs, especially 
the brain. The student should not mistake varicosities in the veins for 
aneurysms. Arteriovenous aneurysm of the retina has been described 
as the result of injury (Fuchs) and as a congenital condition (Leplat). 
E. von Hippel, however, doubts the applicability of the term, because 
he believes that in these cases arteriovenous aneurysm was lacking. 
Angiomatosis of the Retina.-This rare disease has been observed 
by Fuchs (see preceding paragraph), Goldzieher, Darier, and a few OBSTRUCTION OF THE CENTRAL ARTERY OF THE RETINA 
457 
other observers, but its first accurate description is by von Hippel. 
According to him, the most prominent ophthalmoscopic appearances 
are red, spheric formations, with enormous dilatation and tortuosity of 
one or more arteries and the accompanying veins, both sets of vessels 
having the same color. About 30 cases are on record; tuberculosis 
is suggested as a cause. Anatomic examination reveals diseased retinal 
vessels, destruction of the nervous elements, proliferation of the glia, 
and organization of subretinal hemorrhage (von Hippel). According 
to Meller, primarily there is increase of the neuroglia with secondary 
vascular changes. The prognosis as to vision is fatal; blindness from 
secondary glaucoma results. 
Obstruction of the Central Artery of the Retina, Including 
Embolism and Thrombosis.-Rarely an embolus lodges in the central 
artery of the retina; 5 cases on record, according to Coats, namely, his 
own and those of Harms, Schweigger, Manz, and Marple, were definitely 
embolic in nature. Usually the symptoms recorded in the following 
paragraphs are caused by thrombosis or by obliterating endarteritis. 
Symptoms.-The main branches of the artery are thin, and can be 
followed only a short distance over the edge of the papilla into the 
retina, and there is a diminution in the number of ramifications. The 
veins are also contracted, and very often they present unequal disten- 
tion. They may present ampulliform broadening, alternate contrac- 
tions and swellings, and especially a contraction at the disk, succeeded 
by broadening in the periphery, where they assume almost their natural 
breadth. Pressure from before backward, so as to increase the intra- 
ocular tension, causes a regular current to flow through the vessels. 
This consists of broken cylinders of blood, separated by clear spaces, 
which move sluggishly along. In the veins, without such pressure, and, 
it may be, directly after the accident, an intermittent blood-stream is 
often visible. The appearance is not unlike that produced when air is 
allowed to mix with a fluid in a tube. Occasionally a few hemorrhages 
are seen along the course of the vessels. 
The papilla assumes a pallid, grayish-white appearance, owing to 
the lack of blood in its capillaries. An opacity in the retina develops, 
grayish-white or fog-like in appearance, sometimes permitting the red- 
dish tint of the normal eye-ground to shine through it, and sometimes 
being so opaque that it is quite milk-like in its density. This occurs 
especially in the neighborhood of the papilla and in the macular region, 
the space between the two often being free, although gradually the areas 
meet. The opacity comes on within a few hours after the accident, or 
may be delayed for a day or two. The author has watched it form 
within twenty minutes after sudden stoppage of the central retinal 
circulation. It is due, according to Coats, not to edema, but to an 
ischemic necrosis. 
Characteristic of sudden obstruction of the arterial circulation is 
the formation in the macula lutea (corresponding to the position of the 
fovea) of a central red spot, which resembles a round hemorrhage in 
the midst of the milky-white area. It is known as the cherry-red spot 458 
DISEASES OF THE RETINA 
of the macula lutea, and is caused by the red color of the choroid appear- 
ing through the much-thinned retina, and changes in the pigment epi- 
thelium. As a rare phenomenon, at least in the dark-skinned races, 
the usual cherry-red spot has been replaced by a coal-black one. The 
spot appears at the same time with the opacity in the macula lutea. 
It is less likely to form where there is a stoppage of a branch of the 
retinal artery instead of one of the main trunks. 
In the course of several weeks there is a gradual disappearance 
of the retinal opacity, the optic disk undergoes atrophy, and the retinal 
vessels are shrunken or even converted into white cords; if there have 
been hemorrhages, spots of degeneration appear at their positions, and 
Fig. 207.-Small visual field representing area of functionating retina surrounding blind- 
spot. 
not infrequently cholesterin crystals and pigment markings may be 
seen around the disk and in the macula lutea. 
Instead of the main trunk, a branch may be obstructed, and this 
obstruction is sometimes visible to the ophthalmoscope as a yellowish 
body, but, more frequently, at one point of the artery there is a swelling, 
while beyond it the vessel is obliterated or its caliber is much reduced. 
Vision is lost with characteristic suddenness. Usually preceding 
the blindness there is temporary obscuration of vision, or a little head- 
ache and giddiness, with flashes of light, representing a species of aura. 
Periods of temporary blindness lasting from a few minutes to one-half 
hour, during several years (in one of the author's cases twelve years), 
may precede the ultimate obstruction of the artery. In obstruction of 
a branch, on the other hand, there may be very good acuteness of vision. OBSTRUCTION OF THE CENTRAL ARTERY OF THE RETINA 
459 
The presence of a cilioretinal vessel may be the means of preserving vision. 
A rare condition is obstruction of a cilioretinal artery (Hirsch, Zent- 
mayer, F. Krauss). 
The field of vision varies according to the extent of the blocking 
of the circulation. In cases where the obstruction is complete, even 
light perception is absent. If only a branch has been occluded, that 
portion of the retina which receives its blood-supply from this source 
will be paralyzed, and the opposite area of the field will be darkened. 
The presence of a cilioretinal vessel permits, as a rule, an oval portion 
of the field of vision to remain in the neighborhood of the fixation-point, 
but, according to C. F. Clark, the evidence is not sufficient to warrant 
the conclusion that such a vessel is the means of preserving the in- 
tegrity of the papillomacular region of the retina. Even if the main 
stem of the artery is obstructed, a small portion of the field may be 
preserved on the temporal side, corresponding to an area on the nasal 
side of the fovea in the region of the blind-spot. An uncommon effect 
is a central scotoma, which may be due to obstruction of the macular 
arteries; the scotoma may also be paracentral. 
The intra-ocular tension is sometimes raised, sometimes lowered, 
and sometimes unaffected. The pupil may be large and irresponsive to 
light if the case is one of complete stoppage of the central artery.1 
Causes.-The most frequent causes of obstruction of the central 
artery of the retina are valvular disease of the heart, especially if com- 
plicated by a fresh endocarditis, and general arterial sclerosis, aneurysm 
of the aorta or of the carotid, Bright's diseasS and pregnancy; in a 
few instances it has been noted with chorea. Thrombotic obstruction 
depends upon endarterial changes, alteration of the composition of the 
blood and its coagulability. Stoppage of the central artery may occur 
at almost any age of life, and has been recorded from the fifteenth to 
the eightieth year. The accident usually is unilateral, simultaneous 
obstruction of the central artery of each eye being very rare; occa- 
sionally both eyes are affected, with a definite interval between the 
attacks.2 Blindness with ophthalmoscopic appearances exactly similar 
to those caused by obstruction of the central artery has followed sub- 
cutaneous injections of paraffin in the nasal region and of bismuth 
paste into the accessory sinuses. 
Diagnosis.-The ophthalmoscopic picture just detailed indicates 
that a block in the central retinal circulation has occurred, due usually 
to one or other of the causes already named. Similar appearances have 
been ascribed to hemorrhage into the sheath of the optic nerve, to spasm 
of the muscular wall of the central artery, and to thrombosis of the 
central vein so situated that it presses upon and occludes the lumen 
of the artery lying beside it. Schweigger taught that emptiness of 
the arteries was an important sign of true embolism. Some cases of 
1 The symptoms which have been described refer to typical cases; a variety of excep- 
tions occurs. 
2 In a certain number of cases, although all the ordinary ophthalmoscopic appearances 
of embolism of the central artery of the retina have been present, it has been impossible 
to assign a cause. 460 
DISEASES OF THE RETINA 
obstruction of the central retinal circulation appear to be due to collapse 
of the arterial walls, so that they come in contact (Hoppe). In these 
circumstances recovery may occur spontaneously or be brought about 
by treatment. While it is true that "there is at present no proof that 
obstruction may be caused by spasm apart from endarteritis" (Coats), 
the effect of an apparent spasm from the clinical standpoint must be 
conceded. The author has examined Harbridge's patient, and watched 
complete collapse of the retinal arteries, followed in four minutes by the 
restoration of their caliber. Intermittent closing of the retinal arteries, 
apparently due to vessel cramp, has been many times recorded; for 
example, with angiosclerosis, Raynaud's disease, epilepsy, and migraine 
(see also page 422). 
Prognosis.-This is exceedingly unfavorable, and in most instances 
blindness is the result. Even when temporary improvement occurs, 
subsequent atrophy of the nerve is likely to ensue. In obstruction of a 
branch the prognosis is more favorable, and, as has been stated, normal 
central vision may be present. The presence of a cilioretinal vessel 
improves the prognosis. According to Swanzy, in cases of bilateral 
obstruction, unless vision is lost simultaneously, a fair amount of 
vision may be restored. Glaucoma may follow stoppage of the central 
retinal artery. 
Treatment.-This does not often prove of much avail. In the hope 
of restoring the circulation by reducing the intra-ocular tension, scle- 
rotomy, iridectomy, and repeated paracentesis of the anterior chamber 
have been practised, but without success. 
Massage of the eyeball has been recommended, and in some cases 
has been followed by good results. It should be given a faithful trial; 
the author can confirm its value. With the massage, inhalations of 
nitrite of amyl may be given (Gifford). 
Thrombosis of the Central Vein.-This has been observed a 
number of times as the result of a phlebitis, and also in patients with 
cardiac disease, arteriosclerosis, nephritis, and diabetes. 
In some instances the appearances have been closely similar to 
those of embolism; in others they have assumed an inflammatory char- 
acter similar to that described under Hemorrhagic Retinitis, of which it 
may be a cause (see page 432). Several grades of this condition have 
been recorded. If the ophthalmoscope reveals tortuosity of the vessels, 
engorgement of veins, and normal or contracted caliber of the arteries, 
venous pulse, and interrupted venous circulation and extensive retinal 
hemorrhages, thrombosis of the central vein may be suspected (Ange- 
lucci). There may be complete obscuration of the disk, which is hidden 
by infiltrated retina, and surrounded by large flame-shaped and some- 
times sheet-like hemorrhages, which extend widely over the fundus. 
Instead of the main trunk, one of its branches may be thrombosed, and 
the ophthalmoscopic appearances confined to the area which it drains 
(Fig. 208). According to conditions various visual fixed alterations 
are demonstrable; a central scotoma may be present. 
Prognosis.-If the thrombosis is in the central vein, hope of res- TRAUMATISMS OF THE RETINA 
461 
toration of vision practically must be abandoned; in obstruction of a 
branch the prognosis is more favorable. A secondary glaucoma, some- 
times developing acutely, is not an uncommon complication, due to 
obstruction of the filtering area by an albuminous exudate. Iritis with 
the formation of fibrovascular membrane has been observed. 
Treatment.-This depends upon the general condition. Other things 
being equal, iodids and syrup of hydriodic acid may be administered. 
Diaphoresis may be tried; mydriatics should not be used lest they cause 
glaucoma. 
Traumatisms of the Retina.--Under this general term may be 
included traumatic anesthesia, traumatic amblyopia, traumatic per- 
forations of the macula lutea, detachment, and rupture. There are 
no characteristic symptoms common to all varieties, but pain and dis- 
Fig. 208.-Thrombosis of a retinal vein. 
turbance of vision, in part due to the direct injury and in part to a 
transient astigmatism, are likely to be present. 
1. Traumatic anesthesia of the retina is the name proposed by Leber 
to describe effects of a blow upon the eye without discoverable ophthal- 
moscopic changes, but with considerable defect in vision and contrac- 
tion of the visual field-results, moreover, which may remain un- 
changed for a long time, or, indeed, never entirely pass away. 
The treatment is rest and the use of strychnin internally, or by hy- 
podermic medication. 
2. Traumatic amblyopia {commotio retinae; edema of the retina} is a 
condition also arising from an injury, especially a blow from a ball, cork, 
or similar body, and is attended by the following symptoms: Hyperemia 
of the globe marking the position of contact of the missile; clear media; 
and gray opalescence of the retina, especially in the macular region, 
but also around the papilla, which may be somewhat hyperemic. If 462 
DISEASES OF THE RETINA 
the retina under the point of contact is visible, this also may exhibit 
the white infiltration. In addition, several pale-yellowish spots, and, 
occasionally, small hemorrhages may be present. The vessels are un- 
changed, or, in some instances, are contracted (arteries) or distended 
(veins) and pass over the gray area. A central scotoma may exist. 
An interesting complication is the development of a transitory 
astigmatism, which helps to reduce the visual acuteness. 
The gray infiltration forms cpiickly and is also absorbed with rapid- 
ity, usually having subsided at the end of two or three days, although 
the visual defect may last for longer periods. Decided retinochoroiditis, 
the result of concussion, may occur, and this fact should be remembered 
Fig. 209.-Hole in macula and rupture of choroid after a blow on eye (patient in the 
University Hospital). 
in investigating old cases of choroidal disease presenting themselves with 
meager history. According to Fuchs, changes in the macula after con- 
tusion may be due to inflammatory edema as the result of a low-grade 
inflammation of the ciliary region. 
The treatment consists in keeping the pupil dilated with atropin 
and covering the injured eye with a shade or dark glass, all use of the 
uninjured organ being forbidden. 
3. Traumatic Perforations of the Macula Lutea.-Haab has called 
attention to the fact that a contusion or concussion injury of the eye 
may cause a round hole in the macula about half the size of the surface 
of the optic disk, surrounded by a gray ring. The bottom of the hole is 
of reddish color, with a stippling of white and red. F. M. Ogilvie, who RETINAL CHANGES FROM THE EFFECT OF SUNLIGHT 
463 
calls the affection "holes in the macula," points out that these perfora- 
tions are the immediate and direct result of the injury. In his observa- 
tions these were represented by areas depressed below the level of the 
surrounding retina, of a deep-red color, and sharply margined by clean- 
cut edges. In some cases the retina is detached; in others it is not. 
A central scotoma may exist. Other signs of injury may be present in 
the eye-ground-for example, rupture of the choroid-as in an eye 
observed by the author. This "hole" in the macula is produced by an 
edema of the retina at the posterior pole (Coats). 
4. Detachment of the retina after injury has been mentioned (see 
page 448). 
5. Rupture of the Retina.- Rupture, uncomplicated by choroidal fis- 
sure the result of injury, is a rare accident, and might be recognized by 
observing the frayed edges of the tear and seeing the exposed choroidal 
tissue. Long describes such an occurrence following a fall upon the 
back of the head. 
Purtscher has described a fundus lesion after fracture and trauma- 
tisms of the skull, to which he gives the name angiopathica traumatica 
retina. The ophthalmoscopic picture consists in the presence of shining 
white patches, chiefly associated with the veins; hemorrhages may also 
occur. These patches are supposed to be due to cerebrospinal fluid 
which has been forced into the retinal perivascular lymph-spaces. To 
this condition Korber applies the term lymphorrhagia of the fundus. 
Retinal Changes from the Effect of Sunlight (Solar Retinitis') 
and Electric Light (Electric Retinitis).-It has been experimentally 
proved that retinal changes can be produced in animals' eyes by con- 
centrating upon them the rays of the sun. Clinically, analogous dis- 
turbances have been found in the human retina after exposure to in- 
tense light, most frequently in those who, with unprotected eyes, have 
watched an eclipse of the sun (eclipse blindness). Similar conditions 
are caused by intense electric light, especially among those engaged in 
electric welding. 
The symptoms are: Persistence of an after-image or, later, a dark 
spot in the field of vision (positive scotoma); distortion of objects, and 
evidences of slight retinitis or retinochoroiditis in the macular region. 
Thus, there may be a maroon-colored area with a central gray patch, 
and numerous faintly marked yellowish-white dots. A cherry-red spot 
has been detected by Ischreyt and a definite "hole in the macula" has 
been described. 
Decided improvement is not infrequent, but complete recovery is 
exceptional (Mackay); hence prognosis must be guarded. The central 
scotoma may be permanent (Duane); ring-shaped scotoma has also been 
observed. Degeneration of the papillomacular bundle may occur (E. T. 
Collins). 
The treatment is that suited to retinochoroiditis. The preventive 
treatment consists in wearing suitable colored glasses-yellow glass or 
a combination of blue and red, or, as in Sheffield, several layers of ruby 
glass. 464 
DISEASES OF THE RETINA 
Glioma of the Retina.-This is a malignant growth of the retina, 
and is a soft, vascular tumor, made up of small round, deeply staining 
cells, many of them containing long protoplasmic processes. They form 
thick mantles of well-preserved cells around the thickened blood-vessels, 
the cells between the mantles staining poorly and undergoing calcareous 
degeneration. In many of these neoplasms peculiar rosettes have been 
described by Flexner, Wintersteiner, and others, which are composed of 
elements resembling the rod and cone visual cells, and for these growths 
the name neuro-epithelioma has been suggested. Alt thinks the rosette 
formation is due to the growing of tumor-cells around a tissue enclosure, 
and not to rudimentary rods and cones, and Ginsberg believes they 
correspond to cells of the rudimentary retina, which are not differen- 
tiated into spongioblasts and neuroblasts. Glioma usually arises from 
the inner retinal layers; less frequently from the outer retinal layer. 
According to Leber, it mav develop from various layers not only in 
different eyes, but in the same eye (Par- 
sons). Exactly how glioma originates is 
not certainly known, but probably in fetal 
retinal cells. 
According to the direction which the 
growth takes, it has been described by 
systematic writers as glioma endophytum 
and glioma exophytum. In the former 
the vitreous chamber is occupied by the 
growth; in the latter, it lies between the 
retina and choroid. 
The tumor is usually of a light-gray or 
grayish-red color. It is subject to various 
degenerative changes-fatty, cheesy, and 
calcareous-and tends, on the one hand, 
to invade the orbit, involve the optic 
nerve, and travel by the way of its sheath to the brain, and, on the 
other, to pass forward, bursting through the sclerotic and cornea. 
Recurrence in loco after extirpation may occur, and metastases, 
especially in the cranial and facial bones and the brain, may take 
place. They also occur, according to F. M. Wilson and E. S. Thom- 
son, in the lymph-glands, parotid, liver, ovaries, kidneys, spleen, lungs, 
and spine. Glioma may cause changes in and invade tissues of the 
eye other than the retina: the vitreous, choroid, iris, ciliary body, and 
anterior chamber. 
Like sarcoma of the choroid, glioma passes through several stages. 
In the first, there are no signs of irritation, the media are clear, the 
pupil is dilated, and often the growth produces a whitish reflection 
which has given rise to the designation amaurotic cat's eye. As the 
disease progresses symptoms of irritation and increase in the size and 
tension of the globe become manifest, and the process begins to involve 
the optic nerve. Finally, the tumor bursts from its bounds, perforates 
the globe at its corneoscleral junction, grows rapidly, involving the orbit 
Fig. 210.-Glioma of retina 
(patient in the University Hos- 
pital) . GLIOMA OF THE RETINA 
465 
and neighboring temporal regions, and presents a huge vascular mass, 
to which, in former times, the name fungus hamatodes was applied. 
Glioma of the retina is probably always congenital. It may appar- 
ently occur as late as the eleventh year, but in such circumstances it is 
probable that the growth has been present, but has remained quiescent. 
It is not a common affection. Hereditary predisposition has not been 
established. Several members of the same family may be affected. 
One or both eyes may be involved. 
Diagnosis.-The following conditions, according to E. T. Collins, 
may be mistaken for glioma: Persistence of the posterior part of the 
Fig. 211.-Recurrence of glioma, forming the so-called fungus haematodes (from a 
patient in the Philadelphia General Hospital under the care of Dr. Hearn. Photograph 
by Dr. Pfabler). 
fetal fibrovascular sheath of the lens; masses of tubercle in the choroid; 
inflammatory or purulent effusion into the vitreous following retinitis or 
cyclitis, usually with detachment of the retina (see also Pseudoglioma, 
page 414). Circinate retinitis (white degeneration of the retina), 
according to de Wecker, has been mistaken for glioma. The author and 
E. A. Shumway have recorded a case of detachment of the retina with 
extensive dropsical degeneration of the rod and cone visual cells which 
exactly simulated glioma. In glioma the anterior chamber is uniformly 
shallow; in inflammatory exudations into the vitreous the chamber is 
deepened at its periphery (retraction of iris) and shallow at its center 
(bulging of pupillary border). Synechiae are occasionally present in 466 
DISEASES OF THE RETINA 
glioma. Tension is usually increased in glioma, but may be minus; 
rarely the v tension is elevated in pseudoglioma. In case of doubt the 
eye should be enucleated. 
Sarcoma of the choroid is differentiated from glioma by the fact 
that the former usually occurs at a later period of life, and that in the 
earlier stages of each affection the ophthalmoscopic findings are differ- 
ent. In glioma the tumor is seen to involve the retinal structure, which 
does not, as in sarcoma, merely act as a covering to the growth. Unlike 
sarcoma, glioma is never pigmented. 
Prognosis.-This is unfavorable, and if the disease has involved the 
optic nerve or bursts from its bounds, it is fatal. Although so-called 
spontaneous cure has been observed (Lindenfield) as an almost inva- 
riable rule, unmolested glioma causes death. Numbers of recoveries 
after proper enucleation are on record, and an opinion must be based 
on the extent of the disease, the condition of the optic nerve being the 
most important element in the prognosis. According to Hirschberg, a 
favorable prognosis may be given if the tumor has not passed the limits 
of the retina, and if the time elapsing since the first appearance of the 
growth has not exceeded ten weeks. Recurrence is rare after three 
years of immunity. In a number of fatal cases which have been ana- 
lyzed (Lawford, Collins) the optic nerve was unaffected in only four. 
In unfavorable circumstances recurrence in the orbit occurs, with ex- 
tension to the brain, and, more rarely, metastasis to a distant organ. 
Treatment.-Thorough enucleation, with division of the optic nerve 
as far back as possible, is the only treatment. Any suspicious tissue in 
the orbit is to be sacrificed. In several instances both eyes have been 
removed, and recovery after such procedure has been recorded-for 
example, by Simeon Snell. 
Subretinal Cysticercus.-This, like the presence of the same 
parasite in the vitreous, is exceedingly uncommon in this country. 
Cysts of the Retina.-Small cysts or cystic spaces due, probably, 
to arteriosclerosis of the retinal capillaries are not infrequently found 
in the eyes of old persons just behind the ora serrata (E. T. Collins). 
Cysts are also found in the detached retinas of blind eyes, where they 
may be multiple. They may commence in the degenerated retina, or 
be due to the adhesion of folds of this membrane (Parsons). Some- 
times they are visible with the ophthalmoscope. In a patient under 
the author's care a large retinal cyst springs from the upper part of an 
inferior detachment of the retina, leans over and partially obscures 
the disk. G. S. Derby describes a similar cyst. 
Symmetric Changes at the Macula Lutea in Infancy.-This 
disease, which occurs almost always in children of Hebrew parentage 
and begins from the third to the sixth month of life, is also known as 
"amaurotic family idiocy" (a name given by B. Sachs); it was first de- 
scribed by Waren Tay, and consists of a grayish-white zone about the 
size of the papilla in each macular region, with a brownish or cherry-red 
spot in the center, closely resembling the appearances seen in obstruction 
of the central artery. At first the remainder of the fundus is normal, but FAMILY CEREBRAL DEGENERATION WITH MACULAR CHANGES 
467 
later the optic disks undergo atrophy. Kingdon has thus summarized 
the general clinical signs: muscular enfeeblement, apathy, mental weak- 
ness, and gradual loss of sight. Death occurs in from one to two years. 
The autopsies show a change in the pyramid cells of the cortex and 
degeneration of the cord. According to Sachs, this is an arrest of devel- 
opment. Ward Holden, by Nissl's method, has shown that there is 
degeneration of the retinal ganglion cells, and his results have been con- 
firmed by Shumway and others. Verhoeff attributes the dark spot in 
the macula to contrast; no edema or hole was found in this region. 
The ocular conditions of this disease are merely, as Sachs insists, one 
symptom of a family affection. Syphilis is not a cause of the disease. 
Fig. 212.-Changes at the macula lutea in amaurotic family idiocy (from a patient in the 
University Hospital). 
Family Cerebral Degeneration with Macular Changes.- 
This affection, first described by R. D. Batten and named by Oatman 
"maculocerebral degeneration" (familial), presents itself in two forms: 
(a) The maculocerebral type, both retina and brain being affected, 
and (6) the macular type, the lesions being confined to the retina. It 
develops at a later age than family amaurotic idiocy, and is not' race 
selective. In the first type the disease begins usually about the sixth 
year of life and is characterized by macular pigmentation, progressive 
blindness, progressive paralysis, and dementia (Batten and Mayou). 
In the second type the period of development is delayed and begins 
about the thirteenth year, and the central nervous system is not affected. 
Such cases have been described by Stargardt as "progressive family 468 
DISEASES OF THE RETINA 
degeneration in the macular region." Brown Pusey's investigations of 
this type of the disease suggest to him it may be an expression of early 
arteriosclerosis. These and allied lesions have been discussed by 
Gifford under the title of "Juvenile Types of Amaurotic Family Idiocy." 
Macular Atrophy of the Retina.-Various types of central or 
macular retinochoroiditis have already been described, and it is not un- 
common to find in the eyes of old persons, in the macular regions, areas 
of yellow-white spots interspersed with pigment dots and small hemor- 
rhages, or irregular areas of erosion which may go on to atrophy of the 
elements and pigment heaping. Haab, however, has called attention 
to a pure retinal senile affection consisting of yellowish-red or whitish, 
or else darkly pigmented spots, the rest of the eye-ground being normal, 
and Harms, by microscopic investigation, demonstrated that the lesions 
depend upon an atrophy and disappearance of the involved tissues, 
affecting chiefly the neuro-epithelial layer. The pigment epithelium is 
much altered, but the choroid is practically not affected. Kuhnt, 
Haab, and the author have described a senile macular affection (retinitis 
atrophicans centralis), probably belonging to this class, which in all par- 
ticulars in its ophthalmoscopic appearances resembles the lesion known 
as traumatic perforation, or "hole" of the macula (see page 462). It 
may be caused by retinal vascular disease, and a similar appearance 
may arise as the result of a non-traumatic iridocyclitis or from a toxin. 
Indeed, Fuchs has shown that hole-formation in the macula may occur 
in a variety of conditions; for example, iridochoroiditis, neuroretinitis, 
retinal detachment, and retinitis pigmentosa. 
These macular changes do not respond to treatment. CHAPTER XVI 
DISEASES OF THE OPTIC NERVE 
Congenital Anomalies.-Opaque or Medullated Nerve-fibers.- 
In the normal eye the fibers of the optic nerve cease to be invested with 
a medullary sheath at the lamina cribrosa, and consequently the axis- 
cylinders, which are distributed to the retina, are transparent. As an 
anomalous condition, sometimes bilateral, but more frequently only in 
one eye, the medullary sheaths reappear at the upper or lower margin 
of the disk as a dull or glistening bluish-white patch, which extends for 
a variable distance out into the retina, and ends in a somewhat feathery 
or fan-shaped margin. Usually the retinal vessels are hidden by the 
patch, but reappear again on its distal side. 
This plaque may be a single one above or below, or it may appear 
both above and below the disk, more rarely on the nasal side, and very 
exceptionally upon the temporal margin. The size varies from a small 
expansion to a huge sweep of white tissue, continuous above and below 
with margins of disk, and taking somewhat the general direction of the 
vessels, which are wholly or in part concealed. Opaque nerve-fibers 
of the retina at a considerable distance from the disk have been recorded 
by Randall, Nettleship, Arnold Lawson, and other observers. 
This condition produces no change in vision except an increase in 
the size of the normal blind-spot, and should not be mistaken by the 
beginner for pathologic lesions-for example, an atrophy of the retina 
and choroid, or a bank of fatty degeneration as it occurs in retinitis 
albuminurica. 
Coloboma of the Sheath of the Optic Nerve.-This congenital 
anomaly is characterized by an apparent augmentation of the surface 
of the disk and an excavation of the papilla backward and downward. 
The periphery is usually bounded by pigment massing. There is an 
unequal division of the retinal vessels, which are first seen as they bend 
over the margin of the excavation. It is a rare anomaly, and has been 
mistaken for posterior staphyloma. It depends upon imperfect closure 
of the fetal fissure. 
Irregularities in the Disk.-Instead of its usual round or oval shape, 
the disk may be markedly irregular in outline, one side being occa- 
sionally at an apparently lower level than the other, or it may present 
a gibbous appearance. Congenital pigmentation of the optic nerve-fibers, 
most intense in the position of the physiologic excavation, has occa- 
sionally been described; the pigment may exist as a small spot or cover 
an area one-fifth of the size of the disk. 
When the nerve-head fails to fit the choroidal aperture accurately, 
a space is sometimes formed, usually crescentic, known as a "cone" 
469 470 
DISEASES OF THE OPTIC NERVE 
or "conus" (Loring). This generally is seen at the outer side of the 
papilla, but also inward, below, and very rarely above (see also page 131). 
It should not be confused with the cases of atrophy of the choroid seen 
in myopic eyes, to which the name posterior staphyloma is given (see 
page 132), nor with the crescents of choroiditis seen in astigmatic and 
stretching eyes, in which the scleral ring broadens out into a semi- 
atrophic area of disturbed choroid, usually bounded by an irregular 
pigment line, and most commonly developed at the temporal side of the 
disk. Congenital inferior crescent or conus is caused, according to 
Elschnig, by a pulling away of the choroid from the disk margin. The 
affected eyes are usually astigmatic. 
Fig. 213.-Spurious optic neuritis. 
Shreds of Tissue on the Disk.-These appear as glistening white 
patches of tissue, sometimes almost transparent, at other times thicker 
and more opaque, either completely or partially hiding the vessels 
(De Beck). Occasionally there is a white membrane more or less com- 
pletely covering the disk. 
Such appearances probably represent remains of the hyaloid artery 
or of its adventitious coat. 
Hyperemia of the Nerve=head {Congestion of the Disk}.-The 
color of the intra-ocular end of the optic nerve varies considerably, and 
it is not accurate to describe a nerve-head as congested if it simply is 
redder than usual. INTRA-OCULAR OPTIC NERVE INFLAMMATION AND EDEMA 
471 
As Gowers pointed out, the term simple congestion is applicable when 
the papilla presents a dull red or brick-dust hue, which shades almost 
imperceptibly, through a blurred margin, into the general red color 
of the fundus; when it is more marked in one eye than in the other, the 
latter serving as a picture for comparison; when at some antecedent 
examination the same optic disk has presented a more natural color; 
and when its borders are obscured, but not hidden. 
In other circumstances-and the appearance is a frequent one- 
the surface of the nerve is covered by a semitransparent or edematous 
layer, is unduly injected, and its margins, especially the nasal ones, are 
veiled by striations composed of fine grayish lines and minute capil- 
laries ordinarily not visible. The perivascular lymph-sheaths at the 
same time are unduly prominent in the form of white lines along the 
central vessels, especially the veins. This appearance has received the 
name "hyperopic disk," and has also been called "spurious optic neuri- 
tis" (Spicer) and "pseudorieuritis" (Stephenson). (See Fig. 213.) 
Causes.-(a) Refractive error, especially hyperopia and hyperopic 
astigmatism. (6) Prolonged exposure to glare and heat, (c) Certain 
toxic agents presently to be -described, and inflammation of the iris, 
usually of the syphilitic type, (di) Certain disorders of the brain, espe- 
cially various types of chronic insanity. Focal brain lesion-for ex- 
ample, cerebral embolism-may be associated with hyperemia of the 
nerve-head. 
Treatment.-This depends entirely upon the cause. Refractive 
error should be corrected if this is the apparent origin of the trouble. 
Constitutional measures will be required if there is reason to believe that 
some general cause is at work. 
Anemia of the Nerve=head.-This is not a disease peculiar to the 
optic nerve, but, like retinal anemia, occurs as part of a general anemia, 
or because of obstruction to the central vessels-for example, in em- 
bolism. 
It is most difficult to interpret the significance of pallor of the 
papilla. Usually it will require more than mere inspection to decide 
whether or not a pallid disk is pathologic. 
1. Intra=ocular Optic Nerve Inflammation and Edema.- 
For convenience these conditions may be described as (a) intra-ocular 
optic neuritis, or peripheral optic neuritis, and (6) engorgement-edema 
of the papilla, or choked disk. 
If the lesions consist of a hyperemia and a moderate swelling of the 
nerve-head and no unusual overfilling of the veins, and of an exudation 
which produces discoloration and opacity of the papilla, so that its 
margins and surface are obscured or hidden, and the whole process is 
not strictly limited to the disk, but passes into the retina immediately 
surrounding it, descending neuritis is often employed as a descriptive 
term. 
If the lesions are chiefly confined to the nerve-head itself, and there 
are great swelling and engorgement, suggesting mechanical compres- 
sion, marked distention of the retinal veins, and hemorrhages in and 472 
DISEASES OF THE OPTIC NERVE 
near the edematous papilla, the term choked disk, or papilledema (Elsch- 
nig, Parsons) is used to describe the condition. 
If the retina is extensively involved, with hemorrhages along the 
vessels, spots of degeneration, sometimes collected in a star-shaped 
figure analogous to that seen in renal retinitis, the term neuroretinitis 
is frequently utilized. 
To avoid this confusion of names, Leber proposed the general term 
papillitis, and if it is understood to refer only to those types evidently 
of inflammatory origin, the word is suitable. 
Symptoms.-In general terms, the symptoms which follow belong 
to the conditions now under consideration, but vary in their intensity or 
Fig. 214.-Ophthalmoscopic picture of papillitis and semidiagrammatic representation of a 
longitudinal section of the nerve-head. 
elaboration chiefly in so far as the swelling of the papilla is concerned, 
according as neuritis (optic neuritis) or engorgement-edema (choked 
disk, papilledema) is present. 
1. Changes in the Nerve-head.-(a) There are increased redness of 
the disk and obscuration of its borders, followed by swelling of the 
papilla, loss of the light-spot, and complete hiding of the margins, the 
center usually remaining more red than the periphery, which has a 
grayish tint and shades gradually into the surrounding retina. The 
swelling may increase, assume a mound shape of mixed grayish color, 
and finally the form of the disk is lost, and its position can be inferred Plate VI. 
The fundus of the right eye of a patient with tumor of the brain, 
showing choked disc. INTRA-OCULAR OPTIC NERVE INFLAMMATION AND EDEMA 
473 
only by the convergence of the vessels. The height of this swelling is 
measurable by the table given on page 107 and by the parallactic test. 
White spots and patches are often seen in the elevation sometimes cover- 
ing the retinal vessel. 
2. Changes in the Vessels.-The arteries, smaller than normal, pursue 
a moderately straight course and are difficult of recognition, being 
partly concealed by the swelling. Occasionally spontaneous pulsation is 
visible. The veins are dark in color, distended and tortuous, and pass 
along the slope of the elevation, often dipping into the infiltrated tissue. 
The light-streak is not lost, at least not where the vessel is clearly visible. 
The tortuosity of the vessels is sometimes remarkable, and has been 
compared to the writhing snakes in the Medusa-head. The point of 
emergence and convergence of the vessels may be hidden by the infil- 
tration, so that the center of the swelling seems somewhat destitute 
of vessels. In some instances thickening of the adventitia of the vessels 
gives rise to the appearance of white lines along their sides. 
3. Hemorrhages.-In many cases hemorrhages are found upon the 
swollen papilla or in its immediate neighborhood. They are in the 
form of narrow, flame-shaped extravasations if they lie in the fiber- 
layer, but may also assume other shapes if situated in a deeper plane. 
The number varies from a single hemorrhage to so many that the 
swollen nerve-head assumes a hemorrhagic form, or the surrounding 
retina may be freely occupied by elongated or other shaped patches of 
blood. Usually optic neuritis and choked disk are bilateral, although 
it is not uncommon to find the process more advanced in one eye than 
the other. Occasionally the condition is confined to one eye and the 
other remains unaffected. 
In addition to the ophthalmoscopic changes just detailed, the fol- 
lowing points deserve notice: 
1. Vision in optic neuritis and in choked disk may be defective or 
it may be entirely unaffected; hence the mere presence of good central 
sight should never be considered cause to omit ophthalmoscopic examina- 
tion. Usually the vision of one eye is more affected than its fellow. 
Impairment of sight may come on rapidly or slowly. Occasionally 
vision is lost with great suddenness, but this is rare. Photometric ex- 
amination will usually reveal disturbance of the light-sense (see page 66). 
2. The field of vision presents for consideration its periphery, which 
may at first be unaffected and later show irregular and concentric 
contraction; the increase in the size of the normal blind-spot, which 
becomes correspondingly great in comparison with the amount of 
swelling; the formation of an abnormal blind-spot or scotoma due to 
involvement of the axial fibers and occasionally simulating the Bjerrum 
type (V. Szily); the absence of half of the visual field (hemianopsia) 
if the intracranial mischief which may have been the cause of the 
neuritis or choked disk is so situated as to produce this phenome- 
non; and finally, defective color-perception, which may exist when 
there is no change in central vision and no limitation of the form-field. 
Cushing and Bordley have described reversal of the color lines as it 474 
DISEASES OF THE OPTIC NERVE 
occurs in hysteria in association with increased intracranial tension, 
with and without choked disk, as well as blue-blind areas, which disap- 
peared after the restoration of intracranial tension to normal by opera- 
tion. Although reversal of the color lines in these circumstances un- 
doubtedly is frequently demonstrable, it must not be regarded as a safe 
indication of the existence of increased intracranial tension. 
3. External Appearances.-There are no changes in the exterior of 
the eye indicative of swelling or inflammation in the nerve-head. There 
are no characteristic pupillary phenomena. The pupil may be moder- 
ately dilated, but, as Kampherstein has shown, in the majority of cases 
of choked disk its reaction is normal. If blindness is complete, the iris 
usually is immobile. Normal reaction, however, has been noted even 
in the presence of complete blindness (Kampherstein). 
Diagnosis.-The diagnosis of optic neuritis and of choked disk de- 
pends upon a direct ophthalmoscopic examination of the inflamed or 
edematous disk. The method of determining the height of the elevation 
has been explained. 
The student should not mistake the slightly prominent disks that 
are occasionally seen in hyperopia for beginning papillitis or papille- 
dema. There may be a superficial neuritis in hyperopia, and in these 
circumstances it is difficult at times to decide whether the disk has be- 
come edematous or inflamed under the influence of an intracranial or 
general disease, or whether it is congested as the result of eye-strain. 
If the condition is due to intracranial disease the disk edges are more 
blurred than in pseudoneuritis, the physiologic pit is contracted or filled 
in, the veins are darker and usually more tortuous, and a careful ex- 
amination of the size and shape of the blind-spot, of the light-sense, and 
of the visual field should, in most instances, establish the diagnosis. 
The average swelling of papilledema in cerebral tumors is, according to 
the author's and Holloway's measurement, 4.57 D. It varies from 3 
to 9 or 10 D. 
The course of the disease is a variable one. Occasionally swelling 
of the intra-ocular end of the nerve will come on with great rapidity; 
in other instances it is slow in its course and lasts for months and even 
years, with progressive failure of vision. While in a certain sense the 
various stages into which systematic writers have divided choked disk 
(papilledema) and optic neuritis are artificial, they are convenient for 
descriptive purposes. The following, referring especially to choked disk, 
are those, somewhat modified, which were recorded by Marcus Gunn: 
1. Increased redness of the disk, with blurring of its upper and 
lower margins, with a gradual progression of the blurring to the nasal 
edges, while the temporal margin is still visible, represents the first 
stage. 
2. Increased edema of the nerve-head, beginning filling in of the 
physiologic pit, involvement of the temporal margin of the disk, with a 
tendency of the edema to spread into the surrounding retinal area, and 
uneven distention and darkening of the retinal veins represent the second 
stage. INTRA-OCULAR OPTIC NERVE INFLAMMATION AND EDEMA 
475 
3. Decided increase of edema, elevation and size of the nerve-head, 
with vascular striation of the swollen tissue and strise of edema in the 
form of lines in the swollen retina between the disk and macula, marked 
distention of the retinal veins and retinal hemorrhages represent the 
third stage. 
4. Increase in the prominence of the disk, which assumes a mound 
shape and begins to lose its reddish color and juicy appearance and to 
become opaque, exudation in and on the swollen disk and surrounding 
retina, elaboration of the retinal hemorrhages in size and number repre- 
sent the fourth stage. 
5. Decided subsidence of the vascularity of the papilledema and 
increasing pallor, with or without sinking of its prominence, apparently 
contraction of the retinal arteries and thickening of their perivascular 
lymph-sheaths, spots of degeneration in the retina, especially in the 
macula, represent the fifth stage, which passes into the final stage of 
so-called papillitic atrophy. 
As the last stage is ushered in the borders of the disk begin to be 
visible, usually first upon the temporal side, until finally all margins 
again are apparent, at first a little mellowed, while the center is still 
covered by the remnant of the inflammatory tissue. Finally, the edges 
of the disk are clear, its color is white and atrophic, and its center be- 
comes apparent. Both sets of vessels are contracted, and may be 
streaked along their sides with whitish tissue. Areas of retinochoroiditis 
and elevated patches of degeneration, marking spots of former hemor- 
rhages, are often apparent. Second attacks of neuritis and choking of 
the disk may occur, as in a case observed by the author and A. G. 
Thomson. A choked disk may be implanted on an atrophic nerve-head. 
In addition to the swelling of the disk, there may be marked edema 
of the retina and lines of edema in the macular region, forming the so- 
called macular figure, or macrdar fan (Paton), not unlike the appearance 
which is so striking in certain types of renal retinitis (see page 433). 
It occurs in a fair percentage of cases of cerebral and cerebellar tumors 
(fully 15 per cent, according to Paton's figures), and may reach a 
height equal to or greater than that of the choked disk. In addition to 
these areas of retinal edema, there may develop in the macular region 
yellowish-white and degeneration spots, intermixed with hemorrhages. 
The prognosis of optic neuritis and choked disk depends upon the 
cause and the duration of the process.- If, for example, syphilis is the 
active agent, there is reason to hope that suitable treatment will be fol- 
lowed by good results. If the focus of disease, for instance, in the ac- 
cessory sinuses can be removed, vision may be saved and edema and 
inflammation will subside. If the papilledema depends upon increased 
intracranial tension, and this is relieved by decompressive trephining, 
or by a radical operation with removal of the growth, and the disk 
changes have not passed beyond the third stage, the prognosis as to 
sight is favorable. Untreated choked disk, or optic neuritis, almost 
always produces blindness; very exceptionally the original disease con- 
tinues, but the neuritis subsides (Oppenheim). 476 
DISEASES OF THE OPTIC NERVE 
Causes.-The most frequent cause of choked disk is tumor of the 
brain, inasmuch as it occurs in fully 80 per cent, of the cases. Usually 
the intracranial neoplasm must have existed for some time and the 
increased intracranial tension have lasted for a definite period before 
the engorgement-edema develops. The period from the beginning of 
choked disk to the height of its swelling in some instances comprises 
only a few weeks; in others, months and even years may elapse before 
the disk-edema appears. It is not possible to determine with certainty 
from the stage of the disk or retinal phenomena what the duration of 
the cerebral lesion is, but if choked disks arise with suddenness and the 
edema rapidly increases, they indicate an increase in intracranial pres- 
sure, either because the growth itself has gained in volume or because 
hemorrhage has occurred in or around it. 
Tumors of the corpora quadrigemina give the highest percentage 
of choked disk, and next tumors of the parieto-occipital region and of 
the cerebellum, which yield an almost identical percentage (tables of 
John E. Weeks and J. M. Martin). Tumors of the basal ganglia are 
usually associated with papilledema. Choked disk, if it does not fail 
entirely as a symptom of tumor of the pons, of the medulla, and of the 
corpus callosum, is apt to be late in its development, and, to a certain 
extent, this lateness of development applies to tumors of the frontal and 
parietal convolutions. It is probable that pontine tumors give rise to 
choked disk only if they also involve some neighboring structure, and, 
according to Paton's researches, the bulk of cases of brain tumor without 
choked disk are those of pontine and subcortical origin, but if the sub- 
cortical growths spread to the base, the disk changes appear. Tumors 
of the cerebellum are prone to cause a more intense form of choked disk, 
with rapid depreciation of vision, than cerebral neoplasms, and the same 
intensity of the process is, according to some authors, evident in morbid 
growths of the midbrain and thalamus, while it is less pronounced in 
subcortical, parietal, and frontal lobe tumors. Whether the refraction 
of the eye has any influence on the development of choked disk is un- 
decided. That myopia seems to have a deterrent effect has been 
asserted (Marcus Gunn, the author); its influence in this respect is 
doubted by other observers (Paton, Parsons, Bordley, and Cushing). 
The development of choked disk does not necessarily depend upon the 
size, situation, or structure of the intracranial neoplasm, and all types 
of morbid growths may originate papilledema-fibroma, sarcoma, glioma, 
carcinoma, solitary tubercle, and gumma. 
It also appears with echinococcus cysts, epidural and subdural clots, 
intracranial trauma, abscess of the brain, and middle-ear disease, when 
this has extended to the cerebrum. Von Hippel describes a form of 
optic neuritis with affections of the ear which may exist without disturb- 
ing sight and remain even after operation has removed its apparent 
cause. Acute blindness with normal fundus due to the pressure of 
internal hydrocephalus caused by brain abscess has been described 
(Pagenstecher). 
Of the four varieties of meningitis-simple, tuberculous, traumatic, INTRA-OCULAR OPTIC NERVE INFLAMMATION AND EDEMA 
477 
and cerebrospinal-tuberculous disease of the brain is the most frequent 
cause of optic neuritis, the percentage varying from 76 to 81 per cent. 
The appearances of the disk most often are those which have been de- 
scribed in connection with descending neuritis (see page 471). When 
there is direct pressure upon the tracts and chiasm, the swollen papilla 
has a peculiar grayish-white color, without much vascularity, and a 
similar appearance is sometimes caused by tumors of the cerebellum. 
Other intracranial causes are softening of the brain, hemorrhagic 
pachymeningitis, cerebritis, hemorrhage, thrombosis of the cavernous 
sinus, hydrocephalus, aneurysm, and enlarged pituitary body in acro- 
megaly. 
Occasionally general paresis, epilepsy, and disseminated sclerosis 
are accompanied by optic neuritis and by choked disk. Papillitis may 
precede, accompany, or follow myelitis (ophthalmoneuromyelitis). 
In addition to the intracranial causes of papillitis, this phenomenon 
may arise from a general infection. To this form Uhthoff gives the name 
infectious optic neuritis. According to this observer, it should be differ- 
entiated from those cases which are caused by orbital, intra-ocular, or 
intracranial lesions, and may be originated by any of the following dis- 
eases placed in order of their frequency: Influenza, syphilis, rheuma- 
tism, malaria, typhus fever, measles, whooping-cough, diphtheria, 
polyneuritis, small-pox, beriberi, erysipelas, scarlet fever, tuberculosis, 
typhoid fever, gonorrhea, and relapsing fever. The neuritis may mani- 
fest itself as a papillitis or as a retrobulbar neuritis, and Uhthoff thinks 
that the optic nerve conditions are most apt to arise during the stage of 
convalescence and are probably due to the action of toxins, and not 
directly to the micro-organisms. In children with congenital syphilis, 
even when only a few weeks old, optic neuritis is not uncommon, accord- 
ing to Mohr. Optic neuritis may also be caused by toxic agents, for 
example, by lead, atoxyl, filix mas, and alcohol, by anemia, both when 
this is an essential process and when it is caused by excessive hemor- 
rhage, by disturbances of menstruation, by lactation, by exposure to 
cold, by myxedema, by sunstroke, and by injuries. An association 
of chlorosis, choked disk, and abducens palsy has been observed, at- 
tributed by Meller to thrombosis in the region of the cavernous sinus. 
Metastatic optic neuritis has been recorded as occurring in sepsis 
(Axenfeld, von Michel). Optic neuritis may be associated with diseases 
and injuries of the anterior part of the eye. Under these conditions vit- 
reous opacities may also be present. 
Optic neuritis followed by atrophy may arise in association with 
deformities of the skull, and, according to Friedenwald's analysis, the 
patients for the most part have had oxycephalic or steeple-shaped skulls 
("tower skulls"). Blindness without changes in the intra-ocular end 
of the optic nerve due to cranial deformity has been reported by C. A. 
Oliver. Papillitis occasionally occurs as a congenital affection in sev- 
eral members of the same family and sometimes appears without evident 
cause. 
Choked disk and optic neuritis may depend upon disease of the 478 
DISEASES OF THE OPTIC NERVE 
orbital region-inflammation of its contained tissues, tumors, caries, 
and periostitis, especially around the optic foramen, upon purulent 
disease of the antrum of Highmore and the frontal sinus, and morbid 
processes of the upper posterior portion of the nose and of the sphe- 
noid and ethmoid bone {sinusitis). In most of these instances, unless 
both orbits or the sinuses are affected, the papillitis is unilateral, and 
there are other symptoms around the eye which point to the local 
condition. Optic neuritis has also been ascribed to dental disease. 
A rare form of optic neuritis is that described in association with 
persistent dropping of a watery fluid from the nose. Headache, vomit- 
ing, unconsciousness, and delirium are present. The fluid has been 
believed to be identical with the cerebrospinal fluid (Leber) or to be 
Fig. 215.-Fundus of the right eye of a patient with tumor of the brain and choked disk; 
swelling 6 D. (Service of Dr. Edward Martin in University Hospital.) 
due to nasal disease in the form of small polypi (Nettleship and Priestley 
Smith). Internal hydrocephalus was present in some of the patients. 
Treatment.-This depends upon the cause of the condition. In all 
syphilitic cases rapid mercurialization should be tried, followed later 
by the iodids. Salvarsan and neosalvarsan have been effectively 
employed. Orbital and sinus diseases indicate appropriate surgical 
measures. 
Since Sir Victor Horsley's announcement, twenty-seven years ago, 
that the release of intracranial tension arrests and cures optic neuritis 
(choked disk), numerous operations have been performed, with sat- 
isfactory results. In a certain number of cases of brain tumor the 
growth can be removed by a radical operation, but even if it is inoper- 
able, as it frequently is, or cannot be localized, a palliative operation, INTRA-OCULAR OPTIC NERVE INFLAMMATION AND EDEMA 
479 
that is, cerebral decompression, should be performed in order to save sight, 
and the earlier it is done, the better the results will be-i. e., operation 
should be undertaken before the third stage of the disk change is reached. 
Usually, after technically correct operations (and in all pretentorial 
tumors temporal decompression is the operation of choice, and in all 
subtentorial lesions a suboccipital decompression is indicated [C. H. 
Frazier]), the choked disk begins to subside from the third to the tenth 
day, and the subsidence is complete at the end of six weeks. The same 
operation is urged by Cushing in choked disk caused by cerebral edema, 
infections, and intracranial hemorrhage. Choked disk has also been 
treated by lumbar puncture, but with this procedure for this purpose 
the author has had no experience, and it should be remembered that 
Fig. 216.-Fundus of the right eye of the same patient shown in Fig. 215 one month after 
cerebral decompression. 
lumbar puncture is not free from danger in the presence of intracranial 
tumor. Puncture of the corpus callosum and drainage of the ventricle 
have been utilized to reduce intracranial pressure and thus relieve pap- 
illedema. 
Significance of Choked Disk.-Double choked disk is highly sig- 
nificant of intracranial disease, especially tumor or basilar meningitis. 
Indeed, it is the most important general symptom of this condition, but 
it is not a pathognomonic sign. The other causes of optic neuritis and 
choked disk which have been mentioned must be excluded, and care 
must be taken not to mistake the macular figure (see page 475) for an 
albuminuric retinitis. Although the presence of choked disk is so highly 
significant of cerebral tumor, of itself it possesses no distinct localizing 
importance. Usually papilledema is bilateral, but in a certain number 480 
DISEASES OF THE OPTIC NERVE 
of instances it is unilateral, and frequently there is an excess of choking 
in one eye as compared with the other. Whether this is a sure indication 
that the tumor is on the same side as the choked disk or the excess of 
edema is undecided. Horsley believes that choked disk tends to de- 
velop earlier and is not more marked in the eye corresponding to the 
side on which the tumor grows, but Paton doubts if reliance can be 
placed on this sign. In the author's and Holloway's investigations in 
the majority of cases the greater swelling was on the same side as the 
tumor; but there were many cases in which this rule did not hold good. 
The development of choked disk does not depend upon the size nor on 
the type of the tumor, although according to some authorities disk 
changes are most frequently absent in tuberculous growths and most 
frequently present with sarcoma, glioma, and cysts. According to 
Walter R. Parker, choked disk caused by increased intracranial tension 
appears first in the eye with the lesser intra-ocular tension, as measured 
with the Schiotz tonometer. As this author himself points out, this 
observation requires confirmation. 
Pathogenesis of Papillitis and Choked Disk.-As is well known, 
von Graefe at one time sharply distinguished between descending 
neuritis and choked disk {Stauungs-papille). 
If, for example, in meningitis the sheaths of the optic nerve, which 
are continued over it as prolongations of the corresponding brain- 
membranes, participate in the inflammation, as they undoubtedly 
may, there is at first, as Greeff points out, a perineuritis, which extends 
by way of the connective-tissue septa to the trunk of the nerve. The 
evidences of this inflammation, soon visible to the ophthalmoscope, 
present the appearances of a moderate, that is, not engorged, intra- 
ocular optic neuritis, and the whole process is a descending neuritis. 
If, on the other hand, the state of the nerve-head indicates engorge- 
ment, edema, and mechanical obstruction, and the evidences of these 
conditions are visible to the ophthalmoscope in the appearances already 
described (see page 474), the process is a choked disk or papilledema. 
Inasmuch as ophthalmoscopically it is frequently difficult to dis- 
tinguish a neuritis from a beginning choked disk, and as the conditions 
may be mixed, Hughlings Jackson expressed the opinion that there is 
one kind of optic neuritis from intracranial disease which may manifest 
itself under different appearances, sometimes with and sometimes with- 
out "swelling of the disk." It would seem, however, that it is still 
proper to maintain, within the limits described, the distinction to which 
reference has been made. 
Numerous theories have been propounded to explain the patho- 
genesis of choked disk. Von Graefe believed that choked disk was due 
to a venous stasis occasioned by obstruction to the return of venous 
blood from the cavernous sinus. This theory ceased to be tenable when 
Sesemann demonstrated the anastomosis between the ophthalmic and 
the anterior facial veins. Parinaud taught that choked disk is due to 
extension of the interstitial edema of the brain tissue through the optic 
nerve to its intra-ocular end, a theory to which Sourdille subscribes; and INTRA-OCULAR OPTIC NERVE INFLAMMATION AND EDEMA 
481 
Kampherstein believes that often it can be explained only by a preceding 
edema of the brain, extending through the optic nerve to the lamina 
cribrosa and thus causing choking of the nerve-head. 
The inflammatory or toxin theory, with various modifications, assumes, 
as Leber suggested and Deutschmann afterward endeavored experi- 
mentally to show, that so-called papillitis is not a product of edema, but 
an inflammatory affection, the fluid which distends the sheath of the 
nerve possessing an irritative quality; or, in other words, that the sub- 
arachnoid fluid is infected by products from the intracranial disease or 
lesion which is the prime cause of the trouble. 
The mechanical {lymph-space) theory of Schmidt-Rimpler, ascribed 
to the dropsy of the intersheath space of the optic nerve, which is caused 
by the increased subarachnoid fluid being forced into this situation 
under the influence of elevated intracranial pressure, a mechanical or 
compressing action, or to the fluid which found its way into the lym- 
phatic spaces of the optic nerve, an action causing edema, congestion, 
and later inflammation. 
Merz, trusting to experimental evidence, which has not always been 
confirmed (Frazier, J. E. Sweet, Holloway, and the author), declares 
that increased intracranial tension alone is sufficient to produce choked 
disk and that it is only necessary that this tension shall be maintained 
uninterruptedly for a certain time. Cushing and Bordley have, repeat- 
ing and elaborating Merz's experiments, reached similar results, and 
believe that a mechanical rather than a toxic process plays the chief 
role in the causation of choked disk. That the disk changes are due to 
compression of the vessels as they pass through the lamina was originally 
maintained by Manz. Choked disk, according to Schieck, is due to 
lymph stasis, the cerebrospinal fluid passing by way of the perivascular 
lymph-sheaths of the axial bundle of the optic nerve and along the central 
vessels into the disk. Paton and Gordon Holmes believe that their 
observations establish the fact that papilledema is an edema of the 
nerve-head due to two factors-venous engorgement and lymph stasis. 
In general terms it is probable that choked disk is produced by a 
combination of factors. In this combination increased intracranial 
tension or pressure is most prominent, and the mechanical theory of its 
pathogenesis affords the most satisfactory explanation. If other factors 
are potent, they have not yet been definitely discovered. 
Certainly, inflammatory or irritative processes in the optic nerve 
and its sheaths sometimes have an active influence, and if the inflam- 
matory condition predominates, the elevation of the disk is less marked 
and the process is apt to extend to the retina, where exudations and 
hemorrhages are visible; in other words, the lesions warrant the descrip- 
tive term inflammatory optic neuritis. 
Pathology.-Sections of choked disk examined with the microscope 
reveal the following lesions: Edema and swelling of the nerve-head, 
blood extravasations, swelling and varicosities of the nerve-fibers, 
and slight cellular exudation along the thickened and dilated ves- 
sels. In the interstitial form of neuritis the inflammation begins in 
31 482 
DISEASES OF THE OPTIC NERVE 
the sheath and septa, with the formation, in addition to the edema, of 
an exudation rich in cells, which subsequently organizes. There follow 
thickening of the interfascicular septa, increase of the nuclei, and de- 
generation and atrophy of the nerve-fibers from pressure.' In some cases 
degeneration of the ganglion cells of the retina is evident, depending upon 
the fact that an arterial branch supplying that particular area has been 
occluded. Such degenerative areas may give rise to scotomas or sector- 
like defects in the visual field. An ampulliform dilatation of the optic 
nerve sheath posterior to the eyeball is found in a certain number of 
cases, and in addition to distention of the intervaginal space there may 
be an infiltration of small cells in the sheath. 
1. Optic=nerve Atrophy.-Under the general term atrophy of the 
optic nerve are included the various types of degeneration and shrinking 
of the fibers of the optic nerve, usually described under the subdivisions 
primary, secondary, consecutive (neuritic or postpapilliticf and retinal 
and choroiditic atrophy. The last are really forms of consecutive atrophy. 
Symptoms.-Certain general symptoms are common to optic-nerve 
atrophy, although these are subject to variations according to the clinical 
types. 
1. Changes in the Nerve-head.-(a) Alterations of the Normal Color 
of the Disk.-The color of the disk varies from a slight gray pallor to a 
pure gray, greenish-gray, or entirely white hue. Many intermediate 
forms of discoloration occur; thus there may be a commingling of gray 
and red, producing the so-called "gray-red disk," and often there is a 
decided greenish tinge, rarely a blue one. 
Grayness of the optic nerve is not always detected by ordinary 
methods of examination, especially in the deeper layers of the disk, 
but if the fundus is examined by means of properly regulated illumina- 
tion, and through a lens which neutralizes any error of refraction, this 
deep pallor is usually evident. It is important to employ both the 
direct and indirect methods of examination, and the concave and plane 
ophthalmoscopic mirror. 
(6) Alteration in the Center of the Disk.-Sinking of the surface of the 
disk, varying from a slight depression to a complete excavation (see 
page 370), occurs according to the degree of degeneration which the 
nerve-fibers have experienced. The shape of the excavation depends 
somewhat upon the presence or absence of a normal physiologic cup. 
At the bottom of the atrophic excavation the mottling of the lamina 
cribrosa is very distinct in some cases of atrophy; in others it is not 
apparent. 
(c) Alterations of the Margins of the Disk and of the Scleral Ring.- 
In complete atrophy the margin of the optic disk is unusually distinct. 
In the atrophy which follows a neuritis or retinitis, however, the margins 
are often slightly veiled for a long time. 
Undue broadening of the scleral ring indicates shrinking of the disk. 
Even in the early stages of spinal atrophies the disk may be surrounded 
by a broad scleral ring, which, taken into consideration with alteration 
in the color of the papilla and contraction of the color-field (especially OPTIC-NERVE ATROPHY 
483 
red and green), affords diagnostic aid in the study of gray degeneration 
of the optic nerve. • 
2. Changes in the Vessels.-In simple atrophy, while there may be 
narrowing of the vessels, this is not always the case, and certainly not 
in the manner seen in consecutive atrophies. Sometimes the arteries 
are narrowed and the veins unchanged. 
In neuritic (consecutive) atrophy the arteries are much contracted 
and the veins in contrast are larger than usual, often retaining some of 
the tortuosity which was so marked a feature during the papillitic stage. 
By the contraction of the tissue these, too, may later become narrowed. 
Development of white tissue along the course of the vessels, due to 
thickening of the perivascular lymph-sheath, is common in this form 
of atrophy. 
In retinitic and choroiditic atrophy there is marked contraction of 
both veins and arteries, which at the same time are diminished in 
number. 
3. Changes in the Surrounding Eye-ground.-The presence of altera- 
tions in the general fundus depends entirely upon the cause of the 
atrophy. In simple gray and white atrophy such signs are absent; but 
in postpapillitic and retinitic atrophy, spots of degeneration, marking 
the places of former hemorrhages, and patches of pigment heaping, are 
commonly seen. 
In addition to these ophthalmoscopic changes the following symp- 
toms occur: 
1. Change in Central Vision.-This varies from a slight depreciation 
to blindness, and, if the atrophy is bilateral, is usually more marked 
in one eye than in the other. In every case, where this is possible, 
especially in early cases or cases of doubtful atrophy, any existing re- 
fractive error should be corrected before deciding the degree of deprecia- 
tion of central sight. 
2. Change in Light-sense.-Usually it has been found, in pure optic- 
nerve atrophy, that the light-difference is increased, but the light- 
minimum not much influenced. P. F. Hay, however, has also observed 
considerable increase in the light-minimum. Adaptation, or the ac- 
commodation of the eye to varying degrees of illumination, is greatly 
restricted, for example, in tabetic optic-nerve atrophy (Lohmann). 
3. Change in the Field of Vision for Form (White').--The following 
changes occur: Concentric contraction; very irregular limitations pre- 
senting large re-entering angles (peripheral scotomas); quadrant-shaped 
defects; complete loss of one-half of the visual field (hemianopsia); and 
an abnormal blind-spot in the center of the field (central scotoma) or 
adjacent to it (paracentral scotoma). 
The field of vision, concentric restriction being most common, does 
not give evidence of the cause of the atrophy, although it may afford 
information of the localization of the defect; thus, an affection of the 
macular fibers will produce a central scotoma. In spinal atrophy the 
limitation more frequently begins at the outer side than in other situa- 
tions. 484 
DISEASES OF THE OPTIC NERVE 
4. Change in the Field of Vision for Colors.-There is always a defect 
in color vision. Usually there is, first, contraction of the green field, 
then of the red, and afterward of the blue and the yellow fields. In 
late stages of optic-nerve atrophy color-sense is abolished. Occasion- 
ally the perception of red becomes defective before that of green is 
influenced by the atrophic- process. 
Generally the contraction of the color-field is much greater than 
that of the form-field (white) (compare page 386). Central vision may 
be good, the form-field but slightly or not at all affected, and yet the 
green and the red fields may be considerably contracted. Hence the 
importance of combining all these examinations before deciding whether 
discoloration of the papilla is pathologic or not. 
4. Changes in the Pupil.- 
The relations of the pupil to 
the action of light depend upon 
the degree of atrophy. In many 
cases there is more or less per- 
fect paralytic mydriasis, and 
when the atrophy is complete 
the pupil is dilated and the iris 
motionless. Even when the 
pupil fails to contract under 
the influence of light thrown 
upon the retina, it may do so 
in the act of convergence. (See 
also page 63.) 
If the atrophy is confined to 
one eye, no reaction will occur 
when the light falls upon the 
corresponding retina, but in- 
stant contraction takes place 
when this is directed upon the 
retina of the opposite (unaf- 
fected) side. The pupil changes in spinal disease (tabetic atrophy) have 
been described (see page 63). 
Varieties of Optic-nerve Atrophy.-1. Primary Atrophy (Some- 
times called Gray, Progressive, Spinal, or Tabetic Atrophy).-'The color 
of the disk is gray or white; sometimes it has a greenish or bluish tint; 
the discoloration is associated with translucency, and the stippling of the 
lamina is evident; the excavation, if it exists, is complete and saucer-like; 
the vessels either are smaller than normal, especially the arteries, or 
they are unaffected in size; the edge of the disk is sharply marked, and 
the scleral ring clean cut all around. These symptoms describe the 
fully formed atrophy. 
In the earlier stages of the degeneration, according to the late Dr. 
W. F. Norris, the disks are of a dull red tint, their capillarity is super- 
ficial, and the deeper layers, in the neighborhood of the lamina cribrosa, 
are gray and wanting in circulation. There is often sufficient haze of 
Fig. 217.-Field of vision of the right eye 
in a case of optic-nerve atrophy. The form- 
field is slightly contracted, the color-fields 
markedly restricted (compare Fig. 43, page 
84). OPTIC-NERVE ATROPHY 
485 
the retinal fibers to veil the scleral ring. Later the nerves become pallid, 
are somewhat woolly superficially, and are surrounded on all sides by 
broad and sharply cut scleral rings. The larger retinal arteries and 
veins do not at this stage present any appreciable change in their caliber 
or appearance. Both eyes usually are affected, one showing a further 
advance of the degenerative process than its fellow. 
2. Secondary Atrophy.--'The color of the disk may be gray and 
assumes a tint not greatly dissimilar from the atrophy which has just 
been described. In other instances the color is more decidedly white. 
Both sets of vessels may be contracted, usually the veins being less 
affected than the arteries. In a certain number of cases of secondary 
atrophy it is probable that preceding the degenerative stage there is a 
transient congestion of the disks; certainly this is true in those cases 
where there has been a retrobulbar neuritis. 
3. Consecutive Atrophy.-(a) Postpapillitic Atrophy.-The color of 
the disk is very gray or white, sometimes with a decidedly greenish tinge 
or even a blue tint. It is noticeable, however, that the translucency 
present, in the primary form of atrophy is absent, and the stippling of the 
lamina cribrosa is not visible, owing to the existence of a non-transparent 
tissue which covers it. The borders of the disk are slightly veiled, and 
the perivascular lymph-sheaths are thickened. The arteries are con- 
tracted, the veins frequently exhibiting distinct tortuosity. Retino- 
choroidal changes are often evident. 
(6) Retinitic and Choroiditic Atrophy.-This is in the form of atrophy 
of the nerve to which reference has already been made, and which follows 
severe forms of retinitis and choroiditis. The disk has a distinctly 
yellowish tinge, being somewhat waxy in appearance; its borders are 
not sharply marked, and the vessels are narrowed, often to a great 
degree. 
Causes.-In addition to the forms of atrophy which follow inflam- 
mation of the nerve (postpapillitic atrophy), inflammation of the choroid 
and retina (choroiditic and retinitic atrophy), embolism and thrombosis 
of the central artery and thrombosis of the central vein of the retina 
(embolic and thrombotic atrophy), the varieties which are gathered under 
the general terms primary and secondary atrophy require mention. 
Gray degeneration of the optic nerve occurs, in the great majority 
of instances, under the influence of diseases of the spinal cord, and 
especially of locomotor ataxia. It is frequent in general paralysis of the 
insane and insular sclerosis, but less common in lateral sclerosis. There 
is some difference of opinion in regard to the frequency of optic-nerve 
atrophy in locomotor ataxia, but an average of a number of observations 
gives 33.7 per cent, of atrophies. In most instances it begins in the 
preataxic stage. To one variety of the affection, in which the atrophic 
process precedes, often by long intervals, the ataxic symptoms, the 
name optic-nerve type of tabes dorsalis is often applied. Optic-nerve 
atrophy has also been seen with Friedreich's ataxia, amyotrophic lateral 
sclerosis, chronic myelitis, paralysis agitans, spastic spinal palsy, and 
bulbar palsy. 486 
DISEASES OF THE OPTIC NERVE 
Primary atrophy has been ascribed to the influence of cold, imperfect 
nutrition, disturbed menstruation, and venereal excesses. It may be 
caused by diabetes, syphilis, the toxic action of certain drugs, and ex- 
cessive hemorrhage (see also page 501). Its association with deformities 
of the skull has been described (see page 477). Undoubtedly it may 
be due to arteriosclerosis, the thickening of the arterial wall closing the 
lumen of the vessels. 
Hereditary Optic-nerve Atrophy.-A remarkable type of optic-nerve 
atrophy, that is, of the papillomacular bundle, first systematically 
described by Leber (Leber's disease), is hereditary, and may appear for 
a number of generations usually, but not always, in the male members 
of the family. It is transmitted by unaffected females. An affected 
male seldom transmits the disease (Nettleship). The disease generally 
begins between the eighteenth and twenty-third year, but has been ob- 
served as early as the fifth year and delayed as late as the forty-third 
year. According to Norris, there are three stages of the affection: 
(1) Stage of edema and congestion of the disk; (2) stage of gray discolora- 
tion of the nerve-head; and (3) stage of pronounced atrophy. Central 
scotomas are commonly present. In Arnold Knapp's cases the first 
generation presented central scotomas and peripheric contractions of 
the visual fields; but in the second and third generations no central 
scotomas developed. Gould suggests "homeochronous hereditary optic- 
nerve atrophy" as a suitable name for the disease. Usually treatment 
has little or no effect, but improvement and even recovery have been 
reported (Cargill). 
Secondary atrophy appears under the influence of compression of the 
optic tract and the optic fibers-for instance, by bulging of the lateral 
ventricles, or by pressure of a tumor, pituitary neoplasm or struma, 
exostosis, or aneurysm upon the chiasm. It is also said to occur with 
meningitis without preceding neuritis. Compression around the optic 
foramen is likely to produce secondary atrophy by direct injury to the 
fibers of the optic nerve. Blows on the head, especially in the neigh- 
borhood of the supra-orbital foramen, causing fracture of the orbital 
plate or periostitis, may be followed by a like result. Atrophy may re- 
sult from inflammation of the axis of the nerve posterior to the eyeball. 
Pathology.-In simple degeneration as it occurs in tabes of the 
cord the nerve-fibers lose their medullary sheaths and are converted 
into fine fibrillae, between which are numerous fatty granular cells; no 
true inflammatory process appears. Later all nervous elements may 
disappear. Tabetic atrophy of the optic nerve has been ascribed to 
disease and disappearance of the retinal ganglion cells (Ward Holden), 
but from a comparison of the visual fields in glaucoma with those in 
tabetic atrophy Bonne concludes that the lesion is in the optic nerve- 
fibers, and Stargardt seems to have demonstrated that an exudative 
process in the chiasm and nerves precedes the degenerative one. In 
postneuritic atrophy there is considerable new-formed connective tissue 
in the nerve-head and trunk, through which run the thickened vessels; 
the sheaths of the nerve-fibers degenerate, break down into fine drops, Plate VII. 
Primary atrophy of the optic nerve. OPTIC-NERVE ATROPHY 
487 
and the nerve-fibers become varicose and either shrink or disappear. 
The septa are much thickened, and in advanced cases the nerve be- 
comes a narrow, purely connective-tissue cord. 
Diagnosis.-The student is warned not to mistake the pallor of age 
for the pallor of disease; not to mistake a large physiologic cup, with its 
margin shelving toward the temporal border of the disk, for an atrophy 
confined to half of the optic papilla; and not to mistake small patches 
of retained marrow-sheath for atrophic changes. 
Not every gray disk, with an unusually marked scleral ring, is indic- 
ative of atrophy, and it is only when these appearances accord with 
the other manifestations of beginning degeneration that the diagnosis 
of incipient atrophy is justified. The Wassermann test should always 
be employed, and a stereoscopic .r-ray plate should be made in order to 
determine the condition of the pituitary region and the accessory 
sinuses of the skull. 
The differential points between a chronic glaucoma and an optic- 
nerve atrophy have been described (see page 386), and also the relation 
of light-sense to optic-nerve atrophy. According to Lohmann's in- 
vestigations all those cases with a disproportionately great affection of 
adaptation appear to belong to the group of glaucomatous degenerations 
in contrast to other forms of atrophy. 
Course and Prognosis.-The course of optic-nerve atrophy is always 
a slow one, lasting for months and it may be years, depending to a cer- 
tain extent upon the original cause of the atrophy. 
The prognosis is unfavorable in primary or, as it is sometimes called, 
progressive atrophy, the tendency being to a gradual deterioration of 
sight with shrinkage of the field of vision, until complete blindness is 
the result. The prognosis of a consecutive atrophy depends entirely 
upon the amount of damage which is likely to ensue from the shrinking 
which follows during the subsidence of the neuritis. In the forms of 
atrophy which follow an inflammation of the axis of the nerve the prog- 
nosis is better. 
Treatment.-This depends upon the cause. If syphilis is present, 
the usual remedies are indicated; but mercury is useless in advanced 
cases, even in syphilitics. While salvarsan or neosalvarsan exercise no 
detrimental effect on a healthy optic nerve, at one time it was maintained 
that salvarsan exerted an evil influence on tabetic atrophy. Recently 
this contention has been largely set aside and there are now a number 
of observations on record which tend to show that neosalvarsan, if 
used early and while color perception is still good, represents a thera- 
peutic agent of value in the treatment of tabetic atrophy. Salvarsanized 
serum injected intraspinously (Swift-Ellis method) may do good if em- 
ployed before the degenerative process has begun. Strychnin has been 
much employed administered in full doses, preferably by the hypodermic 
method; it may be enforced by nitroglycerin. Other remedies, accord- 
ing to the cause, are iodid of potassium, nitrate of silver, phosphorus, 
arsenic, iron, santonin, lactate of zinc, hypodermics of antipyrin (Valude), 
and injections of organic liquids, all of doubtful value. Negative gal- 488 
DISEASES OF THE OPTIC NERVE 
vanism has been advised, and good results have been reported by L. W. 
Fox, Ziegler, Radcliffe, F. W. Coleman, and many other observers. 
Coleman especially recommends the sinusoidal current, a binocular 
electrode being placed over the eyes and an oval pad to the nape of the 
neck. The treatment should take place for twenty minutes each day. 
High-frequency currents have been advocated and they should be tried. 
In a few instances suspension is said to have been followed by improve- 
ment of vision in tabetic atrophy. There is no satisfactory evidence 
that radium and the Rontgen rays are useful therapeutic agents in the 
treatment of optic-nerve atrophy. 
Orbital Optic Neuritis {Retrobulbar or Axial Neuritis; Central 
Amblyopia).--In contradistinction to the optic neuritis which is spec- 
ially localized at the intra-ocular end of the nerve, an inflammation 
occurs in the orbital part of the optic nerve, which is called orbital optic 
neuritis-retrobulbar or axial neuritis. It appears in an acute and a 
chronic type. 
1. Acute Retrobulbar or Axial Neuritis.--The symptoms of this 
affection are the following: Obscuration of vision, beginning always in 
the center of the visual field, and rapidly progressing in from one to 
eight days to complete or nearly complete blindness; at first negative 
ophthalmoscopic appearances, later blurring of the margins of the disk, 
hyperemia of its surface, and sometimes, in severe cases, diminished 
caliber of the retinal arteries and fulness and pulsation of the retinal 
veins; distinct pain on movement of the eyeball, or when the globe is 
pressed backward into the orbit. 
The affection appears to depend upon an interstitial neuritis, most 
severe in the optical canal, and at first chiefly located in the papillo- 
macular tract, from which it may extend, however, until the whole 
diameter of the nerve is involved. If the process is unchecked, neces- 
sarily secondary degeneration of the nerve-fibers takes place. There is 
also degeneration in the ganglion cells of the macula. 
Cause.-The determining cause of the disease is the presence in 
the blood of an infecting agent existing in association with some dis- 
ease-for example, rheumatism, tuberculosis, gout, syphilis, influenza, 
diabetes, small-pox, and scarlet fever; or coming directly from a focus 
of infection in the mucous membrane of the nose, the mouth (the teeth), 
the tonsils, the ethmoid cells, and the sphenoid sinus; or arising as the 
direct result of an inflammatory process in the orbit-e. g., cellulitis, 
or in the optic canal-for example, periostitis, gummatous deposits, 
etc. The disease has also been attributed to certain toxic agents, such 
as alcohol, lead, etc.; to menstrual disturbances, especially sudden 
suppression of the menses, to auto-intoxication, and to overwork and 
prolonged eye-strain. A certain number of cases exist for which no 
cause can be ascertained. Nettleship divided cases of retrobulbar 
neuritis into two groups: the idiopathic, in which the disease starts in the 
nerve itself, and symptomatic, in which it is communicated to the nerve 
by the surrounding tissues. 
This disease may be part of the symptomatology of multiple scle- ORBITAL OPTIC NEURITIS 
489 
rosis and of acute or subacute myelitis, and is in these circumstances of 
most serious prognostic import. Retrobulbar neuritis ipsolateral to the 
lesion has been recorded as a symptom of tumor or abscess of the 
frontal lobe (F. Kennedy). The author has observed several cases 
of this character. 
The course of the disease may be rapid or fulminant, as it is called. 
It is sometimes bilateral, but more frequently unilateral, or a long 
interval may occur between the involvement of the first and second eye. 
Relapses may occur, and the affection may alternate between the two 
eyes. As pointed out by Mr. Marcus Gunn, there is marked analogy 
between axial inflammation of the optic canal and paralysis of the 
facial nerve (Bell's palsy) when its trunk is involved in its tortuous 
course through the wall of the skull. Indeed, as the author has shown, 
retrobulbar inflammation may be preceded by an attack of peripheral 
facial palsy, either upon the same or the opposite side. 
Although the prognosis must always be guarded, in the majority of 
instances the tendency is to recovery, and, under careful treatment, 
Fig. 218.-Central scotoma from a case of tobacco amblyopia: f, Fixation; b, blind-spot. 
to perfect recovery. In severe cases, permanent pallor of all or part 
of the optic nerve, defective central vision for colors, central scotoma, 
and contraction of the peripheral field may remain. The fact that 
retrobulbar neuritis may indicate the future onset of disseminated 
sclerosis should not be forgotten. It may precede the other symptoms 
by many years. According to Marx, it may develop in a certain per- 
centage of the cases from one to seven years after apparent recovery. 
There is also a variety of the disease due to exposure, menstrual dis- 
turbances, and rheumatism, in which the same symptoms appear as 
those previously described, but all of a milder type and all more amen- 
able to treatment. 
Treatment.-In so far as possible the patient must be removed 
from the influence of the cause. If the affection has occurred during 
the course of an acute infectious disease, the treatment of this par- 
ticular malady is indicated. In other circumstances the best results 
follow active diaphoresis, full doses of salicylic acid, the free use of 
mercury, the iodids, and counterirritation on the temple. No patient 490 
DISEASES OF THE OPTIC NERVE 
with retrobulbar neuritis should escape searching examination of the 
nasopharynx, the ethmoid, frontal, and sphenoid sinuses. If purulent 
disease is found, operation with suitable drainage may speedily relieve 
the ocular condition; if this is neglected, blindness may result. (See 
also page 589.) Retrobulbar neuritis of tuberculous origin has been 
relieved by injections of tuberculin (Igersheimer). 
2. Chronic Retrobulbar or Axial Neuritis (Tobacco Amblyopia; Toxic 
Amblyopia).-The clinical symptoms of this affection are as follows: 
Diminution of sight, associated with fogginess in the center of the field 
of vision, unimproved by glasses and most noticeable in bright light; 
reduced acuteness of vision, which varies from f to counting fingers; 
negative ophthalmoscopic appearances or pallor of the temporal half 
or of a quadrant-shaped portion of the papilla; normal peripheral 
boundaries of the field of vision; symmetric central color scotomas, 
especially for red and green, usually oval in shape, stretching from the 
fixing-point to the blind-spot, and rarely passing much to the nasal side 
of the former; defective light-sense. The scotoma, which is the most 
important of the symptoms, represents a red-green blind area, and com- 
monly the extent of green-blindness is greater than that of red, which, 
in its turn, may be surrounded by an area of imperfect color-sense. 
Sometimes its beginning is a small, easily overlooked scotoma exactly 
over the fixing-point (Groenouw). After the typical egg-shaped 
scotoma is developed, the process may cease, or there may be a stage of 
progression characterized by an increase in the size of the color defect, 
usually above, until it meets the limit of the red field; that is, the 
scotoma has "broken through." In severe cases there may be scotoma 
for blue and yellow. Finally, small absolute defects may be found, 
and in neglected cases, or in those not typically toxic, the entire scotoma 
may become absolute. The periphery of the visual field is not always 
intact, and contractions may be found if the tests are made under di- 
minished illumination. According to Dorrell and Herbert Fisher the 
sensory pupil reflex is much diminished or entirely absent in toxic am- 
blyopia. 
Causes.-The most important drugs and toxic substances which 
may be responsible for the clinical symptoms which have just been 
detailed are tobacco and alcohol, either singly or combined, stramonium, 
cannabis indica, chloroform, chloral, opium, bisulphid of carbon, nitro- 
benzol, arsenic, atoxyl, lead, iodoform, and the toxin of diabetes. Of 
the substances mentioned, tobacco is the one most often responsible 
for this affection, but as the users of tobacco are also usually consumers 
of alcohol it is difficult to separate the etiologic influence of these two 
drugs, and hence the name intoxication or toxic amblyopia is used to 
describe a central amblyopia which may be due to either of these sub- 
stances or to their combined influence. A pure tobacco amblyopia, 
which the author believes he has observed, is uncommon; indeed, some 
observers deny its existence. Although usually bilateral, a few instances 
have been recorded in which the symmetric development of tobacco 
amblyopia has been delayed. It is rare before the thirty-fifth year. ORBITAL OPTIC NEURITIS 
491 
The pathologic lesion which causes this form of amblyopia, according 
to Uhthoff and other observers, is an interstitial inflammation of the 
papillomacular fibers of the optic nerve. These fibers, traced by means 
of their degeneration, consist of a bundle shaped like a triangle near 
the eye, with its base in the lower and outer part of the nerve, and its 
apex at the central vessels. Gradually it passes to the center of the 
nerve, which it reaches in the optic canal. Finally, it can be followed 
into the chiasm and tracts. Nuel and others believe that central toxic 
scotoma is not caused primarily by a neuritis of the macular bundle, 
but represents a disease of the macula lutea, causing degeneration of 
its cells, and that the optic nerve changes are secondary to destruction 
of the nerve-cells in the macula. The investigations of Birch-Hirsch- 
feld lead him to doubt that the process depends upon a primary inter- 
stitial inflammation of the optic nerve. He believes that there is a 
primary involvement of the nervous elements of the nerve and retina, 
with an accompanying proliferation of the glia and increase in the 
Fig. 219.-Sections of the right optic nerve in a case of toxic amblyopia, showing 
degeneration of the papillomacular bundle (Weigert's stain): A, Transverse section of the 
optic nerve 13 mm. behind the globe; B, transverse section of the optic nerve in the region 
of the optic foramen. 
connective tissue. Schieck concludes that the disease begins with an 
alteration of the blood-vessels within the optic nerve, and, as the central 
fibers are less liberally supplied with blood, they are the first to be 
affected. While vessel disease may have an important bearing on this 
affection, a direct action of the toxin on the nervous elements seems un- 
doubted. 
Course and Prognosis.-The course is, as its name indicates, a 
chronic one, but the prognosis of the tobacco and alcoholic cases is good, 
provided the patients present themselves at an early enough stage for 
treatment. In rare instances complete optic-nerve atrophy results. 
Treatment.--This consists in total abstinence from the use of tobacco 
and alcohol, and in the earlier stages this alone will be sufficient to bring 
about a cure. Later, a remedy of value is strychnin, which, as in other 
instances of optic-nerve disease, should be pushed to its full physiologic 
limit. In order to help in the absorption of inflammatory products, 
iodid of potassium may be given. Regulation of diet and free diapho- 
resis are valuable measures. Examination of the urine, as the author 492 
DISEASES OF THE OPTIC NERVE 
and David Edsall have shown, is apt to reveal an excessive secretion 
of enterogenous decomposition products, and with its restoration to 
normal, under the influence of proper dietetic regimen, the eye condi- 
tions improve. The patients should drink water freely. Temporary 
improvement occurs under the influence of inhalations of nitrite of 
amyl, and the circulation of the optic nerve may be stimulated by the 
exhibition of digitalis and nux vomica. Lecithin has been recom- 
mended in the treatment of tobacco amblyopia (H. de Waele). 
Necessarily, if some poison other than alcohol or tobacco is active, 
the patient must be removed from its influence. 
Injury of the Optic Nerve.-This may be produced by the entrance 
of a foreign body into the orbit, for example, the end of a sharp stick, or 
from a fracture involving the bony wall of the orbit or base of the skull. 
Atrophy of the optic nerve is the result. Indirect injury of the optic 
nerve may be caused, as Evans has shown, by a blow in the region of the 
external angular process of the frontal bone. The primary impairment 
Fig. 220.-Intradural tumor of the optic nerve. 
of vision and loss of the temporal field may be followed by atrophy of 
the nerve. 
Tumors of the Optic Nerve.-These may be divided into intra- 
dural and extradural tumors. Of the former, 102 cases have been col- 
lected by W. G. M. Byers in his notable monograph on this subject, 
and they include fibroma, sarcoma, glioma, endothelioma, gumma, 
tubercle, and myxoma.1 Of the latter (extradural tumors) Parsons has 
been able to find 12 undoubted cases, and of these, 9 were almost cer- 
tainly endotheliomas. 
The symptoms are: Exophthalmos, the eye being pushed downward 
and forward, the motion of the globe being unaffected, and defective 
vision, which is an early manifestation. The growth is slow and pain- 
less, but sometimes a suppurative keratitis may result. The oph- 
thalmoscope reveals distended veins, edema, and choking of the papilla, 
followed later by white atrophy and shrinking of the vessels. Atrophy 
1 Many cases have been recorded since this publication appeared. The subject has 
also been elaborately investigated by Finlay, T. F. Bullar, and C. Devereaux Marshall. 
The author has observed psammo-endothelioma of the optic nerve and another tumor 
composed of fibrous tissue, neuroglia, and apparently ganglion cells. HYALINE BODIES (DRUSEN) IN THE PAPILLA 
493 
of the papillomacular bundle and central scotoma may occur, as in one 
of the author's cases. With intradural tumors the movement of the 
eye is usually restricted in the opposite direction to any modification 
of the proptosis directly forward (Parsons). 
Treatment.-In most instances the eyeball must be removed with 
the tumor, but occasionally the globe can be saved (11 times in Finlay's 
collection-subsequent loss in 4 cases). Exenteration of the orbit has 
been necessary, primarily, in a few instances, and secondarily on ac- 
count of local recurrence. Even after enucleation, and sometimes at a 
period long removed from the time of operation, the growth has recurred 
and death may occur from intracranial involvement. Since the intro- 
Fig. 221.-Microscopic section of a nerve-head containing hyaline bodies (from a photo- 
micrograph). 
duction of Kronlein's operation and its modifications the opportunity 
of exploration of the orbit has been greatly facilitated and the oppor- 
tunity of saving the eyeball has been increased. 
Hyaline Bodies (Drusen) in the Papilla.-This affection is char- 
acterized by the formation in the optic papilla of small excrescences 
or globular formations, which are sometimes described as colloid masses. 
The bodies are variously shaped, chiefly roundish, of a yellowish-white 
or bluish-gray color, forming a mulberry-like appearance and presenting 
a striking ophthalmoscopic picture. They may occur at any age of life, 
sometimes in association with choroidoretinitis, optic neuritis, and optic- 
nerve atrophy, but also in eyes free from other pathologic changes and 
with perfectly normal vision. Two views have been maintained in 
regard to the origin of the drusen: (1) That they are hyaline excres- 
cences of the lamina vitrea of the choroid which become embedded in 494 
DISEASES OF THE OPTIC NERVE 
the head of the optic nerve, and (2) that they have nothing in common 
with the choroidal excrescences, but are a special pathologic process 
confined to a small portion of the optic nerve. The microscopic studies 
of the author indicate that the latter view is the more nearly correct 
of the two. The exact nature of the material thus deposited has not 
been determined. One investigation by Hirschberg and Cirincione indi- 
cates that the bodies are amorphous and organic, and their composition 
appeared most to resemble that of elastin. They may undergo calcifi- 
cation, like the cheesy nodules in the lung. According to Parsons, 
"Drusenbildungen" upon the optic disk represent exudations which have 
been laid down in layers. CHAPTER XVII 
AMBLYOPIA, AMAUROSIS, AND DISTURBANCES OF VISION 
WITHOUT OPHTHALMOSCOPIC CHANGES 
Amblyopia and amaurosis are terms which signify dimness of 
vision, the former being used to describe obscurity of sight, and the latter 
the more advanced, condition of loss of vision. Although these terms 
usually describe defective vision unexplained by lesions in the eye, this 
limitation is not strictly followed, and eyes blinded by inflammatory 
disease are sometimes described as amaurotic.1 
Modern methods of examination have greatly lessened the number 
of conditions to which the older writers applied the words "amblyopia" 
and "amaurosis." Amblyopia is a symptom and describes the defective 
vision from which the patient suffers. This may be due to functional 
disturbance or to disease of the visual apparatus (retina, optic nerve, or 
visual centers), and may be unassociated with changes in the eye-ground; 
or there may be atrophy of the optic nerve. 
Amblyopia may be congenital or acquired; temporary or permanent; 
symmetric or non-symmetric. 
Congenital Amblyopia.-This term is used to describe that 
variety of defective vision which for the most part is uncomplicated 
with fundus lesions, although sometimes the papilla is discolored and 
the macula deeply pigmented, and there is a scotoma, either small and 
absolute, or larger and for colors alone. According to Heine, a central 
scotoma can be demonstrated in 90 per cent, of the cases. The faulty 
vision has existed from birth, and often high grades of refractive 
error, especially hyperopia and astigmatism, are present, and clear 
images have never been focused upon the retina. Correction of the 
optical error usually fails to improve, materially, the vision; the retinal 
images continue to be defective. In very young patients an eye of this 
character may occasionally be trained to more nearly perfect vision 
after a proper correction of the refractive error, and this attempt should 
always be made.2 Naturally, before the diagnosis of congenital am- 
blyopia is established, the possible influence of orbital, nasal sinus, and 
central nervous disease must be eliminated. The origin of congenital 
amblyopia is obscure; an anatomic basis for the condition has not been 
discovered (Heine, Lohmann). 
1 The term "amaurosis" is also applied to certain cases of blindness in young children 
dependent upon hereditary influence, syphilis, tuberculous disease, and meningitis. The 
eye-grounds may or may not be diseased. 
2 A form of amblyopia has been described by Martin and called astigmatic amblyopia, 
dependent upon an imperfect development of the functions of the finer anatomic elements 
of the retina. It has been attributed to the fact that at the time of the education of the 
sense of sight, owing to astigmatism the retina has been asymmetrically stimulated, and 
consequently there has been asymmetry of visual acuteness. 
495 496 
AMBLYOPIA, AMAUROSIS, AND DISTURBANCES OF VISION 
Defective vision, attributed to lack of use (amblyopia ex anopsia, 
argamblyopia, according to Gould), may occur on account of obstruc- 
tion to the rays of light falling upon the retina-e. g., congenital corneal 
opacities, congenital cataract, and impervious persisting pupillary mem- 
brane; or in an eye which from early infancy has squinted, and has, 
therefore, not been concerned in the visual act (compare with page 542). 
The amblyopia of a squinting eye may disappear if the seeing eye 
becomes blind or is removed, as in a remarkable case reported by W. B. 
Johnson. 
Gould maintains that certain cases of amblyopia which have been 
attributed to disuse are really due to a low grade of choroidoretinitis 
affecting the macular region, brought into existence by an irritating 
stimulus with which a long-continued ametropia has supplied this area. 
In this category of amblyopias are also placed certain congenital 
defects of structure-e. g., coloboma of the iris and deficient develop- 
ment of the entire eye (microphthalmos). Retinal hemorrhages in the 
newly born explain some cases. Usually one eye is affected; if both 
are amblyopic, nystagmus commonly is present.1 
Congenital Amblyopia for Colors (Color-blindness}.-Congenital 
disturbance of the color-sense has been found in about 3 per cent, of the 
examinations made for this purpose, but it is extremely rare in women 
(0.2 per cent.). Both eyes, except in rare instances, are affected, and a 
distinct hereditary tendency has been noted in many instances. In 
other respects the functions of eyes which are "color-blind" are normal, 
and the cause of the condition has not been determined. 
The methods of detecting color-blindness have been described on 
page 67. Congenital color-blindness must not be confounded with the 
various disturbances of the color-sense in diseases of the optic nerve 
and retina or in hysteria. 
Derangements of the perception of colors have been divided into two 
varieties: the one characterized by an absence of the power to perceive 
colors, or achromatopsia; and the other characterized by difficulty in dis- 
tinguishing colors, or dyschromatopsia. The former condition, or color- 
blindness, is rarely total as a congenital defect (a condition which is not 
uncommon as the result of pathologic changes in the optic nerve, etc.); 
generally it is partial-i. e., one or more of the fundamental colors are 
not recognized. 
According to Helmholtz's theory, three classes of partial color- 
blindness exist-blue-blindness (also called violet-blindness), green- 
blindness, and red-blindness. 
A person afflicted with blue-blindness (yellow-blue blindness, accord- 
ing to Hering) sees only red and green. He usually confounds blue with 
green, purple with red, orange with yellow, and violet with yellow-green 
or gray. 
1 A persistent cramp of the lid, such as occurs in children, unrelieved for weeks at a 
time, may produce blindness, noticed when the eyes are finally opened, temporary in its 
character, with normal ophthalmoscopic appearances. In other cases the loss of vision, 
however, is permanent, with gross changes in the eye-ground. This condition has been 
referred to under Blepharospasm (page 178). CONGENITAL AMBLYOPIA FOR COLORS 
497 
A person afflicted with green-blindness (red-green blindness, according 
to Hering), to quote from Thomson, confounds light green with dark 
red, does not recognize a dark-green letter on black, but recognizes well 
a red one on the same background. Preyer states that the most fre- 
quent confusions are: brown with dark green, red with green, red with 
orange, red with yellow, red-yellow with green-yellow, bluish-green with 
purple. 
A person afflicted with red-blindness (red-green blindness, according to 
Hering), again to quote from Thomson, confounds light-red colors with 
dark green, and cannot see a dark-red square on a black ground. Accord- 
ing to Preyer, the most frequent confusions are: red with dark green, 
yellow with green, green with bright red, bluish green with gray, orange 
with greenish yellow or with red, orange with golden yellow, with grass 
green, or with red, purple with blue. 
Red- and green-blindness are the most usual manifestations of color- 
blindness; it is often hereditary; the other type-blue-blindness-is 
not common. According to Lohmann, records concerning the hereditary 
factors in blue-yellow blindness are wanting. Knies has described con- 
genital violet-blindness; red and purple are not distinguished from each 
other, both being called red. 
In the second variety, or imperfection in the color-sense (reduced 
color-sense), the individual may correctly recognize brightly marked 
colors, but confuses colors which are closely allied and the various 
shades. To him violet and blue and orange and red are difficult dis- 
tinctions. Dyschromatopsia should be distinguished from partial 
color-blindness (Landolt). 
The theory of color vision has been the subject of much speculation, 
and many theories have been advanced. Two will be mentioned. The 
Young-Helmholtz theory assumes the existence in the retina of three 
kinds of end-organs, each with its own photochemical substance, which 
can be decomposed by a certain color; that is, there is a red-sensitive 
substance, a green-sensitive substance, and a blue-sensitive substance. 
If a light mainly stimulates the red-, green-, or blue-sensitive substance 
it gives rise to the sensation, respectively, of red, green, and blue, while 
simultaneous stimulation of two or more of these substances gives rise 
to other color-sensations, including white light. A color-blind person, 
according to this theory, is one in whom two of these substances have a 
like composition. The Hering theory assumes the existence in the retina 
of a white-black, red-green, and yellow-blue visual substance, which 
may be either decomposed (disassimilated) or restored (assimilated) by 
the light. A destructive process, or one of disassimilation, in the white- 
black substance by white light or any other simple or mixed color, pro- 
duces a sensation of white; a process of restitution, or assimilation, in 
this substance produces the sensation of black. Red light produces 
disassimilation in the red-green substance, and thus the sensation of 
red; green light causes a process of restitution, or assimilation, in the 
red-green substance, and thus the sensation of green. From decom- 
position of the yellow-blue substance by yellow light arises the sensation 
32 498 
AMBLYOPIA, AMAUROSIS, AND DISTURBANCES OF VISION 
of yellow, while the sensation of blue is produced by a process of assimila- 
tion in the same substance. A color-blind person, according to this 
theory, is one in whose retina the red-green or blue-yellow substance is 
absent. 
Treatment is ordinarily unavailing, but recent investigations indi- 
cate that if the defect is ascertained early enough systematic training 
may succeed in developing the deficient color-sense; hence the impor- 
tance of the examination of the color-sense in young children. 
Congenital Total Color=blindness.-This rare affection has been 
particularly well studied by Grunert and Uhthoff. To those affected 
(twice as many males as females) colors appear only as impressions of 
light and dark. According to Grunert, the colors at the red end of the 
spectrum seem lighter than to the normal eye, while those at the violet 
end seem darker. Total color-blindness is nearly always associated 
with defective central vision, nystagmus, and photophobia. The eye- 
ground may be normal; or there may be pallor of the disk and macular 
changes. A central scotoma is common. The eyes are more frequently 
myopic than hyperopic. Several members of the same family may be 
affected, and in some instances consanguinity of the parents has been 
determined. 
Congenital Word=blindness.-In this condition the memory for 
the optic impression of words and letters is greatly deficient or wanting. 
The affection is more frequent in boys than in girls, although girls are 
by no means exempt, as has sometimes been stated. As C. J. Thomas 
points out, it may assume a family type, and in a number of instances 
more than one member of a family has suffered. Examination reveals 
normal eyes, good vision after any refractive errors have been corrected, 
and either inability to learn to spell and to read, or else great difficulty 
in these respects. Sometimes figures are more readily recognized than 
letters. In other respects the subjects of this affection are normal and 
other forms of memory are good, indeed, not infrequently the auditory 
memory is more developed than in a normal child. The condition is 
probably due to a congenital defect in the visual memory center for 
words and letters. As Hinshelwood (to whom we are particularly in- 
debted for early studies of this affection) and all those who have written 
on the subject since insist, great care should be exercised to detect this 
affection early in life, because it is much more common than is generally 
supposed. Its frequency is greater, in all probability, among the lower 
classes. Much can be done by systematic training-for example, with 
block letters-as Hinshelwood suggests, so that the child may assist the 
visual memory by the sense of touch. C. J. Thomas, discussing the treat- 
ment of this affection, suggests the phonic method as a suitable one to 
employ, because in it, at first at least, the visual word-images are ignored. 
Reflex Amblyopia.-Certain cases of partial or complete loss of 
vision have been vaguely attributed to irritations in distant portions of 
the body-for instance, the presence of parasites in the intestinal canal. 
In many of these instances, however, a proper investigation has shown 
that other causes have been active in producing the defective sight. TRAUMATIC AMBLYOPIA 
499 
A number of cases are on record in which an irritation through the 
branches of the fifth nerve has been supposed to produce an amblyopia, 
chiefly with disease of the teeth. At all events, in any case of amblyopia 
unattended with ophthalmoscopic changes, and not readily classified in 
any of the well-recognized groups, a thorough examination of the teeth 
is advisable. 
