CLINICAL CONTRIBUTIONS TO OPHTHALMOLOGY. 
P. 33. KEYSER, M.D., 
OP PHILADELPHIA. 
[From the Medical and Surgical Reporter, January 10, 18 
Diphtheritic Conjunctivitis — Complete Re- 
covery. 
On Dec. 21st, 1871, Ida Zimmerman, one year 
old, was brought to my clinic at the Philadel- > 
phia Eye and Ear Infirmary, with a well-devel- 
oped case of diphtheretie conjunctivitis. The i 
lids were very much swollen, hard and tense, , 
the conjunctiva covered with a grayish-yellow 
membrane, of a smooth, glistening appearance, 
thicker and more opaque in different parts. 
This membrane could with difficulty be torn off' 
in flakes or shreds, leaving beneath a yellowish 
tissue through which oozed a little thin blood. 
The cornea of the right eye was slightly hazy, 
while that of the left was clear. The little pa- ■ 
tient was suffering much, appeared emaciated 
and debilitated. The mother said the child had 
not been well for some time, but that nothing 
was the matter with the eyes until the day pre- 
vious to her coming to my clinic, when they be- 
came suddenly inflamed and greatly swollen. 
No other person in the house had sore eyes or 
any throat disease. 
This most dangerous and destructive disease 
of the eye is almost unknown in this country ;. 
a few cases occur at times in England and 
France, but manyiji some of the northern parts 
of Germany, particularly in the city of Berlin, 
where I saiv seyeral cases in the clinic pf the 
late Professor v, Graefe, during the winter of 
J863 and ’64. In this city I had not seen a case 
before this one, and since which date I have 
treated many thousands ofeaSus of uycTcliseases 
without meeting another one. 
What was to he done liere for this poor little 
creature ? Under the circumstances the prog- 
nosis was unfavorable. The great and most 
important thing in these cases is to get the 
swelling reduced, the circulation restored, the 
tissue softened and a purulent discharge to carry 
off with it the diphtheritic membrane. 
To do this there are different theories of treat- 
ment by several writers of experience. Prof. v. 
Graefe used ice cold cloths applied continually 
to the eyes, and touched the conjunctiva with 
aqua chlorinii. Drs. Wecker, Morren, and Ber- 
lin recommend hot fomentations continually ap- 
plied to hasten forward the second stage (that 
of softening and discharge), without anything 
in the eyes. All writers caution against the use 
of astringent lotions, as nitrate of silver and 
sulphate of zinc or copper in the first stage of 
the disease. At the same time, also, it is recom- 
mended by some to bring the patient under the 
influence of mercury as quickly as possible, if 
not in too feeble health, to accelerate the stage 
of vascularization and elimination of the fibrin- 
ous infiltration of the conjunctiva, while others 
have found that mercury does not produce an 
influence rapid enough in such cases, and ad- 
vise against its use as being injurious. 
Inclining to the theory of Wecker, Morren 
and Berlin, 1 ordered immediately and continu- 
ally applications of cloths, dipped in hot water, to hasten the stage of vascularization, etc. At 
the same time, knowing that the chlorate of po- 
tassa was a sovereign remedy in the treatment 
of diphtheria of the throat, I touched the con- 
junctiva daily with a solution containing forty 
grains of that salt to an ounce of water, and 
dropped in the eyes hourly a collyrium of a 
twenty grain solution of the same. Internally 
was given the elixir of calisaya and pyrophos- 
phate of iron as a tonic. 
Under this treatment the little patient did as- 
tonishingly well. The lids soon began to soften, 
the membrane came off, and the conjunctiva re- 
sumed a bright red color, but no purulent dis- 
charge of any account took place. The warm 
fomentations were now discontinued. Fearing 
a relapse on the use of astringents, the above 
collyrium was continued, gradually reducing its 
strength. The whole disease passed off' without 
any purulent discharge or other treatment, leav- 
ing the eyes in a perfectly healthy condition, 
excepting the cornea of the right eye, which was 
slightly clouded. This soon cleared up. 
This case is interesting— 
1st. From its rarity in this city and country. 
2d. From its successful termination under so 
simple a treatment, and without purulent dis- 
charge. 
3d. From the use of a remedy not mentioned 
nor recommended by any of the writers upon the 
subject as far as I can learn. 
In relation to the treatment, I am of the opin- 
ion that the hot fomentations is the proper one, 
as it without doubt softens the tissue of the lids 
and renews the circulation in the blood vessels, 
which has been retarded or stopped by the pres- 
sure from the greatly swollen lids. By so do- 
ing, the elimination of the fibrinous infiltration 
is accelerated, and the cornea as well relieved. 
The chlorate of potash acted upon the mucous 
membrane and tissues of the conjunctiva the 
same as it does on that of the throat. 
culty that the edges could be drawn out. The 
cilise were pretty well preserved. The cornea 
of each eye was covered by a vascular pannus. 
