!R, IE IP O ZR, T 
O N 
OPHTHALMOLOGY. 
A PAPER READ BEFORE THE 
(fyhio jftate Jjhdiidl §>ocktu, 
JUNE 18, 1873, 
\y BI 5, W1 
J. H. BUCKNER, M. D., 
CINCINNATI, OHIO. 
DAYTON, OHIO; 
UNITED BRETHREN PUBLISHING HOUSE. 
1873. OPHTHALMOLOGY 
BY 
J. H. BUCKNER, M. D 
CINCINNATI, OHIO 
Mr. President and Gentlemen: 
It might be expected perhaps that I would enumerate in 
some detail the most valuable contributions of the year to 
the subject of this report. In doing this, however, I should 
only be rehearsing what has already been done by an abler 
pen than mine. The last volume of the R. L. O. H, reports 
furnishes a full and comprehensive review of the valuable 
work in this department for the year 1872. Neither is it 
my purpose to enter into an elaborate review of the progress 
and present condition of the science of ophthalmology, but 
I propose to submit what is mainly an abstract of notes 
taken during a recent visit to some of the principle eye 
clinics ot Europe, trusting in the hope that however un- 
worthy it may be in a purely scientific point of view to re- 
ceive a place among the archives of Ophthalmology, it may 
not prove wholly uninteresting to this society. I wish also 
to remark by way of apology for its imperfections, that for 
reasons which it would be tedious to state, the preparation 4 
Ophthalmology. 
of the paper was necessarily postponed until on ship hoard, 
and those who have experienced the rocking and pitching 
of the vessel upon the billows of Old Ocean, are well aware 
that the situation is not very favorable to literary and 
scientific labor. 
The greatest progress in the science of ophthalmology 
may be said to date from the discovery of the ophthalmo- 
scope and its description by Helmholtz in 1851. This was 
the beginning of the new era. From this time, diseases 
which had hitherto baffled the skill of the eye specialist 
were investigated under a new light, and diagnosticated by 
this simple instrument. A great variety of ophthalmoscopes 
have been constructed, all embodying, with some modifica- 
tions of form, the original idea of Helmholtz. In this con- 
nection I wish to mention, briefly, some of the merits and 
demerits of the ophthalmoscopes which are most generally 
used at this day. I shall avoid as far as possible, a detailed 
description of these instruments. 
The instrument of Prof. Edward Jaeger, which is exten- 
sivly used in Germany, may be considered the best for the 
erect image, as on account of its shape it may be approach- 
ed nearer to the eye of the patient with comfort to the 
observer than most other instruments; but for general use 
it is too cumbersome, and for the inverted image is inferior 
to other opthalmoscopic instruments. 
The Loring opthalmoscope, the invention of Dr. Por- 
ing of Hew York, is regarded by eminent men of Europe 
and America as a decided improvement upon the instru- 
ments previously in use. The clinical assistant of Prof. 
Jaeger,—Dr. Schnabel,—prefers the Loring instrument to 
all others. Some of its advantages are its compactness and 
the facility with which the small ocular lenses can be ad- 
justed so as to suit the refractory condition of the eye of the Ohio State Medical Society. 
5 
patient, and that of the observer. An obstacle, however, to 
its universal employment is its cost; in this respect, a con- 
siderable reduction has been made upon its original price. 
It can be purchased in Vienna at half the cost at which it 
is sold in New York. 
An instrument has been made recently by Mr. Hawksley, 
of London, which is intended as an improvement upon the 
Loring opthalmoscope. There is a slight difference in the 
arrangement of the sets of lenses, and what is more impor- 
tant the metallic discs in which the small lenses are fitted 
are thinner than in the original Loring; the central hole is 
also not so deep. This makes a lighter instrument, and by 
diminishing the depth of the central aperture fewer rays 
from the fundus of the eye under observation are obstructed 
in their passage to the eye of the observer. 
Dr. Loring has, however, in a measure anticipated these 
improvements, and his later instruments are similarly con- 
structed but still not so light as those made by Hawksley. 
Mr. John Couper, one of the surgeons to the It. L. 0. 
Hospital, has endeavored to combine the advantages of 
Jaeger’s opthalmoscope for the erect image, with those 
of the Loring opthalmoscope. His instrument is so con- 
structed as to admit of a plain or concave mirror being 
used. The mirror swings in a metallic frame and can be 
placed at any angel. Upon its metallic back is a spring for 
holding the three separate discs in which are fitted the con- 
cave and convex lenses as in the Loring opthalmoscope. 