Traumatic Amblyopia.-This may occur after severe injuries to 
the head, especially in the occipital region and the region of the external 
angular process of the frontal bone; bruises along the course of the spinal 
cord after a railroad injury; and blows upon the brow in the region of the 
supra-orbital nerve. 
Fig. 222.-Hematoma of optic nerve-sheath. (Patient in the University Hospital.) 
In some of the cases there is a fracture across the optic canal, a 
hemorrhage into the intracranial cavity, or some disorganization of the 
brain-contents, followed by secondary changes in the optic nerve. (See 
also page 492.) In other instances no ophthalmoscopic changes are 
discovered, and the defective vision may be temporary in character, or 
there may be effusion or hemorrhage into the intersheath of the optic 
nerve, edema of the retina, and neuritis. Hemorrhage into the sheath 
of the optic nerve after fracture or traumatism of the skull has been ob- 
served a number of times and has been especially well studied by 
Uhthoff. In a specimen recently examined by the author and T. B. 
Holloway the sheaths were fully distended with blood and there were also 
many retinal hemorrhages. An extensive fracture of the base of the 
skull had occurred and had caused this hematoma of the optic nerve- 
sheath. 500 
AMBLYOPIA, AMAUROSIS, AND DISTURBANCES OF VISION 
Amblyopia after railroad injuries is often exaggerated by patients 
in the hope of securing damages. Recently many soldiers suffering 
from shell-shock caused by their proximity to bursting shells have been 
examined. The symptoms, according to C. S. Myers, are sleeplessness, 
amblyopia, contracted visual fields, slight deafness, and sometimes 
imperfect sense of smell and taste. Parsons suggests that the loss of 
vision has a definite neural basis associated with what is called a "func- 
tional condition." 
Amblyopia and amaurosis occur under the influence of disease and 
the toxic action of certain drugs, due either to a direct effect upon the 
retina and optic nerve, to an influence upon the visual centers, or to some 
change, perhaps of vasomotor origin, affecting the blood-supply of these 
structures. 
In this category may be noticed: 
1. Uremic Amblyopia, or Amaurosis.-This may occur in any 
form of renal disease, but is more common in the acute nephritis of the 
eruptive fevers, especially scarlet fever, and of pregnancy than in other 
varieties of kidney affections. In scarlet fever it appears with albu- 
minuria in the stage of desquamation, and is bilateral, the blindness in 
many cases being absolute and often associated with brain symptoms: 
convulsions, vomiting, stupor, coma, and hemiplegia. In spite of the 
blindness, the preservation of the pupillary reactions is the rule; some- 
times the pupils are dilated and motionless. 
The ophthalmoscope picture may be negative, or there is a slight 
neuritis, a little woolliness of the surface of the optic disk or delicate 
edema of the retina. The prognosis, as far as vision is concerned, is good. 
The treatment does not differ from that which is applicable to the 
disease which produced it. 
2. Glycosuric Amblyopia.-In addition to the affections of vision 
already described in connection with diabetes (paresis of accommoda- 
tion, premature presbyopia, alterations in refraction, cataract, and retinal 
hemorrhages), there occurs an amblyopia in this disease in which the 
visual field is sometimes peripherally intact, sometimes peripherally 
restricted, and occasionally hemianopic, but in which there is a central 
color scotoma. Ronne ascribes diabetic amblyopia not to an interstitial 
neuritis, but to a process of degeneration. This amblyopia may be the 
only symptom of diabetes, and in any unexplained case of amblyopia 
the urine should be examined for sugar, a practice which is necessary if 
color scotomas are found, even if the history of the abuse of tobacco is 
obtainable. 
The prognosis is unfavorable, and the treatment, which should 
include the usual measures suited to diabetics, is not very efficacious. 
3. Malarial Amblyopia.-In addition to amblyopia in malarial 
cachexia with lesions apparent in the fundus, are those cases, without 
such lesions, due to a special action of the malarial poison upon the 
optic nerve and the retina. There is transient loss of vision, or complete 
blindness, lasting from several hours to some days or even months. 
In most of the instances ophthalmoscopic findings are negative, or the QUININ AMAUROSIS 
501 
descriptions are couched in vague terms applied to the retina and optic 
nerve-"congestion," "hyperemia," and "redder than normal." The 
affection may be unilateral or bilateral. 
4. Amblyopia from Loss of Blood.-Loss of sight often follows 
hemorrhage, more frequently if this is spontaneous than if it is trau- 
matic, and is said to be most complete after hemorrhage from the 
stomach. It also may follow epistaxis, hemoptysis, urethral and in- 
testinal hemorrhage. 
Two very different results may ensue: Either a temporary blindness, 
owing to the impoverished blood-supply of the visual centers or retina, 
or a permanent loss of sight and atrophy of the optic nerve. Ward 
Holden has shown that the amblyopia following hemorrhage is due to 
degeneration of the retinal ganglion-cells, together with their long 
processes, which make up the centripetal fibers of the optic nerve. 
The ophthalmoscopic appearances vary from a slight pallor to com- 
plete atrophic whiteness of the papilla, with contraction of the arteries. 
The lesions in the unfavorable cases usually do not appear until a week 
or more after the hemorrhage has taken place. Neuritis and hemor- 
rhages into the retina may also arise. The prognosis is most favorable 
in uterine cases. 
The treatment consists in the use of iron, arsenic, and strychnin, 
complete rest, and an easily assimilated diet. Intravenous saline injec- 
tions are also recommended as remedial agents (Elschnig).1 
Amblyopia from the Abuse of Drugs.-A certain number of 
toxic agents (lead, tobacco, alcohol, etc.) produce an axial neuritis or a 
degeneration and destruction of the retinal ganglion-cells, with great 
loss of vision, and these have been described under the general term 
orbital optic neuritis (see page 488). 
Amblyopia, more or less complete, may also arise under the toxic 
influence of nitrate of silver, chlorate of potassium, mercury, arsenic, 
atoxyl, bisulphid of carbon, nitrobenzol, salicylic acid, oil of winter- 
green, cannabis indica, coffee, tea, stramonium, male fern, iodoform, 
osmic acid, chloral, antipyrin, and lead. The last agent may produce 
a neuritis, but also an amblyopia without ophthalmoscopic changes. 
It is usually transient, occurs in acute cases, and has been compared by 
Gowers to the temporary amaurosis of uremia. 
Some of these toxic agents may cause, in addition to the loss of 
vision, a central scotoma-for example, bisulphid of carbon, stramo- 
nium, and iodoform; complete blindness and atrophy of the optic nerve 
may be the result of the action of others-for instance, male fern and 
iodoform. 
The loss of vision which occurs under the influence of three sub- 
stances-quinin, methyl-alcohol, and atoxyl-deserves special mention. 
Quinin Amaurosis.-Although in most instances quinin amblyopia, 
or amaurosis, follows the ingestion of a large quantity of the drug, occa- 
1 Sudden blindness with preserved pupillary reaction and without ophthalmoscopic 
changes has been noted in whooping-cough, and is probably due to edema between the 
corpora quadrigemina and occipital lobes. Sudden blindness in old persons with arterio- 
sclerosis has been observed (Uhthoff). 502 
AMBLYOPIA, AMAUROSIS, AND DISTURBANCES OF VISION 
sionally the symptoms are caused by moderate doses. The author has 
seen 12 grains (0.78 gm.) produce decided temporary amblyopia in a 
susceptible and neurotic woman. 
The characteristic clinical features of quinin amaurosis are total 
blindness subsequent to taking large doses of the drug, extreme pallor 
of the optic disks, marked diminution of the retinal blood-vessels in 
number and caliber, and contraction of the field of vision. Other 
symptoms which have been noted are: diminution of the color- and 
light-sense, dilated pupils, and immobile iris during the blind stage, and 
occasionally anesthesia of the cornea. Usually the effect of quinin upon 
the ear is manifested by deafness and tinnitus. 
The restoration of central vision may be perfect or incomplete. 
The contracted field of vision gradually widens out, but does not regain 
its normal limits. The disk may remain pallid and quite atrophic looking 
years after the poisoning; in other instances it resumes its normal tint. 
In one case (Gruening) a cherry-colored spot was noted in the macula, 
in another a scotoma in the visual field. Occasionally the blindness is 
permanent. 
The first effect of the toxic influence of quinin is to lessen the blood- 
supply of the retina and optic nerve, and later, as the author has ex- 
perimentally shown in dogs, permanent optic-nerve atrophy ensues. 
Ward Holden has demonstrated, and his results have been fully con- 
firmed by Drualt, Birch-Hirschfeld, and a number of other observers, 
that the blindness is due to.a degeneration of the ganglion-cells and 
nerve-fibers of the retina, followed by an ascending degeneration of the 
optic nerve. 
The treatment, in addition to the discontinuance of the drug, con- 
sists in the administration of nitrite of amyl, which will cause tem- 
porary improvement in vision, and of the exhibition of strychnin and 
digitalis. 
Methykalcohol Blindness, or Amaurosis.-The amount of wood- 
alcohol which may cause blindness represents a varying quantity. 
Thus, blindness and atrophy of the disk have followed the ingestion of 
2 to 5 drams (7.8-19.4 gm.), while recovery after drinking | pint (236 c.c.) 
of this liquor has been observed (Moulton). In short, methyl-alcohol 
intoxication is an example of idiosyncrasy (F. Buller, C. A. Wood). 
The number of immune persons, however, cannot be great. Methyl- 
alcohol itself, Columbian spirits, other varieties of purified wood-alcohol, 
and the drug in the form of an adulterant for ethyl-alcohol in cheap 
whiskies and other alcoholic beverages, as well as in Jamaica ginger, 
certain essences, bay-rum, cologne water, etc., are capable of producing 
the most violent general toxemia and visual disturbance. Igersheimer 
believes the influence of methyl-alcohol depends upon the admixture of 
fusel oil. Briefly, the symptoms are these: Intense gastro-intestinal 
disturbance if the dose is not too large, followed, if it is greater, by 
severe headache, giddiness, and coma; rapid failure of sight, which may 
improve, but soon relapses; contracted visual fields and usually absolute 
central scotomas; and, finally, total or nearly total blindness. Oph- ARSENIC AMBLYOPIA 
503 
thalmoscopically, there have been noted blurring of the edges of the 
disk, positive neuritis (rare), and complete atrophy without signs of 
preceding inflammation. In many instances there is diminution in 
the size of the retinal vessels. Occasionally, there is decided pain on 
movement of the eyes or on pressing them backward into the orbit. The 
prognosis of methyl-alcohol poisoning is most unfavorable. A number 
of fatal cases have been reported. Not only may the poison enter 
in the usual manner through the stomach, but blindness has resulted 
from inhalation, aided by absorption, as the author has shown, through 
the cutaneous surface. A very few examples of restoration to nearly 
normal vision have been reported. The blindness depends, as Holden 
and Birch-Hirschfeld have demonstrated, upon nutritive changes in the 
ganglion-cells of the retina. It is possible that there may be a simulta- 
neous action on the ganglion-cells and the tissues of the optic nerve 
(Gifford). The treatment of this form of amaurosis recommended by 
F. Buller and C. A. Wood includes in the early stages pilocarpin and 
potassium iodid, later strychnin hypodermically and by the mouth. 
Arsenic Amblyopia.-Atoxyl has been much employed in the 
treatment of various conditions, notably certain skin diseases, chlorosis, 
syphilis, and trypanosomiasis. Serious visual disturbances have fol- 
lowed its use in a number of instances. The following have been re- 
ported: Reduction of visual acuteness from one-half to complete blind- 
ness; contraction of the visual field, especially on the nasal side; pallor 
and atrophy of the optic disk, with narrowing of the retinal vessels; 
usually no central scotoma, but at times a central scotoma for colors 
and sometimes visual hallucinations and colored vision (cyanopsia). 
In one patient retinal hemorrhages were found. The amount of the 
drug which has produced these visual disturbances has varied con- 
siderably: 1.2 grams, given subcutaneously for anemia, within twenty- 
six days (Steinebach); 5.1 grams within twenty-six days (Lesser and 
Greeff); 50 grams within seven months (Von Krudener); 4.5 grams 
within one month (Kopke). Koch observed a number of cases of blind- 
ness without ophthalmoscopic change after injection of 1 gram of atoxyl 
for the cure of sleeping-sickness. The blindness has been ascribed to 
optic-nerve atrophy with primary involvement of the retina, and to 
retrobulbar neuritis and consecutive atrophy; it has also been attributed 
to central lesions. 
Blindness following the administration of other aryolarsenates, for 
example, soamin, arsacetin, hectin, orsudan, have been reported. 
The harmful action is due to the anilin in these compounds and not to 
the arsenic. Amblyopia d*ue to inorganic arsenic compounds presents 
features entirely different from those which the organic preparations 
produce and the prognosis is good (Schirmer). The aryolarsenates 
cause progressive optic-nerve attrophy. It has been suggested that the 
primary action of the drug may be on the blood-vessels (E. T. Collins). 
The harmful dose has varied; much depends on idiosyncrasy. Salvar- 
san does not cause blindness, i. e., it has no poisonous influence on the 
healthy optic nerve. 504 
AMBLYOPIA, AMAUROSIS, AND DISTURBANCES OF VISION 
Hysteric Visual Disturbances (Amblyopia, Amaurosis, Asthen- 
opia).-Hysteric amaurosis is characterized by complete abeyance of 
the visual sensation. It occurs both as a unilateral and a bilateral 
affection, the former being far more frequent than the latter. The 
subjects of this condition are more frequently females than males. 
Occasionally, the blindness lasts but a very brief period of time, and 
occurs during a crisis; at other times it lasts for weeks, months, and, it 
is said, for years. The eye-grounds are normal. Usually the pupils 
react to the influence of light. Sometimes only a feeble contraction 
follows the light stimulus; occasionally the pupils are dilated and in- 
sensitive to light (Kernels). Generally it is possible to prove by ordi- 
nary prismatic, stereoscopic, and other tests that the supposed blind 
eye really sees. 
In place of amaurosis, incomplete anesthesia of the visual sense, or 
hysteric amblyopia, may occur. This includes reduction of visual 
acuteness, disturbances of the visual field for white and for colors, dis- 
chromatopsia, and achromatopsia. The essential characteristic of the 
visual field in hysteria is concentric contraction, which is evident at the 
beginning of the examination, and is not produced by repeated measure- 
ment (retinal tire field), and the amount of reduction varies from a 
slight contraction to such extreme restriction that the most peripheral 
circle is just beyond the fixing-point. Sometimes the field has a tubular 
character-that is, the contracted visual field maintains the same size, 
no matter at what distance from the examined eye the point of fixation 
is placed. Similar reductions take place in the field for colors. A 
somewhat characteristic variation is that the red field is the last to be 
affected, with the result that its extent may exceed that of blue, and 
become the most peripheral of the color circles. Occasionally it is the 
most peripheral circle for the entire field. This is the so-called inversion 
of the color-field. Sometimes there is an excessive extent of the color- 
circles. These visual field phenomena in hysteria are, according to 
Babinski, due to suggestion; if this can be eliminated, he maintains 
they do not develop. It should be remembered that inversion of the 
color-fields is not peculiar to hysteria; it has been observed in brain 
tumor, ataxia, hemorrhage in the brain, and in certain toxemias, not- 
ably those produced by lead and nitrobenzol. A rare hysteric phe- 
nomenon is central scotoma; zonular scotoma and the so-called oscillat- 
ing field have been observed. Crossed amblyopia-that is, complete or 
partial blindness on the same side as the hemianesthesia, and associated 
with some deficiency of acuteness of vision upon the opposite side-is 
sometimes an hysteric manifestation. Hemianopsia in an enduring 
form is never due to hysteria. As a temporary visual-field phenomenon 
it has been observed. 
Hysteria produces many other functional disturbances of the eye- 
monocular diplopia, ptosis, blepharospasm, conjugate deviation of the 
eyes, and the great symptom-group gathered under the term "retinal 
asthenopia" (see page 423). PRETENDED AMBLYOPIA 
505 
The prognosis of these cases in the main is good, although the blind- 
ness may last for long periods of time. 
The treatment consists of measures calculated to improve the condi- 
tion of the patient-massage, rest, electricity, and tonics. 
Pretended Amblyopia (Malingering).-For the purpose of escap- 
ing irksome duties-for example, in the army-or to excite sympathy 
patients will occasionally pretend to be blind in one eye. In order to 
detect the deception many plans have been originated. Three methods 
will be described: 
1. The Diplopia Test.-This is performed in the same manner as 
the ordinary examinations of the external ocular muscles with prisms. 
The subject is seated before a lighted candle at 20 feet distance, and a 7° 
prism placed before the admittedly sound eye. If, now, superimposed 
double images are acknowledged, there is binocular vision, and the fraud 
is detected. The examiner may vary the test by placing the prism before 
the supposed blind eye, either base up or base down. 
2. Harlan's Test.-This is an extremely useful and simple test, 
and is performed as follows: Place an ordinary trial-frame upon the 
subject's face and put before the admittedly sound eye a high convex 
glass (+ 16 D), and before the eye which is claimed to be blind a plain 
glass or a weak concave spheric (- 25 D), which will not interfere with 
vision. If letters placed at a distance of 6 meters are read, the act 
of reading must have been done by the eye which was claimed to be 
sightless, inasmuch as vision at that distance with the other eye is ex- 
cluded by the presence of the high convex lens. The test may be further 
elaborated by covering the pretended blind eye and requesting the 
patient to read the letters; if he is unable to do so, the fraud is at once 
exposed. 
3. Tests with Colored Glasses and Letters.-These are numerous. 
The method generally employed, or some modification of it, is known 
as Snellen's method. The patient is required to look at alternate red 
and green letters. The admittedly sound eye is covered with a red 
glass, and if the green letters are read evidence of fraud is present. 
Instead of a red glass, a green glass may be used, through which 
the red letters will be invisible. Ingenious letters, based upon the 
fact that red upon a white background viewed through a red glass 
disappears, and viewed through a green glass appears black, have 
been designed. Tests with stereoscopes may also be made to detect 
malingering. 
If a malingerer claims to be blind in both eyes, these tests will not 
avail, and he can be detected by placing a careful watch over him. 
The fact that the pupil contracts on exposure to light does not prove 
that there is sight in the eye, because, as Swanzy pointed out, a lesion 
in the center of vision, or in the course of the fibers connecting this 
center with the corpora quadrigemina, producing absolute blindness, 
would still permit a perfect reaction of the pupil to light. Priestley 
Smith and E. Jackson suggest the following test for feigned binocular 
blindness. Place a lighted candle in front of the subject; now hold a 6° 506 
AMBLYOPIA, AMAUROSIS, AND DISTURBANCES OF VISION 
prism, base out, before one eye; if both eyes see, the one behind the prism 
will move inward, and on removing the prism will move outward, the 
other eye remaining fixed. 
Night=blindness (Functional Night-blindness; often incorrectly 
termed Hemeralopia, but properly Nyctalopia).-It has already been 
pointed out that night-blindness is one of the early symptoms of pig- 
mentary degeneration of the retina. In the present condition, however, 
there are no retinal lesions. 
It is a functional complaint, consisting in a diminished sensibility 
or imperfect adaptation power of the retina (Treitel), due, apparently, 
to exposure of the eye to strong light and glare, together with a debili- 
tated and often scorbutic state of the system. It affects residents in 
tropical countries, often soldiers and sailors, and has been occasionally 
observed in large schools, usually in the early spring or summer (Nettle- 
ship, Snell). It has been reported as an endemic in certain countries, 
especially in Russia during the Lenten fasts. Other causes are diet 
deficient in fat and albumin, disease of the liver, malaria, and 
alcoholism. 
Krienes divides the affection into acute essential nyctalopia (hemer- 
alopia) and chronic nyctalopia, and he gives the following syllabus of 
symptoms: Decided dread of light, abnormal width of the pupil in the 
dark, depreciation of the central quantitative color-sense, particularly 
the blue sense in daylight, narrowing of the color-fields in daylight, 
particularly the blue field, abnormal shrinking of the visual field 
for white and colors in increasing twilight. Other not absolutely 
constant symptoms are loss of visual acuteness by daylight, shrink- 
ing of visual field for white in daylight, retinal tire field, paresis of 
accommodation, epithelial xerosis, erythropsia, and xanthopsia (see 
also page 230). 
Night-blindness is occasionally a family disorder. Bordley has 
described a negro family of night-blind persons extending over five 
generations. The subjects eventually became blind, and shortly after 
blindness death ensued. Nettleship has published a history of stationary 
night-blindness in nine consecutive generations. 
Treatment.-This includes the administration of iron, quinin, 
strychnin, and cod-liver oil, according to the indications. Dark-colored 
glasses should be worn. If scurvy is present, the diet and remedies 
suited to this condition should be prescribed. 
Day=blindness (Often incorrectly termed Nyctalopia, but properly 
named Hemeralopia).-This is an affection, or rather a symptom, as the 
name implies, characterized by the fact that its subjects see better on 
dull days and in the dark than in a bright light. The visual field is not 
concentrically contracted. 
This symptom occurs with the condition described by Arlt as retinitis 
nyctalopia, and with orbital optic neuritis of the chronic type (tobacco 
amblyopia, see page 490). It also occurs in other affections of the optic 
nerve and in some diseases of the retina. The same condition may be 
present in certain congenital anomalies-albinism, coloboma of the ERYTHROPSIA, OR RED VISION 
507 
iris, and irideremia. It also occurs as an idiopathic affection, and may 
develop in those who have long been excluded from the light. It may 
be congenital, and may be associated with an amblyopia of like 
origin. 
A tonic treatment should be tried and the retina gradually educated 
to sustain bright light. 
Snow=blindness.-As this ordinarily is seen in northern regions, 
it is an affection of the conjunctiva. There are burning pain, photo- 
phobia, blepharospasm, hyperemia of the conjunctiva, and chemosis. 
In severe cases there may be ulceration of the cornea. The pupils are 
small, and there is congestion of the retina. The visual acuteness may 
be unaffected, or it may be distinctly lessened, especially if corneal 
complications arise; under these conditions restricted visual fields, 
both day- and night-blindness, red-green blindness (Lohmann), and 
scotomas have been observed. The local irritation in snow-blindness is 
analogous to sunburn, and like it is due to the action of ultraviolet 
rays. The pain caused by glare is due to excessive contraction of the 
orbicularis and to pressure of the supra-orbital nerve against the frontal 
bone. 
Symptoms analogous to so-called "snow-blindness" develop as the 
result of exposure of unprotected eyes to any type of light rich in ultra- 
violet--for example, a naked arc light {electric ophthalmia); molten metal 
in electric welding; the flash of a short circuit high-tension current, and 
a mercury vapor lamp. To the injurious effect of light in these circum- 
stances, interpreted by the irritative phenomena already described, 
Parsons has applied the term photophthalmia. Although the ultra- 
violet rays probably cause the greater damage, rays of greater wave 
length-infra-red and luminous rays-are also capable of harmful action. 
For a long time after subsidence of photophthalmia there may be per- 
sistent asthenopia, ciliary pain, frontal and other placed headaches. 
Those who are much engaged in work with Rontgen rays often suffer 
from decided conjunctival hyperemia or positive conjunctivitis (x-ray 
conjunctivitis). 
Experimentally, it has been demonstrated that ultraviolet rays may 
cause changes in the lens (Hess) and in the retina (Birsch-Hirschfeld). 
These changes are not likely to occur under ordinary conditions in 
healthy persons. Special forms of glass supposed to have the power 
of absorbing ultraviolet rays have been devised; all of them have a 
greenish-yellow tint, chief among them are "Enixanthos," Fieuzal glass, 
and "Euphos" glass. According to Parsons, almost colorless didymium 
glass is the best protection against ultraviolet rays.1 
Erythropsia, or Red Vision.-Colored vision in glaucoma (irid- 
escent vision), in the form of variously tinted halos about the lamp- 
lights, has been described, and patients with blind eyes occasionally 
complain of being conscious of colored lights, owing probably to some 
irritation of the visual centers. 
1 "Some Effects of Bright Light on the Eyes," by J. Herbert Parsons, Trans, of Section 
of Ophthalmology, Amer. Med. Assoc., 1910. 508 
AMBLYOPIA, AMAUROSIS, AND DISTURBANCES OF VISION 
Erythropsia in most instances has been noted after cataract extrac- 
tion. Visual acuteness is not affected, but everything appears of a red 
or violet color. According to Fuchs, erythropsia can be caused by the 
visible rays alone, but a simultaneous action of the ultraviolet rays is 
probable. An uncommon phenomenon is blue vision or kyanopsia. 
Bromid of potassium is indicated, and is said to ameliorate these symp- 
toms. Green vision has been noted after cataract extraction and corneal 
wounds, and in connection with diseases of the optic nerve and retina- 
for example, with tabetic optic-nerve atrophy (H. W. Dodd). 
Micropsia and macropsia have been described in connection with 
syphilitic retinitis. They may appear as functional disorders in hysteric 
cases. CHAPTER XVIII 
AMBLYOPIA OF THE VISUAL FIELD, SCOTOMAS, AND 
HEMIANOPSIA 
The importance of perimetric measurements in the study of various 
forms of ocular disease, especially in glaucoma and in affections of the 
retina, choroid, and optic nerve, has been noted (for the methods of 
examination consult Chapter II). There remain to be considered cer- 
tain conditions in which a defect in the field of vision constitutes one 
of the most prominent symptoms. 
1. Partial Fugacious Amaurosis (Flimmer-scotom; Migraine 
Ophthalmique).-The symptoms are: A sense of vertigo; a positive 
darkening of the field of vision of each eye, beginning at the center 
and widening out in a vibratory movement until it overspreads the 
field, with corresponding sinking of the central acuteness of sight; 
or a scotoma surrounded by flashing zigzag lines, and cessation of the 
amaurosis with the onset of headache and vomiting; a true hemianopia 
without light or flashing is also described. These symptoms may be, 
and often are, a prodrome of hemicrania or migraine, but they also arise 
without it, and may occur in syphilitic subjects. The condition prob- 
ably depends upon circulatory disturbances in the occipital lobes, or 
upon vascular spasm. 
The treatment is directed toward the headache, the partial amaurosis 
being exceedingly temporary in character, and includes the measures 
suited to migraine. Syphilis calls for the usual remedies. 
2. Amblyopia of the Visual Field (Anaesthesia Retinae).-This 
functional disturbance as part of a general neurosis has been described 
on page 423. Because of the peculiar changes in the visual field many 
authors prefer the name "amblyopia of the visual field" to that of 
"anesthesia of the retina." 
Fatigue restrictions of the visual field, in the form already described, 
are seen after injuries (traumatic neurosis), and sometimes with trau- 
matic anesthesia of the retina. The element of hysteria cannot always be 
eliminated, and the phenomena described in connection with hysteric 
ocular manifestations may predominate. 
3. Scotomas.-Any lesion which blots out the function of a por- 
tion of the retina produces a corresponding blind area in the field of 
vision, or a scotoma-for example, a hemorrhage, a patch of retino- 
choroiditis in the macular region, or spots of disseminated choroiditis 
in the periphery of the eye-ground. In rare instances the scotoma seen 
by a patient with central retinochoroiditis is colored. Papillitis causes 
an enlargement of the natural blind-spot, and retrobulbar neuritis a 
central scotoma. The different forms which scotomas assume are 
509 510 
AMBLYOPIA OF VISUAL FIELD, SCOTOMAS, AND HEMIANOPSIA 
described on page 85. The scotomas associated with chronic glau- 
coma are depicted on page 373. Unilateral scotomas may occur in 
hysteria, in neurasthenia (central exhaustion scotomas), with menstrual 
disorders, in obstruction of the central artery of the retina, and 
with disease of the macular cortical center. Ring-shaped or annular 
scotomas have attracted much attention. Ordinarily, they are to be 
explained by the presence of chorioretinitis. According to Burnett, 
circumscribed neuritis of the bundles of the optic nerve supplying the 
intermediate retinal zone may explain 
some cases. Such scotomas may be 
caused by chorioretinitis, pigmentary 
degeneration of the retina, and by 
interstitial neuritis, choked disk, sinu- 
sitis (ethmoid and sphenoid disease), 
and glaucomatous atrophy of the optic 
nerve (see page 374). They have also 
been observed in hysteric subjects and 
have been reported as part of the 
symptomatology of migraine (Zent- 
mayer). 
In addition to these diseases cer- 
tain affections of the optic nerve are 
accompanied by a scotoma. 
Following the classification of Jensen, these may be described as:1 
(a) Central Amblyopia with Scotoma {Toxic Amblyopia}.-1This 
affection has been described on page 490. 
(6) Chiasmal Central Amblyopia.-Central scotomas, difficult to 
distinguish from those occurring in toxic amblyopia, are sometimes the 
initial signs of chiasm disease. According to Nettleship, the loss of the 
central field in the earlier stages is more abruptly defined than in tobacco 
amblyopia. With increase in the size of the growth they may expand 
into complete bitemporal hemianopsia (see page 515). As the visual 
phenomena in pituitary body disease have assumed such importance 
in ophthalmic and neurologic examinations, a brief resume of them 
follows: 
Visual Phenomena in Pituitary Body Disease.-These consist in 
impairment of vision, varying from blurred sight to complete blindness; 
intra-ocular optic-nerve alterations, varying from partial or general 
pallor of the nerve-head to partial or complete atrophy, less frequently 
postneuritic atrophy, choked disk, and non-prominent optic neuritis; 
alterations in the visual fields for form and colors, especially homonymous 
and heteronymous hemianopsia and scotomas. Other ocular symptoms 
which have been described are visual hallucinations, chromatopsia, 
especially cyanopsia, persistent photophobia, palsy of various exterior 
ocular muscles, nystagmus, exophthalmos, thickening and pigmentation 
Fig. 223.-Ring-shaped scotoma from 
a case of interstitial neuritis. 
1 A translation by Dr. G. A. Berry of a lengthy abstract of Jensen's article on " Diseases 
of the Eye Accompanied by a Central Scotoma" appeared in the Ophthalmic Review, Janu- 
ary, 1891. SCOTOMAS 
511 
of the eyelids with hypertrophy of the palpebral glands. A very early 
symptom, noticeable sometimes for weeks and months before fundus 
changes are detected, is a form of blurred vision, characterized by ill- 
defined indistinctness of sight. Visual disturbances are more frequent 
in primary hypopituitarism than in acromegaly. Generally the oph- 
thalmoscopic appearances are those of so-called simple atrophy; choked 
disk is rare. Even when the pallor of the disk gives every indication of 
simple atrophy, marked improvement in vision may follow successful 
operation or prolonged organotherapy. Evidently there is a physiologic 
block to light impulses, and not at this period a destruction of the nerve- 
fibers. While bitemporal hemianopsia is a common visual field defect, 
homonymous lateral hemianopsia is not infrequent, especially if with 
homonymous defects are included what Cushing calls the tendencies in 
this direction. In all cases the defect for colors precedes that for form. 
There may be unilateral hemianopsia. In bitemporal hemianopsia in 
this disease it will be found that the temporal field tends to be lost from 
above downward. This is the so-called "temporal slant." A pecu- 
liarity of the visual fields in pituitary body disease is the variations which 
they undergo, hence the necessity of frequent perimetric observations. 
Central and paracentral scotomas are common, especially the para- 
central varieties; they may be situated to the outer side of each fixa- 
tion-point, that is, they are bitemporal hemianopic scotomas. These 
scotomas antedate the more elaborate visual field defects and they may 
expand into complete hemianopsia. Sometimes the defect may be de- 
tected upward and outward, forming a quadrant. The most elaborate 
and satisfactory study of the visual field phenomena in pituitary body 
disease has been made by Harvey Cushing and C. B. Walker, and they 
have demonstrated the necessity of frequent examination of the visual 
fields with test-objects of various sizes. (See footnote, page 82.) 
(c) Stationary Optic Atrophy with Scotoma.-This is characterized 
by a scotoma similar to the one which occurs in toxic amblyopia, but 
much more decided. There are marked diminution of central vision, a 
depreciation of the color-sense, and ophthalmoscopically the appearances 
of optic-nerve atrophy. The process is stationary, and vision does not 
improve, under treatment. Jensen finds this affection exclusively in men 
before their thirty-fourth year. It. has a hereditary tendency, and is 
said to be caused by exhaustion and lack of sleep. Sometimes no cause 
can be demonstrated. Preceding the atrophy there may be slight 
neuritis. 
In the cases of hereditary atrophy of the optic nerve recorded by W. F. 
Norris, the ophthalmoscopic changes commenced with a stage of cloudy 
swelling of the disk and passed on to a gradual death of the nerve. The 
disease began with a central scotoma, first for color, but gradually this 
became complete. Both the males and females of the family were 
affected (see also page 486). 
(d) Progressive Optic Atrophy with Scotoma.-This includes the 
class of cases in which the optic-nerve atrophy of spinal disease (tabes 
dorsalis and disseminated sclerosis) is associated with a scotoma. The 512 
AMBLYOPIA OF VISUAL FIELD, SCOTOMAS, AND HEMIANOPSIA 
scotoma is central and shaped like the one in tobacco amblyopia, but 
as the disease progresses the peripheral field contracts, and finally it 
becomes difficult to detect the central defect. A central scotoma in 
tabetic atrophy of the optic nerve, according to Fuchs, is of more fre- 
quent occurrence than the ordinary records would seem to indicate. 
The scotoma is nearly always bilateral, and he regards it not as an acci- 
dental complication, but as an integral part of the tabetic process. 
Some authors maintain that the influence of tobacco and alcohol in the 
formation of these scotomas cannot be eliminated. Central scotoma 
is common in insular sclerosis. 
(e) Optic Neuritis with Scotoma.-An unusual symptom of intra- 
ocular neuritis caused by meningitis is a central scotoma, either relative 
or absolute. The student should not confuse this with an enlargement 
of the natural blind-spot due to the inflammatory swelling of the nerve- 
head. Ring scotoma has been reported with choked disk caused by 
brain tumor, and in optic neuritis due to sinusitis a central scotoma 
may develop. 
As has already been pointed out, the cause of central scotoma in 
orbital optic neuritis (toxic amblyopia) is degeneration of the papillo- 
macular bundle in the optic nerve or a destruction of the macular 
ganglion-cells. Whether a partial affection of the optic nerve will ex- 
plain all cases of central scotoma remains to be seen, and Jensen suggests 
that a common central cause may be active. 
Obscuration of One=half of the Visual Field, or Hemianopsia.1 
-In diseases of the eye-e. g., glaucoma-one-half of the visual field 
may be wanting, and also in optic-nerve atrophy and neuritis, ev6n if 
they are unconnected with disease of the visual pathway. These cases, 
however, are not included in the present account. 
Hemianopsia is that defect of vision characterized by an obscuration, 
usually in each eye, of one-half of the field, which occurs under the 
influence of a lesion situated at the optic chiasm, in the optic tract, in 
the visual radiations, or at their ultimate destination in the brain 
(occipital lobe). 
Visual Tract.-The visual tract, or visual conduction paths, may briefly be 
described as follows: 
The retina is a highly evolved structure, which, from the histologic standpoint, 
may be divided into three layers: (1) The layer of the neuro-epit helium, composed of 
two strata, namely, the layer of rods and cones and the external nuclear layer, the former 
constituting the specialized outer portions and the latter the nucleated bodies of the 
visual cells; (2) the layer of the bipolar cells, which by some authorities are looked upon 
as the peripheral visual neurons; (3) the layer of the ganglion-cells. 
The long processes, or axons, of the ganglion-cells pass into the nerve-fiber layer 
of the retina, reaching the papilla or nerve-head, and proceed to the optic nerve. Having 
reached the optic chiasm, a portion of the fibers of one optic nerve cross over and 
enter the optic tract of the opposite side, forming the crossed fasciculus, while a certain 
number of other fibers do not cross, but enter the optic tract of the same side, forming 
the non-crossed fasciculus. The non-crossed fasciculus arises chiefly from the tem- 
1 The terms hemiopia and hemianopsia are often used synonymously. Really, hemi- 
opia signifies loss in the perceptive power of one-half of the retina, while hemianopsia means 
obscuration of one-half of the visual field (Seguin). Other names which are used are 
hemianopia and hemiablepsia. OBSCURATION OF ONE-HALF OF VISUAL FIELD, OR HEMIANOPSIA 
513 
poral side of the retina, while the crossed fasciculus arises from the ganglion-cells 
of the nasal side of the retina. The bundle from the macula lutea, called the macular 
fasciculus, or papillomacular bundle, in general terms, is situated in the central part 
of the optic nerve and maintains its central position in the optic chiasm and in the 
optic tract, and is composed of crossing and direct fibers. The optic tract on each 
side behind the chiasm passes around the cerebral peduncle of the same side and 
arrives at the junction of the interbrain and midbrain, and divides into a lateral 
and a medial root. The fibers of the lateral root terminate in the lateral geniculate 
body, in the pulvinar of the thalamus, and in the- superior colliculus of the corpora 
quadrigemina. These structures have been designated the primary visual ganglia 
or primary optic centers.1 The corpora quadrigemina are not concerned in the act 
of vision, but in the activity of the pupil. The medial root of the optic tract has 
no connection either with the retina or with the optic centers of the interbrain and 
midbrain. 
From the regions just described 
fibers proceed backward through the 
posterior part of the internal capsule 
to the cortex. These are the optic 
or visual radiations, or fibers of Grati- 
olet or of Wemicke. Passing through 
the internal capsule, they cross the 
sensitive fibers coming down from 
the hemisphere, and spreading out 
like a fan, rise upward, wind outside 
of the tip of the lateral ventricle, to 
reach their destination at the lower 
part of the median surface of the 
occipital lobe-that is, the cortical 
termination of the visual tracts. 
The exact area occupied by the 
cortical center of vision has not been 
determined. In general terms it is 
situated about the cuneus and cal- 
carine fissure, and does not comprise 
the whole of the occipital lobe. 
By comparing the descrip- 
tion of the varieties of hemi- 
anopsia which follow with Fig. 
224, the student will under- 
stand the mechanism of their 
development. 
The following from Seguin explains the lettering of the illustration 
Fig. 224.-Diagram illustrating the visual 
path and its relation to the visual field, left 
lateral hemianopsia being shown (Seguin). 
L. T. F., left temporal half-field; R. N. F., right nasal half-field; 0. 8., left eye; 
0. D., right eye; N., nasal, and T., temporal halves of the retinas; N. 0. 8., left 
optie nerve; N. 0. D., right optic nerve; F. C. 8., left crossed fasciculus; F. L. D., 
right lateral or non-crossed fasciculus; C., Chiasm or decussation of the fasciculi; 
T. 0. D., right optic tract; T. 0. 8., left optic tract; C. G. L., corpus geniculatum 
laterale (medial corpus geniculatum and its arms are omitted); L. 0., optic lobes 
(corpora quadrigemina); P. 0. C., primary optic centers (including corpora quadri- 
gemina, corpora geniculata, and pulvinar of the optic thalamus); F. 0., optic fas- 
1 According to W. G. Spiller, the chief "primary " optic center is the external geniculate 
body. The pulvinar of the optic thalamus is also an important "primary" optic center. 
The anterior colliculus of the quadrigeminal body in man has an unimportant relation to 
vision. The hypothalmic body, the habenula, the internal geniculate body, probably are 
not part of the visual system (consult Spiller, "A Case of Complete Absence of the Visual 
System in an Adult," Univ, of Penna. Medical Bulletin, February, 1902). 514 
AMBLYOPIA OF VISUAL FIELD, SCOTOMAS, AND HEMIANOPSIA 
ciculus, radiating visual fibers of Gratiolet in the internal capsule; C. P., posterior 
horn of the lateral ventricle; G. A., region of the gyrus angularis; L. 0. S., left oc- 
cipital lobe; L. 0. D., right occipital lobe; Cu., cuneus and subjacent gyri constituting 
the cortical visual center in man. The shaded lines represent the parts connected 
with the right halves of the retinas. 
Varieties of Hemianopsia.-Hemianopsia is divided into horizontal, 
in which the dividing-line between the darkened and preserved field is 
horizontal; and vertical, in which the dividing-line is vertical. 
1. Horizontal hemianopsia (altitudinal) may be inferior or superior, 
both lower or both upper half-fields being wanting. In addition to dis- 
eases of the eye, it is possible that such a condition could arise under 
the influence of a lesion so situated as to press upon the upper or lower 
part of the chiasm, or downward upon one optic tract, or upon the lower 
or upper part of both optic nerves. A double lesion in front of the 
chiasm may produce loss of the upper half of the field in one eye and of 
the lower half of the field in the other eye. 
Fig. 225,-Bitemporal hemianopsia. The shaded areas represent the portions of the 
fields which are dark, and it is evident that there are entire loss of both temporal fields and 
some contraction of the preserved fields (from a case of acromegaly). 
2. Vertical Hemianopsia.-This is subdivided into several varieties: 
(a) Bitemporal hemianopsia (peripheral), in which both temporal 
fields are wanting, is characteristic of lesion of the chiasm. The defect 
is not necessarily complete from the beginning. Color-sense at first 
may be alone affected, followed later by loss of form- and light-sense. 
In place of complete bitemporal hemianopsia there may be paracentral 
or bitemporal hemiopic scotomas, which gradually broaden into bitem- 
poral hemianopsia (see also pages 510 and 511). There are a number 
of types or combinations of bitemporal visual field defects. Wildbrand 
described nine, Cushing and Walker have elaborated his list. 
(6) Binasal hemianopsia, in which both nasal fields are wanting, is 
rare. Unilateral nasal hemianopsia also occurs. 
(c) Homonymous hemianopsia (central), in which the corresponding 
half of the field in each eye is wanting: thus, both right or both left 
fields are darkened, in the former case indicating loss of function of the 
left half of each retina and designated right homonymous lateral hemian- OBSCURATION OF ONE-HALF OF VISUAL FIELD, OR HEMIANOPSIA 
515 
opsia, and in the latter case indicating loss of function of the right half 
of each retina, and designated left homonymous lateral hemianopsia (see 
Figs. 226 and 227). 
This is the commonest form of hemianopsia. 
Hemianopsia may be complete-i. e., the entire half of each field is 
wanting-or incomplete, i. e., a portion of each half-field is wanting, the 
Fig. 226.-Left homonymous hemianopsia, from a case of gunshot wound, with sus- 
pected lesion of the right cuneus. The shading shows where vision was lost (from a patient 
under the care of the late Dr. S. Weir Mitchell in the Infirmary for Nervous Diseases). 
defect usually being in the form of a quadrant (Fig. 227). The pre- 
served half-fields may be of their normal size, or they may exhibit con- 
centric contraction. 
Finally, the hemianopsia may be absolute-i. e., all the three func- 
tions of sight (perception of light, of form, and of color) are wanting- 
or it may be relative, i. e., perception of color only is lacking, light-sense 
Fig. 227.-Right homonymous hemianopsia (from a patient under the care of the late Dr. 
Wharton Sinkler). 
and form-sense being preserved; or perception of color and form is want- 
ing in the deficient area of the field, but the light-sense is preserved. 
Those cases in which the half-defect is present for colors alone are de- 
scribed under the name homonymous hemiachromatopsia. They prob- 
ably represent a cortical lesion of less intensity than one which produces 
absolute hemianopsia. In a remarkable case of this kind which the author 516 
AMBLYOPIA OF VISUAL FIELD, SCOTOMAS, AND HEMIANOPSIA 
has studied with Dr. J. William White, at the onset the hemianopsia 
was absolute; later light-sense and form-sense returned. The oblitera- 
tion of the color-sense remains, although in all other respects the patient 
has recovered. Non-cortical lesions may also produce hemiachroma- 
topsia. 
Peculiarities of the Dividing-line.-The dividing-line may exactly 
cut the fixing-point, or, as is usual, it may pass around this point and 
leave it within the region of preserved vision. The want of uniformity 
between the seeing and the blind areas may be manifested by the failure 
of the dividing-line to coincide with the vertical meridian for some dis- 
tance, by its assuming an oblique or irregular direction, or by forming 
an open angle. A number of theories have been advanced to account 
for these peculiarities. They have been explained by Schmidt-Rimpler 
by assuming that there are anastomoses of the fibers from each optic 
tract in the retinas as well as in the optic nerves and chiasm. 
A number of cases of double homonymous hemianopsia are recorded, 
in which there was preserved a small central field of each eye. This 
Fig. 228.-Quadrant homonymous anopsia or tetranopsia, shading as before. A quadrant 
of each field is wanting. The lesion is probably in the cuneus. 
indicates that there is a region in the cortical visual centers which sup- 
plies the macula lutea and that this has not been destroyed. 
Significance of Hemianopsia.-Typical bitemporal hemianopsia of 
permanent character is caused by a lesion-tumor, aneurysm, exostosis, 
arterial disease, etc.-which destroys the conductivity of both crossed 
fasciculi, leaving the non-crossed fasciculi unaffected (see page 515). 
It is a common symptom of pituitary body disease (neoplasm or struma). 
Affections of this region, however, may cause other varieties of visual 
field defects, concentric contraction, homonymous hemianopsia, and 
scotomas. 
A true chiasmal variety of binasal hemianopsia probably does not 
occur, although the visual field defect has been attributed to disease of 
the lateral angles of the chiasm. Most of the cases seem best explained 
by a bilateral inflammation of the trunks of the optic nerves in front of 
the chiasm. Unilateral hemianopsia, if not caused by disease within 
the eye, could originate from injury or lesion in one optic nerve. A nasal OBSCURATION OF ONE-HALF OF VISUAL FIELD, OR HEMIANOPSIA 
517 
hemianopsia on one side could be produced by a lesion affecting the 
lateral portion of the chiasm involving the non-crossing fibers of one 
eye- 
Homonymous lateral hemianopsia is caused by a lesion situated in 
the occipital lobe, the optic radiations, the internal capsule, the primary 
optic centers, or the optic tract (see Fig. 224). 
(a) The lesion in hemianopsia is on the opposite side of the dark fields. 
(6) If the preserved fields are accompanied by concentric contraction, the 
smaller half-field will be in the eye opposite to the lesion; contraction of the preserved 
half-field is most common with lesions of the cortex, but also may occur in lesions of 
the tractus. 
(c) If the hemianopsia is relative, the lesion is probably in the cortex; but corti- 
cal lesions are not excluded by absolute hemianopsia. 
(d) A lesion confined to the cuneus, or to it and the gray matter immediately 
surrounding it, on the mesial surface of the occipital lobe, produces homonymous 
lateral hemianopsia without motor or sensory symptoms, at least without these as a 
direct consequence of the lesion, although they may appear as indirect, or, as they are 
sometimes called, distant symptoms. 
(e) A lesion producing typical hemiplegia, aphasia, if the right side is paralyzed, 
little or no anesthesia and lateral hemianopsia, is probably due to disease in the 
area supplied by the middle cerebral artery. 
(/) A lesion causing hemiplegia, hemianesthesia, and lateral hemianopsia is 
probably situated in the posterior portion of the internal capsule. 
(g) A lesion causing hemianesthesia, ataxic movements of one-half of the body, 
no distinct hemiplegia, and lateral hemianopsia could be situated in the posterior 
lateral part of the optic thalamus. 
(A) A lesion causing the symptoms of disease of the base of the brain, associated 
at the same time with changes in the pupil, changes in the nerve-head, and lateral 
hemianopsia, could be situated in one optic tract or in the primary optic centers on 
one side.1 
(i) Incomplete hemianopsia, assuming usually a quadrant-shaped defect, may 
be present on account of a lesion confined to the lower half of the cuneus. It may 
also occur with less definite limitations in lesions of the subcortical substance of the 
occipital lobe and then may be associated with other symptoms, as hemiplegia and 
hemianesthesia. Finally, it may occur from a lesion of the tract, but then will be 
accompanied by other symptoms indicating basal disease or from a lesion of the 
external geniculate body. 
(j) A hemianopsia in which there is preservation of the light-sense, but loss of 
either the color-sense or the form-sense indicates that the lesion is in the cortex of 
the visual center. 
The Pupil in Hemianopsia.-The reaction of the pupil in hemianopsia 
has usually been regarded as a localizing symptom of importance; 
this is denied by some observers (see footnote). Generally the rules 
are stated as follows: 
If, in hemianopsia, the light thrown upon either the blind or the 
seeing side of the retina causes contraction of the pupil, the lesion is 
back of the primary optic centers. 
If there is no contraction of the pupil when the ray of light falls upon 
the blind side of the retina, but there is contraction when it falls upon 
the seeing side, the lesion is in front of the primary optic centers. 
1 The preceding paragraphs have for the most part been condensed from the rules 
given by Dr. Seguin for the diagnosis of the seat of lesion in cases of hemianopsia. 518 
AMBLYOPIA OF VISUAL FIELD, SCOTOMAS, AND HEMIANOPSIA 
In the former instance the lesion is so situated that there is no dis- 
turbance of the sensorimotor arc of the pupils; in the latter the lesion 
interferes with this arc, and the pupillary change receives the name 
hemiopic or hemianopic pupillary inaction. It is often called Wernicke's 
symptom.1 
1 Henschen (Klin. med. anat. Beitrage zur Pathologic des Gehirns, Th. iii) concludes that 
the hemiopic pupillary inaction (abbreviated H. R.) is present in tract lesions, even when 
minute or merely caused by pressure; lesions of the posterior segment of the thalamus 
and pulvinar-perhaps from pressure on the tract, or by destroying the brachium anterius; 
lesions of the chiasm (occasionally absent from unknown reasons); and in lesions of the 
nerve, with unilateral hemianopsia. It is a difficult symptom to demonstrate (Henschen 
uses a special lamp) and its existence is doubted by some observers. The iris reaction may 
not be entirely absent when the ray falls on the blind side of the retina, but it is much 
less marked than the one which follows light stimulus of the opposite side. C. B. Walker 
(Trans. Section on Ophthalmology, Amer. Med. Assoc. 1914,) has designed a clinical in- 
strument for elucidating the hemiopic pupillary reaction and concludes from his studies 
that it has no topical diagnostic value. To replace Henschen's phenomenon, Wildbrand 
has proposed a prism test. It is thus described by Saenger: The patient fixes a white point 
on a large black plane surface. Suddenly two prisms of equal degree (15°) are brought 
before both eyes, their apices being turned to the hemianopic defect. If cortical hemian- 
opsia exists, the patient's eyes will move so that the fovea is directed to the object; if the 
reflex path is interrupted by a lesion of the tractus, there is no movement of the eyes. CHAPTER XIX 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
Anatomy and Physiologic Action of the Ocular Muscles.- 
The movements of the eye are controlled by the action of six muscles, 
four straight and two oblique, in general terms situated in the orbital 
region. 
1. The external rectus arises by two heads, respectively from the 
outer margin of the optic foramen and the common tendon of the 
inferior and internal recti, and in part from a process of bone on the 
lower margin of the sphenoid fissure. Its tendon is inserted into the 
sclera 7 mm. from the margin of the cornea. It is supplied by the sixth 
or abducens nerve. Its pre-eminent1 muscular action is abduction- 
that is, it rotates the eye directly outward. 
2. The internal rectus arises from the optic foramen by a tendon 
common to it and the inferior rectus, and passes forward to be inserted 
by a tendinous expansion into the sclerotic coat 5 mm. from the margin 
of the cornea. It is supplied by one of the three branches of the inferior 
division of the third or oculomotor nerve. Its pre-eminent muscular 
action is adduction-that is, it rotates the eye directly inward. 
3. The superior rectus arises from the upper margin of the optic 
foramen and from the fibrous sheath of the optic nerve, and is inserted 
by a tendinous expansion into the sclerotic coat 8 mm. from the margin 
of the cornea. It is supplied by the superior division of the third or 
oculomotor nerve. Its pre-eminent muscular action is elevation or 
superduction-that is, it rotates the eye upward. It also adducts it and 
rotates the upper end of the vertical meridian of the cornea inward 
(inward torsion or intorsion). 
4. The inferior rectus arises from the optic foramen by a tendon 
common to it and the internal rectus and passes forward to be inserted 
by a tendinous expansion into the sclerotic coat, 6 mm. from the margin 
of the cornea. It is supplied by one of the three branches of the inferior 
division of the third or oculomotor nerve. Its pre-eminent muscular 
action is depression, or subduction-that is, it rotates the eye downward. 
It also adducts it and rotates the vertical meridian of the cornea out- 
ward (outward torsion, extorsion). 
5. The superior oblique (trochlear) is situated at the upper and inner 
side of the orbit, and arises above the inner margin of the optic foramen. 
It proceeds to the inner angle of the orbit, at which point its rounded 
tendon passes through a fibrocartilaginous pulley occupying a fossa 
just within the supra-orbital margin of the frontal bone, and is next 
1 This term is borrowed from Maddox. 
519 520 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
reflected backward, outward, and downward, to be inserted about 18 
mm. from the edge of the cornea between the superior and external recti. 
It is supplied by the fourth or trochlear nene. Its pre-eminent muscular 
action is intorsion-that is, it rotates the vertical meridian inward. It 
also depresses the eye and abducts it. 
6. The inferior oblique is situated at the bottom of the orbit and arises 
from a depression in the orbital plate of the superior maxillary bone. 
Passing beneath the inferior rectus, it is directed outward, backward, 
and upward, and reaches its insertion into the sclera by means of a 
thin tendon about 19 mm. from the corneal margin, within the position 
of the external rectus. It is supplied by the largest branch of the supe- 
rior division of the third or ocidomotor nene. Its pre-eminent muscular 
action is extorsion-that is, it rotates the vertical meridian outward. It 
also elevates the eye and abducts it.1 
The starting-point from which the actions of the muscles are reck- 
oned is the primary position of the globe, defined by Mauthner as that 
position of the eyes from which the visual lines can be moved without the 
eyes being revolved around their anteroposterior axes. The eyes occupy 
about this position when they are directed straight forward, the head 
being held erect, and a distant object, situated in the median line of the 
visual plane, is observed with practically parallel visual lines. Positions 
of the eyes other than this are called secondary positions. 
Rotation of the Eyeball Around the Visual Line.-If a vertical 
line is passed through the visual line so as to divide the eyeball into two 
lateral halves, it will intersect the surface of the eyeball in what is called 
the vertical meridian. The latter may be defined with sufficient accuracy 
as a line passing through the center of the pupil in a direction perpen- 
dicular to the line joining the centers of the two pupils. It joins the 
uppermost and lowermost points of the corneal margin. 
In movements of the eyeball directly upward (combined action of 
the superior rectus and inferior oblique) or downward (combined action 
of the inferior rectus and superior oblique), or directly inward or out- 
ward, the ^vertical meridian remains vertical. 
In oblique movements of the eyeball, upward and inward (superior 
and internal rectus, with inferior oblique); downward and inward 
(inferior and internal rectus, with superior oblique); upward and out- 
ward (superior and external rectus, with inferior oblique); or downward 
and outward (inferior and external rectus, with superior oblique), the 
vertical meridian will be observed to rotate like the spokes of a wheel 
(pvheel-rotation or torsion). The eyeball appears to rotate around the 
visual line; this is effected by the superior and inferior recti and the 
superior and inferior oblique muscles. The upper extremity of the 
vertical meridian of the cornea is deviated outward (toward the temple) 
by the inferior recti and inferior oblique muscles; and inward (toward 
the nose) by the superior recti and superior oblique muscles. The 
1 Duane, basing his opinion on the results of paralysis, believes that depression is the 
most important muscular action of the superior oblique and that elevation is the most 
important action of the inferior oblique, intorsion and extorsion, respectively, being sub- 
sidiary actions. ASSOCIATED MOVEMENTS 
521 
deviation of the vertical meridian is greatest when the axis of rotation 
coincides with the visual line. 
The superior and inferior recti exercise the greatest degree of torsion 
when the eyeball is drawn toward the nose, and either upward or 
downward. 
The oblique muscles, on the contrary, exercise their maximum 
amount of torsion when the eyeball is drawn toward the temple, and 
either upward or downward. The inferior oblique, while it aids the supe- 
rior rectus in upward movements, antagonizes it in the rotation of the 
vertical meridian and the movement of the eyeball inward. 
The visual line coincides most nearly with the axis of rotation of the 
superior and inferior recti when the eyeball is drawn toward the nose 
and most nearly with that of the superior and inferior oblique muscles 
when the eyeball is turned toward the temple. The superior oblique 
aids the inferior rectus in drawing the eye downward, but antagonizes 
it in the rotation of the vertical meridian and in the movement of the 
eyeball inward. 
In extreme diagonal movements of the eyes the action of the ob- 
liques and the recti is to make the vertical meridian tilt toward the nose 
or temple. But if the muscles are evenly balanced, the vertical meridians 
of the two eyes, however tilted, remain parallel, and under these condi- 
tions the retinal images are projected normally, vertical objects still 
appearing vertical. 
In paralysis of the eye muscles the vertical meridians no longer 
remain parallel, and the image of one eye appears oblique with regard 
to the other. (See also page 526.) 
Associated Movements.-Except in pathologic circumstances, 
there is coordination in the movements of the eyes, and the movement of 
one eyeball is associated with that of its fellow. In other words, both 
eyes are used for seeing (binocular vision), and are so adjusted that the 
image of the object regarded falls simultaneously on both maculas 
(binocular fixation). If a distant object is to be looked at and the right 
eye is turned to the right, the left eye is also turned to the right and to 
the same extent as its fellow, because of the associated action of the ex- 
ternal rectus of the right eye and the internal rectus of the left eye under 
the same innervation-impulse. If one eye is elevated, the other is also 
elevated; if one is depressed, the other is also depressed. These are 
associated movements in the same direction. 
If a near object is to be looked at, the visual axes converge for the 
point at which it is situated because of the associated action of the 
internal recti of the two eyes (convergence or accommodative movement); if 
the eyes are removed from this point and directed to a distant object, the 
visual axes tend to parallelism because of the action of both external recti. 
If the associated movements of the eyes were not thus regulated by 
equal impulses from the coordinating center, single vision would not 
be possible, because the images of any object would not fall upon corre- 
sponding points of the two retinas. Inasmuch as every normal individual 
has two normally constructed eyes, he must receive from every object 522 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
two sets of sensations, which are blended into one when the movements 
of the eyes are so arranged that the images fall upon corresponding 
retinal areas. 
A point situated anywhere upon the right side of one retina has its 
corresponding point upon the right side of the other retina, and points 
on the left side of one correspond with points on the left side of the 
other. The upper half of the retina of the right eye corresponds to the 
upper half of the retina of the left eye, and the lower half of the right to 
the lower half of the left; the nasal side of the right eye corresponds with 
the malar side of the left, and the malar of the right with the nasal of the 
left. If, for any reason, the movements of the eyes become disarranged 
so that the images do not fall upon corresponding or identical retinal 
areas, the images become double. 
The desire for binocular single vision, or single vision with the two 
eyes, wdiich depends upon the blending of the two sets of sensations, or, 
as it is also called, fusion, is believed to be the origin of the impulse which 
directs the movements of the eyeballs, especially in association in the 
same direction. 
In addition to this desire for blending the two sets of sensations into 
one, seen in the associated movements of the eyes in the same direction, 
there is also another regulating factor-i. e., the connection between con- 
vergence and accommodation (see page 43). 
Overcoming Prisms.-When a prism is placed before one eye with 
its base inward and diplopia is produced, an outward rotation of the eye 
occurs, and when the prism is placed with its base outward, an inward 
rotation of the eye takes place, and the influence of the prism is over- 
come, so that single vision again is possible within the limitations which 
have been recorded on page 74, where prism-convergence, prism-diver- 
gence, and sursumvergence are described. 
Field of Fixation.-This includes all points which the eye under 
observation can successively fix, the head being perfectly stationary. 
The field of fixation of an amblyopic eye may be determined by watch- 
ing the image of a candle-flame on the center of the cornea as the eye 
follows the test-light moved along the perimeter arc until the limit of 
movement is reached. Ordinarily the patient should be seated in the 
position for testing the visual field before the perimeter, with the semi- 
circle horizontal, and the eye (the head being rigid) made to follow a 
word composed of small test-letters, and the point where vision ceases 
to be distinct marked on successive meridians. In place of letters, two 
fine dots set close together on a card may be employed, and the point 
noted where the dots cease to appear as two. 
Landolt's measurements of the field of fixation under normal condi- 
tions are as follows: Outward, 45-50; inward, 45; upward, 35-40; 
downward, 60. Duane's average measurements are: Outward, 51; 
inward, 53; upward, 43; downward, 63. 
G. T. Stevens determines the rotations of the eyes with a special 
instrument called a tropometer. According to him, the most favorable 
rotations are: Outward, 50; inward, 50; upward, 33; downward, 50. STRABISMUS, SQUINT, OR HETEROTROPIA 
523 
Strabismus, Squint, or Heterotropia.-Under the general term 
strabismus or squint are included those conditions which occur when 
the visual axis of one eye is deviated from the point of fixation. The 
eye the visual axis of which is directed to the object fixed is termed the 
fixing eye; the other eye is termed the squinting or deviating eye. The 
deviation may be inward {strabismus convergent), outward {strabismus 
divergent), upward {strabismus sursum vergens), or downward {strabis- 
mus deorsum vergens). 
1. Convergent Strabismus, or Esotropia.-In this form of squint 
the visual line of one eye is directed to the object fixed. The visual line 
Fig. 229.-Convergent strabismus. Position and projection of the images (James Wallace). 
of the other eye is deviated inward, and intersects that of the sound eye 
at some point nearer than the object fixed. The image of an object 
situated on the visual line of this eye would be formed on the fovea, and 
projected to the same point in the field of fixation. 
Figure 229 represents a convergent squint of the left eye, and serves 
to explain the results of an inward deviation of one eye from any cause. 
The center of rotation is seen at r. The arrow is the object fixed; its image is 
formed on the fovea of the right eye, and its position in the field is denoted by 
The candle forms its image on the retina of the right eye to the left of the fovea at H; 524 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
its image is properly projected to the right, and its position in the field is denoted 
by h. The visual axis of the left eye is directed to the candle; its image is formed on 
the fovea at F2, and its position in the field is denoted by f2, identical with that of fv 
because formed on an identical point of the retina. The arrow forms an image on 
the retina of the left eye at G, to the right of the fovea; it is consequently projected 
to the left of that of F2, and its position in the field is denoted by g. 
The right eye projects the images correctly; the left eye projects 
them to the left of their true position-i. e., to the side of the squinting 
eye. The diplopia is simple or homonymous. 
2. Divergent Strabismus, or Exotropia.-In this form of squint 
the visual line of one eye fixes the object, while the visual line of the 
Fig. 230.-Divergent strabismus. Position and projection of the images (James Wallace). 
other eye lacks the necessary movement inward to intersect that of its 
fellow at the point of fixation. 
As long as the visual axis of the affected eye intersects that of the 
sound eye in its anterior extremity, the affection may be denominated 
insufficiency of convergence. When the visual axes no longer intersect 
anteriorly, but diverge from each other so that their posterior extremi- 
ties intersect, the affection may be denominated divergent squint. 
Figure 230 represents a divergent squint of the left eye, and explains 
the effects of an outward deviation of one eye from any cause upon the 
position of the images of an object which is fixed. STRABISMUS, SQUINT, OR HETEROTROPIA 
525 
The center of rotation is at r. The arrow is the object fixed; its image is formed 
on the fovea of the right eye at and its position in the field is denoted by A. The 
candle forms its image on the retina of the right eye to the right of the fovea at H; 
its image is properly projected to the left and its position in the field is denoted by 
h. The visual axis of the left eye is directed to the candle; its image is formed on the 
fovea at F2, and its position in the field denoted by f2, identical with that of fv because 
formed on identical points of the retina. The arrow forms an image on the retina of 
the left eye at G, to the left of the fovea; it is consequently projected to the right of 
that of F2, and its position in the field is denoted by g. 
The right eye projects the images properly; the left eye projects them 
to the right of their true position-i. e., the side opposite to the squinting 
eye. The diplopia is crossed or heteronymous. 
Fig. 231.-Convergent strabismus with decided upward deviation (from a patient in the 
Philadelphia General Hospital). 
3. Upward and Downward Squint, or Hypertropia.-If vertical 
deviation (upward or downward) causes diplopia, the images are on 
different levels, the upper image corresponding with the lower eye. 
Simple vertical deviation without lateral is rare. Generally in lateral 
strabismus the squinting eye deviates upward, but may also turn 
downward (Schweigger). According to Hansell, functional internal 
squint (esotropia) is always associated with upward deviation (hyper- 526 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
tropia). In deviations, especially when there is vertical squint, one of 
the images is often oblique with regard to the other. 
This obliquity can be simplified for study by dividing it into two 
kinds: either the vertical meridians incline toward each other by their 
upper extremities, or else they diverge from each other. 
The meridians diverge from each other when the upper extremity 
of one vertical meridian is directed toward the temple, while the vertical 
meridian of the other eye remains perpendicular. An object extending 
in a vertical direction-for example, a candle-would form an inverted 
image on the retina of the eye whose vertical meridian is tilted toward 
the temple by its upper extremity, in which the flame of the candle 
would occupy the lowest portion of the image lying somewhat on the 
temporal half of the retina, while the lower portion of the candle would 
occupy the highest portion of the image, somewhere on the nasal half 
of the retina. In accordance with the law of projection, images on the 
nasal half of the retina are referred to the temporal portion of the 
field, and images on the temporal half of the retina are referred to the 
nasal portion of the field. With the vertical meridian tilted toward the 
temple the candle forms an image on the retina which is projected out- 
ward, so that it seems to converge by its upper extremity toward that of 
the other eye wThen the diplopia is homonymous; when crossed diplopia 
exists, it seems to diverge. 
The meridians converge toward each other when the upper extremity 
of one vertical meridian is tilted toward the nose, while the vertical 
meridian of the other eye remains perpendicular. 
When the vertical meridian is tilted toward the nose by its upper 
extremity, the image of the candle occupies, with its lower portion, a 
point in the nasal half of the retina, and with its upper portion a point 
in the temporal half of the retina. It is projected outward in such a 
manner that it seems to lean away from the image of the other eye when 
the diplopia is homonymous; when crossed diplopia exists, it seems to 
lean toward the image of the other eye. 
In paralysis of the ocular muscles it is usually the image of the 
paralytic eye which appears oblique. Sometimes, however, the patient 
regards this image as vertical and the image of the sound eye as oblique 
(see also pages 520 and 521). 
Paralysis of the Exterior Ocular Muscles {Paralytic Strabismus'). 
-This may be complete (the muscle is entirely paralyzed) or incomplete 
(the muscle is partially paralyzed). 
A. General Symptoms.-Certain symptoms are common to paralysis 
of the external eye muscles. 
1. Loss of Binocular Single Vision, or Diplopia.-The cause of this, 
evident from the previous explanations, depends upon the deviation 
of the affected eye so that the images from an object are no longer fused, 
owing to their failure to fall upon "identical points" in the two retinas. 
Diplopia increases as the object is moved to the side of the paralyzed 
muscle. In slight degree it amounts only to indistinct vision. 
2. Non-correspondence of the Direction of the Two Eyes, or Strabismus. PARALYSIS OF THE EXTERIOR OCULAR MUSCLES 
527 
-This depends upon the deviation to which the affected eye is sub- 
jected by the tone of the unresisted action of the muscle which is the 
antagonist of the paralyzed muscle, and also, in part, upon the effect 
of secondary contractures. Squint is not always plainly manifest, and 
may appear only if an attempt is made to move the eye in the direction 
of the action of the palsied muscle. 
3. Loss or Limitation of Movement {Primary Deviation}.-The lim- 
itation of movement is always in the direction of the action of the 
affected muscle; consequently the deviation of the eye is in a direction 
opposite to the action of the muscle. 
4. Deviation of the Sound Eye, While the Affected Eye Fixes {Secondary 
Deviation).-During the act of fixation by the affected eye the same 
degree of nervous impulse passes from the center to the muscles of the 
affected eye and to those of its non-affected associate; the former re- 
quires an abnormally great impulse to stimulate its movement, and 
hence the latter is overexcited, and the resulting movement is excessive. 
The secondary deviation, therefore, is greater than the primary devia- 
tion. 
In order to demonstrate this the sound eye is covered with the hand, 
while the affected eye is directed toward an object held at a distance of 
about one foot. The covering hand is then moved from the sound to 
the affected eye. In order to fix the object, the sound eye must now 
move in a direction opposite to that toward which the paralyzed muscle 
rotates the ball. This backward movement represents the degree of 
previous excess called into existence by the undue amount of nerve- 
force which the normal muscle originally received. Thus primary and 
secondary deviations are in opposite directions, but both in the line of 
action of the affected muscle. 
5. False Projection of the Field of Vision.-This depends upon an 
inaccurate estimation of the position of an object situated in such a 
portion of the visual field that it requires an effort on the part of the 
affected muscle to turn the eye toward it. A normal individual (his 
head being stationary, and one eye being closed, e. g., the right) can 
readily and accurately touch an object lying within his reach to the left 
of the median line, because the degree of innervation required to make 
the lateral movement of the eye in order to see the object gives the 
necessary information, based on experience, how far to the left the ob- 
ject lies. In the same circumstances an individual with a paretic left 
external rectus, instead of touching the object, would pass |his hand 
beyond it-i. e., to the left of it, because the excessive innervation which 
is now necessary to make the lateral turn gives the impression that the 
object lies farther to the left. In other words, the object is projected 
to a position in the visual field which it does not have. 
6. Vertigo.--This depends, both eyes being open, upon the diplopia 
and the confusion arising from trying to distinguish between the real 
and the false image. If one eye (the unaffected eye) is closed, it de- 
pends upon the condition described in the preceding paragraph. 
In a paretic condition of the muscles which rotate the eye down- 528 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
ward vertigo may result from an erroneous localization of objects in the 
lower field, as they seem to lie in a plane deeper than they really are. 
For these reasons patients with ocular palsies commonly close the 
affected eye, although closure of either eye would remove the diplopia. 
7. Altered Position of the Carriage of the Head.-This depends upon 
the impulse of the patient to carry his head in that direction in which 
he is least troubled by the double images, and this is usually in the 
direction toward which the affected muscle moves the eye. In vertical 
deviation the head is often tilted toward one shoulder-toward the side 
of the higher eye if the hyperphoria or hypertropia is combined with 
crossed diplopia, and toward the other side if the hyperphoria or hy- 
pertropia is combined with homonymous diplopia. 
B. Varieties of Diplopia.-There are two varieties of diplopia, accord- 
ing to the relation which the double images bear to the eyes. If the 
right image pertains to the right eye, and the left image to the left eye, 
the diplopia is designated simple or homonymous; if the right image per- 
tains to the left eye, and the left image to the right eye, the diplopia is 
named crossed or heteronymous. The explanation of these conditions 
has been given (see Figs. 229 and 230). 
Fig. 232.-A, Position of images in paralysis of left external rectus, and B, in paralysis of 
right externus. The false image is drawn in outline (after Fuchs). 
If the two images are on a horizontal line, the phenomenon is called 
horizontal diplopia. Vertical displacement of the double images con- 
stitutes vertical diplopia (see also page 526). 
C. Special Symptoms.-The following paragraphs contain the most 
important symptoms peculiar to paralysis of individual muscles. For 
convenience it is supposed that the right eye is affected. 
1. External Rectus.-The following phenomena may be present: 
(a) Horizontal homonymous diplopia, the images being side by side 
and parallel, if the eyes are directed on a horizontal level, the distance 
between them widening as the test-object is moved to the right-that 
is, the maximum diplopia is to the right (Fig. 232). 
If the test-object is moved to the right and above, and the eyes are 
directed toward it, the false image (image of the right or affected eye) 
diverges from the real image (image of the left or unaffected eye). 
This occurs because, in these circumstances, the movement of the right 
eyeball toward the temple is limited by the feeble external rectus, and 
the eyeball fails to come into the position where the inferior oblique has 
its favorable condition for rotating the vertical meridian outward; 
hence the vertical meridian remains near to a perpendicular, while that PARALYSIS OF THE EXTERIOR OCULAR MUSCLES 
529 
of the sound eye is tilted toward it. There is divergence of the vertical 
meridians (the false image converges toward the real one) when the 
eyes are directed downward and toward the right, because the eyeball 
fails to come into a favorable position to have its vertical meridian tilted 
toward the nose by the superior oblique, while that of the other eye is 
tilted toward the temple by the inferior rectus. 
(6) Convergent strabismus, which increases as the eye attempts to 
follow an object which is moved toward the right, during which it will 
be noticed that there is limitation of movement in this direction. 
(c) The secondary deviation of the sound eye is inward; the false 
projection of the field of vision is to the right side, and the face is turned 
to the right-i. e., to the side of the affected muscle. 
2. Internal Rectus.-There are present: 
(a) Horizontal crossed diplopia, the images being side by side' and 
parallel, if the eyes are directed along a horizontal level, the distance 
between them widening as the test-object is moved to the left, or if the 
eyes are directed upward-that is, the maximum diplopia is to the left 
(Fig. 233). 
If the test-object is moved to the left and above, and the eyes are 
directed toward it, the image of the affected eye is lower than that of the 
Fig. 233.-A, Position of images in paralysis of left internal rectus, and B, in paralysis of 
right internus. The false image is drawn in outline (after Fuchs). 
unaffected eye, and its upper extremity inclines toward it; if the test- 
object is moved to the left and downward, the false image is higher and 
its lower extremity inclines away from that of the real image. These 
inclinations occur because, in these circumstances, the left eyeball is 
placed in a favorable position for one of the oblique muscles to rotate it, 
while the right eye is not brought in sufficiently for the superior or infe- 
rior rectus to exercise its torsion effect; consequently, the vertical 
meridians diverge on looking upward and converge on looking down- 
ward toward the left side. 
(6) Divergent strabismus, which increases when the eye attempts to 
follow an object moved to the left, during which it will be noticed that 
there is limitation of movement in this direction. 
(c) The secondary deviation of the sound e,ye is outward, the false 
projection of the visual field is to the left side, and the face is turned to 
the left-i. e., to the side of the affected muscle. 
3. Superior Rectus.-There are present: 
CD Vertical crossed diplopia in the upper field, the images being one 
above the other, the image of the affected eye being higher than its 530 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
fellow and inclined to the left (healthy side), and the vertical distance 
between them (difference in height) widening as the test-object is moved 
upward and to the right-that is, there is maximum diplopia in looking 
up and to the right (Fig. 234). 
If the test-object is moved upward, and to the left, and the eyes are 
directed toward it, the obliquity of the images increases-i. e., the false 
image is still more inclined toward the sound side, away from that of 
the other. This occurs because, in these circumstances, the inferior 
Fig. 234.-A, Position of images in paralysis of left superior rectus, and B, in paralysis of 
right superior rectus (Fuchs). 
oblique rotates the vertical meridian of the sound eye to the left, while 
the affected eye, owing to the loss of power in the superior rectus, is 
unable to deviate its vertical meridian from the perpendicular; there- 
fore the two meridians diverge, but, the diplopia being crossed, the 
images also diverge. 
(6) Dowmvard strabismus, which increases when the eye attempts to 
follow an object moved upward, during which it will be noticed that 
there is limitation of movement in this direction. 
Fig. 235.-A, Position of images in paralysis of left inferior oblique, and B, in paralysis of 
right inferior oblique (after Fuchs). 
(c) The secondary deviation of the sound eye is upward, the false 
projection of the visual field is too high, and the face is directed upward 
and to the right, or the head is tilted toward one shoulder, generally the 
left. 
4. Inferior Oblique.-There are present: 
(a) Vertical homonymous diplopia (sometimes crossed) in the upper 
field, the images being one above the other, the image of the affected 
eye being higher than its fellow and inclined to the right-i. e., to the 
affected side-the vertical distance between them (difference in height) PARALYSIS OF THE EXTERIOR OCULAR MUSCLES 
531 
widening as the test-object is moved upward and to the left-that is, 
there is maximum diplopia on looking up and to the left. 
If the test-object is moved upward and to the right and the eyes are 
directed toward it, the obliquity of the images increases-i. e., the false 
image is still more inclined away from the sound side. This occurs 
because, in these circumstances, the vertical meridian of the right eye 
is not tilted toward the temple, owing to loss of power in the infe- 
rior oblique, while that of the left eye is tilted toward the nose by the 
superior rectus, now in its best position for tilting the vertical meridian 
inward; therefore the two meridians incline toward each other by their 
upper extremities. 
(6) The direction of the affected eye is downward and inward, which is 
more noticeable when the eye attempts to follow an object moved 
upward and outward, during which it will be noticed that there is 
limitation of movement in this direction. 
(c) The secondary deviation of the sound eye is upward and inward, 
the false projection of the visual field is too far upward, and the face is 
directed upward and toward the left, or the head is tilted toward one 
shoulder. 
Fig. 236.-A, Position of images in paralysis of left inferior rectus, and B, in paralysis of 
right inferior rectus (after Fuchs). 
5. Inferior Rectus.-There are present: 
(a) Vertical crossed diplopia in the lower field, the images being one 
above the other, the image of the affected eye being lower than its 
fellow and inclined to the right-i. e., to the affected side-and the 
vertical distance between them (difference in height) widening as the 
test-object is moved downward and to the right-that is, there is 
maximum diplopia on looking down and to the right. 
If the test-object is moved downward and to the left, and the eyes 
are directed toward it, the obliquity of the images increases-i. e., the 
false image inclines still more toward the affected side. This occurs 
because, in these circumstances, the superior oblique of the left eye is 
in its best position for rotating the vertical meridian toward the nose; 
but the right eye, by reason of its paralyzed inferior rectus, is unable to 
tilt its vertical meridian to correspond; therefore the vertical meridian 
of the right eye remains perpendicular, while that of the left eye inclines 
toward it. The image of the right eye seems to be the oblique one; the 
images diverge, but, the diplopia being crossed, they seem to converge. 532 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
(6) Upward strabismus, which increases when the eye attempts to 
follow an object moved downward, during which it will be noticed 
that there is limitation of movement in this direction. 
(c) The secondary deviation of the sound eye is downward and out- 
ward, the false projection of the visual field is too far downward, and the 
face is directed downward and to the right, or the head is tilted toward 
one shoulder, generally the right. 
6. Superior Oblique.-There are present: 
(a) Vertical homonymous diplopia {sometimes crossed} in the lower 
field, the images being one above the other, the image of the affected 
eye being lower than its fellow, and inclined to the left-i. e., to the sound 
side-the vertical distance between them (difference in height) widening 
as the test-object is moved downward and to the left-that is, there is 
maximum diplopia downward and to the left. 
If the test-object is moved downward and to the right, and the 
eyes are directed toward it, the obliquity of the images increases-i. e., 
the false image inclines still more toward the sound side. This occurs 
because, in these circumstances, the vertical meridian of the left eye 
Fig. 237.-A, Position of images in paralysis of left superior oblique, and B, in paralysis of 
right superior oblique (after Fuchs). 
is inclined toward the left by the inferior rectus, while that of the 
right eye is not rotated, owing to the feeble superior oblique; conse- 
quently, the meridians diverge.1 
(b) The direction of the affected eye is upward and inward, and is 
more noticeable when the eye attempts to follow an object moved 
downward and outward, during which it will be noticed that there is 
limitation of movement in this direction. 
(c) The secondary deviation of the sound eye is downward and in- 
ward, the false projection of the visual field is too far downward, and the 
face is inclined downward and to the left, or the head is tilted toward one 
shoulder, generally the left. 
7. Oculomotor Paralysis.-There are present: 
(a) Complete crossed diplopia, the image of the affected eye being 
higher than its fellow, and its upper extremity inclined to the right- 
1 In paralysis of the inferior rectus the diplopia is usually crossed; this feature helps to 
distinguish it from paralysis of the superior oblique. In both, the image of the affected eye 
sometimes seenis to stand nearer to the patient than the other image. It should be re- 
membered, however, as Maddox insists, that in paralysis of any one of the obliques a pre- 
existing exophoria may complicate the case to such an extent as to change "homonymous" 
into "crossed" diplopia, while in paralysis of the superior and inferior recti pre-existing 
esophoria may convert "crossed" into "homonymous" diplopia. PARALYSIS OF THE EXTERIOR OCULAR MUSCLES 
533 
i. e., to the affected side-the distance between them-i. e., the lateral 
distance-widening as the test-object is moved to the left. If the 
test-object is moved upward the difference in height and the inclination 
of the false image increase. 
(6) Divergent strabismus and limitation of movement in all directions, 
except outward and slightly downward. 
(c) The secondary deviation of the sound eye is outward, the false 
projection of the field of vision is to the inner side, and the face is inclined 
toward the right, the chin being tipped upward. In addition, there are 
ptosis, medium dilatation of the pupil which fails to contract to light, 
and paralysis of accommodation. 
Method of Examination and Diagnosis of the Affected Eye.-If 
the paralysis is complete, there is little difficulty in making a diagnosis 
by attention to the prominent symptoms which have been detailed. 
In the condition is one of partial paralysis (paresis), the diagnosis must 
be based upon an investigation of the double images. 
Fig. 238.-Double oculomotor palsy (from a patient in the Philadelphia General Hospital). 
The patient is seated with the head and eyes in the primary position, 
four meters from the test-object (a candle flame or small electric light), 
and a trial-frame one side of which carries a red glass is placed in posi- 
tion. Hence if diplopia is developed, one image will be yellow and the 
other red. The lighted candle is then moved from the median line to 
the right, to the left, upward and down, while the patient follows these 
movements with his eyes, the head being stationary. By these maneu- 
vers the following facts will be ascertained: 
(1) Double images are chiefly seen when the eyes are turned in a 
direction requiring an action of the affected muscle. (2) The image of 
the affected eye (false image) is projected in a direction toward which 
the paralyzed muscle normally rotates the eye. (3) That image is false 
(image of the affected eye) which travels farther away from the true 
image (image of the sound eye) when the test-object is moved in the 
direction of the paralyzed muscle-i. e., the relative distance of the 
double images increases in these circumstances. 534 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
The effect upon the obliquity of the images and their relation to 
each other of moving the test-object in oblique directions above and 
below the horizontal plane must next be studied; also whether the 
images are present in all portions of the field of fixation, or confined to a 
certain area of it (see also page 526). 
Many tables have been prepared to aid in the diagnosis of the 
affected muscle, and if paralysis of the oblique muscles always produced 
homonymous or simple diplopia, and paralysis of the superior and infe- 
rior rectus muscles always caused heteronymous or crossed diplopia, 
their construction would be comparatively simple. This, however, is 
not the case, and it is well known, as has already been pointed out, that 
the diplopia from paresis of the obliques may be crossed, and that from 
paresis of the superior and inferior recti homonymous. Hence Duane 
insists that paralysis of the obliques and of the superior and inferior 
recti should be diagnosticated from the behavior of the vertical 
diplopia. 
This author divides the twelve muscles moving the two eyes into 
three groups of four each: four moving the eyes laterally, four moving 
them up (elevators), and four moving them down. Each group is 
divided into two pairs. Thus, the four laterally acting muscles are di- 
vided into (a) a pair of right turners (right externus and left internus), 
and (5) a pair of left turners (right internus and left externus). The four 
elevators are divided into (a) a pair of right-hand elevators (right superior 
rectus and left inferior oblique) and (6) a pair of left-hand elevators (right 
inferior oblique and a left superior rectus). The four depressors are 
divided into (a) a pair of right-hand depressors (right inferior rectus and 
left superior oblique) and (6) a pair of left-hand depressors (right superior 
oblique and left inferior rectus). 
In order to assist in the diagnosis of the affected muscle the following 
table has been constructed by Dr. Duane which the author has found to 
be most satisfactory, and which Dr. Duane permits him to insert: 
TABLE OF DIPLOPIA IN OCULAR MUSCLE PARALYSIS, ACCORDING 
TO DUANE 
A. There is a lateral (i. e., a homonymous or crossed) diplopia which increases 
markedly as eyes are carried laterally (to right or left). A laterally acting 
muscle is paralyzed. 
(a) Diplopia increases in looking to the right (= paralysis of a right turner). 
Diplopia homonymous: Paralysis of right externus. 
Diplopia crossed: Paralysis of left internus. 
(6) Diplopia increases in looking to the left (= paralysis of a left turner). 
Diplopia crossed: Paralysis of right internus. 
Diplopia homonymous: Paralysis of left externus. 
B. There is a vertical diplopia which increases in looking up. An elevator is par- 
alyzed. 
(a) Vertical diplopia increases in looking up and to the right (= paralysis of a 
right-hand elevator). 
Diplopia left (i. e., image of right eye above): Paralysis of right superior 
rectus. 
Diplopia right (i. e., image of left eye above): Paralysis of left inferior oblique. PARALYSIS OF THE EXTERIOR OCULAR MUSCLES 
535 
(0 Vertical diplopia increases in looking up and to the left (= paralysis of a left- 
hand elevator). 
Diplopia left (i. e., image of right eye above): Paralysis of right inferior 
oblique. 
Diplopia right (i. e., image of left eye above): Paralysis of left superior 
rectus. 
C. There is a vertical diplopia which increases in looking down. A depressor is 
paralyzed. 
(a) Vertical diplopia increases in looking down and to the right (= paralysis of 
a right-hand depressor). 
Diplopia right (i. e., image of right eye below): Paralysis of right inferior 
rectus. 
Diplopia left (i. e., image of left eye below): Paralysis of left superior oblique. 
(6) Vertical diplopia increases in looking down and to the left (= paralysis of a 
left-hand depressor). 
Diplopia right (i. e., image of right eye below): Paralysis of right superior 
oblique. 
Diplopia left (i. e., image of left eye below): Paralysis of left inferior rectus. 
To illustrate the practical working of the table the following example is quoted: 
The patient with a red glass before the right eye is directed to observe a candle which 
is moved in all directions in his field of fixation. If the patient has single vision when 
he looks down, but has vertical diplopia when he looks up, paralysis of an elevator is 
inferred. The vertical diplopia increases greatly when he looks up and to the right, 
and diminishes to almost nothing when he looks up and to the left. The paralysis 
must affect, a right-hand elevator (right superior rectus or left inferior oblique). 
The red image is higher (left diplopia = right eye below). The paralysis must affect 
the right superior rectus. If it had been the left inferior oblique, the red image would 
have been the lower; and if it had been either the right inferior oblique or the left 
superior rectus, the vertical diplopia would have increased not when the patient 
looked up and to the right, but when he looked up and to the left. 
Causes.-The lesion which causes paralysis of an ocular muscle 
may have an intracranial, orbital, or peripheral situation. If intra- 
cranial, it. may be cerebral-that is, cortical, nuclear, or fascicular in 
situation, or else basal. 
Among the conditions residing in the orbit which produce paralysis 
of the exterior ocular muscles, the so-called orbital palsies are cellulitis, 
tenonitis, periostitis, tumors, metastatic carcinomatous nodules (Elsch- 
nig), hemorrhage, fracture, and affections of the sinuses. 
Syphilis causes about one-half of the cases of exterior ocular muscle 
palsies-according to Alexander, 59.4 per cent. The resulting paralysis 
may be due to an inflammation or gummatous change affecting the nerves 
at the base- of the brain or in the orbit, or it may be central in origin 
from disease of the nuclei of the nerves or of the brain in their imme- 
diate vi.cinity or from lesions in the third ventricle, the aqueduct of 
Sylvius, or the fourth ventricle. Syphilitic paralysis is generally one 
of the later manifestations, but it. has been noted as early as the sixth 
month after the primary infection, particularly in the form of ptosis. 
In rare instances paralysis of the- ocular muscles results from inherited 
syphilis (Graefe, Nettleship, Lawford). 
Other causes, some of which at times occasion central-that is, nu- 
clear-lesions, and at other times act. peripherally, are rheumatism, gout, 
diabetes, whooping-cough, influenza, herpes zoster, and certain toxic 536 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
agents-for example, lead, alcohol, tobacco, gelsemium, conium, chloral, 
carbonic acid, and fish- and meat-poisoning (ptomain-poisoning, toxal- 
bumins, botulism, and allantiasis). 
The external rectus is the muscle most frequently affected by rheu- 
matism and diabetes and often by influenza. So-called '.rheumatic 
palsies, as Mauthner has pointed out, may be followed years after by 
tabes of the cord, disseminated sclerosis, or paralytic dementia. Al- 
though diphtheria usually affects the ciliary muscle, it may attack one 
or more of the exterior muscles, generally the external rectus. The 
condition may be bilateral. Rarely complete ophthalmoplegia occurs. 
The ocular manifestations of fish- and meat-poisoning are usually 
paresis or paralysis of accommodation and paralytic ptosis. The ex- 
terior muscles may be affected. The lesions are probably usually 
nuclear. 
The diseases and lesions which attack the nerves at the base of the 
brain, and thus occasion the so-called basal palsies, are hemorrhage, 
meningitis, both simple and tubercular, particularly the latter, abscess, 
for example, in connection with middle-ear disease, aneurysm, diseases 
of the cavernous sinus, pituitary body disease, syphilis, and tumors. 
Spinal anesthesia may be followed by palsy of the exterior ocular muscles, 
the external rectus being most frequently involved. It probably de- 
pends upon a toxic reaction in the meninges. 
A number of paralyses of the exterior ocular muscles are seen .in 
connection with locomotor ataxia, paretic dementia, disseminated 
sclerosis, and bulbar paralysis. Tabetic paralysis is often transitory in 
its nature; it may be associated with the pupillary changes character- 
istic of this affection. Relapses are frequent. Sherrington has demon- 
strated that the third, fourth, and sixth nerves contain afferent fibers 
which are not derived from the fifth nerve, and concludes that tabetic 
ocular palsies are probably due to implication of these afferent fibers 
and not to the implication of the efferent fibers of the ocular nerves. 
Paralyses of the orbital muscles of cerebral origin may result from de- 
generative, hemorrhagic, or neoplastic lesions affecting the cortex of 
the brain, the corticopeduncular region, the nuclei of the nerves, or the' 
nuclear fibers. 
Injuries may cause ocular muscle palsy-for example, the muscle 
may be torn or the nerve-trunk divided, or there may be paralysis owing 
to periostitis of the orbit, fracture of the orbital walls or base of the skull. 
The palsy may develop secondarily from basal 'meningitis, abscess, or 
nuclear degeneration. 
Anomalies of the external muscles occur, depending upon their 
abnormal insertion. Entire absence of a muscle has been noted. Occa- 
sionally cases of orbital muscle palsy have been attributed to various 
so-called reflex disturbances. 
Recurrent Oculomotor Paralysis (Ophthalmoplegic Migraine- 
Charcot).-The symptoms of this comparatively rare affection are 
violent unilateral headache, nausea, vomiting, slight fever, and usually 
paralysis of the third nerve on the same side as the pain. The attacks RETRACTION MOVEMENT OF THE EYEBALL 
537 
come in periodic crises, and the disease may last from several days to 
long periods of time. Occasionally the paralysis remains permanent. 
The lesion is probably one involving the root of the third nerve. Recur- 
rent paralysis of the abducens has been observed. 
Congenital Paralysis (Congenital Deviation--Duane).-Congenital 
palsies of the exterior ocular muscles, usually stated to be uncommon, 
are comparatively frequent if slight deviations are taken into account. 
They have been particularly well studied by Duane.1 According to 
him, insufficiency of the superior rectus, with fixation with the paretic 
eye and secondary deviation (upshoot) of the other eye, is not infre- 
quent. A striking feature is that when the fixing eye moves outward, 
the other shoots spasmodically up and in (spasmodic action of the infe- 
rior oblique). Other groups described by Duane are palsy of the supe- 
rior rectus with fixation with the non-paretic eye; slight and marked 
insufficiency of the inferior rectus; insufficiency of the inferior and supe- 
rior oblique and combined insufficiencies of the vertical and lateral 
muscles. Congenital palsy of one or both externi has been described, 
and may be associated with retraction movements (see next paragraph). 
The symptoms of congenital palsy usually are: head-tilting, diplopia, 
vertigo, and asthenopia. The patients nearly always close the defective 
eye. 
Retraction Movement of the Eyeball, Associated with Con= 
genital Deficiency of Abduction.-Certain cases of congenital defi- 
ciency of movement of the eyeball are characterized by all or some of the 
following symptoms, which have been thus summarized by Duane: 
Usually complete, occasionally partial, absence of outward movement 
of the affected eye; partial defect of inward movement of the affected 
eye; retraction of the affected eye into the orbit when it is adducted; a 
sharp, oblique movement of the affected eye up and in or down and in 
when it is adducted; partial closure of the eyelids of the affected eye 
when it is adducted; and paresis or, at least, marked deficiency of con- 
vergence, the affected eye remaining fixed in the primary position, 
while the sound eye is converging. 
The affection is undoubtedly congenital. Females are more usually 
affected than males. The affection has been explained by assuming 
that the externus is replaced by an elastic or inelastic strand of connec- 
tive tissue, or that a faulty insertion of the interims causes it to act as a 
retractor. The oblique upward and downward movements of the eye 
observed in many of these cases during adduction is attributed by 
Duane to a spasmodic action of one of the obliques. Operative pro- 
cedures have been suggested for cosmetic purposes-namely, tenotomy 
of the retracted muscle and fixation of the globe in the opposite posi- 
tion (Wolff). 
It is often difficult to ascertain whether the paralysis is central or 
peripheral in its origin. The differential diagnosis 'must be made by 
examining into the completeness of the paralysis and the existence of 
complications or associated symptoms. Peripheral palsies are more apt 
1 Transactions of the American Ophthalmological Society, Vol. XII, Part iii, 1911. 538 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
to be isolated and complete; those of central origin are often associated 
with other symptoms indicative of intracranial mischief. 
Relative Frequency of Paralysis of the Orbital Muscles.-Paralysis 
of the abducens (external rectus) is met with most frequently, the next 
in order of frequency being unilateral paralysis of the oculomotor. 
After these come paralysis of the superior oblique, inferior rectus, 
superior rectus, internal rectus, and inferior oblique. However, statis- 
ticians differ exceedingly on these points-e. g., Duane ranks the supe- 
rior rectus next to the external rectus. 
The prognosis depends upon the cause of the palsy. Some cases 
of peripheral paralysis, especially those depending upon syphilis and 
rheumatism, are readily amenable to treatment; in others not only is 
the paralysis incurable, but the lesion which creates it may be a fatal 
one. Hence the importance of trying to ascertain the character and 
situation of the lesion which produces the palsy. 
Treatment.-In syphilis the usual remedies are applicable, and in 
many instances good results follow very large doses of iodid of potas- 
sium. Massive doses are often tolerated, and even if the paralysis has 
existed for a long time, cure may ultimately result. Salvarsan, in the 
author's experience, is of little or no service in luetic palsy of the exterior 
ocular muscles, that is, in cases of long standing. In rheumatism, in 
addition to iodid of potassium, salicylic acid is useful, especially in the 
earlier stages. It may be given not in combination with, but at the 
same time as, the iodid. The various causes which have been men- 
tioned furnish the indications for other treatment. Care should always 
be taken to examine the nasal accessory sinuses for sources of infection. 
The great annoyance which is produced by the double images may 
be remedied by covering the affected eye with a piece of ground glass, 
which is mounted in a spectacle-frame. If the patient is ametropic, his 
correcting lens for the opposite eye may be placed in the same frame. 
Sometimes prisms may be worn which fuse the double images. The 
rules for adjusting prisms are given on page 560. 
Mechanical treatment has been suggested by Michel, and was tried 
in this country by Bull. The conjunctiva is seized near the inser- 
tion of the affected muscle with forceps, and the eyeball is drawn for- 
cibly, as far as possible, beyond the ordinary limit of contraction, and 
then back again. The eye is first cocainized. The movements are made 
daily, and continued for a minute at a time. 
Electricity may be tried, the great difficulty being in passing the 
current through the muscle. Ordinarily, one pole-the cathode-is 
placed upon the closed lid, while the other is put upon the temple. 
Usually, a current of more than 3 milliamperes is unbearable. This is 
especially true if the pole is placed directly upon the sclera, the eye 
first having been cocainized. Very disagreeable flashes of light will 
usually take place if a current of more than 1 or 1| milliamperes is em- 
ployed. If faradism is tried, a very weak current should be selected. 
Finally, after all other means have failed, tenotomy has been resorted 
to, or else advancement of the paralyzed muscle. In many cases OPHTHALMOPLEGIA 
539 
advancement of the paralyzed muscle and tenotomy of the antagonist 
are necessary. The best results are obtained in the lateral muscles. 
In case an injured muscle-that is, one torn from its insertion-should 
be seen soon after the accident, it would be proper to find the ends of 
the divided muscle and stitch them together. 
Ophthalmoplegia.-Although the term "ophthalmoplegia" might 
with perfect propriety be used to describe all the ocular muscle palsies, 
it is generally reserved for that class of paralyses of the orbital muscles 
due to disease of the nuclei of the third, fourth, and sixth nerves. In 
certain clinical cases it is not possible to determine whether the lesion is 
nuclear or in the nerves. Ophthalmoplegia may be divided into acute 
ophthalmoplegia or acute nuclear palsy, and into chronic ophthalmoplegia or 
chronic nuclear palsy. When it so happens that the intra-ocular muscles 
alone are affected, the term interior ophthalmoplegia is sometimes em- 
ployed, and when the exterior muscles alone are affected, the term 
exterior ophthalmoplegia. When both sets of muscles are involved, the 
term total ophthalmoplegia is appropriate. 
Acute ophthalmoplegia is characterized by a rapid paralysis of all 
ocular muscles, often associated with fever and convulsions. Many 
of the cases have proved to be fatal. They occur with hemorrhage in 
the region of the nuclei, or as an acute hemorrhagic polio-encephalitis, 
the primary cause being tuberculosis, syphilis, ptomain-toxemia, or 
poisoning from alcohol or sulphuric acid. Acute ophthalmoplegia may 
be associated with acute poliomyelitis, with bulbar palsy, or with facial 
palsy. According to Oppenheim, an acute ophthalmoplegia may be 
the result of a peripheral neuritis of nerves of the ocular muscles. 
Certain poisons-for example, nicotin, lead, and carbonic acid-may 
cause an ophthalmoplegia which is not fatal, or, at least, not neces- 
sarily fatal, and the same is true of one type which is seen with certain 
constitutional diseases-for instance, diabetes, syphilis, and influenza. 
Transient bilateral ophthalmoplegia has been described, the symptoms 
developing rapidly and disappearing- completely after one or two 
months. 
Chronic ophthalmoplegia is characterized by loss of power in one or 
more eye muscles, which may gradually increase until every muscle is 
paralyzed. Sometimes the levator escapes; indeed, ptosis may be absent. 
The disease may be stationary or progressive. It is not always symmetric; 
it may be unilateral. Chronic ophthalmoplegia may follow an acute 
palsy, the lesions of which have started chronic degenerative changes; 
it may appear as a congenital and occasionally hereditary affection, 
usually in the form of bilateral ptosis. Thus, A. A. Bradburne observed 
ptosis, with almost complete loss of ocular movement, in a family where 
this affection had been present in five generations. Sometimes epi- 
canthus complicates the ptosis. Ophthalmoplegia is seen in association 
with locomotor ataxia, paretic dementia, progressive muscular atrophy, 
chronic bulbar paralysis, and disseminated sclerosis. The underlying 
constitutional condition may be syphilis and sometimes tuberculosis. 
The disease is essentially chronic, and may last for years. It is more 540 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
common in males than in females, and is more serious in children than 
in adults. 
It is usually stated that if the intra-ocular muscles escape, which is 
not always the case, there is presumptive evidence that the origin of the 
trouble is nuclear, but, as Mauthner has pointed out, it is not a char- 
acteristic sign, and a partial palsy may be peripheral. Siemerling con- 
cludes that nuclear disease may be inferred from exterior ophthalmo- 
plegia, if it is not maintained that nuclear palsy must manifest itself as 
an exterior ophthalmoplegia. In general terms the lesions are degenera- 
tive, inflammatory, or hemorrhagic. According to Siemerling, the 
pathologic states underlying progressive paralysis of the ocular muscles 
may reside in nuclear disease, in degeneration of the muscles and of the 
nerve-trunks, the nuclei being intact, and in interruption of the con- 
ducting power of the intramedullary roots, muscles, nerve-trunks, and 
nuclei being uninvolved. 