He had not perfected the instrument to his satisfaction 
when I saw it last. If he can carry his idea to a successful 
issue, I have no doubt it will prove a further advance in the 
power of this most interesting and valuable means for diag- 
nosis. 
The Liebreich opthalmoscope is probably more generally 6 
Ophthalmology. 
used than any other. It combines simplicity of construc- 
tion with cheapness and lightness. For the general practi- 
tioner it will perhaps continue to be the most popular. 
Some difference of opinion exists upon the subject of the 
size of the mirror; the diameter of its central hole, and 
whether it should be of metal or glass, also whether the 
mirror should be perforated if of glass, or only have the 
covering removed from the center for the aperture. 
Without discussing the question I will quote from Dr. 
Liebreich, who will be recognized as the best authority upon 
this subject. lie says, “I propose to make the hole not 
smaller than two millimeters (.08"), and the mirror not 
smaller than three centimeters (1.2"), and to use in prefer- 
ence a thin silvered glass mirror, the center of which is not 
perforated but only deprived of its silver covering. The fo- 
cus of the mirror may be eight or ten inches.” 
DISEASES OF THE EYE. 
I propose to notice briefily the prevailing character of dis- 
eases of the eye, from my own observation at the clinics of 
London, Paris, Vienna, and Dublin, together with some 
peculiarities of treatment, and a few of the rare and inter- 
esting cases which I met with. 
One of the most noticeable features of the opthalmic 
hospital clinics in London to an American physician, is the 
small number of cases of granular conjunctivitis (Tra- 
choma) as compared to the amount of the same disease met 
with at the principal eye clinics throughout the North- 
eastern, Middle and Western states of this country. 
Dyptheritic conjunctivitis is also a rare affection at the 
London clinics. Of other diseases of the conjunctiva 
catarrhal and strumous opthalmia, (phlyctenular conjunc- 
tivitis) constitute the bulk of cases; next in frequency were Ohio State Medical Society. 
diseases of the cornea, keratitis, scrofulous keratitis (herpes 
of the cornea), and ulcerative corneaitis. Next in order 
were diseases of the appendages of the eye, tinea ciliaris, 
and diseases of the lachrymal passages. Iritis and diseases 
of the retina and choroid were about equal in frequency 
At Paris, the only important difference in the character 
of cases which came under my notice was the greater fre- 
quency of granular conjunctivitis and purulent opthalmia. 
dyptheritic conjunctivitis is also comparatively not an un- 
common affection at the Paris clinics. 
\ 
At Vienna, phlyctenular conjunctivitis, granular con- 
junctivitis and affections of the cornea, particularly herpes 
cornea, form the greater proportion of cases. Purulent 
opthalmia and dyptheritic conjunctivitis is here met with 
in nearly the same proportion of cases as in Paris. Iritis, 
idiopathic and syphilitic, and diseases of the choroid and 
retina are found in the same proportion as in London 
I did not find at the clinics in Vienna a greater amount of 
errors of refraction and accommodation than in London 
and Paris, although it is a well known fact that these af- 
fections prevail more extensively throughout Germany 
and among German-speaking people of other countries 
than elsewhere—a circumstance which I suppose to be due 
to the character of the German type which is undoubtedly 
more trying upon the eyes and, I believe, more productive 
of asthenopia and optical disorders than the Latin type. 
It is so universal a custom among Germans to wear glasses 
that I presume a large proportion of those requiring them 
go to the optician without consulting the eye-surgeon. 
The evil effects of this indiscriminate use of glasses has 
been fully set forth by Dr. Cohn of Breslau. “Among 
10,000 children, he found 1,730 with defective vision, mak- 
ing 17.1 per cent, the average number, increasing with the 8 
Ophthalmology. 
degree of demand upon the eyes at school. lie found only 
107 out of 1,004 near-sighted children wearing glasses; of 
these, only 8 had been ordered by a physician, the other 99 
bought by the children on their own selection. Some had 
changed the glasses prescribed for them by a physician, for 
stronger ones. Of the 107, only 11 had glasses that were 
not injurious.* In this connection permit me to say that 
the propriety of applying to the eye surgeon for his selec- 
tion of glasses instead of the optician, can not be too 
strongly insisted upon. It is a recognized law by the best 
authorities upon opthahnology. 
The prevailing type of diseases at Dublin are granular 
conjunctivitis and strumous opthalmia, (phlyctenular op- 
thalmia.) Here we see those obstinate cases of pannus 
which so vex and worry the soul of the eye specialist. We 
have the same class of cases, chiefly among the Irish in our 
own country. In short, the eye clinic at Dublin was essen- 
tially the same in the general character of diseases as at 
the eye clinics of New York. 
PECULIARITIES OF TREATMENT. 
Dr. Wecker of Paris treats granular conjunctivitis and 
papillary trachoma with a strong solution of Goulards 
extract, about 50 per cent of the extract to the ounce of 
pure water. He applies this solution to the everted lids 
with a camel’s-hair brush, aud washes off the lids imme- 
diately with water. He claims that by this plan these ob- 
stinate affections can be cured much sooner than by the 
usual mode of treatment. Abrasions of the cornea do not 
» 
with him contra-indicate the lead solution. 
♦The Eye in Health and Disease.—(Jeffries.) Ohio State Medical Society. 
9 
Dr. Liebreich, for the same disease, uses chiefly a solution 
of nitrate of silver 10 grains to the ounce of water, brushed 
upon the everted lids. 
Dr. Wecker treats chronic inflammation of the lachrymal 
sac by passing a bent silver tube into the nasal duct, and 
syringing through it solutions of soda, potash, and astringent 
washes, slowly withdrawing the tube at the same time, so 
that the fluid will reach the whole of the diseased surfaces. 
Mr. Henry Powers, surgeon to the O. H. Charing Cross, 
London, eye surgeon to St. Bartholomews, treats purulent 
opthalmia with a solution uf permanganate of potash, 
three to five grains to an ounce of water, applied to the 
eyes three or four times a day. 
STRABISMUS OPERATIONS. 
Metliod of Prof. Arlt: The lids being separated by 
the speculum, the conjunctiva is seized with toothed 
forceps and freely divided across the insertion of the 
rectus muscle, the connective tissue is divided for a short 
distance along the muscle. The points of the forceps 
are now introduced closed under the conjunctiva, and 
when sufficiently far the points are opened and by a 
quick elevation of the hand the muscle is caught and with 
a pair of small blunt-pointed scissors is cut by successive 
snips at its insertion into the sclerotic. A small blunt hook 
is then used to ascertain if all the muscular fibres are com- 
pletely separated at their attachment. The eye is then 
tried and if the division has been sufficient is simply ban- 
daged; if the squint is not overcome he divides more freely 
the connective tissue. If on the other hand the division 
has been too free, which I have not witnessed, he unites 
the conjunctiva with a suture to the capsule of tenon, so as 
to bring it and the tendon of the muscle forwards. 10 
Ophthalmology. 
Operation of Prof. Jaeger: An assistant takes up a fold 
of the conjunctiva over the insertion of the muscle; with 
another pair of forceps Prof. Jaeger takes up a similar fold 
of conjunctiva, just below the inferior margin of the mus- 
cle; a slit is then made in the conjunctiva between the two 
forceps, parallel to and over the border of the muscle, the 
tendon of the muscle is exposed, a blunt hook passed be- 
neath it and its point brought out through the slit in the 
conjunctiva, and with blunt-pointed scissors the tendon is 
divided at its insertion. 
Operation of Mr. Critchett: This is the one usually per- 
formed at the Moorfields Eye Hospital, London. The pa- 
tient having been placed under chloroform and the stop 
speculum introduced, a fold of conjunctiva and subconjunc- 
tival tissue is seized with the forceps at the lower edge of 
the insertion of the rectus muscle; this fold is divided so 
as to expose through a small slit the tendon of the muscle. 
Through this slit a blunt hook is passed beneath the ten- 
don, the latter is then made tense and the points of the 
scissors but slightly apart are introduced into the wound, 
one point passed along the hook beneath the tendon and 
the other in front of the tendon between it and the con- 
junctiva; the tendon is then divided by successive snips 
close to its insertion. 
Either of the above operations is comparatively easy 
performance, although the latter seems to me to be the 
most elegaut. 
CATARACT OPERATIONS. 
Without entering into a detailed description, I wish to 
briefly notice the methods for extraction of cataract as per- 
formed by some of the eminent eye surgeons of Europe. Ohio State Medical Society. 
11 
At Moorfields Hospital, Graefe’s operation or a slight mod- 
ification of it is chiefly done by all of the surgeons in at- 
tendance with the exception of Mr. Streatfield, whose pe- 
culiar method I have reported in the Phil. Med. & Sur. 
Pep., of Feb. 1st. The success of Graefe’s operations as 
compared with the flap and other extraction operations as 
obtained from the books of this hospital, show a large per 
cent in favor of Graefe’s method. 