Treatment.-In many instances this is wholly without result. 
If syphilis is present, the usual remedies are applicable, especially iodid 
of potassium in massive doses. 
Associated Ocular Paralyses.-Sometimes the eyes cannot make 
certain movements in which they are usually associated, although the 
directing power of the muscles may be unimpaired when they exercise 
their function in a different association. In other words, there is 
paralysis of movement and not of the muscles supplied by a given nerve. 
Thus the internal recti may be unable to draw the eyes together in the 
act of convergence, although they may act normally in helping to move 
the eyes from side to side; or there may be loss of the synchronous 
lateral movement of the external rectus of ono eye and the internal 
rectus of the other (conjugate lateral paralysis), although convergence 
is normal; or the upward or downward movements of the eye may be 
lost. Lesions affecting the centers, for combined movements may pro- 
duce such phenomena. According to Spiller, paralysis of lateral asso- 
ciated movement may be caused by a lesion of the posterior longitudinal 
bundle or of the sixth nucleus; symmetric disease of the nuclei of the 
affected nerve explains some cases in which the upward and the down- 
ward movement are lost. But probably the lesion is most frequently in 
or near the corpora quadrigemina. Holmes and Sargent have described 
disturbance of ocular movement with injury of the superior longitudinal 
sinus; in one group temporary palsy of associated conjugate movements 
occurred, attributed to implication of the posterior part of each frontal 
convolution. Typical spasmodic conjugate deviation may be caused 
by hysteria, and this neurosis may also originate palsy of associated 
parallel movements. 
In apoplexy, if the head is drawn from the paralyzed side and the 
eyes are also turned to the sound side, the condition is called conjugate 
deviation of the head and. eyes. The rule is, according to Prevost, that 
in lesions of the hemisphere the eyes are turned toward the lesion and 
away from the paralyzed side, but in lesions of the mesencephalon they 
are turned away from the lesion and toward the paralyzed side. Should PARALYSIS OF THE INTERIOR OCULAR MUSCLES 
541 
there be unilateral convulsions, with the eye tunned toward the con- 
vulsed side, there is an irritative lesion in the hemisphere, but if the head 
and eyes are. turned away from the convulsed side, there is an irritative 
lesion in the mesencephalon (Landouzy). 
Divergence Paralysis.-This condition manifests itself by homon- 
ymous diplopia and convergent strabismus when the eyes are fixed upon 
a distant point. As the test-object approaches the patient, and espe- 
cially on lateral fixation, there is diminution of the convergent strabis- 
mus and the diplopia, and finally a point may be reached where there are 
single vision and orthophoria, •while within this limit there may be 
exophoria. Cases of this character have been, described as secondary 
to an abducens paralysis, and also ascribed to spasm of convergence and 
to paralysis of a supposed divergence center. Berry believes the cor- 
rect diagnosis of this condition to be spasm of convergence and not 
paresis of divergence. Duane, however, maintains -that the only satis- 
factory explanation of the phenomenon is that it is due to a paralysis 
of divergence. It occurs at all ages, and more often in conjunction with 
hyperopia than myopia. He suggests that a lesion near the two abdu- 
cens nuclei would cause this condition. 
Convergence Paralysis.-This, as an extreme variety of conver- 
gence insufficiency, has been referred to (see page 555). The symptoms 
are: crossed diplopia, divergent strabismus, which increases as the 
test-object is made to approach the eye, no increase of diplopia either 
to the right or left, and normal rotation of each eye outward and in- 
ward. It has been observed in various central nervous disorders, and 
notably in locomotor ataxia and disseminated sclerosis. 
Paralysis of the Interior Ocular Muscles.-Under the general 
term cycloplegia are included the cases of paralysis of the ciliary muscle. 
These may or may not be accompanied with dilatation of the pupil. 
If the ciliary muscle is paralyzed, the chief symptom is loss of 
accommodation, precisely as it. occurs after the instillation of a myd- 
riatic. The loss of accommodation may be complete or it may be 
partial; that is, one or more diopters of the entire amount which is 
normal at. the patient's time of life may still remain. After the fiftieth 
year it is difficult to detect cycloplegia. 
It occurs- from a lesion in the trunk of the oculomotor nerve or in 
the anterior part of its nucleus (consult also oculomotor palsy and 
ophthalmoplegia). Unilateral cycloplegia is- said to be possible under the 
influence of disease of the ciliary ganglion. Paralysis of accommodation 
may be caused by affections of the nervous system, infectious diseases, 
and by intoxications. A very common cause of double paralysis of the 
ciliary muscle is diphtheria. Cycloplegia is also occasioned by spinal 
disease, by diabetes, by disease of the accessory sinuses, by disorders 
of metabolism, by traumatism (usually these are. associated with myd- 
riasis), by prolonged eye-work; by mumps, by tonsillitis, and fre- 
quently by acquired syphilis, and is often associated with paralysis of 
the sphincter of the iris. Inherited syphilis is a rare cause of paralysis 
of accommodation. Paresis of the ciliary muscle is common after cer- 542 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
tain fevers-for example, typhoid fever. Various ptomains, toxins, 
fish, and meat poisonings may cause both paresis and paralysis of the 
ciliary muscle. Congenital interior ophthalmoplegia is a rare anomaly 
(Duane). Toxic and traumatic cycloplegias are usually peripheral; 
syphilitic and parasyphilitic varieties may be peripheral, basal, and 
nuclear in origin. 
Under the general term iridoplegia are included the conditions which 
occur when there is loss either of the direct or of the associated action 
of the iris, due to paralysis of its sphincter. The chief symptom is con- 
nected with changes in the action of the pupil. The condition may or 
may not be accompanied with paralysis of the ciliary muscle. The 
various pupillary changes have been discussed in Chapter II, page 55. 
Consult also page 539. 
Concomitant Strabismus or Squint: Heterotropia.-This form 
of strabismus is characterized by the power of the squinting eye to follow 
the movements of the other eye in all directions, the angle of squint 
always maintaining the same size. 
Varieties of Concomitant Strabismus.-The chief deviations of 
squinting eyes, as already given, are: convergent strabismus, or esotropia; 
divergent strabismus, or exotropia; and vertical strabismus, or hypertropia. 
Concomitant squint may be periodic or constant. The latter variety is 
divided into monocidar squint, that is, in ordinary circumstances the 
same eye always deviates when the other eye is used for fixation, and 
alternating squint, that is, either eye is used indifferently for fixation. 
Lateral squint is usually associated with upward deviation. It is prob- 
able that at first squint is generally periodic, but with repeated recur- 
rences, as Priestley Smith expresses it, the suppression of the deviating 
image becomes confirmed, and the squint becomes continuous. The 
average age for squint to begin is three and four-tenth years, although 
it is often noticeable during the first year of life. Squints occurring 
after five years are apt to be alternating, in which case excellent vision 
exists in each eye. According to Duane, a slight vertical congenital 
deviation may be the starting-point of a progressive lateral deviation, 
which is unnoted until the child is five or six years of age. 
Causes of Concomitant Strabismus.-The etiology of strabismus 
has occasioned much discussion, and even at this time is not a settled 
question. In general terms, the factors which have been considered im- 
portant in the causation of squints may be summarized as follows: 
1. Disturbance of the relation between accommodation and con- 
vergence by errors of refraction. 
2. Inequality in the vision of the two eyes, or amblyopia of one eye, 
which removes the natural stimulus of diplopia to exact convergence. 
3. Disturbances of innervation and defective development of the 
fusion faculty. 
These causes of squint are somewhat elaborated in the succeeding 
paragraphs. 
1. Disturbances in the Relations of the Functions of Accommodation 
and Convergence.-The relation between these two functions has been CONCOMITANT STRABISMUS OR SQUINT: HETEROTROPIA 
543 
previously described (see page 43). Some latitude of movement is 
possessed by each function separately; but a limit to the independent 
exercise of either function exists, beyond which neither function can 
operate alone. Thus, a hyperopia of 6 D would require an accommo- 
dation of 6 D to neutralize it, the visual lines being parallel. This is 
rarely possible; some meter-angles of convergence will usually accom- 
pany the accommodative effort. The point of convergence is then 
nearer than the point accommodated for, constituting a convergent 
squint. Hyperopia is, therefore, frequently accompanied by conver- 
gent squint. 
In contrast to this, a myope of 10 D requires 10 meter-angles of 
convergence to see at his far point of vision, that is, the point at which 
he can see with relaxed accommodation. This is not usually possible, 
because the enormous convergence necessary to see at this point is too 
severe a strain; consequently, the visual lines intersect at a greater 
distance than the point for which they are accommodated, and bin- 
ocular vision is abandoned. The eyes, left to the preponderating 
forces, assume the direction seen during sleep and deep anesthesia- 
viz., divergence. Myopia is, therefore, frequently accompanied by 
divergent squint. 
Sometimes individuals possess or acquire unusual power in develop- 
ing one or other of these two functions. Thus, the hyperope may de- 
velop his accommodation sufficiently to equalize the disparity in the 
refraction and thus avoid squinting. The myope may also develop his 
convergence beyond the usual amount so as to prevent divergence. 
Hence all hyperopes do not have convergent squint; neither do all 
myopes have divergent squint. 
2. Inequality in the Vision of the Two Eyes, or Amblyopia of One Eye, 
Which Removes the Natural Stimulus of Diplopia to Exact Convergence.- 
Amblyopia of the squinting eye is present in a large proportion of the 
cases of concomitant convergent strabismus, or, more accurately, the 
amblyopia of the squinting eye exceeds that of the other. Whether this 
amblyopia is a cause or a consequence of the squint has given rise to 
two theories. According to one theory, advocated by Donders and 
others, the squint causes the amblyopia which depends upon a loss of 
vision due to habitual suppression or to lack of use of the squinting 
eye-amblyopia exanopsia-or, according to Hirschberg's terminology, 
amblyopia exablepsia. According to the other theory, advanced by 
Schweigger, the amblyopia is a congenital defect which precedes and 
causes the squint. Priestley Smith points out that all eyes are ambly- 
opic at birth, and reach the normal standard of vision only after several 
years. If strabismus is established before this standard is attained, 
further visual progress of the squinting eye is likely to be hindered or 
even arrested. 
Ophthalmoscopically these amblyopic or so-called "neglected eyes" 
may be entirely normal, or there may be at times distinct changes in 
and around the nerve-head and in the macula. Central scotomas and 
contraction of the visual field are sometimes demonstrable, as the author 544 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
has shown, and in such circumstances these eyes are not susceptible 
of improvement in vision (see also page 496). 
An amblyopia which removes the stimulus of diplopia to exact con- 
vergence may also include cases in which the visual acuteness is di- 
minished by refractive differences in the two eyes, one eye being greatly 
inferior to its fellow by reason of a high degree of hyperopia or myopia, 
with or without astigmatism, by opacities in the media of one eye 
(especially corneal opacities), by congenital cataract, and by complete 
blindness. The failure to recognize diplopia causes the visual axes to 
vary considerably either toward convergence or divergence, without 
appreciation of this on the part of the patient. If the eyes are hy- 
peropic, they are apt to converge; if myopic, to diverge. Numerous 
cases of squint exist without amblyopia, and the refraction of both eyes 
may be equal. 
3. Disturbances of Innervation and Defective Development of'the 
Fusion Faculty.-According to Hansen Grut, "convergent strabismus 
originates and continues as the result of an innervation which effects 
in the interni a shortening exceeding in amount that which is desirable. 
Divergent strabismus is the expression for a relaxation of convergence 
innervation, which permits the eye to take up its anatomic position of 
rest." According to Priestley Smith, "convergent strabismus is a dis- 
order of innervation in which the visual centers fail to control the act 
of convergence, which is degraded and becomes automatic. It is excited 
by the act of accommodation and is excessive because uncontrolled. 
The failure of control depends largely upon faulty development of the 
visual apparatus. Hyperopia, when of considerable degree, predis- 
poses to strabismus by demanding an abnormal effort of control. The 
disorder is confirmed and perpetuated by suppression of the function 
of the squinting eye." 
According to Claud Worth, "when the fusion faculty is fairly well 
developed, neither hyperopia, anisometropia, nor heterophoria can cause 
squint. In fact, then, nothing but an actual muscular paralysis can cause 
an eye to deviate, in which case the resulting diplopia is intolerable. 
Sometimes, however, owing to a congenital defect the fusion faculty 
develops later than it should, or it develops very imperfectly, or it may 
never develop at all. Then, in this case, there is nothing but the motor 
coordinations to preserve the normal relative directions of the eyes, 
and anything which disturbs the balance of these coordinations will 
cause a permanent squint. Thus, the essential cause of squint is a de- 
fect of the fusion faculty." The provocation in the presence of this 
fundamental cause to squint may be supplied, he believes, by various 
conditions-for example, hyperopia, anisometropia, heterophoria, am- 
blyopia of one eye, certain eruptive fevers and infections (whooping- 
cough, especially if hyperopia in any degree is present), violent mental 
disturbance, and hereditary influence. The influence of heredity in 
squint is an important matter, and Mr. Worth believes, and this cer- 
tainly is in accord with the author's experience, that a history of heredity 
can be obtained in fully 50 per cent, of the cases. Therefore it is CONCOMITANT STRABISMUS OR SQUINT: HETEROTROPIA 
545 
important carefully to investigate early in life the eyes of children whose 
parents or grandparents have squinted. Recently Zentmayer has 
convincingly defended Bonders' theory of the causation of strabismus 
(see paragraph 1, page 542). 
A predisposition to strabismus may arise on account of the size and 
shape of the eyeball and orbit. A narrow, horizontal diameter of the 
face might predispose to convergent strabismus, or an unusually broad 
diameter to divergent strabismus. These conditions may coexist with 
hyperopia and myopia. A very short eyeball, flattened in its antero- 
posterior direction, by its greater facility of movement would render 
convergence easier; the opposite condition-namely, elongation of the 
anteroposterior axis of the eyeball-would render this movement more 
difficult. An unusual value of the angle gamma might create a disposi- 
tion to squint by disturbing the relation between convergence and ac- 
commodation. At one time disparity in the length, thickness, and 
tension of opposing muscles was regarded as an important factor in the 
development of squint. 
Single Vision in Concomitant Strabismus.-Diplopia is rarely 
noticed in concomitant convergent strabismus, because the deviating 
eye involuntarily suppresses the image, or else has learned to dis- 
regard it. 
Suppression of the image is not, however, habitually permanent, or 
suppression does not extend over the whole visual field, and many 
patients can be made conscious of diplopia if a red glass or cobalt glass 
is placed before one eye and a prism before the other. When the squint 
is very large it may be necessary to correct the greater part of it with 
prisms before diplopia is manifest. If prisms and the red glass fail, 
Schweigger's test is as follows: A flame is placed to one side of and 
behind the squinting eye, and its image is thrown into this eye with a 
plane glass held close to it. When the reflex reaches the center of the 
pupil the patient sees it and can describe its relation to the image of 
another flame observed by the fixing eye at a distant point. With high 
degrees of amblyopia it may be impossible to produce diplopia. 
In. concomitant divergent squint, especially of low degree, and in the 
convergent strabismus of myopes, diplopia is not uncommon; also in 
moderate degrees of convergent strabismus and in the residual squint 
after tenotomy. Referring to the nature of diplopia in concomitant 
strabismus Claud Worth thus expresses himself: The subject of squint 
with diplopia sees with his deviating eye a faint eccentrically placed 
image of the object to which the fixing eye is directed, and suppresses 
the image of the object which lies in the axis of the deviating eye-i. e., 
he sees two images of the same object, but not two different objects. 
Sometimes after operation, as was first noticed by Von Graefe, the 
diplopia is anomalous or paradoxic, as it is called-that is, there is 
crossed diplopia with convergent squint. Javal observed and studied 
the same phenomenon in strabismic patients upon whom no operation 
had been performed. It has been explained on the theory that there 
has been developed in the squinting eye a spot identical with the macula 546 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
lutea of the straight eye, or that there has been developed what has been 
named a vicarious fovea. According to Tscherning, in certain cases of 
strabismus a period may be reached after operation when the patient 
localizes with reference both to the new and the old fovea, the result 
being binocular triplopia, a name given by Javal to the phenomenon. 
Verhoeff thinks paradoxic diplopia "is due not to the development of a 
new system of corresponding points, but to an absence of any such sys- 
tem whatever, so that when diplopia is produced, each eye localizes its 
image with regard to itself alone and hence more or less correctly." 
Measurement of Strabismus.-1. Squint maybe measured approx- 
mately by the deviation inward of the pupil of one eye while the other 
eye fixes an object. The pupil being situated 10.5 mm. in advance of 
the center of rotation, its deviation inward or outward, measured on a 
rule, represents the tangent of the angle of the squint. A deviation of 
1 mm. represents a squint of 5°. For this purpose an ordinary rule 
divided into millimeters may be employed, or a specially devised in- 
strument curved to adapt itself to the curve of the eyeball and known as 
a strabisometer. 
If diplopia is present, as Landolt has shown, it permits an accurate 
determination of the angle of strabismus. The procedure may be as 
follows: 
Upon a wall of the consulting room, in a horizontal line, and so as to be on a 
level with the eyes of the patient, who is about 3 meters from the wall, are perma- 
nently marked out tangents of angles of 5° each, as seen from the place where the 
squinting eye is. Exactly opposite to the squinting eye is 0°, while toward the right 
and left the points are marked up to 45° or more. The flame of a candle being held 
at 0°, and one eye of the patient being covered with a red glass, he is called on to 
indicate the position of the image belonging to the squinting eye, and the number 
on the wall which corresponds to this gives the angle of the strabismus. 
In these circumstances the degree of prism necessary to fuse the 
double images may be used to measure the squint. 
2. Angular Method.-The perimeter may be employed to measure 
squint with reasonable accuracy, although Worth condemns the method 
because it takes no account of the angle gamma. Landolt thus de- 
scribes the method: 
The deviating eye, R, is placed at the center of the graduated arc of the perimeter, 
P-P, the arc lying on the plane of the deviation. The patient is then required to fix 
with his two eyes a distant object, A, situated at the central radius, R-o-A. This is 
the direction which the deviating eye should have in the normal condition. The 
point n, to which the eye in reality is directed, should now be determined; the angle 
o-R-n, formed by the deviating visual line n, with the normal line of fixation A-o-R, 
is the angle of the strabismus. In order to obtain this direction (i. e., the point n at 
which the eye is directed) it would be necessary only to determine the visual axis. 
As this is not an easy matter, it is sufficient in practice to be contented with the 
optical axis; this differs from the former only by the angle gamma, which, in com- 
parison with the large angle of the strabismus, may be neglected. The flame of a 
candle is moved along the arc of the perimeter until its reflexion is in the center of 
the pupil. This will occur when the flame is at n. The optical axis has now been 
found, and the size of the angle of strabismus may be read off. CONCOMITANT STRABISMUS OR SQUINT: HETEROTROPIA 
547 
Priestley Smith's Tape Method.-This is a very good method, although it is 
not very readily applied to young children. Worth describes it as follows: "A string 
1 meter long has a ring at one end. To the ring is attached a graduated tape. The 
tape has a weight at its other end. The patient holds the free §nd of the string against 
his temple. The surgeon puts the ring on a finger of one of his hands, in which he 
holds an ophthalmoscope mirror. The tape is allowed to slide between the fingers 
of the other hand, the weight keeping the tape taut. The patient is first told to fix 
the mirror, while the light of a lamp is reflected into the fixing eye. The position of 
the image of the mirror on the cornea of the fixing eye is noted. The light from the 
mirror is now thrown on to the deviating eye, and the patient is directed to look at 
the surgeon's tape hand. This is moved horizontally till the position of the image 
of the mirror on the cornea of the squinting eye is similar to that which it formerly 
occupied on the cornea of the fixing eye. The string keeps the ophthalmoscope hand 
at 1 meter from the patient's eye. The observer keeps the tape hand as nearly as 
possible at the same distance from the patient's eye. The graduated scale on the 
tape, where it slides through the tape hand, shows approximately the angle of the 
deviation in degrees." 
Fig. 239.-Measurement of squint with a perimeter. 
Various forms of "deviometers" have been devised for measuring 
strabismus, especially by Nelson Black and by C. Worth. 
Treatment of Concomitant Strabismus.-A. Convergent Concomitant 
Strabismus. 
1. Spectacle Treatment.-Glasses which neutralize the refractive 
error should be ordered for every patient with convergent concomitant 
squint after the use of atropin has thoroughly paralyzed the function of 
the ciliary muscle. In the majority of cases the refraction is hyperopic 
and is often associated with considerable degrees of astigmatism. There 
is no difficulty in estimating exactly the proper lenses by means of 
retinoscopy, and if they are persistently worn early enough-before the 
fifth year-and, in addition, fusion-training is carried on, the strabismus 548 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
will be cured in a very considerable percentage (variously estimated from 
30 to 70 per cent.) of the cases. It is important that this non-operative 
treatment of squint should be begun as soon after the discovery of the 
condition as possible, and glasses may usually be adjusted when the 
child is three years old; sometimes even earlier. 
Prolonged atropinization of both eyes of very young children with 
squint, in order to remove the abnormal stimulus to convergence which 
results from overaction of the ciliary muscle, was at one time a much 
recommended method of treatment. As Worth points out, while it 
may produce temporary improvement, or even disappearance of the 
strabismus, it tends to increase the amblyopia of the deviating eye, and 
is, therefore, a therapeutic measure to be condemned. He properly 
recommends atropinization of the fixing eye only, so that the child 
shall acquire the habit of using the better (atropinized) eye for distant 
vision, and the poorer (unatropinized) eye for close vision, and thus 
avoid amblyopia from disuse. Suitable glasses should be worn. If the 
visual acuteness rises sufficiently, so that the originally deviating eye 
becomes the squinting eye, the drug must be discontinued, and, if the 
original condition repeats itself, be ysed carefully and intermittingly; 
for example, for a few days during each month (Worth). Recently 
Reber recommended invisible bifocal lenses in the treatment of esotropia 
in little children, a sphere of 2 to 3 D being added to the correcting lenses, 
the idea being "to set the spastic accommodation apparatus at rest." 
A 0.5 per cent, solution of atropin is used once daily for two months; 
at the end of this time it is discontinued. A similar recommendation 
has been made by Linn Emerson. 
2. Educative Treatment.-This includes occlusion of the eye by means 
of a shade or pad, bar reading, orthoptic training, and development of the 
fusion-sense. 
(a) Occlusion of the Fixing Eye.-The sound eye should be covered 
with a shade or bandage, not so much with the hope of improving the 
acuteness of vision of the deviating eye, but, as Priestley Smith has 
said, to compel it to use such vision as it has to promote fixation, and to 
prevent or stop the habit of suppression. If the child wears spectacles, 
as it should, a blinder of gutta-percha may readily be adjusted on the 
lens in front of the fixing eye. If the vision of the squinting eye is very 
imperfect, it is permissible during this treatment to wear the patch on 
this eye instead of the sound one for a few hours each day; but both eyes 
should not be allowed to be uncovered at the same time. 
(b) Orthoptic Training .-This consists of the establishment of 
diplopia and training the eyes to fuse the double images, and is a method 
of treatment of squint which was especially advocated by Javal. It is 
particularly suited to moderate degrees of strabismus and to residual 
squint after operation. It requires considerable care and patience 
properly to carry out the details. In order to educate the fusion faculty 
the stereoscope should be employed. The patient's ametropia having 
been fully corrected, the exercises may be performed according to the 
method given by Landolt, as follows: CONCOMITANT STRABISMUS OR SQUINT: HETEROTROPIA 
549 
In an ordinary box-stereoscope, in the place of "views," two objects of some 
very simple shape are introduced-for instance, two vertical lines, one above and 
the other below the same horizontal line. These two lines, which may be brought 
toward or removed farther from each other at will, are placed at a distance about 
equal to that between the two eyes. In such circumstances their fusion into a 
single vertical line necessitates parallelism of the lines of fixation. This parallelism 
is generally possible only in the absence of any accommodative effect. Hence the 
sight-holes of the stereoscope are provided with + 6 D lenses (the length of the 
ordinary stereoscope being 16 cm.), which permit the subject to see at the distance 
of the objects without exercise of the accommodation. 
The majority of patients do not succeed in fusing the images when their eyes 
are directed in a parallel direction. These latter generally show a certain conver- 
gence. The patient is then taught to find the distance between the two objects 
which is requisite for the fusion of their images. When this is accomplished, the two 
objects are gradually separated more and more in successive sittings until fusion is 
effected without the least convergence. 
When binocular vision is obtained, with parallelism of the lines of fixation, which 
is equivalent to binocular vision at a distance, an attempt should be made to realize 
it for a point which requires a certain degree of convergence. To provoke a con- 
vergence of 1 meter-angle, the objects are brought together through a distance vary- 
ing with the base line, the average being about 1 cm. In order to make the patient 
furnish an amount of accommodation equivalent to this amount of convergence, the 
strength of the convex lens is diminished 1 diopter. The trials are continued in this 
way until the two objects are brought on a vertical line. At this moment they 
require, for their binocular fixation, a convergence of 6 meter-angles and an accom- 
modation of 6 D. An emmetrope would, therefore, have to remove the glasses from 
the stereoscope and see with the naked eye; an ametrope would require simply the 
correction of his refractive defect. 
The illumination of the object looked at by the deviating eye may 
be increased in order to reinforce its visual impressions, as in Landolt's 
new stereoscope. 
If the angle of squint is very great, both eyes cannot look at the same 
time into an ordinary stereoscope, and therefore a number of excellent 
instruments have been devised which can be adapted to the angle of 
squint. Kroll's orthoptic exercises, arranged by Perlia, which consist 
of colored plates placed in a suitable stereoscope, are useful. In many 
respects with the instrument devised by Claud Worth, to which he has 
given the name amblyoscope, the most satisfactory results are achieved, 
and, as this accomplished surgeon's method is now so much employed, 
the following directions have been written at the author's request by 
a member of his staff, Dr. H. Maxwell Langdon, who has devoted much 
attention to these exercises: 
The amblyoscope consists of two tubes, one for either eye, each having its own 
illumination, which can be increased or lessened so as to equalize the visual impres- 
sions in case one eye is amblyopic. An object-slide is placed in the objective end of 
each tube, and is reflected in a mirror at the bend of the tubes, which is placed at 
the focal distance of convex lenses fitted in the proximal ends of the tubes, so that 
no accommodation is necessary. The proximal ends of the tubes are hinged in such 
a manner that they may be adapted to a convergent strabismus of 60° or a divergent 
strabismus of 30°. 
The child's vision should be tested, if types or other signs cannot be utilized, 
with small white ivory balls, each with a diameter varying from | to lj inch. 
Each eye is tried separately, and the child is required to pick up the ball, which is 550 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
rolled with a twisting movement. If this test reveals that one eye is amblyopic and 
possesses one-sixth or less of visual acuteness, some form of blinder exercise should be 
instituted to improve the defective visual acuteness (see page 548). Preceding the 
exercises with the amblyoscope, the angle of strabismus should be measured accord- 
ing to the methods elsewhere described, the refractive error having been carefully 
and fully corrected, and the glasses being in position, and during all of these exer- 
cises the glasses must be worn. Amblyoscope training should be begun as soon as 
the child is old enough to look at ordinary pictures and to talk about them, because 
deviation yields far more readily to these exercises in young children than in older 
ones, and, moreover, after the sixth year it is usually practically impossible to make 
any satisfactory impression upon the defective fusion faculty. A child of three 
years is well able to take part in these exercises, especially if they are so conducted 
that they represent to him a game in which he may readily be interested. Usually 
one or two sittings a week, each occupying half an hour, are sufficient. The child 
should be seated on a chair between the surgeon's knees, and the angle of the tubes 
approximated to the angle of strabismus. Next, the illumination, which may con- 
sist of two electric-light bulbs, two lamps, or two candles, equally distant from each 
Fig. 240.-The Worth-Black amblyoscope. 
tube, are arranged, and an object-slide is placed in each holder. These object-'Iides 
should consist of pictures familiar to young children, but the ones used at first should 
be quite dissimilar; for example, the picture of a bird and the picture of a cage. 
The child is now required to look into the tubes, and is asked what he sees. If one 
eye is amblyopic to any considerable degree, it is probable that the image of the 
object before the better or fixing eye will be the only one which is visible. Hence, 
the illumination mast be altered before the other object-slide can be seen by dimin- 
ishing the light before the fixing or better eye, and increasing that before the am- 
blyopic or squinting eye, continuing with this regulation of lights until both objects 
are visible and can be described by the child. This alteration in the lights can be 
accomplished in various ways; for example, by changing the distance of the lights, 
as Mr. Worth suggests, or by adapting to the amblyoscope, as the writer has done, 
a revolving wheel, which contains smoked lenses of different densifies, and which 
can be turned before the non-amblyopic eye. Each object should be seen clearly, 
and the exercise should be varied with several pairs of object-slides. Next, the child 
is required to place one hand on each of the surgeon's knees and to tap that knee on 
the side on which the picture of the bird is seen. If the angle of the tubes is rapidly 
altered a position will be found where the slightest movement of the tubes causes the CONCOMITANT STRABISMUS OR SQUINT: HETEROTROPIA 
551 
picture of the bird to pass directly through from one side of the picture of the cage to 
the other. But, after continuing the exercises, the bird apparently will go directly 
into the cage, indicating that the child is acquiring a certain amount of fusing power. 
If one object is above the other, this vertical deviation must be overcome by means 
of prisms suitably placed in the grooved slides back of the focusing lenses. Dr. 
Nelson M. Black has added a vertical adjustment to the Worth amblyoscope,1 
which simplifies the correction of this deviation (Fig. 240). As soon as the child 
can easily merge the two objects, more difficult tasks are set, with slides demanding 
accurate and complete fusion, and by gradually widening the angle of the tube, a 
range of fusion which varies from 5° to 15° may be acquired by the patient. 
Finally, a series of stereoscopic pictures, intended to teach the child the sense of 
perspective, are employed. During these exercises, by which the fusion faculty is 
stimulated and developed, the strabismus may do one of three things: it may disap- 
pear after a few days of training; it may gradually lessen; or it may not alter at all, 
and operative procedures are required to produce parallelism of the visual axes. 
These methods to overcome the defective development of the 
fusion faculty should be faithfully tried in spite of the trouble which 
their use entails. Certainly the re-establishment of binocular vision 
in these circumstances is worth every effort. 
(c) Bar Reading (Controlled Reading of Javal).-A pencil or, as 
Priestley Smith suggests, a thin strip of metal is held midway between 
the eyes and the book which they regard. Reading can then take place 
without interruption only if both eyes are employed. Priestley Smith 
describes the exercises as follows: "When the patient's fixing eye reaches 
that portion of the line which is hidden from it by the bar, he must use 
his other eye. Then the fixing eye is covered for a moment with a screen. 
Next, the patient is taught to occlude it for himself by a momentary 
closure of the lids. Soon he will be able to travel along the line with only 
a slight hitch where he closes the better eye, and at last he will read 
smooth1 y, keeping both eyes open." The method is chiefly effective 
when practised in conjunction with the use of the shade-that is, the 
shade covers the fixing eye and it is uncovered only for the purpose of 
bar reading; and this should be practised as much as possible. Indeed, 
according to Javal, the exercises must be continued for months, but there 
seems no doubt that they are efficient aids in the recovery of binocular 
vision. It need hardly be stated that the exercises are not suited to 
very young children. They are valuable in the residual squints after 
operation. 
3. Operative treatment consists of tenotomy of one or both internal 
recti, with or without advancement of the externi, or of bilateral ad- 
vancement of the externi without tenotomy of the interni (see page 671). 
If possible, operation should not be undertaken until the fusion faculty 
has been developed by the exercises already described, and in no cir- 
1 The author uses, with much satisfaction,! Dr. A. Maitland Ramsay's (The Ophthal- 
moscope, January, 1905) modification of Worth's amblyoscope, in which totally reflecting 
prisms are employed instead of mirrors. Back of each picture is placed a small electric 
lamp, the relative brightness of which can be varied to any desired extent by shifting a key, 
which increases the resistance for one of the lamps while it diminishes it for the other. 
The author has slightly modified this instrument by adding to it an arrangement by which 
prisms to correct vertical deviations may be inserted, and scales which indicate the exact 
separation of the tubes to suit the interpupillary distance and the degree to which the tubes 
must be converged or diverged, according to the character and angle of the squint. 552 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
cumstances until the refractive error has been fully corrected and glasses 
have been worn for at least six months. If, in spite of such treatment, 
the deviation remains constant, operation is necessary, and may be 
performed if the child has passed the sixth or seventh year. If the 
exercises have failed to develop the power of binocular fusion, or if these 
exercises have begun at a time too late to expect this result, it would 
seem wise, under most conditions, as E. Jackson insists, to wait until 
the patient has reached an age when the operation can be performed 
under local anesthesia and intelligent co-operation secured; to wait, in 
short, until after the period of rapid growth and development. Worth, 
on the other hand, has no objection to general anesthesia. 
There is much difference of opinion in regard to the operations which 
should be practised for the relief of convergent strabismus, and each 
case must be carefully studied before a correct decision can be reached. 
The practice, at one time almost universal, of endeavoring to correct 
convergent strabismus by means of tenotomy of one or both interni, 
according to the amount of the deviation, has been largely and very 
properly abandoned in favor of advancement of the externi. 
While it is true that in small squints (15° to 20°) tenotomy of the 
internus of the deviating eye, if this is not seriously amblyopic, will 
often yield, temporarily at least, a satisfactory cosmetic result and 
that in alterating squint, with good vision of each eye, even a double 
carefully performed tenotomy has been recommended, in most cir- 
cumstances a tenotomy should be avoided. As Landolt has well 
said, the "dosage" of tenotomy is uncertain, and from the dynamic 
standpoint its effects are unfavorable. The outward rotation tends to 
increase, the palpebral fissure is widened, the eye often is slightly 
prominent, and inward rotation is permanently weakened. Free divi- 
sion of the tendinous insertion of the interni and the surrounding capsular 
attachments is never permissible, and almost sure in subsequent years to 
lead to divergence; indeed, this may be the result of bilateral tenotomies 
of the interni, even if they are carefully performed. Admirable results 
follow bilateral advancement of the interni close to the cornea (tenotomy 
is not performed), and in pronounced squint this may be combined with 
resection of more or less of the muscle. In this respect the author can 
confirm the value of Landolt's advice and method, and is in full accord 
with Claud Worth's condemnation, under most conditions, of tenotomy. 
In slight degrees of squint simple advancement will usually suffice. 
After operation either both eyes should be bandaged until the sutures 
are removed, or both eyes should be unbandaged and the patient from 
the first directed to wear his correcting glasses.1 (For the methods of 
performing tenotomy and advancement, see page 671.) 
B. Divergent Concomitant Strabismus.-The treatment of this form 
of concomitant squint includes the correction of the error of refraction 
with suitable glasses, training convergence, and operative measures. 
1 For an important paper on this subject, the reader is referred to "The Indications 
for Operating in Heterophoria and Squint," by Alexander Duane, Archives of Ophthal- 
mology, vol. xh, No. 4, p. 390, 1911. CONCOMITANT STRABISMUS OR SQUINT: HETEROTROPIA 
553 
(a) Glasses which neutralize the refractive error (most commonly 
myopia or myopic astigmatism) should be adjusted according to the 
rules which are given in the chapter devoted to the measurement of 
abnormal refraction. H. Landolt recommends concave glasses of such 
strength that they overcorrect the myopia. According to him the ex- 
cessive effort of accommodation stimulates convergence. Moderate 
degrees of divergent deviation may often be favorably influenced by 
prismatic exercises (see page 559). 
(6) Operative measures depend entirely upon the degree of the de- 
viation, the vision in the diverging eye, and the cause of the difficulty. 
When true divergent strabismus exists, it is usually necessary to perform 
an operation to correct it. This may be either tenotomy of one or both 
externi, or this operation may be combined with advancement of the 
internal rectus. Usually advancement of the interni, one or both, 
according to circumstances, is preferable to tenotomy of the externi; 
but the latter operation may be needed to secure parallelism of the 
visual axes. A coexisting vertical deviation should be remedied, and 
some operators (Hansell and Reber) prefer to make the vertical adjust- 
ment before attacking the lateral deviation. 
Vertical Strabismus.-Often there is an apparent vertical devia- 
tion associated with lateral strabismus, which disappears with the cor- 
rection of the latter defect. In cases of true vertical deviation requir- 
ing operation Worth recommends advancement of the inferior rectus 
muscle of the eye which turns upward. Landolt, although opposed to 
tenotomy of the lateral muscles, does not object to this operation on the 
superior rectus. All surgeons agree that tenotomy of the inferior rectus 
is not permissible. In certain circumstances an upward deviation is 
due to spasmodic action of the inferior oblique and must be corrected 
by tenotomy of this muscle (see page 672). 
Results of Operation in Convergent Strabismus.-The effect of 
the operation, if well performed, is to produce parallel visual axes, and 
thus remove the disfigurement. Properly speaking, a cure is obtained 
only when there is improvement in the vision of the squinting eye and 
binocular vision is secured. There has been much difference of opinion 
on this subject, and some authors-for example, Lang and Barrett- 
have questioned if valuable improvement in the vision of the amblyopic 
eye ever takes place. Noyes believed that binocular vision was secured 
in less than 20 per cent, of the cases, even after the most perfectly per- 
formed operations and after the patients' eyes had been carefully cor- 
rected with glasses and trained by orthoptic exercises. Careful training 
of the fusion faculty should begin early and the exercises already de- 
scribed should be systematically carried out. Indeed, as may have been 
inferred, the necessity for operation, if only the educative treatment 
of strabismus is begun soon enough, is sure to diminish, but should an 
operation become necessary, it is also sure to be followed by far better 
results than can be achieved in the absence of such training. 
It is often difficult to ascertain whether true binocular vision exists, 
especially in young children, and successful bar reading, usually quoted 554 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
as a sufficient test, is, according to Priestley Smith, not without its 
fallacies. This author tests as follows: 
A reversible frame carrying red and blue glasses is placed in front 
of the patient's spectacles, and he is shown, at. the reading distance, a 
card with three disks on a black ground, a white one-in the middle, a red 
one above, and a blue one below. If he can see. all three at once and in a 
line, he is probably using both eyes and fusing the two images of the 
white disk. If with each eye alone he sees two, but with both eyes three, 
the proof is fairly positive. The test may be improved by placing a black 
letter on each disk, which, if the patient has sufficient vision, he should 
read. The same test with larger objects may be used at longer ranges. 
The light should be good, but not too strong, and not artificial. Hering's 
drop-test may also be employed. A simple and ingenious diaphragm 
test for binocular vision has been devised by N. Bishop Harman.1 
Spastic Strabismus.-This condition, more properly characterized 
by the term convergence cramp, or spasm, is seen in hysteria, and is char- 
acterized by convergent squint, limitation of the motility of the external 
recti, and by homonymous diplopia. It somewhat resembles paralysis 
of the abducens, for which it may be mistaken, but from which it 
should be differentiated by a study of the double images. Sometimes 
this form of strabismus or, rather, convergence spasm is accompanied 
with other hysteric manifestations-blepharospasm and ptosis-and 
may be a symptom of meningitis. 
Abnormal Balance of the Ocular Muscles, or Heterophoria 
(Latent Deviation).-This is, as already defined, a disturbance of the 
normal balance of the exterior eye muscles, which creates a tendency for 
the visual lines to depart from parallelism, a tendency which is checked 
by the habitual desire for binocular vision, or that vision .in which the 
images of an object formed on the retinas of the two eyes make but a 
single mental impression. 
Heterophoria (imbalance, according to Gould) differs from squint 
or heterotropia because in the latter the fusion of the images is usually 
impossible-i. e., binocular single vision is absent-and there is an evi- 
dent departure of the visual lines from parallelism, which gives rise to 
the term which designates the condition. 
Causes.-Imbalance of the ocular muscles may be due to: (a) 
weakness of the muscles (properly called insufficiency) of congenital 
origin, or depending upon a general lack in muscular tone, the result of 
anemia, nervous exhaustion, pelvic disorders, etc., or malaria, rheuma- 
tism, gout, et.c., diseases which, however, may also be potent by affecting 
not the muscles themselves, but their innervation; (b) errors of refrac- 
tion and disturbance of accommodative efforts (accommodative hetero- 
phoria) ; (c) the anatomic arrangement of the parts-for example, faulty 
attachment of the muscle (concomitant heterophoria); (d) excessive action 
or spasm of opposing and dominating muscles (spasmodic heterophoria)-, 
(e) disturbances of innervation (central heterophoria); and (f) a paretic 
condition of the muscle (paretic heterophoria of Duane). 
1 For description, see Ophthalmic Review, vol. xxviii, 1909, p. 93. ABNORMAL BALANCE OF OCULAR MUSCLES, OR HETEROPHORIA 
555 
Varieties.-According to Stevens' nomenclature, if there is a tend- 
ing of the visual lines in. parallelism, the term orthophoria is applied; 
if there is a tending of these lines in some other direction, the term 
heterophoria. Heterophoria is divided into: esophoria, a tending of the 
visual lines, inward; exophoria, a tending of the visual lines outward; 
hyperphoria (right or left), a tending of the right or left visual line in a 
direction, above its fellow. Cyclophoria, according to Savage, is a want 
of equilibrium on the part of the oblique muscles (see also page 76). 
Abnormal inward tending of th,e visual lines may depend upon 
excessive convergence or deficient divergence, or upon these conditions 
combined. Duane1 describes the signs as follows: If esophoria for dis- 
tance is less than for near, abduction (prism-divergence) not dispro- 
portionately low, adduction (prism-convergence) readily performed, 
esophoria marked at the near point and the convergence near point 
excessive, convergence-excess is present. If esophoria for distance is 
much greater than for near, abduction (prism-divergence) dispropor- 
tionately low or absent, adduction (prism-convergence) normal or sub- 
normal, esophoria slight, absent, or replaced by exophoria at the near 
point, and the- convergence near point not abnormally close to the nose, 
divergence-insufficiency is present. 
Convergence-excess is followed, if of long standing, by divergence- 
insufficiency, and similarly divergence-insufficiency by convergence- 
excess. In the mixed form thus produced there are .marked esophoria 
for near and far, excessive approximation of the convergence near 
point, and limited, absent, or negative abduction (prism-divergence). 
Finally, the deviation ceases to be latent, binocular vision is lost, and 
esophoria passes, into esotropia. 
Abnormal outward tending of the visual lines may depend upon 
deficient convergence or excessive divergence, or upon these conditions 
combined. Duane records the symptoms as follows: If exophoria for 
distance is slight or absent, abduction, (prism-divergence) not very great 
or even subnormal, adduction (prism-convergence) exceedinglydifficult, 
exophoria marked at the near point, and the convergence near point 
less than 3 inches and maintained only for a moment, there is 
convergence-insufficiency. Sometimes this may be so great as to consti- 
tute a convergence-paralysis. If exophoria for distance is marked, ab- 
duction (prism-divergence) is high, adduction (prism-convergence) 
normal or not greatly subnormal, and the convergence near point 
normal, there is divergence-excess. 
Convergence-insufficiency is followed, if of long standing, by diver- 
gence-excess, and, similarly, divergence-excess by convergence-insuffi- 
ciency. In the mixed form thus produced there are marked exophoria 
for near and far, excessive abduction (prism-divergence), and marked 
retreat of the convergence near point. Finally, the deviation ceases to 
be latent, binocular vision is abandoned, and exophoria passes into 
exotropia. 
1 American Text-book of Diseases of the Eye, Ear, Nose, and Throat, edited by 
de Schweinitz and Randall, page 515. The descriptions which follow are condensed from 
Duane's article. 556 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
If hyperphoria, again to quote Duane, varies noticeably in different 
directions of the gaze, it is non-comitant and is due to underaction or over- 
action of one or more of the elevators or depressors; it may be due to 
spasmodic action of these muscles and may spontaneously disappear. 
If hyperphoria remains the same in all directions of the gaze, it is 
comitant, and may be due to excessive sursumvergence, or more fre- 
quently to the same agencies which produce non-comitant hyperphoria 
which has become comitant. 
Whether the hyperphoria is due to overaction or underaction of one 
or other set of muscles may be determined by examining the rotations 
of the eyes (see page 522). Excessive upward rotation would naturally 
indicate overaction of the elevators of the hyperphoric eye, and excessive 
downward rotation overaction of the depressors. Deficient upward or 
downward rotation would indicate underaction of the vertical muscles, 
and in these circumstances diplopia is readily elicited, as it is in paretic 
conditions, by carrying the test-light in the direction of the action of the 
affected muscle. Hyperphoria usually does not tend to increase, and 
therefore binocular fixation is usually retained, and it is comparatively 
rare for hyperphoria to pass into hypertropia. 
Full correction of hyperopia disturbs the relative range of accom- 
modation and convergence and may cause exophoria (convergence- 
insufficiency-relative insufficiency of the interni, according to Risley). 
The same condition is seen in myopes who do not use glasses at close 
ranges and in presbyopes whose reading-glasses are too strong. Suit- 
able glasses, or a modification of the glasses, and sometimes exercises 
with prisms, will relieve the condition (see also page 150). 
Relative Frequency of Heterophoria.-Faulty directing power of 
the vertical muscles (hyperphoria) is usually stated to be the least 
common of these anomalies, but is much more frequent than was once 
supposed, and, according to Hansell and Reber, will be found in one- 
third of the cases of refractive anomalies. Many of these hyperphorias, 
however, are temporary in character and require no treatment except 
correction of the refraction and any underlying constitutional condition. 
The power of hyperphoria in causing asthenopic symptoms is of para- 
mount importance, and, according to Stevens, its role in disturbing the 
action of the lateral muscles is significant. 
It has been stated exophoria is the most common type of muscular 
imbalance, but Noyes considered esophoria more frequent than exo- 
phoria, the preponderance being 3 to 1, and this certainly is in accord 
with common experience. Heterophoria may be associated with any 
type of refractive error. 
Difference Between Heterophoria and Heterotropia (Squint).- 
The essential difference between these two conditions has already been 
several times defined, and the passage of a heterophoria into a hetero- 
tropia has been described. The differential diagnosis should depend 
upon the results obtained from the application of certain tests. Duane 
describes these as follows: 
"If there is any noticeable deflection behind the screen (see page 72), ABNORMAL BALANCE OF OCULAR MUSCLES, OR HETEROPHORIA 
557 
the screen-test is applied in a second way or by binocular uncovering. 
This procedure consists in covering the left eye and then uncovering 
both eyes and noticing the movement that takes place. If, on thus 
uncovering the left eye, the right eye remains steady and the left moves 
into position, the patient has binocular fixation, and the deflection was 
a heterophoria and not a squint. If, however, the right eye should 
move out of its position and the left eye should move into place, there 
is a squint and the left is the fixing eye. If neither eye moves, there 
is a squint and the right is the fixing eye. By repeating this experiment 
with each eye alternately the examiner can tell whether there is a habit- 
ual binocular fixation, an alternating fixation, or a uniocular squint. 
The diagnosis between the three may be conveniently formulated as 
follows: 
"1. If in binocular uncovering but one eye moves, heterophoria and 
not squint exists. 
"2. If either both eyes move or, in spite of there being an evident de- 
viation, both eyes remain steady, squint exists. 
"3. In the latter case, if, when the left eye is uncovered, the eyes 
behave in the same way as they do when the right eye is uncovered 
(both alike moving or both alike remaining steady, no matter which eye 
is uncovered), the squint is alternating. 
"4. If, when one eye-for instance, the right-is uncovered, both 
eyes move, and when the other eye (in this case the left) is uncovered 
both eyes remain steady, the squint is uniocular (confined in this case 
to the left eye)." 
Symptoms.-These are usually classified under the general term 
muscular asthenopia, and may be divided into the ocular and the general 
symptoms. 
To the first group belong pain, often over the insertion of the affected 
muscle, and especially marked when the eye is suddenly moved in the 
direction of its action; blurred vision and imperfect power of working at 
close ranges; inability to gaze attentively at a stationary object or per- 
son even at long ranges, and great discomfort when attempting to watch 
moving objects; dread of light.and blepharospasm, often confined to a 
few fibers of the orbicularis; and local congestions of the conjunctiva, 
especially over the insertion of the muscle, and on the margins of the 
lids. Often there are eccentric poses of the head, distortions of the 
features, especially wrinkling of the forehead, contractions of the 
sternocleidomastoid, and tilting oi one or other shoulder. 
In the second group the prominent symptom is headache, which may 
be situated in any portion of the cranium, but which is common in the 
occiput. The pain may immediately follow the use of the eyes, or be 
delayed, or come on at a certain hour of the day, or even night.. The 
headache may assume the migrainous type. 
Pain in the back, especially between the shoulder-blades, or precor- 
dial pain, is common. Vertigo, generally subjective, is frequent, one 
variety being characterized by a sense of falling forward when walking 
in a crowd, associated with confusion of ideas. Drowsiness and, on the 558 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
other hand, insomnia may be present, and a variety of general or so- 
called reflex neuroses. 
Chorea, epilepsy, pseudochorea, night-terrors, melancholia, neuras- 
thenia, hysteria, palpitation of the heart, indigestion, constipation, 
flatulent dyspepsia, and a host of other complaints have been attributed 
to muscular imbalance, and also to accommodative strain, and under 
these conditions the eyes should always be examined and the ocular 
defects corrected (see also page 141). Many instances of remarkable 
nervous disturbances are associated with heterophoria, especially 
hyperphoria (as well as with refractive error), and cure will often follow 
the relief of the ocular difficulty. Unfortunately, the whole matter has 
not always escaped exaggeration. 
Method of Examination.-The method of examining the ocular 
muscles has been fully described on pages 72-78. (See also Appendix, 
page 690.) Two points deserve reiteration-viz., that a measurement 
of the relative weakness and power of the muscles is inexact unless this 
has been made after the refractive error has been corrected, and the 
muscles have been tested through the correcting lenses; and that the 
examinations of the muscles should be made both for the near and the 
far point-i. e., at 30 cm. and 6 meters-the latter being the more 
important determination. 
Treatment.-As Duane has well said, "There must be no attempt 
to treat an insufficiency simply as an insufficiency, but account must 
be taken of the complex causes which lie at the root of it." 
Strict orthophoria is rare. Small errors of the lateral muscles are 
often unimportant. 
If there is a constitutional disorder or an insufficient nervous tone, 
this must be treated on general principles. Strychnin or ascending 
doses of tincture of nux vomica have been recommended. Galvanism 
may be tried, but it is doubtful if the current reaches the muscle. Large 
doses of tincture of hyoscyamin are of distinct advantage in cases of 
spasmodic heterophoria. 
In every case of heterophoria the refractive error should be cor- 
rected according to the rules already laid down. In many instances 
this alone will suffice to restore the balance and cure the asthenopia. 
In esophoria of accommodative origin the total amount of the hyperopia 
and astigmatism should be neutralized with suitable glasses, which are 
to be worn constantly, and in high degrees of this muscle defect a convex 
sphere of from 1 to 2 D may be added to the distance correction and 
used in near work in order to diminish accommodative overactivity; in 
exophoria, especially with insufficiency of convergence, the full correction 
of the myopia should be ordered (compare with page 136). Where 
esophoria exists with myopia and exophoria with hyperopia, this plan 
must be modified, and an undercorrection of the refractive error pre- 
scribed. Convergence-insufficiency caused by glasses of improper 
strength has been described on page 556. 
If the symptoms continue, recourse should be had to gymnastic ABNORMAL BALANCE OF OCULAR MUSCLES, OR HETEROPHORIA 
559 
exercises with prisms. The object is to strengthen abduction and adduc- 
tion. A number of methods are in common use: 
1. The patient is instructed to practise fusing the double images 
produced by viewing a candle-flame situated 6 meters away. Abduc- 
tion (prism-divergence) and adduction (prism-convergence) are exer- 
cised, beginning with the weakest prisms and gradually increasing to the 
strongest. This plan probably acts, as Maddox suggests, by training 
the efforts of accommodation and convergence to assume broader rela- 
tions to each other in their work. It is efficient in selected cases. 
2. Rhythmic exercises, contraction and relaxation of the muscle 
being secured by causing the patient to view a small gas-jet 20 feet dis- 
tant through adverse prisms,1 which are lowered and raised at regular 
intervals of five seconds, beginning with weak and gradually going to 
stronger numbers. This is the method of Dr. G. C. Savage. This 
author also recommends rhythmic exercises by rotating convex cylinders 
before the eye for the relief of cyclophoria. 
3. The patient is provided with prisms double the primary distant 
adduction-power. The candle-flame is then slowly carried, while he 
regards it fixedly and continuously from the near point to the distant 
point. This is repeated until, without difficulty, he can, through the 
prisms, secure a single image in all parts of the room. The strength of 
the "handicap-prisms" should be gradually increased. For esophoria the 
reverse of the plan is pursued. This is the method advocated by Dr. 
Gould. 
Referring to muscle exercises, Duane states that he regularly em- 
ploys four, namely: distant exercise with prisms, bases out; exercise 
with prisms, bases out, at near points; exercise with prisms, bases in, 
at near points, and exercises in converging on a pencil-point (see also 
page 74). Exercises with prisms, bases out, are followed by most satis- 
factory results in exophoria, especially in convergence insufficiency, and 
should always be practised not only at the distance, but, as Duane in- 
sists, at the near point. Exercises with prisms, bases in, in esophoria at 
the distant point, in the author's practice, have not been of any value, 
but recent experience, based on Duane's advice to use diverging prisms 
at near points in cases of convergence-excess, indicates that the method 
may produce good results. The author has failed to observe relief in 
hyperphoria from prismatic exercises, but Savage's method has re- 
ceived the commendation of many competent observers, and should be 
tried. 
The next method of treatment is the prescription of prisms. The 
action of prisms has been explained (see page 18). Much difference of 
opinion exists in regard to their therapeutic value. The author believes 
with Duane that "the employment of prisms in lateral deviations is to 
be avoided except as a temporary measure, since prisms, base in, tend 
to produce convergence-insufficiency, and prisms, base out, convergence- 
1 "Adverse prism" is a term used by Maddox, and means one with its apex set in the 
opposite direction from a "relieving prism"; for example, base out if the interni are to be 
affected, base in if the externi are to be exercised. 560 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
excess, so that in both cases they ultimately increase the deviation which 
they are designed to correct." Prisms may be ordered when the range 
of movement is perfect but in an unavailable position. The base of the 
prism should be placed toward the muscle which is to be aided, and the 
apex toward the muscle which is to be weakened. 
It is usually uncomfortable for the patient to wear more than 4° or 
5° constantly-i. e., 2 or 2| over each eye. This statement, however, 
admits of many modifications, and often the strength of the prism may 
be increased much beyond this limit. 
In permanent latent deviations of the vertical muscles (right or 
left hyperphoria) the defect is often quite small, and usually not above 
4° or 5°; hence prisms may readily be ordered for continuous use, and 
combined with the lenses which correct the refractive error, forming a 
prismosphere. If, for example, there is right hyperphoria of 2°, a 2° 
prism base down before the right eye corrects the difficulty, or, what is 
equivalent, the prism may be divided between the two eyes-i. e., 1° 
base down before the right, and 1° base up before the left. It is safe 
to correct very trifling errors in the vertical muscles either with prisms 
or by decentering the correcting lens to an equivalent degree (see page 
20), providing these errors are still maintained after continuous use of 
glasses which neutralize the refractive error. 
In esophoria, which is a frequent cause of muscular asthenopia, 
prisms are often combined with the correcting lenses and worn constantly. 
For the reasons before stated, the author doubts the value of constant 
prisms, with rare exceptions, under these conditions. 
In exophoria the constant use of prisms is not advisable. On the 
other hand, they may be a great help in relieving the strain upon con- 
vergence by removing the point of intersection of the visual axes farther 
from the eyes, and for this purpose they are combined with reading- 
glasses. In high degrees of exophoria, or if there is actual divergence, 
abductive prisms are of little use; if the deficiency of the directing power 
is determined to be equivalent to 10°, one-half of this may be corrected- 
i. e., 2|° base in over each eye; if it is desired to remove all effort, the 
faulty tendency is measured in the usual way, and if it is within suitable 
limits, prisms are ordered, combined with the correcting glasses which 
neutralize the defect.1 
It has also been suggested to strengthen the muscles by means 
of orthoptic exercises-i. e., by causing them to make forced movement in 
different directions; by making forced movements of convergence, the 
patient being required to look at near objects-"thumb exercises"; by 
requiring the eyes to unite the images of .two slightly separated objects. 
Stereoscopic exercises are also of advantage. 
In the event of failure to relieve asthenopic symptoms by the 
methods thus far described operative procedure may be necessary. 
This consists of partial, complete, or graduated tenotomy of the an- 
1 When a spheric lens is combined with a prism, the deviating effect of the combination 
is different from that of the prism alone. Mr. Archibald Percival (Ophthalmic Review, 
October, 1891) has constructed elaborate tables which give the deviating effect. NYSTAGMUS 
561 
tagonistic muscle, or of advancement of the feeble muscle (see chapter 
on Operations). Whether advancement or tenotomy should be per- 
formed depends upon the conditions. Advancement is indicated to 
strengthen a weak muscle, and tenotomy if an overstrong muscle 
is to be weakened. For example, in exophoria due to convergence- 
insufficiency advancement of the internus is a more rational procedure 
than tenotomy of the externus, but if the exophoria depends upon 
divergence-excess, tenotomy of the externus is the better operation. 
The same advice applies to esophoria, convergence-excess indicating 
tenotomy of the internus, and divergence-insufficiency advancement 
of the externus. According to circumstances, one or both externi or 
interni may need readjustment or division. Operations on the vertical 
muscles must be governed by similar rules. In cases of insufficiency 
Landolt performs advancement on one eye. Surgical interference is 
required only after all other measures have been long and faithfully 
tried and have failed to give relief. While cases of muscular imbalance, 
best treated by operative interference, are encountered (aptly called by 
Risley "absolute insufficiencies," equivalent to the structural and 
insertional anomalies of Duane), in the opinion of the author they repre- 
sent a limited proportion of the whole number. Moreover, as our 
knowledge of the etiology of abnormalities of muscular balance in- 
creases and our methods of non-surgical treatment improve, this 
number grows steadily smaller. 
So-called graduated tenotomies and partial tenotomies are performed 
by some surgeons, and it is asserted that adjustments are exactly made, 
Rut in them the author has no .faith. It is true that brilliant results 
have been made and described by experienced operators, but there is no 
doubt that a good deal of injudicious "snipping of the tendons of the 
ocular muscles" has been practised. 
Nystagmus.-This term is applied to a condition characterized by 
an involuntary, rapid movement of the eyeballs. The movement may 
be lateral, vertical, rotary, or mixed-i. e., a compound of two varieties. 
It has been especially studied in this country by Duane and Percy 
Fridenberg. 
The condition may be congenital or acquired, and is bilateral in the 
vast majority of cases, although a few instances of unilateral nystagmus 
have been reported, with the movements usually in the vertical direc- 
tion. It is possible, however, inasmuch as slight forms of nystagmus are 
detected only by using the ophthalmoscope and watching the fundus, 
that some of these supposed unilateral cases have actually been bi- 
lateral. 
The movement is nearly always in the lateral direction. According 
to Gowers, the extent varies from 1 to 10 mm., and the frequency from 
60 to 200 separate oscillations a minute. 
Congenital nystagmus is seen with cases of defective construction 
of the eyeball-coloboma, microphthalmos, etc. It is also common 
in albinism and in color-blind persons with small central scotomas 
(C. L. Franklyn). Nystagmus also occurs with opacities of the media, 562 
MOVEMENTS OF THE EYEBALLS AND THEIR ANOMALIES 
especially when such obstruction to the rays of light has been caused by 
diseases occurring early in life and in blind eyes. In blind eyes the so- 
called searching movements occur; that is, the eyes make a comparatively 
slow and wide movement from the primary position, to which after a time 
they again return, and so the movements are repeated. 
Hereditary nystagmus, extending through a number of generations, 
has been especially studied by Nettleship: two types exist, the first is 
male-limited, the transmission being through unaffected females; in 
the second both sexes are affected, the descent being most frequent 
through the females. In this class head movement is common. 
Nystagmus may be acquired in the pursuit of certain occupations, 
especially mining, and is commonly known as miners' nystagmus. 
It generally occurs among those who use a dim light, and whose work 
necessitates keeping the eyes in an unusual position for many hours 
together (Snell). T. L. Llewellyn's studies lead him to believe that the 
chief cause of this form of nystagmus is strain caused by deficient light. 
Errors of refraction increase the liability to nystagmus. Miners' 
nystagmus has also been attributed to muscle fatigue and to insuf- 
ficiency of the fusion power (Dransart and Van Houtte). The visual 
fields, according to Cridland, are similar to those observed in traumatic 
neurasthenia. 
Finally, nystagmus or, more accurately, pseudonystagmus is ex- 
ceedingly common in diseases of the nervous system, particularly dis- 
seminated sclerosis and Friedreich's ataxia. It occurs in many diseases 
of the brain, and has been noted with great frequency in tumors of the 
cerebellum. Head-jerkings, associated with nystagmus, may occur in 
young children, constituting the so-called spasmus nutans. It may be 
unilateral. 
Nystagmus .has been ascribed to chronic fatigue of the muscles and 
oscillation of the globe consequent upon the muscular atony, and also 
to a central origin. Duane believes that true nystagmus depends upon 
a perversion of the centers for parallel and parallel-rotatory movements 
and not on peripheral muscle or nerve lesions. Labyrinthine nystagmus, 
produced by irritation of the labyrinth, may be horizontal, vertical, 
and rotary, and the movement consists of a slow followed by a rapid 
oscillatio'n, most intense when the visual axes are directed toward a 
certain point on the limits of the binocular field of vision (A. W. Ormond, 
Sydney Scott). 
Treatment.-If practicable, in cases of nystagmus where there is 
interference with the reception of perfect retinal images, the best pos- 
sible vision should be restored by correction of refractive error, by 
tenotomy, or by iridectomy .for new pupil, according to the indications. 
Very often good results have been noted. If nystagmus is brought 
about by any occupation, the evident indication is to remove the patient 
from his surroundings. For central nystagmus from brain or cord dis- 
ease there is practically no remedy. In some instances of acquired 
nystagmus benefit has been reported from the local use of eserin and the 
internal administration of strychnin. MONOCULAR DIPLOPIA 
563 
Monocular Diplopia.-This character of diplopia has been ex- 
plained by one of several conditions: (1) By anomalies of refraction, 
particularly astigmatism; (2) by opacities in the cornea or lens or by 
anomalies of the pupil, for example, polycoria (see also page 395); (3) 
by irregular cramp of the ciliary muscle; (4) by complete or partial 
constriction of the eyelids, by which they are made to impinge on the 
cornea (G. J. Bull); (5) by hysteria or allied functional nervous disturb- 
ance; (6) by organic disease of the brain or its membranes, associated 
with abducens paralysis (Gunn and Anderson); (7) by simulation, the 
symptom being an invention of the patient for the purpose of magnify- 
ing the result of injuries. CHAPTER XX 
DISEASES OF THE LACRIMAL APPARATUS 
Diseases of the. lacrimal structures naturally divide themselves 
into those which have- their seat in the lacrimal glands and those which 
affect the drainage system-i. e., the puncta, canaliculi, lacrimal sac, 
and nasal duct. 
Dacryo=adenitis.-This is an inflammation of the lacrimal gland, 
a comparatively rare affection, which may be acute or chronic, suppura- 
tive or non-suppurative. 
Non-s.uppurative dacryo-adenitis, on account of its analogy to 
bilateral parotitis, has been called mumps of the lacrimal gland (Hirsch- 
berg). It may be caused by influenza, small-pox, leukemia, and mumps. 
Tuberculous, dacryo-adenitis is rare, according to Stieren, who reports 
an example of this affection, only 12 cases being on record. The uni- 
lateral chronic form of inflammation of the lacrimal gland is more com- 
mon, and has been observed in scrofulous subjects, and may be caused 
by an injury or follow diseases of the conjunctiva and cornea. 
If the- gland is chronically enlarged, palpation will reveal its lobu- 
lated border; if the inflammation is acute, there are pain, tenderness, 
and swelling at the upper and outer part of the eyelid, with chemosis of 
the conjunctiva. This may go on to suppuration, and the abscess usually 
points upon the skin, but occasionally through the conjunctiva. Acute 
dacryocystitis may result from infections from the conjunctiva, from 
infectious diseases, and from injury. Metastatic dacryo-adenitis in the 
subjects of gonorrhea has been described. 
Treatment.-Warm applications and poultices to relieve pain are 
needed, and at the first appearance of pus an incision should be made 
either through the integument parallel to the eyebrow, or through the 
conjunctiva. If induration of the gland occurs, this should be treated 
locally with iodin or iodid of cadmium ointment. 
Hypertrophy of the lacrimal gland has been observed at birth, 
but usually is seen in later years, and consists in an indurated lobulated 
tumor having its situation in the upper and outer part of the orbit. 
Atrophy of the lacrimal gland, as the result of xerophthalmos, has 
been described. 
Spontaneous prolapse of the lacrimal gland appears in the form 
of a soft movable tumor under the upper eyelid. Hypertrophy and 
prolapse or prominence of the palpebral portion of the lacrimal gland 
may occur in various corneal and conjunctival inflammations, and is 
evident on everting the upper lid. 
The treatment consists of extirpation of the prolapsed organ. 
564 TUMORS OF THE LAfRIMAL GLAND 
565 
Traumatic Dislocation of the Lacrimal Gland.-This is a rare 
accident, and occurs most frequently in young children (Villard), but also 
in adults (E. Jackson). Usually the gland prolapses through a wound 
in the upper lid. If the gland can be returned to its place and the 
wound sutured, this procedure is preferable to excision, which, however, 
may be necessary, especially if infection occurs. 
Fistula of the Lacrimal Gland.-This may remain on account 
of the rupture of an abscess, but has also been recorded as a congenital 
defect at the outer third of the upper lid. A fringe of hair may sur- 
round the opening of the fistula. 
The fistula may be closed by repeated cauterization, or by a plastic 
operation; in the event of the failure of these measures, extirpation of 
the gland is indicated. 
Syphilis of the Lacrimal Gland.-The lacrimal gland is singularly 
free from syphilitic affections, but specific induration and inflammation 
have been described, and in any instance of unaccounted hypertrophy 
of this gland, careful antisyphilitic 
treatment should be undertaken 
before resorting to surgical meas- 
ures. 
Dacryops.-This affection, often 
classified with diseases of the con- 
junctiva, is caused by a cystic dis- 
tention of one of the main gland- 
ducts or of one of those of the ac- 
cessory lacrimal gland, and appears 
in the form of a bluish, translucent 
swelling beneath the-conjunctiva at 
its upper and outer part. If the 
mouth of the- excretory duct is not 
occluded, pressure upon the tumor 
causes a few drops of liquid to es- 
cape. It is a comparatively infre- 
quent affection, about 35 cases 
being on record (Ernest Thomson). 
Tumors of the Lacrimal Gland.-Adenoma, fibroma, myxoma, 
adeno-angioma, epithelioma, carcinoma, osteochondroma, lymphoma, 
cylindroma, and sarcoma occur. Tubercle, in the form of a small almond- 
shaped tumor, has also been reported in this region. Cysts and concre- 
tions (dacryoliths) occur. The concretions are contained in the excre- 
tory ducts, and are composed of concentric, chalky masses (Levi). 
According to Warthin, the majority of lacrimal tumors are, most prob- 
ably, mixed tumors of endothelial origin, similar to those of the parotid 
and submaxillary glands. They tend to form cartilaginous, hyaline, 
and myxomatous tissue, and their malignancy is relatively slight. F. 
H. Verhoeff believes, however, that mixed tumors of the lacrimal gland 
are essentially epiblastic in origin, that they are dangerous to sight and 
to life, and that they should .be extirpated as soon as possible. 
Fig. 241.-Enlargement and prolapse 
of the palpebral portion of the lacrimal 
gland in an eye with kerato-iritis. 566 
DISEASES OF THE LACRIMAL APPARATUS 
To a symmetric enlargement of the lacrimal and salivary glands the 
name Mikulicz's disease is applied. It is unassociated with any systemic 
affection. According to S. Lewis Ziegler, the tumefactions should be 
regarded as true lymphomas. 
Anomalies of the Puncta Lachrymalia and Canaliculi.-1. 
Congenital Anomalies.-Double puncta lachrymalia and canaliculi have 
been observed as congenital anomalies, and Majewski has observed 
quadruple puncta. There may be congenital absence of these struc- 
tures, or the lacrimal points may be wanting and the canals may be 
represented by furrows along the edge of the lid. 
2. Acquired Anomalies.-The slightest change in the natural rela- 
tion of the lower punctum to the eye, against which it is directed back- 
ward, causes epkphora, or an overflow of tears. 
The most fruitful sources of such abnormal relationship are the 
various chronic inflammations of the lid and conjunctiva-blepharitis, 
granular conjunctivitis, and ectropion-and facial palsy and wounds 
of this region. In facial palsy, watering of the eye is sometimes an 
early symptom, and is caused partly by the loss of the compressing 
power of the lid, especially in the fibers of Horner's muscle, and partly 
by the falling away of the punctum. An overflow of tears may follow 
an abnormal position or enlargement of the caruncle. All these condi- 
tions cause a malposition of the punctum lachrymale. 
Epiphora is also caused by a stye or tumor of the lid near the punc- 
tum, or, if the canaliculus is closed, by the presence of a foreign body, 
usually a cilium; by a mass of fungus (streptothrix), which, by becoming 
calcified, may form a so-called tear-stone, and by a polyp. In like 
manner chronic conjunctivitis and marginal blepharitis may close either 
the lacrimal point or the canaliculus. These affections are included 
under the terms stenosis of the punctum lachrymale and obstruction of the 
canaliculus (for additional causes of epiphora, see page 584). 
Treatment.-If a foreign body is present, it is usually necessary to 
slit the canaliculus in order to remove it. 
In many cases of epiphora which depend simply upon closure of 
the lacrimal point this may be opened by means of a gold or silver 
pin or a dilator, which is pushed along the canaliculus. Afterward the 
permeability of the lacrimal duct may be tested by inserting the point 
of an Anel syringe and injecting boric acid solution and observing 
whether it passes freely into the nose. This very simple procedure will 
often afford great relief without the necessity of either slitting the 
canaliculus or dilating the duct. If the epiphora has been caused 
by facial palsy, the treatment advised does not apply. 
Anomalies of the Lacrimal Sac and Nasal Duct.-1. Dacryo- 
cystitis.-The symptom in affections of the lacrimal sac and nasal 
duct which is always present is epiphora; the eye swims in tears, and 
these are excited to overflow by exposure to dust, cold, or wind; the 
caruncle and plica are swollen; the neighboring conjunctiva is hyperemic 
and injected (lacrimal conjunctivitis'); the skin is macerated, and the 
margins of the lid, especially toward the nose, show signs of blepharitis. ANOMALIES OF THE LACRIMAL SAC AND NASAL DUCT 
567 
Usually there is slight distention over the region of the lacrimal sac 
{mucocele, lacrimal tumor}, and pressure upon this expresses through the 
puncta the retained fluid, which is a clear or semitransparent viscid 
mucus {dacryocystitis catarrhalis}, or turbid from mixture with purulent 
material {dacryocystitis blennorrhoica}. 
This chronic distention of the lacrimal sac is liable to develop into a 
suppurative inflammation producing acute dacryocystitis, which may be 
preceded by fever and chill; the lids and region of the nose become tense 
and tender to the touch, and a red and brawny swelling resembling 
erysipelas, for which it not infrequently has been mistaken, overspreads 
the region. 
Should a phlegmonous inflammation involve the cellular tissue 
{dacryocystitis phlegmonosa} which surrounds it, the pus burrows in front 
of the sac, forms pouches in the connective tissue, and in most instances 
the lacrimal abscess thus formed points below the tendo oculi. If un- 
molested, the abscess ruptures ex- 
ternally with the formation of a 
fistulous opening into the sac, the 
mouth of which is surrounded by 
pouting granulations (Fig. 242). 
2. Prelacrimal Sac Abscess.- 
This consists of a swelling above 
the internal palpebral ligament 
and a little external to the region 
of the lacrimal sac, associated with 
a fistulous opening, from which 
pus flows, having no connection 
with the sac itself. It may be 
caused by a blow at the inner 
angle of the eye and may be as- 
sociated with caries and perforation of the lacrimal bone (Bull). The 
same condition appears without injury in children who are the subjects 
of hereditary syphilis. 
The condition is to be distinguished from a true lacrimal abscess by 
the fact that there is no interference with the passage of tears from the 
conjunctiva into the sac, and by the absence of acute inflammation. 
Prelacrimal sac cysts are described, and small tumors may appear in this 
region. One removed and examined by the author had all the histologic 
appearances of tubercle. 
The treatment is that of an abscess, together with such constitutional 
measures as may be indicated by the dyscrasia of which the patient is 
the subject. 
3. Fistula of the Lacrimal Sac.-This occasionally has been observed 
as a congenital anomaly, and may be present on only one side or on both 
sides. The opening is usually directly under the internal palpebral 
ligament. 
Generally a fistulous opening into the sac is caused by the rupture 
of a lacrimal abscess, but it may result from a carious condition of the 
Fig. 242.-Phlegmonous dacryocystitis; 
pouting granulations surround the fistulous 
orifice (from a patient in the Children's 
Hospital). 568 
DISEASES OF THE LACRIMAL APPARATUS 
upper canine teeth. The opening may appear about 1 cm. below the 
punctum, but also in various spots along a line which runs outward, 
parallel to the lower orbital border. 
It usually communicates with the sac, but in rare instances the 
opening may lead into the lower canal only, the sac above being shrunken. 
Pus and mucopus, and later tears, which should descend into the duct, 
exude from the opening, which for a long time persists as a fine orifice, 
at the mouth of which appears a drop of clear fluid. This is the so-called 
capillary fistula. 
The condition is to be differentiated from a buccal fistula below the 
margin of the orbit, by observing that in the latter the situation is 
never accurately at the orbital margin, that a sound never passes up- 
ward, but only downward, laterally, or posteriorly, and that the secre- 
tion is always purulent. 
4. Obstruction of the Nasal Duct.-This generally antedates the 
affection of the sac. It may be situated at any part, but selects by 
preference the point at which the nasal duct enters into the sac, or the 
lower end where it passes into the nasal chamber. 
In the early stages of catarrhal dacryocystitis there probably is no 
true stricture of the duct, but the flow from the sac into the nose is 
prevented by swelling of the mucous tissue; later, and in other in- 
stances, dense cicatricial strictures occur. 
Causes of Disease of the Lacrimal Sac and Nasal Duct.-Disease of 
the lacrimal sac is rarely primary. In young infants dacryocystitis, 
often double, is not infrequently seen-lacrimal blennorrhea or lacrimal 
abscess of infants. Donald Gunn thinks that the cause of mucocele of 
newborn children, becoming afterward dacryocystitis, depends upon a 
dilated duct, the dilatation being brought about during fetal life by 
obstruction at the lower end, depending, for example, upon some de- 
velopmental fault. The pus usually contains pneumococci; staphy- 
lococci, streptococci, and Bacterium coli are also occasionally present. 
Rochon-Duvignaud has shown microscopically that there may be an 
occasional congenital obstruction at the lower end of the nasal duct. 
Both a local and a general disposition to tear-duct troubles has 
been assumed by some authors, and by others, for example, Haab, 
hereditary predisposition has been given etiologic prominence. The 
female sex suffers more frequently than the male, and the left tear- 
duct is more often diseased than the right (Cahn). 
In the majority of cases blennorrhea of the sac is caused by a reten- 
tion of the secretion on account of stricture or obstruction in the nasal 
duct, and the participation of the lining of the sac in an inflammation of 
the nasopharynx. In other instances strictures result from, rather than 
cause, the blennorrhea. A proper appreciation of the pathologic con- 
ditions of the nasal mucous membrane in relation to diseases of the 
lacrimal apparatus is of the utmost importance, and in nearly every 
case of disease of the lacrimal sac and of the lacrimonasal duct mor-bid 
conditions of the nasal chambers and of the nasopharynx are present, 
especially tumefaction of the mucous membrane, hypertrophy, and CHARACTER OF THE LACRIMAL SECRETION 
569 
abnormal position of the turbinate bones, strictures after nasal ulcers, 
and caries of the nasal bones. Of great importance in this regard, 
especially in suppurative dacryocystitis, is infection of the ethmoid 
cells and of the antrum of Highmore, and in a search for a primary cause 
these regions deserve accurate investigation. 
Although it might seem natural that conjunctivitis, and especially 
purulent conjunctivitis, should cause lacrimal disease, this is by no 
means frequently the case. Conjunctivitis and blepharitis, so often ac- 
companying disorders, follow rather than cause the lacrimal affection. 
Obstruction of the duct and disease of the sac are sequels of measles, 
scarlet fever, and especially small-pox, because these exanthems are 
accompanied by inflammation of the nasal mucous membrane. 
Periostitis and caries of the lacrimal bone, the result of syphilis, 
are important causes. Gummy growths may block the sac and go on 
to rapid suppuration. Igersheimer calls especial attention to the fre- 
quency with which hereditary lues is a cause of disease of the lacrimal 
passages in children. Tuberculosis of the lacrimal sac is of not infrequent 
occurrence. 
The relation between Asymmetry of the face and disease of the 
lacrimonasal duct deserves mention; indeed, Hasner assumed that a 
local disposition to these disorders depended upon this asymmetry. 
Traumatism accounts for certain cases. Most impermeable obstructions 
follow injuries and the rough use of bougies. Stoppage of the lacri- 
monasal duct may be caused by pressure from neighboring tumors- 
for example, in the antrum of Highmore, and by foreign bodies lodged 
in the lower lacrimal canal and in the nasal chambers. Actinomycosis 
of this region has been reported (von Schroeder). 
Fistulas, especially those seen in infants, often arise from disease 
of the bone, which, in turn, is the result of inherited syphilis. 
Tumors of the lacrimal sac are uncommon; epithelioma (Pasetti), 
sarcoma (T. H. Butler), and plasmoma (Verhoeff and Derby) have been 
observed. 
Prognosis in Lacrimal Disease.-The well-known fact that under 
the most skilful treatment affections of the tear-passages often resist 
healing renders a guarded prognosis necessary. This depends entirely 
upon the condition of the nasal chambers, the duration of the malady, 
the permeability of the stricture, and the cause of the trouble. If the 
latter is the result of injury the prognosis becomes especially grave, 
and the malady may be irremediable. 
Character of the Lacrimal Secretion under Pathologic Con= 
ditions.-The lacrimal sac is a reservoir for the fluid secreted by the 
conjunctiva, and this fluid is more or less loaded with micro-organisms. 
The Streptococcus pyogenes, pneumococcus, and other pathogenic 
organisms are always present in dacryocystitis. If the cornea is abraded, 
or if a solution of continuity in this membrane is necessitated by an 
operation, the presence of these organisms in the fluid becomes a serious 
complication. They may turn a simple abrasion into a sloughing ulcer 
or an aggravated hypopyon-keratitis. They may prevent the healing of 570 
DISEASES OF THE LACRIMAL APPARATUS 
an ordinary keratitis, and finally they may inoculate an operative wound 
and defeat the object of the operation. For this reason it is most im- 
portant that in any of the three conditions just quoted the permeability 
of the nasal duct should be ascertained. If it is strictured, it should be 
opened, and the walls of the lacrimal sac, if inflamed, brought to a 
healthy condition as speedily as possible, or the sac should be extirpated. 
The importance of this relation of the lacrimal apparatus to diseases of 
the cornea and to the prognosis of cataract operations has been elsewhere 
described. 
Treatment of Diseases of the Lacrimal Sac and Duct.-Conserva- 
tive measures should always be tried first-viz., intranasal treatment, 
massage over the sac while the inner canthus is kept filled with an anti- 
septic liquid, and dilatation of the punctum and irrigation of the sac. 
Many cases of simple epiphora are due to ametropia and heterophoria 
and even to various nervous diseases-for example, tabes dorsalis and 
neurasthenia-hence operative interference is to be deprecated unless 
the exact cause of the condition is ascertained. Epiphora may be an 
early sign of exophthalmic goiter (Berger, J. T. Carpenter). 
In organic cases, usually, the following procedures are recom- 
mended: slitting the canaliculus, introducing a probe into the nasal 
duct, and syringing the sac and nasolacrimal duct; or, in the presence 
of proper indications, excision of the lacrimal sac. The method of 
slitting the canaliculus and the introduction of a probe are described 
on page 681. 
After the canaliculus has been dilated or incised, the duct and the 
sac should be washed out thoroughly with some antiseptic fluid-a 
saturated solution of boric acid or a 1 :5000 solution of bichlorid of 
mercury, or formaldehyd 1 :3000, or permanganate of ■ potassium 
1 :5000, or protargol or argyrol, 5 to 10 per cent. Argonin, 2 to 4 per 
cent., has been recommended. Great care should be employed in using 
solutions of argyrol and protargol, lest they escape into the surrounding 
structures and produce unsightly staining of the skin. 
Some surgeons, as a rule, split the upper canaliculus, although the 
usual practice is to approach by means of the lower passage. If there 
is much distention of the sac, it has been suggested to enter the upper 
passage and incise both this and the wall of the sac. 
In making use of probes, it is advisable to begin the first trial with a 
No. 1 conical probe (Bowman's or Williams'); if this fails, a smaller 
one may be tried. Either rapid or gradual dilatation is employed, the 
latter being the preferable method. Undue efforts should never be 
used, as it is extremely easy to make a false passage and perforate the 
delicate structure of the lacrimal bone, while roughness in the use of 
probes, by scraping off the mucous membrane, may cause the most im- 
permeable type of stricture. Often it is not necessary to use probes 
at all, but simply by means of a syringe introduced into the mouth of 
the sac to medicate the inflamed tissue, which, as before stated, some- 
times causes occlusion by swelling, without the actual presence of a 
cicatricial stricture. CHARACTER OF THE LACRIMAL SECRETION 
571 
Sounds should be used at first every second or third day, but as the 
case progresses longer intervals may elapse. Large probes (4 mm. in 
diameter) are advocated by Theobald and Snell, but, in the author's 
experience, are not only unnecessary, but often harmful. 
If a lacrimal abscess supervenes and is seen early, the canaliculus 
should at once be slit and, if possible, the secretion evacuated and 
the passage into the nose restored. Frequently the pain and swell- 
ing are such as to render this impossible, and the opening must be made 
upon the face, about 1 cm. below the palpebral tendon, cutting down- 
ward and outward. The cavity should then be thoroughly cureted, 
packed with gauze, and allowed to heal gradually from the bottom. 
An excellent practice is to use hot compresses over the swelling, 
preferably of carbolized water, at a temperature of 120° F., frequently 
changed and applied for five or ten minutes at a time. Later the pass- 
age into the nose may be rendered patulous with probes, in the manner 
already described. The practice of introducing a lead or silver style 
the author has abandoned, although many surgeons are strongly in 
favor of its use, especially the use of a lead style, which is preferable 
to a canula (H. Moulton). The passage of bougies of gelatin impreg- 
nated with 30 to 50 per cent, of protargol has been recommended 
(Antonelli). 
The treatment of dacryocystitis of infants should consist in the use 
of a simple collyrium, boric acid or boric acid and sulphate of zinc, fre- 
quent evacuation by pressure of the contents of the sac, and gentle 
massage. In the experience of the author this is usually sufficient; 
rarely slitting the canaliculus and passing probes may be necessary. 
Swelling over and around the lacrimal sac, together with fistulous 
communication into it, occasionally will subside under the judicious 
use of a compressing bandage. 
The great difficulty that is sometimes experienced in keeping the 
canaliculus open has led to the employment of electrolysis. This is 
applied to the canaliculus by means of a probe fitted in a handle and 
connected with the negative pole of a battery, the positive electrode 
being placed on the back of the neck. The seance should last about 
half a minute with a current of 2 milliamperes. 
In addition to the local measures already mentioned for the purpose 
of producing healing in cases of lacrimal disease associated with a catar- 
rhal condition of the passages, solutions of nitrate of silver, salicylic 
acid, iodoform, aristol, creolin (1 per cent.), and blue pyoktanin (1 : 1000) 
have been advocated. 
In acute inflammation with abscess formation, quinin and iron in 
the form of Basham's mixture are indicated; in syphilis, with disease 
of the bone and gummy deposit, the usual drugs should be exhibited; 
in struma, cod-liver oil, hypophosphites, and iron, in the form of the 
syrup of the iodid, are the most trustworthy remedies. 
Scrupulous attention to the nose and the nasopharynx is necessary, 
and any local lesions which present themselves must be treated. In 
the absence of a special line of practice for this region excellent results 572 
DISEASES OF THE LACRIMAL APPARATUS 
follow a simple spraying of the parts with Dobell's solution or peroxid 
of hydrogen one-third, water two-thirds, while carrying on the regula- 
tion measures for the relief of the lacrimal disorder. If there is decided 
disease of the region, the proper treatment of the part with the view to 
removing diseased structures should be undertaken. The importance 
of examining accessory nasal sinuses has been pointed out, especially 
the ethmoid and the maxillary sinus. 
Occasionally it will happen that although a duct has been thor- 
oughly opened, the probe passes readily, and the liquid used in the 
syringe flows freely from the nose, the epiphora continues, and the eye 
fairly swims in tears. In such circumstances a probe should be passed 
into the nose and the entrance of the duct into the inferior meatus 
properly exposed by means of a nasal speculum. Quite often it will be 
seen that a thickening of the duct entrance, or perhaps a valve-like flap 
of mucous membrane, occludes the passage. This is pushed aside by the 
probe or forced aside by the liquid when it is injected, but entirely stops 
the flow of the tears. This simple precaution will sometimes lead to 
the discovery of the cause of failure to relieve cases which have stub- 
bornly resisted treatment. 
If a fistula remains, this may sometimes be closed, as already stated, 
by compression. In the event of failure, freshening of the edges and 
the galvanocautery may be tried, the surrounding pouting granulations 
being removed by scraping. The capillary fistulas are productive of no 
inconvenience and may be allowed to remain undisturbed. 
Extirpation of the lacrimal sac is indicated, and usually yields good 
results in many cases of chronic dacryocystitis. It may be employed 
if conservative and ordinary surgical measures have failed, if the patient 
cannot or will not devote sufficient time to treatment, if there is an im- 
passible stricture, if an operation on the eyeball is speedily necessary, 
if there is a serpiginous ulcer of the cornea (Kuhnt), and in cases of 
caries of the lacrimal bone. The operation is further indicated in those 
whose occupation exposes them to corneal injury (Axenfeld) and in 
insane patients. The operation is so satisfactory in its results that, in 
the author's opinion, it should in large measure replace the use of 
probes and the other measures which have been described. If, subse- 
quently, the epiphora is annoying, extirpation of the lacrimal gland has 
been performed, and is especially advocated by C. R. Holmes. In 
place of complete excision, removal of the palpebral gland may be tried. 
(For methods of operating, see page 684.) Usually, however, as the 
conjunctiva resumes its normal condition, the epiphora, under ordinary 
conditions at least, ceases to be annoying, and often disappears. (For 
other methods of operating in cases of dacryocystitis, see page 682.) CHAPTER XXI 
DISEASES OF THE ORBIT 
Congenital Anomalies.-Anophthalmos, or complete absence of 
one or both eyes, is an affection which, like the other congenital anoma- 
lies, more frequently is double than one sided. A child born without 
eyes may be healthy and well developed in other respects, or may be the 
subject of additional congenital deformities. The palpebral fissures 
are small, the lids usually deficient in size, sunken, and upon their 
separation the empty orbit without trace of the globe is revealed. 
Sometimes, however, careful dissection will expose a rudimentary eye- 
ball at the apex of the orbit. 
The most reasonable explanation of this anomaly is that no primary 
optic vesicle has budded out from the anterior primary encephalic 
vesicle, or that, having budded out, it has failed to form a secondary 
optic vesicle. 
Microphthalmos and megalophthalmos are anomalies of the globe to 
which reference has been made. Sometimes cysts of bluish hue are con- 
nected with rudimentary eyes, the cyst being evident in the lower part 
of the orbit or the lower iid-orbitopalpebral cyst. Zentmayer and Gold- 
berg have found retinal elements in a cyst of this character. 
Cyclopia is a congenital malformation characterized by a fusion-of 
the orbits and the two eyes in the middle of the face, so that there is 
only one eye situated in the place normally occupied by the root of the 
nose. 
General Symptoms of Orbital Disease.-Two symptoms are so 
constantly present that they may be said to be essential to the clinical 
picture of most of the affections of the orbit: 
1. Proptosis or Exophthalmos.-This consists of more or less pro- 
trusion and displacement of the globe. 
2. Immobility of the Eyeball-This may be complete or partial, and, 
if vision is unaffected, the limitation of the movements of the eye is 
associated with diplopia. Complete immobility may be differentiated 
from a similar condition due to palsy of all exterior ocular muscles 
(ophthalmoplegia externa) by the absence of ptosis (Noyes). 
The following signs may also be associated with orbital disease: 
(a) Chemosis of the conjunctiva, either universal or else localized 
upon a special portion of the globe, indicating the neighborhood of the 
diseased area. 
(6) Redness, swelling, and edema of the eyelids, especially in inflam- 
matory affections of the cellular tissue of the orbit and disease of the 
accessory nasal sinuses. 
573 574 
DISEASES OF THE ORBIT 
(c) Pain, most noticeable when the patient attempts to move the 
eye or when the surgeon palpates the globe and presses it inward. In 
addition to the pain in the orbit itself, frontal headache is a common 
symptom, especially if the sinuses are involved, and tenderness on pres- 
sure along the margin of the orbit and accessible portions of its walls is 
one sign of disease of the periosteum. 
(d) Fluctuation occurs, but not constantly, if an abscess of the orbit 
has formed. 
(e) Disturbance of Vision.-In some cases of orbital diseases there 
is no disturbance of vision; in others there may be marked changes in 
the eye-ground-papillitis (choked disk), atrophy, hemorrhages, and 
vasculitis or perivasculitis. 
Periostitis of the orbit is both acute and chronic, and in the acute 
type appears either as a localized affection or as a diffuse suppurative 
process. 
The symptoms of acute localized periostitis are pain, tenderness 
over the seat of the disease, usually the margin of the orbit, injection 
and chemosis of the conjunctiva, and some swelling of the lids and pro- 
trusion of the ball. In the diffuse variety of the disease all the foregoing 
symptoms are much aggravated, and there may be, in addition, fever, 
general headache, delirium, and stupor. In such a case the differential 
diagnosis between it and an orbital cellulitis becomes extremely difficult. 
In fact, the cellular tissue is associated with the periosteum in the 
inflammation. A subperiosteal abscess may form and become encap- 
sulated or, passing forward, burst through the skin of the eyelid or at the 
angles of the orbit and form an orbital fistula. 
In chronic periostitis there are deep-seated pain, often worse at 
night, tenderness on pressing the eyeball backward, thickening of the 
tissue beneath the orbital margin, and swelling of the lids and conjunc- 
tiva, although the latter symptoms, together with proptosis, may be 
absent. 
According to Mracek, syphilitic periostitis most frequently attacks 
the orbital margins, and may occur in a gummatous or a sclerosing form. 
It less commonly involves the orbital walls behind Tenon's capsule, and 
is then generally gummatous in type. The site is usually in the upper 
or outer wall, and the disease causes trigeminal neuralgia, worse at 
night, and restriction in the mobility of the globe, with squint and 
diplopia. Optic neuritis may occur. 
The causes of periostitis, especially of the chronic form, in addi- 
tion to syphilis, in which disease it is sometimes a secondary, but more 
often a late, manifestation, are rheumatism, tuberculosis, injuries and 
affections of the sinuses, notably the frontal and the ethmoid. 
The prognosis depends upon the type of the disease. If localized, 
this is favorable; if diffuse and suppurative, not only may extensive 
implication of the tissues surrounding the globe leave permanent dis- 
abilities and deformities (exophthalmos, muscle palsy, optic-nerve 
atrophy, necrosis), but the inflammation may extend to the meninges 
of the brain and cause death. CARIES AND NECROSIS 
575 
Chronic periostitis may last for months, and in any type fistulas, 
necrosis, and caries of the bone are the common result. Periostitis due 
to syphilis presents the most favorable prognosis. 
Treatment.-The constitutional treatment depends upon the 
cause, and includes the iodids and salicylates in rheumatic cases, and 
the use of mercurials and salvarsan in syphilitic cases. 
The surgical treatment of acute periostitis consists in an incision 
into the affected area and evacuation of the pus; in short, the treat- 
ment is the same as that applied to acute periosteal disease elsewhere 
located. The relation of periostitis to sinus disease demands a careful 
examination of the sinuses and treatment according to the findings. 
Caries and Necrosis.-Caries is prone to attack the margin of 
the orbit, especially the lower and outer part, and may be due to syph- 
ilis or tuberculosis. An injury often is the exciting cause. 
The symptoms of periostitis are present, suppuration develops, 
the abscess comes to the surface through the lid over the diseased area, 
rupture occurs, with the discharge of pus, a fistula forms, surrounded by 
granulations, and through this a probe will detect the softened bone. 
Very decided deformity of the lid may be occasioned, most commonly 
in the form of an ectropion (compare Figs. 95 and 98). 
Caries of the orbit is most common in children, and, as has been 
pointed out, selects the margin of the orbit for its site, although it 
may occur in the roof, in which case it becomes a complication en- 
dangering life, owing to the proximity of the brain. The inflamma- 
tion may spread to the orbital tissues and cause exophthalmos and 
neuroretinitis. 
Necrosis of the orbit is much less common, and its immediate cause 
is an osteitis occurring as a consequence of acute periostitis. A frag- 
ment of bone completely separated by a fracture from the periosteal 
surroundings would probably undergo necrosis, and the rough use of 
probes may cause mortification of the delicate lacrimal bone. Necrosis, 
unlike caries, is more common in adults. 
Treatment.-This consists of the remedies recommended in the 
treatment of periostitis, and, as caries is a very chronic affection and 
most common in strumous (tuberculous) subjects, cod-liver oil, phos- 
phates, and iodid of iron should be included in the constitutional 
measures, and should be exhibited for long periods of time. 
The local treatment during the early ulcerative stage of caries con- 
sists of evacuation of foci of suppuration, careful cleansing with anti- 
septic solutions, and drainage. Considerable caution is necessary before 
resorting to the removal of the diseased bone with a gouge, because the 
process is essentially chronic and may be aggravated by the manipula- 
tions of the instrument; but roughened bone should be scraped with a 
sharp spoon and the diseased portions thoroughly removed. If the 
roof of the orbit is affected, great care is necessary lest the cranial cavity 
be penetrated. If a piece of the orbital wall has undergone necrosis, 
this should be removed when it has become loose or detached. The 
regions overlying the sinuses should be carefully examined. 576 
DISEASES OF THE ORBIT 
Cellulitis {Phlegmon of the Orbit).-There are several varieties of 
inflammation of the cellulofatty tissue of the orbit. Thus the in- 
flammation may be acute, subacute, or chronic, unilateral or bilateral, 
and finally it may undergo resolution or, as more commonly is the case, 
terminate in suppuration. 
In the mild form the symptoms are dull pain, swelling of the lids, 
slight exophthalmos and diplopia, without inflammatory symptoms and 
without constitutional disturbance. 
In the acute phlegmonous variety of the disease there are chills, 
fever, deep-seated pain, most marked upon attempting to move the 
eyes, general headache, exophthalmos, limitation in the movements of 
the eye (which may become entirely fixed), and swelling and edema of 
the lids, together with hyperemia and 
chemosis of the conjunctiva. The last 
two symptoms are so severe at times 
as to give at first sight the general im- 
pression of a violent attack of puru- 
lent conjunctivitis (Fig. 243). 
In the earlier stages vision is not 
usually affected, but later there may 
be optic neuritis followed by atrophy, 
dilatation of the pupil, anesthesia, and 
even ulceration of the cornea, and, in- 
deed, in severe cases the eyeball may 
suppurate. In certain types of orbital 
cellulitis extensive intra-ocular changes 
occur, with hemorrhages and vascular 
alterations, due to compression of the 
central vessels of the retina producing 
stoppage of the circulation and edema 
and exudation into the retina (Knapp). 
Blindness from orbital abscess may be 
due to retrobulbar necrosis of the optic 
nerve, from thrombosis of the pial vessels, and of the central vessels 
(Bartels). Fluctuation finally develops, and pointing usually occurs 
below the inner portion of the supra-orbital ridge. 
The symptoms of chronic abscess are much less violent and distinc- 
tive than those just described. They may, indeed, be mistaken for 
other morbid conditions, especially as the abscess is commonly asso- 
ciated with diseased bone or periosteum in scrofulous subjects, or may 
occur in them from an injury or the presence of a foreign body. 
The causes of orbital cellulitis are various. It may be traumatic 
or may be due to exposure to cold; it may follow in the wake of 
scarlatina, typhoid fever, or influenza; or it may be the result of 
a meningitis. The most violent types of orbital cellulitis occur with 
facial erysipelas. In these instances the affection is usually double. 
The extension of inflammation from diseased teeth or suppuration in 
the ethmoid cells, sphenoid, or antrum of Highmore may cause the 
Fig. 243.-From a photograph of 
a patient in the Philadelphia General 
Hospital suffering from double orbital 
cellulitis the result of erysipelas. CELLULITIS 
577 
affection. Birch-Hirschfeld's investigation demonstrates that the 
largest number of orbital inflammations (about 60 per cent.) are due to 
accessory sinus inflammation. The infection is conveyed from the 
sinus to the orbital contents by means of septic thrombosis, thrombo- 
phlebitis, lymphangitis, or erosion of the bony partition. Finally, a 
certain number of cases are metastatic, and develop in the course of 
pyemia, especially puerperal septicemia. The association of orbital 
cellulitis with periostitis has already been referred to, and a certain 
amount of cellulitis occurs whenever there is a general inflammation of 
the globe. 
Progress and Prognosis.-In mild cases the prognosis is favorable; 
in severe cases, unfavorable; and in double cases, especially those which 
have originated under the influence of erysipelas, usually fatal. Al- 
though the pus may make its exit through the conjunctiva or eyelid, 
it may also pass backward through the sphenoid fissure. In pyemic 
cases, and, indeed, in the course of any severe inflammation of the 
cellulofatty tissue of the orbit, phlebitis of the orbital veins may become 
a complication and extend to the cavernous sinus, leading to a fatal 
termination. If the disease passes to the cavernous sinus upon the 
opposite side, the other eye also becomes involved and exophthalmos 
is evident. 
In framing a prognosis it is necessary to consider the effect of the 
disease upon the eyesight and upon the life of the patient. Sight may 
be impaired or destroyed by the development of optic neuritis, optic- 
nerve atrophy, exudation and hemorrhages into the retina, or by sup- 
puration of the cornea; life may be endangered by an extension of the 
suppurative process into the cranial cavity, or by the original malady 
which caused the cellulitis. 
Treatment.-The general treatment should include supporting 
measures and iron and quinin. Occasionally the pus points in the con- 
junctival sac and may be evacuated by an incision through the con- 
junctiva between the ball and the side of the orbit, care being taken 
not to injure the ocular muscles and to secure good drainage afterward. 
In deeper situations the purulent focus is best reached by a curved inci- 
sion made over the orbital ridge which divides the periosteum, which is 
next separated with an ordinary bone elevator, kept well between the 
bone and the periosteum, thus avoiding the levator, the tendon of the 
superior oblique, and the lacrimal gland. If pus does not immediately 
present, the depth of the orbit must be explored with a probe until the 
pocket of pus is found, and evacuated by an incision through the peri- 
osteum. Drainage may be secured with iodoform gauze or an ordinary 
drainage-tube. The position of the original incision is determined by 
the probable situation of the pus; that is to say, whether it is made 
along the upper, lower, inner, or outer orbital margin. If the source 
of the pus is from the ethmoid, the orbital plate of this bone should be 
perforated, carious bone and necrotic tissue removed, and a drainage- 
tube carried from the orbit, through the ethmoid, into the nose, which 
not only secures an adequate drainage, but permits the subsequent 578 
DISEASES OF THE ORBIT 
washing out of the tract. Indeed, the frequent association of sinus dis- 
ease with orbital cellulitis usually demands that the incision shall be 
so placed and sufficiently broad to render exploration of the orbital walls 
practicable and treatment of the affected sinus (frontal or ethmoid) 
possible. 
Inflammation of the Oculo=orbital Fascia (Tenonitis).-This 
affection is characterized by swelling of the upper lid, the discoloration 
of the tumefied lid being limited to its tarsal portion (Pincus); pain on 
the slightest movement of the eye, some proptosis and limitation of 
movement, together with the appearance of a watery nodule or vesicle 
situated over one of the recti muscles; in other cases the chemosis may 
be more general. Primary serous tenonitis is a rare disease, about 
40 cases being on record (Birch-Hirschfeld). Tenonitis may follow an 
injury or an operation-for instance, tenotomy; in some instances it is 
due to rheumatism, possibly to tuberculosis, and it has been noted as 
a sequel of diphtheria, typhoid fever, and epidemic influenza, and may 
be caused by syphilis. Lesions almost exactly analogous to those of 
tenonitis are occasionally caused by an intra-ocular growth; for example, 
a sarcoma (see page 362). 
The treatment should consist of warm fomentations and, according 
to the indications, iodid of potassium or the salicylates. 
Thrombosis of the Cavernous Sinus.-During phlegmonous 
inflammation of the orbit there may be thrombosis of the orbital veins, 
and extension from them to the cavernous sinus or to the other sinuses 
of the brain. Primary traumatic non-infective thrombosis of the cav- 
ernous sinus has been described by H. Knapp. Septic thrombosis of 
the cavernous sinus may arise as the result of any infected lesion in the 
area drained by the ophthalmic vein or its branches, for example, pus- 
tules on the face, nostrils, or eyelids, and from purulent affections of 
the accessory sinuses and rhinopharynx, and from erysipelas and 
wounds. According to St. Clair Thomson, next to disease of the 
sphenoidal sinus, pyogenic infection from the ear is the most common 
cause of thrombosis of the cavernous sinus. The ocular symptoms 
which accompany cavernous sinus thrombosis are: proptosis, edema 
of the eyelids and chemosis of the conjunctiva, haziness, anesthesia of 
the cornea, and partial or complete ophthalmoplegia-that is, gradual 
involvement of the third, fourth, and sixth nerves, venous engorgement 
of the retinal veins, and neuroretinitis. The general symptoms include 
headache, fever, delirium, coma, and convulsions. As the prognosis is 
extremely unfavorable, an operation designed to expose the sinus and 
remove the thrombus, the feasibility of which has been demonstrated 
(Hartley, Knapp), would seem to be proper. 
Tumors and Cysts of the Orbit.-Tumors have been divided by 
systematic writers into those which originate in the orbit, but are 
unconnected with the globe of the eye; those which arise from the 
periosteum or bony walls of the orbit; those which commenee in the 
cavities close to the orbit; and those which originate in some vas- 
cular disease within the cavity of the orbit or the neighboring por- TUMORS AND CYSTS OF THE ORBIT 
579 
tions of the cranial cavity, and which usually give rise to pulsating 
exophthalmos. 
Two classes of tumors, namely, those which arise from the optic 
nerve and those which arise from the lacrimal gland, are sometimes in- 
cluded among the orbital growths. They have already been discussed 
in another section. 
The nature of orbital tumors is either benign or malignant, and they 
may be congenital or acquired, primary or metastatic. 
Symptoms.-These vary according to the position, size, and density 
of the tumor, but in general terms are those which have been narrated 
as more or less common to all diseases of the orbit. With regard to the 
protrusion it may be said that a tumor within the cone of the recti 
muscles is apt to cause a forward displacement of the globe, while one 
situated outside of this cone may displace the eyeball in some particular 
direction. 
Considerable proptosis may occur under the influence of an orbital 
tumor without causing the globe to protrude between the fissure of the 
lids. This is due to the fact that the lids are extensible and accommo- 
date themselves to the increasing volume behind them; finally, however, 
the protrusion may be so great that the lids can no longer close over the 
prominent ball. 
Prognosis.-This depends upon the nature of the tumor, the density 
of its tissue, the rate of its growth, and the availability of surgical 
interference. 
Treatment.-In dealing with benign tumors and some encapsu- 
lated sarcomas the eyeball, if uninvolved, should be allowed to re- 
main, if possible; but if the tumor is malignant the eye should be 
excised, in most instances, with the entire contents of the orbit (see 
chapter on Operations). According to C. S. Bull, encapsulated tumors 
of the orbit may be removed with the almost certain hope of favor- 
able result, while non-encapsulated tumors present a most unfavor- 
able prognosis. After removal or in the event of a return, the a-rays 
should be employed. Recently radium has been used with success 
in the treatment of orbital growths. As was pointed out by Panas, 
Snell, and others, certain apparently organic tumors of the orbit, 
probably lymphomas, occasionally disappear under medicinal treat- 
ment-for example, iodid of potassium, arsenic, etc. Hence the neces- 
sity of careful medication before surgical measures are tried. The 
difficulty of distinguishing an orbital tumor from a chronic inflammatory 
process is often great and no method of diagnosis should be omitted, 
especially careful examination of the accessory sinuses. In this regard 
.T-ray examination is important. 
1. Tumors which Originate in the Tissues of the Orbit.-These in- 
clude cysts, fibromas, cavernous and simple angiomas, lymphangiomas, 
lipomas, enchondromas, lymphomas, cylindromas, endotheliomas, and 
various types of sarcoma. Discrete lymphoid infiltration of the orbit, 
causing proptosis, has been reported by Coats. Carcinoma, except 
in connection with the lacrimal gland, does not occur in this situation 580 
DISEASES OF THE ORBIT 
as a primary tumor; it may, arising from the lids or conjunctiva, grow 
inward and involve the orbit. In a total of 68 cases of metastatic 
carcinoma of the choroid there was in 13 of them an extra-ocular exten- 
sion of the growth from the focus in the choroid (Shumway). Metas- 
tasis of carcinoma from distant organs to the ocular muscles has been 
described (see page 535). Adrenal tumors in children, usually under 
four years of age, with metastasis to the orbit, have been reported 
(Quakenboss, Verhoeff). 
Sarcomas of the orbit may be primary or metastatic and may present 
the various types of cellular structure characteristic of these tumors. 
Some sarcomas of the orbit should be classified with the endotheliomas. 
If the morbid process is an extensive one, radical removal of the entire 
contents of the orbit is the only procedure, and subsequently the x-rays 
or, preferably, radium should be employed. Even in inoperable 
malignant disease of the orbit pain is lessened by the application of the 
Fig. 244.-Metastatic sarcoma of the 
orbit (from a patient under the care of Dr. 
Wharton in the Children's Hospital). 
Fig. 245.-Sarcoma of the orbit spring- 
ing from the periosteum over the great wing 
of the sphenoid. 
arrays, and the complete disappearance of sarcoma of the orbit, without 
operation, under the influence of repeated applications of Rontgen 
rays has been reported (L. W. Fox), and represents a therapeutic measure 
deserving of the most thorough trial. In like circumstances radium 
may be used. Encapsulated sarcomas may occasionally be removed 
with preservation of the eyeball. Traumatic sarcomas offer a most un- 
favorable prognosis, and operation hastens rather than retards the fatal 
issue. Sarcomas of the orbit should not be confounded with those 
which arise within the eveball and have burst their boundaries (see page 
362). 
Berlin divides orbital cysts into two principal groups, cephaloceles and 
true cysts. Cephaloceles are located at the root of the nose, and extend 
to the brow, nasal cavities, or orbit. Characteristic of cephaloceles and 
meningoceles is the fact that they present at the inner side of the orbit, 
that they fluctuate and are transparent. True cysts should be divided, TUMORS AND CYSTS OF THE ORBIT 
581 
according to Klingelhoffer, into (a) true cysts from constriction, which 
are derived from congenital meningoceles; (b) extravasation-cysts-that 
is to say, blood-cysts, hematomas, etc.; (c) exudation-cysts, which are 
very rare; (d) dermoids, which are the most frequent cystic tumors 
growing in the orbit; (e) mucous cysts, which may communicate with 
the nose, and (/) echinococcus cysts. Extravasated blood in the retro- 
bulbar tissue may become encapsulated and simulate a blood-cyst, 
and subperiosteal blood-cysts have been described (Denig, Lamb). 
Occasionally a simple incision suffices to cure a cyst if the cavity 
is afterward frequently syringed with an astringent or antiseptic lotion. 
After the evacuation of a dermoid cyst Buller recommended the intro- 
duction of a crystal of nitrate of silver or tincture of iodin to destroy the 
cyst wall. Usually the cyst wall must be dissected out, and, if semi- 
solid or solid contents are present, entire removal is necessary. Care 
must be taken not to confound a cephalocele with an orbital cyst. 
2. Tumors which Arise from the Periosteum or Bony Walls of the 
Orbit.-These include: 
(a) Sarcomas, which arise from the periosteum. 
(6) Thickening of the periosteum, which may simulate a true tumor, 
especially if the underlying bone is hypertrophied (hyperostoses: these 
may be multiple or diffuse), and- 
(c) Exostoses.--The latter are very hard tumors having an ivory- 
like shell and a nucleus of spongy bone, their anatomic structure in 
general being like that of the osteomas proceeding from adjacent 
cavities.1 All orbital osteomas grow slowly-the external exostoses 
more slowly than the bony tumors which originate from the frontal 
and ethmoid sinuses. They spring from the periosteum, and are gener- 
ally found at the upper border of the orbit, although they may occur at 
any portion of the orbital border, and are recognized by their dense 
hardness and evident connection with the bone. 
They may arise from injury; sometimes they are congenital, and 
often their origin is obscure. 
The operation for the removal of an exostosis, after its exposure by 
suitable incisions of the soft parts and periosteal covering, consists in 
drilling it away at the base and completing the separation by means of 
a hammer and chisel. An electric drill and saw is of special service in 
these operations. 
3. Tumors which Arise in Cavities or Tissues Close to the Orbit.- 
These include: 
(a) Encephalocele, a rare condition, which appears in the form of a 
somewhat pulsating, fluctuating protrusion at the inner angle of the 
orbit; it is of congenital origin (see also page 580). 
(6) Nevi, epithelioma, and lupus, which may extend from the skin 
of the face into the orbit. 
(c) Polypi from the nasal chambers and surrounding sinuses, and- 
(J) Osteomas of the frontal and ethmoid sinuses. 
1 For a valuable paper by J. A. Andrews, on "Osteomas of Orbit," see Medical Record, 
.September 3, 1887. 582 
DISEASES OF THE ORBIT 
An osteoma consists of a dense growth, with predominance of the 
ivory shell, and only a trace of spongy tissue (occasionally the reverse 
occurs). Generally the surface is covered with a delicate connective- 
tissue envelope, and part of this may be the seat of polypoid growths 
coming from the remains of the mucous membrane which atrophies under 
pressure of the tumor. 
According to Andrews, osteoma of the frontal sinus first makes 
its appearance by a tumor at the upper inner angle of the orbit, and may 
be associated with the formation of polypi and suppuration of the sinus. 
One which grows from the ethmoid sinus first appears at the inner 
angle of the orbit, and the eyeball is displaced laterally. 
If an osteoma springs from the antrum of Highmore, the tumor 
appears behind the lower eyelid, and the eyeball is displaced upward; 
if it arises in the sphenoid fis- 
sure, sight is affected by com- 
pression of the optic nerve. 
Extirpation of osteomas in 
the sinuses is attended with 
considerable risk, and a number 
of fatal cases are on record. 
4. Tumors which Originate 
in Some Vascular Disease within 
the Cavity of the Orbit or in 
the Neighboring Portions of the 
Cranial Cavity (Pulsating Ex- 
ophthalmos).-Under the name 
pulsating exophthalmos a num- 
ber of conditions of diverse 
origin have been described, and 
more than 300 cases are now 
on record. The conspicuous 
symptoms which may arise 
in the course of this disease, 
although, naturally, not all of 
them are present in each case, are as follows: Exophthalmos, most 
frequently with the eye displaced outward and downward; bruit, usually 
heard over the eye and above the orbit, but sometimes audible over the 
whole skull and evident to the patient in a roaring, humming, buzzing, 
or hissing sound; pulsation, which may be visible or demonstrable only 
by palpation, or by pressing the globe backward into the orbit; disten- 
tion of the veins at the inner angle of the orbit, especially enlargement of 
the angular vein, and of those of the lid and even of the forehead and 
on the surface of the conjunctiva; corneal complications, usually in the 
form of exposure keratitis; frequently hyperemia of the iris and rarely 
actual iritis; commonly hyperemia of the nerve-head, and, occasionally, 
optic neuritis and even choked disk; frequently marked distention of the 
retinal veins and scattered retinal hemorrhages; disturbances of ocular 
motility, sometimes so extensive as to implicate all of the exterior ocular 
Fig. 246.-Pulsating exophthalmos (from a 
case under the care of Dr. Kent Wheelock, Fort 
Wayne, Indiana). EXOPHTHALMIC GOITER 
583 
muscles, sometimes only one or other of them, the external rectus being 
the one most frequently affected where a single muscle is involved; 
occasional involvement of the trifacial, of the facial, and disturbances of 
taste, smell, and hearing. 
Formerly such symptoms were regarded as evidence of true aneurysm 
of the ophthalmic artery, but pulsating exophthalmos may also be due 
to a vascular tumor or an intracranial affection. As Rivington demon- 
strated, the affection may be caused by an extra-orbital aneurysm of the 
ophthalmic artery, aneurysm of the internal carotid, or an aneurysmal 
varix involving the internal carotid and the cavernous sinus.. The 
last-named lesion-arteriovenous communication-is the one most 
frequently responsible for these phenomena. Dilatation from obstruc- 
tion of the ophthalmic vein may cause the condition, but aneurysm by 
anastomosis, which may involve the orbit by spreading from neighbor- 
ing parts, is not accompanied by exophthalmos. Traumatism is re- 
sponsible for the majority of the cases, being the essential cause in 
about 60 per cent. 
Treatment.-This has included: (1) Ligation of the larger arteries 
of the neck; (2) operations upon the orbit; (3) compression of the com- 
mon carotid; (4) direct compression of the venous swellings of the 
eyelids and the angle of the orbit; (5) gelatin injections; (6) the admin- 
istration of certain drugs and rest in the recumbent posture. Of these 
various procedures, ligation of the common carotid and orbital operation 
furnish the most satisfactory results. According to the investigations of 
the author and Holloway in 1907, ligature of the common carotid had 
been performed one hundred and fifty times, with cure or improvement 
in 64.6 per cent., failure in 25.3 per cent., and death in 10 per cent, 
of the cases; in a certain number of them, about 10 of the total number, 
both carotids had been ligated. The orbital operations have included 
ligation of the superior ophthalmic vein, of the inferior ophthalmic 
vein, of the angular vein, and of the smaller orbital veins, and the results 
in almost all of the cases have been good. If ligature of a common 
carotid fails before a second carotid is tied, the operation of dissecting 
out and tying the distended superior ophthalmic vein should be per- 
formed. If there is a distinct venous swelling in the orbit, with evident 
distention of the angular or superior ophthalmic vein, the operation of 
choice should be isolation, ligature, and resection of this venous channel. 
It is not without danger, and the author is aware of one fatal case, death 
being due to extension backward of a thrombus into the brain. Com- 
pression of the common carotid, with or without the administration of 
iodid of potassium, has been successful in a few instances, and may be 
tried before radical surgical means are resorted to. 
Exophthalmic Goiter (Graves' Disease; Basedow's Disease).- 
This disease, when it is perfectly developed, is characterized by three 
cardinal symptoms-enlargement of the thyroid gland, palpitation of 
the heart, and prominence of the eyeballs. As the affection should be 
classified with diseases of the ductless glands, the student is referred for a 
full consideration of the subject to treatises upon the practice of medicine. 584 
DISEASES OF THE ORBIT 
Inasmuch, however, as one of the cardinal symptoms-prominence 
of the eyeballs-is a very marked one, and as there are certain changes 
seen especially in and around the eyes, a few words may be added. 
Exophthalmos varies from a mere prominence of the eyeballs, such, for 
instance, as is noticeable in a highly myopic globe, to a degree of pro- 
trusion so great that the eyelids are unable to close. Excessive epiphora 
may be present as an early symptom-i. e., before exophthalmos appears 
(Berger). Four symptoms should be searched for: 
1. Von Graefe's sign, which is very important in the early recog- 
nition of the disease. Normally, when the globe is turned downward, 
the upper lid moves in perfect accord with it; in this disease, on rolling 
the eyeball downward, the upper lid follows tardily, or does not move 
at all. The symptom is not always present, but it may be noted prior 
to any exophthalmos or at least when there is only a very trifling degree 
of this, and it persists after the protrusion of the eye has subsided. 
2. Stellwag's Sign.-This consists of imperfect power of winking or 
diminished frequency in the act; thus, there may be a number of rapid 
winks, succeeded by a long pause in which there is no movement of the 
lids, or each time that nictitation occurs, it is not complete and the 
margins of the lids do not, as in the normal eye, come together. 
3. Dalrymple's Sign (Cooper-Swanzy).-This consists of retraction 
of the upper eyelid so that there is an unnatural degree of separation 
between the margins of the two lids. The widening of the palpebral 
fissure produces the peculiar stare which is present in the subjects of 
exophthalmic goiter, and which has been compared to a similar appear- 
ance produced by the action of cocain.. 
4. Moebius' Sign.-This consists in an imperfect power, or in an 
entire absence, of convergence, and may be sought for in the usual 
manner (see page 74). A decided pigmentation of the skin of the 
eyelids is seen in some patients with exophthalmic goiter. Gifford 
calls attention to a symptom in exophthalmic goiter, namely, the diffi- 
culty of everting the upper eyelid, which may be present in the early 
stages of the malady. 
Changes in the Cornea.-The exposure to which the eye is subject 
and also the paralysis of the nervous supply may cause drying of the 
epithelium of the cornea, and ulceration of so violent a type as to 
produce destruction of the eye. New vessels may develop in the 
lower part of the cornea on account of its exposure through the 
widened palpebral fissure. These corneal changes necessarily occur in 
severe types of the disease where the protrusion of the eyeballs has 
been considerable. 
Ophthalmoscopic Changes.-These are not commonly present to 
any great degree except in so far as a change in the size of the retinal 
vessels is concerned. The arteries may be dilated and assume a caliber 
larger than normal, and equal to that of the veins. Spontaneous arterial 
pulsation is frequently present (Becker). Alterations in the optic nerve 
and in the general fundus are not usually found, and there are no changes 
in the eye-grounds characteristic of the disease. AFFECTIONS OR DISEASES OF THE SINUSES 
585 
Nature of the Disease.-The cause of exophthalmic goiter is not 
known; but there is little doubt that the symptoms of this disease de- 
pend upon a disturbed function of the thyroid gland, whereby there is 
excessive internal secretion from it, or entrance into the general system 
of more of its active principle than is normal (Hare). 
Treatment.-For the general treatment of exophthalmic goiter 
the student is referred to the text-books on general medicine, surgery, 
and neurology. Sympathectomy has been practised for the relief of 
exophthalmos. Partial thyroidectomy is usually performed and the 
operation meets with great success. If ulceration of the cornea occurs 
the usual treatment is applicable. To prevent exposure of the cornea, 
the widened palpebral fissure may be narrowed by the operation of 
tarsorrhaphy (see Fig. 269). 
Affections or Diseases of 
the Sinuses. - In discussing 
tumors of the orbit, it was noted 
that- growths from the frontal 
sinuses, the sphenoid fissure, the 
ethmoid cells, and the. antrum 
may encroach upon the orbit. 
The limits of this book do not 
permit a full consideration of 
this subject, for which the 
student must turn to special 
treatises. In addition to the 
morbid growths there remain to 
be briefly considered: 
1. Disease of the Frontal 
Sinus.-This is most often a 
distention of the frontal sinus 
by mucus (mucocele) or pus (em- 
pyema). Abscess has. been at- 
tributed to postnasal catarrh, 
syphilis, tuberculosis, and peri- 
ostitis, and is due to the stoppage 
of the normal outlet, thus causing 
the. accumulation, of secretion until the sinus becomes filled, its walls 
distended and thin, and a tumor presents, usually at the upper and inner 
angle of the orbit. It may occur under the influence of erysipelas, 
acute infectious diseases, and epidemic influenza. Sensitiveness on 
pressure- over the frontal bones and frontal headache or supra-orbital 
pain are common and somewhat characteristic symptoms, and are 
especially marked in acute frontal sinusitis. The protrusion may cause 
displacement, of the eyeball downward and outward and diplopia, and 
the pressure upon the lacrimal sac, epiphora. Coryza and purulent 
discharge from the nostril may be present. According to Bull, if a 
dense, hard swelling appears at the upper and inner angle of the orbit, 
which is slow in growth and painless, an osteoma of the sinus is almost 
Fig. 247.-Acute frontal and ethmoid 
sinusitis. Notice the edema of the lid and 
upper and inner portion of the orbit (from a 
patient in the University Hospital). 586 
DISEASES OF THE ORBIT 
certainly present. In rare instances the abscess in the sinus is bilateral. 
The a>rays should be used to establish a diagnosis between osteoma and 
mucocele of the sinus. A stereoscopic radiogram is essential in the study 
of accessory sinus disease, and careful transillumination of the region 
is required (see also Ophthalmodiaphanoscopy, page 110). 
The chronic variety of the disease may occur at any age except before 
the sixth year, because the sinus is not much developed until after that 
time of life. It is most frequent between twenty-five and thirty, and 
commoner in men than in women. 
The treatment consists in opening the abscess and washing out the 
sinus with a bichlorid solution. The incision may be made immediately 
beneath the superior orbital arch, directly outward, so that the bony 
wall of the sinus, which is here very thin, may be easily opened, if it has 
Fig. 248.-Introduction of drain- 
age-tube after evacuation of abscess 
caused by ethmoiditis. (A patient in 
the Philadelphia Polyclinic Hospital.) 
Fig. 249.*-'Ethmoiditis (from a patient in. the 
University Hospital). 
not already perforated. A. Knapp prefers that the external incision 
shall pass along the upper orbital border midway between the eyebrow 
and the bony orbital margin, and next along the inner wall and side of 
the nose to the floor of the orbit. This is better, in his opinion, than 
the Killian incision through the eyebrow. After the wall of the sinus 
has been perforated the contents of the cavity should be carefully 
removed. The communication between the sinus and the nose should 
then be re-established, and a drainage-tube passed from the orbit, 
through the opening, into the nose, or a gauze drain may be passed 
from without into the sinus at its nasal angle (Knapp). 
2. Disease of the Ethmoid.-A common disease of the ethmoid 
cells is caused by a retention of secretion in them-that is, adopting 
H. Knapp's phraseology, a retention-cyst develops. In these circum- 
stances the growth appears at the upper and inner angle of the orbit. AFFECTIONS OR DISEASES OF THE SINUSES 
587 
above and behind the internal canthal ligament, and displaces the eye- 
ball downward and outward. It may not be possible to differentiate 
this mucocele from an exostosis until an exploratory incision is made. 
With ethmoiditis there may also be tumefaction, especially of the inner 
third of the lid, imperfect movement of the eyeball with diplopia, severe 
neuralgic pain, and profuse lacrimation. The last-named symptom may 
cause the affection to be mistaken for dacryocystitis. In purulent dis- 
ease of the ethmoid cells the natural escape for the pus is into the nasal 
cavity, where it can be seen beneath the middle turbinated body, or 
between this structure and the septa; but, as Bosworth remarks, this 
is by no means its invariable course. In a large number of cases pus 
escapes through the os planum into the orbital cavity, giving rise to 
exophthalmos and orbital abscess. The purulent collection should be 
evacuated by a free incision, so placed as to expose the os planum of the 
ethmoid. After all necrotic and carious tissue is removed, an opening 
should be forced into the nose. Through it a drainage-tube should 
Fig. 250.-Purulent disease of ethmoid and frontal sinus, with fistulous opening at inner 
angle of orbit (from a patient in the University Hospital). 
be passed, by means of which the cavities can be frequently cleansed 
with a bichlorid or other antiseptic solution. 
Fistula of the orbit, presenting above the internal canthal ligament, 
may be due to disease of the frontal sinus or of the ethmoid, and par- 
ticularly to disease of the lacrimal division of the anterior ethmoid 
cells. Cases of this character are often mistaken for lacrimal disease, 
and, in fact, they present some of the characteristics of the so-called 
prelacrimal sac abscess. A cure may be effected by forcing with a 
strong probe, as Gruening suggested, an opening through the base of 
the. fistula into the nasal cavity, thus facilitating drainage through 
the nose, or, better, by free exploration of the affected sinuses by means 
of a Killian or Knapp procedure. 
3. Disease of the'Sphenoid Sinus?-Empyema of the sphenoid 
sinus may exist alone, or more often in association with suppuration 
in the ethmoid cells, and may appear in an acute or chronic form. A 
diagnosis can often be made by catheterization of the sinus. It is of 
particular ophthalmologic interest on account of the intimate relation 588 
DISEASES OF THE ORBIT 
between the walls of the sphenoid cavity and the optic nerve (the optic 
nerve may even be free in the sphenoid sinus [Onodi]), and an almost 
necessary symptom is some form of optic neuritis, either retrobulbar 
or localized in the nerve-head itself. Optic-nerve disease should always 
lead the surgeon to take the sphenoid sinus into serious account (see 
also page 589). 
In any case of suspected sinus disease a stereoscopic x-ray plate 
should be prepared; this frequently will give accurate information with 
respect to the size, condition, and the contents of the accessory nasal 
sinuses. 
Other diseases of this re- 
gion are polypi, osteomas, and 
hyperostoses. 
Fig. 251.-Sarcoma of the orbit 
and postnasal space. (From a patient 
under the care of Dr. Wm. Zentmayer). 
Fig. 252..-Exophthalmos from tumor of an- 
trum which involved the orbit (from a patient in 
the Jefferson Hospital under the care of Dr. J. 
Chalmers DaCosta). 
4. Disease of the Antrum.-Empyema of the antrum is not an 
uncommon affection, and although it does not belong to the domain of 
ophthalmology, it is sometimes accompanied by marked ocular signs. 
In addition to the pain located in the cheek, frequently periodic in char- 
acter, together with the escape of pus from the antrum, there may be a 
marked edema of the lids, which, if the disease is of long standing, 
assumes a positively brawny consistency. Dr. Walter Freeman in- 
forms the author that he has seen this edema of the lids when only a 
few drops of pus have been present in the cavity of the antrum. There 
may also be chemosis of the conjunctiva and some edema of the optic 
nerve and overfilling of the retinal veins. A persistent edema of the 
eyelids not otherwise explained should lead the surgeon to make a 
thorough examination of the antral cavity. A certain number of cases 
of lacrimal disease presenting in the ordinary forms of dacryocystitis 
are connected with antral affections. AFFECTIONS OR DISEASES OF THE SINUSES 
589 
Growths in the antrum-sarcoma, fibroma, and polypi-may involve 
the orbit and produce exophthalmos, or more often displacement of the 
eyeball upward and outward. 
The Ocular Complications of Diseases of the Nasal Accessory 
Sinuses.-The relation of diseases of the nasal accessory sinuses to 
diseases of the eye has been referred to in preceding pages in the de- 
scription of various ocular lesions, notably those which occur in the 
optic nerve, but for convenience of reference they are redescribed in the 
following paragraphs: 
(1) Lids and Conjunctiva.--Edema of the lid is a common symptom 
of frontal and ethmoidal sinus disease, either the ordinary variety, or 
else a recurring painful form, fugitive in character and associated with 
violent headache. Watering of the eye, conjunctival congestion, dis- 
tinct catarrhal conjunctivitis, and deep-seated scleral congestions, 
sometimes fugacious, and often accompanied by intense headache, 
ocular pain and slight edema of the corneal epithelium, have been noted 
as frequent symptoms of sinusitis, especially in its acute or early stages. 
(2) The Cornea and Uveal Tract- Keratitis, corneal ulcers, iritis, 
uveitis, choroiditis, and vitreous opacities may be due to sinus disease. 
A form of cyclitis with vitreous opacities, which seems to be due to nasal 
accessory sinus disease, is described by Kuhnt. (See also page 326.) 
(3) Retina and Optic Nerve.-The most important group of ocular 
complications of nasal sinus disease are those in which there is sinusitis 
without external signs of orbital inflammation, but in which there are 
optic neuritis, neuroretinitis, retinal thrombosis, and phlebitis, or in 
which, without marked ophthalmoscopic changes, there is a central 
scotoma. In some cases a typical acute retrobulbar neuritis arises, with 
all of the symptoms which have been detailed on page 488, while in 
others the retrobulbar neuritis manifests its presence by a relative 
central scotoma, with intact outlines of the visual field; later the scotoma 
becomes absolute and the field of vision contracts. The scotoma may 
be unilateral, the more usual condition, or bilateral, and most fre- 
quently depends upon disease of the posterior ethmoidal cells or of the 
sphenoid sinus. Occasionally the scotoma assumes a circular or annu»- 
lar shape. The investigations of Onodi have shown that the optic nerve 
often is in close relation with these posterior ethmoidal cells, and that the 
thinness of the intervening wall renders involvement easy, even easier, 
it is probable, than in the case of the sphenoid, which anatomically 
may come in close relationship with the nerve and form the inner wall, 
or the lower and inner wall, of the optic canal. According to Birch- 
Hirschfeld, the nerve lesions consist in edema, swelling and prolifera- 
tion of the glia cells, and destruction of the nerve-fibers. These he 
attributes to venous stasis, and also to toxic agencies. In a certain 
number of cases the ophthalmoscope reveals the usual picture of optic 
neuritis, or papillitis, with central scotoma, especially, as in a case 
recorded by A. Knapp, if the anterior ethmoidal cells are infected, and 
the author has seen elaborate optic neuritis followed by optic nerve 
atrophy, with extensive disease of the ethmoid, frontal, and sphenoid 590 
DISEASES OF THE ORBIT 
sinus, and sphenoid-sinus disease in which the scotoma assumed the 
form of the so-called hemiopic paracentral scotoma. The visual fields in 
disease of the sphenoid sinus may exhibit alterations analogous to those 
in affections of the pituitary body, for example, bitemporal hemianopsia. 
If the cause of these optic nerve complications is not recognized and 
speedily removed, either by suitable intranasal drainage, with or with- 
out operation, blindness from optic-nerve atrophy is likely to result. 
An important symptom of posterior accessory sinus disease, described 
by J. Van der Hoeve, is enlargement of the blind-spot for white and colors. 
This observation has been confirmed by de Kleijn, the author, and a 
number of others who have investigated the subject. The enlargement 
of the blind-spot is attributed by Van der Hoeve to involvement of the 
peripapillary bundle, which may be the first portion affected in retro- 
bulbar neuritis. If no other cause for such increase in the size of the 
blind-spot can be found, Van der Hoeve considers it to be a symptom 
which justifies operation on the affected sinus. 
(4) Orbit and Lacrimal Region.-A mucocele of the ethmoid or 
frontal sinus may cause mechanical displacement of the orbital contents 
and exophthalmos, and Birch-Hirschfeld's investigations have shown 
that nearly 60 per cent, of the cases of orbital inflammation which he has 
analyzed were due to accessory sinus inflammation. The infection may 
cause a periostitis over the floor of the frontal sinus or over the os 
planum, and bring about exophthalmos. This may disappear on treat- 
ment, or a subperiosteal abscess may develop, which remains encapsu- 
lated, or which, by extension, may perforate the skin of the eyelid, 
leaving an orbital fistula. Such periosteal orbital abscesses are fre- 
quent in children, the infection being transmitted by the ethmoid 
labyrinth (A. Knapp). Reber concludes from his studies that infection 
may reach the orbit (a) by direct continuity, (6) by way of the venous 
circulation, and (c) by way of the lymphatics. The last-named route 
has not been positively demonstrated. 
Finally, there may be involvement of the orbital structures them- 
selves, resulting in cellulitis or abscess, either with or without optic nerve 
inflammation. Extension of antral disease into the orbit is less common 
and rarely occurs, according to A. Knapp, except through the intermedia- 
tion of the ethmoidal cells, but both with antral and with ethmoidal in- 
fection the symptoms of dacryocystitis may appear, and not infrequently 
the mistake is made of treating as a dacryocystitis a manifestation of 
sinusitis. 
Other complications which have been recorded are glaucoma and 
detachment of the retina. The former affection does not occur from 
sinus disease unless the eye is predisposed to increased intra-ocular ten- 
sion (Kuhnt). Intense neuralgia, both ciliary and postocular, stubborn 
asthenopia, and contraction of the visual field have been attributed to 
the same cause, dependent, according to Kuhnt, on absorptions of toxins 
from the purulent processes in the sinuses. 
Palsy of exterior ocular muscles, notably of the superior oblique, may 
be caused by sinus disease. The author has observed isolated palsy of DISLOCATION OF THE EYEBALL 
591 
the internus due to ethmoiditis, and certain exterior ocular muscle 
palsies formerly attributed to rheumatism are doubtless due to sinusitis. 
Evidently in the presence of any of these conditions, notably per- 
sistent or recurring edema of the lids, fugitive episcleral congestion, 
retrobulbar neuritis, both acute and chronic, unexplained failure of 
vision with central scotomas, and stubborn ciliary neuralgia with per- 
sistent asthenopia, expert examination of the sinuses is demanded, not 
only with all of the means at the disposal of rhinologists, but notably 
with the aid of the arrays, and, in some cases, even if the results of 
ordinary examination are negative, especially in the presence of the optic 
nerve complications, exploratory orbital incisions and investigation of 
the sinuses through them are justified. The diagnostic value of Van 
der Hoeve's scotoma has been explained (see page 590). 
Although the ocular manifestations of sinus disease are often marked, 
it should be remembered, as Sattler points out, that excessive dilatation 
of the pneumatic sinuses of the skull may pursue an entirely latent 
course and cause no very decided eye symptoms. 
Injuries to the Orbit.-These include fracture of its bony walls, 
penetrating wounds, the lodgment of foreign bodies, and contusions. 
The effects of an injury of the orbit depend very much upon the char- 
acter of the wound and the missile which has produced it. The injury 
may lead to a phlegmonous inflammation, to hemorrhage within the tis- 
sues, and to loss of sight because of rupture of the eyeball or injury of 
the optic nerve. There are likely to be, according to the circumstances, 
exophthalmos, displacement of the eyeball, and diplopia. Hemorrhage 
into the orbit, especially beneath Tenon's capsule, will be referred to 
again as an accident which complicates strabismus operations. 
Treatment.-After a penetrating wound a careful search for a 
foreign body should be made. In a number of instances extraordinary 
foreign bodies have been found in the orbit, and, curiously enough, very 
remarkable toleration of the presence of such bodies. If the penetrat- 
ing wound has cut off the attachment of one of the ocular muscles and 
the patient is seen soon enough, an endeavor should be made to suture 
the detached ends. In cases of excessive hemorrhage within the orbit 
it may be necessary to make an incision and remove the escaped blood. 
a-Ray examination naturally furnishes a means of detecting foreign 
bodies in the orbit. 
Dislocation of the Eyeball.-The eyeball may be dislocated be- 
tween the lids, which are contracted behind it. It is a rare form of 
injury. An eyeball may purposely be pried from its socket by means of 
a thumb thrust into the orbit from the outer side. Luxation of the globe 
as a self-inflicted injury has been observed among the insane. The 
result of such an accident may be laceration of the optic nerve and de- 
struction of sight. In other instances the vision has remained un- 
affected. In certain cases of exophthalmos it is possible to produce 
this dislocation by pressure upon the globe with the thumbs, the relaxed 
muscles permitting the eyeball to protrude between the lids. The eye 
should be replaced and bandaged; it may be necessary to divide the ex- 
ternal commissure. 592 
DISEASES OF THE ORBIT 
Enophthalmos, or retraction of the eyeball, occurs both as an 
idiopathic and a traumatic affection. Exophthalmos the result of ex- 
hausting diseases is more apparent than real, but a true sinking of the 
globe, producing an appearance not unlike that caused by a badly 
fitting artificial eye (Nieden), may follow a traumatism in the neigh- 
borhood of the orbit (Fig. 253). 
This retraction of the eyeball may immediately follow the injury, 
or be delayed for days or even months. According to the conditions 
which are present, it has been ascribed 
to paralysis of Muller's orbital muscle 
from lesion of the sympathetic (Schap- 
ringer); to atrophy of the retrobulbar 
cellular tissue caused by trophic nerve 
disturbance (Beer); to fracture and 
depression of the orbital bones with 
cicatricial adhesion or contraction; and 
to injury of Tenon's capsule and the 
check ligaments (W. J. Shoemaker). 
It may be associated with palsy of 
the inferior oblique (Fuchs, Sachs). 
Exophthalmos caused by paralysis 
of the ocular muscles, tenotomies for 
the relief of strabismus, Graves' dis- 
ease, orbital disease, orbital growths, 
and affections of the nasal accessory 
sinuses has been referred to. It may 
also occur as the result of irritation of the cervical sympathetic under the 
influence of certain poisons, notably thyroid extract and paraphenylen- 
diamin, in acromegaly, myelitis, and certain tumors of the brain, notably 
those which are situated in the neighborhood of the third ventricle and 
in the middle fossa of the skull. (See also Proptosis, page 88.) 
Hemorrhage into the orbit causing exophthalmos takes place in cer- 
tain diseases-e. g., scorbutus and hemophilia-and has been noted in 
a recurring form in arteriorenal disease. The proptosis in subjects of 
infantile scurvy is sometimes associated with hemorrhage beneath the 
skin of the eyelids and the conjunctiva. 
Intermittent exophthalmos is a rare affection, about 60 cases being 
on record. It has been well described in this country by Posey. The 
characteristic symptoms are a more or less rapid, steadily forward 
movement of one eye when the head is placed in a dependent position, 
or when the flow of blood from the head to the trunk is impeded to any 
extent. In other circumstances the eye usually presents a normal 
appearance, or, on the subsidence of the exophthalmos, there may be 
a slight enophthalmos. According to Birch-Hirschfeld, intermittent 
exophthalmos depends upon a varix of the orbital veins, the origin of 
which may be congenital, although usually the venous stasis does not 
take place until later in life, and occurs under the influence of the 
mechanical factors to which reference has been made. 
Fig. 253.-Traumatic enophthal- 
mos, patient looking straight forward; 
sunken appearance, resembling a 
badly fitting artificial eye, well shown. CHAPTER XXII 
OPERATIONS 
Ophthalmic surgeons, in so far as the preparation of their hands, 
gowns, operating-rooms, and surroundings is concerned, naturally follow 
the strict rules of modern surgery. 
Preparation of the Skin of the Region of Operation.-The skin 
should be treated first with soap and water, then with alcohol, and 
finally with corrosive sublimate (1 :2000). These irritating sub- 
stances must not enter the conjunctival sac, but the face, surface of the 
closed lids, eyebrows, brow, and scalp should be thus prepared. The 
ciliary margins should be carefully cleansed with soap and water, fol- 
lowed by bichlorid of mercury (1 :5000). The parts should be kept 
covered with a compress of lint soaked in the bichlorid solution until 
the operation begins. In place of this preparation the eyelids may be 
cleansed with benzine on a cotton swab, to be followed by a thorough 
washing with fluid neutral soap. This is the practice in Fuchs' clinic. 
The preparation of the conjunctival sac depends upon the nature of 
the operation (see page 652). 
Preparation of the Instruments.-All coarse instruments, such 
as hooks, scissors, etc., should be boiled for at least ten minutes in the 
usual manner in a sterilizer. 
Sharp instruments-cataract knives, keratomes, cystotomes, etc.- 
must be cleansed with great caution lest damage be done to their 
edges. First the edge of the instrument is inspected with a magnifying 
glass, next the instrument, wrapped in cotton, is put into boiling water 
for five minutes, and from this transferred to a dish containing abso- 
lute alcohol, carefully wiped with the cotton saturated in the alcohol, 
and finally placed in a tray of sterile water. Just before the operation 
begins, it is removed from the water, thoroughly dried, laid upon a layer 
of sterile gauze, and covered with another layer of the same material. 
As boiling is likely to spoil the edges of sharp instruments, Stroschein 
believes that it is sufficient to rub them with cotton-wool soaked in a 
mixture of equal parts of alcohol and ether, and subsequently to wash 
them in a 5 per cent, solution of carbolic acid. 
Dressings.-These must be modified according to circumstances. 
In plastic operations about the lids the ordinary dressings-that is to 
say, steam- or heat-sterilized gauze-may be applied, held in place with 
a sterile gauze roller. Iodoform gauze is occasionally useful in packing 
the orbit after evisceration, although ordinary sterile gauze yields equally 
satisfactory results. 
If a wet dressing is desired, the fabric may be soaked in bichlorid 
solution (1 : 5000), saturated boric acid solution, or in a physiologic salt 
593 594 
OPERATIONS 
solution which has been sterilized by boiling, the last preparation being 
especially valuable if skin-grafting has been employed. Bits of sterile 
gauze or tightly packed pledgets of cotton wrung out from a 1 : 5000 
Fig. 254.-Figure-of-8 of one eye. 
Fig. 255.-Figure-of-8 of both eyes. 
bichlorid solution are useful for removing blood, etc., from the area of 
operation. The various dressings used after cataract extraction, iri- 
dectomy, etc., will be described in another section (see page 576). 
Either a single or double gauze 
bandage may be employed, or a modi- 
fication of Liebreich's bandage. 
Sutures.-These may be of catgut 
or of silk. In the author's opinion silk 
is always the preferable material, and 
black silk is more satisfactory on account 
of the ease with which it can be detected 
when the time comes for its removal. 
General Anesthesia.-The indica- 
tions for general anesthesia in ophthal- 
mic surgery are limited. In children or 
in nervous adults, and for enucleations, 
eviscerations, etc., blepharoplastic opera- 
tions, occasionally in advancements of 
the muscles, and in most cases of glau- 
coma, general anesthesia is necessary. 
The surgeon must decide between ether 
and chloroform. 
The author prefers to use the former, as it is safer than chloroform or 
the mixture of chloroform, ether, and alcohol. Bromid of ethyl has 
been recommended. The author has not been favorably impressed with 
this anesthetic. The practice of beginning an anesthesia with nitrous 
oxid, which is to be continued with ether or chloroform, obviously pos- 
sesses many advantages. Primary inhalation of ethyl-chlorid is com- 
Fig. 256.-Modified Liebreich's 
bandage. LOCAL ANESTHESIA AND ANALGESIA 
595 
mended by some surgeons. With scopolamm-morphin anesthesia, 
sometimes employed in surgical operations, the author has had no ex- 
perience, nor has he had experience 'with intravenous injections of 
ether. 
Local Anesthesia and Analgesia.-1. Cocain.-Hydrochlorate of 
cocain is usually employed in a 2 or 4 per cent, solution. A 10 per cent, 
solution has been advised in the operation of curetting lupus and simi- 
lar growths. General anesthesia is more satisfactory. Cocain causes 
drying and roughening of the corneal epithelium. This may be partly 
avoided by keeping the lids, closed after each instillation. The drug 
should not be used too freely, or it may, according to Mellinger, prevent 
closure of the corneal wound. Gelatin disks impregnated with cocain, 
as recommended by some surgeons, have no advantage over a solution 
of the drug. For thorough local anesthesia Haab recommends the 
application of a thin, layer of cocain in crystals. Various fungi grow 
readily in solutions of this alkaloid, and, indeed, in solutions of any of 
the alkaloids commonly used in ophthalmic practice. A number of 
methods of sterilization are employed, namely, sterilization by heat, by 
the addition of an antiseptic (a 1 : 5000 solution of bichlorid of mercury, 
4 per cent, of boric acid, or trikresol, 1 : 1000, 
as was suggested by Dr. E. A. de Schweinitz, 
or by the combination of these two methods). 
The best method, however, is to boil the solu- 
tion. A number of convenient flasks designed 
for this purpose are on the market, among the 
best being those introduced by Dr. Stroschein, 
of Wurzburg (since improved and modified 
by Sidler-Huguenin), and the one devised by 
Llewellyn, of Philadelphia (Fig. 257). The 
solution is placed in the latter flask and boiled. 
After the liquid is cool and ready for use, the 
warmth of the hand causes the fluid to drop 
from' the end of the pipet. If it is desired to preserve the solution 
after boiling, a portion of one of the antiseptic substances previously 
mentioned may be added. Boiling is apt to decompose cocain and 
destroy its anesthetic value. 
2. Novocain, although inferior to cocain as an ocular anesthetic, has 
certain advantages in that its solutions may be sterilized by boiling and 
it is much less toxic. It may be used in a'l or 2 per cent, solution, 
and is employed with advantage in infiltration anesthesia. For this 
purpose it may be combined with adrenalin. 
3. Eucain may be obtained in the form of hydrochlorate of eucain 
"A," which in 2 per cent, solution is an efficient anesthetic, but pro- 
duces disagreeable congestion of the conjunctiva, and in the form of 
hydrochlorate of eucain "B," which is related to eucain "A," and also to 
cocain and tropacocain. It is not decomposed by boiling, and in 2 per 
cent, solution is an active anesthetic which does not dilate the pupil and 
is said not to cause clouding of the corneal epithelium. 
Fig. 257.-Flask for steril- 
izing collyria. 596 
OPERATIONS 
4. Holocain.-A 1 per cent, solution of this drug causes anesthesia 
in from fifteen seconds to one minute, which lasts for about ten minutes, 
preceded by a moderate burning sensation. It is an admirable local 
anesthetic, and its solution does not enlarge the pupil, does not affect 
accommodation nor increase intra-ocular tension, and is said to possess 
bactericidal properties (Randolph). It is preferred by many surgeons 
to cocain in operations on the eyeball, for example, cataract extraction. 
Its value as an application to corneal ulceration has been described. A 
mixture of cocain and holocain is also employed. 
5. Acoin.-This drug is related to caffein and theobromin, and, 
according to Randolph's experiments, is an active local anesthetic in 
unirritated eyes in solutions of 1 : 100 and 1 :300. It has no effect 
upon accommodation, the size of the pupil, and does not increase intra- 
ocular tension or cloud the corneal epithelium. In congested eyes even 
repeated instillations of acoin do not produce satisfactory anesthesia. 
By some Continental observers it has been advocated as an anesthetic 
to prevent the pain of subconjunctival injections. 
6. Stovain.-This drug in 4 per cent, solution, dropped on the 
conjunctiva, causes smarting, burning, and lacrimation, followed by 
anesthesia, which lasts for about five minutes. It has little or no in- 
fluence on the pupil and does not cause paresis of accommodation. 
In aqueous solution it is not altered by boiling, which renders its steriliza- 
tion convenient. It has also been used as an injection into the tissues to 
produce local anesthesia. The author has had no experience with the 
drug. 
7. Alypin.-This synthetic compound is a glycerin derivative. A 
2 per cent, solution instilled into the conjunctival sac causes slight 
smarting, some dilatation of the superficial vessels, especially those 
around the cornea, and anesthesia, which is evident in about one 
minute (Stephenson). It apparently does not dilate the pupil, and is 
said to have no influence on accommodation. 
8. Dionin.-This is a morphin derivative, which produces, a few 
seconds after its instillation into the conjunctival sac, smarting, burn- 
ing, stinging, and marked edema of the conjunctiva, especially of that 
of the bulbar expansion. Occasionally the lid participates in the 
swelling, and not rarely the "dionin reaction" is severe. Soon the eye 
establishes immunity, and after a few applications on succeeding days 
the reaction is little marked and sometimes does not take place. Within 
twenty minutes the edema of the primary reaction subsides and anal- 
gesia appears, which may last for several hours. The drug is a lympha- 
gogue, an analgesic, and probably has some influence in altering and 
conserving the nutrition of certain tissues, for example, the cornea. Its 
lymphagogue action is the important therapeutic one. Its indications 
have been described with the various diseases, and it is especially valu- 
able in the treatment of certain types of ulcerative and parenchymatous 
keratitis, iridocyclitis, and glaucoma. The author employs the drug in 
a solution varying in strength from 1 to 5 per cent., according to the 
indications, from once to four times per diem until immunity is estab- siegrist's method of local anesthesia 
597 
lished; the drug is now discontinued for three days; at the expiration 
of this time a modified reaction will again usually appear. If it is urgent 
that the drug shall be continued after immunity is established, the 
strength of the drug is increased, but never beyond 10 per cent. It 
may also be employed in salve or powder. It is an exceedingly valuable 
remedy; occasionally it produces serious reaction; rarely it aggravates 
existing conditions, especially if the patients are the subjects of arterio- 
sclerosis and renal disease. The value of the drug may be enhanced by 
preceding its application with holocain and following it with adrenalin- 
chlorid. Dionin, although an analgesic, is not a local anesthetic, and in 
that sense does not belong to those drugs which are used to produce 
insensitiveness of the tissue with which they come in contact. 
With peronin, which is.related to benzol and morphin, and has an 
anesthetic as well as a miotic action, and which has been advocated 
in glaucoma, and with yohimbin, which is a local anesthetic and which 
has been investigated in this country by Claiborne, the author has had 
no experience. 
Infiltration Anesthesia.-In lid operations cocain solution (1 to 
2 per cent.) or novocain solution may be injected beneath the skin 
(holocain cannot be used for this purpose), but probably a more effi- 
cacious and safer procedure is the so-called infiltration anesthesia 
introduced by C. L. Schleich. This consists of an intracutaneous (not 
subcutaneous) injection with a hypodermic syringe, or with one spe- 
cially devised for the purpose, of a 0.2 per cent, solution of sodium 
chlorid, which is reinforced by the addition of from to of 1 per 
cent, of cocain. The fluid injected produces edema, and the anesthesia 
is strictly limited to the edematous area. 
A mixture of beta-eucain and cocain may be employed for local 
anesthesia, and very satisfactory results can be produced with beta- 
eucain and adrenalin-chlorid. Arthur E. J. Barker's solution is as 
follows: 
Pure chlorid of sodium 0.8 gm. 
Beta-eucain 0.2 " 
Adrenalin-chlorid 0.001 " 
Distilled water 100.00 " 
The efficiency of this solution can be still further enhanced by 
adding cocain (H. C. Wood). A 1 per cent, solution of cocain to which 
4 minims (0.24 c.c.) of adrenalin (1 :1000) are added is a useful mixture 
for local anesthesia (Meller). Pooley recommends the following formula: 
Alypin, 15| grains (1 gm.); sodium chlorid, 12 grains (0.78 gm.); adre- 
nalin, 10 minims (0.6 c.c.); distilled water, 3| ounces (104 c.c.). 
Siegrist's Method of Local Anesthesia.-The fluid consists of a 
1 or 2 per cent, solution of novocain, to which, after sterilization, a 
few drops of adrenalin (1 : 1000) are added. In enucleation of the 
eyeball the method is as follows: After the conjunctival sac has 
been anesthetized in the usual manner, with a curved canula-needle 
attached to a glass syringe of 2-c.c. capacity, two injections are made 598 
OPERATIONS 
into the posterior part of the orbital cavity behind the eyeball, the 
needle being inserted on the nasal and temporal sides below the hori- 
zontal line, so that it shall not pass through the muscles. Four instead 
of two deep injections may be made, up, down, in and out, 0.75 c.c. 
of the fluid being used at each point. Because Seidel has found that 
this method does not always create satisfactory anesthesia, he has modi- 
fied it in that with a straight needle he injects 1 to 2 c.c. of the novocain- 
adrenalin solution around the cornea, 4 mm. from its border. Next 
four deep injections are made, the needle being inserted upward, down- 
ward, outward, and inward over the muscular insertions to a point mid- 
way between the optic nerve entrance and the optic foramen. Each 
injection should contain 1 c.c. of the solution. The immediate results 
are edema of the lids and exophthalmos, which may be reduced by 
pressure. Elschnig produces local anesthesia by deep injections in the 
neighborhood of the ciliary ganglion. This form of anesthesia may be 
employed in ordinary enucleations, save only that it is not satisfactory 
in children and nervous persons, nor should it be used if the eyeball is 
badly shattered or in a state of panophthalmitis. 
Local Hemostasis.-For the purpose of producing a hemostatic 
and astringent action the surgeon may employ various preparations of 
the suprarenal capsule, as originally suggested by Dr. Bates, of New 
York. The dried and powdered gland (1 part to 10 parts of water) has 
been used; other preparations are atrabilin and suprarenin. The most 
satisfactory preparation (containing the principle isolated by Takamine) 
is adrenalin-Mor id. It is efficacious in a solution of 1 : 10,000, and 
is active in even w'eaker solutions. This preparation is used for control- 
ling hemorrhage during slight operations on the eye, for example, 
tenotomies, excision of pterygia, etc.; for temporarily blanching a con- 
gested conjunctiva, and specially, if it is desired to differentiate the 
types of injection in the different sets of vessels (see page 49); as an 
adjuvant to the physiologic action of certain remedies, for example, 
eserin in glaucoma, atropin in iritis, etc.; to enhance the value of certain 
subcutaneous injections for the purpose of producing local anesthesia 
and controlling hemorrhage (see page 597); and, finally, as a thera- 
peutic agent, the indications for which have already been given. 
OPERATIONS UPON THE EYELIDS 
Epilation of the Eyelashes.-Removal of the lashes is performed 
with forceps known as cilium forceps (Fig. 258). 
Fig. 258.-Cilium forceps. 
The patient being seated in good light, the operator with the fingers of one 
hand puts the lid upon a stretch, at the same time slightly everting its border. The 
faulty cilia are firmly seized and pulled out with a quick motion. After those which OPERATIONS FOR PTOSIS 
599 
are readily seen have been removed, search should be made (with a loupe) for others 
which may have been broken off, leaving small but irritating ends, and for very fine 
white hairs which, owing to their lack of color, may escape detection with the unaided 
eye. 
Removal of a Meibomian Cyst.-This may be removed by a 
conjunctival incision. A sharp scalpel and small curet are required. 
The lid is everted, and the discolored patch marking the position of the chalazion 
is made prominent. This is incised, and the contents are scraped out with the curet. 
Fig. 259.-Chalazion curet. 
The cavity thus formed fills with blood, the absorption of which may be hastened by 
the use of hot compresses. This operation may leave a slight linear scar in the con- 
junctiva (Fig. 260). 
To avoid this the lid may be grasped between the thumb and forefinger, and 
by pressure a drop of the jelly-like contents made to appear at the mouth of the 
Meibomian duct. A few drops of cocain solution are injected by means of a hypo- 
dermic syringe the needle of which is pushed into the tumor along the duct. An 
incision is now made with a Graefe knife, following the course of the needle. A 
small curet is introduced, and the contents of 
the cyst are removed (Agnew-Ray). The 
subsequent blood-clot is absorbed. 
External chalazion should be re- 
moved through a skin incision, the lid 
being steadied in a clamp (Fig. 261), 
and the cyst dissected from its bed in 
the ordinary manner. 
Fig. 260.-Incision of a chalazion 
(Czermak). 
Fig. 261.-Knapp's lid clamp. 
Operations for Ptosis.-Before operating for the relief of ptosis 
the amount of power residing in the levator, or whether it has any activity 
at all, must be ascertained. The surgeon, standing in front of the pa- 
tient, firmly depresses the eyebrow with his thumb and requires the 
subject to open his eyes. Any movement of the lid must be due to the 
levator, as the pressure on the brow checks the frontalis action; entire 
failure of lid elevation indicates absence of levator power. If, the fron- 
talis action still being checked and the levator power absent, there is 
slight elevation of the lid when the eye is rolled upward, it is due to the 
action of the superior rectus, from which a band passes to the levator 
tendon. 600 
OPERATIONS 
All operations for the relief of ptosis, and many have been devised, 
may be gathered into three groups, according to the convenient classi- 
fication of Grimsdale and Brewerton: (1) Those which shorten the lid 
or levator; (2) those which utilize the action of the frontalis muscle; 
(3) those which utilize the action of the superior rectus. 
The simplest of the first group, namely, an elliptic excision of a 
portion of the skin of the lid, is an operation which should not be per- 
formed on account of its inefficiency. 
Eversbusch's Operation.-The lid is drawn downward and fastened with Knapp's 
clamp. An incision is now made through the entire width of the lid midway between 
its margin and the eyebrow, which divides the skin and orbicularis muscle. The 
edges of the wound are separated for 4 mm. from the underlying tissue above and 
below, and the tendon, which is thus well exposed, is next included in a loop, with 
the aid of three double-armed threads passed respectively at the center, the nasal, and 
the temporal margins. Each needle is now thrust vertically downward between the 
tarsus and orbicularis, brought out at the free margin of the lid, and securely tied 
after the wound on the surface of the lid has been closed in the usual manner. 
This operation is intended for the relief of imperfect action of the 
levator and is designed to advance its insertion. 
Other operations belonging to this class are advancement of the 
levator tendon, as designed by Wolff and modified and improved by 
Elschnig, and excision of a semilunar piece of tarsal cartilage, uniting 
the edges of the wound with sutures, as advised by Gillet de Grand- 
mont, which is a modification of an operation long ago suggested by 
Bowman. 
To the second group belong a number of subcutaneous thread or 
wire operations, which act by establishing a contracting cicatrix or by 
supplying an artificial tendon. 
Pagenstecher's Subcutaneous Thread Operation.-A silk suture armed with 
two needles is provided. One needle is introduced close to the ciliary border and 
passed subcutaneously for 2 mm. parallel to the ciliary margin. Next the same 
needle is re-entered at the point of exit and passed between the tarsus and skin and 
brought out above the brow. The second needle is introduced at the point of entrance 
of the first and passed upward beneath the skin to the point of exit of the first above 
the brow. Finally the sutures are tied. 
This method establishes a contracting cicatrix and is suited to 
cases of incomplete ptosis. The operation was modified and elaborated 
by the late Mr. Mules, who embedded a fine loop of gold wire in the 
tarsal cartilage, the two ends from which passed out through the fronta- 
lis and which remained and acted as an artificial tendon. Worth uses 
kangaroo tendon for the same purpose, and Harman "wove-chain" 
made of fine wire, which is passed subcutaneously from the lid margin 
to a point below the brow. 
A number of operations have been designed to form a union between 
the skin of the lid and the frontalis muscle, and among these is the well- 
known Panos operation, which consists essentially in the formation of a 
small cutaneous flap from the lid, which is passed through an incision OPERATIONS FOR PTOSIS 
601 
under the brow and is attached to the fibers of the occipitofrontalis 
muscle, which have been divided by an incision immediately above the 
brow, and which has cut through all the tissues down to the periosteum. 
The steps of the operation may be understood by referring to Figs. 
262 and 263. 
Figs. 262, 263.-Panas' operation for ptosis. 
J. O. Tansley has designed a combination of the Panas and Von 
Graefe operation, or rather, according to M. L. Foster, a modification 
and improvement of Hunt's operation, with which the author has had 
gratifying success: 
Figs. 264-266.-Tansley-Hunt operation for congenital ptosis. 
"Two perpendicular and parallel cuts, A-B, C-D (Figs. 264-266), I inch apart, 
are made, and extend from the upper orbital margin to within two lines of the upper 
edge of the lid. These cuts are united at the upper extremity by a horizontal incis- 
ion, A-C, and the ribbon of tissue is dissected up and permitted to drop down upon 
a wad of cotton lying on the cheek, which is kept moistened with a warm antiseptic 
solution. Next, a curved cut is made from H to G and from E to F, following the 602 
OPERATIONS 
crease, which shows the upper limit of the tarsal cartilage, and a straight cut is made 
from H to B and from D to F, parallel to and about two lines distant from the lower 
border of the lid. The skin and the orbicularis embraced within these cuts are now 
carefully dissected off, leaving the whole tarsal cartilage denuded of tissue. The cut 
edges H-G and E-F are united to the cut edges H-B and D-F, respectively, by 
interrupted sutures. Next, a narrow Graefe knife is entered at A-C, and passed 
beneath and brought out upon the forehead just above the eyebrow, and slight lateral 
cuttings are made so as to give room for the passage of the ribbon of skin which has 
been dissected up at the first stage of the operation. A strong suture placed in the 
upper edge of this ribbon of skin is used to draw it up into the cut made beneath 
the eyebrow and bring it out upon the forehead. When it is drawn up sufficiently 
tight, it is cut off smooth with the forehead and fastened there by two small sutures. 
Then several sutures are placed from A to G and C to E, uniting the edges of the 
ribbon to the bordering derma." The operation can be readily understood by 
reference to Figs. 264-266. 
In place of the operations just described, the procedure of Hess 
receives the commendation of many surgeons. It consists essentially 
in making an incision along the shaved brow, through which the lid skin 
is dissected from the orbicularis muscle, and passing sutures from 
Fig. 267.-Ptosis, showing stitches in Tansley-Hunt operation (from a patient in the Uni- 
versity Hospital). 
without inward through the upper part of the dissected skin of the lid, 
and carrying them upward underneath the skin to a point above the 
brow incision, where they are tied. Cicatrization of the wound surface 
fixes the artificial fold in the upper lid, and the union with the lower part 
of the frontalis transfers its action to the lid. 
Other operations belonging to this group are W. H. Wilder's proced- 
ure, who folds upon itself the tarso-orbital fascia and establishes a firm 
adhesion between the fascia and the frontalis muscle, Fergus' method 
of attaching a strip. of the frontalis to the lid, and Sourdille's modus 
operandi, by which the levator tendon is fastened to the frontalis. 
Finally are those operations which depend for their effect upon a 
utilization of the action of the superior rectus. Among them the one 
most frequently employed is that designed by Motais (Motois' operation), 
which consists essentially in attaching a narrow tongue of tissue formed 
from the center of the tendon of the superior rectus, through an opening 
in the conjunctival surface of the everted lid, to the upper border of the 
tarsus, where it is fastened by means of sutures which are brought out TARSORRHAPHY 
603 
through the tarsus and lid skin and tied on the outer side of the lid. 
While this operation has certain attractive features, it may be followed 
by temporary diplopia and depression of the eyeball. If the sutures are 
tied over the conjunctiva, the knot may cause local irritation. It is 
warmly commended by H. D. Bruns. If the tendon of the superior 
rectus is poorly developed, W. T. Shoemaker suggests that the entire 
tendon of the rectus muscle, in place of a single central strip, shall be 
fastened to the tarsus in the manner described. 
After any of these operations, performed with the usual aseptic pre- 
cautions, the ordinary dressings should be applied and the sutures re- 
moved at the end of a week. The anesthesia may be local or general. 
Fig 268.-Result of a Hess operation for ptosis, showing on left side the position of the 
stitches (from a patient operated upon by Dr. T. B. Holloway). 
Tarsorrhaphy.-This operation is designed to shorten an abnor- 
mally wide palpebral fissure (lateral or angular tarsorrhaphy} or to close 
temporarily the lids over the eyeball (median tarsorrhaphy}. Lateral 
tarsorrhaphy is performed as follows: 
The external commissure is taken between the thumb and index-finger, the 
fissure of the lids closed to the required extent, and the line of incision marked with 
an anilin pencil. A horn spatula or shield is now introduced between the lids, and a 
flap removed from the free margin of each lid near the external commissure; this 
must contain all the hair-follicles. The breadth of the flap is 1 mm. and the length 
about 4 mm. To obtain still firmer union the ciliary margin may be denuded for 
several millimeters beyond the point of removal of the flap, but in this incision the 
cilia must not be injured. The edges are approximated by silk sutures. Figure 269 
explains the steps: a indicates the point of union of the two flap wounds behind 
the commissure; b, b, the termination of the flap wounds in the lid-margins; and c, 
c, the end of the denudation of the ciliary margins. 
Median tarsorrhaphy is accomplished by denuding the ciliary margin of the 
center of each lid for 4 mm., the lashes being untouched, and approximating the 604 
OPERATIONS 
denuded edge with a mattress suture. The eyeball is thus effectually covered, but 
the cornea can be inspected if the globe is rotated either inward or outward through 
the narrowed lid interspace on each side of the central attachment. 
Angular tarsorrhaphy is indicated in ectropion in order to raise the 
angle of the lid, and in lagophthalmos and exophthalmos to improve the 
unsightly appearance and to protect the cornea. 
Fig. 269.-Lateral tarsorrhaphy. 
Median tarsorrhaphy is suited to those conditions in which the 
cornea must be protected, for example, in exposure-keratitis, facial 
palsy, and to prevent ulceration after removal of the Gasserian ganglion. 
Canthoplasty (Blepharotomy).-This operation is performed to 
enlarge an abnormally short palpebral fissure. 
Fig. 270.-Canthoplasty. The stitches ready to be tied (Haab). 
One blade of a pair of probe-pointed scissors is introduced behind the external 
commissure, and the entire thickness of the tissues is divided, making the wound in 
the skin a little longer than that in the conjunctiva. The wound margins are next 
separated, and the surgeon loosens the conjunctiva at the apex of the incision and 
frees it from the underlying tissue. Three sutures are passed, one uniting the ex- double-transplantation operations 
605 
tremity of the conjunctival flap to the center of the skin incision, and one suture 
above and one below, near the angles of the wound. Division of the external canthus 
without subsequent introduction of sutures is known as canthotomy. 
Canthoplasty is frequently performed for the relief of the con- 
tracted fissure which follows long-standing granular lids and certain 
types of chronic blepharitis, and also to lessen the tension on flaps in 
various types of blepharoplasty. Axenfeld recommends blepharotomy 
prior to cataract extraction where the palpebral fissure is extremely 
narrow. 
Operations for Trichiasis.-If only a few hairs are involved, the 
offending lashes should be extracted with cilium forceps in the manner 
already described. 
Fig. 271.-Method of making the intermarginal incision (Czermak). 
Electrolysis, as originally suggested by Michel, of St. Louis, may 
be performed as follows: 
A platinum or iridium needle attached to the negative pole of a constant battery 
is inserted into the follicle of the lash which is to be removed. A sponge electrode 
attached to the positive pole is applied to the cheek and the current closed. A drop 
of froth appears around the needle, which should be kept in place for a few seconds 
and then withdrawn. The lash is easily removed. 
For complete distichiasis some form of transplantation should be 
employed. The Jaesche-Arlt operation, once often employed, is not 
satisfactory, and has been abandoned for more rational procedures. 
Double=transplantation operations, or, in other words, the manu- 
facture of an artificial lid-border by transplanting a strip of skin to the 606 
OPERATIONS 
intermarginal space, have been practised, especially since Spencer 
Watson's suggestion. 
F. C. Hotz designed the following valuable method: 
The lid-border is split by the well-known intermarginal incision (Fig. 271), after 
which a transverse incision is made through the lid-skin and the orbicularis muscle 
just below and parallel with the upper line of the tarsal cartilage. The strip of 
Figs. 272 and 273.-Operation of Anagnostakis and Hotz. 
muscular fibers which covers the upper portion of the cartilage is excised, and the lid- 
skin is united with the upper border of the cartilage by three sutures. Each suture 
passes through the edge of the lid-skin, then through the upper border of the cartilage, 
and finally through the upper edge of the cutaneous wound (Figs. 272, 273). After 
the sutures are tied, the skin of the lid is drawn upward and fastened to the upper 
border of the tarsus. By this means a thorough eversion of the anterior edge of the 
split lid-border is effected, and the intermarginal incision is converted into a gaping 
wound several millimeters in depth. This groove is filled with a skin-graft, long and 
Fig. 274.-Reconstruction of the 
lid-border (Hotz). 
Fig. 275.-Cross-bar entropion forceps. 
narrow and somewhat wedge-shaped, which preferably is removed from the integu- 
ment behind the ear. It should be from 1| to 2 mm. in width, and of a proper 
length to fill the opening. The graft is spread out, gently pressed into the groove, 
and after thorough irrigation with a saline solution both eyes are covered with a 
compress bandage. During the first two weeks the epidermis of the graft is repeat- 
edly shed, and it is advisable to keep the new lid-border well lubricated with vaselin 
(Fig. 274). OPERATIONS FOR ENTROPION 
607 
Because the fine cutaneous hairs in the transplanted flap sometimes 
irritate the cornea Van Millingen proposed his tarsocheiloplastic opera- 
tion, in which the intermarginal gap is covered with a strip of mucous 
membrane taken from the inner surface of the under lip. 
Operations for Entropion.-Several methods of correcting spas- 
modic entropion have been referred to on page 178. Gaillard's suture is 
also useful; the skin of the lid is temporarily shortened by means of a 
fold caught in one or two sutures. In the spasmodic entropion of elderly 
people the following operation may be performed: 
With entropion forceps a strip of skin of suitable width, parallel to the ciliary 
border of the lid, is pinched up. This strip, together with the subjacent fibers of 
the orbicularis muscle, is excised. The wound is closed with silk sutures andjdressed 
in the ordinary way. The sutures are removed on the third day. 
Instead of excising a horizontal fold of skin, excision of a triangular portion may 
be performed (Von Graefe). The base of the triangle is placed 3 mm. from the 
ciliary margin, and the width and length are calculated according to the looseness of 
the tissues. After the flap is excised the margins are freed and brought together with 
sutures, but no sutures are applied to the horizontal incision. If necessary, the sub- 
jacent tarsal cartilage may be removed. 
In organic entropion an operation must be performed which will 
not merely evert the misplaced border, but also alter the curve of the 
tarsal cartilage, which usually has become thickened. Two operations 
will be described: 
Burow's Operation.-This operation is designed to relieve entropion 
of the upper lid following trachoma. It is performed as follows: 
The upper lid is thoroughly everted, and the gray-white scar-line (see page 219) 
which runs parallel with the margin of the lid is exposed At the temporal end of this 
line an incision is made sufficiently large to admit a fine grooved director, which is 
now pushed to the nasal side of the lid between the skin and the conjunctiva, care 
being taken that the point of the director is kept well beneath the cicatricial tissue. 
The tissue thus elevated is divided in its whole length, either with a sharp scalpel 
or with narrow scissors. When the operation is completed a blue line equal in length 
to the line of incision should appear upon the cutaneous surface of the lid. No 
dressing is required, or, at most, cold compresses to allay the irritation. The cica- 
tricial contraction which ensues everts the incurved border of the lid. 
Although the operation is usually primarily successful, its effects 
generally do not long remain, and recurrence of the entropion takes 
place. The operation may be repeated several times. 
Hotz-Anagnostakis Operation.-This procedure, as it was prac- 
tised by Dr. Hotz, is described in his own words, as follows: 
"A transverse incision from canthus to canthus is made through skin and sub- 
jacent tissues, but instead of being made near and parallel with the free border (as 
in the former methods) the incision in this operation is to follow the upper border 
of the tarsus. It, therefore, describes a slight curve beginning and ending at a point 
about 2 mm. above the canthus, but being 6 to 8 mm. distant from the free border 
in the center of the lid. While an assistant is holding the edges of the wound well 
separated, the surgeon lifts up with forceps and excises with scissors a narrow bundle 
of the muscular fibers which run transversely along the upper border of the tarsus. 
Next the sutures, which are to include nothing but the cutaneous wound borders and 608 
OPERATIONS 
the upper border of the tarsus, are inserted. The first suture is placed in the center 
of the lid; the curved needle, armed with fine black aseptic silk, is passed through the 
lower wound border; there taken again in the needle-holder, it is boldly thrust 
through the upper border of the tarsus, and returned through the tarso-orbital fascia 
just above this border; and finally it is carried through the upper wound border (Fig. 
272, a, b). One similar suture is placed at each side of the central one, and these 
three stitches are usually sufficient for our purpose-to wit, to draw the skin of the 
eyelid up toward the upper border of the tarsus and establish a firm union between 
these parts. This artificial union produces a slight tension of the tarsal skin, which, 
however, is sufficient to relieve any ordinary degree of entropion. 
"But when the lids have been badly contracted-when 
the palpebral aperture has become unnaturally narrow, or 
the free border of the lid has become entirely merged into 
the plane of the conjunctiva--these complicated cases re- 
quire, in addition to the above operation, such surgical 
measures as canthotomy, the restoration of the free border 
either by grooving the tarsus or by grafting" (see de- 
scription, page 606, Fig. 274). 
This is a most satisfactory operation, and the 
results in the author's experience have been ex- 
cellent. If grooving the cartilage-that is, cutting 
a groove or narrow gutter along the center of the 
tarsus from one end to the other-is combined 
with the Hotz-Anagnostakis operation, the double 
knife and clamp devised by W. H. Wilder may be 
employed (Fig. 276). This knife is also most use- 
ful for cutting the narrow graft of skin which may 
be required to restore the lid-border and which is 
applied in the manner already described (see page 
606). 
Although the operations for trichiasis and en- 
tropion have been separated in the descriptions, 
it must be remembered that these two conditions 
are constantly associated, and hence their surgical 
treatment in most particulars is identical. Many 
other operations for the relief of these and other 
lid affections have been devised, but necessarily 
the author has described only few standard 
methods, and especially those which have given 
him personal satisfaction. 
Operations for Ectropion.-If ectropion is 
associated with relaxation of the tissues, as is 
often seen in old people, excision of a V-shaped 
piece of the whole thickness of the lid may be practised. This pro- 
cedure may be understood by a reference to Figs. 277 and 278. Instead 
of making the triangular excision, as it is in the illustration, it may be 
placed at the external canthus, and thus disfiguring scars are avoided. 
In place of Adams' operation for shortening the lid-border, Muller's 
modification of Kuhnt's operation may be practised and can be recom- 
mended. 
Fig. 276.-Wilder's 
double knife. OPERATIONS FOR ECTROPION 
609 
Kuhnt-Mtiller Operation.-With a broad, triangular knife a deep incision is 
made into the center of the lid-margin, which divides the lid-substance into two 
portions, the one containing the conjunctiva and the tarsus, and the other the soft 
tissues and the skin. From the first portion a triangular piece is removed by the 
aid of two incisions which should converge toward the fornix (Fig. 279, A, a-c and 
b-c). The two portions of the lid are next separated toward the external canthus 
Fig. 277. 
Fig. 278. 
Figs. 277, 278.-Adams' operation for ectropion by excision of a V-shaped piece of the lid. 
by carrying the knife from under the margin b-c toward d. Next, the V-shaped wound 
of the tarsus is closed with sutures, and the long stretch of the skin margin, d-a, is 
united with the shorter margin, d-b, of the tarsus by means of sutures. Their method 
of application may be understood by examining Fig. 279, B. The puckering which 
occurs after these sutures are tied disappears and the lid margin becomes smooth. 
Fig. 279.-A, Shortening of lid-border after manner of Kuhnt and Muller; B, Kuhnt- 
Miiller operation, final stage (Hotz). 
Kuhnt-Szymanowski Operation.-An even more satisfactory opera- 
tion for the relief of senile ectropion is a combination of the methods of 
Kuhnt and Szymanowski. 
The first step of the operation (Fig. 280) is performed exactly as in the Kuhnt- 
Miiller procedure (see Fig. 279). The next step consists in the excision of a triangu- 
lar piece of the skin at the external canthus in the manner indicated in the diagram 
(Fig. 281). The base of this triangle should be somewhat longer than the base of the 
triangular piece which has been excised from the tarsus. A second incision is carried 
from the canthus downward and slightly outward, and should be twice as long as 610 
OPERATIONS 
the incision from a to b. Finally, the two incisions are united in such a manner 
that the triangular piece of skin can be excised. The skin of the lid is next thor- 
oughly undermined, so that it may be easily drawn outward to cover the defect 
which has been produced by the excision of the triangular area at the outer canthus. 
The operation concludes with the insertion of silk sutures in the manner shown in 
Fig. 282. 
Snellen's Suture Operation.-A suture armed with a needle at each end is 
provided. One needle is entered at the junction of the external and middle third 
Fig. 280.-Showing the division of the lid into two portions and the excision of the 
triangle of thickened conjunctiva and tarsus. 
close to the posterior border of the tarsus, and is passed down beneath the skin of 
the lid to a point at the summit of the lower margin of the orbit, and is there brought 
out. The second needle is entered at a point 5 mm. from the first, and with the 
other end of the thread is carried down close to the first and parallel with it. The 
two extremities of the suture are tied upon the cheek over a piece of drainage-tube. 
The same procedure is repeated with a second double-armed suture, the points of 
entrance being at the junction of the middle and inner third of the conjunctival 
Fig. 281.-Showing the formation of the 
triangle of skin which is later removed. 
Fig. 282.-Showing the condition after 
the excision of the triangular piece of skin 
and the undermining of the lid, which is 
turned outward. The sutures are in place. 
surface. This operation is suited to cases of spastic ectropion. It has been em- 
ployed in senile ectropion, but has in these circumstances no valuable permanent 
effect. 
Galvanocautery puncture is recommended by S. Lewis Ziegler for 
the relief of ectropion and entropion. A lid-clamp is adjusted and the 
galvanocautery point is pushed through the cartilage and quickly OPERATIONS FOR ECTROPION 
611 
withdrawn. The punctures are made 4 mm. from the lid margin, and 
separated from each other by an interval of 4 mm. They are made 
on the conjunctival surface in ectropion, and skin surface in entropion. 
Ectropion from the contraction of cicatrices, abscesses, etc., usually 
requires a plastic operation (lilepharoplasty) in which the vicious cica- 
trix is embraced in an incision. If the scar is small, the operation may 
be done in the manner indicated in Figs. 283, 284-a method which is 
known as Wharton Jones' operation. 
A horn spatula is put into position to protect the eye, and a V-shaped incision 
is made. The flap is then separated sufficiently to enable the lid to be pushed up 
into place. The lower part of the wound is drawn together with sutures, thus 
converting the V into a Y. If possible, the triangular flaps should include the cicatrix 
which has produced the original trouble. 
If the cicatrix is extensive, the operation consists in dissecting out 
the scar and filling the gap by transplanting a flap of skin from the 
forehead, temple, or cheek. Many operations of this kind have been 
Fig. 283. 
Fig. 284. 
Figs. 283, 284.-Wharton Jones' operation for ectropion. 
devised. The site and character of the lesion will in each instance 
determine the best method of procedure, and it would not be possible 
in a chapter of the present scope to indicate in detail the numerous in- 
genious methods which have been devised for the correction of cicatricial 
ectropion by these blepharoplastic operations, or for the formation of an 
entirely new lid to replace one that has been destroyed by some dis- 
ease, such as lupus. 
But in order that the student may have an idea of the formation of 
the flaps for the relief of the deformities just referred to, Figs. 285 to 
291, somewhat modified from those in Meyer's excellent treatise, are 
introduced, and reference to them will explain the essential features of 
these operations. 
During blepharoplastic operations the author is accustomed to 
irrigate the field of operation frequently with a tepid solution of bi- 
chlorid of mercury (1 : 10,000). When the flaps are in place and the 
sutures, preferably of silk, are adjusted, the whole area is thoroughly 612 
OPERATIONS 
flooded with a sterilized physiologic salt solution. The flaps are now 
covered with protective, over which several layers of aseptic gauze 
are placed, care being taken that the gauze itself does not come in con- 
Figs. 285, 286.-Restoration of the lower lid by Dieffenbach's method. The diseased 
tissue has been removed in a triangular flap, a-b-c. This defect is covered by a flap taken 
from the cheek, indicated by the dotted lines, b-d-e, with the result shown in Fig. 286. 
The remaining gap may be covered with Thiersch grafts. 
Fig. 285. 
Fig. 286. 
tact with the flaps, and the whole is secured with several turns of a 
sterile bandage. This dressing is undisturbed if there are no signs of 
reaction for seventy-two hours. At the end of this time it is removed, 
Figs. 287, 288.-Restoration of lower lid by Burow's method. The diseased tissue 
is removed with the flap a-b-c. The horizontal incision is prolonged upon the temple and 
forms the basis of the triangle a-d-e. This flap (B) being removed, the cutaneous flap 
a-c-d is dissected up and drawn inward so that the angle a is sutured at the point b, and 
a-d forms the free border of the lid; c-a is now united with c-b, and d-e with a-e, with the 
result shown in Fig. 288. 
Fig. 287. • 
Fig. 288. 
any exfoliated epithelium trimmed away, and the edges of the flaps 
anointed with boric acid ointment. Any gap which remains after the 
flaps are cut and put in position is subsequently covered with Thiersch OPERATIONS FOR ECTROPION 
613 
grafts, and the same method is practised if any portion of the flap of 
skin should slough. If there is breaking down of the epithelium of the 
flaps, indicating necrosis of the upper layers, the suggestion of Gifford 
to scrape the area until healthy bleeding tissue is reached, and then 
apply a large Thiersch graft, may be followed with advantage, although 
the necessity for this procedure is more likely to occur in cases in which 
Fig. 289.-Restoration of the upper lid by Fricke's method. The diseased tissue 
has been removed in an oval flap. The resulting gap is covered by a similarly shaped flap 
taken from the temple, indicated by the dotted line. 
a flap without a pedicle has been transplanted than where the flaps still 
retain living connection with the surrounding tissues. Sloughing of the 
flaps should not occur if care is taken to make them large enough to 
secure them in position without undue tension, and to prepare them 
in such a manner that they shall receive a sufficient vascular supply 
through their pedicles. 
Fig. 290. 
Fig. 291. 
Figs. 290, 291.-Restoration of the external angle of the lids by Hasner d'Artha's 
method. The diseased tissue is removed by two elliptic incisions, and the defect covered 
with a flap taken from the temporal region at b, cut in the manner indicated by the dotted 
line, with the result shown in Fig. 291. The same operation applies to the inner angle, the 
flap being taken from the nose. 
Many disadvantages are associated with blepharoplastic operations, 
not the least being the extensive scar which may ultimately develop 
in the position from w'hich the flap was removed. To obviate these a 
plan originally introduced by Lefort and Wolfe has been practised with 
success. 614 
OPERATIONS 
Transplantation Without a Pedicle.-This operation consists in transplanting 
skin without a pedicle from a distant part, preferably the inner side of the arm or the 
inner side of the thigh. The flap must be about one-third larger than the spot which 
it is intended to cpver, to compensate for subsequent shrinking. It should be shaved 
dpwn, so as to be as free as possible from subcutaneous connective tissue and fat, and 
may be held in place by interrupted sutures. The dressing is exactly the same as 
that previously described. * 
The primary effect of these operations is sometimes strikingly good, although as 
time goes on the transplanted tissue is apt to shrink and is said to disappear alto- 
gether. The author has been very much gratified with the operation of transplanting 
skin without a pedicle in selected cases, particularly after removal of small growths 
from the lower lid, and after burns causing extensive ectropion of the upper lid. 
Thiersch's Method of Skin-grafting.-This consists in removing only the upper 
layer of the skin with a long, wide razor, which is applied flatwise to the inner side 
of the arm or thigh, and the desired tissue separated by to-and-fro movements with 
the knife, which is kept flooded with a sterile salt solution. The grafts are trans- 
ferred directly from the razor to the area which they are to cover. All bleeding must 
be stopped before they are put in place. They may be dressed in the manner already 
described or, better, surrounded with a lattice-work of protective strips covered 
with a compress moistened with salt solution. Thiersch grafts, as already stated, are 
useful as adjuncts to plastic operations. They may be utilized, however, to supply 
small defects in the lids and to conceal the deformity of burns around the eyes and 
face. They have been employed after exenteration of the orbit. 
OPERATIONS ON THE CONJUNCTIVA 
Operations for Pterygium.-(a) Excision.-The pterygium is seized with a 
toothed forceps, raised from the surface of the eye, and shaved off with a Beer's 
knife from its corneal attachment. It is then turned backward, carefully dissected 
from the underlying tissues, and excised, together with a triangular piece of con- 
junctiva. This leaves a somewhat diamond-shaped gaping wound in the conjunc- 
tiva, which is drawn together with several sutures. If the conjunctiva overlap the 
corneal margin, two small vertical cuts should be made in it at right angles to the 
line of excision. After the apex of the pterygium has been separated from the 
cornea, the vascular subconjunctival tissue must be scraped away down to the sclera; 
otherwise there will be reattachment. The suggestion of Prince to tear loose the 
pterygium with a strabismus hook instead of separating the point with a knife is a 
very good one. Complete excision is not applicable to large nor to fleshy pterygia. 
(6) Transplantation (Knapp's Method).-This consists in dividing the corneal 
attachment, turning the pterygium back, and splitting it from apex to base. The 
ends are then cut off, and each flap is transplanted into its corresponding upper and 
lower conjunctival wound, and fixed in position with fine sutures. The exposed 
surface of the sclerotic is covered by first dissecting up and then drawing together 
the conjunctiva. 
McReynolds' Operation.-This operation, which is a modification of Desmarres' 
method, gives admirable results, and in the majority of cases, so far as the author's 
experience is concerned, has proved by far the most satisfactory one in this affection. 
Dr. McReynolds describes his operation in the following words: 
"Grasp completely the neck of the pterygium with strong but narrow fixation 
forceps. Pass a Graefe knife through the constriction and as close to the globe as 
possible, and then, with the cutting edge turned toward the cornea, smoothly shave 
off every particle of the growth from the cornea. With the fixation forceps still 
hold the pterygium, and with slender straight scissors divide the conjunctiva and 
subconjunctival tissue along the lower margin of the pterygium, commencing at its 
neck and extending toward the canthus, a distance of J to | inch. Still hold the 
pterygium with the forceps, and separate the body of the growth from the sclera 
with any small, non-cutting instrument. Now separate well from the sclera the 
conjunctiva lying below the oblique incision made with scissors. Take a black-silk OPERATIONS FOR SYMBLEPHARON 
615 
thread, armed at each end with small curved needles, and carry both of these needles 
through the apex of the pterygium from without inward and separated from each 
other by a sufficient amount of the growth to secure a firm hold. Then carry these 
cutting needles downward beneath the loosened conjunctiva lying below the oblique 
incision made by the scissors. The needles, after passing in parallel directions beneath 
the loosened lower segment of the conjunctiva until they reach the region of the 
lower fornix, should emerge from beneath the conjunctiva at a distance of about £ to 
| inch from each other. Next, with the forceps, lift up the loosened lower segment 
of the conjunctiva and gently exert traction upon the free ends of the threads which 
have emerged from below, and the pterygium will glide beneath the loosened lower 
segment of the conjunctiva, and the threads may now be tightened and tied and the 
surplus portion of the thread cut off, leaving enough to facilitate the removal of the 
Fig. 292.-McReynolds' operation for pterygium: A, Showing needles 1 and 2, which 
enter the neck of the pterygium p t e at a and b, and then pass beneath the loosened lower 
segment of conjunctiva x y z, and then emerge at c and d below the cornea; B, showing 
pterygium p t e fixed by a single stitch c d beneath the loosened lower segment of conjunc- 
tiva x y z, while the former side of the growth p x t is covered by the normal smooth, 
stretched, and thinned-out conjunctiva p x t. 
threads after proper union has occurred. It is extremely important that no incision 
be made along the upper border of the pterygium; otherwise it would gape and would 
leave a denuded space when downward traction is made upon the pterygium." 
The return of a pterygium after excision is not uncommon; occa- 
sionally the second growth is thicker than the primary one, and may 
exceptionally assume a species of keloid formation. After McReynolds' 
transplantation operation the author has observed no recurrences, nor 
has he observed the formation of cysts. 
Operations for Symblepharon.-An attempt may be made to 
remedy this condition by dividing the adhesion and uniting the cut 
edges of the conjunctiva with sutures, or covering the raw surface left 
after severing the adhesions with flaps of healthy conjunctiva taken 
from the unaffected parts of the eyeball {Teale's operation), or by dis- 616 
OPERATIONS 
secting back the symblepharon as far as the retrotarsal fold, doubling 
it upon itself so as to oppose a mucous surface to the globe, and fixing 
it in this position by means of a ligature which is armed by two needles 
and passed through the lid from the conjunctiva outward. 
The utilization of skin-grafts for the relief of symblepharon is de- 
scribed in the following paragraph: 
Transplantation of Rabbit's Conjunctiva and of Thiersch's Grafts.- 
In cases of extensive adhesion between the ball and the lids the trans- 
plantation of rabbit's conjunctiva has been attempted. 
In this operation, after the adhesions have been severed, the raw 
surfaces are covered by a flap of conjunctiva taken from a rabbit's 
eye, so removed as to be free from all submucous tissue, and somewhat 
larger than the defect which it is expected to cover. It is better to 
insert the sutures, with which it is afterward put in place, before its 
Fig. 293.-Teale's operation for symblepharon (figures from Swanzy). The sym- 
blepharon is detached at A and removed. Two conjunctival flaps, B and C, are formed 
and turned to cover the denuded surface of the eyeball and of the inner side of the lid. 
The conjunctival gaps are closed by sutures, D and E. 
removal, as they mark the position of the flap, and at the same time give 
a means by which it may be transferred from the eye of the rabbit to 
the eye of the patient. It must be kept warm and moist during the 
process of transferring it. All bleeding must be stopped before the 
attachment is made. Instead of utilizing the conjunctiva from a 
rabbit's eye, mucous membrane may be taken from the lip of the 
patient. In the experience of the author transplantation of mucous 
membrane is usually an unsatisfactory procedure. A much better 
method is to utilize Thiersch grafts for this purpose, which are cut in 
the manner already described on page 614, and which are specially 
recommended by Hotz, and which the author has used with the greatest 
satisfaction. The adhesions between the lid and globe are separated 
in the usual manner, and after all bleeding has stopped the Thiersch 
graft is put into position. One difficulty is encountered, namely, the OPERATIONS FOR TRACHOMA 
617 
movement of the lid is apt to displace the graft, especially if the denuded 
area is a large one, and therefore the suggestion of Hotz and May that 
the transplanted skin should be secured by means of a rigid support 
-for example, a thin piece of lead or a suitable glass prothesis-is 
important. 
Operations for Trachoma.-On page 224 the operative procedures 
suited to cases of trachoma are briefly described. Two methods require 
more extended notice: 
Expression {Knapp's Operation).-After the patient is etherized the upper lid 
is everted, seized at the convex border of the tarsus with a pair of fixation forceps, 
and drawn away from the eye so as to expose thoroughly the whole palpebrobulbar 
conjunctiva. If the tissue is infiltrated, it may be superficially scarified, preferably 
with a three-bladed scarifier (Fig. 294). One blade of the roller forceps is pushed 
deeply between the ocular and palpebral conjunctiva, and the other is applied to the 
everted surface of the tarsus. The forceps is compressed with some force, drawn 
forward, and the infiltrated soft substance squeezed out as the cylinders roll over 
the surfaces of the fold held between it. This maneuver is repeated until all the 
morbid material has been expressed-in other words, to use Knapp's expression, 
until the conjunctiva has been thoroughly milked. The lower lid is treated in the 
same way. During the operation the surfaces should be frequently flooded with a 
tepid solution of bichlorid of mercury, 1 : 8000, and after the operation cold com- 
presses may be laid on the lid for twenty-four hours. 
Fig. 294.-Three-bladed scarifier. 
The following day the lids should be everted, and usually a delicate grayish 
layer of lymph will be found covering the entire area of operation. This should be 
removed, the swollen mucous membrane exposed, and touched in the ordinary way 
with a solution of nitrate of silver, 5 to 10 grains (0.324-0.650 gm.) to the ounce 
(30 c.c.). Each day this treatment should be repeated until the swelling has sub- 
sided, when the daily application of a crystal of sulphate of copper is advisable. 
The operation should be done thoroughly, care being taken to include 
the commissural portions of the conjunctiva, and the subsequent local 
treatment of the case must not be neglected. Expression is especially 
valuable in cases of spawn-like granulations (follicular trachoma) and 
diffuse hyaline infiltration. It may be used in cicatricial trachoma when 
patches of hyaline degeneration are present. If the patient suffers a 
relapse, as he may, the operation should be repeated. In a somewhat 
extended experience the author has never seen any save good results 
from this method of treating granular conjunctivitis. It should never 
be used in acute trachoma; indeed, usually no form of operative inter- 
ference is permissible in these circumstances. Some surgeons consider 
the operation more effective if after the expression a germicide is brushed 
into the tissues (Weeks). 
Grattage.-After the patient is anesthetized the conjunctival surface is exposed 
in the manner already described. The trachomatous tissue is then deeply scarified, 
the incisions running parallel to the margin of the lid. The surface is next rubbed 
with the back of the scalpel, and the conjunctiva vigorously scrubbed with an 618 
OPERATIONS 
ordinary tooth-brush carrying a solution of bichlorid of mercury, 1 : 2000. If the 
palpebral fissure is very narrow, canthotomy should precede the operation. The 
after-treatment consists in measures to prevent adhesions between the folds of 
conjunctiva and the conjunctival culdesac, and the daily application of a sublimate 
solution of the same strength as that originally used for at least a week following 
grattage. The subsequent treatment comprises the usual antiseptic lotions and 
applications until cure is effected. 
This operation is applicable to cicatricial trachoma and cases in 
the second stage of the disease characterized by sclerotic masses of 
trachomatous tissue. The reaction is sometimes very severe, and the 
author has not found this method more efficacious than expression pre- 
ceded by thorough scarification. 
Excision of a strip of conjunctiva containing the trachoma granules 
or of the exposed fornix and afterward closing the wound with sutures is 
practised by some surgeons and highly commended. 
Fig. 295.-Knapp's operation for trachoma (Hansell and Sweet). 
Another method includes the removal of a part of the superior 
tarsal cartilage at the same time that the strip of infiltrated fornix is 
excised, as was originally recommended by Heisrath. Kuhnt's elabora- 
tion of this operation, in that he removes the fold, together with the 
cartilage and its conjunctiva to within 2.5 mm. of the margin of the lid, 
is known as the combined excision. In cases of chronic trachoma, asso- 
ciated with great infiltration and thickening of the tarsus, Kuhnt 
recommends extirpation of the tarsus with excision of the conjunctiva. 
With this operation the author has had no experience. The surgical 
treatment of trachoma by means of the combined excision of Heisrath 
and the tarsal excision of Kuhnt has been highly recommended in this 
country by Wootton.1 
1 For details of the method of operating, see Archiv. of Ophthalmology, vol. xxxix, 
1910, p. 110. APPLICATION OF THE ACTUAL CAUTERY 
619 
Subconjunctival Injections.-The eye is thoroughly cleansed and anesthetized 
by the instillation of a 4 per cent, solution of cocain. The patient is required to look 
strongly downward and inward in order to expose the supero-external portion of the 
eyeball. Next, the needle of a hypodermic or Pravaz syringe, properly sterilized 
and charged with the fluid, is introduced very much in the same manner as when 
an ordinary hypodermic injection is given, well beneath the conjunctiva and away 
from the cornea. The quantity to be injected depends upon the nature of the case 
and the character of the fluid employed. If, for example, bichlorid of mercury is 
used in a strength of 1 : 1000, each division of a Pravaz syringe would contain mg. 
of the drug. Ordinarily, a solution of bichlorid of mercury, 1 : 2000 or 4000, may be 
used, and from 4 to 8 minims (0.24 to 0.50 c.c.) injected. Generally, cyanid of mer- 
cury is the preferable drug, and may be used in a strength of 1 : 1000 to 5000. The 
injection may be rendered practically painless by adding a few drops of a 1 per cent, 
acoin solution to the fluid. Darier's directions are to add one-third of a syringeful 
of a 1 per cent, solution of acoin to two-thirds of a syringeful of cyanid of mercury, 
1 : 1000, and, therefore, obtain a solution of 1 : 1500. Physiologic salt solution is 
efficient and much less painful. From 15 to 25 minims (0.92-1.54 c.c.) may be 
injected. If stronger solutions of salt are used, acoin may be added. Solutions of 
hetol (cynamic acid) in 1 per cent, strength have been advised by Pfluger. 
The indications for these injections have been given in connection 
with the diseases for the relief of which they have been recommended, 
and, in the experience of the author, they are useful, particularly in 
various inflammations of the uveal tract, the sclera, and some types of 
parenchymatous, as well as ulcerated, keratitis. Their value in detach- 
ment of the retina, especially solutions of salt, has been described (see 
page 450). 
OPERATIONS ON THE CORNEA 
Paracentesis Corneae.-The local application of cocain is usually 
sufficient, but in nervous subjects and young children general anesthesia 
may be necessary. The operation is performed as follows: 
The cornea is punctured near its lower margin or, in the case of an ulcer, through 
its floor with a paracentesis needle constructed with a shoulder to prevent an undue 
depth of entrance, and inserted at an angle of 45° with the point of contact; or with a 
broad needle held flatwise, the point being kept well forward so as to avoid wounding 
Fig. 296.-Paracentesis needle. 
the lens. By rotating the needle slightly on its long axis the lips of the opening are 
separated and the contents of the aqueous chamber more readily escape. The needle 
must be withdrawn slowly, lest a sudden gush of aqueous cause prolapse of the iris. 
The eyeball may be steadied with a spring speculum (see Fig. 298) or fixation forceps 
(see Fig. 299), provided the former does not put too much pressure on the globe, or 
the lids may be separated by the surgeon's fingers. If it is necessary to reopen the 
wound, the probe end of the instrument should be used. 
Application of the Actual Cautery.-The indications for this 
application in corneal disease are given on page 253. If possible, a suit- 620 
OPERATIONS 
able galvanocautery should be employed. If this is not at hand, a 
platinum probe fixed in a handle similar to the one which is attached to a 
laryngoscope mirror will suffice. The operation is done as follows: 
A few drops of cocain solution are instilled to produce anesthesia, and the probe 
or the point of the cautery is brought to a red heat, transferred to the area of disease, 
and all the sloughing material, and particularly the edge of the ulcer, is gently but 
thoroughly cauterized. It is not necessary to burn beyond the edge of the ulcer into 
sound tissue. The extent of the ulcerated area, even to the finest spot characterized 
by loss of epithelium, may be ascertained by the use of fluorescein, but it should be 
remembered that this drug also colors, but less vividly, diseased epithelium, and 
hence is apt to stain the epithelium for some distance surrounding the ulcer. Ulcers 
with much necrotic tissue on them stain yellow. The separation of the lids with a 
stop speculum is needless; in fact, this is disadvantageous on account of the pressure 
it exerts upon the eyeball. They may be parted by the hands of the operator him- 
self. After the operation the eye may be washed out with boric acid solution, a drop 
of atropin instilled, and a bandage applied. 
Operation of Saemisch: Saemisch's Section.-The upper lid 
being raised on an elevator by an assistant, the surgeon proceeds as 
follows: 
The conjunctiva below the cornea is seized with fixation forceps, a cataract 
knife is entered on one side of the cornea, with its cutting-edge forward, carried 
across the anterior chamber to the other side of the ulcer, and the section made 
directly through the diseased area, evacuating the collection of pus in the layers of 
the cornea and at the bottom of the anterior chamber. If the hypopyon is tenacious, 
this may be removed by inserting a delicate pair of forceps through the incision and 
seizing the slough, or it may be washed out with a specially devised syringe. If the 
pus reaccumulates, the wound should be reopened with a probe and the contents of 
the anterior chamber again evacuated. 
A great objection to this operation is the danger of prolapse of the 
iris; indeed, owing to the improvement in the treatment of hypopyon- 
keratitis by means of various local measures and bacterins (see page 255) 
the operation is much less rarely performed than in former times. 
Operations for Staphyloma.-If the measures used to prevent the 
formation of staphyloma have been unsuccessful (see pages 253 and 
262), an operation must be done for its relief. In partial staphyloma 
vision may sometimes be improved by iridectomy, and even by a 
double excision of the iris, but very often these measures fail, and then 
its removal may be necessary. 