Mr. Henry Powers, at Charing Cross, 0. H., operates by 
Graefe’s method, but still performs the old flap-operation 
in favorable cases, and occasionally operates by reclin- 
atiou. 
Dr. Liebreich operates for extraction in every case by his 
new method. A detailed description of this operation has 
been published by Claxton & Co., of Philadelphia. Some 
of the noticeable features in the minor details of Liebrich’s 
operations are, that he does not give chloroform, does not 
use a speculum, and does not require an assistant. 
Dr. Wecker of Paris usually operates by a modified 
Graef'e method, the details of which are given in Vol. VII., 
part 3, of the R. L. O. H. reports. He also performs the 
operation of removing the lens in its capsule in favorable 
cases as strongly advocated by Dr. Pagenstecher, of Weis 
Baden, and M. Sperino. 
Prof. Arlt does Graefe’s operation according to the 
method—as I was informed by his assistant, Dr. Satler— 
practiced by the distinguished Graefe during the latter 
years of his life. In this operation the puncture and 
counter-puncture is made further back than is ordinarily 
done by other operators. The section is completed in the 
sclerotic and a long conjunctival flap of about 1J to 2 lines 
is made. At the Moorfields Hospital the surgeons are not 
favorable to a long conjunctival flap. 12 
Ophthalmology. 
Prof. Edward Jaeger, the colleague of Prof. Arlt, com- 
pletes the section in the sclero corneal border and seldom 
leaves any conjunctival flap. It is only in the last year 
that he had become reconciled to Graefe’s method, and he 
is still quite partial to the old flap-extraction operation, 
and speaks in very respectful terms of reclination. 
At the Dublin O. H., Graefe’s operation is done by Dr. 
Wilson, and Sir William Wilde. The latter is, however, 
still in favor of the old flap-operation in suitable cases. Dr. 
Wilson prefers to make the iridectomy previous to the op- 
eration of extraction. In cases of secondary capsular cat- 
aract, he makes an incision in the cornea, passes in a pair 
of iris forceps, seizes the capsule and withdraws it. 
In opposition to the current opinion of most European 
operators I may state that Prof. Quaglino of Pavia, Italy is 
a strong advocate for the old operation of reclination. He 
says that “ the most permanent and brilliant results of de- 
pression are obtained in the case of cataracts which are 
either soft or cheesy in consistency, in the fluid ones among 
middle aged people, and in those which occur in infancy. 
In hard senile cataracts it may be adopted, but exception- 
ally.” 
Without stopping to discuss the propriety of performing 
at this day the old flap or reclination operation for cataract, 
we will briefly notice the relative advantages of the Graef- 
ean method and Liebreich’s operation. 
Dr. Satler remarked to me that Prof. Arlt’s loss in ex- 
traction of cataract by Graefe’s method was about two per 
cent for the last year. Other eminent and skillful operators 
have not been nearly so fortunate. Graefe’s best statistics 
showed a failure of 2.8 per cent. The semi-annual report Ohio State Medical Society. 
13 
of Dr. Wecker’s clime for 1871 gives 3.15 per cent of fail- 
ures by his modified Graefe’s operation. 
Judging from my own observation and data, which I am 
not at liberty to use, I am convinced that a fair and impar- 
tial report of all the principal eye-clinics of Europe would 
show an average loss for the last two years, nearly if not 
quite equal to ten per cent by Graefe’s method. The great 
difficulty of arriving at any definite conclusion from pub- 
lished statistics lies in the fact that no uniform standard 
has been fixed for the degree of vision necessary to consti- 
tute a successful case. Dr. Wecker considers an acuity of 
vision of less than 5 th, an incomplete result. While some 
other operators give as low as th. I should be in favor 
of making the uniform standard fths for successful cases, 
and any degree of acuity of vision below this to be classed 
as partially successful. The result of Liebreich’s new oper- 
ation for the extraction of cataract, in the hands of its 
originator has been, according to my observation, more 
successful than any other. Of fifteen cases of cataract 
which I saw Dr. Liebreicli operate upon by his new method 
at Paris during the Christmas holidays, all were successful. 
I saw there, cases three, seven, and ten days after the oper- 
ation, and at my last visit all were doing well and had good 
vision. Slight iritis ensued after the operation in two of 
these cases, but it was really subdued. 