A useful operation for the reduction of the size of a partial staphy- 
loma is recommended by Berry: 
A cataract needle is introduced through the base of the staphyloma and held 
in one hand. An elliptic piece of the cicatricial tissue of which the staphyloma is 
composed is then cut out by making one incision at one side of the needle with a 
cataract knife, and another from the other side, converging toward the first, and in 
such a manner that the portion held by the needle, and consequently the needle 
itself, is cut out. The dressing consists of a firmly applied antiseptic bandage, and 
usually it is necessary to continue the bandage for some time until flattening of the 
mass has been secured. OPERATIONS FOR STAPHYLOMA 
621 
After excision of a small staphyloma it is sometimes possible to promote healing 
by uniting the resulting wound margins with fine silk sutures. 
S. Lewis Ziegler's Trefoil or Stellate Keratectomy for the Relief of Anterior 
Staphyloma.-It may be performed with a punch, thus: A vertical incision is made 
through the base of the staphyloma, and the inferior blade of a punch is passed into 
the anterior chamber and beneath the cornea. The punch is closed and the left 
lateral flap is excised, and in similar manner the right lateral flap is removed. Next 
the upper margin of the oval wound is grasped at its center by the punch and a 
vertical piece excised. The trefoil opening is closed with sutures. 
De Wecker's Method.-This is suited to complete staphyloma 
limited to the cornea. 
Four sutures should be inserted in the conjunctiva after it has first been care- 
fully detached from the corneal margin almost as far as the equator of the eye. In 
order to avoid confusion at the moment of tightening the threads, the precaution 
should be taken of having them of different colors. The removal of the staphyloma 
is performed by transfixing it through the middle and cutting outward, then seizing 
the end of the flap thus formed, and removing the rest with scissors. Care must be 
taken that the lens escapes from the eye. When this is ascertained, the sutures in 
the conjunctiva are tightened and the conjunctiva drawn over the wound. 
In most instances of complete staphyloma, with participation of the 
sclerotic, the best operation is enucleation or one of its substitutes. 
Tattooing the Cornea.-In order to conceal the disfigurement 
of a dense leukoma it has been suggested to tattoo the white tissue. 
This is done as follows: 
India-ink rubbed up with water into a fine paste is placed close at hand. After 
the cornea is rendered anesthetic with cocain, the eye is steadied with the fingers, 
and a drop of the pigment is applied to the surface of the leukoma, and the ink 
pricked into place with the needles. These needles may be fixed exactly at the same 
level, precisely as if they were all fastened into a small circular piece of cork, or they 
may be placed side by side (Fig. 297). Finally, a single needle, somewhat of the type 
Fig. 297.-Tattooing needle. 
of an ordinary cataract needle, may be employed, and the pigment pricked into the 
tissue with little stabs made in an oblique direction. According to the late Dr. Noyes, 
the pigment should be prepared by allowing the India-ink stick to soak for several 
hours in water until it becomes of the consistence of thick paste. A piece of paste 
equal to the size of the spot to be colored is then placed upon the leukomatous area 
and pricked into position with the needles. The tattooing should proceed until a 
uniform black surface is secured. The excess of pigment can be flooded away with 
a saturated solution of boric acid. It has been suggested by some surgeons to use 
variously colored pigments in order to attempt to reproduce the colors of the iris. 
The principal operations for conical cornea, the method of removing 
a foreign body embedded in the cornea, and the manipulations neces- 
sary for closing scleral wounds have been described (see pages 279, 280, 
293). 622 
OPERATIONS 
OPERATIONS UPON THE IRIS 
Iridectomy.-The following instruments are necessary: A stop 
speculum, fixation forceps, bent keratome, narrow Graefe knife, iris 
forceps, blunt hook, iris scissors, and horn spatula. The preparation 
of the patient is described on pages 593, 651, 652. The operation is 
performed thus: 
The patient being in a recumbent position and the eye being under the influence 
of cocain, unless the case is one of glaucoma, when a general anesthetic is preferable, 
the surgeon separates the lids by means of a speculum, fixes the eye by seizing with 
forceps the conjunctiva and subconjunctival tissue at a point directly opposite to 
that of the proposed section, and introduces the lance-shaped keratome in the follow- 
ing manner: The point of the knife is brought into contact with the apparent corneo- 
scleral margin, or, in some instances, about 1 mm. from the junction of the sclera 
Fig. 298.-Eye speculum. 
Fig. 299.-Fixing forceps. 
Fig. 300.-Keratome. 
Fig. 301.-Curved iris forceps. 
with the cornea, and in a direction at right angles to the cornea, which direction it 
keeps until the point just penetrates the anterior chamber. The handle is then well 
depressed, so that the point of the knife shall not wound the iris or lens, while the 
blade is slowly thrust onward until the section is of the desired extent (see Fig. 305). 
The knife is then slowly and cautiously withdrawn, with its point well forward toward 
the posterior surface of the cornea, so as to allow a slow escape of the aqueous humor 
and to avoid scratching the capsule of the lens. 
The/frst stage being completed, the fixation forceps is handed to an assistant, who 
rotates the globe a little downward, if the section has been made upward, and the 
surgeon introduces the curved iris forceps, expanding the blades so as to grasp the 
pupillary margin, cautiously withdrawing the forceps with the included portion of the 
iris, and snipping off the latter close to the wound by one or two cuts with a delicate 
pair of curved scissors (Fig. 303). The scissors may be applied in the manner shown 
in the figure, or they may approach the withdrawn iris from below, the expanded 
blades being passed over the cornea until they include the iris tissue, which is then 
excised (see Fig. 306). IRIDECTOMY 
623 
If the anterior chamber is very shallow, it is safer to substitute for the lance- 
shaped instrument a Graefe cataract knife, making a puncture and counterpuncture, 
and then cutting in the same manner as when the corneal section in cataract is made 
(see page 654). 
If the section of the iris should cause hemorrhage into the an- 
terior chamber, an attempt may be made to remove the blood by 
separating the lips of the wound with a metal spatula (Fig. 304) 
and making very cautious pressure on the cornea, but triturating 
movements carried on to any great extent are done at the risk of 
bruising the lens and causing cataract. The conjunctival culdesac 
is disinfected with a warm physiologic salt solution, and the length 
of the wound, and especially its angles, are inspected to see that 
the iris is not entangled. Should there be any entanglement of the 
iris, this must be carefully disengaged with the spatula or olive- 
pointed probe until the angles of the wound are entirely clear of 
iris tissue and the pillars of the coloboma perfectly in place. If 
the wound appears clear, the eye is dressed in the same manner 
as after cataract extraction (see page 657). One or both eyes may 
be bandaged, or covered with a pad of aseptic gauze held in place 
with strips of adhesive plaster. The author prefers to bandage 
both of them for the first forty-eight hours. Usually the healing is 
kind, the anterior chamber is quickly restored, and the bandage may 
be removed at the end of forty-eight hours and the patient directed 
to wear a shade or dark glass. 
This, in general terms, describes the method of per- 
forming an iridectomy, which, however, may require 
certain modifications according to the indi- 
cations and according to the judgment of 
the operator. 
1. Position of the Operator.-The oper- 
ator may stand behind the patient's head 
and push the knife from him if he is mak- 
ing an upward section, or he may stand in 
front of the patient and push the knife to- 
ward him in a similarly made section. 
The latter procedure has been recommended 
if the anterior chamber is shallow, as the 
operator can more readily watch the point 
of the knife. This direction refers to the 
lance-shaped keratome. The author prefers to stand behind the 
patient's head. 
2. Point of Entrance of the Keratome.-This depends upon whether 
the iridectomy is for optical purposes or for the relief of increased intra- 
Fig. 302.- 
Blunt hook. 
Fig. 303.-Iris 
scissors. 
Fig. 304.-Spatula and probe. 
ocular tension. If for the former, its position should be exactly at the 
apparent corneoscleral border; if for the latter, farther back, about 2 mm. 
from this position, passing through the sclera. Should a cataract knife 
be used, preferable always if the anterior chamber is shallow, the position 624 
OPERATIONS 
of the operator and the manipulations are the same as in the extraction 
of cataract (see page 655). 
Fig. 305.-Operation of iridectomy; keratome within the anterior chamber. 
3. Position of the Iridectomy.-If the iridectomy is for optical pur- 
poses, the point of selection is governed by the condition of the cornea. 
Fig. 306.-Operation of iridectomy; excision of the piece of iris. 
The best position for an artificial pupil is inward or inward and down- 
ward, other things being equal. In optical iridectomy good results are IRIDECTOMY 
625 
obtained and pain lessened by drawing out that portion of iris which is 
to be excised with a small blunt hook. In place of optical iridectomy, as 
Fig. 307.-Healed corneal section after iridectomy (from a specimen prepared by Dr. C. M. 
Hosmer in the author's laboratory). 
Fig. 308.-Broad peripheral iridectomy. 
Fig. 309.-Small iridectomy with ciliary border preserved. 
Fig. 310.-Narrow iridectomy for optical purposes. (Modified from Swanzy.) 
Fig. 308. 
Fig. 309. 
Fig. 310. 
described, Axenfeld performs precorneal iridotomy, in which the iris is 
made to prolapse through a small corneal incision and is incised with a 
40 626 
OPERATIONS 
radial scissor-cut, not excised, and carefully replaced. There is gradual 
separation of the cut. 
If the operation is to restore a pupil to an iris which has been bound 
down by extensive synechise, that portion of the iris is excised which is 
least attached. Generally it is best to perform the section upward and 
make a broad iridectomy. The same is true if the operation is per- 
formed for a partial cataract, although its exact position must be gov- 
erned by the condition of the lens. 
4. The Width and Depth of the Coloboma.-A glance at Figs. 308, 
309, and 310 explains three forms of iridectomy: namely, a broad 
peripheral iridectomy, as in glaucoma; a small iridectomy, with preser- 
Fig. 311.-De Wecker's pince-ciseaux. 
vation of the ciliary border; and a narrow iridectomy, for instance, for 
optical purposes. 
Iridotomy.-This operation, which is designed to manufacture an 
artificial pupil, is commonly selected for eyes from which the lens is 
absent, as after cataract extraction, and in which the pupil has become 
entirely occluded on account of iritis. It may be performed by simply 
splitting the fibers of the iris with a knife-needle, the retraction usually 
affording a sufficient pupil; or a blunt hook (see Fig. 302) may be intro- 
duced and the operation converted into a small iridectomy; or a tri- 
angular-shaped piece of the iris may be excised with delicate scissors 
Fig. 312.-Iritoectomy (one method): 
a-b, Cornea-iris incision; a-b, b-d, excision 
of iris membranes. 
Fig. 313.-Iritoectomy-another proced- 
ure (after Czermak). 
introduced through a corneal wound {iritoectomy). The method of 
de Wecker is performed as follows: 
A small triangular keratome, preferably fitted with a shoulder, is entered into 
the apparent corneoscleral margin, and pushed on until an incision of about 5 mm. is 
made. It is then slightly withdrawn and again reinserted, this time causing the point 
to pierce the iris or the membrane which it is desired to divide. The instrument is 
now withdrawn, and the delicate forceps scissors of De Wecker is introduced as 
follows: The instrument is inserted flatwise with closed blades through the wound. 
One blade is now made to pass through the opening in the iris or membrane and the 
other in front of it. The blades are now pushed onward as far as necessary, closed 
after the manner of a pair of scissors, and withdrawn. The cut thus being made 
across the line in which there is the greatest tension, retraction takes place, and if V-SHAPED IRIDOTOMY 
627 
the operation is successful, a useful pupil results {simple iridotomy). Instead of this 
procedure, after the narrow keratome which has pierced the cornea and made a small 
(2 mm.) opening in the iris-membrane is withdrawn, the iris scissors may be intro- 
duced, as before described, and two oblique cuts may be made from either extremity 
of the incision toward the apex of a triangle, forming thus a triangular flap which is 
removed with forceps {iritoectomy). 
A more satisfactory operation than De Wecker's iridotomy or 
iritoectomy is one devised by S. Lewis Ziegler, with which procedure 
the author has had the most gratifying results. 
Fig. 314.-Ziegler's V-shaped iridotomy. Knife-needle entered through cornea. 
V-shaped Iridotomy {Ziegler's Operation).-The instruments re- 
quired are a speculum, fixation forceps, and Ziegler's modified Hays' 
knife-needle. It is performed as follows: 
First Stage- With the blade turned on the flat, the knife-needle is entered at 
the corneoscleral junction, or through the upper part of the cornea (Fig. 314), and 
passed completely across the anterior chamber to within 3 mm. of the apparent iris 
periphery. The knife is then turned edge downward, and carried 3 mm. to the left 
of the vertical plane (Fig. 315). 
Fig. 315.-Plan of first in- 
cision. 
Fig. 316.-First incis- 
ion completed. Plan of 
second incision. 
Fig. 317.--Pupil re- 
sulting from V-shaped ir- 
idotomy. 
Second Stage.-The point is now allowed to rest on the iris-membrane, and with 
a dart-like thrust the membrane is pierced. Then, without making pressure on the 
tissue to be cut, the knife is drawn gently up and down with a saw-like motion, until 
the incision has been carried through the iris tissue from the point of the membrane 
puncture to just beneath the point of the corneal puncture. This movement is made 
wholly in a line with the axis of the knife, the shank passing to and fro through the 
corneal puncture, and the loss of any aqueous being carefully avoided in the manipu- 
lation. 628 
OPERATIONS 
Third Stage.-The pressure of the vitreous will now cause the edges of the incision 
to immediately bulge open into a long oval (Fig. 316) through which the knife-blade 
is raised upward, until above the iris-membrane, and then swung across the anterior 
chamber to a corresponding point on the right of the vertical plane, which, owing 
to the disturbance in the relation of the parts made by the first cut, is now somewhat 
displaced and the second puncture must be made at least 1 mm. farther over-i. e., 
4 mm. to the right of the vertical plane (Fig. 316). 
Fourth Stage.-With the knife-point again resting on the membrane, a second 
puncture is made by the same quick thrust, and the incision rapidly carried forward 
by the sawing movement to meet the extremity of the first incision, at the apex of 
the triangle, thus making a converging V-shaped cut (Fig. 317). Care must be 
taken at this point that the pressure of the knife-edge on the tissue shall be most 
gentle, and that the second incision shall terminate a trifle inside the extremity of the 
first, in order that the last fiber may be severed and thus allow the apex of the flap 
to fall down behind the lower part of the iris-membrane. If the flap does not roll 
back of its own accord it may be pushed downward with the point of the knife. When 
the operation is completed the knife is again turned on the flat and quickly with- 
drawn.1 
Division of Anterior Synechiae (IF. Lang's Operation).-This operation is per- 
formed with a pair of knives closely resembling Knapp's discission knife-needle. The 
one is sharp and the other blunt pointed. First, the sharp-pointed instrument is 
entered through the corneal tissue at a point favorably located for giving a fair lateral 
movement. It is next withdrawn, and the blunt-pointed knife passed through the 
same opening across the anterior chamber, with its cutting edge in contact with 
the synechiae, which by means of a slight sweeping movement are divided. Oc- 
casionally the iris stretches so freely that it is difficult to sever it. Practically no 
reaction follows the operation, and the subsequent treatment consists in the use of 
atropin and a compress bandage. If it has been successful, the iris may be dilated 
and the distorted pupil become round. 
This operation, according to Lang, is suited to adhesion of the iris or capsule to 
the wound after cataract extraction, to traumatic prolapses where a broad width of 
iris is clamped in the scar, to small adhesions due to perforating wounds or ulcers, 
and, finally, to large adherent leukomas. In the last group the effects are the least 
satisfactory. 
OPERATIONS UPON THE SCLERA 
Sclerotomy (Anterior Sclerotomy') .-This is an operation first per- 
formed by Quaglino, and improved and advocated by de Wecker, which 
is practised for the relief of glaucoma, and in the hands of some surgeons 
is made to substitute the operation of iridectomy (see page 391). It is 
especially recommended in glaucoma simplex with deep anterior cham- 
ber, in inflammatory glaucoma with atrophy of the iris, and where 
iridectomy fails to reduce tension or to relieve the pain of old, blind 
glaucomatous eyes. It is performed as follows: 
A narrow Graefe's cataract knife, or a specially constructed knife known as a 
sclerotome, is passed through the sclerotic, 1 mm. from the margin of the clear cornea 
in front of the iris, and brought out at a corresponding point on the other side-i. e., 
the puncture and counterpuncture are placed as if the surgeon intended to form a flap 
2 to 2.5 mm. in height out of the upper (or lower) part of the cornea. The puncture 
and counterpuncture are enlarged with a slight sawing movement of the knife, which 
is slowly withdrawn before the section is complete, leaving the central quarter of the 
sclerotic flap, and as much of the conjunctiva as possible, except where punctured, 
undivided. Thus, at the upper (or lower) margin of the cornea there remains a 
1 The description of this operation is in Dr. Ziegler's own words, and the figures which 
illustrate it are his, and have been kindly loaned for reproduction. COMBINED IRIDECTOMY AND SCLERECTOMY 
629 
bridge formed of sclera which connects the parts below it. If prolapse of the iris 
occurs, replacement should be attempted with a horn spatula. In the event of failure 
the prolapsed iris must be excised and the sclerotomy converted into an iridectomy. 
Preceding the operation, eserin should be used to contract the pupil, and this drug 
must be continued during the process of healing. 
Posterior Sclerotomy.-This is performed by en- 
tering a Graefe cataract knife at a point between 
the external and inferior recti muscles, 8 mm. from 
the corneal margin, and passing the blade through 
the sclera toward the center of the eyeball to a depth 
of 4 to 6 mm. As the knife is slowly withdrawn it is 
made to execute a quarter turn, the effect being 
the formation of a slight triangular wound, which 
favors filtration. The operation is employed in 
hemorrhagic glaucoma, preliminary to iridectomy 
(see page 388), especially when the anterior chamber is very shallow, and in retinal 
detachment (see page 450). 
Internal sclerotomy was practised by de Wecker and by de Vincentiis under the 
name of incision of the tissue of the angle of the iris. The incision is similar to anterior 
sclerotomy, with omission of the counterpuncture, in place of which the arches of the 
pectinate ligament are incised. 
Fig. 318.-Lines of incision in 
sclerotomy. 
Combined Iridectomy and Sclerectomy (Lagrange's Operation').- 
The operation is performed as follows: 
With a Graefe knife the sclera is punctured at a distance of 1 mm. from the 
limbus and the counterpuncture is made at a corresponding point. The sclera is 
divided in the iridocorneal angle. In terminating the incision the cutting edge of the 
blade is directed backward in such a way as to bevel the sclera, and when the knife 
Fig. 319.-Lagrange's operation: Section of the sclera and conjunctiva. 
is beneath the conjunctiva a conjunctival flap (about 4 mm. in height) is made. In 
the second stage of the operation the conjunctival flap is raised, but not cut in any 
way, and drawn back on the cornea. This maneuver tilts the edge or tongue of the 
scleral flap upward. This is next removed with a sharp curved pair of scissors, and a 
sufficiently large piece of the sclera is resected from the exterior lip of the incision. 
Finally, iridectomy is performed in the usual way, and. the flap of conjunctiva de- 
tached in the first stage of the operation is replaced, thus covering the defect in the 
sclera. The steps of the operation are evident by an examination of Figs. 319 to 321. 
It is not necessary to make a very large flap, 4 to 5 mm. is sufficient. 
Lagrange maintains that by means of this sclerecto-iridectomy a 
communication is made between the chambers of the eye and the peri- 
choroidal space and the subconjunctival cellular tissue. The hyper- 630 
OPERATIONS 
tension of the glaucomatous eye, he believes, is permanently relieved 
by the establishment of a fistulous track between the anterior chamber 
and the subconjunctival tissue. Iridectomy, he is willing to admit, 
cures acute glaucoma, but not the chronic variety. Simple sclerectomy, 
Fig. 320.-Lagrange's operation: Resection of the sclera. 
as practised by Lagrange, is performed in precisely the same way; that 
is, the first two steps of the operation are taken, iridectomy being 
omitted. 
Herbert has devised an operation which, he is satisfied, produces a 
permeable scar. 
Fig. 321.-Lagrange's operation: Making the iridectomy. 
Wedge-isolation Operation {Herbert's Operation).-It is thus described by 
Ballantyne: With a narrow Graefe knife the operator proceeds as if his intention was 
to form a shallow corneoscleral flap. Puncture and counterpuncture are made 
close to the margin of the cornea, the knife-point having previously passed through 
the conjunctiva a little distance above the point of entrance. The upward cut is 
made with the knife blade bevelled a trifle backward and a bridge of sclera is left 
undivided. The knife is next brought down and its edge turned forward and a 
forward cut is made perpendicular to the scleral surface, care being taken not to cut 
the conjunctiva. This incision forms the lower boundary of the wedge. The knife 
is now drawn backward and rotated upward so that it lies in the original incision, 
which is continued upward until the blade emerges through the sclera 1 mm. from SCLERECTOMY WITH A TREPHINE 
631 
the corneal margin. This completes the isolation of the wedge. A long conjunctival 
flap is next formed, left attached at its upper extremity, by turning the knife upward 
and backward. A small, basal iridectomy is made to prevent iris prolapse. This 
technic has been modified in various ways: thus, the primary incision may be made 
with a bent keratome and the lateral cuts with a short narrow knife. M. Bishop 
Harmon has devised "twin scissors" for the purpose of forming the lateral incisions. 
Sclerectomy with Punch Forceps (Holth's Operation).-With a Graefe knife 
puncture and counterpuncture are made in the sclerotic 8 mm. from each other and 
1 mm. from the limbus. Next, a scleral flap 2.5 mm. high and a conjunctival flap 
extending to 8 mm. from the limbus are formed. The conjunctiva is now freed from 
the anterior lip of the scleral flap, raised with forceps, and a piece of the scleral flap, 
3 by 1.5 mm., is removed by means of the punch forceps (Holth-Vaclier's, de 
Lapersonne's, or Ziegler's instrument may be used). A basal or complete iridectomy 
may be performed, after which the conjunctiva is replaced. The primary incision 
may be made with a keratome which pierces the conjunctiva 10 mm. above the 
cornea, enters the sclerotic 2.5 mm. from the limbus, and penetrates obliquely into 
the anterior chamber. 
The important manner in which the results of these operations differ 
from cystoid cicatrices (see page 390) is that the scar is free from adhe- 
sion to the uveal tract. Some difference of opinion exists in regard to 
their permanent value, and Henderson, although willing to admit that 
at an early stage such a scar as has been described may be permeable 
and that filtration may take place, believes it soon becomes impermeable, 
owing to the ingrowth of epithelium, and, therefore, unless a fistula is 
made, filtration ceases. Lagrange believes in his operation the fistulous 
track, before mentioned, is formed. The author has not had ex- 
perience with Herbert's operation, but has performed the Lagrange 
operation with satisfaction in cases of chronic (simple) glaucoma. He 
has not employed it in cases of acute glaucoma, in which form of the 
disease a well-placed peripheral iridectomy has usually yielded excellent 
results. According to Meller, the delay in re-formation of the anterior 
chamber, which is noticeable in some eyes after Lagrange's operation, 
is due to detachment of the choroid. He regards the operation as unsatis- 
factory if the intra-ocular tension is very high. He reports 1.3 per cent, 
of late infections in 389 Lagrange operations. 
Sclerectomy with a Trephine.-Trephining the sclera for the 
purpose of relieving the increased intra-ocular tension of glaucoma is 
not a new procedure. Long ago it was proposed by Argyll Robertson, 
Strawbridge, Blanco, and Froelich, but their operations differed in 
many respects from the newer procedures of scleral trephining which 
have been suggested, particularly by Fergus and by Elliot. 
Scleral Trephining (Fergus' Operation);-The technic is thus summarized by 
Ballantyne: A conjunctival flap is dissected up toward the cornea and laid over the 
corneal surface, while with a Bowman's trephine a small disk of sclera is removed 
1 or 2 mm. from the apparent corneal margin. Next, an iris repositor is passed from 
the trephine opening into the anterior chamber, keeping it in close contact with the 
sclera and cornea. The conjunctiva is then replaced and stitched into position. 
Another operation, and it would seem a more satisfactory one, in 
which the trephine opening is partly in the sclera and partly in the cornea, 632 
OPERATIONS 
has been designed by Lieut.-Colonel R. H. Elliot. This differs from the 
Fergus operation, with which Colonel Elliot was unfamiliar when he 
published his first results, in that a cyclodialysis is not included in its 
technic, but as now practised a basal or complete iridectomy is part of 
the procedure and in the position of the trephine opening. 
Sclerocorneal Trephining (Elliot's Operation).-The description 
of the technic of this operation, at the author's request, has been written 
by Lieut.-Colonel Elliot. 
1. The Quadrant of the Eye Selected.-This should invariably be the upper 
unless there is some strong contra-indication. The presence of an upward coloboma 
resulting from a previous iridectomy does not contra-indicate an upward trephin- 
ing; on the contrary, the operation is made easier thereby. 
Fig. 322.-Sclerocorneal trephining: conjunctival flap reflected; trephine opening partly 
in the cornea and partly in the sclera. (After S. Lewis Ziegler.) 
2. The Flap.-This should be large. The incision runs roughly concentric with 
the limbus and ends on either side opposite the highest point of the cornea, and 
about 8 mm. from its inner and outer sides. The conjunctiva should be seized as 
high as possible with forceps and drawn well down, while the patient looks strongly 
toward his feet. One free horizontal cut, followed by a couple of snips at each side, 
will outline the flap. Only the central area of the flap thus marked is to be dis- 
sected up. As we approach the limbus, we should work down to the sclera and 
should lay the latter bare in the last few millimeters of the wound. We must then 
clearly define the limbus as a rounded ridge overhanging the adjacent sclera. The 
area for the application of the trephine must be cleared of all tags of loose tissue. 
The conjunctival flap should be gently drawn downward by the aid of a blunt instru- 
ment, and the cornea is then to be split with the scissor points or with any other fairly 
sharp instrument. As the dissection proceeds the "dark crescent" of the cornea can 
be seen as an area convex in outline toward the sclera, and with a straight edge on 
the corneal side. It is sufficient to split the cornea over an area 1 mm. in depth. 
This enables a 2-mm. trephine to be applied half on the cornea and half on the sclera. SCLEROCORNEAL TREPHINING 
633 
3. The Application of the Trephine.-The trephine (2 mm. in diameter) should 
be placed as far forward as possible, being slid into place from the scleral side, the 
edge of the flap being meantime keenly watched, so as to avoid buttonholing. A 
sharp blade is required to make sure of cutting a definite groove in the corneosclera 
on its first application. Our object should be to make the blade cut through first 
on its corneal edge, and to ensure this we must slope the upper edge of the instrument 
a little toward the patient's feet, so that the disk cut out may be hinged on its scleral 
side. A bead of iris tissue will prolapse through the corneal side of the hole, pushing 
the disk before it. The disk together with the prolapsed iris is seized in a pair of 
iris forceps and the two structures are cut with one snip of the scissors, thus perform- 
ing a sclerecto-iridectomy with a single cut. The amount of disk removed can be 
graduated according to the needs of the case. 
4. Toilet of Wound.-The iris is replaced by massage, aided by an irrigator, if 
necessary, and a dressing is applied. The role of the iridectomy is the same here 
as it is in cataract extraction; no more, no less. It is safer, in European practice, to 
secure the flap by means of one or two sutures. 
5. Instillation of Drops.-From the second or third day onward, provided the 
tension is down, atropin drops are freely instilled. 
Fig. 323.-sp, Speculum; i, i, incision; c, cornea; t, trephine hole; p, pupil; a, a, chan- 
nels in conjunctiva along which filtration fluid passes to enter the main area of the sub- 
conjunctival space. (Elliot.) 
6. After-treatment.-The unoperated eye is opened after twenty-four hours, and 
both eyes after forty-eight hours. The patient sits up in bed on the second day and 
moves about the room on the third day. 
Naturally, various operators have advised modifications of the 
procedure; for example, L. Webster Fox (who prefers his type of the 
Von Hippel trephine) forms the conjunctival flap as in the Van Lint 
sliding flap in cataract extraction, and McReynolds dissects out a piece 
of sclerocornea with a knife-point after fixing it with a traction suture. 
In general terms it has seemed to the author that the most satisfactory 
results are obtained if Elliot's method is exactly followed. The author 
prefers a hand-driven trephine; good models are those recommended 
by Stephenson, Lang, and Elliot. 
Indications.-Although many surgeons utilize this operation in 
acute glaucoma, the author is unconvinced that it is a better procedure 
than a technically correct iridectomy. It and other methods which 
secure a so-called "filtering area" are better operations in chronic, 634 
OPERATIONS 
non-congestive glaucoma than iridectomy. If an iridectomy in this 
disease has failed of its purpose, corneoscleral trephining is preferable 
to a second iridectomy or sclerotomy. In chronic glaucoma with 
greatly contracted field it appears to be a safer operation than ordinary 
iridectomy. It is not a wise procedure if glaucoma is complicated with 
cataract, but it should be considered in glaucoma secondary to cataract 
in those eyes in which the vitreous and aqueous chambers are not in 
communication. It may be performed in absolute glaucoma in the 
hope of preventing enucleation, but this prevention is not assured. 
It is not likely to meet with success in glaucoma due to intra-ocular 
hemorrhage and thrombosis of the central retinal veins; it may be tried 
in staphyloma and secondary glaucoma, but the outlook is not a brilliant 
one. 
Complications and Causes of Failure.-The chief complications are 
buttonholing the conjunctival flap, extensive hemorrhage into the ante- 
rior chamber, entrance of the scleral button into the aqueous chamber, 
wounding the lens, loss of vitreous (which should never occur if the 
trephine opening is correctly placed); intra-ocular hemorrhage, detach- 
ment of the choroid, purulent infection, and iritis. After this operation 
iritis occurs not infrequently, and appears early either as a quiet iritis, 
with almost no signs of inflam- 
mation of the uveal tract, but 
with the gradual development 
of soft synechiae, or arises as 
a sharp, plastic inflammation 
at a later period than the first 
type of the affection. Parker's 
investigations indicate that iritis 
is much less apt to develop if 
complete iridectomy is part of 
the operative procedure-a sig- 
nificant observation. Its incidence should be prevented by the early 
use of a mydriatic-the author prefers scopolamin. 
The causes of failure in this operation, according to Elliot, depend 
upon forward dislocation of the lens or vitreous body and prolapse of 
uveal tissue into the trephine hole, which is blocked by proliferated con- 
nective tissue either from the episclera or the uvea. In Stephenson's 
observations the trephine tract was occluded by vascular fibronuclear 
tissue and iris pigment. A number of late infections (from a few weeks 
to some months after operation) are now on record, the process varying 
in severity from an infected iridocyclitis and hypopyon to panoph- 
thalmitis. Such disasters not peculiar, however, to this operation (see 
page 414) are due to the entrance of micro-organisms through delicate 
and invisible fistulas in the conjunctiva covering the trephine opening. 
After this operation patients with very thinly covered "filtering areas" 
should be carefully watched and should daily use a collyrium of boric 
acid and sulphate of zinc (Gifford). Fluorescein should be employed to 
detect the presence of epithelial defects (Axenfeld, Harms). 
Fig. 324.-Stephenson's sclerectomy trephines. CYCLODIALYSIS 
635 
Naturally, in a chapter of limited scope numerous operations de- 
signed for the relief of glaucoma cannot be described. In Holth's 
iridocleisis the incised iris is incarcerated in the scleral keratome 
incision and the conjunctival flap allowed to heal over it. To this pro- 
cedure, entailing iris incision, Borthen objects, and to substitute it has 
designed an operation called iridotasis, the effect being produced by 
inclusion of a fold of the iris, allowing the posterior surface to coalesce 
with the subconjunctival tissues, assuring a position of the sphincter 
external to the section, and with 
free drainage. In this country 
this operation is commended 
by David Harrower. Zorab's 
operation consists essentially of 
thread drainage of the anterior 
chamber. A silk thread is in- 
troduced into the aqueous 
chamber and covered with 
a conjunctival flap. Casey 
Wood, in this country, has 
practised this procedure. 
Cyclodialysis {Heine's 
Operation).-By means of this 
operation, suggested by Heine 
in 1905, an endeavor is made 
to form an artificial communi- 
cation between the anterior 
chamber and the supracho- 
roidal space, but there is no 
positive proof that after it 
drainage occurs into this space, although it is possible that a success- 
ful cyclodialysis reopens the angle and brings it again into communica- 
tion with Schlemm's canal. It is performed as follows: 
Fig. 325.-Corneoscleral trephining; note 
the filtering area at corneoscleral margin; small 
peripheral iridectomy. 
After the reflection of a small conjunctival flap, preferably on the outer side 
of the eyeball, an opening is made into the sclera with a straight lance, parallel to the 
corneal margin and from 6 to 8 mm. away from it, without injuring the uveal tissue. 
This opening should be from 2 to 3 mm. in length, and through it a spatula is intro- 
duced with which the ciliary body is separated from the overlying sclera and the 
instrument gradually pushed through the ligamentum pectinatum into the anterior 
chamber. Finally, a quadrant of the iris periphery is detached. Occasionally 
some difficulty is experienced in passing the spatula between the ciliary body and the 
sclera into the anterior, chamber, and in a few instances hemorrhage into this chamber 
has occurred. 
According to Meller, in successful cases reduction of tension is not 
noticeable until the following day. All increased tension should disap- 
pear by the second or, at the latest, by the third day. Occasionally 
subnormal tension results. If the tension remains low for a week, the 
ultimate result is likely to be favorable. The operation has proved to 
be satisfactory in secondary glaucoma due to anterior synechia or sub- 636 
OPERATIONS 
luxation of the lens, in glaucoma following cataract extraction, in ad- 
vanced cases of chronic glaucoma where iridectomy has failed, and in 
absolute glaucoma. It is not an operation which is likely to replace 
iridectomy, and does not seem to the author, who has performed it a 
number of times with satisfaction in advanced glaucoma, that it should 
be used for the relief of acute glaucoma or chronic glaucoma of ordinary 
type. 
OPERATIONS ON THE GLOBE AND REMOVAL OF FOREIGN BODIES 
Enucleation of the Eyeball.-The following instruments are neces- 
sary: A stop speculum, fixation forceps, dissecting forceps, strabismus 
hook, and a pair of scissors curved on the flat (enucleation scissors). 
The lids are held apart with a stop speculum while the surgeon divides the con- 
junctiva and adjacent fascia with scissors in a circle as close as possible to the margin 
of the cornea. This is sometimes called "circumcising the cornea." The tendons 
of the ocular muscles, beginning with the superior rectus, are next successively raised 
upon a strabismus hook and divided. The eye being made to start forward by 
inserting the stop speculum somewhat more deeply, the eye is drawn forward, the 
face of the patient being turned toward the operator, and the curved scissors are in- 
troduced on the nasal side between the severed conjunctiva and the freed eyeball, 
and made to follow the curve of the latter until the optic nerve is reached, where the 
blades are expanded and the nerve seized and cut squarely off. The attachments of 
the oblique muscles and the remaining tissue which may cling to the eyeball are 
then severed. Subsequently the conjunctival wound is closed with a few inter- 
rupted sutures. 
Hemorrhage is usually not severe, and is readily controlled by pressure. After 
freely irrigating the socket with a bichlorid solution, it may be dusted with iodoform 
and a full antiseptic dressing should be applied. In place of general anesthesia, 
local anesthesia, by means of retrobulbar injections (see page 597), is preferred by 
some surgeons. 
The operation just described is sometimes known as Bonnet's 
method. The eye may also be removed by what is known as the 
Vienna method, as follows: 
The only instruments necessary are a pair of strong scissors and toothed forceps. 
The tendon of the internal rectus, together with the overlying conjunctiva, is seized 
in one grasp with the forceps. It is then divided and the stump retained in the grasp 
of the instrument. With the scissors the inferior rectus and superior rectus are now 
divided, together with the overlying conjunctiva. The globe is drawn forward, 
rotated outward, and the optic nerve divided. The operation is concluded by cutting 
the external rectus and the two oblique muscles close to the globe. This operation 
can be rapidly performed. It, however, does not always yield as good a stump as 
the more slowly performed procedure previously described. 
The methods of enucleation just described were almost universally 
employed until recent years. The technic, however, has been mate- 
rially improved, chiefly by the various methods of suturing the tendons 
to the conjunctival bed to prevent their retraction. Suker sutures 
the severed ends of the recti muscles one to the other, after which 
the conjunctiva from above and below is brought over the muscle- ENUCLEATION OF THE EYEBALL 
637 
stump and fastened with a continuous suture, which also attaches 
the conjunctival covering to the muscle-stump. H. Schmidt secures 
each rectus tendon with a catgut suture and makes a slit in the con- 
junctiva over each muscle, in which then the divided conjunctiva is 
fastened. The conjunctiva is brought together with a continuous suture. 
Priestley Smith pinches up a narrow horizontal fold of the conjunctiva 
over the internal rectus, so as to include the subjacent connective tissue 
and muscle, and carries a black silk suture through these structures 
with a curved needle, the suture being tied firmly, but not too tightly. 
In a similar manner the other straight muscles are attached, after which 
the enucleation is carried out in the usual manner and the conjunctival 
aperture closed with one or more vertical sutures. 
Freeland Fergus' method of enucleation is as follows: 
The conjunctiva is divided freely over the external rectus so as to expose thor- 
oughly that muscle. As soon as this is done, one blade of the scissors is passed 
beneath the muscle and it is divided, a small portion of its tendon-being left still 
attached to the sclerotic. This portion is taken hold of with the forceps and the 
eye is gently rotated toward the inner canthus. When in this position the optic 
nerve is severed. After the division of the nerve the movement of rotation is con- 
tinued and all the other tissues are, as they come in view, resected as closely as 
possible to the sclerotic. A few snips of the scissors suffice. The wound, which 
is always neat, may be closed with or without the insertion of a gold ball, or with 
or without suturing together of the muscles, as recommended in the following 
paragraph. 
The author has operated in the following manner with satisfactory 
results: 
The conjunctiva is divided as close as possible to the corneal margin; each rectus 
tendon is next seized with forceps, separated from the sclera, and drawn forward to 
the edge of the cut conjunctiva, where it is fastened with a black silk suture. The 
eyeball is next enucleated in the ordinary manner, hemorrhage being checked by 
packing the cavity with a small wad of sterilized gauze. Finally, after removal of 
the packing, the edges of the conjunctiva are united with interrupted sutures, 
which are generally placed in a horizontal direction, and which also include the 
capsule of Tenon. The usual dressing is applied, both eyes being bandaged for 
twenty-four hours. 
The effect of this operation, whereby each rectus tendon is "ad- 
vanced" to the margin of the conjunctiva and prevented from retract- 
ing, is to give a movement to the conjunctival bed very much greater 
than that which is secured after the ordinary enucleation. 
Accidents.-(a) Hemorrhage.-Occasionally severe hemorrhage oc- 
curs during the enucleation of an eyeball, sometimes caused by an 
anomalous distribution of the vessels. If necessary, the orbit can be 
packed with antiseptic gauze. The tissues of the orbit may become 
very much infiltrated with blood and puff out in an alarming manner. 
The blood-clot, however, will gradually be absorbed, and usually no 
harm results. 
(6) Perforation of the Sclera.-Sometimes, especially in a ball having 
very thin walls, the sclera is punctured in the endeavor to cut the optic 638 
OPERATIONS 
nerve. This simply complicates the operation, because it is more diffi- 
cult to remove a collapsed ball than one which is distended. Should the 
operator be so unfortunate as to cut through the sclera and leave a 
portion of it remaining behind, he must proceed to search for the frag- 
ment, which can be picked up with forceps, and cut it off, together with 
the nerve. 
(c) Consecutive or Secondary Hemorrhage.-Occasionally a consecu- 
tive or secondary hemorrhage occurs after enucleation. The bandages 
should be removed, the lids separated, the blood-clot removed, the orbit 
irrigated with an antiseptic fluid, and, if pressure fails to stop the hemor- 
rhage, a packing of antiseptic gauze should be inserted. Excessive 
hemorrhage in hemophilic subjects has been checked by the intravenous 
injection of normal blood-serum. 
The after-treatment of an enucleation consists in placing the patient 
in bed, certainly for the first few days. No severe pain ought to follow 
an enucleation, and decided headache, elevation of temperature, and 
restlessness may indicate meningeal complication. In a certain number 
of instances meningitis has followed the operation, especially when it 
has been performed on an eye within which suppuration is taking place. 
Under modern methods of operating and with antiseptic precautions 
this accident is, fortunately, a rare one. 
Fig. 326.-Average artificial eye or shell. 
Fig. 327.-Solid artificial eye. 
Insertion of Artificial Eyes.-An artificial eye may be inserted as 
early as the second or third week after an enucleation of the eye; indeed, 
some operators insert it at a much earlier date. For the first week or two 
the artificial eye should be smaller than that which is a perfect match 
for the opposite side. The eye may then be exchanged for one which 
in size is as nearly as possible a match for the fellow-eye. At first the 
eye may be worn for several hours at a time. Soon it can be worn all 
day, but it never should be allowed to remain in the socket during the 
night. It is not necessary to keep an artificial eye in water during the 
night. It should be washed with a little alcohol and water, and allowed 
to dry. The wearer of an artificial eye must be cautious that the enamel 
is always smooth. 
In order to insert an artificial eye, the upper eyelid is seized between 
the fingers of the left hand and drawn gently down and out, and the 
larger end of the shell is inserted vertically beneath it, then brought to a 
horizontal direction, while at the same time the lower lid is pulled down, 
when the shell slips into place. In order to remove an artificial eye, the 
head of a large pin is inserted beneath its lower margin, the lower lid 
being at the same time depressed, while the eye is tipped upward and 
forward, when the pressure of the upper lid will force it out. Very soon EVISCERATION OF THE EYEBALL 
639 
patients become exceedingly expert in taking out and introducing 
artificial eyes, and do not require the aid of a pin in making the manip- 
ulation just described. 
One of the chief objections to the shell-shaped prosthesis, or artificial 
eye, is the fact that in its hollow undersurface tears and mucus may 
accumulate, while its thin edges may bruise the conjunctival bed. To 
obviate this difficulty the so-called "reformed artificial eye" has been 
introduced, largely through the efforts of Professor Snellen, which con- 
sists of a double-walled shell, or sometimes of a solid eye, the smooth 
rounded contour of which neutralizes the objections to the thin edges 
of the old-fashioned shells. The movements of an eye of this charac- 
ter, placed in the socket after a properly performed enucleation with 
suture of the tendons or implantation of a gold sphere in Tenon's cap- 
sule, are nearly as extensive as those which follow Mules' operation. 
Instead of the operation of enucleation, certain substitutes have 
been proposed, the most important of which are: 
Evisceration of the Eyeball.-This consists in an evacuation of 
the contents of the eye, the sclerotic being unmolested, and closure of 
the scleroconjunctival wound with sutures, thus forming a movable 
stump for the artificial eye. 
The instruments required for the operation are a speculum, fixation 
forceps, a narrow knife, a pair of scissors, and an evisceration spoon. 
It is performed as follows: 
The speculum being introduced, the conjunctiva is loosened around the cornea; 
the anterior chamber is transfixed with the knife on a level with the horizontal 
meridian, the lower portion of the cornea separated, the flap seized with forceps, and 
the remainder of the cornea cut away at the corneoscleral margin. With the eviscera- 
tion scoop the contents of the globe are thoroughly and cleanly evacuated. The cavity 
of the globe is wiped out with sterilized cotton-wool, and all bleeding is stopped. 
The edges of the conjunctiva are united by means of a suture similar to the string 
which draws shut a tobacco-pouch-a suture sometimes called the tobacco-pouch 
suture, or by interrupted sutures. These may include the conjunctiva alone, 
unless this is very much macerated, when it may be necessary to include the sclera. 
The author is accustomed to suture both the sclera and the conjunctiva. The 
evisceration may be accomplished without sacrificing the cornea provided this mem- 
brane is not infected (Gifford). 
Considerable pain may follow the operation, together with edema 
and swelling of the surrounding tissues. In order to avoid this, it has 
been recommended to introduce a horse-hair drain, and Prince has 
suggested wiping out the cavity with carbolic acid in order to allay the 
pain. 
The chief indication for evisceration is panophthalmitis (see also 
page 359), although it may also meet the indications which are men- 
tioned below in connection with Mules' operation. Evisceration is 
contraindicated by sympathetic inflammation or irritation, malignant 
disease, and much shrunken eyeballs. Although the stump after evis- 
ceration is primarily more voluminous than that which is secured after 
an enucleation, subsequent shrinking of this stump ultimately renders 640 
OPERATIONS 
the cosmetic effect of the operation no better than that which is secured 
by a properly performed enucleation, while its inconveniences are much 
greater. 
Evisceration of the Eyeball, with Insertion of an Artificial 
Vitreous.-Mules' Operation.-Mules modified the operation of 
evisceration by the introduction of a glass ball into the cavity of the 
sclera. The operation is performed as follows: 
After general anesthesia a stop speculum is introduced, and the conjunctiva dis- 
sected from the corneoscleral attachment in all directions to the equator of the ball 
without disturbing the muscles. The cornea and 1 mm. of the scleral margin are 
removed in the manner described under evisceration. Next the contents of the 
globe are emptied by any convenient method, a small evisceration scoop being a 
satisfactory instrument. Great care must be taken to remove the entire contents, 
leaving a perfectly clean, white sclera. Hemorrhage is controlled by packing the 
scleral cavity with sterilized gauze, and by frequently irrigating it with a tepid 
solution of bichloridof mercury (1 : 5000). A glass or gold sphere (gold is preferable), 
of such size that it may be introduced within the scleral cup without difficulty, is 
selected, its introduction being facilitated by slitting the sclera vertically for about 
4 mm. at the upper and lower margins of the opening. The introduction of the 
sphere is further facilitated by the use of an instrument specially devised by Mules 
for this purpose. The concluding steps of the operation consist in stitching the 
sclera vertically, the conjunctiva horizontally, and applying a full antiseptic dressing. 
The patient should be confined to bed for at least four or five days. Considerable 
reaction may follow, and marked chemosis of the conjunctiva. This may be con- 
trolled by the continuous application of cold, and probably be avoided by not re- 
moving the bandage for forty-eight or even seventy-two hours. Mules recom- 
mended that the sutures should be of catgut; the author prefers silk sutures. 
The chief indications for this operation are ruptured or injured eye- 
balls, provided the sclera is not too much lacerated, and the accident 
of recent date; staphyloma of the cornea and sclera, or complete 
leukoma; absolute glaucoma; buphthalmos; and non-traumatic irido- 
cyclitis. The chief contraindications are suppuration of the eyeball; 
morbid growths; much shrunken eyeballs, the contents of which have 
undergone bony or calcareous change; sympathetic ophthalmitis, sym- 
pathetic irritation, and pathologic conditions of the eyeball which are 
likely to produce either of the last-named affections; extensive injuries 
of the eyeball, with much bruising and laceration of the sclera; dacryo- 
cystitis; and ocular conditions demanding enucleation or its equivalent 
in very old persons. 
Implantation of an Artificial Globe in Tenon's Capsule After Removal of the 
Eyeball (Frost-Lang Operation).-The eyeball is enucleated in the ordinary manner, 
and, after all bleeding has been checked, a gold or glass sphere is inserted within 
Tenon's capsule. The capsule and conjunctiva are next sutured over the artificial 
globe with silk sutures, the tendons of the ocular muscles having previously been 
secured by one of the methods described under Enucleation. The subsequent treat- 
ment is the same as that suited to Mules' operation. 
Sponge-grafting into the orbit for the support of an artificial eye has 
been suggested by Claiborne and Belt, and Suker wraps the glass sphere 
in a layer of sponge before its implantation. OPERATIONS FOR PROSTHESIS IN CASES OF CICATRICIAL ORBIT 
641 
A number of surgeons have recommended, in place of the in- 
sertion of a glass or gold sphere within Tenon's capsule, the use of 
paraffin spheres, and admirable results have been reported, especially 
by Charles Nelson Spratt. He uses a suitably sized paraffin sphere 
and places it within Tenon's capsule. Following this, the superior rectus 
is sutured to the inferior by a mattress suture, and the two lateral recti 
by a similar suture. Tenon's capsule is closed over the globe by means 
of a catgut purse-string suture. Finally, the conjunctiva is closed 
with a similar suture. 
Fat implantation into Tenon's capsule after enucleation of the eyeball, 
originally proposed and practised by Barraquez, came into prominent 
notice after Bartels called attention to the operation in 1908. The 
eyeball is enucleated, the recti muscles being secured in the manner 
already described. A mass of fat taken from the abdominal wall is 
inserted into Tenon's capsule so as to fill, but not to overstretch, it. 
The muscles are sutured crosswise or by means of a purse-string suture, 
and next the cut conjunctiva is united with stitches. Either catgut or 
silk may be employed. The cosmetic result is said to be good. 
L. Webster Fox has devised an operation which consists of implan- 
tation of a glass or gold ball into the orbit after remote enucleation of an 
eyeball. It is performed as follows: 
If the operation is to be performed on the right orbit, the eyelids are separated 
by a speculum, the conjunctiva is grasped up and in above the inner canthus, and 
the tissues are well pulled out. Next, a Beer's knife or curved keratome is passed 
through the tissues somewhat obliquely and well down into the orbit, and an opening 
made large enough for the insertion of the globe behind the tissues. This opening 
may be enlarged with curved scissors to the desired size. When ready, a gold ball 
is inserted through the opening, which is closed with two stitches and over which a 
shell is placed, modeled after an artificial eye. The eyelids are then closed over this 
shell, which is left in place for twenty-four hours. The stitches are taken out on 
the third day. If the operation is to be performed on the left orbit, the incision is 
made up and out above the external rectus muscle and the dissection carried out as 
above described. 
Opticociliary neurotomy and neurectomy have been employed as 
substitutes for enucleation, and are still performed by some surgeons, 
but in the opinion of the author they are rarely to be recommended. 
Operations for Prosthesis in Cases of Cicatricial Orbit.-Con- 
traction of the conjunctival sac and the formation of cicatricial bands, 
especially after lime-burns and trachoma, may render the introduction 
of an artificial eye impossible. The same state of affairs may be brought 
about by the neglect to wear a suitable eye. Numerous operations 
have been devised to enlarge the socket under these circumstances, 
mere incisions of the contracting bands being entirely insufficient. 
If there is complete closure, or practically complete closure, of the 
orbital cavity, the most satisfactory results are reached by dissecting 
loose the attachments of the lid to the contracted orbital tissues and 
preventing readhesion by the introduction of grafts of skin-either a 
Wolfe-Lefort flap or a Thiersch graft. It is usually best to restore only 642 
OPERATIONS 
one culdesac at a time, and after the flaps are in place their position 
in the culdesac should be maintained by the insertion of a plate, which, 
as John Weeks suggests (and he has elaborated one of the best of these 
operations), may be made of flexible rubber, such as is used by dentists. 
If the cavity of the orbit is not entirely obliterated, it is sometimes pos- 
sible, after dividing the cicatricial bands, to form a socket, in which 
later an artificial eye may be placed, by introducing lead plates, which 
are bent to conform to the size of the cavity, and from time to time 
increased in size. The plate gradually creates a groove in the dense 
tissue, into which afterward the margin of the artificial eye is fitted. 
Removal of Metallic Foreign Bodies from the Interior of the 
Eye.-For this purpose, as has already been noted on page 295, a giant 
magnet may be employed (the Haab pattern), and the body drawn into 
Fig. 328.-Showing the use of the large magnet in extracting an iron spicule from the eye 
(Haab). 
the anterior chamber, or, having been properly localized by means of 
the x-rays, it is removed by means of a large magnet or one of more 
moderate size (the Sweet model), through a suitably placed scleral 
incision which directly overlies the position of the metal. The extension- 
point of the magnet, however, does not enter the sclera. 
Haab's Operation.-This may be performed as follows, according 
to this distinguished operator's directions: 
After the usual aseptic preparations and thorough cocain anesthesia of the 
eye, the operator assumes one of the two positions shown in the accompanying 
figures. 
In the majority of cases-that is, in all those in which a small- to a medium- 
sized splinter is probably present-the center of the cornea should be placed exactly 
opposite the pole of the magnet. If the presence of a large splinter is suspected the 
pole of the magnet should first be allowed to act at some distance from the eye. The 
patient is told to look in the direction of the pole of the magnet. The first closure of EXTIRPATION OF THE WHOLE CONTENTS OF THE ORBIT 
643 
the current may bring the foreign body behind the iris. If it does not, the current 
must be repeatedly opened and closed. If now there is no bulging of the iris, more 
lateral portions of the cornea are successively brought opposite the pole, but the 
region of the ciliary body must be scrupulously avoided. To draw the splinter for- 
ward, from behind the iris, through the pupil into the anterior chamber is not always 
an easy matter, although, if it is smooth, it usually comes without difficulty. Occa- 
sionally iridectomy is necessary, although Haab has not found this requisite in his 
personal experience. According to Lang's suggestion, a smooth steel spatula, at- 
tached to the magnet, may be carried through a corneal incision behind the iris 
where the splinter is lodged. In uncomplicated cases after the splinter reaches the 
anterior chamber it may be removed through a suitable corneal incision by introduc- 
ing the extension point of a small magnet, although Haab himself finishes the opera- 
tion with the large magnet. Each case must be carefully considered and the technic 
varied according to the conditions.. 
The author's views in regard to the method of removing foreign bodies have 
already been given on page 295. 
Fig. 329.-Showing the use of the large magnet in extracting an iron spicule from the eye 
(Haab). 
Extirpation of the Whole Contents of the Orbit (Exenteration).- 
This is the operation necessary in certain cases of malignant disease. 
The eyeball having been removed in the ordinary way, an incision is made 
through the outer commissure to the edge of the orbit. The lids having been widely 
separated, the tissues back of them and the periosteum within the orbital margin are 
divided with a scalpel. Next, the periosteum is separated to the apex of the orbital 
cavity, where the entire mass of tissue is detached with strong curved scissors or 
other suitable instrument. Bleeding, which is sometimes considerable, may be 
checked by pressure or, if necessary, by the actual cautery. The cavity is loosely 
packed with iodoform or ordinary sterile gauze, one strand of which may be left at 
the outer commissure for drainage. Next, the ciliary borders, including all hair- 
follicles, is removed, and the lids, thus prepared, are sutured together up to the point 
where the gauze strand protrudes. The packing should be removed at the end of 
twenty-four hours. In favorable cases the lid-skin will be retracted inward and 
completely line the socket. Thiersch grafts are also used for this purpose. It may 644 
OPERATIONS 
Fig. 330.-Spindle-cell sarcoma of the orbit which was removed, with preservation of the 
functions of the eye, through an incision beneath the entire orbital arch. 
Fig. 331.-Result after removal of sarcoma of orbit. EXOSTOSES AND OSTEOMAS 
645 
happen that the eyeball is so involved with the malignant disease which is present 
that its extirpation as the first step of the operation is not feasible. The operator 
then proceeds as before described, removing the eyeball with the entire mass of 
tissue. 
Removal of Tumors and Cysts from the Orbit.-Tumors in the 
anterior portions of the orbit may be reached by an incision similar to 
that already described in connection with deep-seated purulent pockets 
(see page 577), and the growth removed by an ordinary dissection. 
Occasionally, in favorable situations, such growths may be reached by 
a dissection through the conjunctiva. If the growth is an angioma, 
and is encapsulated, it may often be removed in similar manner by a 
slow dissection, without much loss of blood. If non-encapsulated, and 
especially if it protrudes and involves the skin of the lid and brow, it is 
a much more difficult procedure. To a certain extent the hemorrhage 
can be controlled, as Knapp suggests, by pushing a horn spatula be- 
neath the upper lid, between the eyeball and the orbit, which may be 
manipulated to act as a controller of hemorrhage, while the dissection 
proceeds from the skin surface. Although the main body of the angi- 
oma may thus be removed, it is often impossible, without sacrifice of 
too much tissue, to extirpate those portions of it which involve the skin 
of the eyelids and eyebrow. These, however, may disappear later, or 
may be treated by electrolysis. Recent investigations indicate that 
they may be successfully treated by applications of liquid air. Some- 
times encapsulated sarcomas, endotheliomas, and certain non-malig- 
nant growths, especially in the anterior portion of the orbit, may be 
reached without sacrificing the eyeball, according to a method advo- 
cated by Lagrange and Knapp, namely, first severing, if, for example, 
the growth is on the inner side, the internal and perhaps the inferior 
rectus, which are secured with threads, next separating the conjunctiva, 
and gradually dissecting out the growth through the opening thus 
made. After controlling the hemorrhage the severed recti muscles are 
sewed in place exactly as in the operation of advancement. Again, the 
growth may be reached by means of a dissection which begins with an 
incision which extends beneath the entire length of the orbital arch 
and is continued slightly downward and outward along the outer margin 
of the orbit. Should it become necessary to divide an ocular muscle it 
can first be secured in the manner just described. This operation, care- 
fully performed, may, in suitable cases, replace resection of the temporal 
wall of the orbit and produces much less deformity. Orbital cysts, 
dermoids, serous or blood cysts are treated in the same manner as 
growths, the dissection proceeding either through an incision along 
the orbital margin or, if conditions are favorable, through the conjunc- 
tiva, great care being taken to remove every particle of the cyst wall, 
often a difficult procedure. In some instances the cyst elaboration is 
so extensive that the eyeball cannot be saved. 
Exostoses and osteomas growing from the wall of the orbit, or 
pushing their way into it from the ethmoidal or frontal sinus, may be 
reached by an ordinary dissection through an incision along the orbital 646 
OPERATIONS 
margin, with the usual precautions to avoid the pulley of the superior 
oblique, the tendon of the levator, and the lacrimal gland. After the 
body of the growth is fully exposed, it may be chiseled from its position 
in the ordinary manner or, if it is very dense and resisting, its base may 
be perforated several times with a drill suitably attached to a dental 
engine. It is next broken from its position with a stout pair of forceps, 
all rough spicules of bone carefully smoothed away, and the wound 
closed. 
Resection of the Temporal Wall of the Orbit (Kronlein's Operation).-The 
operation, following Haab's directions, begins by dividing the soft parts with a curved 
incision (Fig. 332), which should be about 7 cm. in length in adults and 4 to 5 cm. in 
children, which commences above the supra-orbital margin and describes a gentle 
curve along the outer edge of the orbit to the upper edge of the zygoma, where it is 
bent backward and ends at the center of this structure. The center of this curved 
incision should bisect a horizontal line which connects the outer canthus with the 
Fig. 332.-Skin incision (curved line) and bone incisions (heavy lines) in Kronlein's opera- 
tion (Haab). 
outer orbital margin, and here should be sufficiently deep to expose the opening of 
the orbit, while above and below' only the skin and fascia and muscular layer are at 
first divided. Next, at a position corresponding to the central portion of this incis- 
ion, a strong elevator is introduced, with which the periosteum is separated from 
the external orbital wall. The inferior orbital fissure is now localized, and, beginning 
at the anterior end of this fissure, the bony wall of the orbit is cut through with a 
chisel or with an electric saw, up and out to a point a little above the external 
angular process of the frontal bone, the line of incision being, for all practical pur- 
poses, along the suture between the great wing of the sphenoid and the malar bone, 
and outward and forward over the external surface of the malar bone in a line above 
the insertion of the zygomatic arch. Thus, a wedge-shaped piece of bone is formed, 
and with its muscular and cutaneous attachments is forced backward, giving free 
access to the orbit, which will be still partly covered with the periosteum. The 
latter must now be split from before backward and separated with retractors. This 
brings into view the external rectus muscle, and, if necessary, this may be divided 
near its tendinous insertion after the introduction of sutures, with which later the 
divided ends are united, or sometimes the muscle may be pushed aside and the dis- 
section continued to the apex of the orbit. With suitable retractors the orbital fat NEEDLE OPERATION 
647 
and ocular globe are pushed aside. After the exploration is complete, and this 
must sometimes be carried to the nasal side and the growth removed, the osteo- 
plastic flap is replaced, the periosteum stitched with fine catgut sutures and the 
soft parts with silk. The question of drainage must be decided by the conditions 
remaining after operation. The usual full antiseptic dressing is applied, great care 
being taken that the lids cover the cornea, especially if the latter structure is anes- 
thetic. 
Various complications have occurred after this operation; for ex- 
ample, outward limitation of the eye owing to injury to the abducens, 
ptosis, sinking of the eyeball, and infection. 
Indications.--Domela, Haab, and other writers have classified the 
indications for Kronlein's operation as follows: Retrobulbar cysts; tu- 
mors of the optic nerve and its sheath; neurofibroma of orbit (Parker); 
retrobulbar vascular growths, for example, cavernous angioma, lymphan- 
gioma, aneurysms, and varicose dilatations of the orbital veins; deep- 
seated foreign bodies in the orbit and exploration of the orbit in doubt- 
ful cases in order to establish a diagnosis. The operation has also been 
performed in deep orbital abscess, to open the sheath of the optic nerve 
in choked disk, and even for the removal of subretinal effusions. The 
two last indications are of doubtful value; certainly in choked disk a 
far better operation is a decompression-trephining. 
Gifford recommends as a substitute for the Kronlein operation a 
definite resection of the outer wall of the orbit. He makes a horizontal 
incision 2| to 3 inches long, beginning | inch from the outer commissure, 
care being taken not to open into the conjunctival sac. Next, the lips 
of the wound should be widely separated, and the periosteum pushed 
back from the outer side of the bone. Following this, with strong bone 
forceps the outer margin of the orbit and as much of the outer wall as 
desired is removed. Finally, the periosteum of the orbit is opened, and 
the operation terminates in the usual manner. 
OPERATIONS FOR CATARACT 
The following methods constitute the most important varieties of 
operation which are practised for the cure of cataract: 
Extraction without iridectomy, so-called simple extraction; extrac- 
tion with iridectomy, so-called combined extraction; extraction in the 
capsule; linear extraction; the needle operation, or discission; and the 
suction method. The old operation of reclination, depressing, or couch- 
ing, as it has been variously called, by which the lens was forcibly 
thrust down into the vitreous, is rarely practised at the present time, 
although some surgeons have suggested that the operation is advisable 
in patients greatly enfeebled by age or other infirmities, if chronic con- 
junctivitis or dacryocystitis fails to yield to treatment, in lunatics, 
imbeciles, and others whose actions cannot be controlled, and particu- 
larly if one eye has been lost by intra-ocular hemorrhage. 
1. Needle Operation (Discission-Operation for Solution).-By 
this operation the capsule of the lens is opened, the aqueous humor ad- 648 
OPERATIONS 
mitted to the lens matter, and absorption thus promoted. It is applic- 
able to congenital and juvenile cataracts, and to some traumatic cata- 
racts, and is rarely employed after the fifteenth year. 
The instruments required are two cataract needles (lance-headed or 
knife-needle, according to the fancy of the operator), a stop speculum, 
and fixation forceps. The eye in this and all operations of similar char- 
acter should be prepared in the manner described on page 651. 
After the induction of general anesthesia in young children, or the 
use of cocain in older subjects, and full dilatation of the pupil, the 
operation is thus performed: 
The lids being separated by the stop speculum, the surgeon fixes the eye with 
forceps, and enters the cataract needle through the cornea at its outer margin or 
at the limbus and carries it across to the center of the pupil, where the point is turned 
Fig. 333.-Bowman's stop needle. 
Fig. 334.-Knife-needle. 
to the lens, and a laceration made in the capsule by depressing the handle of the 
instrument with a lever-like movement. Two cuts are made at right angles to each 
other, and the lens-matter may then be slightly broken up with the point of the 
needle. Care must be taken not to use so much force as to dislocate the lens, and 
not to lacerate too freely in the first operation, lest the lens substance, swelling up 
from contact with the aqueous humor, should produce injurious pressure on the iris 
and ciliary body. The operation usually has to be repeated at intervals, the second 
operation being performed after the swollen lens matter caused by the first incision 
has disappeared by absorption and the eye has become perfectly quiet. 
Fig. 335.-Discission with two needles. 
At the second operation the needle may be used more freely, or two needles may 
be used in the manner shown in Fig. 335. The points enter the lens substance and 
the handles are approximated, thus making a decided separation in the remaining 
opaque matter. In order to prevent too deep entrance of the needle it is sometimes 
constructed with a shoulder (stop needle; see Fig. 333). In place of this procedure 
Ziegler's operation (see page 627) may be utilized. Instead of repeating the need- 
lings, the first discission may be very free, with the understanding that in a few days 
it is to be followed by a linear extraction and a few weeks later by division of the 
capsule (C. F. Clark). LINEAR EXTRACTION 
649 
After-treatment.-The conjunctival sac should be irrigated with 
boric acid or physiologic salt solution, atropin freely instilled, and 
pupillary dilatation maintained during the entire treatment. Both 
eyes should be lightly bandaged. 
Decided reaction, with hyperemia of the iris, pain, and ciliary 
congestion, indicates a more frequent use of atropin, dionin, and iced 
compresses. Great swelling of the lens matter, in addition to the 
symptoms of iritis, may give rise to a glaucomatous state. In these 
circumstances the lens matter which has escaped into the anterior 
chamber must be evacuated by a linear extraction or, what is practically 
the same thing, by a free paracentesis of the cornea. The suction 
method may also be employed in these circumstances. Some operators 
invariably extract the lens a few days after needling-a practice 
which certainly hastens the restoration of vision, but which is usually 
considered to be a procedure less safe than repeated discissions. C. F. 
Clark is not in accord with this belief and recommends linear extraction 
soon after a primary free needling. 
For the removal of the lens in high myopia (see page 135) needling is 
employed. According to W. E. Lambert, the Fukala method, that is, 
needling the lens followed by a linear extraction, yields the best results 
in young subjects. If the patient is fifty or more years of age, and the 
lens is more or less cataractous, Lambert advises a preliminary iridec- 
tomy with subsequent extraction of the lens in the usual manner. 
2. The Suction Method.-This operation is specially adapted for 
completely soft or fluid cataracts, and is also used, as has been stated, 
to remove lens matter which has been broken up by discission or by 
traumatism. It is performed as follows: 
The pupil being dilated with atropin, the anterior capsule of the lens is freely 
lacerated with two needles. A small wound is made with a keratome passed ob- 
liquely through the cornea between its center and periphery. Through this opening 
and into the lens matter the "suction curet" is passed. This consists of a curet 
roofed in to within 2 mm. of its extremity, with a handle and a piece of India- 
rubber tubing- furnished with a mouth-piece, -which the operator applies to his lips 
and gently sucks out the lens matter into the syringe. This is Teale's method. 
The same may be accomplished by using the syringe of Bowman, in which a 
sliding piston is worked by the hand. The point of the syringe must not penetrate 
too deeply, must be behind the lens matter which is to be removed, and must not 
be pushed back of the iris. 
The after-treatment consists of rest, bandage, and the local use 
of atropin. 
3. Linear Extraction.-This operation is designed for the removal 
of soft cataracts or those with a very small nucleus, and may be em- 
ployed to remove lens matter after discission. Although any lens the 
substance of which is liquid enough to pass through a small corneal 
wound may be removed by this method, it is better, if possible, to 
restrict the operation to cases of soft cataract occurring in patients 
under thirty years of age, and to some varieties of traumatic cataract. 
The following instruments are necessary: A keratome or lance- 650 
OPERATIONS 
shaped knife, fixation forceps, cystotome, curet, and stop speculum. 
The operation is as follows: 
The surgeon fixes the eye with forceps, after the introduction of the stop specu- 
lum, wide dilatation of the pupil having previously been obtained, introduces the 
keratome about 1 mm. within the margin of the cornea, and makes a wound 5 mm. 
wide. The instrument is now carefully withdrawn, with a slight lateral motion to 
make the wound a little larger if necessary, and a sharp cystotome is introduced 
and the capsule of the lens is freely lacerated. The soft lens matter is now caused 
to extrude by counterpressure on the cornea with a metal spud, the outer lip of the 
corneal wound at the same time being depressed with a curet. This is a simple linear 
extraction. 
The same manipulations may be performed, assisted by an iridectomy after the 
corneal section, a small segment of the iris being withdrawn with either hook or 
forceps and excised. Instead of using the cystotome to open the capsule of the lens, 
some operators do this with the keratome after making the incision in the cornea by 
causing the instrument to dip directly into the lens. 
The after-treatment consists of bandage, atropin, and rest in bed 
until the eye is quiet. 
Fig. 336. 
Fig. 337. 
Fig. 338. 
Fig. 339. 
Fig. 340. 
Fig. 336.-Flap extraction. 
Fig. 337.-Modified flap extraction (Knapp's section). 
Fig. 338.-Modified peripheral linear incision. 
Fig. 339.-Short 3-mm. flap with iridectomy. 
Fig. 340.-Corneal incision. 
4. Extraction of Hard Cataract.-It would be impracticable to 
indicate the numerous modifications which have been employed in this 
operation, than which, as the late Dr. Noyes has said, no surgical pro- 
cedure has been more carefully studied and elaborated in every detail. 
Hence only a few well-recognized methods will be described. 
(a) Extraction without iridectomy, often called simple extraction. 
The author is accustomed, .following the directions of the late Dr. H. 
Knapp, to proceed as .follows: The corneal section for full-sized cataracts 
comprises exactly the upper half of the cornea; for smaller, Morgagnian, 
and soft cataracts, somewhat less. A perfect section passes in its whole 
extent exactly through the'transparent margin of the cornea, the knife 
(see Fig. 345) remaining in the same plane throughout, particular care 
being taken that in completing the section the blade of the knife is not 
turned forward nor backward. In many cases a small central con- EXTRACTION OF HARD CATARACT 
651 
junctival flap is formed, which is an advantage. (For steps of operation, 
see pages 654-657.) 
(&) Extraction with iridectomy, often called combined extraction. 
The peripheral linear extraction of von Graefe, by means of which the 
extreme periphery of the anterior chamber was opened by an incision 
10 mm. long, through the sclerotic, 1 mm. external to the margin of the 
cornea and 2 mm. below the tangent of its summit, has been abandoned 
by almost all operators owing to its dangers-hemorrhage from the con- 
junctiva, loss of vitreous favored by the peripheral position of the wound 
and cyclitis, and consequently danger of sympathetic involvement of 
the other eye-and in its place one or other of the various so-called 
short-flap operations is performed. 
A useful method is the following: A Graefe cataract knife is entered 
exactly at the corneoscleral junction at the outer extremity of a hori- 
zontal line which would pass 3 or 4 mm., according to the size of the 
cataract, below the summit of the cornea. Counterpuncture is made 
at a similar point directly opposite, and a flap is cut which embraces one- 
fourth or one-third of the cornea. A small conjunctival flap may be 
made or not. Iridectomy is performed. (For steps of operation, see 
pages 654-657.) 
With the various corneal incisions which have from time to time 
been practised for the removal of cataract the author has no experience. 
Liebreich made an incision in the form of a curved section through the 
lower portion of the cornea, puncture and counterpuncture being- 
effected in the sclerotic, while Lebrun caused the corneal flap to occupy 
the upper portion of the cornea and to be 3 mm. high, puncture and 
counterpuncture being made 2 mm. below the extremities of the trans- 
verse diameter of the cornea. In these operations iridectomy was 
usually omitted. 
(c) Extraction without capsulotomy is performed by some surgeons- 
that is to say, the lens is delivered in its capsule. The operation was 
formerly chiefly employed to remove overripe cataracts and cataracts 
complicating high myopia with vitreous changes. Pagenstecher in 
these circumstances expelled the lens after an incision of about one-third 
of the corneal circumference and an upward iridectomy. The expulsion 
was accomplished either by pressure or with the aid of a spoon or loop. 
The chief danger of the operation is the risk of extensive loss of vitreous. 
The visual results are very good in successful cases. The author not 
infrequently has performed this operation, delivering the lens with a 
loupe after iridectomy through a section made in the corneoscleral 
junction. 
Some ophthalmic surgeons of great experience in India and in this 
country believe that extraction in the capsule should be the operation 
of election. (For Colonel Smith's Method, see page 660.) 
Preparation of the Patient and the Eye.-This should include a 
thorough examination of the patient, and the removal of the condi- 
tions already named (see page 406), which contraindicate the opera- 
tion. 652 
OPERATIONS 
For some days previous to the operation, as H. Knapp insisted, the 
eye should be protected from anything which may produce congestion, 
and the patient should remain in the hospital, perfectly resting his eye 
and body, and frequently washing his face and the surfaces and margins 
of the eyelids with soap and water. This simple regimen will fre- 
quently change a congested and irritated conjunctiva into a pale and 
shining membrane. If there is any abnormal conjunctival discharge 
the instillation of a solution of argyrol (25 per cent.) is recommended by 
some surgeons, who also employ this drug in subsequent dressings of the 
operated eye (Callan). Bacteriologic examination should always be 
made, and if pathogenic organisms are present the operation should be 
postponed until they have been made to disappear by suitable treat- 
ment. Axenfeld recommends an injection of antipneumococcic serum 
prior to the performance of an operation in the presence of conjunctival 
pneumococci. During these days scrupulous attention should be given 
to the nasopharynx. The author, following a suggestion of J. A. Lippin- 
cott, of Pittsburgh, is accustomed to spray the nasopharynx three times 
daily with a solution of permanganate of potassium (1 :5000), with 
gratifying results. Dr. J. A. White recommends that the conjunctival 
sac shall be filled with bichlorid-vaselin (1 :3000) on the night prior to 
the operation, where it remains until the next day. 
The preparation of the skin of the region of operation, and particu- 
larly the ciliary margins, has been described on page 593. These 
preparations should be made at least two hours, before the operation, 
and the eyes should be covered with squares of lint soaked in a solu- 
tion of bichlorid of mercury (1 : 5000), held in placet with a gauze 
roller. Just preceding the operation, the preparatory bandage having 
been removed, the ciliary margins may again be washed with soap and 
water, followed by bichlorid of mercury (1 :5000), with the same pre- 
cautions previously described (see page 593). Next, the conjunctival 
culdesac should be flushed with a tepid solution of boric acid applied 
with some force, or with a sterile physiologic salt solution. During these 
irrigations pressure should be made over the lacrimal sac in order to 
be sure that no deleterious secretion is contained within it. The canal- 
iculi and lacrimal canal may be irrigated with a boric acid or saline solu- 
tion introduced by means of an Anel syringe. The lids are next everted, 
the tarsal conjunctiva and the region of the inner canthus wiped with a 
pledget of cotton moistened in the boric acid solution. The cornea 
should be anesthetized with three instillations of a sterile 4 per 
cent, solution of cocain, applied at intervals of five minutes, and 
the eye carefully closed and covered with the antiseptic pad after 
each instillation. In place of cocain some surgeons prefer holocain 
in 2 per cent, solution or a mixture of holocain and cocain. Just 
before the knife is entered the surface of the cornea should be care- 
fully wiped with a pledget of cotton soaked in boric acid solution. 
This same method of preparing an eye should be practised not only in 
cataract extraction and discission, but also prior to all operations requir- 
ing corneal incision-for example, iridectomy, iridotomy, etc. With EXTRACTION OF HARD CATARACT 
653 
injection, of physiologic salt solution prior to extraction to deepen an 
abnormally shallow anterior chamber the author has had no experience. 
He has not deemed its wise to flush the conjunctival sac vigorously with 
strong solutions (1 : 2000 or 3000) of bichlorid of mercury, but this prac- 
tice is commended by surgeons of great experience, for example, Col. 
Henry Smith. Placing a preparatory dressing over the eyes during 
the night preceding the. operation the author is satisfied 
is an unwise procedure. 
Position of the Patient.-The patient during the opera- 
tion should lie, according to the custom of the operator, 
upon an operating chair or table. If, as is sometimes 
advisable, the operation is performed while the patient 
reclines in bed, the head should rest on a moderately 
hard cushion or pillow, covered with a sterile- sheet, an- 
other pillow at the same time supporting the shoulders, 
Fig. 342.- 
Metal spoon. 
Fig. 343.- 
Wire loop. 
Fig. 344.- 
Cystotome. 
Fig. 345.- 
Cataract knife. 
Fig. 341.- 
Lid-elevator. 
Fig. 346.-Capsule forceps. 
so that the position is as little strained as possible. In all circum- 
stances the face must be turned so that uniform daylight falls upon 
it, or the area of operation should be illuminated with a suitable 
electric lamp, the model of Ziegler being most satisfactory. 
Instruments, Solutions, and Dressings.-The instruments required 
are the following: A stop speculum, a lid-elevator, a large strabismus 
hook, a spatula, a wire loop, a spoon, an. olive-tipped probe, a curet, a 
cystotome, capsule forceps, a pair of scissors, iris forceps, iris scissors, 
and the cataract knife. 
The following lotions and dressings should be at hand: Atropin 
drops, 4 grains (0.26 gm.) to the ounce (30 c.c.); eserin drops, | grain 654 
OPERATIONS 
(0.0324 gm.) to the ounce (30 c.c.); cocain solution (4 per cent.); satu- 
rated solution of boric acid; two solutions of bichiorid of mercury 
(1 : 5000 and 10,000), and boiled distilled water containing 0.5 per cent, 
of chlorid of sodium. Suitable bulb syringes and an irrigating appa- 
ratus, for example, Lippincott's, should be ready. 
For the purpose of dressings the following may be needed: Several 
rollers, 2 inches wide and 5 yards long, made of sterilized gauze, and 
sterilized oval pads of lint and absorbent cotton. A useful ^andage is 
composed of a broad band of knitted material which is tied with four 
tapes, which pass above and below each ear. 
Everything being in readiness, the operation may be performed as 
follows: 
The surgeon, if he is ambidextrous, may stand behind the patient, no matter 
which eye is to be operated upon; if he is not, he should take this position for the 
right eye only, standing at the patient's side and in front for an operation on the left 
eye. Again, if the surgeon is ambidextrous, he may stand in front and at the patfent's 
right side for an operation upon the right eye, and at the patient's left side and in 
front for an operation on the left eye. 
The speculum having been inserted, the surgeon steadies the eyeball and draws 
it downward with the fixation forceps (it is supposed that the section is being made 
upward) by taking firm hold of a fold of conjunctiva below the inferior border of the 
cornea (some surgeons prefer fixation at the inner side, over the internal rectus 
tendon), enters a Graefe cataract knife exactly at the corneoscleral junction, as 
before described, at the outer extremity of a horizontal line which would pass 3 or 
4 mm., according to the size of the cataract, below the summit of the cornea, passes 
across the anterior chamber to a corresponding point upon the opposite side, and 
makes the counterpuncture. The knife is pushed steadily onward as far as possible, 
with an upward tendency, and the incision is completed by a free cutting, not a saw- 
ing or dragging movement, keeping the knife in the same plane throughout, and 
not turning its edge at the completion of the section either forward or backward. 
This maneuver will create a small conjunctival flap. If this is not desired, when 
the summit of the cornea is reached the knife must be turned a little forward before 
the completion of the flap. It is the practice of some surgeons to remove the specu- 
lum as soon as the section is completed; other operators prefer not to use a speculum, 
but to separate the lids with their fingers or with a lid-elevator or a Smith's or 
Fisher's hook held by an assistant. This completes the first stage (Fig. 347). 
In the second stage, or the stage of iridectomy, the fixation forceps are intrusted 
to the assistant (trained to hand the instruments in their proper order), who gently 
draws the eyeball downward, while the operator takes in his left hand the iris forceps 
and in his right the iris scissors. If the iris is already protruding in the wound, a 
small portion of it may be seized and snipped off with a single cut close to the border 
of the cornea. If not, the blades of the instrument must be introduced in the manner 
described under Iridectomy, and the pupillary border of the iris seized, the tissue 
drawn out and toward the cornea, and cut off close to the cornea. It is not necessary 
to make a large coloboma. If the patient is to be trusted, it is not necessary that the 
assistant shall draw the eyeball downward while iridectomy is being performed. 
The patient may simply be directed to look downward while the surgeon proceeds 
to remove a small portion of the iris in the manner already described. The pillars 
of the coloboma should now be carefully smoothed out with a delicate spatula. 
This completes the second stage (see Fig. 306). 
In the third stage, or the stage of capsulotomy, the operator takes in one hand 
the fixation forceps and gently steadies the eyeball, while with the other he introduces 
the cystotome, held flatwise during its insertion, passes it to the bottom of the colo- 
boma, and then turns its cutting-edge toward the capsule. From this point a verti- 
cal incision is traced until the upper portion of the coloboma is reached, where a trans- EXTRACTION OF HARD CATARACT 
655 
verse cut is made. Great care should be taken to cut, and not to tear, and the whole 
maneuver should be accomplished without undue pressure lest the lens be dislocated. 
Other methods of opening the capsule are the following: Two cuts inclined to each 
other are made like the limbs of the inverted letter y, together with a transverse cut 
at the periphery; or, as was recommended by H. Knapp, the capsule may be opened 
in its extreme periphery, with the understanding that later on the necessity for the 
operation for after-cataract will arise. Some surgeons open the capsule with capsule 
forceps, as a rule, and this method is especially recommended by E. Treacher Collins; 
the author prefers to use this instrument only in cases in which the anterior surface 
of the capsule is thickened. In withdrawing the cystotome the operator should again 
turn it flatwise, and be careful not to drag any tags of capsule into the wound. This 
completes the third stage. 
In the fourth stage, or that of delivery of the cataract, the operator draws the eye 
slightly downward, or, if he has a docile patient, causes him to look downward, 
while the assistant raises the speculum so that its blades shall not press upon the eye- 
ball and yet shall hold the lids away from the eye or lifts the upper lid with a Smith's 
hook or with an elevator, at the same time drawing away, with his thumb, the lower 
lid from contact with the globe. The back of a curet or the convex surface of the 
Fig. 347.-The incision in cataract extraction. Puncture and counterpuncture have 
been made. The section will pass in its whole extent exactly through the transparent 
margin of the cornea, the knife remaining in the same plane throughout. 
metal spoon is now laid against the inferior portion of the cornea, and firm but at 
the same time gentle pressure is made, causing the upper margin of the lens to 
appear in the wound. The pressure is exercised with an upward motion to coax 
out the cataract, but is relaxed as soon as the major portion has been expelled, in 
order that no undue tension be put upon the zonula. As the cataract slips through 
the wound the spoon is made to follow it, catch it, and lift it out with a little sweep- 
ing motion which may at the same time remove any small fragments of the cortex 
which have broken off and lie at the margins of the incision. The speculum or lid- 
elevator is then removed. This completes the fourth stage (Fig. 348). 
In the fifth stage, or that which is now called the "toilet of the wound," after the 
eye has been allowed to remain closed for a few moments the operator cautiously 
inspects the wound, after raising the upper lid with his fingers, or preferably with a 
lid-elevator, while the patient looks downward. In this inspection he should ascer- 
tain whether the pupil is clear or whether any cortical remnants are present or tags 
of capsule lie between the lips of the incision. If cortical matter remains, it should 
be removed as follows: The eye being turned downward, the operator makes a gentle 
rubbing movement in an upward direction on the cornea with the convex surface of 
a horn spoon, great care being taken not to press too hard lest vitreous escape. By 656 
OPERATIONS 
rubbing gently in a circular manner the cortical particles will gather in the upper 
part of the wound, and then, while the slight pressure continues, the lips of the 
wound may be gently separated with the metal spatula and the expulsion of the 
cortical remnants effected. Blood-clot, the result of hemorrhage from the iris, may 
be expelled in like manner. While these manipulations are being made, the author 
is accustomed to flood the surface of the eye and lips of the wound with a physiologic 
salt solution. After they are completed, a final inspection is made, and in order to 
be sure that no tag of capsule remains in the wound, or that no portion of the con- 
junctival flap has been caught between its lips, the olive-pointed probe is gently 
passed from one end of the incision to the other. ' . 
Some surgeons advocate irrigation of the anterior chamber, which, as has already 
been stated, is used also in the operation of unripe cataract. In this maneuver the 
tip of a specially devised syringe is introduced between the lips of the wound, and 
the irrigating liquid injected, which causes blood-clot or cortical matter to be washed 
out. If irrigation is employed, two cautions are necessary: (a) No strong antiseptic 
solution should be used, certainly never bichlorid of mercury, which is liable to pro- 
duce indelible staining of the cornea. The irrigating fluid should be boiled distilled 
water containing 0.5 per cent, of the chlorid of sodium. (5) In passing the liquid 
from the syringe into the anterior chamber, the direction of the flow should be over 
Fig. 348.-The delivery of the lens; the lens is presenting in the wound (capsulotomy has 
been performed). 
the wound from within outward, and not the reverse, lest particles of blood and 
cortex be driven inward. 
A general inspection of the conjunctival sac may now be made; sometimes a 
little blood-clot or a cilium may be present. In wiping away any clots, delicate 
pieces of sterilized gauze are very suitable, or the clots may be picked up with the 
iris forceps. If all these manipulations have been successfully performed, the con- 
junctival culdesac will be free from foreign matters, the edges of the wound nicely 
coapted, the pillars of the coloboma as straight as possible, and the angles not caught 
in the margins of the wound, the pupil black, and the patient readily able to count 
fingers. This completes the fifth stage. 
If the operator intends to perform extraction without iridectomy, the 
following additional directions will be found useful. As the author is 
accustomed to perform the operation according to the late Dr. Knapp's 
rules, the advice of this surgeon is quoted: 
After performing the section according to the method already given (see page 654, 
also Fig. 347), the expulsion of the lens is effected by pressing the lower part of the 
cornea with a Daviel spoon directly toward the center of the globe. When the 
lens presents in the gaping section, its exit is aided by slight strokes with the spoon EXTRACTION OF HARD CATARACT 
657 
on the outer surface of the cornea. If the sphincter proves to be rigid, it may be 
drawn backward with a wire loop or with a special iris retractor, and usually it is 
safer to remove both fixation forceps and speculum immediately after the corneal 
section and during the process of expelling the lens, or the speculum may be raised 
in the manner already described. If desirable, the upper lid may be elevated in 
these circumstances with a large strabismus hook or with a lid-elevator. The 
pupillary space should be cleared by pressing on the cornea with the edge of the lower 
lid-care being taken that it does not come in contact with the lips of the wound- 
or, better, with the convex surface of a polished spoon. The cortical remnants are 
wiped away with a probe-pointed curet. During this operation the lips of the wound 
may be flooded with the boric acid or sterilized 
salt solution (Knapp used a 1 : 10,000 solution 
of corrosive sublimate). 
The concluding steps of the operation are 
described in Knapp's own words: "The con- 
junctival flap is smoothed out by introducing 
the end of a polished grooved spatula, pre- 
viously sterilized, into the anterior chamber, 
and passing it through the wound from one 
end to the other, stroking from within out- 
ward, in order to remove particles of lens, re- 
dress a curved-in flap, and carefully adjust the 
edges of the wound. This is, however, not 
done before the iris has spontaneously or arti- 
ficially recovered its natural position. Should 
the corneal section be too peripheric, the best 
thing is to make a small iridectomy at once, 
for peripheric (Graefe's) sections commonly 
lead to large and harmful prolapses. If the 
iris does not spontaneously resume its position, 
frequently it does so when the lower part of 
the cornea is pressed upon with the edge of the lid. This paradoxic phenomenon may 
thus be explained: The iris being pinched in the tightly closing wound, pressure on 
the part of the cornea raises the flap and disengages the iris, which then, by its natural 
elasticity and contraction of the sphinter pupillse, can resume its natural position. 
If this procedure fails, the iris should be pushed back with a spatula into the anterior 
chamber.- When the periphery of the iris remains folded in the sinus of the anterior 
chamber, it is smoothed out with the olive-tipped point of a probe introduced into 
the iris angle behind the opaque corneal margin." 
The final stage of all cataract operations is the application of the dressing. 
Much difference of opinion exists upon this subject. Some operators simply close 
the lids with a strip of isinglass plaster, while others place upon them an elaborate 
bandage. 
The author is accustomed to use the following dressing: An oval piece of soft 
lint soaked in a solution of boric acid is laid upon each closed lid, the margins of which 
have previously been liberally smeared with bichlorid-vaselin (White's ointment, see 
page 652); over this is placed a similarly shaped piece of sterilized cotton, large 
enough to be flush with the eyebrow and lower margin of the orbit, and is held in 
place with three narrow strips of surgeon's isinglass plaster, passed from the inferior 
edge of the orbit to a point above the brow. Over this a very light, single piece of 
knitted bandage is tied by means of four tapes which pass above and below the 
ears. The entire dressing is usually covered with the mask devised by Dr. Frank 
Ring, of New York (Fig. 349). The patient is put to bed in a comfortable po- 
sition in a slightly darkened room, although with the aid of the mask the latter 
precaution is unnecessary, and the patient may remain in the open ward of the 
hospital or in an ordinary room without danger. If the caruncles are tumid, or if 
there has been any suspicious secretion from the lacrimal sac, the author is accus- 
tomed to fill the inner canthus with dry sterile iodoform powder, which forms a small 
cake and prevents access of infection to the wound. 
Fig. 349.-Ring's ocular mask. 658 
OPERATIONS 
After-treatment.-For the first few hours, the effects of the cocain 
having passed away, there are some smarting and burning, but severe 
pain should not occur. If at the end of twenty-four hours after a 
combined extraction there has been no discomfort, no headache, and 
nothing to indicate that any anomaly in the course of healing is going 
on, the dressings need not be removed; but if they have become disar- 
ranged or the patient has been uncomfortable, they should be taken off 
and the lids inspected. A little staining of the strip of lint is of no con- 
sequence, and if the eyelids are not swollen and there is no discharge 
and the delicate veins in the skin of the lids show no distention, the 
eyelids need not be opened and the dressing may be reapplied; or the 
lower lid may be gently drawn downward so as to permit the escape of 
tears which may have accumulated in the conjunctival culdesac, or to 
liberate the eyelashes if they have become inverted. At the end of 
forty-eight or seventy-two hours the wound may be inspected by 
candle-light, a drop of sterile atropin solution instilled, and each suc- 
ceeding day the usual dressing reapplied; at the end of three days the 
dressing may be removed from the unoperated eye, and at the end of a 
week or even earlier the patient needs only a shade and dark glasses. 
Although some operators do not require cataract patients to go to bed 
at all, it seems to the author that it is safer to keep them in bed for two 
or three days. The recumbent posture too long maintained may lead 
to hypostatic congestion of the lungs. Sometimes elderly patients 
are very uncomfortable when confined to bed and become slightly 
delirious; in these circumstances they may be allowed to rest in an easy 
chair. For a few days liquid food, or at least food which does not 
require much chewing, should be given; after this the ordinary diet 
suited to the patient is permissible. 
Some surgeons prefer the "open method" of managing eyes after 
cataract extraction-i. e., no occlusive dressing is applied, but the 
eye is protected with spectacles made of wire-gauze or similar material. 
With this procedure the author has no experience. 
If the operation has been an extraction without iridectomy, it is 
proper to inspect the eye at the first dressing, usually at the end of 
twenty-four hours, in order to ascertain whether there has been any 
prolapse of the iris. Should this accident have occurred, the treatment 
must be pursued according to the directions given elsewhere. If the 
iris is in place and the pupil circular, although it is proper to change the 
dressings once in twenty-four hours, it is unnecessary to inspect the line 
of incision. All that is required is to draw down the lower lid and per- 
mit the escape of any accumulated tears. As soon as the wound is 
closed, a drop of a sterile atropin solution may be instilled and this 
instillation repeated at subsequent dressings. 
Accidents.-The following accidents may occur during the per- 
formance of a cataract extraction: 
1. The knife may be introduced with the cutting edge turned in the 
wrong direction. If this somewhat inexcusable mistake should occur, 
the knife must be withdrawn and properly inserted. If this cannot EXTRACTION OF HARD CATARACT 
659 
be done, owing to the escape of the aqueous, postponement of the opera- 
tion until the anterior chamber has refilled is necessary. 
2. The conjunctiva in the neighborhood of the counterpuncture 
may become distended with aqueous humor. This produces an eleva- 
tion resembling a bleb. The section should be completed as if the 
accident had not happened. 
3. The iris may fall before the knife. The incision should be com- 
pleted in the ordinary way. An irregular coloboma will result, which 
may be remedied by seizing the jagged edges with the iris forceps and 
trimming them with the scissors. 
4. Free hemorrhage may occur if a conjunctival flap is made or in 
performing the iridectomy. Under pressure the bleeding will some- 
times cease, and the operator should then endeavor to get rid of the blood 
in the manner already described. If success does not follow the maneu- 
ver, the cystotome must be introduced, even though everything is ob- 
scured by the blood, the capsule lacerated, and the lens expelled. Dur- 
ing its expulsion sufficient blood will often come away to clear the pu- 
pillary space. 
5. The wound may be too small. This is a very unfortunate occur- 
rence and can be remedied by enlarging the incision, which is best 
done with a small pair of probe-pointed scissors. 
6. Undue pressure of the cystotome may cause the lens to be par- 
tially or completely dislocated. If the dislocation is partial, the eyes 
should be closed and gentle pressure should be made with a bandage; 
the lens probably will right itself and can be delivered. If the dis- 
location is complete and the lens slips back into the vitreous, it must 
be removed bv means of the scoop or wire loop or by pressure (see page 
413). 
7. The vitreous may escape before or after the expulsion of the lens. 
If before the expulsion of the lens, the operator should at once remove 
the cataract with the wire loop, which is gently inserted behind the lens. 
At the same time all pressure upon the eye must be removed. If 
vitreous escapes after the lens has been extracted, the wound should be 
cleared of protruding vitreous as gently and rapidly as possible and a 
bandage applied. The patient should be required to look upward, as a 
downward position of the eye favors the prolapse of the vitreous. 
Although escape of vitreous is an undesirable accident, its consequences 
are not always serious and good visual results may be obtained. If the 
escape of vitreous has been great, particularly if the vitreous is thin 
and there is tendency for the eyeball to collapse, a tepid sterile physiologic 
salt solution should be injected into the vitreous chamber until the globe 
assumes its proper contour, as has been recommended by J. A. Andrews 
and Herman Knapp. 
8. Occasionally the corneal flap is everted because it has been caught 
by the* margin of the lid, owing to a sudden movement of the patient. 
It must be replaced and a bandage quickly applied. Sometimes imme- 
diately at the conclusion of the section, or directly after the delivery of 
the lens, especially in old and feeble subjects, there is great collapse of 660 
OPERATIONS 
the cornea, which, instead of keeping its proper curve, looks like a 
wrinkled membrane. In these circumstances the anterior chamber 
should be filled with physiologic salt solution, which will not only aid 
in making proper coaptation of the lips of the wound, but will prevent 
the sucking in of the conjunctival juices which might lead to infection. 
9. Capsulotomy may not have been sufficient and pressure upon 
the inferior half of the cornea fails to cause the lens to present. In 
such a case the cystotome must be reintroduced and the laceration 
enlarged, or if the obstruction is due to the presence of a tenacious 
center in the capsule, this may be removed with capsule forceps. 
Within the last few years Colonel Henry Smith's method of extrac- 
tion of cataract in the capsule (radical operation for cataract, according 
to Vail) has attracted much attention. 
Smith's Operation for the Extraction of Cataract (Indian Method 
of the Extraction of Cataract in the Capsule).-The operation is performed 
as follows:1 
After a spring speculum has been inserted, the eye being fixed with special 
forceps, a Graefe knife is entered at the corneoscleral junction and counterpuncture 
made in the corneoscleral junction of the opposite side, so that the incision when 
completed shall include half or nearly half of the circumference of the cornea. The 
knife is driven through to the heel, the handle being lowered as it passes onward and 
the point elevated. If the manipulation is a proper one, after the counterpuncture 
is made the knife cuts as it goes through the tissues, and the incision is completed 
with one thrust, the incision ending in the cornea in such a manner that the edges 
of the corneal wound are cut as nearly as possible at right angles to the surface. 
An iridectomy may or may not be done, but it is advisable, for the beginner at least, 
to make this part of the operative procedure. 
The speculum is next removed, and the eyelid and brow are held away from the 
eye by means of a large blunt hook and the assistant's fingers (Fig. 350). The patient 
is required to look steadily upward. In the case of an immature lens or of a hard 
cataract the operator next presses back with the point of a strabismus hook toward 
the optic nerve, the point of the hook being placed over the lower third of the cornea. 
This pressure must be steady, and the point of the hook should not be removed until 
the upper edge of the lens tilts forward. The moment the lens is seen to be dislo- 
cated, the pressure through the point of the hook is gradually turned more and more 
toward the wound, pressure during all of this time being maintained, so as to keep the 
lens up to the sclerotic margin, the pressure with the hook becoming gradually lighter 
and lighter and the hook gradually sliding under the lens until the cornea is folded 
beneath it. At this stage the lens is delivered (Fig. 351). 
If the tension of the eye is low, the emerging lens should be followed with a 
spatula as well as with a hook, and sometimes, in these circumstances, a light counter- 
pressure with a spatula above the wound is indicated. 
In the case of intumescent lenses and Morgagnian cataract, the capsules of which 
are extremely delicate and liable to burst, pressure with the point of the strabismus 
hook is made sufficiently deep over the lower border of the lens to cause it to dislocate 
below and turn a half somersault, the pressure and traction always being made over 
the zonula. As soon as the lens turns up into the wound the operator ceases to make 
traction toward the patient's feet and directs the pressure backward, next back- 
ward and upward. and finally more and more toward the wound, folding the cornea 
beneath the lens until it falls outside of the cornea. As the capsule has not yet 
been dislocated from the zonula in the neighborhood of the wound, the hollow 
of the curve of the strabismus hook should be made to sweep along between the 
1 This description, condensed and slightly modified, is taken from the late Dr. D. W. 
Greene's quotation of Colonel Smith's own account of his operation. EXTRACTION OF HARD CATARACT 
661 
lens and the wound to complete this detachment. It is advisable in these circum- 
stances to keep up sufficient tension on the eyeball with the spatula placed on the 
cornea in order to prevent the lens from slipping back into the eye. 
Hypermature cataract is difficult to dislocate, and the operator should proceed 
with the strabismus hook as in the case of immature and hard cataract, but a spatula 
in his left hand should be in position at the margin of the wound to drop behind the 
lens the instant its edge appears. As it is dropped almost straight down into the 
eye, the back of the spatula must be placed against the sclerotic margin of the wound 
and the lens pressed against it with the hook from the outside. The lens, therefore, 
slides along the inclined plane of the spatula. 
Fig. 350.-Smith's operation for cataract: 
Spectator's view, while the lids are being 
held by the assistant and the hook for expel- 
ling the lens is applied. Notice the gable- 
like space under the upper lid above the 
eyeball. The operator may look obliquely 
under the upper lid in this field and get a 
good exposure of the entire upper culde- 
sac. The assistant can shift this exposure 
to the right or left to enable the operator 
to have an unobstructed view of the lens 
and wound; also to give him access to 
the angles of the wound and the summit 
when replacing the cut sides of the iris, 
and the apron of the iris that adheres to 
the scleral wound after delivery. (Descrip- 
tion and illustration by Vail.) 
Fig. 351.-Smith's operation for cata- 
ract: Shows where the bulbous end of 
the lens hook is applied in the act of 
pressing to expel the lens. The pressure 
is made "straight back toward the optic 
nerve," not quickly or plungingly, but 
with intelligent and bold onward pres- 
sure, never varying the direction of the 
pressure until either the lens breaks from 
its moorings above or below and shows 
a disposition to be delivered, in which 
case the exit is favored by shifting the 
pressure, or the lens stubbornly refuses 
to yield and advance because of tough 
ligaments or small, size of the incision. 
(Description and illustration by Vail.) 
Great care should be taken to return the iris to its proper position, whether or 
not an iridectomy has been made, and with a suitable repositor the operator should 
release any part of the iris from the sclerotic' or from the angles of the wound. If 
this is carefully done, the eye need not be dressed until the expiration of the eighth 
day, and many of the complications which have been described may be attributed 
to meddlesome dressings and meddlesome inspections. If vitreous escapes, it 
should be snipped off with the scissors in the usual manner. 
According to Colonel Smith, cataracts occurring in children and 
young persons are not suited to this operation, because it is practically 662 
OPERATIONS 
impossible to dislocate their lenses. The operation seems to be valuable 
in unripe cataract, and in those forms of cataract which are immature 
and which require long periods of time for their complete opacification. 
Much difference of opinion exists as to the value of this operation and 
its permanent place in surgical practice. In our own country the opera- 
tion was particularly recommended by the late D. W. Greene. Derrick 
T. Vail, A. Timberman, and especially W. A. Fisher (who has suggested 
useful modifications and who has designed an admirable lid elevator), 
who have had large opportunities of learning the technic in Colonel 
Smith's clinic in India, are enthusiastic advocates of this procedure. It 
has also received the commendation of Robert Sattler and other Ameri- 
can surgeons. 
One of the objections to the Indian operation is that the percentage 
of loss of vitreous is much higher than in the ordinary extractions of 
cataract. Colonel Smith has reported his vitreous loss to be 8 per cent., 
while Vail, in a series of uncomplicated cataracts, did not exceed 2 per 
cent, of vitreous loss, and therefore he believes, to use his own expres- 
sion, that vitreous escape is not the argument to be used against Smith's 
technic. W. A. Fisher, although admitting the disadvantage of frequent 
vitreous loss, believes this can be overcome by careful technic and that 
Smith's operation should be the procedure of choice. Naturally, the 
ordinary accidents of cataract extraction are liable to occur, but appar- 
ently in Smith's Indian service they are not greater than those which 
occur in ordinary extraction. It is the author's impression, based on a 
very limited experience and upon his observation of certain operators 
who are familiar with the Smith technic, that while this operation will 
retain a place in ophthalmic surgery, especially in the extraction of 
unripe cataracts, it is not likely to drive from the field those proced- 
ures which have for years been firmly and favorably established. 
Several operations for the extraction of cataract in the capsule after 
subluxation of the lens with capsule forceps have been devised. Stan- 
culeanu's operation, which has been commended by Simpson and 
Howard Hansell, in its main features is as follows: 
After an incision in the limbus somewhat larger than the usual one, a sickle- 
shaped forceps is entered into the anterior chamber, and a fold of capsule is grasped 
within its branches. By horizontal, upward, and downward movements the zonula 
is ruptured. When the operator feels that the lens has been dislocated, the forceps 
is withdrawn, and the lens is expressed in the usual manner with the aid of two 
spatulas. 
Arnold Knapp's method is as follows: 
"After the usual preparation and the instillation of 1 drop of atropin, under 
holocain anesthesia, the Koster speculum is introduced and left in place until the 
operation is completed, unless there is danger of or actual prolapse of vitreous. 
An assistant is necessary only in the presence of complications. The section must 
be large and should be just short of half the corneal circumference with a con- 
junctival flap. After the iridectomy, the capsule forceps is introduced to a point 
below the center of the pupil, the branches are then allowed to separate broadly, EXTRACTION OF HARD CATARACT 
663 
and a distinct knuckle of capsule is grasped. The grasp should not be too tight 
lest the capsule be torn, but sufficiently firm to exert traction on the periphery of 
the lens capsule. The closed branches of the forceps are gently moved from side 
to side, up and down or rotated, and the capsule can be seen to follow in the 
various directions. When the dislocation has succeeded, a part of the margin of 
the cataract in the capsule appears free in the pupillary space. The portion dis- 
located is usually below, generally slightly to one side or the other, with the 
upper attachment unruptured. The forceps is then released and withdrawn. 
Pressure is exerted straight back on the lower part of the cornea with Smith's 
hook, and the cataract can be seen to turn a somersault; it "tumbles," in other 
words, as Smith calls it, and is delivered feet first. When the entire lens has been 
delivered, it will be found adherent above, where it is finally separated by a lateral 
stroking motion. In some cases the head presents first; the delivery is then slower, 
and counterpressure must be applied at the scleral margin. The iris columns are 
then carefully replaced. The coloboma should ultimately not appear any different 
from that after an ordinary extraction." 
To prevent iris and vitreous prolapse a number of operators have 
placed, prior to the extraction, a suture, Kalt's corneal suture in this 
regard being well and favorably known. The point of a sharp needle, 
armed with fine linen thread, is passed into and out of the substantia 
propria on one side of the proposed section and next obliquely through 
the opposite border of the limbus and through the scleral tissue. The 
loop thus formed is drawn aside, the incision completed, and after the 
delivery of the lens the threads are tied in a single knot. Sliding 
conjunctival flaps, which cover the line of incision, for example, the 
Van Lint flap, recommended in certain cases by L. Webster Fox, have 
also been used to prevent iris prolapse and infection. A number of 
operations whereby a subconjunctival extraction of cataract is performed 
have been devised, for example, by Dimmer, and in this country by 
Frank Todd. 
Anomalies in the Healing Process after Cataract Extractions.- 
Pain.-Should pain occur and not be due to the circumstances already 
mentioned, but become violent in character, either in the earlier stages 
after the operation or some days afterward, one of three things may be 
apprehended: intra-ocular hemorrhage, suppuration of the wound, or 
iritis. 
Expulsive Intra-ocular Hemorrhage.-Usually, soon after the operation 
has been completed, the patient complains of very severe pain, or vomit- 
ing may occur and the dressings begin to be stained with blood. On 
removal of the bandage a clot of blood will be found protruding through 
the palpebral fissure, and on raising the lid the anterior chamber is seen 
to be full of blood and the corneal wound gaping widely. As soon as 
the symptoms of this accident are manifest, the patient should be 
placed in an upright position and a hypodermic injection of morphin 
administered. The blood should be carefully removed, the conjunctival 
sac washed out with a bichlorid solution (1 : 8000), and a full anti- 
septic dressing applied. The dressings should be changed once or twice 
daily. In this way it may be possible to avert suppuration, even though 
the eye remains blind. If the hemorrhage should continue and the 
pain become intense, enucleation is necessary. 664 
OPERATIONS 
Suppuration of the Wound.-According to E. T. Collins, purulent in- 
fection is more common in old people than in young, and the tendency is 
greater between sixty and seventy than between seventy and eighty, 
though it is certainly greater between eighty and ninety than between 
sixty and seventy. It may be caused by lacrimal complication, inflam- 
mation of the upper respiratory tracts, conjunctivitis, blepharitis, by 
infection introduced at the time of the operation, or during the first 
dressing of the eye, for example, a non-sterile atropin solution. Sup- 
puration commences on the first, second, or third day, more rarely on 
or after the fifth day, but sometimes as late as the thirteenth day. 
The symptoms are pain, swelling of the lids, chemosis of 'the con- 
junctiva with undue secretion, haziness of the cornea, turbidity of the 
aqueous, and the formation of a slough along the margins of the wound. 
Two terminations are possible: The suppurative process may be 
limited, so that at the end of the inflammation the pupil is closed and 
Fig. 352.-Section of an eye with postoperative infection which began on the ninth 
day after spontaneous reopening of the wound. Notice the dense infiltration of the wound 
edges and that the lens capsule has been caught in this material between the lips of the 
wound. 
the iris drawn upward, or the entire globe may participate in a general 
destructive inflammation (purulent panophthalmitis). 
If the suppuration is limited to the margin of the wound, prompt 
treatment may be of avail. The conjunctival sac should be carefully 
disinfected, the lips of the wound gently parted after removal of the 
slough and irrigated with a bichlorid solution, and the whole line of 
incision freely cauterized with the actual cautery or with liquid carbolic 
acid. In other words, the treatment is practically that which has been 
advised for a sloughing ulcer. At each subsequent dressing the lips 
of the wound should be parted with a probe, and the anterior chamber 
drained. Argyrol solution (25 per cent.) may be instilled into the con- 
junctival sac, and its introduction into the anterior chamber has been 
advised. Hansell recommends the injection into the anterior chamber 
of a few drops of a solution of bichlorid of mercury (1 : 1000). Ziegler 
advises the constant application of ice and the application of formalin to EXTRACTION OF HARD CATARACT 
665 
the wound and its injection into the anterior chamber. Subconjunctival 
injections of bichlorid of mercury or cyanid of mercury have been 
recommended in these circumstances, and the introduction of iodoform 
into the anterior chamber has been suggested, and successes have been 
reported. In recent times postoperative suppuration has been treated 
with vaccines; for example, the injection of Wright's antistaphylococcic 
vaccine (Morax) and the administration of an emulsion of staphylococci 
by the mouth, the dose being gradually increased from 100,000,000 to 
700,000,000 (Grimsdale). A bacterin prepared from the micro-organ- 
ism which is active has in more than one instance proved highly suc- 
cessful, and should certainly be given full trial. The bacterin treat- 
ment may be combined with the internal administration of urotropin. 
Should the infecting micro-organism prove to be the pneumococcus, 
ethylhydrocuprein may be tried (see page 256). 
If the infection manifests itself in the form of a ring abscess, treat- 
ment is usually unavailing, and' the eye passes into a state of panoph- 
thalmitis and requires the treatment for that condition which has al- 
ready been detailed. Suppuration, instead of beginning in the cornea, 
may sometimes commence in the iris and even in the vitreous, and the 
process go on to a rapid destructive panophthalmitis. It is a clinical 
fact that if one eye has been lost on account of postoperative suppuration, 
the other eye, if submitted to operation, is in grave danger of meeting a 
similar fate. 
Iritis and Iridocyclitis.-It is not uncommon for attachments to 
form between the capsule of the lens and the margin of the pupil or of 
the coloboma. These may be regarded as non-inflammatory synechiae 
and are not of serious consequence. Iritis itself, with the usual symp- 
toms of this condition, generally sets in about the fifth day, but may be 
delayed to the tenth day. It may be caused by an imperfect toilet of 
the wound, with the retention of pieces of cortex, and sometimes by too 
early exposure of the eye, but usually should be regarded as a manifes- 
tation of infection. If the ciliary body becomes involved and an 
iridocyclitis is set up, the gravity of the situation increases and the 
process may terminate in distortion and closure of the pupil, with 
exuded lymph. Iridocyclitis may last for weeks, the inflammatory 
symptoms varying in their intensity, but finally the iris becomes dull 
and discolored and there is grave danger of sympathetic trouble in 
the opposite eye. Indeed, sympathetic ophthalmitis in these circum- 
stances has been reported a number of times. Late cyclitis-that is, 
an inflammation occurring after the first week, is characterized by 
deep-seated circumcorneal injection, thickening- and opacity of the cap- 
sule, and posterior synechiae. Under* treatment the symptoms may 
subside or secondary glaucoma may develop. 
The treatment of these conditions, in general terms should include 
bleeding from the temple by means of leeches, the free use of atropin, 
dionin, holocain, hot fomentations (usually recommended, but iced 
packs are preferred by some surgeons, and generally are more satisfac- 
tory than heat), the internal administration of full does of salicylate 666 
OPERATIONS 
of sodium, and in most circumstances mercury and iodid of potassium. 
A number of observers have obtained good results from the adminis- 
tration of neosalvarsan. If the process closes the pupil, after the eye 
becomes quiet iridectomy, iridotomy, or iridocystectomy may be 
required. 
A remarkable condition to which H. Knapp called special attention 
is the formation of a spongy or gelatinous exudation in the anterior 
chamber, associated at first with considerable pain, congestion of the 
conjunctiva, and edema of the margins of the lid. The manifestations 
are those of spongy iritis without an inflammation of the iris. Several 
times the author has observed this complication. The exudation dis- 
appeared and the result was good, although at first the appearances 
were most alarming. 
Bulging or Cystoid Cicatrix.-Instead of perfectly smooth healing, 
the cicatrix at the end of a week or two may begin to bulge, sometimes 
at one or other extremity of the wound, and sometimes through its 
entire length. The bulging consists in a vesicle-like, semitransparent 
elevation, and is generally associated with an entanglement of the iris 
in its margins, together with distortion of the coloboma. Eyes in which 
such entanglement of the iris has taken place are likely to develop 
iridokeratitis, and it has been recommended that the cystoid cicatrix 
should be removed and the opening closed by the application of the 
electro- or thermocautery. This procedure, however, has proved to be 
a dangerous one in several instances, and has been followed by severe 
inflammation and even by sympathetic ophthalmia. 
Glaucoma after Extraction.-This complication occurs after a severe 
iritis, with numerous posterior synechiae, which has led to the formation 
of a membrane. It may be the sequel of an iritis, which is characterized 
by a deep anterior chamber and dotted opacities on the cornea, or also 
of an iritis which is only slight in character, but where there has been an 
adherence of the pillars of the coloboma to the cicatrix and also to the 
lens-capsule, or where tags of capsule have attached themselves to the 
under surface of the corneal wound (see also page 392). This tends to 
obliterate the canal of Schlemm. Glaucoma may be caused by imperfec- 
tions in technic and by obstruction caused by remnants of capsule and 
iris, and is prone to follow slow closure of the wound and the formation 
of an anterior synechia. Elschnig's investigations show that this condi- 
tion may arise by reason of a proliferation of epithelial cells within the 
anterior chamber-that is, by an abnormal ingrowth from the anterior 
corneoscleral surface. Glaucoma of similar origin also occurs after the 
operation of laceration of the capsule-i. e., after discission. If uncon- 
trolled by miotics, iridectomy, sclerotomy, or cyclodialysis should be 
performed. 
Opacities of the Cornea and Keratitis.-Opacity in the cornea may 
be due to the introduction of antiseptic fluid, especially solutions of 
bichlorid of mercury, into the anterior chamber. It has a peculiar, 
milky-white appearance, and is located chiefly at the posterior surface 
of the cornea, although the epithelium may also be rough. It does not EXTRACTION OF HARD CATARACT 
667 
disappear, and, if sufficiently thick, entirely vitiates the effect of the 
operation. 
This opacity must not be confounded with a very common type of 
keratitis occurring after cataract extractions, which has received the 
name striated keratitis, consisting of fine stripes of opacity radiating in 
several directions across the cornea. This entirely disappears in a few 
days, and need not give rise to apprehension. As Frederick Tooke 
points out in his admirable studies of the pathology of the corneal 
section, this condition is more common in elderly subjects than in those 
of younger years, and may be due to alterations in the endothelium or 
in Descemet's membrane dependent on age, which permit access of 
aqueous through the cells, the tension having been released by the 
corneal section. Occasionally at the end of a week or more herpes of 
the cornea, heralded by sharp pain and lacrimation, may develop, and 
from the herpetic spots small filaments may arise-filamentous keratitis. 
The lesions will subside under the influence of light bandages and anti- 
septic lotions; holocain is of much service. 
Prolapse of the Iris.-This complication is the chief objection to the 
operation of simple extraction, and varies in frequency from 3 to 10 
per cent., according to different statistics. The prolapse is usually 
heralded by a sudden sharp pain, which gradually passes away. It 
generally results from trauma-for example, striking the hand against 
the eye-or is due to a fit of coughing, violent exertion, straining effort, 
or similar cause. If the prolapse is discovered soon after its occurrence, 
-that is, at the first dressing-it should be cut off and the edges of the 
iris reduced, exactly as after the operation of iridectomy. If the pro- 
lapse is not noted until the third or fourth day, it is sometimes proper to 
allow it to remain. The eye should be firmly but gently bandaged and 
atropin may be instilled, although some surgeons prefer eserin. Small 
prolapses may disappear, others produce no irritation, while still others 
become larger, constricted at their bases or cystoid. H. Knapp allowed 
these to remain until the irritation had disappeared, and then ampu- 
tated them in the same manner as a small staphyloma is abscised, and 
usually obtained smooth and permanent recovery. Occasionally irido- 
cyclitis occurs, and sympathetic ophthalmitis has been reported. In 
general terms the safest procedure is to excise the prolapsed iris as soon 
after its discovery as is possible. 
Prolapse of the iris after combined extraction-i. e., entangle- 
ment of the edge of the cut iris in the angle of the wound-is not 
uncommon. 
Delayed Restoration of the Anterior Chamber and Delayed Healing.- 
Often the wound after cataract extraction is closed at the end of twenty- 
four hours, usually not later than the third day. Occasionally, how- 
ever, there is delayed restoration of the anterior chamber, which in 
most instances is caused by some foreign substance-for example, a 
particle of capsule or conjunctiva between the lips of the wound, or to 
an almost imperceptible incurvation of the flap (Trousseau). Doubt- 
less, in most cases, an error in the technic of making the section is 668 
OPERATIONS 
responsible for slow closure of the wound. In a few instances the 
failure to unite appears to be due to excessive secretion of aqueous 
humor or to lack of reparative power, depending upon some anomaly 
in the condition of the patient. Derrick Vail attributes this complica- 
tion to an involuntary spastic contraction of the orbicularis and has 
remedied it by severing the muscle, cutting directly upward and down- 
ward, from its external attachment. A conservative treatment is 
generally indicated, and it is usually recommended that bandaging and 
rest in bed shall be continued until the chamber is restored, but the 
author agrees with Berry that if any dressing be applied at all, if the 
wound does not close readily, it should be of the lightest character 
and should exert no pressure on the lids. Usually removal of the 
bandage and the adjustment of protecting spectacles (wire-gauze) 
facilitates the healing (Gifford). If a piece of capsule or other foreign 
substance can be detected, it should, of course, be removed. A light 
cauterization of the line of incision with a point of nitrate, of silver 
or a probe dipped in carbolic acid is often of service. Delayed union 
of the wound, especially after corneal incisions, with separation of its 
margins, may end in recovery, but has been followed by infection and 
by glaucoma, especially if the lens capsule becomes adherent to the 
corneal wound. Associated with tardy or imperfect wound closure 
there may be a glossy edema of the conjunctiva in its lower part, which 
H. Knapp called filtration chemosis. It will subside when the union of 
the incision is firm. 
Postoperative Delirium and Insanity.-Delirium after operation has 
been referred to. Sometimes marked dementia follows cataract extrac- 
tion. The delirium has been ascribed to the use of the bandage, to the 
effect of atropin, to imperfect mental balance existing prior to the opera- 
tion, and to auto-intoxication. If possible, the bandage should be re- 
moved and the patient given various sedatives, e. g.-the bromids- 
according to the indications. Paraldehyd is useful; morphin usually 
does not act well in these circumstances. 
Choice of an Operation.-Obviously, the advantages of simple 
extraction are the absence of mutilation of the iris, and consequently 
the formation of a round pupil which reacts freely to the changes of 
light and shade and prevents the dazzling caused by the presence of a 
coloboma. Its disadvantages are the difficulty of expelling the lens, 
the increased difficulty of performing perfect toilet of the wound, and 
the danger of prolapse of the iris. In the judgment of the author cer- 
tain cases require iridectomy-namely, those in which the ball is hard, 
the lens is large, the anterior chamber is shallow, the iris is not readily 
dilatable, or there is ciliary irritation. The combined method is also 
preferred if the cataract is not ripe or if the patient's mental or physical 
condition tends to create restlessness. In other circumstances simple 
extraction may be performed, and this was the author's practice until 
within the last few years. He has, however, returned to combined 
extraction with a small iridectomy, as it is, on the whole, a more satis- 
factory procedure. For the reasons already given the author is unable OPERATIONS FOR AFTER-CATARACT 
669 
to agree with those surgeons who believe extraction of the lens in its 
capsule should be the operation of choice. 
Cataract extraction without iridectomy may be performed according 
to Chandler's method, in which a small piece of iris, 1 mm. in diameter, 
is removed, making a very small, round opening as near the root of the 
iris as possible. This facilitates drainage and prevents iris prolapse. 
This operation is recommended by C. Hess and also receives the con- 
mendation of Fuchs. In Angelucci's modification of cataract extraction 
fixation is on the superior rectus muscle, and the entire operation is com- 
pleted without speculum or aid of assistant. 
Preliminary Iridectomy.-Some operators, almost as a rule, perform 
a preliminary iridectomy and extract the cataract several weeks later, 
because by this method the dangers of the final operation are lessened. 
It is to be recommended in any case where serious complications are 
apprehended, where for any reason an extraction in one eye has ter- 
minated unfavorably, or where the cataract is not ripe. 
Preliminary Capsulotomy.■-Operative procedures designed for the 
purpose of ripening immature cataract are described on page 409. 
Homer E. Smith advises preliminary capsulotomy and operates as fol- 
lows: 
The capsulotomy knife is thrust through the middle of the superotemporal 
quadrant of the right cornea and is made to reach the lowest point of the dilated 
pupil and to rest on the vertical meridian of the lens. The handle is now raised until 
the blade penetrates the capsule. Next, the handle is made to describe an arc of a 
circle away from the operator, the capsule being incised along the vertical meridian, 
while the shank is gradually withdrawn. The point of the knife is next released, 
the shank introduced, the blade carried to the nasal margin of the pupil, and the 
capsule incised along the horizontal meridian. If the left eye is to be operated upon, 
the knife is entered in the temporo-inferior quadrant of the cornea and the first in- 
cision is from above downward. Eserin (gr. 1^ to fgj-0.097 gm. to 30 c.c.) is 
instilled and the eye bandaged. At the expiration of six hours the lens is extracted 
in the usual manner. The object of this operation is to separate the capsule from 
the lens and bring about a union of the nucleus and of the cortex. 
Smith's procedure has received the endorsement of a number of 
surgeons. Apparently there is no harm in extending the interval 
between the two operations to twenty-four hours (Hansell and Shannon). 
Fig. 353.-Knapp's knife-needle. 
Operations for After=cataract.~After-cataract-or, as it is usually 
called, secondary cataract-has been described. If it is a delicate, web- 
like membrane which stretches across the pupil, and which is best seen 
by artificial illumination-^. e., by condensing with a large magnifying- 
glass a beam of light into the pupillary space-the treatment may 
consist in the introduction of a cataract needle in the manner described 
under Discission, and making a laceration in the membrane. The 670 
OPERATIONS 
author is accustomed to operate with Knapp's knife-needle (Fig. 353) 
in the manner advised by this surgeon-namely: 
The pupil being dilated ad maximum, and the area of the operation being per- 
fectly illuminated, the knife-needle is thrust through the cornea 3 mm. from its 
margin in the horizontal meridian. Next, the knife-needle is advanced to a point 
close to the opposite margin of the iris, where the membrane is punctured, and a 
horizontal incision of 4 or 5 mm. is made. This being accomplished, the point of the 
needle is raised toward the cornea and passed upward in front of the membrane, 
which it transfixes at a point 2 mm. above the horizontal incision, and divides it by a 
cutting movement downward, as far as the horizontal incision. The same procedure 
is performed on the lower half of the membrane, cutting from below upward. Thus, 
a crucial incision is formed, and if successful, the retraction of the edges leaves a good 
central aperture in the membrane. It is essential to cut the after-cataract, and not 
to tear it nor drag upon the ciliary body. Therefore the instrument should avoid 
thickened portions of the capsule. It is also desirable that it should not enter 
deeply into the vitreous. 
Fig. 354.-Sections of secondary cataract, showing inclusion of cortical remnants 
between the posterior and anterior capsule and curling of the capsule upon itself. (From a 
specimen prepared by Dr. C. M. Hosmer in the author's laboratory.) 
In place of entering the knife through the cornea in the manner already de- 
scribed, the puncture may be made through the conjunctiva at the corneoscleral 
border, after the manner recommended by Kuhnt, a method which the author is 
accustomed to follow. In place of this operation, Ziegler's method (see page 627) 
may be employed; indeed, in recent years the author has used this admirable opera- 
tion almost exclusively in all types of after-cataract. 
Where the membrane is thick and there has been much proliferation 
of the epithelium, discission with a knife-needle, owing to the dense and 
resisting character of the tissues and the danger of dragging upon the 
ciliary body and iris, is a dangerous operation. In these circumstances 
iridotomy or Ziegler's operation should be employed (see page 627). 
Other plans are to divide the capsule with delicate cannula scissors, or 
to cut the desired opening with an instrument which works on the 
principle of a punch. In place of entering the knife through the cornea 
or corneoscleral border it may be passed through the sclera 6 mm. 
behind the corneal margin, and pushed forward so that its point passes COMPLETE TENOTOMY 
671 
through the membrane into the anterior chamber. The membrane is 
cut by causing the knife to make a sweeping movement from before 
backward. 
Discission is an operation invested with many dangers. In no cir- 
cumstances should there be rough handling; the discission instruments 
must be very sharp, and the operator must avoid dragging upon resist- 
ing bands. Preceding the operation and following it there should be 
the free use of atropin. If signs of reaction occur, the treatment of 
iritis is indicated. 
Glaucoma after discission is an occasional complication, and is char- 
acterized by pain, steamy cornea, impaired vision, and increased tension. 
It should be treated by eserin locally, morphin and chloral internally, 
and, if these measures fail, by iridectomy or paracentesis and evacua- 
tion of the vitreous from the anterior chamber. 
In cases of occlusion of the pupil by a drawing up of the iris, or where 
there are bands of strong inflammatory lymph, to which also the name 
secondary cataract is sometimes applied, discission is not advisable. 
In most instances iridotomy or V-shaped iridotomy with a knife-needle 
is the best operation. 
OPERATIONS UPON THE EYE-MUSCLES 
These consist of complete and partial tenotomy and advancement or 
readjustment, advancement with muscle resection. For the operation of 
tenotomy the following instruments are required: A stop speculum or 
lid-elevator, two strabismus hooks (Figs. 355, 356), fixation forceps, and 
a pair of probe-pointed scissors, the form devised 
by Dr. Jackson being particularly suitable. In 
young children general anesthesia may be neces- 
sary; but, if possible, cocain should be used. 
Usually the internal rectus is divided; quite fre- 
quently the external rectus; less commonly the 
other straight muscles. 
Complete Tenotomy.-In a tenotomy on the 
internal rectus, for example, the operator proceeds 
as follows: 
The eyelids being separated with a stop speculum, the 
surgeon catches with a fine-toothed forceps a fold of con- 
junctiva and subjacent fascia on a level with the lower 
border of the tendon, and with the probe-pointed scissors 
makes an opening just large enough to admit the strabismus 
hook. He may with one clip divide conjunctiva, subjacent 
fascia, and the capsule of Tenon; otherwise, after the division 
of the conjunctiva and subconjunctival tissue, Tenon's capsule must be picked up 
and incised in a length equal to the cut made in the overlying structures. A stra- 
bismus hook is next passed behind the tendon, its point turned upward, and made to 
appear at the upper border of the tendon beneath the conjunctiva. It is next drawn 
forward and outward toward the cornea, and scissors, with their blades slightly 
parted, are introduced between the hook and the eye, and the tendon cut close to its 
sclerotic attachment. This is the subconjunctival operation, and was introduced by 
Critchett. 
Figs. 355, 356.-Stra- 
bismus hooks. 672 
OPERATIONS 
Instead, the subconjunctival method, especially in cases where 
there is a considerable squint, the open operation, or, as it is known, the 
Graefe method, may be performed as follows: 
The operator seizes with fixation forceps a fold of conjunctiva and subconjunctival 
tissue parallel with the corneal margin over the insertion of the tendon and divides 
the tissue raised by the forceps horizontally down to the sclera. Next the point of 
a strabismus hook is pressed firmly against the sclera below and behind the insertion 
of the tendon, under which it is passed until it reaches its upper margin. With the 
hook in position the exposed tendon is put slightly upon the stretch and separated 
from its attachment by means of blunt-pointed scissors. The hook is next passed 
with its point turned above and below and any tendinous fibers which may have 
escaped are divided. The hook should now pass readily to the corneal margin. 
Sutures used for closing the wound should be inserted vertically, unless it is desired 
to lessen the effect of the operation, in 
which case they are placed in a hori- 
zontal direction. 
After tenotomy the conjunctival sac 
should be thoroughly irrigated with 
boric acid solution or bichlorid of mer- 
cury (1 : 10,000) and both eyes bandaged 
for a day or two. The conjunctival su- 
ture may then be removed and the 
patient wear his correcting glasses. If 
the patient is in suitable surroundings, 
a bandage may be dispensed with and 
the spectacles which correct the refrac- 
tive error may be worn immediately 
after the operation. The latter pro- 
cedure is followed by the best results. 
Snellen's method of operating 
is satisfactory, and one which the 
author often employs. A small 
opening, about 4 mm. in width, 
is made through the conjunctiva 
over the insertion of the tendon, 
the center of which is then incised 
vertically. Through this opening the point of a strabismus hook is 
inserted and the upper and lower half of the tendon divided. A suture 
closes the conjunctival wound. Stevens' method, described on page 
674, is a modification of this operation and may be used for complete 
as well as for partial tenotomies. 
Tenotomy of the other straight muscles may be performed according 
to the methods already described, the operator remembering the dis- 
tance of the insertion of each tendon from the corneal margin (see page 
519). 
Tenotomy of the Inferior Oblique.-This operation was orig- 
inally suggested by E. Landolt, but its indications and technic have 
been especially elaborated by Duane. Posey, who has made a valu- 
able contribution to this subject, thus describes the operation: 
Fig. 357.-Exposure of the internal rec- 
tus tendon, which is lifted upon a hook 
(after Haab). This drawing also illus- 
trates Prince's method of advancement 
(see page 677). The suture in the sclera, to 
which the tendon is afterward fastened, is 
seen lying along the corneal margin. 
After injecting the tissues with a 2 per cent, solution of the novocain, a curvi- 
linear incision is made just superior and parallel to the lower and inner bony rim TENOTOMY OF THE INFERIOR OBLIQUE 
673 
of the orbit, the tissues being divided down to the bone. A strabismus hook is 
next inserted, and gentle traction is made on the tissues until the muscle is encoun- 
tered. This is assured by the upward movement imparted to the globe by trac- 
tion on the hook. The tendon is next drawn forward and divided. The wound 
having been closed with one or two stitches, a firm dressing is applied and allowed 
to remain in place for forty-eight hours. Occasionally a subconjunctival ecchy- 
mosis appears at the lower and inner part of the globe. 
The indications for this operation, based upon Duane's studies, 
are thus summarized by Posey: 
(a) Complete stationary paralysis (especially congenital or trau- 
matic) of the opposite eye. 
(6) Partial paralysis of the superior rectus of the opposite eye if, 
owing wto fixation being performed by the latter, the fellow eye de- 
velops a spasm of the inferior oblique, giving rise to diplopia, a dis- 
figuring upshoot of the affected eye, or a lasting torticollis. 
(c) Spasm of the inferior oblique, either secondary to paralysis of 
the superior oblique or some other muscle in the same eye, or occurring 
as a primary condition, provided the symptoms are sufficiently dis- 
turbing to warrant operation. 
Complications in Tenotomy Operations.-1. The operator may fail 
to have divided the capsule of Tenon. In these circumstances he will 
also fail to introduce the hook beneath the tendon, and by such failure 
will recognize that he has not sufficiently incised the tissues. 
2. Hemorrhage.-Occasionally severe hemorrhage follows a tenot- 
omy, the blood rapidly pouring out beneath the capsule of Tenon 
and causing alarming proptosis. A firm pressure bandage should be 
applied, and gradually the proptosis will subside and the blood be ab- 
sorbed. 
3. Orbital Cellulitis and Tenonitis.-Cellulitis has occurred from 
infection of the wound, the inflammation traveling back and causing 
an inflammation of the tissues of the orbit. The treatment of orbital 
cellulitis, described in another section, is indicated. Tenonitis, or 
inflammation of the orbito-ocular fascia, has followed squint opera- 
tions. 
4. Perforation of the Sclera.-Although this is a rare accident, it has 
happened to operators of considerable experience as the result of the 
use of sharp-pointed scissors, and for this reason the probe-pointed 
instrument is always to be preferred. In such circumstances the eye 
should be treated in the manner described on page 293. 
5. Retraction of the caruncle, so that it sinks away from its normal 
position and gives a most disagreeable and peculiar stare to the eye, is a 
very unfortunate occurrence after a squint operation. A very slight 
degree of this is liable to occur even after the most careful tenotomy 
of the internus. Where it exists in great degree, it is due in part to ex- 
cessive dissection of the tissues, and in part to retraction of the muscle. 
There are several methods of overcoming this defect, the essential char- 
acter of which is the loosening up of the contracted tissues and stitching 
the caruncle into place. 
43 674 
OPERATIONS 
Partial or Graduated Tenotomy.-Graduated tenotomies are 
performed for the purpose of correcting those conditions w'hich are 
described under Heterophoria. The operation has been especially elab- 
orated by Dr. Stevens, of New York, and is performed as follows: 
With a pair of small, narrow-bladed scissors a transverse incision is made through 
the conjunctiva exactly corresponding to the line of insertion of the tendon. This is 
seized behind, but near its insertion, and a small opening is made dividing the center 
of the tendinous expansion exactly on the sclera. This opening is then enlarged 
by careful cuts with the scissors toward each edge, keeping carefully on the sclera 
as the border of the tendon is approached; the amount to be cut depends upon the 
Figs. 358, 359. 
Fig. 360. 
Figs. 361-363. 
Figs. 358-363.-Stevens' instruments for tenotomy. 
judgment of the operator and the need of the case, and is further regulated by placing 
the patient before a lighted candle and testing the sufficiency of the muscle upon 
which the operation is made, in the manner already described in connection with 
the investigation of heterophoria. In dealing with strabismus, the surgeon may 
determine to continue his section through the border, leaving uninjured, as far as 
possible, both the anterior and posterior lamellae of the capsule, as well as the expan- 
sion at each border, to hold the muscle in relation to the eye. Turning the scissors 
then in the direction of the other border, this portion is dissected with equal care. 
Figures 358 to 363 illustrate the delicate instruments which are 
used in this operation. They may with equal propriety be employed 
in ordinary tenotomies, and are satisfactory for this purpose, inas- ADVANCEMENT OR READJUSTMENT 
675 
much as the laceration of the tissues is less marked, while the effect 
is equally great if the incisions are carried sufficiently far according to 
the directions already given. 
Several other operative procedures for the purpose of elongating the 
tendon by partial tenotomies have been designed, especially by Ziegler, 
Verhoeff, and Todd. The first-named surgeon describes the character- 
istics of his operation as "complete division of each lateral third of the 
tendon and careful snipping of the superficial fibers in the central third, 
until sufficient elongation is obtained to yield a measurement of ortho- 
phoria." 
Advancement or readjustment is an operation in which the 
tendon of a rectus muscle is brought forward to a new attachment. 
The operation is applicable to cases in which the tendon has become 
weakened, as, for instance, in myopia, together with the production of 
divergent squint; to those cases of convergent strabismus in which it is 
desirable to combine advancement of the external rectus with tenotomy 
of the internus; to free bilateral advancement to the exclusion of tenot- 
omy; to certain cases of heterophoria (see page 561); and to cases in 
which an injudicious division of the internal rectus, for instance, has 
converted a convergent into a divergent squint. For other indications, 
see pages 551 and 552. General anesthesia may be necessary in young 
subjects and nervous patients. 
The same instruments which are used in tenotomy are required, in 
addition to which suitable curved needles, a needle-holder, silk thread, 
fine catgut, and advancement forceps should be provided. Numerous 
methods of advancement have been designed. With the operation, a 
description of which follows, recommended by Swanzy, the author has 
achieved satisfactory results: 
An opening is made in the conjunctiva immediately over the insertion of the 
tendon which is to be advanced, twice the breadth of the tendon. A band of con- 
junctiva between the opening and the cornea is next separated with the scissors 
from the sclerotic. A strabismus hook is now passed under the tendon, which is 
freely separated from the sclera; the hook is brought well up to the insertion of the 
tendon, care being taken that the whole width of the tendon is held on the hook. A 
curved needle carrying a strong black silk suture is introduced from its upper margin 
between the tendon and sclerotic, and passed through the tendon at its middle line. 
In the same way another suture is passed behind the tendon from its lower margin, 
and through it close to the first suture. Each of these sutures is knotted firmly on 
the tendon, a long end being left to each. For the strabismus hook Prince's ad- 
vancement forceps is now substituted, which firmly grasps the tendon, which is next 
separated with scissors from the sclerotic close to its insertion. The needle on the 
end of each suture is next passed through the superficial layers of the sclera and 
beneath the conjunctival flap to the margin of the cornea in the manner illustrated 
in Fig. 365, and while an assistant rotates the eyeball toward the muscle which is 
to be advanced, each suture is tied with its own end. If there is redundant tissue, 
it is trimmed away and the conjunctiva sewed with three interrupted sutures over 
the advanced tendon, the central suture being passed through the conjunctiva and 
the advanced tendon to the margin of the cornea. Naturally, a greater or less 
effect is produced according as the sutures are placed farther from or nearer to the 
insertion of the tendon, and according to the extent to which the loosened tendon 
is drawn toward the corneal margin. Both eyes are bandaged and should remain 676 
OPERATIONS 
covered for at least four days, when the superficial sutures are removed. The deep 
sutures are allowed to remain, if they produce no irritation, from eight to ten days. 
An objection to this operation is the knot in the tendon, which must be removed 
through a small opening in the conjunctival surface, but if black silk is used the 
author has not experienced any difficulty; and it has seemed to him that the re- 
sults were better than if the suture was not fastened in the manner described. 
Fig. 364.-Advancement of the external rectus. The tendon has been exposed and the 
sutures tied upon it. 
Landolt's Method of Advancement.-"The speculum having been adjusted, a con- 
junctival flap the summit of which reaches the edge of the cornea is cut and folded 
back so as to expose the insertion of the muscle which is to be advanced. Next a 
flattened hook is passed beneath the tendon and a second one in the opposite direc- 
tion. The first hook is then withdrawn and the second intrusted to an assistant. 
Fig. 365.-Advancement of the external rectus. The tendon has been separated from 
its scleral attachment, and the sutures will be passed through the scleral tissue beneath the 
conjunctiva in the direction of the broken line. 
Two sutures are now introduced from without inward, about one-third of the width 
of the muscle from either edge. These sutures also include the surrounding tissues. 
In simple advancement the sutures are introduced immediately behind the hook, 
and the insertion of the muscle is detached from the ocular globe. In a resection 
the sutures are introduced further back and the muscle divided between them and 
the hook. In order to- accomplish this the muscle is gently raised-at one part by ADVANCEMENT OR READJUSTMENT 
677 
means of the four ends of the stitches, which the surgeon holds in his left hand, and 
at the other by the hook which the assistant holds-and the tendinous end separated 
from the eyeball. One of the needles is next passed above, and the other below, the 
meridian, into the episcleral tissue close to the corneal margin (a-b, Fig. 366), to the 
extent of several millimeters. If the needle does not penetrate sufficiently deep, it 
should be guided farther underneath the conjunctiva, and if it is feared that it has 
not a thorough grasp, it may be passed once more through the conjunctiva. The 
assistant now seizes the ocular globe with a fixation forceps at the level of the an- 
tagonistic muscle, and rotates it toward the muscle which is to be advanced, while 
the surgeon ties the sutures, one of which is composed of white silk and the other of 
black silk. Both eyes are bandaged for five days in divergent, and for a week in 
convergent, strabismus. The sutures are usually removed on the sixth day." 
In A. E. Prince's method of advancement an unyielding fixation 
point is obtained by utilizing the dense episcleral tissue, severing the 
muscle, and regulating the effect by a "pulley suture." In Schweig- 
Fig. 366.-Landolt's method of advancement. 
ger's method a free exposure of the muscle is made, and after the tendon 
is divided a portion of the end is resected; catgut sutures are employed 
to advance the muscle (see Reese's operation, page 678). H. D. Bruns, 
of New Orleans, has recently described an ingenious operation for ad- 
vancement of the recti tendons, performed with the aid of a Clark hook 
and the formation of a tuck in the tendon, which is firmly flattened 
down and drawn strongly forward, and held in place by a combination 
of pulley and guy suture.1 
Todd, after exposing a considerable portion of the tendon by means 
of a flap incision through the conjunctiva and capsule, forms, with the 
aid of an instrument known as the tendon folder, an actual folding, and 
fixes the duplicature with catgut sutures reinforced with silk sutures, 
which include the conjunctival flap. Major R. O'Connor has designed 
1 For the method of performing this operation, see Ophthalmic Record, June, 1903. 678 
OPERATIONS 
an ingenious and new operative procedure for shortening and length- 
ening ocular muscles.1 
In Worth's method of advancement the needles carrying the sutures 
pass through the conjunctiva, capsule, and muscle. The main sutures 
ultimately are passed through the sclerotic, the needles traversing at 
least one-half the thickness of the sclerotic.2 
Of the methods of advancement which have been recorded, the 
author is in the habit of employing the one which is described first 
and Landolt's procedure; he also finds Worth's operation exceedingly 
valuable. 
Reese's Muscle=resection Operation.-Dr. Robert G. Reese 
operates as follows, the description of the operation being in his own 
words: 
For the external and internal rectus make a vertical incision in the conjunctiva 
6 mm. from the corneoscleral margin, commencing at the level of the upper corneal 
border, and extending to the horizontal plane of the lower border. 
Fig. 367.-Reese's forceps for operation in squint. 
At the upper and lower limits of the incision just made grasp the tissue anterior 
to the sclera with forceps and open with scissors, directing their point away from 
the muscle. This procedure allows the passage of the strabismus hook under the 
entire muscle. 
When the muscle is held on the hook, dissect all the conjunctival and subcon- 
junctival tissue back to the canthus, exposing the bare muscle completely. 
Fig. 368.-Passage of the strabismus hook under the entire muscle (Reese). 
The lateral invaginations of Tenon's capsule, which are attached to the tendons 
of the ocular muscles, must be dissected free and clear. 
One blade of the resection forceps is then inserted beneath the muscle at a right 
angle to its course, so that the groove on the blade lies directly over the middle 
1 For the method of operating, see Ophthalmic Record, December, 1914. 
2 For the method of operating, see Squint: its Causes, Pathology, and Treatment, 
4th edition, by Claud Worth. reese's muscle-resection operation 
679 
fibers of the muscle. Clamp the forceps to the last notch, and do not let its grasp 
include anything but muscle. 
Sever the muscle 2 mm. from its scleral attachment, leaving a stump, so that the 
resected end can be sewed to its original insertion. Free the belly of the muscle 
from any scleral adhesions. Three sutures are necessary. 
Fig. 369.-Showing the three necessary sutures (Reese). 
Put the sutures in, commencing with the middle, which is a No. 3 braided silk 
with a needle on each end. Pass one needle through the scleral surface of the muscle 
posterior to the blade of the forceps and 4 mm. back of the point of resection, and 
Fig. 370.-Showing the muscle resected and sutures in scleral stump (Reese). 
1 mm. to the side of the groove on the forceps; then pass the other needle the same 
way, but to the other side of the groove, making a loop with the suture on the scleral 
surface of the muscle. As the needles pierce the muscle, let them include the dis- 
sected edge of subconjunctival and conjunctival tissues. 680 
OPERATIONS 
The two wing sutures are No. 5 silk with a single needle passed first through the 
upper and lower part of the dissected conjunctiva and episcleral tissues, including 
the superior and inferior border of the muscle, and slightly posterior to the loop 
made by the middle suture. 
Cut the muscle anterior to the sutures, leaving at least 2 mm. in front of the 
loop. 
Insert the two needles attached to the middle suture 2 mm. apart, through the 
center, and the other two needles through the upper and lower edges of the scleral 
stump. These needles should include the conjunctiva as they pass from behind 
forward. 
Tie the middle suture first in a loop, and do not use a surgeon's knot, as it will 
not pull up well. The lateral sutures are next tied. No supplementary conjunctival 
sutures are necessary. 
The middle suture is removed in ten days, and the others can be taken out any 
time after forty-eight hours, or if left in they soon fall out. 
The eye operated upon only is bandaged and is dressed daily for five days, when 
boric acid bathing, three times a day, is ordered; and if the .eye is not over corrected, 
the correcting lenses are ordered for constant use. On the other hand, if there is an 
undercorrection, a mydriatic is used and the proper glass is worn constantly. 
The operation consists in resecting the muscle only, and not cutting out any of 
the other tissues of the eyg. It is a myectomy, because in no degree of squint, how- 
ever slight, will removing ftie tendinous portion of the muscle be sufficient. 
Operation for Shortening the Tendon.-G. C. Savage and Francis 
Valk secure the advantages of advancement by an operation in which 
the tendon is shortened. The last-named surgeon operates as follows: 
"The conjunctiva is raised with forceps over the lower or upper point of the 
insertion of the tendon, and a vertical incision followed by a horizontal one, forming 
an L, is made. This is dissected loose from the underlying tissue, and then an open- 
ing is made in Tenon's capsule and a small hook is passed beneath the tendon. As 
the point of the hook comes out, another hook is inserted in an opposite direction, 
and the two hooks forcibly drawn apart, thus exposing the tendon and part of the 
muscle. Next a small instrument called a twin strabismus hook is passed beneath 
the muscle, and the hooks are allowed to separate by the action of a small spring in 
the joint, and the two hooks are then removed. The muscle and the tendon are now 
fully exposed and ready for the future. A needle threaded with catgut is passed 
first through the lower part of the tendon, then through the muscle as far backward 
as it is desired to make the 'tuck,' passing from within-outward. It then goes across 
the belly of the muscle and is passed through, from without inward and back to the 
tendon, where it passes from within outward, at a point corresponding to its. first 
insertion. As the ends are tied over the tendon at this point it is easy to see the 
'tuck' formed as the muscle-belly is drawn forward and its long axis shortened." 
Advancement of the capsule of Tenon is recommended by some 
surgeons. S. Lewis Ziegler has designed a capsidomuscular advancement 
with partial resection. His method is as follows: 
A vertical incision is made in the conjunctiva near the limbus and the tendon 
and muscle raised on two tenotomy hooks introduced from below upward and put 
slightly on a stretch. One arm of a double armed suture is then inserted through 
the lower edge of the muscle from before backward and the same suture repeated 
behind the first, thus making a marginal whip-stitch. The thread is then passed 
partly across the top of the muscle and a similar double stitch is duplicated on the 
upper margin of the muscle. 
Each needle is now carried backward in a parallel line beneath Tenon's capsule 
and made to emerge on the conjunctival surface. A small wedge or V-shaped piece INTRODUCTION OF THE LACRIMAL PROBE 
681 
is then cut away from each peripheral third of the muscle, above and below, with 
punch or scissors, leaving a central strand of fibers intact. 
The needles are now entered through the conjunctiva at the upper and lower 
extremities of the wound, passed firmly into the sclera for solid anchorage, and 
brought out near the limbus, where the suture is tied after the toilet of the wound 
has been performed. This leaves a knot and two parallel lines of thread exposed 
on the conjunctival surface, thus holding all the tissue flat against the sclera. The 
good judgment of the operator must decide how much capsule shall be engaged and 
just how tight the graduated suture shall be drawn. As a rule, the squint should 
be slightly overcorrected. If indicated, certain measures should also be taken to 
weaken the pull of the antagonist. 
Slitting the Canaliculus.-This is performed as follows: 
OPERATIONS UPON THE LACRIMAL APPARATUS 
The lid being drawn down and out with the thumb, and the canaliculus knife 
held vertically, the probe point is introduced into the punctum. The handle is now 
Fig. 371.-Weber's canaliculus knife. 
depressed into the horizontal position, and the instrument pushed along the canal 
until the probe point touches the inner wall of the lacrimal sac. It is then raised to 
the vertical line with the cutting blade turned slightly inward, and the roof of the 
canaliculus divided. Either the upper or the lower canaliculus may be slit. 
Fig. 372.-Introduction of a lacrimal probe (Meyer). 
Introduction of the Lacrimal Probe.-The probe (Bowman's or 
Williams' probes are commonly employed; modifications have been de- 
vised by Theobald and Tansley) is introduced by passing it horizontally 682 
OPERATIONS 
along the canaliculus until its point touches the lacrimal bone. It is 
raised to the vertical position and pushed into the duct, remembering 
that the direction should be downward, slightly backward, and outward 
(Fig. 372). 
Incision of a Stricture.-If the stricture resists, it may be divided 
with a knife, either the one which has been employed in slitting the 
canaliculus or, still better, with the instrument of Stilling. The knife 
is introduced in the same way as the probe, pushed down into the duct, 
and the stricture incised. The knife is next partially withdrawn, turned 
slightly, and the maneuver repeated. Dr. Charles Hermon Thomas, 
Fig. 373.-Lacrimal probes. 
of Philadelphia, has devised a special knife, or stricturotome, which may 
be utilized for this purpose. 
Introduction of the Lacrimal Syringe.-The nozzle of an Anel 
syringe can be introduced along the canaliculus without slitting it. The 
lid is drawn down and outward in the same manner as if the operation 
of slitting the canaliculus were to be performed, and the point of the 
syringe introduced. Sometimes the punctum is swollen shut and the 
nozzle cannot be inserted. In these circumstances the punctum may 
be dilated with a silver pin. Ordinarily a lacrimal syringe is fur- 
nished with a cannula probe. This is introduced into the duct in pre- 
Fig. 374.-Thomas' stricturotome. 
cisely the same manner as the solid probe; the syringe is filled with an 
antiseptic fluid, inserted into the mouth of the cannula, and the liquid 
injected into the duct. 
Excision of the Lacrimal Sac.-In order to meet the indications 
described on page 572, excision of the lacrimal sac may be performed as 
follows: 
After thorough cleansing of the sac through the canaliculus with a 1 : 10,000 
bichlorid of mercury solution, general anesthesia may be induced, although in most 
instances careful local anesthesia will be sufficient (see page 595). With the skin 
drawn toward the bridge of the nose, the surgeon makes a slightly curved incision 
down to the periosteum, which extends from 4 mm. above the internal palpebral EXCISION OF THE LACRIMAL SAC 
683 
ligament to 5 mm. below it, its length being 2j cm. The canthal ligament may or 
may not be divided with scissors, and while the lips of the wound are separated, the 
temporal lip being especially drawn outward, the fibrous expansion from the tendo 
oculi is divided through its whole length, exposing the sac, which usually can be 
recognized by its bluish color. The sac is next gradually separated from the perios- 
teum, being dissected out very much in the manner of removing a cyst, care being 
Fig. 375.-Anel syringe. 
taken not to rupture its walls. The internal surface, the upper end and the posterior 
surface of the sac having been freed, is cut through at the commencement of the 
nasal duct. Sometimes the field of observation is obscured by a smart hemorrhage, 
which usually can be controlled by pressure or by specially devised specula; for 
example, those introduced by Axenfeld, or even more satisfactorily with the retractor 
designed by .Bishop Harmon. Should the operator experience any difficulty in out- 
lining the sac, its position may be localized by inserting a strabismus hook through 
Fig. 376.-Extirpation of the lacrimal sac (Haab). 
the canaliculus into the sac and keeping it there during the operation. This method 
was introduced by E. A. Shumway, and is most satisfactory in practice. Some 
surgeons advise that the sac shall be filled with melted paraffin prior to-the operation, 
a procedure which the author has never found to be necessary. 
C. R. Holmes does not believe that division of the tendo oculi is required in 
order to expose the sac, but dissects out the sac from underneath the tendon. If the 
tendo oculi has been severed, it may be replaced or repaired by a strong suture. 684 
OPERATIONS 
Great care must be taken that every portion of the sac is removed, and the operation 
may be terminated by thoroughly cureting the region (which Meller regards as un- 
necessary if the technic has been correct) and the ductus ad nasum, removing all 
traces of mucous membrane. Two sutures close the wound, which usually heals 
promptly. Holmes advises that the canaliculi should also be destroyed. Otherwise 
a blind pocket forms at the inner canthus. In order to accomplish this he splits the 
canaliculi through their entire length and destroys their lining membrane with the 
actual cautery. The dressing should consist of a pressure bandage placed over a 
light compress. 
Fig. 377.-Excised lacrimal sac. Dense infiltration of mucosa with round cells; erosion 
and degeneration of the epithelium; sac wall densely fibrous and vessels engorged. In- 
sane patient (Philadelphia General Hospital). 
Extirpation of the Lacrimal Gland.-Following the direction of 
C. R. Holmes, this may be performed as follows: 
An incision beginning near the center of the upper orbital arch and following the 
bony margin is carried to a point 3 mm. below the outer canthus. Next the fascia or 
septum orbitale is cut through along its attachment to the orbital margin. Should 
fatty tissue present in the wound, it must be held to one side with retractors and all 
bleeding from the edge of the wound must be controlled before the gland is separated 
from its surroundings, inasmuch as it is sometimes very difficult to distinguish the 
gland from the surrounding fatty tissue. By means of blunt-pointed scissors, 
fixation forceps, a small knife, and tenotomy hooks the dissection of the gland can 
be accomplished, and it may be removed without leaving any portion of it behind. 
Before the wound is closed all bleeding must be stopped. The lips of the wound are 
united with interrupted silk sutures, and the usual antiseptic dressing applied. As 
complications, hemorrhage into the orbit and atrophy of the optic nerve bave been 
reported, and on a number of occasions a persisting conjunctivitis, and also, as, for 
example, in Veasey's case, a form of keratitis. west's operation 
685 
Extirpation of the Palpebral Portion of the Lacrimal Gland.- 
Instead of the removal of the orbital lacrimal gland, extirpation of the 
palpebral gland is often practised. It is a much simpler operation and 
may be performed as follows: 
Thorough local anesthesia having been secured, the upper lid is everted and 
drawn upward from the eyeball while the patient looks strongly downward. This 
exposes the palpebral gland, which may be seized with toothed forceps and drawn 
outward. Its conjunctival covering is next incised, and the gland dissected from its 
surroundings. Hemorrhage having been controlled, the wound may be closed with 
one or two interrupted silk or catgut sutures, the upper lid replaced, and a light 
pressure bandage applied. The stitches are removed on the third day. 
Toti's Operation (D aery ocystar hinostomid).-In this operation a 
passageway for the tears is made through the bony wall of the nose, and 
its main points are briefly summarized by Torok, who recommends it as 
a valuable procedure, as follows: After chiselling through the bony 
lacrimal fossa, the internal wall of the lacrimal sac is resected, and at the 
same time a part of the mucous membrane of the nose is removed, which 
is of approximately the same size as the remaining external wall of the 
sac. The edges of the two mucous membranes are now brought into 
close connection, so as to permit their growing together. The mucous 
membrane of the lacrimal sac takes the place of the removed nasal 
mucous membrane. Together they now form one continuous mucous 
membrane, and with that the closing of the defect is prevented. The 
author has had no experience with this operation. 
West's Operation (JVindou' Resection of the Nasal Duct in Stenosis'). 
-This consists in resecting, under local anesthesia, a window from the 
nasal duct in the upper part of the nose above the inferior turbinate, 
and involves the removal of part of the lacrimal bone and also a piece 
from the superior maxilla. This removes a stricture in the upper part 
of the duct, but leaves a stenosis in the lower part untouched. It is, 
according to J. M. West, who has designed this operation and whose 
description is quoted, immaterial whether the lower part of the duct is 
stenosed, so long as the tears can drain through the artificial window. 
Previous to operation a probe is passed into the duct to act as a guide. 
The author has had no experience with this operation. APPENDIX 
The Use of the Ophthalmometer.-Ophthalmometry or, more 
properly, keratometry has been briefly referred to on page 110. A 
number of new models of the Javal-Schiotz ophthalmometer are now 
obtainable, with variations in the disk, form of arm, and method of 
illumination, but they do not introduce radical changes. The following 
rules, prepared by the late Dr. E. W. Stevens, formerly associated with 
Fig. 378.-Javal-Schiotz ophthalmometer (old model). 
the author in the Philadelphia Polyclinic, will enable the student to 
understand the proper method of using this instrument, as it is illus- 
trated in Fig. 378: 
The examiner, after satisfying himself that the illumination from the electric 
bulb is accurate, should carefully adjust the telescope by looking through it and 
turning the eye-piece either to the right or the left until the cross-hairs are brought 
clearly into view. The telescope is then turned so that the long pointer is below 
and at zero. The stationary mire on the parallelogram (Fig. 379, A) should be ex- 
amined to see that it is in proper position, which is at 20° on the graduated arc. 
The patient is now seated before the instrument in an easy position, with his 
chin resting on the chin-rest and his forehead pressed against the forehead-rest. His 
eyes should be widely opened and exactly horizontal-points to be determined by 
sighting through the transverse slit above the telescope. One eye is now covered 
with a small shade, and the observer sights along the telescope, through the notch 
687 688 
APPENDIX 
above it, at the patient's eyebrow; then, sighting through the tube, he moves the 
instrument forward or backward and raises or lowers it by the thumb-screw until 
the eye is brought into the field of the telescope, and a distinct image of the disk and 
mires is seen on the cornea. 
The images of the disk are doubled, and, overlapping each other, form an oval 
space in which are seen the two mires or targets, to which the beginner should confine 
his attention. The observer now slides the mire at his right along the arc until its 
reflection touches the reflection of the stationary mire, and notes whether the two 
lines bisecting the two mires are continuous. If these two lines are not continuous, 
the telescope is turned so that the long pointer will move from 0° toward 135°. If 
the transverse lines do not become continuous when 135° is reached, the rotation 
proceeds no farther in this direction, but the long pointer is turned back to 0° and 
then toward 45°, but never beyond 45°. With regular astigmatism the lines always 
become continuous within 45° of 0°. When the lines are continuous the mires 
must be brought into perfect approximation (Fig. 379, 1). This is the primary 
position, which should be carefully recorded according to the position of the long 
pointer. 
The telescope is next turned so that the long pointer moves 90° to the left of the 
primary position-i. e., to a point which is known as the second position. 
Fig. 379.-The mires. 
Tf the mires overlap (Fig. 379, 3)-for example, two steps in the second position 
with the long pointer at 90°--there is astigmatism of 2.00 D with the rule, because 
each step is equivalent to 1 diopter of corneal refraction, and this is recorded + 2.00 D 
cyl., axis 90°, or - 2.00 D cyl., axis 180°. 
If, on the other hand, the mires separate (Fig. 379, 2) in the second position, there 
is astigmatism against the rule. For example, if the primary position is found at 
30°, and when the tube is turned to the left until the long pointer reaches 120° 
a separation of one step has occurred, there is astigmatism of 1 diopter against the 
rule, which is recorded + 1.00 D cyl., axis 30°, or - 1.00 D cyl., axis 120°. 
In order to ascertain the exact number of steps to which the separation of the 
mires in the second position is equivalent, they are approximated by moving the 
sliding mire until the reflections touch, and the telescope is then rotated back to the 
primary position. The mires will now overlap, and the amount of astigmatism can 
be read off just as in astigmatism with the rule. The observer should remember, 
in finding the primary position, not to turn the long pointer farther than 45° on 
each side of 0° at the lower margin of the disk, lest he record astigmatism against 
the rule when it is with the rule, and vice versa. 
The upper surface of the arc carrying the mires is graduated on its outer circle to 
show diopters of refraction. It does not give the hyperopia or myopia of the eye, 
but indicates the corneal curvature. On the clamp of each mire there is a mark 
which enables one to read at a glance from this graduated arc the total refraction of 
each meridian of the cornea. The total refraction of at least one corneal meridian THE USE OF THE OPHTHALMOMETER 
689 
should be recorded, and preferably the one of least refraction. For example, if the 
examiner finds in the right eye 1 diopter of astigmatism with the rule, the long 
pointer being at 75° in the second position, and the right-hand mire at 23° on the 
graduated arc, the refraction may be recorded O. D. 43.00 D = 1.00 D cyl., axis 75° 
with the rule. 
If so desired, the astigmatism can be read from the graduated arc by measuring 
alternately the meridians of greatest and least refraction of the cornea. 
On the right of the inner circle of the arc there is a scale graduated from 6 to 10, 
each space being divided into ten equal parts. These spaces record the radius of 
curvature of the cornea in millimeters, and the amount is indicated by a mark on the 
clamp of the traveling mire. 
In some eyes it is impossible to bring into a continuous line the two lines bisect- 
ing the mires of the ophthalmometer, owing to irregular astigmatism or conical 
cornea. In these cases, however, the instrument is perhaps superior to all other 
methods of corneal measurement, as the overlapping or separation of the mires 
Fig. 380.-Javal-Schiotz ophthalmometer (model of 1907). 
gives a clue to the axes of the meridians of least and greatest corneal curvature, as 
well as the amount of astigmatism. 
Not infrequently the instrument indicates that the principal meridians of the 
cornea are not at right angles to each other-for example, it may record + 3.00 D 
cyl., axis 80°, or - 3.00 cyl., axis 180°. In these cases, when there is hyperopia, 
the axis of the cylinder should be 80°, and when there is myopia, 180°. 
In patients with heavy overhanging lids, deep-set eyes, or long lashes it is at times 
extremely difficult or even impossible to measure the vertical meridian of the 
cornea with the ophthalmometer. 
Nothing is more common than to see the mires separate and overlap again, so 
that the apparent curvature of the cornea seems to change while under observation. 
This change is due to slight movements of the eye which bring different portions of 
the cornea into view. It is difficult for most patients to remain long in the required 
position before the instrument, and hence the readings should be rapid as well as 
accurate. 
44 690 
APPENDIX 
As to the correspondence between the amount of corneal astigmatism indicated 
by the ophthalmometer and the total astigmatisrh under a mydriatic, there is a 
difference of opinion among observers. Probably the rule formulated by Burnett is, 
in the main, correct: "For the total subjective astigmatism, subtract 0.50 D from 
the corneal astigmatism when it is according to the rule, and add 0.50 D if the corneal 
astigmatism is against the rule." 
In addition to the Javal ophthalmometer, a number of excellent 
models may be obtained. To some of these brief reference has been 
made on page 111. In so far as the author's practice is concerned, his 
best results have been obtained with the Javal instrument (Fig. 380). 
The ophthalmometer is exceedingly useful, and one of the most im- 
portant of all the instruments of precision we possess for the diagnosis of 
Fig. 381.-The tropometer. 
astigmatism of the cornea; but it should never be used for the prescrip- 
tion of glasses to the exclusion of other methods-the trial-lenses after 
mydriasis, and retinoscopy.1 
The Use of the Tropometer.-Dr. G. T. Stevens2 attaches special 
importance to the determinations, absolute as well as comparative, of 
the rotations of the eyes, since he believes that excessive tensions upon 
the vertically acting muscles of the eyes often induce converging or 
diverging strabismus, independently of any anomalous tension of the 
laterally acting muscles, and that many conditions of heterophoria may 
be explained in a like manner. 
1 For a thorough exposition of the principles of keratometry the student should consult 
Carl Weiland, Archives of Ophthalmology, vol. xxii, pp. 37-64; Optique Physiologique, 
by Tscherning, pp. 46-68. 
2 International Ophthalmological Congress, Edinburgh, August, 1894; Annales d'Ocu- 
listique, April and June, 1895. THE USE OF THE TROPOMETER 
691 
The most favorable rotations, according to Dr. Stevens, are: up- 
ward, 33°; downward, 50°; inward, 55°; outward, 50° (compare with 
page 522). 
He has devised an instrument, called the tropometer (Fig. 381), for 
the determination of the various rotations, a description of which, 
kindly revised by Dr. Stevens, follows: 
The instrument consists essentially of a telescope in which an inverted image 
of the eye is found at the eye-piece, where its movements can be observed upon a 
Fig. 382.-The long line between and at right angles to the shorter lines divides two 
similarly graduated scales running in different directions. The larger circle represents the 
outer border of the cornea, the edges of which are in contact with the two strong lines. The 
interval between each pair of short lines of the scale is ten degrees of an arc, commencing at 
the strong line in each case. If, now, the head of the person examined is held firmly in the 
primary position, and the eye caused to rotate strongly in a given direction, the arc through 
which the border of the cornea passes may be accurately read upon the scale. In the figure 
the curved dotted line represents a new position of the border of the cornea. Suppose that 
the person examined has been directed to look strongly upward. Then the cornea has 
moved down the scale, and reaches the point in this example of 40°, that being the measure 
of this rotation. 
By means of the small lever the scale can be placed horizontally, vertically, or obliquely, 
and by means of the two graduations measurements in opposite directions can be made. 
If it is desired to determine the upward rotation, the border of the cornea is made to 
coincide with the strong line which appears in the upper part of the scale at the right hand. 
This adjustment is made by means of the milled head at the side of the standard. As the 
eye rotates up, the image moves apparently down. In determining the downward rota- 
tion the strong line at the lower left-hand side of the scale is taken as the point of departure. 
For lateral rotations the scale is turned to the horizontal position, and the corresponding 
strong lines used as before. 
graduated scale, permitting rotations in any direction to be measured. A prism or a 
diagonal mirror at the objective end of the telescope permits the observer to sit at 
the side of the observed. By means of a head-rest and an adjustable stirrup with a 
wooden bar, which the observed holds closely between the teeth, the head may be 
held firmly in the primary position. This position is indicated by the two buttons 
at the extremities of the guiding rods. 
In order to adjust the upper border of the cornea to the line, it will generally be 
necessary for the examiner to place the left hand upon the forehead of the patient 692 
APPENDIX 
and make gentle traction of the upper eyelid by the thumb. An application of the 
hand to the head is advisable in all measurements, as by this means the examiner 
is able to detect even a slight movement of the head, which would vitiate any measure- 
ment of the rotation. 
In adjusting the head to the head-rest the teeth should be closed upon the 
wooden bar of the stirrup with force; then, after adjusting the stirrup to the proper 
height, the two indicators should be adjusted, one touching the glabella or ridge 
just above the root of the nose, the other pressing the commissure of the upper lip 
close below the nose. By pushing the stirrup forward or backward the lower indica- 
tory button should be at a distance from the bone equal to that of the upper indicator. 
The hoop passing around the head is designed to indicate, when the knob presses 
against the occipital protuberance, that the head is in position for lateral measure- 
ments. 
If the cornea is large, the telescope must be moved backward upon the base 
until the borders of the cornea just encroach upon the two strong lines of the scale. 
When the cornea is small the tube is moved forward. 
The wooden bar of the stirrup may be thrown away after use and replaced by 
another. 
For measuring declinations of the retinal meridians, Dr. Stevens has designed 
an instrument known as the clinoscope. For a full description of this instrument 
and the manner of using it the student should consult the Medical Record, February 
16, 1901, where he will find Dr. Stevens' complete directions. 
Localization of Foreign Bodies in the Eyeball with the Rbnt= 
gen Rays.-The following paragraphs have been written by Dr. 
William M. Sweet, and, therefore, in his own words describe the 
method which he has originated and which has proved to be most 
satisfactory: 
The methods of locating foreign bodies in the eyeball by means of 
the Rontgen rays are based upon the study of the shadow of the 
foreign substance on the radiograph in its relation to the shadow of one 
or more known points in the vicinity of the eyeball. These fixed points 
from which measurements are made may be situated on the skin of the 
eyelid or cheek, or suspended in front of the eyeball. If an apparatus 
is employed to fix the position of the a-ray tube at each exposure, only 
one indicating point will be required, but with two fixed points of 
measurement the position of the tube at the time the radiographs are 
made need not be known. 
The earlier form of the Sweet localizing apparatus consisted of a 
small platform to which the head of the patient was firmly clamped. 
Two ball-pointed indicator rods were used, one opposite the center of 
the cornea, and the other at a fixed distance to the temporal side. 
Two exposures wTere made, and the situation of the steel in the eye was 
determined from a study of the position of the shadow of the foreign 
body on the two plates in relation to the shadow of the two indicating 
rods. 
A new form of apparatus has been designed, in which only one indi- 
cating rod is used. The planes of shadow of the foreign body are accu- 
rately determined by the instrument without the necessity on the part of 
the operator of taking measurements from the plates or in drawing lines 
on the chart. The tube-holder, indicating ball, and plate-holder are 
upon a movable stage, and therefore preserve a known relation to each LOCALIZATION OF FOREIGN BODIES IN THE EYEBALL 
693 
other which does not vary. The angle of the rays with the eyeball and 
the distance of the tube from the plate are always the same, so that one 
indicator is sufficient, and this consists of a small steel ball supported 
in a ring of transparent celluloid. The setting of this ball opposite 
the center of the cornea is made by means of adjusting screws con- 
veniently placed on the frame of the instrument. Accuracy in the 
measurement of the distance of the indicating ball from the center of 
the cornea is secured by means of a telescope and reflecting mirror. 
The mirror gives an image of a cross-wire and a lateral image of the 
cornea. Through the telescope the observer adjusts the instrument 
until the image of the cross-wire is in direct contact with the image of 
the summit of the cornea (Fig. 383). When the adjustment is made, the 
indicating ball is exactly 10 mm. from the center of the cornea. A 
miniature incandescent lamp, mounted in an adjustable shade, illumi- 
nates the side of the nose of the patient, insuring a well-lighted image of 
the cornea and cross-wire. 
Instead of a ball of cotton or other object for fixation, as in the older 
method, a circular mirror is placed at a distance of 12 inches above the 
injured eye. The patient gazes in the mirror and sees a reflected image 
of the injured eye and the circular celluloid disk with the steel indicat- 
Fig. 383.-Image of cross-wire and cornea (W. M. Sweet). 
ing ball in its center. After the ball has been adjusted to a point oppo- 
site the center of the cornea of the injured eye, the patient by fixing the 
ball with the seeing eye prevents any movement of the eye during the 
exposures and holds the visual line of the injured eye parallel with the 
plate. Two exposures are made upon one plate, metallic shutters pro- 
tecting those portions of the plate which are not to be exposed to the 
rays. 
The tube-holder contains the usual cylindric lead-glass shield for 
protecting the operator from the action of the rays, with the custom- 
ary lead diaphragm. The central orifice of the diaphragm is covered 
with aluminum, which offers little obstruction to the rays, but lessens 
the risk of any unfavorable action of the rays upon the patient and 
guards against possible damage to the eyes in the event of breakage of 
the tube. The tube-holder slides upon a graduated rod, and the first 
exposure is made with the indicator at zero, in which position the rays 
pass in a direction corresponding with the horizontal plane of the eye- 
ball. The second exposure is made with the tube at its farthest point 
to the right or left of the first position, depending upon which eye is to 
be examined. 
Since the relative position of the tube in reference to the indicating 694 
APPENDIX 
ball and the photographic plate remains fixed and known, the .x-rays in 
passing through the eyeball follow a definite course, which is always 
the same for the two separate exposures. It is, therefore, possible to 
indicate on the localization chart the direction of the rays at the two 
exposures, and this has been done in the chart, a copy of which is repro- 
duced in Fig. 384 reduced in size one-half. Only those lines representing 
rays 2 mm. apart are reproduced, but each line is drawn with the re- 
quired amount of divergence to indicate the rays as coming from a point 
the distance of the tube from the photographic plate. 
Fig. 384.-Localization chart, with lines representing course of the x-rays (one-half actual 
size) (W. M. Sweet). 
In employing the new apparatus (Fig. 385) the jointed portion con- 
taining the upright tube, T, is raised, and the patient lies with the 
head on a platform of hard fiber, with a pillow beneath the shoulders 
and a small sand-bag under the head and neck. The upright supports 
for holding the head are now adjusted by means of the wheel 1, and the 
jointed part of the apparatus brought down in position. The indicating 
ball is now roughly adjusted until it is opposite the center of the cornea 
and about 12 or 15 mm. distant. The patient looks with the uninjured LOCALIZATION OF FOREIGN BODIES IN THE EYEBALL 
695 
eye into the mirror (TH) and fixes upon the iris or cornea of the injured 
eye, or, better, upon the indicating ball in the center of the celluloid 
disk. The indicating ball is now adjusted directly over the corneal 
center by means of the wheels 2 and 3, and the correctness of the posi- 
tion verified by observation through an opening in the mirror (M). 
The operator then adjusts the light of the small electric lamp so that the 
side of the nose next the injured eye is illuminated, but the light is not 
thrown into the eye. With this area lighted it is possible, through the 
telescope (T), to note when the cross-wire is exactly tangent with the 
summit of the cornea. The movement necessary to secure this position 
of the wire is made by means of the adjusting wheel 4. When the image 
Fig. 385.-Sweet's apparatus for localizing foreign bodies in the eyeball. 
of the cross-wire touches the image of the corneal summit, the indicating 
ball is exactly 10 mm. from the eyeball. 
The photographic plate is inserted beneath the spring clips (C, C), 
the shutters (S, S) moved so that the center area is open, and the tube- 
holder adjusted to the zero point on the sliding scale. The current is 
turned on, and one exposure made. The tube-carriage is then moved 
to the limit of the sliding rod, always in the direction of the chin of the 
recumbent patient (to the end marked R if the radiographs are made of 
the right eye, and to L if of the left eye). The upper shutter is moved 
to cover the exposed central portion of the plate and uncover the upper 
unexposed portion. The current is again turned on and the second 
exposure made. 696 
APPENDIX 
After the plate is developed it is placed in the frame P (Fig. 385), 
containing the key plate or focal coordinates (Fig. 386), with the film side 
of the radiograph next to the key plate. The radiograph is moved until 
the shadow of the indicating ball of the first exposure is in apposition 
with the middle ball on the key plate and the heavy horizontal line of 
the radiograph parallel with the horizontal line on the plate. Holding 
the frame to the light, there is noted the position occupied by the 
shadow of the foreign body with respect to the vertical lines of C and D. 
A reading is made of the line or lines which pass through the body, and 
this is transferred to the corresponding lines of the C or D scale of the 
chart, to the right or left side, depending on which eye is under examina- 
Focal Go-ordinates 
For 
Dr.Sureets Improded Eqe Localizer 
Made Bq 
Roentgen Manufacturing Co. 
Fig. 386.-Plate showing focal coordinates (three-fourths actual size) (W. M. Sweet). 
tion. Without moving the plate the E reading is similarly made and 
transferred to the chart. To take the A or B reading the plate is shifted 
slightly until the image of the indicating ball on the second exposure 
coincides with the "Right" or "Left" ball of the vertical coordinates 
A or B. The line or lines of the A or B coordinates which cross the 
shadow of the body are noted and indicated on the A or B lines of the 
chart. The horizontal coordinate E should be the same in both read- 
ings. If the focus point on the anode of the tube was accurately set 
by the cross-lines on the lead-glass shield of the tube-holder, the images 
of the indicating ball on the plate will coincide simultaneously with 
those on the transparent key plate, and it will then not be necessary to 
reset the plate to read the position of the A and B coordinates. LOCALIZATION OF FOREIGN BODIES IN THE EYEBALL 
697 
After the three readings have been transferred to the chart, the 
point of crossing of the A or B and the C or D lines is found, which 
gives the location of the foreign body in reference to the front view of 
the eyeball, indicating its situation above or below the center of the 
cornea and to the nasal or temporal side of the vertical plane. Where 
a vertical line from this point crosses the E reading on the horizontal 
section of the globe it gives the depth of the body in the eyeball or 
orbit. In bodies of large size both ends should be localized to give the 
position in which the body rests in the globe. The situation of the body 
Fig. 387.-Radiograph of foreign body in eye (three-fourths actual size) (W. M. Sweet). 
on the side view is determined by transferring its measured depth from 
the horizontal section and its distance above or below the horizontal 
plane from the front view localization. 
The accuracy of the localization depends only upon the care with 
which the operator adjusts the indicating ball opposite the center of the 
cornea and at the definite and fixed distance from it. After the ex- 
posures are made and the plate developed, the determination of the 
situation of the foreign body is simply a question of reading from a 
key plate and transcribing these readings to the chart. INDEX 
Note.-The bold-face folios indicate the pages on which the subjects are treated 
in extenso. 
Abderhalden reaction, 279 
Abducens nerve, 519 
Abduction, 519 
deficiency of retraction of eyeball with, 
537 
test for, 74 
Aberrant choroidal vein, 103 
Aberration, 116 
Ablatio retinae, 447. See also Retina, 
detachment of. 
Ablepharia partialis, 158 
totalis, 158 
Abnormalities of visual field, 85 
Abrus precatorius, 225 
Abscess, brain, 63 
from disease of nasal accessory sinuses, 
590 
lacrimal, 567 
of infants, 568 
rupture of, 567 
of conjunctiva, 231 
of cornea, 248 
ring, 283 
treatment, 254 
of eyelids, 161, 186 
of frontal lobe, 489 
from nasal sinuses, 590 
of orbit, 587 
blindness from, 576 
of prelacrimal sac, 567 
of sclera, 292 
of vitreous, 414 
rectal, 289 
ring, after cataract extraction, 665 
subperiosteal, 574, 590 
Acanthosis nigricans, 169 
Accommodation, 35, 70 
abnormal, 40 
amplitude of, 38, 70 
in glaucoma, 372 
convergence and, disturbances of, 
strabismus and, 542 
relations of, 44, 46 
excessive, 41 
exercise of, 37 
Grossmann's theory, 36 
Helmholtz's theory, 36 
ill-sustained, 40 
inequality of, 40 
inertia of, 40 
Accommodation, insufficiency of, 40 
in concomitant strabismus, 542 
mechanism of, 35 
near point of, 38 
paralysis of, 64 
phenomena of, 70 
power of, 38 
range of, 37, 39, 70 
at different ages, 40 
finding of, 38 
formula for finding, 39 
reaction of pupil, 56, 59 
region of, 37 
relation with convergence, 46 
relative, 46, 70 
negative part of, 46 
positive part of, 46 
spasm of, in hyperopia, 122, 126 
in iritis, 303 
in myopia, 129 
strain and, 379 
cataract from, 401 
subnormal, asthenopia in, 122 
synkinesis, 56 
table of range, 39 
testing of, 70 
theories of, 36 
Tscherning's theory, 36 
Accommodative asthenopia, 122 
movement, 521 
Acetate of lead, 309 
Achromatopsia, 496, 504 
Acne rosacea conjunctivitis, 189 
keratitis, 265 
Acoin, 205, 256, 310, 596, 619 
Acromegaly, 592 
Actinomycosis, lacrimal, 569 
Actual cautery, 666 
for powder grains in cornea, 281 
in astigmatism, 147 
in conical cornea, 279 
in corneal disease, 619 
ulcers, 253, 257 
in detachment of retina, 450 
in ectropion and entropion, 610 
in marginal degeneration of cornea 
276 
in wounds of sclera, 297 
Acuteness, visual, 35 
normal, 35 
699 700 
INDEX 
Adams' operation for ectropion, 609 
Addison's disease, 298 
Adduction, 519 
associated, 74 
test for, 74 
Adeno-angioma of lacrimal gland, 565 
Adenocarcinoma of conjunctiva, 234 
Adenoid vegetations, 241 
Adenoma of caruncle, 239 
of choroid, 364 
of ciliary body, 331 
of eyelid, 171 
of lacrimal gland, 565 
of Meibomian glands, 171 
of sweat-glands, 171 
Adrenal tumors, 580 
Adrenalin, 188, 255, 595 
chlorid, 213, 227, 387, 597, 598 
Advancement, 675 
capsulomuscular, with partial resec- 
tion, 681 
in concomitant strabismus, 551, 552 
in convergent strabismus, 675 
in divergent strabismus, 552 
in heterophoria, 561 
of external rectus, 676 
of Tenon's capsule, 680 
simple, 676 
Afferent pathway, 59 
After-cataract, 394, 405 
anterior polar, 404 
discission for, 671 
operations for, 669 
posterior polar, 404 
treatment, 410 
Agnew's operation for dislocation of lens, 
413 
Albinism, 343 
Albumin in aqueous glaucoma, 391 
Albuminuria,- 435 
cataract and, 399 
physiologic, 53 
Albuminuric choroiditis, 351 
Alcohol, 178, 256, 275, 490, 501, 536, 539, 
593, 594 
amblyopia, 501 
poisoning, 539 
Alcoholic neuritis, 63 
Alcoholism, 64 
Allantiasis, 536 
Alopecia of eyelids, 181 
Alpha angle, 41 
Alum, 193, 206, 227 
Alypin, 596 
Amaurosis, 495. See also Amblyopia. 
hereditary, 495 
hysteric, 504 
methyl-alcohol, 501, 502 
partial fugaceous, 509 
quinin, 501 
uremic, 500 
Amaurotic cat's eye, 464 
family idiocy, 466 
Amblyopia, 495, 504 
acquired, 495 
alcohol, 490, 501 
Amblyopia, antipyrin, 501 
arsenic, 490, 503 
astigmatic, 495 
atoxyl, 490 
cannabis indica, 501 
carbon bisulphid, 501 
central, 488. See also Optic neuritis, 
orbital. 
chiasmal, 510 
with scotoma, 510 
chloral, 490, 501 
chlorate of potassium, 501 
chloroform, 490 
coffee, 501 
congenital, 402, 495 
for colors, 496. See also Color- 
blindness. 
crossed, 504 
exablepsia, 543 
exanopsia, 496, 543 
from abuse of drugs, 501 
from blepharospasm, 496 
from congenital eye defects, 496 
from dental disease, 499 
from diabetes, 500 
from disease, 500 
from loss of blood, 501 
from shell-shock, 500 
glycosuric, 500 
hysteric, 504 
in strabismus, 543 
intoxication, 490, 501 
iodoform, 490 
lead, 490 
malarial, 500 
male fern, 501 
malingering, 505 
mercury, 501 
methyl-alcohol, 502 
nitrate of silver, 501 
nitrobenzol, 490, 501 
non-symmetric, 495 
of squinting eyes, 543 
of visual field, 509 
osmic acid, 501 
partial fugaceous, 509 
permanent, 495 
pretended, 505 
diplopia test for, 505 
Harlan's test for, 505 
quinin, 501 
reflex, 498 
salicylic acid, 501 
stramonium, 490, 501 
symmetric, 495 
sympathetic, 334 
temporary, 495 
tobacco, 62, 490, 501 
toxic, 490, 501, 502 
traumatic, 461, 499 
uremic, 500 
wintergreen oil, 501 
Amblyoscope, 549 
Ametropia, 121 
axial, 121 
curvature, 121 INDEX 
701 
Ametropia, curvature, measurement of, 
91 
definition, 121 
retinal image in,, 34 
Ammonia burns of eye, 283 
Ammonium chlorid, 261 
Amotio retinae, 447. See also Retina, 
detachment of. 
Amplitude of convergence, 45 
Amyloid disease of conjunctiva, 230 
Amyotrophic lateral sclerosis, 485 
Anaesthesia retinae, 423, 509 
Anagnostakis-Hotz operation for entro- 
pion, 607 
Analgesia, local, 595 
Anaphylactic uveitis, 337 
Anaphylaxis, 270 
Anel syringe, 683 
Anemia, 61, 324, 351, 416, 417, 452, 456, 
554 
of optic nerve-head, 471 
of retina, 422 
Anesthesia, general, 594 
hysteric, 51 
infiltration, 597 
lacrimal reflex in, 51 
local, 595 
Barker's solution for, 597 
Elschnig's method, 598 
Seidel's method, 598 
Siegrist's method of, 597 
of retina, 423, 509. See also Retina, 
anesthesia of. 
spinal, 536 
Aneurysms, 432, 536 
of retinal vessels, 456 
Angelucci's method of cataract extrac- 
tion, 669 
Angioid streaks of retina, 455 
Angioma, capillary, 169 
cavernous, of choroid, 364 
of conjunctiva, 233 
of eyelids, 169 
of orbit, 579 
Angiomatosis of retina, 456 
Angiomegaly of eyelids, 170 
Angioneurotic edema of conjunctiva, 232 
of eyelids, 160 
Angiopathica traumatica retinae, 619 
Angiosarcoma of caruncle, 239 
of choroid, 361 
of conjunctiva, 236 
Angiosclerosis, 400, 464 
of retina, 454 
Angle alpha, 41 
gamma, 41, 545 
in emmetropia, 42 
in hyperopia, 42, 127 
in myopia, 130, 131, 132 
measuring, 41 
strabismus and, 545 
meter, centrads and, relations of, 20 
prism-diopters and, relations of, 20 
of anterior chamber, 381 
tumors of, 321 
of convergence, 44 
Angle of deviation, 19 
of incidence, 18 
of iris, incision of, 629 
of prism, 18 
of refraction, 18 
of strabismus, 546 
refracting, of prism, 18 
visual, 34 
Angular method of measuring strabismus, 
546 
Aniridia, 320 
Anisocoria, 64 
Anisometropia, 148 
Ankyloblepharon, 158, 180 
Annular scleritis, 291 
Anophoria, 71 
Anophthalmos, 573 
Anotropia, 71 
Anterior chamber, alterations in contents 
of, 320 
in depth of, 320 
angle of, cysts of, 321 
in glaucoma, 381 
tumors of, 321 
anomalies of, 320 
blood in, 320, 366 
cilium in, 320 
cysticercus in, 321 
deepening of, 320 
Filaria sanguinis hominis in, 320 
foreign bodies in, 320 
implantation cyst in, 320 
in cataract, 395 
in glaucoma, 369 
irrigation of, after cataract extrac- 
tion, 656 
normal angle of, 381 
parasites in, 320 
pus in, 320 
shallowing of, 320 
turbidity of, 320 
hyaloid membrane, 379 
synechiae, division of, 628 
Anthrax of eyelid, 161 
Antidiphtheritic serum, 255 
Antigonococcus serum, 203, 205 
Antimetropia, 148 
Antipneumococcus serum, 255, 652 
Antipyrin, 214, 261 
amblyopia from, 501 
Antistaphylococcic vaccine, 665 
Antistreptococcus serum, 255 
Antitoxin, diphtheria, 210 
Antrum of Highmore, disease of, 588 
empyema of, 588 
fibroma of, 589 
polypi of, 589 
sarcoma of, 589 
Aortic insufficiency, 61 
Apex of prism, 18 
Aphakia, 410 
congenital, 394 
glasses in, 411 
Apoplexy, cerebral, 62 
conjugate deviation of head and eyes 
in, 540 702 
INDEX 
Apoplexy of retina, 451. See also Ret- 
ina, hemorrhages in. 
Appendix, 687 
Aqua chlorini, 200, 252 
Aqueduct of Sylvius, 57 
Aqueous in glaucoma, 369 
albumin in, 383 
fluid, 380 
humor, 120 
Aquocapsulitis, 323. See also Uveitis. 
Arc of propagation, 246 
Arcus senilis, 274, 278 
lentis, 398 
Arecolin, 387 
Argamblyopia, 496 
Argentamin, 193, 203 
Argonin, 570 
Argyll Robertson pupil, 63 
Argyria conjunctivae, 240 
Argyrol, 165, 193, 195, 200, 202, 223, 252, 
570, 652, 664 
discoloration from, 240 
Argyrosis, 240 
Ariol, 256 
Aristol, 163, 223, 238, 252, 571 
Arsenic, 164, 214, 226, 238, 244, 272, 290, 
490, 501, 579 
amblyopia, 503 
Arteriosclerosis, 41, 417, 453, 459 
ophthalmoscopic signs of, 453 
Arthritis deformans, 204, 311, 324 
Artificial eye, 638 
insertion of, 638 
reformed, 639 
Aryolarsenates, blindness from, 503 
Aspergillus fumigatus, 248 
nigricans, 248 
Aspirin, 312, 328 
Asteroid hyalitis, 416 
Asthenopia, 41, 126, 141, 504, 507 
accommodative, 157 
from astigmatism, 141 
hysteric, 504 
in subnormal accommodation, 122 
muscular, 557 
nervous, 423. See also Retina, anes- 
thesia of. 
neurasthenic, 423. See also Retina, 
anesthesia of. 
retinal, 504 
Astigmatic chart, 144 
eye, focussing of vessels of meridians 
by, 108 
form of image of point focused by, 139 
lens, 146 
Astigmatism, 43, 108, 121, 125, 138 
after cataract extraction, 410 
against rule, 139, 395, 410 
asthenopia from, 141 
atrophic crescents in, 356 
clock-dial chart in, 144, 146 
compound, determination of, 108 
hyperopic, 142 
example of, 145 
myopic, 142 
Astigmatism, hyperopic myopic, example 
of, 145 
reading glasses for, 151, 152 
contrary to rule, 139, 395, 410 
corneal, in myopia, 133 
incision for, 147 
correction, 143 
objective methods, 146 
cylindric lenses in, axes of, 152 
definition, 138 
determination of, 108, 146 
eye strain from, 141 
form of image in, 139 
galvanocautery for, 147 
glasses for, 146 
headache in, 141 
in cataract, 395 
in glaucoma, 372 
in myopia, 130 
inverse, 139 
irregular, 138, 147 
iridectomy for, 147 
skiascopy in, 116 
Johnson's method of determining, 146 
measurement of, 107, 110, 143 
meridians of, 139 
migraine from, 141 
mixed, 142, 145 
example of, 145, 
reading glasses for, 151, 152 
nervous disturbances in, 141 
oblique, 129, 139 
operation for, 147 
ophthalmoscope in ascertaining, 108 
ordinary glasses for, 145, 147 
reading glasses in, 151, 152 
axes of cylindric lenses and, 152 
recognition, 143 
regular, 138, 141 
principal meridians of cornea in, 139 
skiascopy in, 115 
seat, 138 
semiatrophic crescents in, 356 
simple hyeropic, 142 
example of, 144 
myopic, 142 
example of, 144 
spinal curvature from, 141 
stenopaic slit in, 144 
surgical treatment, 147 
symptoms, 139 
transient, in iritis, 303 
Wallace's chart for, 144 
with hyperopia, 143 
with myopia, 143 
with rule, 138 
Astigmia, 138. See Astigmatism. 
Ataxia, 504 
Atheroma of carotid, 400 
Atheromatous ulcers of cornea, 260 
Atophan, 341 
Atoxyl, 272, 328, 341, 490 
amblyopia, 490 
Atrabilin, 598 
Atrophia gyrata choroideae et retinae, 442 
Atrophic crescents, 356 INDEX 
703 
Atrophy, choroiditic, 346, 349, 369 
senile areolar, 352 
circumpapillary, 356 
in retinitis, 427 
of ciliary body, 331 
of conjunctiva, 230 
of cornea, 251 
of corneal margin, 278 
of eyeball, 367 
from cyclitis, 323 
of iris, 301, 305, 308 
of lacrimal gland, 564 
of optic nerve, 61, 482. See also Optic 
nerve, atrophy of. 
of retina, 426 
macular, 468 
papillitic, 475 
progressive muscular, 539 
Atropin, 62, 117, 121, 163, 203, 228, 238, 
243, 251, 254, 255, 262, 264, 271, 275, 
281, 288, 290, 301. 309, 312, 319, 328, 
340, 366, 421, 451', 462, 548, 598, 628, 
633, 649, 658, 664, 665, 667 
conjunctivitis, 228 
Atroscin, 119 
Auto-intoxication, gastro-intestinal, 187, 
273 
Autotoxemic iritis, 311 
Axes of eye, 138 
of lens, 26 
optic, 41 
secondary, 26 
visual, 41 
Axial cataract, 404 
ray, 94 
Axons of retina, 512 
Azodolen, 257 
Bacterial vaccines in ulcers of cornea, 255 
Bacterins, 255 
Neisser 313 
Bacterium coli, 189, 208, 248, 568 
conjunctivitis from, 189 
Ballantyne's classification of retinal ar- 
terial pulse, 101 
Bandages, 593, 594 
Barker's solution for local anesthesia, 597 
Barraquez fat implantation into Tenon's 
capsule, 641 
Bar-reading in strabismus, 551 
Basal palsies, 536 
Basedow's disease, S83. See also Exoph- 
thalmic goiter. 
Base of prism, 18 
Basham's mixture, 571 
Belladonna, 164 
Bell's palsy, 180 
Benign follicles, 218 
Benzine, 593 
Benzol, 597 
Benzosalin, 341 
Berger corneal loupe, 52 
Beri-beri, 477 
Berry's operation for staphyloma, 621 
test for scotomas, 86 
Beta-eucain, 597 
Betanaphthol, 223 
Biborate of sodium, 188, 193 
Bichlorid of mercury, 193, 194, 195, 200, 
206, 208, 210, 215, 222, 239, 252, 256, 
258, 266, 272, 281, 290, 293, 328, 341, 
359, 417, 438, 453, 570, 583, 586, 593, 
595, 611, 618, 640, 652, 654, 656, 663, 
664, 666, 672, 682 
solution, 663 
Bichlorid-vaselin, 652, 657 
Biconcave lens, 30 
Biconvex lens, 30 
Bifocal lenses, 153, 154 
concealed, 154 
Franklin, 157 
kryptok, 154 
split, 157 
Biniodid of mercury, 277 
Binocular field of vision, 82 
fixation, 521 
screen test for, 557 
magnifying lens, 52 
malingering, tests for, 505 
single vision, 522 
in paralytic strabismus, 526 
triplopia, 546 
vision, 521 
tests for, 553 
Bipolar ceils, 512 
Bismuth oxyiodid tannate, 212 
subnitrate, 163, 244 
Bisulphid of carbon, 490 
amblyopia from, 501 
Bjerrum's scotoma, 386 
symptom, 374 
test of vision, 81 
Black eye, 186 
spot of macula in myopia, 133 
Bach's accommodation test, 56 
pupil-reflex test, 55 
Bacillus anthracis, 161 
hay, 358 
influenzse, 188, 191 
if infected marginal ulcer, 249 
of Klebs-Loffler, 208 
of Koch-Weeks, conjunctivitis, 190, 
208, 215 
lepra, 248 
ozense, 189 
of Morax-Axenfeld, 167, 192, 215 
of ozena, 189, 248 
conjunctivitis from, 189 
of panophthalmitis, 358 
of Petit, 247 
of trachoma, 217 
Pfeiffer's, 191 
capsulated, 248 
pyocyaneus, 193, 248 
pyogenes fcetidus, 248 
subtilis, 188, 189, 247 
conjunctivitis from, 189 
tuberculosis, 248, 329 
tularense, 195 
xerosis, 172, 188 
Bacterial vaccines, 162 704 
INDEX 
Black's modification of Worth amblyo- 
scope, 551 
Blastomycosis, 168 
of eyelids, 161 
Blear eye, 166 
Blennorrhea, acute, 204 
chronic, 204 
lacrimal, 568 
Blenolenicet salve, 203 
Blepharitis, 123, 165, 187, 228, 265, 407, 
566 
acaria, 167 
ciliaris, 165 
ulcerosa, 166 
etiology, 166 
hypertrophic, 166 
in hyperopia, 123 
ionic medication in, 168 
pediculosa, 168 
pustular form, 166 
simple, 165 
solitary form, 165 
squamous, 165 
superficial form, 165 
syphilitic, 168 
treatment, 167 
trichophytica, 167 
ulcerosa, 165 
vaccine, 163 
vasomotor, 165 
Blepharo-adenitis, ciliaris, 165 
Blepharochalasis, 179 
Blepharoconjunctivitis, 192 
Blepharophimosis, 158, 181 
Blepharoplasty, 611 
for ectropion, 611 
Blepharoptosis, 178. See also Ptosis. 
Blepharospasm, 178, 241 
Blepharotomy, 604 
Blind spot, enlargement of, as symptom 
of posterior accessory sinus disease, 
590 
Mariotte's, 85 
Blindness, acute, in optic neuritis, 476 
binocular feigned, 505 
blue, 396, 496 
color-, 496. See also Color-blindness. 
day-, 506 
eclipse, 463 
from aryolarsenates, 503 
from orbital abscess, 576 
green-, 497 
hysteric monocular, 504 
methyl-alcohol, 502 
night-, 506 
red-, 497 
red-green, 497 
searching movements of eyes in, 562 
snow-, 507 
unilateral reflex, 63 
word-, congenital, 498 
yellow-blue, 496 
Blood-cysts of orbit, 581 
Blood-pressure, increased, and cataract, 
relation between. 400 
Blood-staining of cornea, 278 
Blood-vessels of conjunctiva, 48 
of eye, 101 
distribution of, 102 
Blue blindness, 396, 434, 496 
pyoktanin, 571 
sclerotics, 298 
vision, 508 
Bluestone, 243 
Blunt hook, 623 
Boil, 324 
Bonnet's method of enucleation, 636 
Boric acid, 87, 161, 162, 165, 222, 243, 
251, 261, 290, 407, 570, 634 
Borobismuth ointment, 212, 244 
Boroglycerid, 213, 215, 223 
Borsch's bifocal lenses, 154 
Borthen's iridotasis, 635 
Bottle-makers' cataract, 400 
Botulismus, 536 
Bowman's operation for ptosis, 600 
stop needle, 648 
syringe, 649 
Brain abscess, 62, 476 
hemorrhage in, 504 
tumor, 434, 476, 504 
Bridge coloboma, 300 
Bright's disease, 459. See also Nephritis. 
retinitis of, 433. See also Retinitis, 
albuminuric. 