A few days before leaving London, Dr. Liebreich informed 
me that he had operated for extraction of cataract in 23 
cases (by his new mode) at Paris, during the first week of 
last April, without a single failure. The perfectly clear, 
round, and natural pupil, and the absence of secondary 
capsular cataracts after Liebreich’s operation would seem to 14 
Ophthalmology. 
make it preferable to Graefe’s method, but other operators 
have not had the success with it which it has been attend- 
ed in the hands of Dr. L., prolapse of the iris and attach- 
ment to the corneal wound, (anterior synechia,) being a fre- 
quent occurrence. I may also state that among the many 
eminent eye surgeons with whom I conversed in Europe, 
but one or two were favorable to Liebreichs cataract 
operations. 
INTERESTING CASES. 
' Moorfields Hospital, London. Congenital hypertrophy 
of the conjunctiva forming a ridge-like tumor upon which 
were long hairs growing. Operated upon by Mr. Hutch- 
inson. 
Displacement of the lachrymal gland: clinic of Dr. Lie- 
breich.* 
Cyst of the iris. Clinic of Prof. Arlt, Vienna, February 
14, 1873. The patient, a young man, received a blow upon 
the eye with some sharp instrument, which penetrated the 
cornea and wounded the iris. The accident occurred some 
four or five years previous to his applying to the clinic. 
Four or five months since the cyst was fiirst noticed, it now 
fills one fourth of the space occupied by the anterior cham- 
ber, and is of a delicate pearly shade. Prof. Arlt made an 
incision in the cornea and introduced the iris forceps, seiz- 
ed the cyst wall, dfew it out and snipped it off with scissors. 
The eye did well, and after several weeks there was no re- 
turn of the cyst.f 
by me in Philadelphia Med. and Surg. Reporter, February 1. 
fDr. Rothmund quoted all the eases of cysts of the iris he could find record- 
ed—37. In twenty-eight there was a history of injury. Vol. VII., Ii. L. 0. H. 
reports. Ohio State Medical Society. 
15 
Prolapse of iris and its attachment to a fold of conjunc- 
tiva. Clinic of Prof. Arlt P. T , age twenty-four, 
had suffered with phlyctenular conjunctivitis. On the 3d 
of January he was attacked with acute blenorrhea, was 
treated abroad for three weeks, when he applied at the 
clinic. There was observed a large prolapse of the iris of 
the left eye, and only a small portion of the cornea remain- 
ing. A large fold of conjunctiva was drawn over the up- 
per part of the cornea of the right eye, presenting the ap- 
pearance of a superior Pterygium; the fold had become at- 
tached to the prolapsed iris. At one point, a probe could 
be passed under the fold close to the edge of the cornea, 
and could be moved upward freely beneath the retrotarsai 
fold. The greater part of the cornea was opaque. The 
anterior chamber was narrowed by the attachment, but of 
moderate depth. The pupil was pear-shaped, and fixed by 
the prolapse of iris. Operation: A ligature, double, was 
passed under the fold and cut so as to leave both ends free. 
One ligature was tied near the point of conjunctival at- 
tachment to the iris, and the other was tied near the car- 
tila ge. The following day the lids were much swollen and 
the cornea infiltrated with pus; consequently the thread 
was removed and the fold cut near its attachment. The 
e}'e could at once be freely turned downward, and upon 
the application of ice the swelling of the lids and the cor- 
neal infiltration disappeared, and no trace of the fold or its 
attachment remains. 
Transplantation of the conjunctiva of the rabbit to the human 
eye after the removal of an epitheliom.a. Clinic of Mr. Henry 
Powers, F. R. C. S., Charing Cross O. II. This man was 
operated upon by Mr. Powers ten years ago for epithelioma 16 
Ophthalmology, 
upon the lower lid of the left eye. Two years afterward it 
reappeared. Three operations have been performed upon 
it. Condition May 12, 1873: The lower lid destroyed and 
the inferior portion of the ocular conjunctiva invaded by 
the cancer. The diseased parts were removed with the 
knife; a white rabbit in fine condition, being ready, it was 
stunned by a blow upon the head and before life was ex- 
tinct Mr. Powers dissected the conjunctiva in separate 
strips from the lids and eye balls, and transferred them as 
fast as removed to the surface wound upon the human eye. 
These strips were united to the human conjunctiva and to 
each other by a few fine sutures. On the third day after 
the eperation the strips were found to have adhered at a 
few points inferiorily. but on the eye ball adhesion seemed 
to have been prevented by the effusion of pus, which had 
carried away from this part the patches of conjunctiva. 
Mr. Powers informed me that he had several times suc- 
cessfully ingrafted a portion of the cornea of the rabbit to 
the human cornea but the new growth becoming opaque 
rendered the operation futile.