Bromid, ethyl, 594 
of potassium, 345, 408, 427 
of sodium, 408 
Bronchitis, 189, 264, 358, 378, 407 
Bronchocele, 401 
Brossage, 213, 224 
Bruit, 582 
Bruns' method of advancement, 677 
Buccal fistula, 568 
Budge's ciliospinal center, 61 
Bulbar injection, 265 
paralysis, 485 
Bulging cicatrix after cataract extraction, 
666 
Buller's shield, 206, 207, 263 
Buphthalmos, 88, 280 
Burchardt's international tests, 66 
Burnett's rule, 690 
Burns, cutaneous, retinal hemorrhage 
from, 452 
of conjunctiva, 238 
of cornea, 282 
of eyelids, 186 
Burow's method of blepharoplasty, 612 
operation for entropion, 607 
Cachectic retinitis, 452 
Cacodylate of sodium, 283 
Cadmium iodid, 564 
Caffein, 596 
Calcarine fissure, 513 k 
Calcification of ciliary body, 331 
Calcium salts, 418 
Calomel, 163, 164, 223, 243, 252, 253, 258 
conjunctivitis, 212 
Camphor, 244 INDEX 
705 
Campimeter, 79 
Canal of Cloquet, 420 
Canaliculi, anomalies of, 566 
obstruction of, 566 
polyp of, 566 
slitting of, 681 
in dacryocystitis in infants, 571 
streptothrix, 566 
Canaliculus knife, 681 
Cannabis indica, 490 
amblyopia from, 490, 501 
Canquoin's paste, 175 
Canthoplasty, 225, 244, 604 
Canthotomy, 605 
Capillary angioma, 169 
fistula, 568 
pulse of retinal arteries, 101 
Capsular cataract, 394 
Capsule forceps, 653 
of Tenon, advancement of, 680 
Capsulolenticular cataract, 394 
Capsulotomy, extraction of cataract 
without, 651 
preliminary, 408 
to cataract extraction, 669 
Carbolic acid, 164, 203, 223, 253, 265, 283, 
593, 639, 668 
Carbon bisulphid, amblyopia from, 490, 
501 
Carbonate of iron, 258 
Carbon-dioxid snow, 170, 224 
Carbonic acid, 536 
Carbuncle, 438 
Carcinoma of brain, 476 
of caruncle, 316 
of choroid, 364, 580 
of ciliary body, 331 
of eyelids, 174 
of iris, 318 
of lacrimal glands, 565 
of orbit, 579 
of sclera, 292 
of stomach, 452 
Caries of orbit, 575 
Carotid, atheroma of, 400 
ligation of, for hemorrhage into vitre- 
ous, 418 
Caruncle, abscess of, 239 
adenoma of, 239 
affections of, 239 
angiosarcoma of, 239 
carcinoma of, 239 
cylindroma of, 239 
dermoid of, 239 
diseases of, 239 
epithelioma of, 239 
fibroma of, 239 
lymphangioma of, 239 
lymphosarcoma of, 239 
papilloma of, 239 
retraction of, after tenotomy, 673 
sarcoma of, 239 
tumors of, 239 
Castor oil, 238 
Cataract, 53, 129, 305, 456, 500, 527 
accidents during extraction, 658 
Cataract, accommodative strain with, 
401 
acute glaucoma in, 395 
after-, 394, 405. See also After-cata- 
ract. 
age factor in, 399 
in prognosis, 407 
albuminuria and, 399 
amber, 395 
among glass-blowers, 400 
anterior capsular, 403 
chamber in, 395 
polar, 403, 404 
area of future operation and, 407 
artificial ripening of, 408 
astigmatism in, 395 
axial, 404 
black, 395, 401 
bottle-makers', 400 
capsular, 198, 394, 406 
capsulolenticular, 394, 406 
catoptric test for, 396 
causes, 399 
central, 403 
lental, 403 
treatment, 410 
cholesterin crystals in, 401 
choroidal congestion in, 407 
chromatic asymmetry in, 53 
classification, 395 
complete, 394, 402 
congenital, treatment, 410 
in young, 402, 409 
treatment, 409 
complicated, 394, 404 
anterior polar, 404 
family, 404 
concussion, 400, 405 
condition of, in prognosis, 407 
of patient in prognosis, 407 
congenital, 394, 402 
anterior capsular, 403 
polar, 403 
complete, treatment, 409 
partial, 402 
treatment, 410 
posterior polar, 403 
pyramidal, 403 
treatment, 410 
coralliform, 404 
cortical, 394 
senile, 397 
couching, 647 
course, 397 
depression, 647 
dermogenetic, 400 
development of, 397 
diabetes and, 399 
diagnosis, 396 
direct, 400 
discission for, 647 
disk-shaped, 410 
disease and, 399 
Doynec's, 404 
drugs for, 407 
electricity in, 407 706 
INDEX 
Cataract, equatorial, 397 
ergotism and, 400 
extraction of. See Extraction of cata- 
ract. 
eye diseases and, 401 
interior of, in prognosis, 406 
fevers and, 399 
fluid, 395 
from electric shock, 401 
from iridodialysis, 319 
from lightning-stroke, 401 
furnace-workers', 400 
fusiform, 404 
gray, 401. See Cataract, senile. 
hard, 395, 399, 401 
extraction of, 650 
treatment, 409 
heredity and, 400 
hyaloid, 401 
hyperemia of conjunctiva in, 395 
immature, 400 
treatment, 407, 408 
Smith's method, 408 
incipient, 406 
incomplete, 404 
Indian operation for, 409, 660 
indications for iridectomy in, 408 
indirect, 400 
inherited, 400 
iridectomy in, 408 
iris in, 399 
mobility of, in prognosis, 407 
iritis in, 665 
juvenile, 394, 401 
treatment, 409 
knife, 653 
lamellar, 402. See also Cataract, zonu- 
lar. 
lens after extraction of, 410 
lenticular, 394 
treatment, 410 
light-field in, 406 
lightning-stroke, 401 
linear extraction for, 649 
location of opacities in, 397 
massage in, 407 
mature, treatment, 407, 409 
membranous, 405 
method of determining when ripe, 397 
mobility of iris in prognosis, 407 
monocular diplopia in, 395 
Morgagnian, 399 
mydriatic action in prognosis, 407 
naphthalin, 400 
nephritic, 399 
nuclear, 394 
oblique illumination for detection of, 
397 
occupation and, 400 
opacities in, 398 
operations for, 647 
ophthalmoscopic diagnosis, 396 
overripeness, 399 
pain in, 395 
partial, 394, 395 
congenital, 402 
Cataract, partial congenital, treatment, 
410 
pathology, 397 
photophobia in, 395 
polyopia in, 395 
posterior polar, 346, 403, 404 
preliminary capsulotomy in, 408 
presenile, 394, 402 
primary, 394 
prognosis, 406 
progressive, 394 
senile, 397 
punctate, 404 
treatment, 410 
pupil in, 396 
pyramidal, 198, 403 
congenital, 403 
treatment, 410 
radical operation for, 660 
raphanic, 400 
reclination of, 647 
refraction in, 407 
prognosis, 406 
ripe, 397, 406 
secondary, 394, 404, 405. See also 
After-cataract. 
senile, 394, 397, 401 
spontaneous disappearance of, 406 
sex in, 399 
simple, 401 
Smith's operation for, 409, 660 
soft, 395, 399, 401 
extraction of, 649 
treatment, 409 
solution operation for, 647 
spontaneous disappearance, 406 
stationary, 394, 395 
striae of refraction in, 396 
subcapsular, 394 
suction method for, 649 
supranuclear, 394 
symptomatic, 394 
symptoms, 395 
tetany, 403 
toxic agents and, 400 
traumatic, 395, 400, 405 
ring-shaped opacity in, 405 
treatment, 407 
traumatic, 394, 405 
contusion-lesion of lens in, 405 
ring-shaped opacity in, 405 
traumatism and, 400 
type of, in prognosis, 407 
unilateral, 401 
treatment, 410 
unripe, extraction, 408, 662 
urine in, 399 
varieties, 394 
vision after extraction of, 411 
visual acuity in, 395 
white, 395 
with glaucoma, 393 
zonular, 402 
riders in, 402 
treatment, 410 
Cataracta accreta, 305 INDEX 
707 
Catarrh, dry, 187 
epidemic, 194 
conjunctival, 190 
fruejahr's, 212 
nasal, 193 
postnasal, 585 
silver, 200 
spring, 212 
with swelling, 194, 215 
Caterpillar hairs, conjunctivitis from, 229 
Catoptric power of mirror, 90 
test for cataract, 396 
Cat's eye, amaurotic, 464 
Cautery. See Actual cautery. 
Cavernous sinus, disease of, 536 
thrombosis of, 578 
Cell-nests, 175 
Cellulitis of orbit, 576 
after tenotomy, 673 
from diseases of nasal accessory si- 
nuses, 590 
treatment, 577 
Center of rotation, 41 
optical, 25 
Centrads, 19 
meter angle and, relations of, 20 
prism-diopters and, relative values, 20 
Wallace's table of relative values of, 20 
Centrifugal pathway, 57, 58 
Cephalocele of orbit, 580 
Cerebellum tumors, 476, 562 
Cerebral cortex reflex of pupil, 56, 60 
decompression in albuminuric retinitis, 
438 
in optic neuritis, 479 
Cerebritis, 477 
Cervical sympathetic, 58 
irritation of, dilatation of pupil from, 
61 
Chalazia, 123, 171 
Chalazion, causes of, 172 
curet, 599 
external, removal, 599 
pathologic anatomy of, 172 
removal, 599 
symptoms, 172 
treatment, 172, 599 
Chambers-Inskeep ophthalmometer, 111 
Chancre of eyelid, 168 
Chandler's method of cataract extraction, 
669 
Chemosis, filtration, after cataract ex- 
traction, 668 
of conjunctiva, 232, 573 
Cherry-red spot of macula, 457 
Chiasm, 59, 512 
Chiasmal central amblyopia, 510 
Chlamydozoa, 217 
Chlor acetic acid, 175 
Chloral, 164, 387, 490, 501, 536, 671 
amblyopia from, 501 
Chlorate of potassium, 501 
amblyopia from, 501 
Chlorid of calcium, 408 
of iron, 258, 272 
of mercury, 309, 593, 594 
Chlorid of sodium, 209, 256, 597, 654, 656 
of zinc, 194 
Chlorin-water, intra-ocular injections of, 
415 
Chloroform, 490 
as anesthetic, 594 
Chlorosis, 214, 351, 477 
Choked disk, 471. See also Optic neuritis. 
Cholera, 422 
Cholesteatoma of iris, 317 
Cholesterin crystals in cataract, 401 
in vitreous, 419 
Chondroma of lacrimal sac, 565 
Chorea, 53, 558 
habit, 178 
Chorioretinitis, familial, 351 
Choroid, 105 
absence of pigment in, 343 
adenoma of, 364 
angiosarcoma of, 361 
atrophy of, 369 
gyrate, 442 
atrophy of, senile areolar, 352 
blood-vessels of, 105 
calcification of, 367 
carcinoma of, 364 
cavernous angioma of, 364 
colloid changes in, 353 
coloboma of, 343 
congenital anomalies, 343 
congestion of, 123, 344 
detachment of, 366 
diseases of, 343 
enchondroma of, 364 
endothelioma of, 361 
foreign bodies, 365 
hemorrhage into, 366 
hyperemia of, 344 
inflammation of, 345. See also Cho- 
roiditis. 
injuries of, 365 
interfascicular endothelioma of, 360 
involvement of, in uveitis, 325 
leukosarcoma of, 359 
macular coloboma of, 343 
melanoma of, 361 
melanosarcoma of, 359 
miliary tubercles of, 364 
ossification of, 367 
perithelioma of, 361 
pigment heaping in, 345 
ring, 100 
rupture of, 366 
sarcoma of, 359 
alveolar, 361 
anomalous, 361 
diagnosis, 362 
diffuse, 361 
enucleation for, 364 
episcleral tumor stage, 362 
first stage, 362 
flat, 361 
fungus state, 362 
generalization stage, 362 
glaucomatous stage, 362 
glioma of retina and, 362 708 
INDEX 
Choroid, sarcoma of, inflammatory stage, 
362 
liver sarcoma from, 362 
metastatic stage, 362 
pathology, 360 
prognosis, 363 
ring, 361 
symptoms, 362 
telangiectatic, 364 
transillumination in, 363 
treatment, 364 
sclerosis of vessels of, 352 
senile areolar, atrophy of, 352 
tuberculosis of, 364 
treatment, 365 
tumors of, 359 
diagnosis, 362 
pathology, 360 
prognosis, 363 
symptoms, 362 
treatment, 364 
tuberculous, 364 
verrucosities of, 354 
woolly, 345 
wounds of, 365 
Choroidal disturbance, 344 
dust, 364 
fissure, 343 
incomplete closure of, 301 
ring, 100 
vein, aberrant, 103 
Choroideremia, 343 
Choroiditic atrophy, 346, 349 
Choroiditis, 53, 129, 334, 345, 346, 352, 
401, 406, 411, 416 
acute, 325, 347 
in uveitis, 325 
plastic, in uveitis, 325 
albuminuric, 351 
ametropia, 354 
anterior, 269, 290, 351 
causes, 351, 354. 
prognosis, 352 
treatment, 352, 354 
areolata, 353 
atrophic, 345 
atrophy of, 346 
causes, 345 
central, 353 
causes, 354 
treatment, 354 
character of pigment in, 346 
chronic, 347, 348 
atrophic, 354 
circumscribed plastic, 350 
complications, 346 
course, 346 
deep, 347 
diagnosis, 346 
diffuse exudative, 347 
disseminated, 269, 349, 351, 404, 509 
epithelial, 347 
familial, 351 
from disease of nasal accessory sinuses, 
589 
from injury, 351 
Choroiditis, guttate senile, 353 
hemorrhagic, 354 
hereditary, 351 
intra-uterine, 343 
localized exudative, 350 
macular, 355 
metastatic, 432 
myopic, 356 
non-suppurative exudative, 347 
old, 346 
optic nerve atrophy in, 346, 349 
pain in, 345 
pathologic anatomy, 346 
pigment heaping in, 345 
pigmented, 351 
pigmentation of retina in, 349 
plastic, 347 
prognosis, 346 
purulent, 347, 357. See also Choroid- 
itis, suppurative. 
recent, 345 
retinitis and, 346 
scotomas in, 346 
serous, 347 
structures involved, 346 
superficial, 347 ' 
suppurative, 347, 357 
causes, 357 
enucleation in, 359 
panophthalmitis from, 357 
pathology, 358 
phthisis bulbi from, 357 
prognosis, 358 
symptoms, 357 
treatment, 359 
sympathetic, 334 
symptoms, 345 
syphilitic, 345 
traumatic, 351 
treatment, 352 
tuberculous, 345, 351, 456 
unclassified forms, 354 
with descemetitis, 350 
Choroidoretinitis, 346, 348, 428 
atrophic, 426 
central, from ametropia, 496 
hereditary syphilitic, 431 
miliary, 345 
symptom^, 429 
syphilitic, 351, 428, 446 
Chromatic asymmetry, 53 
sense, feeble, 68 
Chromatometer, 70 
Chromidrosis, 184 
palpebral, 184 
Chrysarobin conjunctivitis, 228 
Cicatricial orbit, operations for prosthesis 
in, 641 
trachoma, 219 
Cicatrix, bulging, after cataract extrac- 
tion, 666 
Cilia. See Eyelashes. 
Ciliary attachment, rupture of, 319 
body, adenoma of, 331 
atrophy of, 331 
blood-vessels of, 49 INDEX 
709 
Ciliary body, calcification of, 331 
carcinoma of, 331 
cysts of, 331 
degeneration of, senile, 331 
diktyoma of, 331 
diseases of, 322 
epithelial hyperplasia of, 331 
foreign bodies in, 293 
glands of, 327 
glioma of, 331 
gumma of, 330 
inflammation of, 268, 322. See also 
Cyclitis. 
injuries of, 329 
leprosy nodules of, 331 
myoma of, 331 
leukosarcoma, 331 
myoma of, 331 
myosarcoma of, 331 
ossification of, 331 
sarcoma of, 331, 363 
senile degeneration of, 331 
syphilis of, 329 
treatment, 330 
tetraneuroma embryonale of, 331 
tuberculosis of, 331 
tumors of, 331 
wounds of, 329 
congestion, 49 
epithelial tumors of, 331 
ganglion, 57 
muscle, 36 
paralysis of, 542 
nerves, 57 
neuroma of, 331 
pain, 303 
processes, 36 
veins, anterior, 379 
vessels, anterior, 49 
Cilioretinal vessels, 103 
in obstruction of central artery, 459 
Ciliospinal center, Budge's, 61 
Cilium forceps, 598 
Cinnamate of sodium, 288 
Cinnamic acid, 619 
Circumcising cornea, 636 
Circumcorneal zone, 49 
Circumlental space, 382 
Circumpapillary atrophy, 356 
Cirrhosis, 286 
Citrate of copper, 223 
of lithium, 258, 290 
Cleft eyelid, 158 
Climacteric, 266, 432 
Clinoscope, 692 
Clock-dial chart in astigmatism, 144 
Cloquet, canal of, 420 
Coagulose, 418 
Cobalt test for ocular muscles, 76 
Cocain, 51, 61, 87, 106, 118, 176, 228, 
243, 251, 253, 255, 261, 280, 290, 396. 
450, 595, 652 
hydrochlorid, 119 
in corneal ulceration, 251 
solution, sterilization of, 595 
Codein, 206, 258 
Cod-liver oil, 226, 243, 258, 272, 290, 
506, 571, 575 
Coffee amblyopia, 501 
Colchicum, 258, 290 
Collapsing pulse of retinal arteries, 102 
Collins' magnifier, 52 
Colloid degeneration of conjunctiva, 230 
Collodion, 162, 182 
Collyria, 193, 571 
flask for sterilizing, 595 
Coloboma, bridge, 300 
extrapapillary, 343 
macular, 343 
of choroid, 343 
of crystalline lens, 394 
of iris, 300 
of sheath of optic nerve, 469 
palpebrse, 158 
width and depth of, 626 
Color-blindness, 67, 496 
chromatometric test for, 70 
congenital, 496 
partial, 496 
congenital total, 496, 498 
Holmgren's.test for, 67 
incomplete, 68 
lantern test for, 69 
special tests for, 70 
spectroscopic test for, 70 
Stilling's pseudo-isochromatic plates 
for testing, 70 
Thomson's test for, 68 
Colored glass test for malingering, 505 
Color-field, 83 
in glaucoma, 373 
inversion of, 504 
Color scotomas, 85 
sense, 67 
direct, 70 
feeble, 68 
reduced, 496, 497 
vision, theory of, 497 
Colors, direct vision for, 70 
Coma, 578 
Combined excision for trachoma, 618 
Commotio retinae, 461 
Compound astigmatism, determination 
of, 108 
Concave lens, 23. See also Lens, concave. 
mirror, 89, 116 
skiascopy with, 112 
Concavoconvex lens, 30 
Concomitant strabismus, 542 
Concussion cataract, 400, 405 
Cones of retina, 512 
Congenital cataract, 402 
ptosis, 160 
Conical cornea, 128, 278, 320 
operations for, 279 
optical treatment, 279 
Conium, 178, 536 
Conjugate deviation of head and eyes, 540 
foci of concave lens, 25 
of convex lens, 23 
lateral paralysis, 540 
Conjunctiva, abscess of, 231 710 
INDEX 
Conjunctiva, acne rosacea of, 189, 195 
acute blennorrhea of, 195, 204 
adenocarcinoma of 234 
adenoma of, 234 
amyloid disease of, 230 
angioma of, 233 
angioneurotic edema of, 232 
angiosarcoma of, 236 
argyria of, 240 
arteries of, 48 
atrophy of, 230 
blood-vessels of, 48 
burns of, 238 
cavernous angioma of, 233 
chancre of, 232 
chemosis of, 232, 573 
colloid disease of, 230 
congenital anomalies of, 187 
congestion of, 49 
cysts of, 233 
dermo-epithelioma of, 233 
dermoids of, 234 
diphtheria of, streptococcus, 209 
diseases of, 187 
from diseases of nasal accessory sinuses, 
589 
ecchymosis of, 232 
eczema of, 211 
edema of, 232 
emphysema of, 232 
endothelioma of, 236 
epithelioma of, 235 
essential shrinking of, 238 
fibroma of, 234 
folliculosis of, 214 
foreign bodies in, 238 
granuloma of, 234 
hemangioma of, 234 
hemorrhage of, 232 
hyaline degeneration of, 230 
hyperemia of, 186, 507 
in cataract, 395 
symptoms, 187 
treatment, 188 
implantation cysts of, 233 
inflammation of, 188. See also Con- 
junctivitis. 
injuries of, 238 
lepra of, 236 
lime-burns of, 239 
lipoma of, 234 
lithiasis of, 228 
lupus of, 236 
lymphangiectasis of, 232, 233 
lymphangioma of, 233 
lymphatic follicles of, 217 
lymphoma of, 226 
melanocarcinoma of, 235 
melanoma of, 236 
melanosis of, 233 
moles of, 233 
naevus pigmentosus of, 233 
operations on, 614 
osteoma of, 234 
papilloma, 234 
pemphigus of, 238 
Conjunctiva, pigment spots of, 236 
pseudotuberculosis of, 229 
rabbit's, transplantation of, 616 
sarcoma of, 235 
siderosis of, 240 
sporotrichosis of, 227 
streptococcus diphtheria of, 209 
syphilis of, 232 
tuberculosis of, 237 
tumors of, 233 
ulcers of, 232 
vessels of, 49, 50 
in glaucoma, 369 
wounds of, 238 
xerosis of, 230 
infantile ulceration of cornea with, 
262 
flaps in ulcer of cornea, 257 
Conjunctival sac after cataract extrac 
tion, 656 
temperature of, 50 
Conjunctivitis, 49, 123, 188, 232, 273 
acne rosacea, 189 
acute contagious, 190 
diagnosis, 190 
etiology, 190 
prognosis, 190 
symptoms, 190 
treatment, 194 
mucopurulent, 190 
angular, 192 
antepartum, 196 
associated, 189 
atropin, 228 
calomel, 212 
catarrhal, 188 
epidemic, 194 
hemorrhagic, 190 
chronic, 227 
treatment, 206 
chrysarobin, 228 
complicating corneal ulcer, 257 
croupous, 208 
causes, 208 
diagnosis, 209 
treatment, 209 
cysts of, 233 
diphtheritic, 209 
causes, 209 
diagnosis, 210 
prognosis, 210 
symptoms, 210 
treatment, 210 
diplobacillus, 192 
symptoms, 192 
treatment, 194 
duboisin, 228 
Egyptian, 228 
eserin, 228 
exanthematous, 189, 195 
treatment, 195 
follicular, 214 
causes, 214 
symptoms, 214 
prognosis, 215 
treatment, 215 INDEX 
711 
Conjunctivitis follicularis simplex, 214 
folliculosis of, 214 
from anilin dyes, 228 
from Bacillus subtilis, 188 
from Bacterium coli, 189 
from caterpillar hairs, 229 
from chrysophanic acid, 228 
from electric light, 507 
from ozena bacillus, 189 
from plant hairs, 229 
from sting of insects, 229 
from x-rays, 229, 507 
gonorrheal, 195, 204 
corneal ulceration in, 206 
diagnosis, 204 
epibulbar, 207 
prognosis, 204 
prophylaxis, 206 
symptoms, 204 
treatment, 204 
granular, 566 
acute, 221 
bacteriology, 216 
causes, 215 
cicatricial, 219 
diagnosis, 221 
expression for, 617, 618 
follicular, 218 
gelatinous, 220 
granulations of, 215, 217 
grattage in, 617 
medication in, 225 
mixed, 219 
non-inflammatory follicular, 219 
operations for, 224, 617, 618 
papillary, 218 
pathology, 217 
prognosis, 222 
sclerosing, 219 
sequelae, 221 
symptoms, 219 
treatment, 222 
varieties, 217 
x-ray treatment of, 224 
hemorrhagic catarrhal, 190 
homatropin, 228 
hyoscyamin, 228 
in hyperopia, 123 
indications of, 49 
infectious, 226 
influenza bacillus, 191 
pseudomembranous form, 192 
treatment, 194 
Koch-Weeks', 190 
lacrimal, 228, 566 
larval, 229 
mechanical, 189 
meibomiana, 227 
membranous, 197, 208 
meningococcus, 189 
metastatic gonorrheal, 207 
micrococcus catarrhalis, 189 
military, 228 
Morax-Axenfeld bacillus, 192 
mucopurulent, 189 
neonatorum, 195 
Conjunctivitis neonatorum, acute blen- 
norrhagic, 199 
causes, 196 
diagnosis, 199 
prognosis, 199 
prophylaxis, 199 
symptoms, 196 
treatment, 200 
nodosa, 229 
non-specific purulent, 207 
parasitic, 229 
Parinaud's, 226 
periodic hyperplastic, 212 
petrificans, 230 
phlyctenular, 207, 211, 304 
iritis and, differential diagnosis, 304 
symptoms, 211 
treatment, 211 
photophobia in, 189 
plastic, 208 
pneumococcus, 191 
symptoms, 191 
treatment, 194 
podophyllin, 229 
pseudomembranous, 208 
recurring, 208 
purulent, 195 
in young girls, 203 
septic, 226 
sicca, 227 
simple, 188 
causes, 189 
duration, 190 
iritis and, differential diagnosis, 304 
prognosis, 190 
symptoms, 189 
treatment, 193 
spring, 212 
squirrel-plague, 195 
staphylococcus, 189 
subacute, 192 
swimming-bath, 192 
symptomatic, 189 
symptoms, 208 
syphilitic, 233 
tea-leaf, 194 
toxic, 228 
treatment, 193 
tuberculous, 237 
vernal, 212 
pathologic histology, 213 
prognosis, 213 
symptoms, 212 
treatment, 213 
varieties, 213 
Widmark's, 232 
xerosis, 227, 230, 262, 506 
x-ray, 507 
Connective-tissue ring, 100 
Consensual light-reflex of pupil, 59 
Constipation, 141, 558 
Constrictor muscle, 61 
Continuity of visual field, 83 
Contraction, fatigue, 423 
of pupil, 62 
Contusion-lesion of lens, 405 712 
INDEX 
Conus, 102, 356, 470 
congenital inferior, 470 
in myopia, 131 
underlying, 102 
Convergence, 43, 44, 521 
accommodation and, disturbances of, 
strabismus and, 542 
relations of, 44, 46 
amplitude of, 45 
angle of, 44 
anomalies of pupils, 63 
cramp, 554 
excess in esophoria, 555 
far point of, 45 
in concomitant strabismus, 542 
insufficiency of, 524, 555 
from convex glasses, 556 
meter angle of, 45 
near point of, 45 
test for, 74 
paralysis, 541, 555 
power of, 78 
reaction of pupil, 56, 59 
neurotonic, 64 
paradoxic, 64 
relation with accommodation, 46 
spasm of, 541, 554 
Convergent rays, 22 
strabismus, 42. See also Strabismus, 
convergent. 
Converging meridians, 526 
Convex lens, 23. See also Lens, convex. 
mirror, 89, 90 
Convexoconcave lens, 30 
Convulsions, 578 
Cooper-Swanzy sign in goiter, 584 
Copper in eye, 294 
sulphate, 206, 207, 215, 223, 224, 227 
Coralliform cataract, 404 
Corectopia, 299 
Corelysis, 316 
Cornea, abrasions of, 50 
abscess of, 248 
ring, 283 
treatment, 254 
variolar, 249 
absorption ulcer of, 246 
anesthesia of, in glaucoma, 372 
annular ulcer of, 250 
anterior synechia of, 258 
application of actual cautery to, 619 
as mirror, 90 • 
atheromatous ulcer of, 260 
atrophy of, 250 
margin of, 278 
blood-staining of, 278 
blood-vessels of, 49 
burns of, 282 
changes in, in goiter, 584 
circular ulcer of, 250 
circumcising, 636 
congenital anomalies of, 285 
flatness of, 286 
melanosis of, 286 
opacities of, 285 
staphyloma of, 286 
Cornea, conical, 278 
operations for, 279 
creeping ulcer of, 246, 249 
cysts of, 285 
deep scrofulous infiltrates of, 243 
ulcer of, 246 
degeneration of, family punctate, 275 
marginal, 276 
dendriform ulcer of, 250 
dermoid tumor of, 284 
diameter of, in glaucoma, 378 
diseases of, 241 
from diseases of nasal accessory 
sinuses, 589 
dots on, in uveitis, 325, 326, 327 
eczema of, 241 
edema of, 369 
endothelioma of, 284 
epaulet-like swelling of, 268 
epithelial dystrophy of, 276 
epithelioma of, 284 
erosions of, 281 
relapsing, 281 
examination of, by transmitted light, 
98 
excavated ulcer of, 246 
exhaustion ulcer of, 250 
faceted ulcer of, 246 
family punctate degeneration of, 275 
fibroma of, 284 
fistula of, 261 
foreign bodies in, 51, 280, 311 
gouged ulcer of, 246 
guttate opacity of, 275 
haziness of, 303 
herpes of, 264 
after cataract extraction, 667 
image of, 90 
in exophthalmos, 585 
incision of, in astigmatism, 147 
indolent ulcer of, 246 
infantile ulceration of, with xerosis of 
conjunctiva, 262 
infected ulcer of, 246 
marginal, 249 
infiltration of, peripheral annular, 283 
inflammation of, 239. See also Kerati- 
tis. 
in glaucoma, 369 
injuries of, 280 
obstetric, 284 
inspection of, 50 
irregularities of, 50 
leprosy of, 236 
leukoma of, 258 
loss of transparency, in glaucoma, 369 
lupus of, 276 
macula of, 258 
marginal degeneration of, 276 
ring ulcer of, 250 
massage of, 261 
melanosis of, congenital, 286 
meridians of, 138, 139, 140, 520 
migratory pustule of, 242 
Mooren's ulcer of, 249 
mutton-fat deposits on, 325, 327 INDEX 
713 
Cornea, myxoma of, 284 
nebula of, 258 
necrosis of, 262 
normal diameter of, 378 
obstetric injuries of, 284 
opacity of, 275, 277 
after cataract extraction, 666 
congenital, 285 
grill-like, 275 
myopia from, 128 
nodular, 275 
primary, 277 
operations on, 619 
oval, 267 
papilloma of, 284 
paracentesis of, 206, 253, 315, 619 
parenchymatous infiltration of, central, 
273 
perforation of, 250, 252 
treatment, 254 
phlyctenular ulcer of, 242 
pigmentation of, 286 
pits of, 278 
plana, 286 
powder grains in, 281 
principal meridians of, 139 
purulent ulcer, 246 
refractive power of, 120 
relapsing erosion of, 281 
herpes of, 273 
reparative ulcer of, 246 
rodent ulcer of, 249 
rupture of, 292 
sarcoma of, 284 
scalds of, 282 
scar-fibroma of, 284 
sclerosis of, 278, 285 
sensibility of, 51 
serpiginous ulcer of, 246, 249 
acute, 246 
chronic, 249 
shallow central, 246 
simple ulcer of, 245 
sloughing ulcer of, 246 
small central, 245 
smallness of, glaucoma and, 378 
staphyloma of, 245, 259, 260 
congenital anterior, 286 
tattooing of, in leukoma, 621 
temperature of, 50 
teratoid tumors of, 285 
transplantation of, 261 
transverse calcareous film of, 277 
tuberculosis of, 251 
tumors of, 284 
ulcers of, 50, 198, 206, 207, 239, 241, 
244, 401, 404, 406, 576, 596 
absorption, 246 
acute serpiginous, 246 
annular, 250 
atheromatous, 260 
circular, 250 
chronic serpiginous, 249 
conditions associated with, 257 
creeping, 246, 249 
deep, 246 
Cornea, ulcers of, dendriform, 250 
diplobacillary, 247 
excavated, 246 
exhaustion, 250 
faceted, 246 
from diseases of nasal accessory 
sinuses, 589 
gouged-out, 246 
indolent, 246 
infected, 246 
causes, 249 
marginal, 249 
internal, 260, 286 
leukoma after, 258 
local measures for, 256 
marginal ring, 250 
Mooren's, 249 
phlyctenular, 242 
pimple, 245 
prognosis, 251 
purulent, 246 
reparative, 246 
results, 258 
rodent, 249 
serum treatment, 255 
shallow central, 246 
simple, 245 
sloughing, 246 
causes, 249 
small central, 245 
subconjunctival injections for, 256 
treatment, 251, 254 
constitutional, 257 
of associated conditions, 257 
of results of, 261 
tuberculous, 251 
ulcus rodens of, 249 
variolar abscess of, 249 
vertical meridian of, 520 
width of, 51 
wounds of, 282 
Corneal complications in pulsating ex- 
ophthalmos, 582 
image, size of, 91 
incisions in extraction of cataract, 651 
loupe, 52, 396 
microscope, 52 
opacities, myopia from, 128 
pits, 278 
Corneitis. See Keratitis. 
Corneoscleral trephining in glaucoma, 389 
in chronic^glaucoma, 391 
Cornu cutaneum of eyelids, 170 
Corpora geniculata, 59, 513 
quadrigemina, 60, 513 
tumor of, 476 
Corpus callosum, puncture of, in optic 
neuritis, 479 
tumors of, 476 
Corrosive sublimate, 201, 593 
Cortical center, 514 
Coryza, 585 
Couching cataract, 647 
Cover test of ocular muscles, 72 
Crab-lice, 168 
Cramp, convergence, 554 714 
INDEX 
Crampton's ophthalmoscope, 92 
Crede's method, 200 
Creolin, 193, 229, 571 
Crescents, atrophic, 356 
congenital inferior, 470 
scleral, 356 
semi-atrophic, 356 
Cribriform ligament, 383, 384 
Critchett's operation for sympathetic 
ophthalmitis, 341 
subconjunctival tenotomy, 671 
Crossed cylinder, 146 
fasciculus, 512 
Croton chloral hydrate, 164 
Cryptophthalmos, 158 
Crystalline lens. See also Lens, crystal- 
line. 
Cuneus, 513 
Cupping of nerve-head in glaucoma, 493 
Cuprocitrol, 223 
Curet, chalazion, 599 
Cutaneous horns of eyelids, 170 
stimulation, dilatation of pupil from, 
61 
Cyanid of mercury, 193, 195, 203, 222, 
223, 224, 252, 256, 271, 281, 310, 313, 
328, 352, 408, 450, 456, 665 
Cyanopsia, 503 
Cyanosis of retina, 424 
Cyanotic polycythemia, 425 
Cyclitic membrane, 420 
Cychtis, 50, 53, 322, 405. See also Irido- 
cyclitis. • 
acute, 323 
after cataract extraction, 665 
atrophy of eyeball from, 323 
causes, 323 
chronic, 323 
plastic, 323 
fibrinoplastic, 305 
from diseases of nasal accessorv sinuses, 
589 
from injuries, 323 
from operations, 323 
heterochromic, 53 
infective, 333. See also Ophthalmitis, 
sympathetic. 
pain in, 322 
pathology, 322 
phthisis bulbi from, 323 
plastic, 322 
chronic, 323 
prognosis, 323 
purulent, 323 
serous, 322, 323 
suppurative, 323 
sympathetic ophthalmitis from, 323 
symptoms, 50, 53, 322 
traumatic, 323 
treatment, 323 
varieties, 323 
with keratitis punctata, 326 
with vitreous disease, 326 
Cyclodialysis, 391, 635 
in chronic glaucoma, 391 
Cyclophoria, 72, 76, 555 
Cyclophoria, Savage treatment, 559 
test of, 76 
Cyclopia, 573 
Cycloplegia, 541 
complete, 541 
partial, 541 
unilateral, 541 
Cycloplegics, 117. See also Mydriatics. 
Cylinder, crossed, 146 
Cylindric lens, 30 
combination with spheric, 32 
concave, 31 
convex, 31 
Cylindroma of caruncle, 239 
of eyelids, 172 
of lacrimal glands, 565 
of orbit, 579 
Cysticercus, 321, 448 
in anterior chamber, 321 
in iris, 316 
in vitreous, 420 
intra-ocular, 332 
subretinal, 448, 466 
Cystoid cicatrix, 390, 414 
after cataract extraction, 666 
iridectomy for, 390 
Cystotome, 653 
Cysts, Meibomian, 171 
removal of, 599 
of angle of anterior chamber, 321 
of ciliary body, 331 
of conjunctiva, 233 
of cornea, 285 
of eyebrow, 185 
of eyelid, 169, 185 
of iris, 301, 316 
of lacrimal glands, 565 
of orbit, 573, 578 
of prelacrimal sac, 567 
of retina, 466 
of sclera, 292 
orbitopalpebral, 573 
retention, 184 
sebaceous, 185 
D'Artha's method of blepharoplasty, 
613 
Dacryo-adenitis, 564 
acute, 564 
chronic, 564 
metastatic, 564 
non-suppurative, 564 
suppurative, 564 
treatment, 564 
tuberculous, 564 
Dacryocystitis, 253, 566 
acute, 567 
blenorrhoica, 567 
catarrhalis, 567 
chronic, 567 
from diseases of nasal accessory sinuses, 
590 
of infants, 568 
treatment, 571 
phlegmonosa, 567 INDEX 
715 
Dacryocystorhinostomia, 685 
Dacryoliths, 565 
Dacryops, 565 
Dalrymple's sign in goiter, 584 
Danger zone, 329, 332 
Day-blindness, 506 
Deafness, 334 
Decapsulation of kidney in albuminuric 
retinitis, 438 
Decompression, cerebral, in albuminuric 
retinitis, 438 
in optic neuritis, 479 
Degeneration, marginal, of cornea, 276 
Delirium after cataract extraction, 668 
Dellen, 278 
Dementia, paretic, 61, 539 
Demodex fohiculorum, 167 
Demonstrating ophthalmoscope, 92 
Dennett's method of numbering prisms, 19 
Depression, 519 
for cataract, 647 
Dermo-epithelioma of conjunctiva, 233 
Dermoid cysts of caruncle, 239 
of conjunctiva, 233 
of cornea, 284 
of eyelids, 185 
of orbit, 581 
Descemetitis, 273, 323 
choroiditis with, 350 
Descemet's membrane, fissures in, 280 
in uveitis, 327 
Descending test for binocular vision, 553 
De Schweinitz's method of enucleation, 
637 
Desiccating powders, 164 
Deutschmann's operation-serum, 255 
Deviating eye, 523 
Deviation, angle of, 19 
congenital, 537 
crossed lateral, 73 
homonymous lateral, 73 
horizontal Maddox rod test for, 77 
latent, 554 
vertical, Maddox rod test for, 78 
testing for, 78 
Deviometers, 547 
De Wecker campimeter, 79 
internal sclerotomy, 629 
iridotomy, 626 
operation for staphyloma, 621 
photometric types, 67 
pince-ciseaux, 626 
Diabetes, 129, 312, 324, 417, 460, 535, 
539, 541 
cataract and, 399 
retinitis in, 438 
Diaphanoscopy, 363 
Diarrhea, 251, 262 
Didymium glass, 507 
Dieffenbach's method of blepharoplasty, 
612 
Digitalis, 258, 422, 492 
Diktyoma of ciliary body, 331 
Dilatation of pupil, 61 
Dilatation-reflex of pupil, 57, 59 
Dilatator paralysis, 62 
Dilatator pupillse, 57 
contraction of, 61 
tract, 58 
Dionin, 203, 206, 224, 243, 251, 254, 261, 
264, 271, 277, 288, 290, 309, 312, 328, 
340, 352, 387, 393, 408, 450, 596, 649, 
665 
Diopter, 28 
Dioptric apparatus, 120 
Diphtheria, 358, 477, 541, 578 
antitoxin, 210 
streptococcus, of conjunctiva, 209 
Diphtheritic conjunctivitis, 209 
Diplobacillary keratitis, 193 
ulcers 247 
Diplobacillus, 188, 208, 248 
conjunctivitis, 192 
of Morax-Axenfeld, 192, 247 
Diplobacteria, 217 
Diplococcus, 208 
intracellularis meningitidis, 415 
Diplopia, 88, 148, 525, 526, 528, 537., 545 
after operation, 545 
anomalous, 545 
binocular, 546 
complete crossed, 532 
crossed, 525, 528, 530 
complete, 532 
homonymous, 525, 528 
horizontal, 529 
vertical, 529, 531 
heteronymous, 524, 525, 528, 532 
homonymous crossed, 525, 528 
horizontal, 528 
crossed, 529 
homonymous, 528 
in concomitant strabismus, 545 
in convergent strabismus, 545 
in ocular paralysis, 532 
table of, 534 
in paralytic strabismus, 526 
monocular, 563 
in cataract, 395 
paradoxic, 545, 546 
Schweigger's test for, 545 
simple, 524, 528 
table of, in ocular paralysis, 534 
test for malignancy, 505 
varieties, 528 
vertical, 528 
crossed, 529, 531 
homonymous, 530, 532 
Direct method of ophthalmoscopy, 92, 
96. See also Ophthalmoscopy. 
vision, 79 
Disc. See Optic nerve, head of. 
hyperopic, 471 
Dischromatopsia, 504 
Discission, 332 
for after-cataract, 669 
for cataract, 647 
glaucoma after, 671 
Disseminated sclerosis, 64, 477, 536, 539, 
562 
Distention of retinal veins, 582 
of veins at inner angle of orbit, 582 716 
INDEX 
Distichiasis, 158, 181 
Divergence of light rays, 21 
paralysis, 541 
Divergence-excess, 555 
Divergence-insufficiency, 555 
Divergent rays, 22 
Diverging meridians, 526 
Dobell's solution, 244, 572 
Donovan's solution, 328 
Double perforation of eye, 293 
vision, 43 
Double-transplantation operations, 605 
Doynec's cataract, 404 
Dressings, 593 
Drugs, amblyopia from, 501 
Drusen in optic nerve, 493 
Duane's diagnostic table of ocular paral- 
ysis, 534 
method of testing range of accommo- 
dation, 39 
tenotomy of inferior oblique, 672 
Dubois and Leroy ophthalmometer, 111 
Duboisin, 118, 228 
Ductus ad nasum. See Nasal duct. 
Dynamic strabismus, 71 
Dyschromatopsia, 496, 497 
Dysentery, 251, 314, 358 
Dyspepsia, 141, 558 
Dystrophy, epithelial, of cornea, 276 
Edema of optic nerve, intra-ocular, 471 
of retina, 427, 454, 461 
fog-like, 457 
Educative treatment of concomitant stra- 
bismus, 548 
Efferent path, 58 
Egyptian ophthalmia, 215, 228. See also 
Conjunctivitis, follicular. 
Electric light, retinal changes from, 463 
ophthalmia, 507 
retinitis, 463 
shock, 401 
Electricity in blepharitis, 168 
in cataract, 427 
in paralytic strabismus, 538 
in uveitis, 328 
Electrolysis, 212, 213, 571, 605 
for nevi of eyelids, 170 
for xanthelasma, 171 
in angioma, 170 
in corneal opacities, 261 , 
in lacrimal disease, 571 
in trichiasis, 605 
Electromagnet, 295 
Elephantiasis Arabum of eyelids, 177 
telangiectodes of eyelid, 177 
Elevation, 519 
Elliot's operation, after-treatment, 633 
application of trephine in, 633 
atropin instillation after, 633 
causes of failure in, 634 
complications arising in, 634 
flap in, 632 
indications for, 633 
late infections after, 634 
modifications of, 633 
quadrant of eye selected for, 632 
toilet of wound after, 633 
Elschnig's operation for ptosis, 600 
method of local anesthesia, 598 
Embolism of central artery of retina, 457. 
See also Retina, embolism of central 
artery of. 
Embryotoxon, 298 
Emmetropia, 22, 112, 120 
angle gamma in, 41 
definition, 120 
nodal point in, 34 
retinal image in, 34 
skiascopy in, 115 
Emotion, dilatation of pupil from, 61 
Emphysema of conjunctiva, 232 
of eyelids, 185 
Empyema of antrum, 588 
of frontal sinus, 585 
of sphenoid sinus, 587 
Encanthis, 239 
Encephalocele, 581 
Enchondroma of choroid, 364 
of orbit, 579 
of sclera, 292 
of tarsus, 171 
Endamoeba buccalis, 328 
Endarteritis, syphilitic, 428, 430 
Endocarditis, 199, 204, 459 
ulcerative, 358 
Ear disease, 536 
pyogenic infection of, 578 
Eau de cologne, 167 
Ecchymosis of conjunctiva, 232 
of eyelids, 185 
Echinococcus cysts of orbit, 581 
Eclampsia, 435 
Eclipse blindness, 463 
Ectasia, marginal, 276 
sclene, 289 
Ectogenous infection, 306 
Ectopia lentis, 411 
hereditary, 411 
Ectropion, 158,. 182, 566 
acute, 182 
chronic, 182 
congenital, 158 
of uvea, 301 
operations for, 608 
Eczema, 208, 211, 241, 407 
of conjunctiva, 211 
of cornea, 241 
of eyelids, 163 
of lid-border, 165 
marginal, 165, 276 
seborrhoicum, 167 
Edema, angioneurotic, of eyelids, 160 
engorgement, of papilla, 471 
of conjunctiva, 232 
of eyelids, 160, 185 
from diseases of nasal accessory si- 
nuses, 788 
in orbital disease, 573 
malignant, 161 
solid, 160 INDEX 
717 
Endogenous infection, 306 
Endophthalmitis, 327 
septica, 358 
Endothelioma, interfascicular, of choroid, 
360 
of angle of anterior chamber, 321 
of conjunctiva, 236 
of cornea, 284 
of eyelid, 175 
of lacrimal gland, 565 
of optic nerve, 492 
of orbit, 579, 580 
Enixanthos glass, 507 
Enlargement of blind spot as symptom 
of posterior accessory sinus disease, 590 
Enophthalmos, 63, 88, 592 
Enteritis, 262 
Entozoa in vitreous, 420 
Entropion, 158, 182 
congenital, 159 
forceps, cross-bar, 606 
operations for, 607 
Enucleation of eyeball, 262, 292, 339, 
364, 636 
accidents in, 637 
after-treatment, 638 
Bonnet's method, 636 
De Schweinitz's method, 637 
fat implantation in Tenon's capsule 
after, 641 
for choroidal tumor, 363, 364 
for tumors of optic nerve, 493 
Fergus' method, 637 
Fox's implantation operation after, 
641 
hemorrhage after, 637, 638 
implantation of artificial eye after, 
640 
instruments used, 636 
in glaucoma, 391, 393 
in panophthalmitis, 359 
in suppurative choroiditis, 359 
iridochoroiditis, 359 
in sympathetic ophthalmitis, 339 
in wounds of ciliary body, 329 
perforation of sclera in, 637 
preventive, 340 
remote implantation after, 641 
Vienna method, 636 
Eosin, 51 
Eosinophils, 213 
Epaulet-like swelling of cornea, 268 
Ephedrin-homatropin, 119 
Ephidrosis, 184 
Epicanthus, 159 
external, 159 
Epilation of eyelashes, 598 
Epilepsy, 53, 62, 400, 460, 477, 558 
Epiphora, 566, 570 
Episcleral blood-vessels in glaucoma, 369 
nodes, 287 
tissue, blood-vessels of, 49 
tumors, 362 
Episcleritis, 287 
fugacious periodic, 288 
prognosis, 288 
Episcleritis, treatment, 288 
Epistaxis, 501 
Epitarsus, 159, 187 
Epithelial dystrophy of cornea, 276 
Epithelioma, contagious, 184 
of caruncle, 239 
of conjunctiva, 235 
of cornea, 284 
of eyelids, 174 
of lacrimal sac, 569 
glands, 565 
of orbit, 581 
epibulbar, 235 
Equator of eye, 138 
Equilibrium test for ocular muscles, 73 
Erect image, 93, 96. See also Ophthal- 
moscopy, direct method. 
Ergotism and cataract, 400 
Erosions of cornea, 281 
Erysipelas, 161, 163, 189, 422, 477, 576, 
585 
of eyelids, 161 
Erythema of eyelids, 160 
Erythropsia, 423, 507 
Eserin, 41, 87, 118, 206, 228, 252, 254, 255, 
262, 279, 288, 328, 386, 562, 598, 653, 
667, 669, 671 
conjunctivitis, 228 
in conical cornea, 279 
in corneal ulcers, 252 
in glaucoma, 386, 387, 388 
in scleritis, 288 
iritis, 314 
salicylate, 386, 387 
sulphate, 453 
Esophoria, 72, 555, 556 
prisms in, 559 
tests for, 72 
treatment, 558, 561 
with convergence-excess, 555 
with divergence-insufficiency, 555 
with myopia, 137 
Esotropia, 72, 523, 525, 542, 555. See 
also Strabismus, convergent. 
Ether, 17, 594 
Ethmoid sinus, disease of, 510, 586 
mucocele of, 587 
osteoma of, 581 
retention-cyst of, 586 
Ethmoiditis, 587 
Ethyl chlorid, 594 
Ethylate of sodium, 234 
Ethylhydrocuprein, 256, 665 
Eucain, 595, 597 
Euphos glass, 507 
Euphthalmin, 106, 118, 396 
Europhen, 256 
Eversbusch's operation for ptosis, 600 
Eversion of eyelid, 182 
Evisceration of eyeball, 340, 639 
for panophthalmitis, 359 
for sympathetic ophthalmitis, 340 
with insertion of artificial vitreous, 
640 
Eversion of eyelid, 182 
Examination of eye, external, 47 718 
INDEX 
Examination of patient, 47 
Exanthematous conjunctivitis, 195 
eruptions on eyelids, 162 
keratitis, 248 
Excessive accommodation, 41 
Excision, combined, for trachoma, 618 
for pterygium, 614 
Exciting eye, 332, 334 
Exenteration of orbit, 643 
Exophoria, 72, 127, 555, 556 
prisms in, 559 
tests for, 72 
treatment, 558, 561 
with convergence-insufficiency, 555 
w'ith divergence-excess, 555 
Exophthalmic goiter, 128, 180, 570, 583 
. corneal changes in, 584 
nature of, 585 
ophthalmoscopic changes, 584 
signs of, 584 
treatment, 585 
Exophthalmometer, Hertel's, 88 
Exophthalmos, 88, 492, 592 
from diseases of nasal accessory sinuses, 
590 
intermittent, 592 
pulsating, 579, 582, 583 
Exotropia, 72, 524, 542, 555. See also 
Strabismus, divergent. 
Expansile pulse of retinal arteries, 101 
Expression of trachoma, 617 
External eye muscles, balance of, 71 
rectus, 519 
advancement of, 676 
in myopia, 135 
paralysis of, 528 
diagnosis, 533 
frequency, 538 
Extirpation of lacrimal gland, 684 
palpebral portion, 685 
sac, 682 
of tarsus for trachoma, 618 
Extorsion, 519, 520 
Extract of hamamelis, 160 
Extraction of cataract, 406-411, 649-651, 
668 
accidents, 658 
acuteness of vision in, 411 
after sympathetic inflammation, 341 
after-treatment, 658 
amount of vision after, 411 
anomalies in healing after, 663 
bulging cicatrix after, 666 
by corneal incision, 651 
by discission, 647 
capsulotomy stage, 654 
Chandler's method, 669 
choice of operation for, 668 
combined, 647 
conjunctival sac after, 656 
corneal incisions in, 650 
opacities after, 666 
correction of vision after, 410 
cortical matter after, 656 
couching for, 647 
cyclitis after, 323, 665 
Extraction of cataract, cystoid cicatrix 
after, 666 
delayed healing after, 667 
delayed restoration of anterior cham- 
ber after, 667 
union after, 668 
delirium after, 668 
delivery stage, 655 
depressing for, 647 
dressings for, 653, 657 
expulsive intra-ocular hemorrhage 
after, 663 
eye preparations for, 651 
fifth stage, 655 
filamentous keratitis after, 667 
filtration chemosis of conjunctiva 
after, 668 
final stage, 657 
first stage, 654 
fourth stage, 655 
gelatinous exudation into anterior 
chamber after, 666 
glaucoma after, 666 
herpes of cornea after, 667 
in capsule, 409, 647 
Indian method, in capsule, 409, 660 
insanity after, 668 
instruments for, 653 
iridectomy stage, 654 
iridocyclitis after, 665 
iritis after, 665 
irrigation of anterior chamber in, 656 
keratitis after, 666 
Knapp's method of, 662 
late cyclitis after, 665 
lenses after, 410 
linear, 647, 649 
peripheral, 650 
needle operation for, 647 
open treatment after, 658 
pain after, 663 
peripheral linear, 650 
position of patient for, 653 
preliminary iridectomy with, 647, 
661, 669 
preparation of eye, 651 
of patient for, 651 
prolapse of iris after, 667 
reclination for, 647 
ring abscess after, 665 
second stage, 654 
simple, 647, 650 
Smith's operation for, 660 
solution operation for, 647 
solutions for, 653 
spongy exudation into anterior 
chamber after, 666 
Stanculeanu's operation for, 662 
subconjunctival, 663 
suction method of, 649 
suppuration of wound after, 664 
technic, 654 
third stage, 654 
toilet of wound after, 655 
unilateral, 410 
vision after, 411 INDEX 
719 
Extraction of cataract with capsulotomv, 
669 
iridectomy, 647, 651, 669 
without capsulotomy, 651 
iridectomy, 650, 656 
Extravasation-cysts of orbit, 581 
Exudation-cysts of orbit, 581 
Exudative retinitis, 455 
Eye, aberration of, 116 
amaurotic cat's, 464 
artificial, insertion of, 638 
associated movements of, 521 
parallel, 74 
axis of, 138 
black, 186 
blood-vessels of, 101, 103 
distribution of, 102 
center of rotation, 41 
circulation of fluids in, 379 
deviating, 523 
deviation of conjugate, 540 
latent, 71 
manifest, 71 
direct inspection of, 47 
emmetropic, 22 
equator of, 138 
examination of, external, 47 
exciting, 332, 334 
far point of, 37 
fixing, 523 
foreign bodies in, removal of, 293, 636, 
642, 692 
functional testing of, 47 
hot, 288 
hyperopic, 22 
in apoplexy, 540 
inspection of, direct, 47 
meridians of, 138 
mobility of, 71 
muscles. See Ocular muscles. 
myopic, 22 
near point of, 37 
neglected, 543 
nodal point, 34 
oblique illumination of, 51 
poles of, 138 
position of, 88 
primary, 520 
secondary, 520 
preparation of, for cataract extraction, 
651 
protrusion of, 88 
speculum, 622 
squinting, 523 
sympathizing, 331 
vasomotor dilatation of vessels of, 288 
visual axis of, 121 
Eyeball, accommodative movement of, 
521 
adherence of eyelid to, 180 
anomalies, 519 
artificial implantation of, in Tenon's 
capsule, 640 
associated movements, 521 
atrophy of, 323, 367 
convergence movements of, 521 
Eyeball, dislocation of, 591 
double perforation of, 293 
elongation of, 129, 130 
enucleation of, 636. See also Enuclea- 
tion. 
evisceration of, 639. See also Evis- 
ceration. 
fluids within, 379 
foreign bodies in, 293 
localization with x-ray, 294, 692 
metallic, removal of, 642 
prognosis, 297 
removal of, 636 
treatment, 294 
glass in, 292 
hardness of, in glaucoma, 368 
immobility of, 573 
massage of, in glaucoma, 388 
movements of, 519 
accommodative, 521 
associated, 521 
convergence, 521 
movements, oblique, 520 
retraction, with congenital deficiency 
of abduction, 537 
torsion, 520 
muscles of, 521. See also Ocular 
muscles. 
operations on, 636 
penetrating wounds of, 292 
primary position, 520 
protrusion of, 88 
retraction of, 592 
with congenital deficiency of abduc- 
tion, 537 
rotation of, 44 
around visual line, 520 
secondary positions, 520 
separation of, 44 
shape of, strabismus from, 726 
siderosis of, 297 
sinking of, 88 
steel in, 293, 294, 692 
tenderness of, 303 
tension of, 86 
torsion of, 520 
vertical meridian, 520 
wheel-rotation of, 520 
wounds of, 292, 293 
Eye-glasses, 154-157 
tilting of, 157 
Eyelashes, epilation of, 598 
false, 181 
graying of, 181 
trichophyton tonsurans in, 167 
Eyelid, abscess of, 161, 186 
absence of, 158 
adenoma of, 171 
adherence of, to eyeball, 180 
alopecia of, 181 
angioma of, 169 
angiomegaly of, 170 
angioneurotic edema of, 160 
anthrax of, 161 
arthritic edema of, 160 
blastomycosis of, 161 720 
INDEX 
Eyelid, burns of, 186 
carcinoma of, 174 
cavernous growths of, 170 
chromidrosis of, 184 
cleft, 158 
cohesion of, 158 
complete absence of, 158 
congenital anomalies of, 158 
fistula of, 160 
ptosis of, 160 
cornu cutaneum of, 170 
cramp of, 178 
cutaneous horns of, 170 
cylindroma of, 172 
cysts of, 169 
dermic granuloma of, 168 
dermoid cyst of, 185 
diseases of, 158 
ecchymosis of, 185 
eczema of, 163, 165 
border of, 165 
edema of, 160, 185 
from diseases .of nasal accessory 
sinuses, 788 
elephantiasis of, 177 
elevator, 653 
emphysema of, 185 
endothelioma of, 179 
ephidrosis of, 184 
epithelioma of, 174 
erysipelas of, 161 
erythema of, 160 
essential edema of, 160 
eversion of, 48, 49, 158, 182 
examination of, 47-49 
exanthematous eruptions of, 162 
fat hernias of, 171 
favus of, 167 
fibroma of, 170 
fissure of, 158 
fistula of, 160 
foreign bodies in, 186 
furuncle of, 161 
gangrene of, 161 
glandular carcinoma of, 175 
gumma of, 169 
hemangioma of, 170 
herpes facialis of, 164 
zoster of, 163 
hives of, 160 
hyperemia of, 160, 165 
border of, 165 
hyperidrosis of, 184 
hypertrophy of, 169 
in orbital disease, 573 
injuries of, 185 
inversion of, 182 
keratosis of, 169 
lepra of, 177 
lipoma of, 170 
lupus vulgaris of, 172, 176 
lymphangioma of, 170 
lymphoma of, 174 
malignant edema of, 161 
pustule of, 161 
marginal eczema of, 163 
Eyelid, method of eversion, 48 
milium of, 183 
molluscum contagiosum of, 184 
fibrosum of, 170 
neurofibromatosis of, 170 
neuroma of, 170 
nevi of, 169 
noma of, 161 
operations on, 598 
papilloma of, 169 
partial development of, 158 
phthiriasis of, 168 
postvariolous ulcer of, 163 
powder burns of, 206 
ptosis of, 178 
lipomatosis of, 171 
relaxation of skin of, 179 
retention cysts, 184 
rodent ulcer of, 174 
sarcoma of, 173 
sebaceous cyst of, 185 
seborrhea of, 165, 183 
nigricans of, 184 
solid edema of, 160 
spasm of, 178, 179 
sporotrichosis of, 168 
spreading gangrene of, 161 
supernumerary, 160 
syphilis of, 168 
tertiary ulcers of, 169 
tuberculosis of, 176 
tumors of, 169 
urticaria of, 160 
vaccine vesicles of, 163 
verruca of, 169 
warts of, 169 
wounds of, 185 
xanthelasma of, 171 
xanthoma of, 171 
xeroderma pigmentosum of, 177 
Eye-lotions, sterilization of, 595 
Eye muscles. See Ocular muscles. 
Eye-strain, 41, 120, 141, 345 
hyperopia from, 122 
Facial palsy, 180, 182, 566 
orbital optic neuritis and, 489 
Familial choroiditis, 351 
Far point in hyeropia, 123 
in myopia, 127 
of convergence, 45 
of eye, 37 
Far-sightedness, 121. See also Hyperopia. 
Fascicular keratitis, 242 
Fasciculi, 512 
Fat hernias of eyelid, 171 
implantation in Tenon's capsule after 
enucleation, 641 
Fatigue contraction, 423 
Favus of eyelids, 167 
Felon, 289 
Fergus' method of enucleation, 637 
operation, 631 
for ptosis, 602 
Fergus-Elliot operation in chronic glau- 
coma, 391 INDEX 
721 
Fetal cleft. See Choroidal fissure. 
Fever, 578 
Fibers of Gratiolet, 513 
of Wernicke, 513 
Fibrinoplastic cyclitis, 305 
Fibrochondroma of sclera, 292 
Fibrolysin, 261 
Fibroma of antrum of Highmore, 589 
of caruncle, 239 
of conjunctiva, 234 
of cornea, 284 
of eyelids, 170 
of lacrimal gland, 565 
of limbus, 212 
of optic nerve, 492 
of orbit, 579 
of sclera, 292 
Field of fixation, 522 
of vision, 79 
abnormalities of, 85 
amblyopia of, 509 
binocular, 82 
Bjerrum's test for, 81 
color, 83 
continuity of, 83 
displacement type, 423 
exhaustion type, 424 
exhaustion-spiral type, 424 
false projection of, in paralytic 
strabismus, 527 
fatigue restrictions of, 509 
in glaucoma, 372 
in hysteria, 504 
in obstruction of central artery of 
retina, 459 
in optic nerve atrophy, 483, 484 
neuritis, 473 
in papillitis, 474 
in paralytic strabismus, 527-531 
in retinal anesthesia, 424 
detachment, 449 
embolism, 459 • 
in retinitis, 426 
pigmentosa, 443 
limits of, 79, 80 
map of, 80 
obscuration of one-half of, 512. See 
also Hemianopsia. 
oscillating, 424 
recuperation-extension type, 424 
relative, 82 
scotomas and, 85 
shape of, 82 
shifting type, 423 
tubular, 504 
unstable concentric, 424 
Fieuzal glass, 507 
Filaria sanguinis hominis, 321 
in vitreous, 420 
Filix mas, 477 
Filtration area, 390 
scar after iridectomy, 391 
Fissures in Descemet's membrane, 280 
Fistula, buccal, 568 
capillary, 568 
congenital, of eyelid, 160 
Fistula, lacrimal, 569 
of cornea, 261 
of lacrimal gland, 565 
sac, 567 
of orbit, 574, 587, 590 
from diseases of nasal accessory 
sinuses, 590 
Fixation, binocular, 71, 521 
field, 522 
line of, 41 
Fixing eye, 523 
forceps, 622 
Flimmer-scotom, 509 
Fluorescide, potassic, 51 
Fluorescein, 50, 250, 253, 254, 281, 334, 
620, 634 
to detect corneal abrasions, 50, 334 
Focal co-ordinates for Sweet's localizing 
apparatus, 696 
distance of lens, 28 
Foci, conjugate, 25 
Focus of concave lens, 25 
conjugate, 25 
principal, 25 
of convex lens, 23 
conjugate, 24 
principal, 25 
virtual, 24 
Follicles, benign, 218 
school, 214 
Follicular conjunctivitis, 214 
Folliculitis, 166 
Folliculosis of conjunctiva, 214 
Fontana's spaces, 382 
Forceps, capsule, 653 
cilium, 598 
curved iris, 622 
entropion, 606 
fixing, 622 
Reese's, 678 
Foreign bodies in anterior chamber, 320 
in caruncle, 239 
in choroid, 366 
in conjunctiva, 238 
in cornea, 280 
in crystalline lens, 413 
in eye, metallic, removal of, 643 
in eyeball, 293 
in eyelids, 186 
in iris, 319 
in sclera, 293 
in vitreous, 420 
localization of, with x-ray, 692 
removal of, 293, 636, 642, 692 
Formaldehyd, 203, 253, 570 
in corneal ulcers, 253 
Formalin, 664 
Form-sense, 66 
in glaucoma, 373 
Forster's method of ripening cataract, 
408 
Fourth nerve, 520 
Fovea centralis, 41, 43, 104 
vicarious, 546 
Foveal reflex, 104 
Fox's implantation operation, 641 722 
INDEX 
Fracture of skull, hemorrhage into optic 
nerve-sheath after, 499 
Frankel-Weichselbaum diplococcus, 191 
Franklin bifocals, 157 
Fricke's method of blepharoplasty, 613 
Friedreich's ataxia, 485, 562 
Fright, dilatation of pupil from, 61 
Frontal sinus, disease of, 585 
empyema of, 585 
mucocele of, 585 
osteoma of, 585 
Frontal sinusitis, 585 
treatment, 586 
Frost-Lang operation of implantation, 
640 
Fruehjahr's catarrh, 212 
Fuchs' rule for location of opacities, 99 
Functional testing, 47 
Fungus hematodes, 465 
Furrow-keratitis, 276 
Furuncle of eyelids, 161 
Furunculosis, 324 
Furnase-workers' cataract, 400 
Fusion, 522 
defective, from strabismus, 544 
Glaucoma, absolute, opticociliary neu- 
rotomy, 391 
accommodation in, 372 
acute, 164, 375, 386, 395 
absolute, state of, 376 
cataract in, 395 
congestive, 368 
glaucomatous attack, 376 
state of, 376 
incubation period, 375 
inflammatory, 368 
iridectomy in, 388 
iris in, 376 
period of attack, 376 
prodromal stage, 375 
seasons and, 379 
symptoms, 375 
after cataract extraction, B66 
discission of cataract, 671 
aqueous in, 369 
arteries in, 371 
amplitude of accommodation in, 372 
anesthesia of cornea in, 372 
anterior, 383 
chamber in, 369 
aqueous in, 369 
arteries in, 371 
astigmatism in, 372 
attack, 376 
blood-pressure and, 383 
cataract with, 393 
causes, 378 
central visual acuteness in, 372 
chronic, 368, 377, 378 
albumin in aqueous in, 383 
angle of anterior chamber in, 381 
atrophy of optic nerve and, 385 
blood-pressure and, 383 
cataract and, 393 
causes, 378 
congestive, 368, 377 
treatment, 387 
corneoscleral trephining in, 391 
cyclodialysis in, 391 
diagnosis, 385 
field of vision in, 372 
Fergus-Elliot operation in, 391 
field of vision in, 372 
Heine's operation in, 391 
Herbert's wedge-isolation operation 
for, 391 
Holth's punch operation in, 391 
hypersecretion and, 382 
inflammatory, 368, 377 
treatment, 387, 390 
intra-ocular tension and, 368 
iridectomy for, 387, 390 
iris adhesion in, 380 
Lagrange's operation, 391 
light-sense in, 386 
lymphatic obstruction and, 382 
massage of eyeball in, 388 
neuritis and, 383 
non-congestive, 368 
non-inflammatory, 368 
iridectomy for, 390 
Gaillard's suture for entropion, 607 
Galvanism in choroiditis, 352 
in corneal scars, 261 
ulcers, 254 
in heterophoria, 558 
in optic atrophy, 487 
in uveitis, 328 
Galvanocautery. See Actual cautery. 
Gallicin, 212 
Gamma, angle, 41 
Gamo Pinto's operation, 254 
Ganglia, basal, tumors of, 476 
Ganglion-cells, 513 
Gangrene, 438 
spreading, of eyelids, 161 
Gasserian ganglion, 59, 263 
Gastro-intestinal auto-intoxication, 187, 
273 
Gelatin, 450 
bougies in lacrimal disease, 571 
Gelatinous exudate after cataract extrac- 
tion, 666 
trachoma, 220 
Gelsemium, 178, 536 
Geniculate bodies, 513 
Gerontoxon, 278 
Gifford-Galassi reflex, 57 
Gifford's modification of Kronlein's re- 
section of temporal wall of orbit, 647 
Gillet de Grandmont's operation for 
ptosis, 600 
Glass, didymium, 507 
enixanthos, 507 
euphos, 507 
in eyeball, 292 
Glaucoma, 50, 61, 164, 252, 265, 272, 304, 
320, 323, 347, 350, 368, 401, 406, 417, 
456, 486, 597, 640 
absolute, 392 INDEX 
723 
Glaucoma, chronic, of both eyes, 378 
operation for, 386 
ophthalmic migraine and, 385 
pathogenesis, 379 
pathology, 379 
prognosis, 386 
retention theory of, 380 
retina in, 385 
sclerotomy in, 391 
sex and, 379 
simple, 377. See also Glaucoma, 
chronic. 
treatment, 386 
visual field in, 372 
color-field in, 373 
complicated, 393 
congenital, 280, 393 
congenitum, 280 
congestive, 368, 375. See also Glau- 
coma, acute. 
conjunctival vessels in, 369 
cornea in, 369 
corneal anesthesia in, 372 
edema in, 384 
sensibility in, 372 
smallness and, 378 
corneoscleral trephining in, 389 
cupping of nerve-head in, 369 
cystoid cicatrix in, 390 
after operation for, 390 
dilatation of pupil in, 61 
disposition toward, 384 
Elliot's operation for, 631 
enucleation in, 391, 393 
episcleral vessels in, 369 
excavation of, 369 
excision of sympathetic ganglion for, 
391 
Fergus operation for, 631 
field of vision in, 372 
form-field in, 373 
from diseases of nasal accessory sinuses, 
590 
from injury, 378 
from mydriatics, 379, 382 
fulminans, 376 
halo in, 369, 375 
hardness of eyeball in, 368 
head of optic nerve in, 369 
hemorrhagic, 392 
enucleation in, 393 
iridectomy in, 392 
high-frequency currents in, 388 
high myopia with, 393 
hypersecretion and, 382 
inflammatory, 375. See also Glaucoma, 
acute. 
intra-ocular tension in, 368, 384 
iridectomy for, 388, 390 
cystoid cicatrix after, 390 
filtration scar after, 391 
iridectomy in, preventive, 389 
symptoms after, 390 
iridescent vision in, 375 
iris in, 368, 369 
adhesion of, 380, 385 
Glaucoma irritatif, 368 
juvenile, 378 
light difference in, 386 
loss of corneal transparency in, 369 
lymphatic obstruction in, 382 
malignant, 390 
massage in, 388 
mydriatic, 382 
test in, 389 
nerve-head in, 369 
neuritis and, 383 
non-inflammatory, 377. See also 
Glaucoma, chronic. 
ophthalmic migraine in, 385 
pain in, 372 
parallax test in, 370 
pathogenesis of, 379 
period of attack in, 376 
peripheral vision in, 372 
posterior, 383 
primary, 368, 378 
prognosis, 386 
pulsation of vessels in, 371 
pupil in, 368 
refractive power in, 372 
retention theory, 380 
retina in, 385 
ring in, 369 
rise of tension, 368 
rupture in, spontaneous, 376 
sclerotomy for, 391 
scotomas in, 373, 374, 375 
secondary, 326, 360, 368, 392, 405 
diagnosis, 392 
pathogenesis, 385 
treatment, 392 
Seidel's sign in, 375 
sex and, 379 
simple, 368 
cause, 383 
simple chronic, 377. See also Glaucoma, 
chronic. 
iridectomy for, 390 
simplex, 368, 377. See also Glaucoma, 
chronic. 
state of, 376 
subacute, 377, 390 
congestive, 368 
treatment, 387, 390 
sympathectomy for, 391 
symptoms, 50, 368 
objective, 372 
subjective, 368 
theories of, 380 
treatment, 386 
traumatic, 378 
trephining sclera for, 631 
varieties, 368 
veins in, 371 
vessel pulsation on disk in, 371 
visual acuity in, 372, 373 
vitreous in, 369 
with cataract, 393 
with myopia, 393 
with retinitis pigmentosa, 444 
yellow halo in, 369 724 
INDEX 
Glaucomatous attack, 376 
disposition, 384 
ring, 369 
state, 376 
Glioma endophytum, 464 
exophyturn, 464 
of angle of anterior chamber, 321 
of brain, 476 
of ciliary body, 331 
of iris, 318 
of optic nerve, 492 
of retina, 365, 464. See also Retina, 
glioma of. 
of sclera, 292 
Globe. See Eyeball. 
Glycerin, 206, 215, 223, 227, 238, 407 
Glycerol of tannin, 227 
Glycosuria, 438 
Goiter, exophthalmic, 180, 583. See also 
Exophthalmic goiter. 
Gonoblenorrhea of young girls, 204 
Gonococcic vaccine, 313 
Gonococcus of Neisser, 196, 215, 313 
Gonorrhea, 289, 313, 324, 477 
Gonorrheal conjunctivitis, 204 
epibulbar, 207 
iritis, 313 
Gonotoxin, 207 
Gould prism exercises in heterophoria, 
559 
Gout, 187, 291, 312, 324, 399, 418, 535 
Gouty iritis, 312 
Graefe. See von Graefe. 
Grandmont's operation for ptosis, 600 
Granular conjunctivitis, 215. See also 
Conjunctivitis, granular. 
Granuloma, dermic, of eyelids, 168 
Gratiolet's fibers, 513 
Grattage, 224, 617 
Graves' disease, 88, 583. See also Ex- 
ophthalmic goiter. 
Gray cataract, 401 
Graying of eyelashes, 181 
Gray-red disc, 482 
Green spot in myopia, 133 
vision, 508 
Green-blindness, 497 
complete, 68 
Grill-like keratitis, 275 
Grossmann's theory of accommodation, 
36 
Gruebler's fluorescein, 50 
Grut's theory of strabismus, 544 
Gum tragacanth, 223 
Gumma of angle of anterior chamber, 
321 
of brain, 476 
of ciliary body, 330 
of eyelids, 169 
of iris, 308 
of optic nerve, 492 
Gullstrand ophthalmoscope, 92 
Gunn's dots, 104 
Guttate choroiditis, senile, 353 
iritis, 312 
Gymnastic exercises with prisms, 558 
Haab's cerebral cortex reflex of pupil, 56 
giant electromagnet, 295, 319, 413, 642 
operation for foreign bodies, 642 
pupillometer, 54 
Habenula, 513 
Habit chorea, 178 
Habit-spasm, 141 
Haitz's stereoscope, 86 
Half-hook fronts, 157 
Halo, 104 
in glaucoma, 369, 375 
in iritis, 375 
Handicap-prisms, 559 
Hanke's bacillus, 283 
Hardy ophthalmometer, 111 
Harlan's test for malingering, 505 
Harman's operation for ptosis, 600 
test for binocular vision, 554 
Hay bacillus, 358 
fever, 212 
Head in apoplexy, 540 
Headache, 123, 126, 130, 423, 557, 574, 
578, 589 
Head-tilting, 537 
Hearing, disturbances of, 583 
Heart disease, 378, 432, 452 
Hectin, 503 
Heine's operation, 635 
operation in chronic glaucoma, 391 
Heisrath's operation for trachoma, 618 
Helmholtz's ophthalmoscope, 91 
theory of accommodation, 36 
of color-blindness, 496 
Hemangioma of eyelids, 170 
Hematoma of optic nerve sheath, 499 
of orbit, 581 
Hemeralopia, 506 
Hemiablepsia, 512. See also Hemianop- 
sia. 
Hemiachromatopsia, homonymous, 515 
Hemianopia, 512. See also Hemianopsia. 
Hemianopic blindness, 422 
pupillary inaction, 518 
Hemianopsia, 509, 512 
absolute, 515 
altitudinal, 514 
binasal, 514, 516 
bitemporal, 510, 514, 516 
central, 514 
complete, 515 
distant symptoms in, 517 
dividing line in, 516 
homonymous, 514 
double, 516 
left lateral, 515 
right lateral, 514 
horizontal, 514 
in optic neuritis, 473 
incomplete, 515 
iris reaction in, 518 
peripheral, 514 
pupil in, 517 
relative, 515 
significance, 516 
symptoms, 516 
unilateral, 516 INDEX 
725 
Hemianopsia, varieties, 514 
vertical, 514 
Wernicke's symptom in, 518 
Hemiopia, 512. See also Hemianopsia. 
Hemiopic pupillary inaction, 64, 518 
Hemiplegia, 438 
Hemolytic serum, 418 
Hemophilia, 320, 592 
Hemoptysis, 501 
Hemorrhage after enucleation of eye- 
ball, 637, 638 
after tenotomy, 673 
expulsive intra-ocular, 663 
in albuminuric retinitis, 433 
in retina, 426, 451 
into choroid, 366 
into orbit, 591, 592 
into sheath of optic nerve, 499 
into vitreous, 417 
preretinal, 451 
recurrent subconjunctival, 232 
Hemorrhagic central retinochoroiditis, 
352 
choroiditis, 354 
glaucoma, 392 
Hemosiderin, 297 
Hemostasis, local, 598 
Henschen's phenomena, 518 
Herbert's method of sclerotomy, 630 
wedge-isolation operation, 630 
in glaucoma, 391 
Hering's theory of color-blindness, 496 
of color-vision, 497 
Hernias, fat, of eyelids, 171 
Herpes of cornea, 264 
after cataract extraction, 667 
relapsing, 273 
facialis of eyelids, 165 
treatment of, 166 
zoster, 314, 535 
ophthalmicus, 163, 164, 332 
corneal lesions in, 163 
treatment, 164 
Herschel prism, 75 
Hertel's exophthahnometer, 88 
telescopic spectacles in myopia, 136 
Hertzell's ophthalmodiaphanoscope, 110 
Hess' operation for ptosis, 602 
Heterochromia, 299 
iridis, 53 
Heterochromic cyclitis, 53 
Heterophoria, 71, 72, 554 
accommodative, 554 
adverse prisms in, 559 
causes, 554 
central, 554 
classification, 72 
cobalt glass test, 76 
concomitant, 554 
convergence excess in, 555 
insufficiency in, 555 
paralysis in, 555 
correction of refractive errors for relief 
of, 558 
divergence-excess in, 555 
divergence-insufficiency in, 555 
Heterophoria, equilibrium test for, 73 
examination in, 558 
frequency, 556 
galvanism in, 558 
gymnastic exercise with prisms in, 558 
headache in, 557 
heterotropia and, difference between, 
556 
method of examination in, 558 
mixed, 555 
muscle exercises in, 559 
muscular asthenopia in, 557 
ocular symptoms in, 557 
operation for, 560 
orthoptic exercises in, 560 
parallax test for, 72 
paretic, 554 
prescription of prisms in, 559 
prism exercises in, 558 
test for, 73 
rod test for, 77 
screen test for, 72, 556 
spasmodic, 554 
strabismus and, differentiation, 556 
surgical treatment, 560 
symptoms, 557 
tests for, 72-78 
thumb exercises in, 560 
treatment, 558 
varieties, 555 
Heterotropia, 71, 72, 523, 542. See also 
Strabismus. 
Hetol, 288, 619 
Heurteloup, 309 
High-frequency currents, 224, 488 
in glaucoma, 388 
in optic nerve atrophy, 488 
in trachoma, 224 • 
in xanthelasma, 171 
Hippus, 65 
Hirschberg's electromagnet, 295 
Hives of eyelids, 160 
Holden's test for light-sense, 84 
Hole of macula, 462, 468 
Holloway's mounted set of Bjerrum's 
tests, 82 
Holmes' extirpation of lacrimal gland, 684 
Holmgren's test for color-blindness, 67 
Holocain, 87, 212, 213, 223, 243, 251, 253, 
255, 264, 274, 280, 290, 309, 312, 393, 
596, 652, 665 
Holth's iridocleisis, 635 
operation, 631 
punch operation in chronic glaucoma, 
391 
Homatropin, 106, 118, 228, 396 
Homonymous lateral deviation, 73 
Hook, blunt, 623 
Hook fronts, 157 
Hook, strabismus, 671 
Hordeolum, 161, 162 
treatment, 162 
Horizontal deviation, Maddox rod test 
for, 77 
meridian, 32 
Hot eye, 288 726 
INDEX 
Hotz's operation for artificial lid border, 
606 
Hotz-Anagnostakis operation for entro- 
pion, 607 
Howe's apparatus for measuring of rela- 
tive accommodation at near-point, 46 
Hunt-Tansley operation for ptosis, 601 
Hutchinson's salmon patch, 267 
teeth, 269 
Hyaline bodies in papilla, 493 
Hyalitis, 305, 414 
asteroid, 416 
punctata, 416 
treatment, 415 
Hyaloid artery, persistent, 420 
cataract, 401 
membrane, hemorrhage under, 451 
Hydrastin, 223 
Hydriodic acid, 244, 258, 417, 453 
Hydrocephalus, 476 
Hydrochlorate of cocain, 595 
Hydrochlorid of cocain, 119 
Hydrogen peroxid, 572 
Hydrophthalmos, 280, 393 
Hyoscin, 118, 312 
in iritis, 312 
Hyoscyamin, 117, 228, 558 
in iritis, 312 
Hypersemia marginalis, 165 
palpebralis, 187 
Hyperemia of choroid, 344. See also 
Choroid, hyperemia of. 
of conjunctiva, 187 
causes of, 187 
in cataract, 395 
symptoms, 187 
treatment of, 188 
of eyelids, 160 • 
of iris, 301 
of lid-border, 165 
of optic nerve-head, 470. See also 
Optic nerve, head of. 
of retina, 421. See also Retina, hyper- 
emia of. 
Hyperesophoria, 72 
Hyperesotropia, 72 
Hyperesthesia of retina, 421, 422. See 
also Retina, hyperesthesia of. 
Hyperexophoria, 72 
Hyperexotropia, 72 
Hyperidrosis, 184 
Hypermetropia, 121. See also Hyperopia. 
Hyperopia, 22, 106, 107, 112, 121, 129, 
471, 544 
absolute, 121 
accommodation spasm in, 122 
angle gumma in, 127 
alphakial, 121 
astigmatism with, 143 
axial, 121 
blepharitis in, 123 
causes, 121 
chalazia in, 123 
choroidal congestion in, 123 
coats of eye in, 122 
congenital, 121 
Hyperopia, conjunctivitis in, 123 
convergent strabismus in, 122, 543 
correction of, 123 
in children, 125 
correction of, ophthalmoscope for, 125 
skiascopy for, 125 
test types for, 124 
trial lenses for, 124 
curvature, 121 
definition, 121 
degree, 125 
determination of, 123 
facultative, 121 
far point in, 123 
from eyestrain, 122 
glasses for, 125 
headache in, 123 
hereditary, 121 
latent, 121 
lengthening of eye from, 107 
manifest, 121 
ordering of glasses in, 125 
retinal image in, 34 
shortening of eye from, 107 
skiascopy in, 114 
styes in, 123 
symptoms, 122 
total, 121 
transitory increase in, 129 
varieties of, 121 
dish, 471 
Hyperostoses of sphenoid sinus, 588 
Hyperphoria, 72, 555, 556 
accommodative, 554 
central, 540 
comitant, 556 
concomitant, 540 
frequency, 556 
noncomitant, 556 
paretic, 540 
prisms for, 559 
spasmodic, 540 
varieties, 540 
Hyperplasia, epithelial, of ciliary body, 
331 
Hypertension, vascular, 41 
Hypertrophy of eyelids, 169 
of lacrimal gland, 564 
of tarsus, 171 
Hypertropia, 72, 525, 542, 556 
Hyphemia, 320 
Hypophosphites, 226, 571 
Hypopyon, 245, 247, 262, 320, 323 
keratitis, 246, 256 
treatment, 254 
Hypopituitarism, 41 
Hypothalmic body, 513 
Hysteria, 62, 122, 504, 554, 558 
Hysteric visual disturbances, 504 
ICHTHARGAN, 203, 223 
Ichthyol, 164, 165, 213 
Ichthyosis, 238 
Identical points, 43 
Idiocy, amaurotic family, 466 INDEX 
727 
Ill-sustained accommodation, 40 
Illumination, oblique, 51 
method of, 52 
Image, 95 
formation of, by lens, 25 
in direct method, 92 
in indirect method, 95 
inverted, 95, 108. See also Ophthal- 
moscopy, indirect method. 
of concave lens, 27 
of convex lens, 27 
position of, 26 
retinal, in ametropia, 34 
in emmetropia, 34 
in myopia, 35 
size of, 26 
in direct method, 95 
in indirect method, 96 
Imagination reflex of pupil, 57 
Imbalance, 554 
Immobility of eyeball, 573 
Impetigo contagiosa, 189, 209 
Implantation cyst in anterior chamber, 
320 
of conjunctiva, 233 
of artificial globe after remote enuclea- 
tion, 640 
in Tenon's capsule after enuclea- 
tion, 641 
Incidence, angle of, 18 
Inclusion-blenorrhea of newborn, 197, 203 
Index of refraction, 17 
opsonic, 162 
Indian method of cataract extraction, 
409, 660 
Indigestion, 141, 558 
Indirect method of ophthalmoscopy, 95, 
108. See also Ophthalmoscopy, indi- 
rect method. 
vision, 79 
Inequality of accommodation, 40 
Inertia of accommodation, 40 
Inferior oblique, 57, 520, 521 
paralysis of, 530 
diagnosis, 534, 537 
tenotomy of, 672 
rectus, 519, 520 
paralysis of, 531, 538 
Infiltration of cornea, peripheral annular, 
283 
Inflammation of iris, 301. See also Iritis. 
of knee-joint, 199 
of lacrimal gland, 564. See also 
Dacryo-adenitis. 
of optic nerve, intra-ocular, 471 
of retina, 425. See also Retinitis. 
of tarsus, 177 
Influenza, 249, 314, 324, 358, 399, 477, 
535, 539, 564, 576, 578, 585 
bacillus conjunctivitis, 191 
Inhibitory constrictor center, 60 
dilator center, 60 
Injections, subconjunctival, 619 
Injuries of choroid, 365 
of ciliary body, 329 
of conjunctiva, 238 
Injuries of cornea, 280 
obstetric, 284 
of iris, 318 
of optic nerve, 492 
of orbit, 591 
of sclera, 292 
Innenpol magnet, 296 
Innervation of iris, 57 
Insanity, 64, 471 
after cataract extraction, 668 
Insomnia, 378 
Inspection of eye, direct, 47 
Instruments, preparation of, 795 
Insufficiencies, absolute, 40, 561. See also 
Heterophoria. 
Intermittent closing of retinal arteries, 
460 
Internal capsule, 513 
geniculate body, 513 
rectus, 44, 519 
paralysis of, 529 
tenotomy of, 671 
Interstitial keratitis, 266. See also 
Keratitis, interstitial. 
Intestinal hemorrhage, 501 
Intorsion, 519 
Intra-ocular fluid, 379 
injections, 341, 455 
in detachment of retina, 450 
tension in glaucoma, 368 
Inversion of eyelid, 182 
Inverted image, 108. See also Ophthal- 
moscopy, indirect method. 
lodid of cadmium, 564 
of iron, 245, 258, 575 
syrup of, 571 
of lithium, 328 
of potassium, 162, 240, 256, 272, 288, 
290, 313, 345, 352, 407, 427, 442, 491, 
538, 540, 578, 579, 583 
of silver, 223 
of sodium, 328, 345, 407, 417, 418, 433, 
453 
lodin, 253, 264, 293, 564 
lodin-vasogen, 256 
Iodoform, 203, 206, 223, 238, 244, 252, 
253, 293, 490, 501, 571, 636, 665 
amblyopia from, 501 
lodogallicin, 212 
Iodol, 256 
in corneal ulcers, 256 
Ionic medication in blepharitis, 168 
Iontophoresis, zinc, 257 
Iridectomy, 147, 266, 272, 291, 315, 332, 
460, 622, 629 
broad peripheral, 625 
combined with sclerectomy, 629 
filtration scar after, 391 
in glaucoma, 387, 392 
in hemorrhagic glaucoma, 392 
in hydrophthalmos, 280 
in irregular astigmatism, 147 
in sympathetic ophthalmitis, 340, 341 
in uveitis, 329 
instruments required for, 622 
intra-ocular hemorrhage after, 452 728 
INDEX 
Iridectomy, narrow, 625 
optical, 625 
in cataract, 408 
point of entrance of keratome in, 623 
position of, 624 
of operator in, 623 
preliminary to cataract extraction, 409, 
669 
preventive, in glaucoma, 389 
small, 625 
with extraction of cataract, 651 
without extraction of cataract, 650, 
656, 658 
Irideremia, 301, 507 
Iridescent vision in glaucoma, 375, 507 
Iridochoroiditis, 305, 326, 346, 347, 
357 
chronic serous, 326 
plastic, 315 
serous, sympathetic, 333 
suppurative, 357. See also Choroiditis, 
suppurative. 
Iridocleisis, Holth's, 635 
Iridocyclitis, 181, 206, 228, 247, 265, 277, 
305, 322, 401, 410, 449, 596, 640 
after cataract extraction, 665 
anterior, 381 
dots on cornea in, 325, 326, 327 
malignant, 333 
plastic, 333, 360 
serous, 333 
sympathetic, 333 
symptoms, 322 
traumatic, 332 
Iridodesis, 332 
Iridodialysis, 319 
Iridodonesis, 412 
Iridoplegia, 61, 542 
unilateral reflex, 63 
Iridotasis, Borthen's, 635 
Iridotomy, 626, 671 
in sympathetic ophthalmitis, 341 
precorneal, 625 
V-shaped, 627 
Iris, 379 
adhesion of, 380, 385 
anteversion of, 320 
atrophy of, 301, 308 
layers of, 305 
blood-vessels of, 49 
bombe, 304 
bridge coloboma of, 300 
carcinoma of, 318 
change in color of, 302 
cholesteatoma of, 317 
chromatic asymmetry of, 53 
coloboma of, 300, 343, 344, 496, 506 
color of, 52 
congenital anomalies, 299 
constriction of, 60 
continuity of, rupture of, 320 
cysticercus in, 316 
cysts of, 301, 316 
detachment of, 320 
discoloration of, 53 
diseases of, 299 
Iris, diseases of, from diseases of nasal 
accessory sinuses, 589 
displacement of, 320 
forceps, curved, 622 
foreign bodies in, 314, 319, 320 
glioma of, 318 
gumma of, 318 
hyperemia of, 301 
implantation cysts of, 320 
in cataract, 399 
in glaucoma, 368, 369, 376 
inflammations of, 301. See also Iritis. 
injuries of, 318 
innervation of, 57 
irregularities of surface of, 303 
leprosy of, 318 
melanoma of, 318 
mobility of, 55, 99 
in cataract, 407 
multiple cysts of, 316 
muscular tissue of, 57 
myoma of, 318 
nevi of, 301, 318 
operations on, 622 
papilloma of, 301 
pearl-cysts of, 317 
pearl-like tumor of, 317 
piebald, 53 
prolapse of, 250 
after cataract extraction, 659, 667 
treatment, 254 
pseudocoloboma of, 300 
reaction, 518 
retention cysts of, 316 
retroflexion of, 320 
rupture of continuity of, 320 
rupture of sphincter of, 320, 366 
sarcoma of, 318 
scissors, 623 
serous cysts of, 316 
sphincter of, paralysis of, 541 
rupture of, 320, 366 
syphilis of, 306 
syphilitic papules of, 308 
tremulous, 412 
tuberculosis of, 317 
treatment, 318 
tumors of, 316 
wall-chamber cysts of, 317 
wounds of, 318 
Iris-syphilids, 308 
Iritis, 50, 53, 135, 232, 246, 268, 269, 301, 
369, 385, 401, 456 
after cataract extraction, 665 
astigmatism in, 303 
autotoxemic, 310 
treatment, 311 
cachectic, 302 
catamenalis, 314 
causes, 301 
chronic, 315 
complications, 304 
condylomatosa, 308 
course, 304 
diabetic, 312 
diagnosis, 303 INDEX 
729 
Iritis, disturbance of vision in, 303 
eserin, 314 
fibrinous, 306 
luetic, 308 
gonorrheal, 302, 313 
treatment, 313 
gouty, 302, 312 
gummatous, 308 
guttate, 312 
halo vision in, 375 
in arthritis deformans, 311 
infectious disease, 314 
iridectomy in, 316 
in chronic, 315 
in recurrent, 316 
lacrimation in, 303 
luetic fibrinous, 308 
malaise in, 303 
nodular, 306 
operative treatment, 315 
pain in, 303 
papulosa, 308 
parenchymatous, 306 
pathology of, 306 
pericorneal injection in, 302 
periodic, 314 
phlyctenular conjunctivitis and, dif- 
ferential diagnosis, 304 
photophobia in, 303 
plastic, 314 
primary, 301 
prognosis, 304 
purulent, 306, 314 
quiet, 311 
recurrent, 311 
relapses in, 306 
rheumatic, 302, 310 
scrofulous, 302, 314 
secondary, 301, 315 
to mucous membrane infection, 
314 
septic, 302 
serous, 306, 315, 323 
sympathetic, 333 
simple conjunctivitis and, differential 
diagnosis, 304 
spastic accommodation in, 303 
spongy, 314 
sympathetic, 302, 333 
serous, 333 
symptoms, 53, 302 
syphilitic, 302, 306 
treatment, 309 
tenderness of globe in, 303 
transient myopia in, 303 
traumatic, 282, 302, 314 
treatment, 309, 312, 313 
operative, 315 
tuberculous, 302, 317 
types of, 306 ' 
varieties, 302 
Iritoectomy, 626 
Iron, 163, 164, 210, 212, 226, 243, 266, 
328, 352, 417, 419, 438, 487, 501, 506, 
571 575 577 
spicule in eye, 294, 642, 643 
Irrigation of anterior chamber after 
cataract extraction, 657 
Irritation mydriasis, 61 
myosis, 62 
Ischemia of retina, 422 
Itrol, 223 
Jackson binocular magnifying lens, 52 
proptometer, 88 
test for malingering, 505 
for muscle balance, 73 
Jacob's ulcer, 174 
Jaeger's type, 70 
Jaesche-Arlt operation for trichiasis, 605 
Javal's controlled reading in strabismus, 
551 
Javal-Schiotz ophthalmometer, 110, 687 
latest model, 689 
Jequiritol, 225 
serum, 225 
Jequirity, 225 
Johnson's method of determining astig- 
matism, 146 
Jones (Wharton) operation for ectropion, 
611 
Juvenile cataract, 401 
glaucoma, 378 
Kalt's corneal suture, 663 
irrigations, 205 
Katophoria, 71 
Katotropia, 71 
Keratalgia, traumatic, 281 
Keratectomy, Ziegler's, for staphyloma, 
621 
Keratite ulcereuse en sillons etoiles, 250 
Keratitis, 241 
after cataract extraction, 666 
anaphylactic, 271 
annularis et disciformis, 275 
bullosa, 265 
relapsing traumatic, 281 
circumscribed parenchymatous, 273 
deep, 273 
dendritica, 250 
diffuse interstitial, 266 
parenchymatous, 251 
diplobacillary, 193 
disciformis, 275 
e lagophthalmo, 262, 263 
endogenous gonorrheal, 207 
exanthematous, 248 
exposure, 582 
fascicular, 242 
filamentous, 277 
after cataract extraction, 667 
flame-shaped marginal, 227 
from diseases of nasal accessory si- 
nuses, 589 
furrow-, 250, 276 
gittrige, 275 
grill-like, 275 
herpetic, 264 
hypopyon, 246 
inherited, 266 730 
INDEX 
Keratitis, interstitial, 50, 266 
abscess forms of, 270 
acute, 273 
atypical forms of, 270 
causes, 266 
central annular, 270 
congenital, 267 
diagnosis, 269 
epaulet-like swelling in, 268 
pathology of, 270 
prognosis, 270 
punctiformis specifica, 272 
symptoms, 267 
treatment, 271 
interstitialis punctiformis specifica, 272 
leprous, 236 
maculosa, 273 
marginalis, 242, 274 
phlyctenular, 242, 250 
profunda, 274 
superficiahs, 249 
vascular, 270 
mycotic, 248 
neuroparalytic, 262, 274 
nummular, 274 
of desiccation, 263 
oyster-shuckers', 281 
parenchymatous, 164, 251, 266 
circumscribed, 273 
petrificans, 277 
phlyctenular, 241 
causes, 241 
diagnosis, 243 
marginal, 242, 250 
pathology, 242 
prognosis, 243 
symptoms, 242 
treatment, 243 
profunda, 273 
punctata, 53, 229, 272, 317, 322, 323, 
325, 326 
profunda, 272 
syphilitica, 272 
vera, 272 
purulent, 246 
riband-like, 277 
rosacea, 265 
scar, 260 
sclerotizing, 274, 290 
specific, 266, 275 
striata, 283, 667 
after cataract extraction, 66,7 
subepithelialis centralis, 273 
superficialis punctata, 273 
suppurative, 249 
syphilitic, 266 
traumatic, 280 
striped, 283 
trophica, 277 
tuberculous, 251 
vascular, 221, 265 
vesiculosa, 265 
xerotic, 251, 263 
Keratocele, 260 
Keratoconjunctivitis, 241. See also Kera- 
titis, phlyctenular. 
Keratoconus, 278 
Keratoglobus, 280 
Kerato-iritis from bee-sting, 281 
Keratomalacia, 230, 250, 262 
Keratome, 622 
Keratometer, Smith's, 51, 54 
Keratometry, 110, 687 
Keratomycosis aspergillina, 248 
Keratoscope, 50 
Keratoscopy, 50 
Keratosis senilis pegmentosus, 169 
xerotic, 262 
Kerectasia, 260 
Kidney, decapsulation of, in albuminuric 
retinitis, 438 
Klebs-Loffler bacillus, 208 
Knapp's knife-needle, 669 
lid clamp, 599 
operation for after-cataract, 670 
for cataract, 662 
without iridectomy, 656 
for pterygium, 614 
for trachoma, 617 
Knee-joint, inflammation of, 199 
Knife, canaliculus, 681 
cataract, 653 
double, 608 
Knife-needle, 648 
Knapp's, 669 
Koch-Weeks bacillus, 190, 208, 215 
conjunctivitis, 190. See also Con- 
junctivitis, acute contagious. 
Kroll's orthoptic exercises, 549 
Kronlein's resection of temporal wall of 
orbit, 646 
Gifford's modification, 647 
Kryptok bifocal lenses, 154 
Kuhnt's operation for trachoma, 618 
Kuhnt-Miiller operation for ectropion, 
608 
Kuhnt-Szymanowski operation for ec- 
tropion, 609 
Kyanopsia, 508 
Labyrinthine nystagmus, 562 
Lacrimal abscess, 567 
of infants, 568 
rupture of, 567 
treatment, 567 
actinomycosis, 569 
apparatus, diseases of, 564 
operations on, 681 
blenorrhea of infants, 568 
bone, caries of, 569 
periostitis of, 569 
conjunctivitis, 228, 566 
diseases, 564 
causes, 568 
prognosis, 569 
treatment, 570 
duct, diseases of, 568 
electrolysis in, 571 
treatment, 570 
stricture, incision of, 682 
fistula, 569 INDEX 
731 
Lacrimal glands, adeno-angioma of, 565 
adenoma of, 565 
atrophy of, 564 
carcinoma of, 565 
cylindroma of, 565 
cysts of, 565 
epithelioma of, 565 
extirpation of, 572, 684 
of palpebral portion of, 685 
fibroma of, 565 
fistula of, 565 
hypertrophy of, 564 
infection of, 199 
lymphoma of, 565 
mucocele of, 567 
mumps of, 564 
myxoma of, 565 
osteochondroma of, 565 
palpebral portion, extirpation of, 685 
prolapse of, 565 
sarcoma of, 565 
spontaneous prolapse of, 564 
syphilis of, 565 
traumatic dislocation of, 565 
treatment of diseases of, 570 
tuberculosis of, 565 
tumors of, 565 
probes, 682 
introduction of, 681 
reflex, 51 
region, diseases of, from diseases of 
nasal accessory sinuses, 590 
sac, anomalies of, 566 
capillary fistula of, 568 
chronic distention of, 567 
epithelioma of, 568 
diseases of, causes, 568, 569 
treatment, 570 
excision of, 572, 682 
extirpation of, 572 
fistula of, 567, 569 
buccal, 568 
capillary, 568 
plasmoma of, 569 
sarcoma of, 569 
tuberculosis of, 569 
tumors of, 569 
secretion, character of, under patho- 
logic conditions, 569 
stricture, incision of, 682 
syringe, introduction of, 682 
tumor, 566 
Lacrimation, 228, 250, 265 
Lacrimonasal duct, diseases of, asym- 
metry of face and, 569 
Lactate of zinc, 487 
Lactic acid, 238 
Lactophosphate of lime, 258 
Lagophthalmos, 158, 180 
Lagrange's combined iridectomy and 
sclerectomy, 629 
operation in glaucoma, 391 
simple sclerectomy, 630 
Lagrange and Knapp's operation for or- 
bital tumors, 645 
Lamina cribrosa, 100, 370 
Lance-headed needle, 648 
Landolt's method of advancement, 676 
ophthalmodynamometer, 78 
optotypes, 66 
treatment for strabismus, 548 
Lang's operation for division of synechiae, 
628 
Lantern test for color-blindness, 69 
Lapis divinus, 227 
Largin, 193 
argyrosis from, 240 
Larval conjunctivitis, 229 
Lateral geniculate body, 513 
sclerosis, 485 
Lead, 490, 501, 536, 539 
amblyopia from 501 
ophthalmoplegia from, 539 
Lead-poisoning, 504 
Lead-water, 160 
and laudanum, 164 
Leber's disease, 486 
Lebrun's method of extraction, 651 
Lecithin, 492 
Leeching, 665 
in iritis, 309 
Lefort and Wolfe's operation for trans- 
plantation, 613 
Leiter's tubes, 205 
Lens, crystalline, 36, 395 
anomalies of, 395 
coloboma of, 394 
congenital anomalies of, 395 
contusion-lesion of, 405 
diseases of, 394 
dislocation of, 392, 411 
into vitreous, 412 
symptoms, 412 
treatment, 412 
under Tenon's capsule, 412 
examination of, by transmitted light, 
98 
fetal fibrovascular sheath of, 465 
foreign bodies in, 413 
in cataract, 410 
increase in size of, 396 
removal of, in myopia, 135 
Lenses, 23 
as prisms, 22 
astigmatic, 146 
axes of, 26 
biconcave, 30 
biconvex, 30 
bifocal, 154, 157 
binocular magnifying, 52 
combination of, 30 
concave, 23 
combination with convex, 32 
conjugate foci of, 25 
cylindric, 31 
designation of, 30 
image of, 27 
principal focus of, 25 
concavoconvex, 30 
concealed, 154 
convex, 23 
combination with concave, 32 732 
INDEX 
Lenses, convex, cylindric, 31 
designation of, 30 
focus of, 23 
conjugate, 23 
principal, 23 
virtual, 24 
virtual image of, 27 
convexoconcave, 30 
cylindric, 30 
combination of spheric with, 32 
concave, 31 
convex, 31 
decentered, prismatic deviation of, 20 
focal distance of, 28 
formation of images by, 25 
horizontal meridian, 32 
kryptok, 154 
neutralization of, 155 
numeration of, 28 
oblique illumination of, 51 
optical center of, 25 
planoconcave, 30 
planoconvex, 30 
punktai, 30 
refractive power, 28 
secondary axes of, 26 
spectacle, optical center of, 155 
spheric, 30 
combination with cylindric, 32 
with prism, deviating effect, 559 
star, 139 
toric, 30 
trial-, for correcting hyperopia, 124 
trifocal, 157 
vertical meridian of, 32 
Lens-measure, 155 
Lens-testing, protractior for, 156 
Lenticonus, 394 
Lenticular cataract, 394 
Lepra bacillus, 248 
of conjunctiva, 236 
of eyelids, 177 
of iris, 318 
Leprosy nodules of ciliary body, 331 
of iris, 318 
of cornea, 236 
Leprous keratitis, 236 
Leroy and Dubois ophthalmometer, 111 
Leukemia, 438, 564 
splenic, 439 
Leukoma, 259 
adherent, 198, 258, 260, 385 
total anterior, 198 
congenital, 284 
tattooing cornea in, 621 
Leukorrhea, 324 
Leukosarcoma of choroid, 359 
of ciliary body, 331 
Levator palpebrae, contraction of, in as- 
sociation with the external pterygoid, 
179 
Lid clamp, Knapp's, 599 
Lid-border, artificial, 605, 606 
Lid-closure reflex of pupil, 57 
retinal, 51 
Lid-elevator, 653 
Lids, granular, 215. See also Conjuncti- 
vitis, granular. 
Lid-edema, 178 
Liebreich's method of extraction, 651 
Ligamentum pectinatum, 379 
rupture of, 319 
Ligation of carotid for hemorrhage into 
vitreous, 418 
Light, 17 
perception, 84 
qualitative, 66 
rays of, 17, 20 
reflex of retinal vessels, 101 
spot, 100 
transmission of, 17 
Light-difference, 66 
Light-field in cataract, 406 
Light-minimum, 66, 67 
Light-reflex, 101 
of pupil, consensual, 55, 59 
direct, 55, 59 
indirect, 55, 59 
Light-sense, 66, 130, 473, 483 
in glaucoma, 386 
in myopia, 130 
test for, in periphery of retina, 84 
test-types for, 67 
Lightning-stroke, cataract from, 401 
Limbus, fibroma of, 212 
Limit of perception, 35 
Lindner's initial bodies, 217 
Line of fixation, 41 
Linear extraction of cataract, 649 
Lipemia retinalis, 439 
Lipoma of conjunctiva, 234 
of eyelids, 170 
of orbit, 579 
Lippitudo, 166 
ulcerosa, 165 
Liquor potassa, 223 
Lithiasis conjunctivae, 228 
Lithium iodid, 328 
Liver, diseases of, 452 
sarcoma of, from choroidal sarcoma, 
362 
Locomotor ataxia, 64, 485, 536, 539 
optic-nerve type, 485 
pulse of retinal arteries, 101 
Loffler bacillus. See Klebs-Loffler bacil- 
lus. 
Loring ophthalmoscope, 92 
Lotio nigra, 163 
Loupe, corneal, 52 
Lumbar puncture in choked disc, 479 
Lupus, 238 
of conjunctiva, 236 
of cornea, 276 
of eyelids, 176 
of orbit, 581 
Lymphangiectasis of conjunctiva, 232 
Lymphangioma, 170 
of caruncle, 239 
of conjunctiva, 233 
of eyelids, 170 
of orbit, 578 
Lymphangitis, 160, 577 INDEX 
733 
Lymphocytosis in sympathetic ophthal- 
mitis, 333, 335 
Lymphoma of conjunctiva, 226 
of eyelids, 174 
of lacrimal glands, 565 
of orbit, 579 
Lymphorrhagia of fundus, 463 
Lymphosarcoma of caruncle, 239 
Lymph-space theory of papillitis, 481 
Media, transparent, location of opacities 
in, 99 
Medulla, tumors of, 476 
Medullated fibers of optic nerve, 469 
Megalocornea, 280 
Megalophthalmos, 573 
Meibomian cyst, 171. See also Chalazion. 
gland, 162, 227 
adenoma of, 171 
Melancholia, 141, 558 
Melanocarcinoma of conjunctiva, 235 
Melanoma of choroid, 361 
of conjunctiva, 236 
of iris, 318 
Melanosarcoma of choroid, 359 
Melanosis, congenital, of cornea, 286 
of conjunctiva, 233 
sclersc 297 
Meningitis, 62, 199, 262, 359, 400, 414, 
476, 512, 536, 554, 576 
basic, 358, 479 
cerebrospinal, 314, 358, 476 
ophthalmitis and, 414 
simple, 476 
spinal, 61 
traumatic, 476 
tuberculous, 364, 476 
Meningococcus intracellularis, 189, 415 
conjunctivitis, 189 
Menstrual disorders, 278, 287, 289, 416, 
432, 452, 477, 486, 489 
Mercury, 210, 271, 272, 277, 297, 309, 
310, 328, 330, 339, 341, 352, 369, 427, 
430, 433, 478, 487, 489, 575, 665, 666 
amblyopia from, 501 
bichlorid. See Bichlorid. 
chlorid, 309 
cyanid. See Cyanid. 
in iritis, 310, 311 
oxid. See Oxid. 
oxycyanid, 194, 205 
Meridians, converging, 526 
diverging, 526 
horizontal, 32 
of eye, 138 
vertical, 520 
abnormal positions of, 526 
Metal spoon, 653 
Metallic foreign bodies, removal of, 294, 
642 
Metamorphopsia, 346, 426 
in detachment of retina, 448 
in retinitis, 426 
Meter angle, 20, 44 
centrads and, relations of, 20, 44 
of convergence, 45 
prism-diopters and, relations of, 20 
Methyl-alcohol amblyopia, 501 
blindness, 502 
Methylatropin, 119 
Microblepharon, 167 
Micrococcus catarrhalis conjunctivitis, 
189 
Microphthalmos, 285, 402, 496, 561, 573 
Micropsia, 61, 346, 508 
in retinitis, 426 
Macropsia, 62, 346, 426, 508 
Macula lutea, 41, 104, 258 
appearance of, 105 
black spot of, 104, 133 
cherry-red spot in, 458 
color of, 105 
halo of, 104 
holes in, 463, 468 
in retinal embolism, 458 
symmetric changes in, infancy, 466 
traumatic perforation of, 461, 462, 
468 
vessels of, 105 
whitish ring of, 104 
Macular arteries, 101 
fan, 475 
fasciculus, 513 
figure, 475 
reflex, 104 
veins, 101 
Madarosis, 166 
Maddox obtuse-angled prism, 75 
rod test, 74, 77 
for vertical deviation, 78 
Magnesium sulphate, 261 
Magnet, Innenpol, 296 
of Haab, 295, 319, 413, 642 
Malaise in iritis, 303 
Malaria, 128, 250, 266, 273, 416, 452, 477, 
500, 554 
Male fern, amblyopia from, 501 
Malignant pustule of eyelids, 161 
Malingering, 505 
binocular, test for, 505 
diplopia test for, 505 
Harlan's test for, 505 
Snellen's test for, 505 
Mania, acute, 61 
Manifest deviation of eye muscles, 71 
Manz's theory of papillitis, 481 
Marginal degeneration of cornea, 276 
ectasia, 276 
Mariotte's blind spot, 85 
Marple's ophthalmoscope, 92 
Mask, Ring's ocular, 657 
Massage, 261, 423, 460 
in cataract, 407 
in glaucoma, 388 
McKenzie-Davidson's x-ray method of 
localizing foreign bodies, 294 
McReynold's operation for pterygium, 
614, 615 
Measles, 160, 166, 189, 209, 249, 262, 358, 
477, 569 
Mechanical theory of papillitis, 481 734 
INDEX 
Microscope, corneal, 52 
Migraine, 64, 141, 422, 460 
ophthalmic, 385, 509 
ophthalmoplegic, 536 
Migratory pustule, 242 
Mikulicz's diseases of lacrimal glands, 566 
Miliary choroidoretinitis, 345 
tubercles of choroid, 364 
of iris, 317 
Military conjunctivitis, 228 
ophthalmia, 215. See also Conjunctivi- 
tis, follicular. 
Milium, 183 
Miners' nystagmus, 562 
Minimum stimulus, 66 
Miosis, 62, 302 
irritation, 62 
of cerebral origin, 62 
of spinal origin, 62 
paralytic, 62 
spastic, 62 
spinal, 62 
traumatic, 62 
Miotic nerves, 57 
tract, 58 
Mires of ophthalmometer, 688 
Mirror, 89 
catoptric power of, 90 
concave, 89, 116 
principle focus of, 90 
convex, 90 
conjugate focus of, 90 
negative focus of, 90 
corneal, 90 
plane, 89 
reflective power of, 90 
Mobility of eye, 71 
Moebius sign, 584 
Moles of conjunctiva, 233 
Moll's glands, 169 
Molluscum contagiosum of eyelids, 184 
fibrosum of eyelids, 170 
sebaceum of eyelids, 184 
Monochromatic vision, 68 
Mooren's ulcer of cornea, 249 
Morax-Axenfeld bacillus, 167, 215, 247 
conjunctivitis from, 215 
Morgagnian cataract, 399 
Morgagni's spheres, 398 
Morning ptosis, 227 
Morphin, 164, 178, 206, 258, 312, 387, 
597, 671 
Motais' operation for ptosis, 602 
Mucocele, 567 
of ethmoid sinus, 587 
of frontal sinus, 585 
of lacrimal gland, 567 
of orbit, 590 
Mucous cysts of orbit, 581 
Mules' operation, 640 
for ptosis, 600 
Miiller-Kuhnt operation for ectropion, 
609 
Multiple cysts of iris, 316 
Mumps, 541, 564 
Muscae volitantes, 417 
Mutton-fat deposits in cornea, 325, 327 
Mycotic keratitis, 248 
Mydriasis, 110, 252, 401 
alternating, 64 
drug, 62 
irritation, 61 
medicinal, 62 
one-sided, 64 
paralytic, 61 
spasmodic, 61 
spastic, 61 
springing, 64 
traumatic, 320 
Mydriatic nerves, 57 
test in glaucoma, 389 
tract, 59 
Mydriatics, dilatation of pupil from, 61 
reaction to, in cataract, 407 
use of, 117 
Mydrol, 119 
Myelitis, 477, 485, 489, 592 
Myocarditis, 255 
Myodesopia, 417 
Myoma of ciliary body, 331 
of iris, 318 
of orbicularis, 171 
Myopia, 22, 88, 106, 107, 112, 127, 404, 
417, 544 
age and, 132 
angle gamma in, 130, 131, 132 
astigmatism in, 130, 133, 143 
atrophic spots in, 356 
atropin in, 135 
axial, 128 
black spot of macula in, 133 
causes, 127, 129 
ciliary body, 133 
congenital, 128 
conus in, 131 
correction, 133 
curvature, 127 
definition, 127 
degree, 134 
determination, 133 
diameter of orbit in, 129 
divergence strabismus in, 130, 544 
effect of development of choked disc, 
476 
elongation of eyeball in, 129, 130 
far-point in, 127, 134 
from corneal opacities, 128 
from scleroticochoroiditis, 128, 129 
full correction in, 136 
glasses for, 136 
green spot in, 133 
heredity in, 128 
Hertel's telescopic spectacles in, 136 
high, removal of lens in, 649 
with glaucoma, 393 
in diabetes, 129 
late development of, 128 
lengthening of eye from, 107 
light-sense in, 130 
malignant, 130, 132, 411, 448 
near point in, 133 
operation for, 135 INDEX 
735 
Myopia, ophthalmoscopic appearances in, 
131 
ordering glasses in, 136 
pernicious, 130, 132 
phakolysis in, 135 
position of lens for, 137 
posterior staphyloma and, 132 
prevalence, 128 
prodromal, 395 
progressive, 130, 133 
prophylactic measures, 135 
reading glasses for, 151 
removal of lens in, 135 
retinal image in, 35 
school hygiene and, 135 
scotoma in, 133 
semi-atrophic spots in, 356 
shortening of eye from, 107 
skiascopy in, 113 
strength of eyes in, 131 
symptoms, 130 
stationary, 130 
tenotomy of external rectus in, 135 
transient, in iritis, 303 
treatment, 135 
varieties, 127 
with esophoria, 137 
Myopic choroiditis, 356 
crescent, 131 
Myosarcoma of ciliary body, 331 
Myotonic pupil movement, 64 
Myxedema, 266, 477 
Myxoma of cornea, 284 
of lacrimal gland, 565 
Negative aberration, 116 
Neglected eyes, 543 
Neisser bacteria, 313 
gonococcus of, 196 
Neosalvarsan, 169, 272, 290, 478, 487, 
310, 328, 352, 431, 666 
Nephritis, 88, 232, 339, 351, 399, 417, 434, 
435, 436, 437, 453, 454, 460 
chronic, 88, 453 
interstitial, 435 
parenchymatous, 434 
retinitis in, 433 
scarlatinal, 435 
Nerve, optic. See also Optic nerve. 
Nerve-fiber layer of retina, 512 
Nerve-head. See Optic nerve, head of. 
Nerves, mydriatic, 57 
miotic, 57 
Nervous diseases, dilatation of pupil in, 
61 
Neuralgia, 378, 423 
supra-orbital, 250 
Neurasthenia, 41, 141, 558 
Neurectomy for sympathetic ophthal- 
mitis, 340 
opticociliary, 641 
Neuritis, alcoholic, 63 
descending, 480 
glaucoma and, 383 
multiple, 62 
optic, 471. See also Optic neuritis. 
retrobulbar, 488. See also Optic neuri- 
tis, orbital. 
Neuro-epithelioma of retina, 464 
Neuro-epithelium layer of retina, 512 
Neurofibromatosis of eyelids, 170 
Neuroma of ciliary nerve, 331 
of eyelid, 170 
Neuroparalytic keratitis, 262 
Neuroretinitis, 305, 434, 437, 468, 472 
from disease of nasal accessory sinuses, 
589 
Neurosis, reflex, 558 
sympathetic, 332 
traumatic, 509 
Neurotomy, opticociliary, 391, 641 
Neurotonic convergence reaction, 64 
Nevi of eyefids, 169 
of iris, 301, 318 
of orbit, 581. See also Angioma. 
Nicotin, ophthalmoplegia from, 539 
Night-blindness, 230, 444, 506 
family, 506 
functional, 506 
in retinitis pigmentosa, 446 
Night-terrors, 141, 558 
Nitrate of amyl, 501 
of silver, 193, 200, 202, 206, 223, 251, 
252, 501, 571, 581, 617, 668 
amblyopia from, 501 
argyrosis from, 240 
Nitric acid, 253 
Nitrite of amyl, 422, 460, 492 
Nitrobenzol, 490, 501 
amblyopia from, 501 
poisoning from, 504 
Naevus pigmentosus of conjunctiva, 233 
Naphthalin cataract, 400 
Nasal accessory sinuses, diseases of, ocu- 
lar complications in, 589 
arteries, 101 
catarrh, 189, 193 
duct, anomalies of, 566 
causes of disease in, 568 
treatment, 570 
obstruction of, 568 
window resection of, in stenosis, 685 
veins, 101 
Nasopharynx, diseases of, 568 
Near-point, 37, 38, 39, 70, 78 
in presbyopia, 149 
of accommodation, 38 
of convergence, 45, 74 
Near-sightedness, 121. See also Myopia. 
Nebula of cornea, 258 
Necrosis corneae, 262 
of orbit, 575 
Needle, Bowman's stop, 648 
knife-, 648 
Knapp's, 669 
lance-headed, 648 
operation for cataract, 647 
after-treatment, 648 
instruments required, 648 
paracentesis, 619 
tattooing, 621 736 
INDEX 
Nitroglycerin, 388, 390, 393, 453, 487 
in optic-nerve atrophy, 487 
Nitrous oxid, 594 
Nodal point, 34 
Noduli cornese, 273 
Noma of eyelids, 161 
Nose-glasses, 156 
Nosophen, 244, 253, 256 
Novocain, 595 
Nuclear layer of retina, external, 512 
palsy, acute, 539 
chronic, 539 
Numbering of prisms, 19 
Numeration of lenses, 28 
Nux vomica, 492, 558 
Nyctalopia, 506 
acute essential, 506 
chronic, 506 
retinitis, 506 
Nystagmus, 443, 496, 561 
acquired, 561 
congenital, 561 
in retinitis pigmentosa, 443 
labyrinthine, 562 
miners', 562 
nervous diseases and, 562 
treatment, 562 
Ocular muscles, Maddox rod test for, 74, 
77 
manifest deviation of, 71 
obtuse-angled prism test of, 75 
operation for shortening tendons of, 
680 
operations on, 671 
parallax test for, 72 
paralysis of, 88 
associated, 540 
causes, 535 
cerebral, 536 
congenital, 537 
conjugate lateral, 540 
Duane's diagnostic table, 534 
from injuries, 536 
from reflex disturbances, 536 
from spinal anesthesia, 536 
prognosis, 538 
relative frequency, 538 
table of diplopia in, 535 
tenotomy of, 538 
treatment, 538 
physiologic action of, 519 
prism tests for, 73 
resection of, 678 
rod test for, 74, 77 
screen test for, 72 
testing of, 72 
vertical deviation of, 78 
von Graefe's test for, 73 
Oculomotor nerve, 57, 519, 520 
paralysis, 164, 179, 532 
recurrent, 536 
Oculo-orbital fascia, inflammation of, 578 
Oidium, 162 
Oil of cade, 163 
of wintergreen, amblyopia from, 501 
Olive oil, 238 
Opacities, corneal, 275 
after cataract extraction, 666 
grill-like, 275 
myopia from, 128 
primary, 277 
in cataract, 397, 666 
in retinitis pigmentosa, 443 
in transparent media, 99 
in vitreous, 53, 346, 415. See also 
Vitreous opacities. 
Open method of managing eye after cat- 
aract extraction, 658 
Operations, 593 
preparation for, 593 
Ophthalmia, 188. See also Conjunctivitis. 
Egyptian, 215. See also Conjunctivitis, 
follicular. 
electric, 507 
follicular, 214 
hepatica, 351 
military, 215. See also Conjuctivitis, 
follicular. 
neonatorum, 195, 251. See also Con- 
junctivitis neonatorum. 
nodosa, 229 
phlyctenular, 211 
purulent, 204 
Obesity, 128 
Oblique illumination, 51, 99 
for detection of cataract, 397 
muscles, insufficiency of, 76, 77. See 
also Cydophoria. 
Obstetric injuries of cornea, 284 
Obtuse-angled prism test of ocular mus- 
cles, 75 
Occipital lobe, 513 
Occlusion treatment in concomitant 
squint, 548 
O'Connor's method of advancement, 678 
Ocular complications of diseases of nasal 
accessory sinuses, 589 
mask. Ring's, 657 
motility, disturbances of, 582 
muscles, anatomy of, 519 
associated paralysis of, 540 
balance of, 71, 521 
abnormal, 554. See also Hetero- 
phoria. 
classification, 534 
cobalt test for, 76 
cover test for, 72 
deviation of, 71, 73 
disparity in, strabismus from, 543 
disturbances in, 582 
for equilibrium test, 73 
exterior, paralysis of, 526, 590. See 
also Strabismus, paralytic. 
horizontal deviation of, 77 
insufficiency of, 71. See also Hetero- 
phoria. 
interior, paralysis of, 541 
Jackson's test for, 73 
latent deviation of, 71 
lateral deviation of, 73 INDEX 
737 
Ophthalmia, pustular, 211 
scrofulous, 211 
sympathetic. See Ophthalmitis, sym- 
pathetic. 
tarsi, 165 
Ophthalmic artery, aneurysm of, 583 
migraine, 385 
nerve, 59 
vein, obstruction of, 583 
Ophthalmitis, 164, 414 
destructive, 357, 358 
endogenous, 432 
metastatic, 358, 432 
migratory, 337 
sympathetic, 181, 277, 282, 331, 333, 
420, 640, 666 
causes, 332 
ciliary -nerve theory, 337 
Critchett's operation for, 341 
cytotoxin theory, 338 
drugs in, 340 
endogenous theory, 339 
enucleation in, 339 
evisceration for, 340 
forms of, 333 
from cyclitis, 323 
from uveitis, 336 
giant-cells in, 336 
incubation period, 335 
infection theory, 337 
inflammations causing, 336 
iridectomy for, 340, 341 
iridotomy for, 341 
metastasis theory, 335, 338 
migration theory, 337 
neurectomy for, 340 
operation for, 339, 341 
pathogenesis, 337 
pathology, 335 
prognosis, 341 
prophylaxis, 339 
sclerotomy for, 340 
symptoms, 335 
treatment, 339 
transferred, 333. See also Ophthal- 
mitis, sympathetic. 
Ophthalmoblennorrhea of young girls, 204 
Ophthalmodiaphanoscope, 110 
Ophthalmodiaphanoscopy, 110, 363 
Ophthalmodynamometer, 78 
Ophthalmomalacia, 367. See also Phthi- 
sis bulbi. 
Ophthalmometer, 110 
Chambers-Inskeep, 111 
Hardy, 111 
Javal and Schiotz, 110, 687, 689 
Leroy and Dubois, 111 
Reid, 111 
Sutcliffe's, 111 
use of, 687 
Ophthalmometry, 110, 687 
Ophthalmoplegia, 539 
acute, 539 
chronic, 539 
congenital, 539 
exterior, 539, 573 
Ophthalmoplegia, hereditary, 539 
interior, 539 
migraine of, 536 
progressive, 539 
stationary, 539 
total, 539 
transient bilateral, 539 
treatment, 540 
Ophthalmoplegic migraine, 536 
Ophthalmoneuromyelitis, 477 
Ophthalmoscope, 89, 91. See also Oph- 
thalmoscopy. 
correction of hyperopia with, 125 
Crampton's, 92 
demonstrating, 92 
determination of astigmatism with, 108 
of compound astigmatism with, 108 
of refraction by, 106, 110 
electric, 91, 97 
Gullstrand, 92 
von Helmholtz, 91 
Loring, 91, 92 
Marple, 92 
methods of using, 92, 95, 96, 108 
refraction, 91 
Ophthalmoscopic changes in exophthal- 
mos, 584 
Ophthalmoscopy, 89, 96 
direct method, 92, 96 
image in, 95 
position of patient, 98 
size of image in, 95 
in cataract detection, 396 
indirect method, 95, 108 
size of image in, 96, 109 
Opium, 206, 258, 309, 490 
Opsonic index, 162 
Optic axis, 41 
canal, fracture of, 499 
centers, 25 
determination of, 155 
primary, 513 
chiasm, 59, 513 
principles, general, 17 
nerve, 57, 100, 512 
anemia of, 471 
anomalies of, 102 
congenital, 469 
appearance by reflected light, 100 
atrophv of, 61, 164, 401, 482, 491, 
501 
adaptation in, 483 
causes, 485 
cavernous, 370 
central vision in, 483 
choroiditic, 346, 349, 485 
color changes in, 482 
consecutive, 482, 483, 485 
course, 487 
diagnosis, 487 
dilatation of pupil in, 61 
embolic, 485 
excavation in, 482 
eye-ground changes in, 483 
field of vision in, 483, 484 
from skull deformities, 486 738 
INDEX 
Optic nerve, atrophy of, galvanism in, 487 
glaucoma and, 385 
gray, 484 
hereditary, 486, 511 
scotoma with, 512 
homochronous hereditary, 486 
lacunar, 370 
light-sense in, 483 
nerve-head in, 482 
neuritic, 482 
pathology, 486 
postpapillitic, 482, 485 
primary, 482, 484, 486 
prognosis, 487 
progressive, 484 
scotoma with, 511 
pupil in, 484 
radium in, 488 
retinal, 482, 483, 485 
Rontgen rays in, 488 
scleral ring in, 482 
secondary, 482, 485, 486 
spinal, 484 
stationary, with scotoma, 511 
sympathetic, 334 
symptoms, 482 
tabetic, 484 
tyrombotic, 485 
treatment, 487 
varieties, 484 
vessel changes in, 483 
vision in, 483 
visual field in, 483, 484 
with excavation, 378 
central opening of, 101 
white patch of, 100 
choroiditic atrophy of, 346, 349, 482, 
485 
coloboma of sheath, 469 
congenital anomalies, 469 
congestion of, 470 
consecutive atrophy of, 482, 483, 485 
degeneration of papillomacular bun- 
dle of, 491 
diseases of, 469 
from diseases of nasal accessory 
sinuses, 589 
drusen in, 493 
edema of, intra-ocular, 471 
engorgement edema of, 471 
fibers of, medullated, 469 
opaque, 469 
pigmentation of, 469 
gray atrophy of, 484, 485 
degeneration of, 485 
gray-red, 482 
hyperemia of, 470, 582 
hyperopic, 470 
in atrophy, 482 
in glaucoma, 369 
in papillitis, 472 
irregularities in, 469 
tissue shreds on, 470 
head of, 512 
anemia of, 471 
congestion of, 470 
Optic nerve, hematoma of sheath of, 499 
hemorrhage into sheath of, 499 
hereditary atrophy of, 486, 511 
homochronous hereditary atrophy 
of, 486 
hyaline bodies in, 493 
hyperemia of, 470 
in emoblism of central retinal artery 
458 
inflammation of, 471. See also 
Optic neuritis. 
intra-ocular, 471 
injury of, 492 
light-spot of, 100 
medullated fibers of, 469 
opaque fibers of, 469 
papillomacular bundle of, 491 
perivascular lymph-channels in, 379, 
382 
physiologic excavations of, 100, 108 
variations, 102 
pigmentation of fibers, 469 
resection of, 340 
rings of, 100 
sheath, dilatation of, 482 
tumors of, 492 
symptoms, 492 
treatment, 493 
type of tabes dorsalis, 485 
neuritis, 269, 401, 434, 471, 478, 479, 
501, 510, 574, 576, 577, 582, 588 
acute blindness in, 476 
axial, 488, 490 
brain tuberculosis and, 477 
causes, 476 
cerebral decompression in, 479 
changes in nerve-head, 472 
course, 474 
corpus callosum puncture in, 479 
descending, 471, 477, 480 
diagnosis, 474 
external appearances in, 474 
field of vision in, 473 
from brain disease, 477 
tumor, 476 
from diseases of nasal accessory si- 
nuses, 478, 589 
from general diseases, 477 
from meningitis, 477 
from skull deformities, 477 
from toxic agents, 477 
hemianopsia in, 473 
hemorrhages in, 473 
infectious, 477 
inflammatory, 481 
theory of, 481 
intra-ocular, 471 
light-sense in, 473 
lumbar puncture in, 479 
lymph-space theory of, 481 
macular fan in, 475 
mechanical theory of, 481 
metastatic, 477 
nerve-head in, 472 
orbital, 488, 506 
acute, 488 INDEX 
739 
Optic neuritis, orbital, cause, 488, 490 
chronic, 490 
course, 489, 491 
facial palsy and, 489 
idiopathic, 488 
prognosis, 489, 491 
symptomatic, 488 
treatment, 489, 491 
pathogenesis, 480 
pathology, 481 
peripheral, 471 
prognosis, 475 
retinal edema in, 475 
retrobulbar, 488 
acute, 488 
chronic, 490 
scotoma with, 512 
idiopathic, 488 
symptomatic, 488 
second attacks, 475 
significance of, 479 
spurious, 471 
symptoms, 472 
theories of, 480, 481 
tower skull and, 477 
treatment, 478 
vessel changes in, 473 
vision in, 473 
von Graefe's theory of, 480 
with ear diseases, 476 
with diseases of anterior part of eye, 
477 
with dropping of fluid from nose, 478 
with scotoma, 512 
perineuritis, 480 
principles, general, 17 
pseudoneuritis, 471 
radiations, 513 
thalamus, pulvinar of, 513 
tract, 512 
Opticociliary neurotomy, 391, 641 
in glaucoma, 391 
vessels, 103 
Optochin, 256 
Optometer, 111 
Optometry, 111 
Optotypes, Landolt's, 66 
Orbicularis, myoma of, 171 
paralysis of, 180 
pupillary reaction, 57 
tonic cramp of, 178 
Orbit, abscess of, 587 
aneurysm by anastomosis in, 383 
blindness from, 576 
from diseases of nasal accessory 
sinuses, 590 
angioma of, 579 
blood-cysts of, 581 
carcinoma of, 579 
caries of, 575 
cellulitis of, 232, 535, 576 
after tenotomy, 673 
causes, 576 
from diseases of nasal accessory si- 
nuses, 590 
in tenotomy, 673 
Orbit, cellulitis of, prognosis, 577 
progress, 577 i 
treatment, 577 
cephalocele of, 580 
cicatricial, operations for prosthesis in, 
641 
congenital anomalies, 573 
cylindroma of, 579 
cysts of, 578, 580 
removal of, 645 
dermoids in, 581 
diameter of, in myopia, 129 
diseases of, 573 
symptoms, 573 
echinococcus cysts, 581 
encephalocele of, 581 
enchondroma of, 579 
endothelioma of, 579, 580 
epithelioma of, 581 
exenteration of, 643 
exostoses of, 581 
operation for, 645 
extirpation of contents of, 643 
extravasation cysts of, 581 
exudation cysts of, 581 
fibroma of, 579 
fistula of, 574, 587, 590 
foreign bodies in, 591 
fracture of, 591 
hematoma of, 581 
hemorrhage into, 591, 592 
injuries of, 591 
lipoma of, 579 
lupus of, 581 
lymphangioma of, 578 
lymphoma of, 174, 579 
mucocele of, 590 
mucous cysts of, 581 
necrosis of, 575 
nevi of, 581 
osteoma of, 581 
operation for, 645 
periosteal thickening in, 581 
periostitis of, causes, 574 
prognosis, 574 
treatment, 575 
phlebitis of veins of, 577 
phlegmon of, 576 
polypi of, 581 
resection of temporal wall of, 646 
sarcoma of, 579, 580, 581 
tumors of, 180, 535, 578, 645 
originating in bony wall, 581 
in cavities, 581 
in tissues, 579 
in vascular disease in cavity, 582 
prognosis, 579 
removal of, 645 
Lagrange and Knapp's method, 
645 
symptoms, 579 
thrombosis of veins of, 161, 358 
treatment, 579 
optic neuritis, 488 
palsies, 535 
Orbitopalpebral cyst, 573 740 
INDEX 
Orsudan, blindness from, 503 
Orthoform, 223, 555 
Orthophoria, 71, 555, 558, 675 
Orthoptic exercises in heterophoria, 560 
training in strabismus, 553 
convergent, 548 
treatment of concomitant squint, 553 
Oscillating field, 424 
Osmic acid, amblyopia from, 501 
Ossification of choroid, 367 
of ciliary body, 331 
of tarsus, 171 
Osteochondroma of lacrimal glands, 565 
Osteoma of conjunctivitis, 234 
of ethmoid, 582 
of frontal sinus, 582, 585 
of orbit, 581 
removal, 645 
of sclera, 292 
of sphenoid sinus, 588 
Oval cornea, 267 
Overcoming prisms, 522 
Oversightedness, 121. See also Hyper- 
opia. 
Oxaluria, 423 
Oxid of mercury, 162, 207, 223, 232, 243, 
252, 272, 273, 288 
Oyster-shuckers' keratitis, 281 
Ozena, bacillus of, 189, 248 
conjunctivitis from, 189 
Papilloma of eyelids, 169 
of iris, 301 
Papillomacular bundle, 513 
degeneration of, 463 
fibers, 491 
Papilloretinitis, 433. See also Retinitis, 
albuminuric. 
sympathetic, 333, 334 
Paracentesis of cornea, 206, 315, 619, 649 
in glaucoma, 393 
in uveitis, 329 
needle, 619 
Paraffin in excision of lacrimal sac, 683 
spheres in Tenon's capsule, 641 
Parafolliculitis, 166 
Parallax test, 72, 370 
of ocular muscles, 72 
Parallel rays, 22 
Paralysis, accommodation, 64 
acute nuclear, 539 
agitans, 485 
basal, 536 
bulbar, 62, 485 
chronic bulbar, 539 
nuclear, 539 
congenital, 537 
conjugate lateral, 540 
convergence, 541, 555 
dilatator, 62 
divergence, 541 
general, 64 
oculomotor, 532 
recurrent, 536 
of ciliary muscle, 541 
of exterior ocular muscles, 526, 590 
rectus, 528 
of inferior oblique, 530 
rectus, 531 
of internal ocular muscles, 541 
rectus, 529 
of ocular muscles. See Ocular muscles. 
of orbicularis, 180 
of sphincter of iris, 542 
of superior oblique, 532 
rectus, 529 
orbital, 535 
recurrent oculomotor, 536 
rheumatic, 536 
spastic spinal, 485 
Paraphenylendiamin, 592 
Parasites in anterior chamber, 320 
Paresis, 477 
Paretic dementia, 61, 536, 539 
Parinaud's conjunctivitis, 226 
Parotitis, 314 
Patient, examination of, 47 
Pearl cysts of iris, 317 
Pectinate ligament, 379 
Pellidol, 257 
Pemphigus, 180, 230 
of conjunctiva, 238 
Pencil, 94 
Pepsin, 244 
Perception, limit of, 35 
Perforation, double, of eye, 293 
Peribulbar epithelioma, 235 
Pachymeningitis, 477 
Paderstein's inclusion bodies, 192 
Pagenstecher's salve. See also Yellow 
oxid of mercury. 
subcutaneous thread operation for 
ptosis, 600 
Pain in cataract, 395 
in glaucoma, 372 
reaction of pupil, 56, 57 
Palpebral portion of lacrimal gland, ex- 
tirpation of, 572, 685 
reflex, 51, 57 
Palsy. See Paralysis. 
Panas' fluid, 193 
operation for ptosis, 600 
Pannus, 52, 221, 265 
crassus, 221 
phlyctenular, 242, 265 
tenuis, 221 
with trachoma, treatment, 224 
Panophthalmitis, 198, 239, 260, 265, 282, 
332, 357, 598, 639 
bacillus of, 358 
embolic, 432 
enucleation in, 359 
evisceration in, 639 
Papilla. See Optic nerve. 
Papillary trachoma, 218 
Papilledema, 472 
Papillitic atrophy, 475 
Papillitis, 472. See also Optic neuritis. 
Papilloma of caruncle, 239 
of ciliary border, 171 
of cornea, 284 INDEX 
741 
Pericorneal injection, 302 
Perimeter, 80, 81 
electric light, 80 
for measuring squint, 547 
hand, 80 
self-registering, 80 
Perineuritis, 480 
Periosteum of orbit, thickening of, 581 
Periostitis of orbit, 575 
syphilitic, 574 
relation of, to sinus disease, 575 
Perithelioma of choroid, 361 
Peritomy, 225, 244, 266 
Perivasculitis, 453, 454, 574 
Permanganate of potassium, 203, 205, 
223, 244, 570, 652 
Peronin, 597 
Peroxid of hydrogen, 193, 572 
in powder burns, 186 
Persistent hyaloid artery, 420 
pupillary membrane, 299 
Pertussis, 314 
Petit, bacillus of, 247 
Pfeiffer's bacillus, 191, 248 
Phakolysis in myopia, 135 
Phlebitis of veins of orbit, 577 
retinal, 589 
Phlegmon of eyelid, 161 
of orbit, 576 
Phlyctama pallida, 212 
Phlyctenular conjunctivitis, 207, 211 
keratitis, 241 
keratoconjunctivitis, 241 
pannus, 242 
ulcer, 242 
Phorometer, Stevens, 75 
Phosphates, 575 
Phosphorus, 487 
Photometer, 66 
Photometric types, 67 
Photophobia, 189, 212, 251, 303, 396, 426 
Photophthalmia, 507 
Photopsies, 346 
Phototherapy, 261 
Phthiriasis, 168 
Phthisis bulbi, 323, 326, 357 
essential, 367 
from choroiditis, 357 
from cyclitis, 323 
Physiologic albuminuria, 53 
cup, 100, 102 
excavations of optic nerve, 100 
salt solution. See Salt solution. 
Pigment heaping, 345 
spots of conjunctiva, 236 
Pigmentary degeneration of retina, 442. 
See also Retinitis pigmentosa. 
Pigmentation of cornea, 286 
of eye, hematogenous, 297 
xenogenous, 297 
of retina, 426 
of sclera 277 
Pilocarpin,' 41, 61, 62, 87, 203, 252, 279, 
288, 328, 340, 352, 387, 417, 418, 427, 
450 
diaphoresis, 288, 290, 352 
Pilocarpin diaphoresis in iritis, 313 
hydrochlorate, 387 
in glaucoma, 387 
in scleritis, 288, 290 
Pimple ulcer of cornea, 245 
Pince-ciseaux of de Wecker, 626 
Pinguecula, 231 
Pink eyes, 190 
Pits, corneal, 278 
Pituitary body, diseases of, 516, 536 
visual phenomena with, 510 
neoplasm, 486, 516 
Pituitrin, 418 
Pix liquida, 163 
Placido's disk, 50 
Plane mirror, 89 
skiascopy with, 112 
Planoconcave lens, 30 
Planoconvex lens, 30 
Plasmoma of lacrimal sac, 569 
Plethora, 62 
Pneumobacillus, 248 
Pneumococcus, 188, 191, 194, 196, 208, 
247, 569 
conjunctivitis, 191, 194 
in corneal ulcers, 247 
serum, 255 
Pneumonia, 314, 358 
Podophyllin, conjunctivitis from, 229 
Point, nodal, 34 
of reversal, 111, 113 
Poles of eye, 138 
Polio-encephalitis, hemorrhagic, 539 
Polycoria, 299, 563 
Polycythemia, cyanotic, 425 
Polyneuritis, 477 
Polypi in cataract, 395 
of antrum of Highmore, 589 
of orbit, 581 
of puncta lachrymalia, 566 
of sphenoid sinus, 588 
Pons, tumors of, 476 
Porus opticus, 101 
Position of image, 26 
Positive aberration, 116 
Potassic fluorescid, 51 
Potassium bromid. See Bromid. 
chlorate, amblyopia from, 501 
iodid. See lodid. 
permanganate. See Permanganate. 
Power of convergence, 78 
Pregnancy, albuminuric retinitis in, 436 
Prelacrimal sac abscess, 567 
cysts, 567 
Prentice's method of numbering prisms, 
20 
Presbyopia, 40, 41, 148, 187 
age and, 148 
bifocal lenses in, 153 
cause, 148 
correction, 149 
glasses in, 149 
near point in, 149 
premature, from diabetes, 500 
reading-glasses in, 150 
Presenile cataract, 402 742 
INDEX 
Pressure pulse of retinal arteries, 101 
Priestly Smith. See Smith. 
Primary deviation, 527 
in paralytic squint, 527 
position of eyes, 520 
visual ganglia, 513 
Prince's method of advancement, 677 
Principal focus of concave lens, 25 
of convex lens, 23 
Prism-convergence, 74, 522 
Prism-diopters, 20 
and meter angle, relations of, 20 
and centrad, relative values of, 20 
Prism-divergence, 522 
test for, 74 
Prism tests for ocular muscles, 73 
Prismosphere, 560 
Prisms, 18 
adverse, 559 
angle of deviation, 19 
apex of, 18 
base of, 18 
Dennett's method of numbering, 19 
deviation produced by, 19 
exercises with, in heterophoria, 558 
in squint, 553 
handicap, 559 
Herschel, 75 
in heterophoria, 558, 559 
numbering of, 19 
overcoming, 522 
Prentice's method of numbering, 20 
refracting angle of, 18 
refraction through, 18 
relieving, 559 
revolving, 75 
rotary, Risley's, 74, 75 
spheric lens with, deviating effect, 560 
testing with, in heterophoria, 73 
Probe and spatula, 623 
in lacrimal disease, 570, 572 
lacrimal, 682 
introduction of, 681 
Prolapse, spontaneous, of lacrimal gland, 
564 
Proliferating uveitis, 337 
Proptometer, Jackson's, 88 
Proptosis, 88, 573. See also Exophthal- 
mos. 
Prosthesis, operations for, in cicatricial 
orbit, 641 
Protargol, 193, 195, 200, 202, 214, 223, 
252, 590 
argyrosis from, 240 
Protiodid of mercury, 328 
Protractor for lens-testing, 155 
Protrusion of eye, 88 
Prowazek bodies, 217, 221 
Pseudochorea, 141, 558 
Pseudocoloboma of iris, 300 
Pseudodementia paralytica, 62 
Pseudoglioma, 357, 414 
Pseudo-isochromatic plates of Stilling, 70 
Pseudoneuritis, optic, 471 
Pseudonystagmus, 562 
Pseudopterygium, 231, 250 
Pseudoptosis, 179 
Pseudotuberculosis of conjunctiva, 229 
Psoriasis, 238 
Psorophthalmia, 165 
Pterygium, 231 
congenital, 159, 187 
excision of, 614 
keloid formation after removal, 615 
McReynolds' operation for, 614 
operations for, 614 
recurrent, 615 
transplantation, 614 
Ptomain-poisoning, 536, 539 
Ptosis, 179, 504 
congenital, of eyelid, 160 
lipomatosis of eyelids, 171 
morning, 227 
operations for, 599 
paralytic, 179 
partial, 63 
sympathetic, 63 
unilateral, 179 
Puerperal sepsis, 358 
Pulley suture, 677 
Pulsating exophthalmos, 582 
Pulsation in retinal blood-vessels, 101 
Pulvinar of thalamus, 513 
Puncta lachrymalia, anomalies of, ac- 
quired, 566 
congenital, 566 
malposition of, 567 
polyp of, 566 
stenosis of, 566 
Punctum proximum, 37, 38, 39, 70, 78 
remotum, 37, 38, 39, 70 
Puncture, lumbar, in choked disk, 479 
scleral, 388 
Punktai lens, 30 
Pupil, 53 
adapted width of, 54 
age and, 53 
Argyll-Robertson, 63 
associated action of, 56, 59 
cat-like, 54 
color of, 396 
contraction of, 60, 62 
convergence anomalies of, 63 
dilatation of, 61 
paradoxic, 64 
reflexes of, 57 
dilator muscle of, 57 
exclusion of, 304 
fibers, constricting, 57, 304 
dilating, 57, 61 
immobility, 63 
in atrophy of optic nerve, 484 
in cataract, 396 
in glaucoma, 368 
in hemianopsia, 517 
measurement of, 54 
myotonic movement of, 64 
occlusion of, 304, 671 
paralysis of sphincter muscle of, 61 
position of, 53 
reaction of accommodation, 56, 59 
cerebral cortical, 56, 60 INDEX 
743 
Pupil reaction, convergence, 56, 59 
neurotonic, 64 
orbicularis, 57 
pain, 56 
special, 64 
Westphal-Piltz, 57 
reflex action of, indirect, 55 
light, 55, 59 
centrifugal pathway of, 58 
cerebral cortex, 56 
consensual, light, 55, 59 
dilator, 57, 59 
direct light, 55, 59 
explanation of, 57 
Gifford-Galassi, 57 
Haab's, 57 
immobility of, 63 
lid-closure, 57 
of imagination, 57 
palpebral, 51, 57, 64 
relaxation, 57 
sensory, 56, 59 
skin, 56, 61 
retinal adaptation to light and, 54 
seclusion of, 304 
sex and, 53 
size of, 53, 54 
sphincter muscle of, 57 
unequal, 64 
varying inequality of, 64 
width of, 64 
Pupillary dilatation, paradoxic, 64 
inaction, hemianopic, 518 
hemiopic, 64,518 
membrane, persistent, 299 
movements, 55 
muscle, 57 
phenomena, 64 
reactions, paradoxic, 64 
rigidity, 61 
Pupillometer, 54 
Haab's, 54 
Purpura, 452 
Pus in vitreous, 414 
Pustule, migratory, 242 
Pyemia, 249, 452 
Pyocyanase in hypopyon keratitis, 256 
Pyoktanin, 175, 256, 571 
Pyorrhea alveolaris, 324, 328 
Pyramidal cataract, 198 
Radium in angioma of eyelid, 170 
in carcinoma of eyelids, 176 
in granular conjunctivitis, 224 
in optic atrophy, 488 
in orbital growths, 579 
in sarcoma of eyelid, 173 
in ulcer of cornea, 257 
in vernal conjunctivitis, 214 
in uveitis, 329 
in xanthelasma, 171 
Ramsay's modification of Worth's ambly- 
oscope, 551 
Raphanic cataract, 400 
Raynaud's disease, 460 
Rays, 17, 20 
axial, 94 
convergent, 22 
divergence of, 21 
divergent, 22 
parallel, 22 
significance of kinds of, 22 
Reading-glasses, adjusting of, 156 
Readjustment for squint, 675 
Reclination for cataract, 647 
Rectal abscess, 289 
Rectus, external, 519. See also External 
rectus. 
inferior, 519. See also Inferior rectus. 
internal, 519. See also Internal rectus. 
superior, 519. See also Superior rectus. 
Red vision, 507 
Red-blindness, 68, 69, 497 
complete, 68 
Red-green blindness, 497 
Reese's forceps, 678 
muscle-resection operation, 678 
Reflection, 89 
Refracting angle of prism, 18 
Refraction, 17 
abnormal, 120 
angle of, 18 
determination of, by ophthalmoscope, 
106, 110 
development of choked disk and, 476 
errors of, vitreous opacities from, 416 
index of, 17 
normal, 120 
ophthalmoscope, 91 
skiascopy for, 111. See also Skiascopy. 
striae of, in cataract, 396 
through prism, 18 
Refractometer, Thomson's, 111 
Region of accommodation, 37 
Reid ophthalmometer, 111 
Relapsing fever, 477 
Relative accommodation, 46, 70 
Relaxation-reflex of pupil, 57 
Relieving prism, 559 
Resection of temporal wall of orbit, 
646 
Retention cyst of ethmoid sinus, 586 
of eyelid, 184 
theory of chronic glaucoma, 380 
Retina, 104 
adaptation of, 54, 84 
anemia of, 422 
Quaglino's operation for glaucoma, 628 
Quinin, 163, 164, 210, 212, 244, 290, 359, 
422, 506, 571, 577 
amaurosis from, 501 
sulphate, 213 
Rabbit's bite, 256 
conjunctiva, transplantation of, 238, 
616 
cornea, transplantation, 261 
Rachitis, 266, 399 
Radian, 19 
Radium, 170, 214, 257, 329, 579, 580 744 
INDEX 
Retina, anesthesia of, 423, 509 
symptoms, 423 
traumatic, 461, 509 
treatment, 424 
aneurysms in, 456 
angioid streaks of, 455 
angiomatosis of, 456 
angiosclerosis of, 454 
apoplexy of, 451. See also Retina, 
hemorrhages in. 
arteries of, 101, 104 
changes in, 453 
intermittent closing of, 460 
atrophy of, 426, 427 
gyrate, 442 
in retinitis, 426, 427 
macular, 468 
blood-vessels of, 101, 104 
capillary congestion of, 421 
central artery of, embolism of, 457. See 
also Retina, central artery of, ob- 
struction of. 
obstruction of, 457 
causes, 459 
cilioretinal vessels in, 459, 460 
diagnosis, 459 
field of vision in, 459 
intra-ocular tension in, 459 
ischemic necrosis in, 457 
macula in, 457 
massage in, 460 
opacity in, 457 
optic nerve in, 458 
prognosis, 460 
symptoms, 457 
treatment, 460 
vein of, thrombosis of, 460 • 
prognosis, 460 
secondary glaucoma in, 461 
symptoms, 460 
changes in, from electric light, 463 
from sunlight, 463 
color of, 104 
congestion of, 123 
corresponding points of, 521 
capillary, 421, 422 
cyanosis of, 424 
cysticercus, 448, 466 
cysts of, 466 
degeneration of ganglion-cells in, 467, 
486, 491, 501, 503 
detachment of, 99, 135, 362, 363, 392. 
401, 418, 442, 447, 456, 463, 468 
causes, 448 
color of, 447 
complete, 447 
congenital, 449 
diagnosis, 450 
diffusion theory of, 449 
examination for, 99 
field of vision in, 448 
flat, 447 
from diseases of nasal accessory si- 
nuses, 590 
hemorrhagic, 449 
hereditary, 449 
Retina, examination for, mechanical 
theory of, 449 
mechanism, 449 
metamorphopsia in, 448 
partial, 447 
prognosis, 450 
sclerotomy for, 450 
serous, 447 
symptoms, 447 
traumatic, 449 
treatment, 450 
vision in, 448 
diseases of, 421 
edema of, 427, 454, 461 
family cerebral degeneration of, with 
macular changes, 467 
glioma of, 365, 464 
diagnosis, 465 
endophytum, 464 
exophyturn, 464 
fungus hematodes in, 465 
prognosis, 466 
recurrence of, 464, 466 
rosettes in, 464 
sarcoma of choroid and, 362 
stages of, 464 
treatment, 466 
gyrate atrophy of, 442 
hemorrhages in, 426, 451, 582 
causes, 452 
flame-shaped, 426 # 
prognosis, 453 
subhyaloid, 451 
treatment, 453 
histology of, 512 
hyperemia of, 421 
hyperesthesia of, 422 
causes, 423 
in glaucoma, 385 
treatment, 423 
increased redness of, 421 
irritation of, 422, 430 
ischemia of, 422 
light perception of, 84 
reflex of vessels of, 101 
light-sense of periphery of, 84 
macular atrophy of, 468 
massive exudation of, 455 
neuro-epithelioma of, 464 
opacity in, in embolism, 458 
periphery of, acuteness of vision in, 84 
functions of, 83 
light-sense in, 84 
pigment striae of, 455 
pigmentary degeneration of, 442. See 
Retinitis pigmentosa. 
pigmentation in, 426 
in choroiditis. 349 
syphilis and, 350 
pulsation of blood-vessels of, 101 
rupture of, traumatic, 461, 463 
sclerosis of, without pigmentation, 445 
shot-silk, 104 
snow-bank appearance in, 433, 438 
spontaneous pulsation of veins of, 102 
structure of, 512 INDEX 
745 
Retina, subhyaloid hemorrhage of, 451 
symmetric changes in macula of, 466 
transparency of, 425 
traumatic amblyopia of, 461 
anesthesia of, 461, 509 
edema of, 461 
perforation of macula of, 461 
traumatisms of, 461 
undue capillarity of, 421 
veins of, 101, 104 
vessels of, changes in, 453, 454 
distribution of, 102 
Retinal artery, central, embolism of, 457 
intermittent closing, 460 
spasm of walls of, 459 
thrombosis of, 457 
images, 43 
in ametropia, 34 
in emmetropia, 34 
in hyperopia, 34 
in myopia, 35 
exudation, massive, 455 
lid-closure reflex, 57 
periphlebitis, 418 
phlebitis, 589 
pigment striae, 455 
thrombosis, 589 
vein, central, thrombosis of, 460 
distention of, 583 
vessels, aneurysm of, 456 
diseases of, 392, 453 
endarteritis, 429 
intermittent blood-stream in, 457 
Retinitis, 416, 425 
acute, 427 
albuminuric, 392, 433, 438 
blue-blindness in, 434 
causes, 435 
complications, 436 
course, 435 
date of occurrence, 435 
degenerative, 434 
diagnosis, 437 
exudative, 434 
forms of, 434 
frequency, 435 
hemorrhages in, 433, 434 
inflammatory, 434 
in pregnancy, 435, 436 
neuritic, 434 
papillitic, 434 
pathology, 435 
pigmentation in, 442 
prognosis, 435, 436 
star-shaped figure in, 433 
symptoms, 433, 434 
treatment, 438 
unilateral, 435 
varieties, 434 
violet-blindness in, 434 
angiopathic, 433 
areas of exudation in, 425 
atrophicans centralis, 468 
atrophy in, 426, 427 
blood-vessels in, 425 
cachectic, 452 
Retinitis, caliber of vessels in, 425 
causes, 425 
central punctate, 442 
and striate, 442 
diabetic, 438 
relapsing, 428, 431 
choroiditis and, 346 
chronic, 427 
circinata, 438, 441 
circumscribed, 425 
classification, 425 
complications, 427 
course, 427 
deep, 428 
prognosis, 428 
diabetic, 425, 438 
central punctate, 438 
exudative, 438 
hemorrhagic, 438 
treatment, 439 
diagnosis, 427 
diffuse, 425, 427 
distortion of vision in, 426 
edema of, 427 
electric, 463 
exudation areas in, 425 
exudative, 455 
field of vision in, 426 
haemorrhagica externa, 455 
hemorrhages in, 425, 426, 432 
hemorrhagic, 277, 425, 432 
causes, 432 
prognosis, 433 
treatment, 433, 453 
leukemic, 439 
loss of transparency in, 425 
macropsia in, 426 
macularis, 431 
metamorphopsia in, 426 
metastatic, 432 
micropsia in, 426 
nerve-head in, 426 
nyctalopia, 506 
of Bright's disease. See also Retinitis, 
albuminuric. 
pain in, 426 
parenchymatous, 425, 427 
pathology, 425 
photophobia in, 426 
pigmentosa, 347, 426, 442, 446, 468, 
510 
atypical varieties, 444 
causes, 444 
contracted visual field in, 443 
contraction of vessels in, 443 
course, 446 
depreciation of central vision in, 443 
diagnosis, 446 
field of vision in, 443 
glaucoma with, 444 
heredity in, 445 
nerve-head in, 443 
night-blindness in, 444 
nystagmus in, 443 
opacities in, 443 
pathology, 445 746 
INDEX 
Retinitis pigmentosa, prognosis, 446 
symptoms, 442 
treatment, 446 
varieties of, 444 
vessel contraction in, 443 
vision in, 443 
wainscoted fundus in, 443 
primary, 425 
suppurative, 432 
prognosis, 427 
. proliferating, 440 
punctata albescens, 442 
renal, 433. See also Retinitis, albumin- 
uric. 
Roth's septic, 432 
secondary, 425 
serous, 427 
simplex, 427 
solar, 463 
striata, 442 
symptoms, 425 
syphilitic, 425, 428 
course, 430 
date of occurrence, 430 
endarteritis in, 429 
prognosis, 430 
simple, 428 
symptoms, 430 
treatment, 430 
tortuosity of vessels in, 425 
transparency in, 425 
treatment, 427, 430 
types, 427 
varieties, 425 
visual acuteness in, 426 
field in, 426 
vitreous opacities in, 427, 443 
with exudations, 428, 430 
with hemorrhages, 428, 430 
Retinochoroiditis, 346, 428. See also 
Choroidoretinitis. 
juxta papillaris, 350 
Retinoscopy, 111. See also Skiascopy. 
Retrobulbar neuritis. See Optic neuritis. 
Revolving prism, 75 
Rheumatic iritis, 310 
palsies, 536 
Rheumatism, 287, 289, 310, 324, 477, 488, 
535. 574, 578 
Rhinitis, 199, 211, 241, 244 
infectious, 241 
purulent, 257 
Rhinopharyngitis, 189 
Rice-starch powder, 164 
Ring abscess after cataract extraction, 
665 
choroidal, 100 
connective-tissue, 100 
glaucomatous, 369 
scleral, 100 
scotoma, 85, 444 
Vossius', 405 
Ring's ocular mask, 657 
Risley's rotary prism, 74, 75 
Rod test of heterophoria, 74, 77 
Rodent ulcer of cornea, 249 
Rodent ulcer of eyelids, 174 
Rods of retina, 512 
Roemer's method of using jequiritol, 225 
serum, 255 
Rbnne's nasal step in scotoma, 375 
Rontgen rays. See x-Rays. 
Rosacea keratitis, 265 
Roseola, 307 
Rotary prism, Risley's, 74, 75 
Rotation, center of, 41 
Roth's septic retinitis, 432 
Rupture of choroid, 366 
spontaneous, of glaucomatous eyeball, 
376 
Saccharinate of sodium, 272 
Saemisch's operation, 254, 620 
ulcer of cornea, 246 
Sago-grain granulations, 220 
Salicylate of eserin, 387 
of sodium, 164, 261, 264, 288, 312, 339, 
340, 387, 391, 450, 665 
in glaucoma, 387 
of strontium, 312 
Salicylates, 578 
Salicylic acid, 288, 422, 489, 538, 571 
amblyopia from, 501 
in iritis, 312 
ointment, 213, 258, 288, 312, 489, 
538, 571 
Salmon patch of Hutchinson, 267 
Salol, 258, 290 
Salt solution, physiologic, 238, 297, 328, 
352, 409, 417, 450, 501, 593, 649, 652, 
653, 657, 659, 660 
Salvarsan, 169, 272, 310, 328, 341, 352, 
387, 430, 478, 487, 538, 575 
Salvarsanized serum, 487 
Santonin, 487 
Sarcinae, 188 
Sarcoma of anterior chamber, 321 
of antrum, 589 
of brain, 476 
of caruncle, 239 
of choroid, 359, 363, 392, 448, 464. See 
also Choroid, sarcoma of. 
of ciliary body, 331, 363 
of conjunctiva, 235 
of cornea, 285 
of eyelids, 173 
of iris, 318 
of lacrimal glands, 565, 569 
of liver from choroidal sarcoma, 362 
of orbit, 579, 580, 581 
of sclera, 292 
Savage's method for shortening tendons, 
680 
orthoptic exercises, 559 
Scalds of cornea, 282 
Scar-fibroma of cornea, 284 
Scar, filtration, 391 
keratitis, 260 
Scarifier, three-bladed, 617 
Scarlet fever, 249, 358, 477, 500, 576 
red in corneal ulcer, 257 INDEX 
747 
Schiotz tonometer, 86, 87, 377 
Schiotz and Javal ophthalmometer, 110 
Schlemm's canal, 379,• 385 
Schmidt's enucleation method, 637 
School follicles, 214 
folliculosis, 214 
Schweigger's hand perimeter, 80 
method of advancement, 677 
test, 545 
Schweinitz's enucleation method, 637 
modification of amblyoscope, 551 
test for binocular vision, 554 
Scissors, enucleation, 636 
iris, 623 
Sclera, abscess of, 292 
blood-vessels of, 49 
brawny infiltration of, 291 
carcinoma of, 292 
congenital pigmentation of, 297, 298 
cysts of, 292 
diseases of, 287 
enchondroma of, 292 
fibrochondroma of, 292 
fibroma of, 292 
foreign bodies in, 293 
glioma of, 292 
inflammations of, 287. See also Scleri- 
tis. 
injuries of, 292 
prognosis, 293 
symptoms, 292 
treatment, 293 
melanosis of, 297 
operations on, 628 
osteoma of, 292 
perforation of, 292 
after tenotomy, 673 
in enucleation, 637 
pigment spots in, 297 
rupture of, 292, 367 
sarcoma of, 292 
staphyloma of, 291 
stiffened, 368 
trephining, 391, 631, 632 
tumors of, 292 
ulcers of, 292 
vasomotor dilatation of, 288 
wounds of, 292 
Scleral crescents, 356 
puncture, 388 
ring, 100 
in optic nerve atrophy, 482 
sutures, 293 
trephining, 391, 631, 632 
Sclerectomy combined with iridectomy, 
629 
simple, 630 
with punch forceps, 631 
with trephine, 631 
Scleritis, 50, 287, 288, 290 
annular, 291 
causes, 289 
gummatous, 289 
hyperplastic, 288 
indurative, 382 
nodular, 288 
Scleritis, pathology of, 289 
posterior, 291 
scrofulous, 290 
symptoms, 50 
treatment, 290 
tuberculous, 289 
Sclerochorioretinitis, intra-uterine, 285 
Sclerocorneal trephining, 632 
Sclerokeratitis, 289 
Sclerokerato-iritis, 290 
Sclerophthalmia, 285 
Sclerosing trachoma, 219 
Sclerosis, 477, 485 
amyotrophic lateral, 485 
disseminated, 539, 562 
multiple, 64 
of choroidal vessels, 352 
of cornea, 278, 285 
of retina without pigmentation, 444 
posterior, 291 
Scleroticochoroiditis, 128, 346 
acute posterior, 128 
anterior, 356 
myopia from, 128, 129 
posterior, 356 
Sclerotics, blue, 298 
transillumination of, 363 
Sclerotome, 628 
Sclerotomy, 332, 391, 460, 628 
anterior, 628 
in chronic glaucoma, 391 
in detachment of retina, 450 
in glaucoma, 391 
in hydrophthalmos, 280 
in sympathetic ophthalmitis, 340 
internal, 629 
lines of incision in, 629 
posterior, 329, 629 
Scopolamin, 118, 312, 328, 340. 634 
Scorbutus, 592 
Scotomas, 85, 326, 346, 352, 462, 463, 
483, 500, 502, 507, 509, 543 
absolute, 85 
annular, 444, 510 
Berry's test for, 86 
Bjerrum's, 386 
symptom in, 374 
central, 85, 483 
exhaustion, 510 
color, 85 
detection of, 86 
from diseases of nasal accessory sinuses, 
589 
in choroiditis, 346 
in glaucoma, 373 
in hysteria, 509 
in myopia, 133 
negative, 85 
optic neuritis with, 512 
paracentral, 85 
peripapillary, 85 
peripheral, 85 
physiologic, 85 
positive, 85 
relative, 85 
ring, 85, 444, 510 748 
INDEX 
Scotomas, Ronne's nasal step in, 374 
stationary optic nerve atrophy with, 
511 
unilateral, 510 
van der Hoeve's, 591 
with central amblyopia, 510 
with optic atrophy, 511 
neuritis, 512 
Scotometers, 86 
Screen test for heterophoria, 72, 557 
Scrofula, 208, 241, 266, 289 
Scrofulosis, 241, 258 
Scrofulous ophthalmia, 211 
Scurvy, 452 
Sea-sickness, 400 
Sebaceous cyst of eyelids, 185 
Seborrhea nigricans, 184 
of lid-border, 165, 183 
Second sight, 129, 395 
Secondary axes, 26 
deviation, 527, 529, 530, 531, 532 
position of eyes, 520 
Seidel's method of local anesthesia, 598 
sign in glaucoma, 375 
Semi-albinism, 344 
Semi-atrophic crescents, 356 
Senile cataract, 401 
degeneration of ciliary body, 331 
Sensibility of cornea, 51 
Sensory reflex of pupil, 56, 59 
Septic iritis, 302, 314 
Serpiginous ulcers of cornea, 246 
Serum, antidiphtheritic, 255 
antigonococcus, 203, 205 
antipneumococcic, 255, 652 
streptococcal, 255 
treatment of corneal ulcers, 255 
Sexual abuses, 423, 486 
Shadow test, 111. See also Skiascopy. 
Shock, electric, 401 
Short-sightedness, 121. See also Myopia. 
Shot-silk retina, 104 
Sick headaches, 422 
Sideroscope method of locating foreign 
bodies, 294 
Siderosis bulbi, 297 
conjunctivae, 15. 
Siegrist's method of local anesthesia, 597 
Sight, 17. See also Vision. 
second, 129, 395 
Silver catarrh, 200. See also Nitrate. 
Single vision, 43 
in concomitant strabismus, 545 
Sinuses, diseases of, 535, 585 
Sinusitis, 88, 478, 585 
Sinusoidal currents, 488 
Sixth nerve, 519. See also Abducens. 
Skiascopy, 89, 111 
in astigmatism, 115, 116 
in emmetropia, 115 
in hyperopia, 114 
in myopia, 113 
with concave mirror, 112, 113, 116 
with plane mirror, 112 
Skin, preparation of, for operation. 593, 
652 
Skin-grafting by Thiersch's method, 614 
without pedicle, 614 
Skin-reflex of pupil, 56, 61 
Skull deformities, papillitis from, 477 
fracture of, hemorrhage into optic 
nerve sheath after, 499 
Sloped molar of Gifford, 269 
Small-pox, 249, 358, 477, 564 
Smell, disturbances of, 583 
Smith's (Col. Henry) operation for cat- 
aract, 660 
(Homer E.) capsulotomy before cat- 
aract extraction, 669 
(Priestly) enucleation method, 637 
keratometer, 51, 54 
tape measurement of strabismus, 547 
test for binocular vision, 554 
for malingering, 505 
theory of strabismus, 544 
Snellen's artificial eye, 639 
method of tenotomy, 672 
suture operation for ectropion, 610 
test for malingering, 505 
types, 67 
Snow-blindness, 507 
Snydacker's test for colors, 70 
Soamin, blindness from, 503 
Sodium bromid, 408 
chlorid, 209, 256, 450, 597, 654, 656 
citrate, 387 
iodid. See lodid. 
saccharinate, 272 
salicylate. See Salicylate. 
sulphate, 261 
Solar retinitis, 463 
Solution operation for cataract, 647 
Sophol, 200 
Sourdille's operation for ptosis, 602 
Sozoiodolate of zinc, 194 
Spasm of convergence, 541 
Spasmus nutans, 562 
Spastic mydriasis, 61 
myosis, 62 
Spatula and probe, 623 
Spectacles, 154 
adjustment of, 154 
stenopaic, 147 
telescopic, 136 
testing of lenses in, 155 
treatment of strabismus by, 538, 548, 
553 
Spectroscope, 70 
test for color-blindness, 70 
Speculum, eye, 622 
Sphenoid sinus, disease of, 587 
empyema of, 587 
hyperostoses of, 588 
osteoma of, 588 
polypi of, 588 
Spheres of Morgagni, 398 
Spheric lenses, 30 
combination with cylindric, 32 
with prism, deviating effect, 560 
Sphincter, muscle of, 61 
paralysis of, 61, 542 
pupillae, 57 INDEX 
749 
Sphincter, rupture of, 320, 366 
Spinal disease, 541 
miosis, 62 
Spirochaeta pallida, 169, 262, 307, 329, 
351 
Split bifocals, 157 
Sponge grafting into orbit, 640 
Spongy exudate after cataract extraction, 
666 
Spontaneous pulsation of retinal veins. 
102 
Spoon, metal, 653 
Sporothrix Beurmanii, 168 
Sporotrichosis of conjunctiva, 227 
of eyelids, 168 
Spring catarrh, 212 
conjunctivitis, 212 
Squint, 71, 523. See Strabismus. 
Squinting eye, 523 
Squirrel plague conjunctivitis, 195 
Stanculeanu's operation for cataract, 662 
Staphylococcus, 161, 162, 167, 189, 195, 
208, 209, 211, 226, 242, 248, 568, 665 
conjunctivitis, 189, 208 
in corneal ulcers, 247 
pyogenes albus, 188, 211, 242, 324 
aureus, 188, 211, 242 
vaccine, 255, 665 
Staphyloma, 88, 245 
annular posterior, 356 
anterior, 198 
of cornea, 259 
congenital anterior, 286 
treatment, 262 
of sclera, 291 
operations for, 620 
posterior, 128, 132, 356, 470 
annular, 356 
Starch, 163 
Stauungs-papille, 480 
Steel splinter in eyeball, 293, 295 
Stell wag's sign in goiter, 584 
Stenopaic slit, 144 
spectacles, 147 
Stenosis of punctum lachrymale, 566 
Stephenson's sclerectomy trephines, 634 
Stereoscope, 548, 549 
Stevens' classification of hetercphorias, 71 
clinoscope, 692 
phorometer, 75 
tenotomy, 672, 674 
instruments, 674 
tropometer, 690 
Stiffened sclera, 368 
Stilling's pseudo-isochromatic plates, 70 
Stomach, carcinoma of, 452 
Stony hardness of eye in glaucoma, 368 
Stop needle, Bowman's, 648 
Stovain, 596 
Strabismus, 41, 71, 88, 523 
alternating, 542, 546, 552 
amblyoscope in, 549 
angle of, 546 
atropinization of, 548 
concomitant, 542 
accommodation in, 542 
Strabismus, concomitant, amblyopia in, 
543 
bar reading in, 551 
causes, 542 
constant, 542 
convergence in, 542 
educative treatment, 548 
fusion faculty in, 544 
inequality of vision in, 543 
innervation in, 545 
operative treatment, 551 
periodic, 542 
single vision in, 545 
spectacle treatment, 547 
stereoscope in, 548, 549 
tenotomy for, 551, 553 
treatment, 547 
varieties, 542 
Worth's amblyoscope in, 549 
congenital paralytic, 537 
constant, 542 
convergent, 42, 523, 529, 542 
accommodation and convergence, 
disturbances as cause, 543 
advancement in, 675 
angle gamma in, 545 
atropinization for, 548 
constant, 542 
diplopia in, 545 
educative treatment, 548 
fusion faculty in, 544 
in hyperopia, 122 
Javal's controlled reading in, 551 
occlusion of fixing eye in, 548 
operative treatment for, 551, 553 
orthoptic training in, 548 
readjustment in, 675 
results of operation in, 553 
shape of eyeball as cause, 545 
single vision in, 545 
stereoscope in, 548 
treatment, 547 
deorsum vergens, 523 
divergent, 41, 523, 524, 529. 533, 542 
advancement in, 552, 675 
cause, 544 
concomitant, 552 
glasses in, 553 
myopia and, 130, 543 
operations for, 553 
readjustment in, 675 
tenotomy for, 553 
treatment, 553 
downward, 525, 530 
dynamic, 71 
functional, internal, 525 
heredity and, 544 
heterophoria and, differentiation, 556 
hooks, 671 
in hysteria, 554 
latent, 71 
measurement of, 546 
angular method, 546 
Smith's tape method, 547 
tangent method, 546 
monocular, 542 750 
INDEX 
Strabismus, operations for, 551, 553, 671 
outward, 45 
paralytic, 526 
binocular single vision in, 526 
carriage of head in, 528 
causes, 535 
complete, 526 
congenital, 537 
diagnosis, 533 
diplopia in, 526 
examination of eye in, 533 
field of vision, 527, 529, 531, 532 
from injury, 536 
incomplete, 526 
method of examination in, 533 
orbital, 535 
primary deviation in, 527 
prognosis, 538 
secondary deviation in, 527, 529, 531, 
532 
symptoms, 526, 528 
treatment, 538 
periodic, 542 
spastic, 554 
suppressed, 71 
sursum vergens, 523 
tenotomy for, 551, 552, 553 
uniocular, 557 
upward, 525, 532 
vertical, 542, 553 
Strabisometer, 546 
Stramonium, 490 
amblyopia from, 501 
Streptococcal serum, 255 
Streptococcus pyogenes, 161, 188, 195, 
196, 209, 228, 248, 568, 569 
diphtheria of conjunctiva, 209 
Streptothrix, 248, 566 
Striae of refraction, 396 
Stricturotome, Thomas', 682 
Stroschein flasks, 595 
Struma, 128, 571 
Strychnin, 163, 258, 388, 422, 446, 461, 
487, 491, 501, 558, 562 
Stye, 123, 162 
Subconjunctival hemorrhage, 232 
injections, 256, 271, 272, 288, 341, 352, 
619 
in corneal opacities, 261 
ulcers, 256 
in detachment of retina, 450 
in iritis, 310 
Subduction, 519 
Subperiosteal abscess, 574, 590 
Subretinal cysticercus, 448, 466 
Suction method of cataract extraction, 
649 
Suker's enucleation method, 636 
Sulphate of copper, 206, 207, 215, 223, 
994 997 
of eserin, 386, 453 
of quinin, 213 
of zinc, 168, 193, 571, 634 
Sulphuric acid poisoning, 539 
Sunlight, retinal changes from, 463 
Sunstroke, 477 
Superduction, 519 
Superior colliculus of corpora quadrigem- 
ina, 513 
oblique, 519 
paralysis of, 532 
frequency, 538 
rectus, 519 
paralysis of, 529 
frequency, 538 
tenotomy of, 673 
Suprarenal extract, 188, 213, 227 
Suprarenin, 598 
Sursumduction, test for, 74 
Sursumvergence, left, 74 
right, 74 
test for, 74 
Suspensory ligament, 379 
Sutcliffe's ophthalmometer, 111 
Sutures, 594 
Kalt's corneal, 663 
pulley, 677 
tobacco-pouch, 639 
Sweet's x-ray method of locating foreign 
bodies, 293, 295, 692 
Swelling with catarrh, 215 
Swimming-bath conjunctivitis, 192 
Sycosis tarsi, 165 
Symblepharon, 158, 180 
congenital, 158 
operations for, 615 
Sympathectomy in glaucoma, 391 
Sympathetic affections, conditions pro- 
ducing, 332 
ganglion, superior cervical, excision of, 
391 
inflammation, 322, 331, 333. See also 
Ophthalmitis, sympathetic. 
irritation, 322, 331, 332, 333 
causes, 332 
incubation period, 335 
pathology, 335 
symptoms, 333, 335 
neurosis, 332 
ophthalmia, 331. See also Ophthalmi- 
tis, sympathetic. 
ophthalmitis, 331. See also Ophthal- 
mitis, sympathetic. 
paralysis of, 62 
uveitis, 333, 335 
Sympathizing eye, 331 
Synchysis, 418 
scintillans, 419 
Synechia, anterior, 258 
division, 628 
posterior, 302 
Synkinesis, 55 
accommodation, 56 
Syphilis, 63, 162, 168, 176, 177, 232, 262, 
266, 289, 291, 298, 306, 308, 309, 324, 
329, 351, 378, 399, 407, 416, 477, 535, 
539, 541, 571, 574, 578, 585 
choroiditis from, 351 
hereditary, 266, 309 
in oculomotor palsies, 535 
of ciliary body, 329 
of conjunctiva, 232 INDEX 
751 
Syphilis of eyelids, 168, 169 
of lacrimal gland, 565 
Syphilitic iritis, 306 
keratitis, 266 
papules of iris, 308 
Syphiloma of ciliary body, 329 
Syringe, Anel, 683 
Syrup of hydriodic acid, 408, 461 
Szymanowski-Kuhnt operation for ec- 
tropion, 609 
Tenotomy, graduated, for heterophoria, 
560 
in ocular paralysis, 538 
in strabismus, 551, 553 
of external rectus in myopia, 135 
of inferior oblique, 672 
indications for, 673 
open method, 672 
partial, 560, 674 
subconjunctival, 671 
Tension, intra-ocular, 86 
Tensor choroidese, 36 
Teratoid tumors of cornea, 285 
Teratoneuroma embryonale, 331 
Test types, 35, 65, 67, 124 
Testing of eye, functional, 47 
Test-letters and lines, Thorington's met- 
ric, 146 
Tetany cataract, 403 
Thalamus, pulvinar of, 513 
Theobromin, 596 
Thermotherapy, 257 
Thiersch's method of skin-grafting, 614 
in symblepharon, 616 
Thiosinamin, 238, 261 
Third nerve, 57, 519, 520. See also Ocu- 
lomotor nerve. 
Thomas' stricturotome, 682 
Thomson's lantern test for color-blind- 
ness, 69 
refractometer, 111 
test for color-blindness, 68 
Thorington's metric test-letters and Unes, 
146 
Thorium, 177 
Thread operation for ptosis, 600 
Three-blade scarifier, 617 
Thrombophlebitis, 577 
Thrombosis of cavernous sinus, 161, 578 
of central artery of retina, 457 
vein of retina, 460 
vessels, 576 
of orbital veins, 161 
of pial vessels, 576 
retinal, 589 
septic, 577 
Thumb exercises in heterophoria, 560 
Thyroid extract, 258, 329, 592 
Tincture of benzoin, 244 
of iodin, 581 
of iron, 438 
Tinea tarsi, 165 
Tobacco, 501, 512, 536, 539 
amblyopia, 62, 490, 512 
Tobacco-pouch suture, 639 
Todd's method of advancement, 677 
Toluidin-blue, 51 
Tonic cramp of orbicularis, 178 
Tonometer, Schiotz, 86, 87, 377 
Tonometers, 86, 368 
Tonsillitis, 314, 541 
Toric lenses, 30 
Torsion, inward, 519 
outward, 519 
vertical, 520 
Toti's operation, 685 
Tabes dorsalis. See Locomotor ataxia. 
Tachycardia, 141, 558 
Takamine's adrenalin-chlorid, 598 
Tangent method of measuring strabismus, 
546 
Tanin, 206, 215, 223 
Tansley-Hunt operation for ptosis, 601 
Tape method of measuring squint, 547 
Tarsadenitis Meibomica, 172 
Tarsal tumor, 171. See Chalazion. 
Tarsitis, 177 
Tarsocheiloplastic operation, van Millin- 
gen's, 607 
Tarsorrhaphy, 603 
angular, 604 
lateral, 603 
median, 604 
Tarsus, enchondroma of, 171 
extirpation of, in trachoma, 618 
hypertrophy of, 171 
inflammation of, 177 
ossification of, 171 
Taste, disturbances of, 583 
Tattooing cornea in leukoma, 621 
needle, 621 
Teale's method of cataract extraction, 649 
operation for symblepharon, 615, 616 
Tear-duct, diseases of, 568 
Tear-stone, 566 
Teeth, Hutchinson's, 269 
Telescopic spectacles, 136 
Temporal arteries, 101 
slant, 511 
veins, 101 
wall of orbit, resection of, Kronlein's 
operation, 646 
Gifford's modification, 647 
Tendo oculi, 567 
abscess below, 567 
Tendons, shortening of, 680 
Tenonitis, 362, 535, 578 
after tenotomy, 673 
Tenon's capsule, 357, 639 
advancement of, 680 
artificial globe in, after enucleation, 
640 
fat implantation into, after enuclea- 
tion, 641 
Tenotomy, 671 
after-treatment, 672 
complete, 671 
complications after, 673 
for heterophoria, 560 
graduated, 560, 674 752 
INDEX 
Toxalbumins, 536 
Toxic agents and cataract, 400 
conjunctivitis, 228 
Trachoma, 215. See also Conjunctivitis, 
granular. 
bacillus, 216 
bodies, 217 
folliculare, 214 
granules, 217 
operations for, 617 
Tractus. See Optic tract. 
Transferred ophthalmitis, 333 
Transillumination of frontal sinus, 586 
of sclerotic in choroidal sarcoma, 363 
of light, 17 
Transparent media, opacities in, 99 
Transplantation for pterygium, 614 
of cornea, 261 
of rabbit's conjunctiva, 238, 616 
operations, double, 605 
without pedicle, 614 
Trephining, scleral, 391, 631, 632 
sclerocorneal, 632, 635 
Trial lenses for correcting hyperopia, 124 
Trichiasis, 166, 181 
double transplantation for, 605 
electrolysis for, 605 
operations for, 605 
Trichloracetic acid, 171, 244, 253 
Trichophyton tonsurans in eyelashes, 167 
Trichosis carunculae, 239 
Trifocal lenses, 157 
Trikresol, 595 
Triplopia, binocular, 546 
Trochlear muscle, 519 
nerve, 520 
Tropacocain, 595 
Tropometer, 522, 690 
use of, 690 
Trypanosomiasis, 266 
Tscheming's theory of accommodation, 
36 
Tubercle bacillus, 248, 329 
Tuberculin, 242, 258, 288, 290, 318, 328, 
341, 352, 441, 490 
T, 271 
T R, 238, 365 
Tuberculosis, 41, 162, 262, 266, 313, 321, 
324, 364, 418, 457, 477, 539, 574, 578, 
. 585 
of angle of anterior chamber, 321 
of brain and optic neuritis, 477 
of choroid, 364 
of ciliary body, 331 
of conjunctiva, 237 
of cornea, 251 
of eyelids, 176 
of iris, 317 
of lacrimal glands, 565 
sac, 569 
Tuberculous iritis, 317 
keratitis, 251 
ulcer of cornea, 251 
Tumors, intra-ocular, 332 
of angle of anterior chamber, 321 
of brain, 434, 476. 504 
Tumors of choroid, 359 
of ciliary body, 331 
of conjunctiva, 233 
of cornea, 284 
of eyelids, 169 
of iris, 316 
of lacrimal gland, 565 
sac, 569 
of optic nerve, 492 
of orbit, 578 
of sclera, 292 
Tyloma conjunctivae, 227 
Tylosis, 166 
Types, Snellen's, 67 
Typhoid fever, 249, 314, 477, 542, 576, 
578 
Typhus fever, 249, 314, 477 
Ulcerans mycotica, 250 
Ulcers, diplobacillary, 247 
of conjunctiva, 232 
of cornea, 244. See also Cornea, ulcers 
of. 
phlyctenular, 242 
of sclera, 292 
tertiary, of eyelids, 169 
Ulcus rodens of cornea, 249 
Umbilical vein, inflammation of, 358 
Underlying conus, 102 
Upright image, 96. See also Ophthalmos- 
copy, direct method. 
Uremic amblyopia, 500 
Urethral hemorrhage, 501 
Urine in cataract, 399 
Urotropin, 665 
Urticaria of eyelids, 160 
Uterine disease, 424, 554 
Uvea, congenital ectropion of, 301 
Uveal tract, diseases of, from diseases of 
nasal accessory sinuses, 589 
Uveite irienne, 311 
Uveitis, 207, 301, 323, 324 
anaphylactic, 337 
anterior, 266 
causes, 324 
choroiditis in, 325 
chronic, 324 
Descemet's membrane in, 327 
dots on cornea in, 324, 325, 326 
drugs in, 328 
fibrinosa sympathetica, 333 
galvanism in, 328 
infective, 333 
iridectomy in, 329 
malignant, 326 
massage in, 328 
mutton-fat deposits in, 325, 327 
paracentesis in, 329 
pathology, 327 
proliferative, 337 
punctate deposits on cornea in, 325, 
326, 327 
radium in, 329 
recurrent, 326 
sclerotomy in, 329 INDEX 
753 
Uveitis, senile, 326 
serous sympathetic, 333 
sympathetic, 333 
symptoms, 324 
treatment, 327 
Vision in retinitis, 443 
indirect, 79 
inequality of, strabismus from, 543 
iridescent, in glaucoma, 375, 507 
loss of, 495 
monochromatic, 68 
normal acuteness of, 35 
obscurity of, 495 
of periphery of retina, acuity of, 84 
peripheral, in glaucoma, 372 
relative field of, 82 
red, 507 
single, 43, 522 
in concomitant strabismus, 545 
test for acuteness in peripheral parts of 
retina, 84 
testing acuteness of, 65 
Visual acuteness, 35, 65 
in cataract, 395 
in glaucoma, 372 
in retinitis, 426 
normal, 35 
angle, 34 
axis, 41 
cells, 512 
disturbances, hysteric, 504 
ganglia, primary, 513 
field. See also Field of vision. 
line, 41 
rotation of eyeball around, 520 
neurons, peripheral, 512 
phenomena with pituitary body dis- 
ease, 510 
radiations, 513 
tract, 512 
zone, 116 
Vitreous, 379, 380 
abscess of, 414 
artificial, insertion of, after evisceration, 
640 
blood-vessel formation in, 419 
cholesterin in, 419 
cyclitis with, 326 
cysticerci in, 420 
detachment of, 420 
diseases of, 414 
dust-like opacities of, 416 
entozoa in, 420 
examination of, bv transmitted light, 
99 
exudation into, 305 
fatty degeneration of, 416 
filaria sanguinis hominis in, 420 
fluidity of, 418 
foreign bodies in, 420 
hemorrhage into, 417 
malignant, 418 
recurring, 418 
spontaneous, 418 
in glaucoma, 369 
inflammation of, 305, 414. See also 
Hyalitis. 
opacities, 99, 346, 415 
causes, 416 
detection, 415 
dust-like, 416 
Vaccine, 665 
antistaphylococcic, 665 
bacterial, 162 
blepharitis, 163 
gonococcic, 313 
treatment of corneal ulcers, 255 
of infectious conjunctivitis, 227 
staphylococcic, 328 
vesicles of eyelid, 163 
Valk's method of shortening ocular ten- 
dons, 680 
Van der Hoeve's scotoma, 591 
test for accessory sinus disease, 590 
Van Millingen's tarsocheiloplastic opera- 
tion, 607 
Variola, 262, 314 
Vascular keratitis, 221, 265 
Vasculitis 453, 574 
Vaselin, 163, 239, 282 
bichlorid, 652, 657 
Vasomotor blepharitis, 165 
Vernal conjunctivitis, 212, 213 
Verruca of eyelids, 169 
Verrucosities of choroid, 354 
Vertical meridian, 32, 520 
abnormal positions of, 526 
of lens, 32 
Verticillium graphii, 248 
Vertigo, 141, 527, 537, 557 
Vibration massage, 261 
Vicarious fovea, 546 
Vienna method of enucleation, 636 
Violet-blindness, 68, 434, 497 
Virtual focus of convex leps, 24 
Vision, 17 
. acuteness of, 35, 65 
testing, 65 
binocular, 82, 521 
field of, 82 
binocular single, 522 
loss of, in squint, 526 
tests for, 553 
blue, 508 
color field of, 83 
dimness of, 495 
direct, 79 
for colors, 70 
disturbances of, without ophthalmo- 
scopic changes, 495 
double, 43 
field of, 79. See also Field of vision. 
green, 508 
halo in glaucoma, 369, 375 
in iritis, 375 
in atrophy of optic nerve, 483 
in cataract, 395 
in choked disk, 473 
in optic neuritis, 473 
in orbital disease, 574 754 
INDEX 
Vitreous opacities, fixed, 415 
from diseases of eye, 416 
from injuries of eye, 416 
from refractive error, 416 
from systemic disease, 416 
in retinitis, 427, 443 
method of detection, 415 
in transparent media, 99 
moving, 415 
prognosis, 416 
symptoms, 415 
treatment, 416, 418 
without apparent cause, 416 
pus in, 414 
symptoms, 414 
treatment, 415 
Von Graefe's equilibrium test, 73 
method of extraction with iridectomy, 
651 
of tenotomy, 672 
sign in goiter, 584 
von Helmholtz's ophthalmoscope, 91 
Vossius' ring, 405 
Wolffberg's test, 66 
Wood alcohol, amblyopia from, 502 
Woolly choroid, 345 
Word-blindness, congenital, 498 
Worth's amblyoscope, 549 
method of advancement, 678 
operation for ptosis, 600 
Worth-Black amblyoscope, 550 
Wright's antistaphylococcic vaccine, 665 
Xanthelasma, 171 
Xanthoma, 171 
Xanthopsia, 506 
Xeroderma pigmentosum of eyelids, 177 
Xeroform, 256 
Xerophthalmos, 230 
Xerosis, 221 
bacillus, 172, 188 
of conjunctiva, 230, 262 
Xerotic keratosis, 262 
X-rays, 162, 214, 224, 487, 579, 580, 586, 
588, 591 
conjunctivitis from, 507 
for carcinoma of eyelids, 175 
localization of foreign bodies with, 294, 
692 
Wainscoted fundus in retinitis pigmen- 
tosa, 443 
Wallace's astigmatic chart, 144 
table of relative values of centrads and 
prism-diopters, 20 
Warts of eyelids, 169 
Wassermann serum reaction, 169, 269, 
270, 307, 487 
Weber's canaliculus knife, 681 
Weeks' bacillus, 190, 208, 215 
Wernicke's fibers, 513 
symptom, 518 
Westphal-Piltz reaction, 57 
West's operation, 685 
window resection of nasal duct, 685 
Wharton-Jones operation for ectropion, 
611 
Wheel-rotation of eyeball, 520 
White's ointment, 652, 657 
Whooping-cough, 358, 422, 477, 535, 544 
Widmark's conjunctivitis, 232 
Wildbrand's hand perimeter, 80 
prism test, 518 
test of retinal adaptation, 85 
Wildbrand-Saenger test, 19 
Wilder's double knife, 608 
operation for ptosis, 602 
Window resection of nasal duct in steno- 
sis, 685 
Winking, 51 
Wintergreen oil, amblyopia from, 501 
Wire loop, 653 
Wolfe-Lefort transplantation operation, 
613 
Wolff's operation for ptosis, 600 
Yeast serum, 255 
Yellow halo in glaucoma, 369 
oxid of mercury, 207, 212, 223, 232, 
243, 252, 261, 272, 282, 288 
spot, 104. See also Macula lutea. 
Yellow-blue blindness, 496 
Yohimbin, 597 
Young-Helmholtz theory of color vision, 
497 
Zeiss binocular magnifier, 52 
corneal microscope, 52 
glands, 162 
Ziegler's iridotomy, 627 
keratectomy for staphyloma, 621 
method of advancement of Tenon's 
capsule, 680 
partial tenotomy, 675 
Zinc, 256 
chlorid, 194, 256 
ions in Mooren's ulcer of cornea, 257 
iontophoresis in keratitis, 257 
lactate, 487 
oxid, 163, 164 
salicylate, 256 
sozoiodolate, 194 
sulphate, 168, 193, 256, 571, 634 
Zone, visual, 116 
Zonula of Zinn, 36 
Zorab's operation, 635 SAUNDERS' BOOKS 
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Mallory arid Wright's 
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Stengel & Fox's Pathology 
Pathology. By Alfred Stengel, M. D., Sc. D., Professor of Medi- 
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Stiles on the Nervous System 
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Stiles' Nutritional Physiology 
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Wadsworth's Postmortems 
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Heisler's Embryology 
A Text-Book of Embryology. By John C. Heisler, M. D., Pro- 
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Bohm, Davidoff, and 
Huber's Histology 
A Text-Book of Human Histology. Including Microscopic Tech- 
nic. By Dr. A. A. Bohm and Dr. M. Von Davidoff, of Munich, and 
G. Carl Huber, M. D., Professor of Embryology at the Wistar Insti- 
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361 beautiful original illustrations. Flexible cloth, $3.50 net. 
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complete students' text-book on Histology in existence. 
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Wells' Chemical Pathology 
Chemical Pathology.-Being a Discussion of General Pathology 
from the Standpoint of the Chemical Processes Involved. By H. 
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Lusk's 
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Elements of the Science of Nutrition. By Graham Lusk, Ph. D., 
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Daugherty's 
Economic Zoology 
Economic Zoology. By L. S. Daugherty, M. S., Ph. D., Professor 
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Part I-the Field and Laboratory Guide-is designed for practical instruction in 
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Drew'*/* 
Invertebrate Zoology 
A Laboratory Manual of Invertebrate Zoology. By Gilman A. 
Drew, Ph. D., Assistant Director at Marine Biological Laboratory, Woods 
Hole, Mass. With the aid of Former and Present Members of the Zoological 
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The subject is presented in a logical way, and the type method of study has 
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" I think it is the best laboratory manual of zoology I have yet seen. The large number 
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Norris' Cardiac Pathology 
Studies in Cardiac Pathology. By George W. Norris, M.D., 
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SUPERB ILLUSTRATIONS 
The illustrations are superb. Each illustration is accompanied by a detailed 
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Boston Medical and Surgical 'Journal 
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the rare cardiac lesions, and the accompanying descriptive text constitutes a fairly continuous 
didactic treatise." 
McConnell's Pathology 
A Manual of Pathology. By Guthrie McConnell, M. D., As- 
sistant Surgeon, Medical Reserve Corps, U. S. Navy. I2mo of 523 
pages, with 170 illustrations. Flexible leather, $2.50 net. 
NEW (2d) EDITION 
Dr. McConnell has discussed his subject with a clearness and precision of 
style that make the work of great assistance to both student and practitioner. 
The illustrations have been introduced for their practical value. 
New York State Journal of Medicine 
" The book treats the subject of pathology with a thoroughness lacking in many works of 
greater pretension. The illustrations-many of them original-are profuse and of exceptional 
excellence." 
McConnell's Pathology and Bacteriology Students 
Pathology and Bacteriology for Dental Students. By Guthrie 
McConnell, M. D., Assistant Surgeon, Medical Reserve Corps, U. S. N. 
I2mo of 309 pages, illustrated. Cloth, $2.25 net. 
ILLUSTRATED 
This work is written expressly for dentists and dental students, emphasizing 
throughout the application of pathology and bacteriology in dental study and prac- 
tice. There are chapters on disorders of metabolism and circulation; retro- 
gressive processes, cell division inflammation and regeneration, granulomas, pro- 
gressive processes, tumors, special mouth pathology, sterilization and disinfection, 
bacteriologic methods, specific micro-organisms, infection and immunity, and 
laboratory technic. HISTOLOGY. 13 
Diirck and Hektoen's 
Special Pathologic Histology 
Atlas and Epitome of Special Pathologic Histology. By Dr. H. 
Durck, of Munich. Edited, with additions, by Ludvig Hektoen, M. D., 
Professor of Pathology, Rush Medical College, Chicago. In two parts. 
Part I.-Circulatory, Respiratory, and Gastro-intestinal Tracts. 120 
colored figures on 62 plates, and 158 pages of text. Part II.-Liver, 
Urinary and Sexual Organs, Nervous System, Skin, Muscles, and 
Bones. 123 colored figures on 60 plates, and 192 pages of text. Per 
part: Cloth, $3.00 net. In Saunders' Hand-Atlas Series. 
The great value of these plates is that they represent in the exact colors the effect 
of the stains, which is of such great importance for the differentiation of tissue. 
The text portion of the book is admirable, and, while brief, it is entirely satisfac- 
tory in that the leading facts are stated, and so stated that the reader feels he has 
grasped the subject extensively. 
William H. Welch, M. D., 
Professor of Pathology, Johns Hopkins University, Baltimore. 
"I consider Diirck's 'Atlas of Special Pathologic Histology,' edited by Hektoen, a very 
useful book for students and others. The plates are admirable." 
Sobotta and Huber's 
Human Histology 
Atlas and Epitome of Human Histology. By Privatdocent Dr. 
J. Sobotta, of Wurzburg. Edited, with additions, by G. Carl Huber, 
M. D., Professor of Histology and Embryology in the University of 
Michigan, Ann Arbor. With 214 colored figures on 80 plates, 68 
text-illustrations, and 248 pages of text. Cloth, $4.50 net. In 
Saunders' Hand-Atlas Series. 
INCLUDING MICROSCOPIC ANATOMY 
The work combines an abundance of well-chosen and most accurate illustra- 
tions, with a concise text, and in such a manner as to make it both atlas and text- 
book. The great majority of the illustrations were made from sections prepared 
from human tissues, and always from fresh and in every respect normal specimens. 
The colored lithographic plates have been produced with the aid of over thirty colors. 
Boston Medical and Surgical Journal 
" In color and proportion they are characterized by gratifying accuracy and lithographic 
beauty." 14 SAUNDERS' BOOKS ON 
Bosanquet on Spirochaetes 
Spirochaetes: A Review of Recent Work, with Some Original Ob- 
servations. By W. Cecil Bosanquet, M.D., Fellow of the Royal Col- 
lege of Physicians, London. Octavo of 152 pages, illustrated. $2.50 net. 
ILLUSTRATED 
This is a complete and authoritative monograph on the spirochaetes, giving 
morphology, pathogenesis, classification, staining, etc. Pseudospirochsetes are 
also considered, and the entire text well illustrated. The high standing of Dr. 
Bosanquet in this field of study makes this new work particularly valuable. 
Levy and Klemperer's 
Clinical Bacteriology 
The Elements of Clinical Bacteriology. By Drs. Ernst Levy and 
Felix Klemperer, of the University of Strasburg. . Translated and 
edited by Augustus A. Eshner, M. D., Professor of Clinical Medicine, 
Philadelphia Polyclinic. Octavo volume of 440 pages, fully illustrated. 
Cloth, $2.50 net. 
S. Solis-Cohen, M. D., 
Professor of Clinical Medicine, Jefferson Medical College, Philadelphia. 
" I consider it an excellent book. I have recommended it in speaking to my students." 
Lehmann, Neumann, and 
Weaver's Bacteriology 
Atlas and Epitome of Bacteriology: including a Text-Book of 
Special Bacteriologic Diagnosis. By Prof. Dr. K. B. Lehmann 
and Dr. R. O. Neumann, of Wurzburg. From the Second Revised and 
Enlarged German Edition. Edited, with additions, by G. H. Weaver, 
M. D., Assistant Professor of Pathology and Bacteriology, Rush Medical 
College, Chicago. In two parts. Part I.-632 colored figures on 69 
lithographic plates. Part II.-511 pages of text, illustrated. Perpart: 
Cloth, $2.50 net. In Saunders' Hand-Atlas Series. PATHOLOGY, BACTERIOLOGY, AND PATHOLOGY 15 
Durck and Hektoen's General Pathologic Histology 
Atlas and Epitome of General Pathologic Histology. By Pr. 
Dr. H. Durck, of Munich. Edited, with additions, by Ludvig Hek- 
toen, M. D., Professor of Pathology in Rush Medical College, Chicago. 
172 colored figures on 77 lithographic plates, 36 text-cuts, many 
in colors, and 353 pages. Cloth, $5.00 net. In Saunders' Hand-Atlas 
Series. 
American Text-Book of Physiology Second Edition 
American Text-Book of Physiology. In two volumes. Edited by 
William H. Howell, Ph. D., M.D., Professor of Physiology in the Johns 
Hopkins University, Baltimore, Md. Two royal octavos of about 600 
pages each, illustrated. Per volume: Cloth, $3.00 net; Half Morocco, 
$4.25 net. 
" The work will stand as a work of reference on physiology. To him who desires to know 
the status of modern physiology, who expects to obtain suggestions as to further physio- 
logic inquiry, we know of none in English which so eminently meets such a demand."- 
The Medical News. 
Warren's Pathology and Therapeutics Second Edition 
Surgical Pathology and Therapeutics. By John Collins Warren, 
M. D., LL.D., F. R. C. S. (Hon.), Professor of Surgery, Harvard Med- 
ical School. Octavo, 873 pages, 136 relief and lithographic illustrations, 
33 in colors. With an Appendix on Scientific Aids to Surgical Diagnosis 
and a series of articles on Regional Bacteriology. Cloth, $5.00 net; 
Half Morocco, $6.50 net. 
Raymond's Physiology Ne„ (3d) Meon 
Human Physiology. By Joseph H. Raymond, A. M., M. D., Pro- 
fessor of Physiology and Hygiene, Long Island College Hospital, New 
York. Octavo of 685 pages, with 444 illustrations. Cloth, $3.50 net. 
" The book is well gotten up and well printed, and may be regarded as a trustworthy 
guide for the student and a useful work of reference for the general practitioner. The 
illustrations are numerous and are well executed."-The Lancet, London. 16 BACTERIOLOGY, PHYSIOLOGY, AND HISTOLOGY. 
Ball's Bacteriology Seventh Edition, Revised 
Essentials of Bacteriology : being a concise and systematic intro- 
duction to the Study of Micro-organisms. By M. V. Ball, M. D., Late 
Bacteriologist to St. Agnes' Hospital, Philadelphia. i2mo of 289 pages, 
with 135 illustrations, some in colors. Cloth, $1.00 net. In Saunders' 
Question- Compend Series. 
" The technic with regard to media, staining, mounting, and the like is culled from the 
latest authoritative works."-The Medical Times, New York. 
Budgett's Physiology New (4th) Edition 
Essentials of Physiology. Prepared especially for Students of Medi- 
cine, and arranged with questions following each chapter. By Sidney 
P. Budgett, M. D., formerly Professor of Physiology, Washington Uni- 
versity, St. Louis. Revised by Havan Emerson, M. D., Demonstrator 
of Physiology, Columbia University. 121110 volume of 250 pages, illus- 
trated. Cloth, $1.00 net. Saunders'Question-Compend Series. 
"He has an excellent conception of his subject. . . It is one of the most satisfactory 
books of this class"-University of Pennsylvania Medical Bulletin. 
Leroy's Histology New (4th) Edition 
Essentials of Histology. By Louis Leroy, M. D., Professor of 
Histology and Pathology, Vanderbilt University, Nashville, Tennessee. 
i2mo, 263 pages, with 92 original illustrations. Cloth, $1.00 net. In 
Saunders' Question-Compend Series. 
" The work in its present form stands as a model of what a student's aid should be; and 
we unhesitatingly say that the practitioner as well would find a glance through the book 
of lasting benefit."-The Medical World, Philadelphia. 
Barton and Wells* Medical Thesaurus 
A Thesaurus of Medical Words and Phrases. By Wilfred M. 
Barton, M. D., Assistant Professor of Materia Medica and Therapeutics, 
and Walter A. Wells, M.D., Demonstrator of Laryngology, Georgetown 
University, Washington, D. C. umo, 534 pages. Flexible leather, 
$2.50 net; thumb indexed, $3.00 net. 
American Pocket Medical Dictionary New (9th) Edition 
American Pocket Medical Dictionary. Edited by W. A. New- 
man Dorland, M. D., Editor 0 American Illustrated Medical Dic- 
tionary." Containing the pronunciation and definition of the principal 
words used in medicine and kindred sciences, with 75 extensive tables. 
693 pages. Flexible leather, with gold edges, $1.00 net; with patent 
thumb index, $1.25 net. 
" I can recommend it to our students without reserve."-J. H. HOLLAND, M. D., of 
the Jefferson Medical College, Philadelphia.