Knowing that in such a severe case the re- 
moval of a fold of skin, and slitting the lid as 
recommended by Arlt, v. Graefe, or Jrnsch, or 
the removal of a wedge-shaped piece of the car- 
tilage, according to Streatfield or Snellen, would 
not give the necessary relief, 1 proposed to re- 
move the whole of the cartilages as recom- 
mended by Pope, in the Archives for Ophthal- 
mology and Otology, Part I, Vol. 1. 
For that purpose I admitted her as a house 
patient in the hospital, December 14th, 1872. 
The same day I operated as follows: The pa- 
tient being thoroughly under the influence of 
ether, an incision was made along the free mar- 
gin of the lid between the cartilage and the or- 
bicularis muscle, close on, in reality almost shav- 
ing the cartilage, and back or up along the 
cartilage to its attachment with the levator mus- 
cle. The cartilage being thus well exposed was 
removed by grasping it with rat-toothed forceps, 
and snipping it off in pieces with the scissors. 
In this way the upper cartilages were all re- 
moved excepting a small line along the upper 
rim just at its point of muscular attachment. 
This remaining rim was dissected up for some 
distance from the conjunctiva. The posterior 
flap came down well, and to keep it in its proper 
position with the anterior one, the two ends of 
a silk suture were passed through both flaps of 
the lid from the inner to the outer surface, and 
tied together. No sutures were applied to the 
edges of the wound, they being allowed to ad- 
here and cicatrize naturally, which occurred by 
first intention. 
In making the incision along the edge of the 
lower lid it was carried between the cartilage 
and conjunctiva, and the whole of the cartilage 
removed. Here, three sutures were applied to 
the edges of the wound. 
After the operation the cilise stood in their 
proper positions. Cold wet cloths were applied 
over the lids to control inflammation. On the 
second day all the sutures were removed. There 
was great chemosis the next day after the opera- 
tion, but it soon began to recede, and the heal- 
ing process was both rapid and favorable. 
The lids kept their position perfectly, and the 
corneas cleared up remarkably. On being dis- 
charged she went home alone, the first time for 
over a year that she had gone out without a«- 
sistance. 
Entropium with Great Incurvature of the Car 
tilages, Cured by Removal of the Cartil- 
ages of both Upper and Lower Lids. 
Mrs. B., get. 43, came to my clinic at the Wills’ 
Ophthalmic Hospital, Philadelphia, December 
3d, 1872, with one of the most marked cases of 
Entropium, with very great incurvature of the 
cartilages of the upper and lower lids of the left 
eye, and the upper of the right one. The lids 
were curled in on themselves so that the cartil- 
ages were almost doubled. It was with diffi- 3 
It will be seen that I made the incisions in 
the upper lids different from Dr. Pope’s, he 
making his between the cartilage and conjunc- 
tiva, while mine were made anterior to the car- 
tilage. This was done for more convenience and 
ease in cutting the flaps and greater facility in 
removing the cartilages. 
Great care must be taken in removing the car- 
tilage, that the conjunctiva be not cut through, 
because cicatrices therein will cause more shrink- 
age and contraction. 
The removal of t\ie cartilage from the lid in 
this case was imperatively necessary, as the cur- 
vature was so great that the operations recom- 
mended for the removal of such defects would 
have been of no effect. 
Removal of Two Cancroidal Tumors from the 
Surface of an Eye. 
Mr. E. C., of Bradford county, Pa., aet. 59, 
noticed, four years ago, an inflamed and tender 
spot on the outer corneal border of the right eye. 
It has continued to grow in breadth and promi- 
nence, and at times is very painful. About a 
year ago another such spot appeared on the up- 
per border of the cornea, and between the two 
he has suffered at times considerable pain and 
trouble. Different washes that he has used have 
given no relief, so that he was sent to me for 
treatment, June 18tli, 1873. 
On examining the eye I found two reddish 
tumors of different sizes on the eyeball, the 
larger lying on the outer sclero-corneal border, 
extending 3 m.m. over the edge of the cornea, 
and 4 m.m. back on the sclerotica, and having 
a width or breadth of not quite 5 m.m. The 
other Avas on the upper border extending only 
1 m.m. over the cornea, and 3 m.m. back on the 
sclerotic, the width about the same measure- 
ment, so that it was nearly round. The neigh- 
ance of cancroids. The vision of the eye was 
xx- Presbyopia 2V- 
As long as the sight of the eye was good I 
could do nothing but advise removal of the tu- 
mors by operation. 
He consented to the removal of the larger one 
at first, which was done the following day. 
The patient being well etherized, the tumor 
was cut off close to the surface of the cornea and 
sclerotica, cutting into both of the latter a little, 
to remove as much as possible from the base. 
After removal it was plainly seen that the dis- 
eased part extended deeply into the tissue of 
the sclerotica and cornea. The conjunctiva 
Avas cut out around, and the edges brought to- 
gether over the exposed sclerotica by two su- 
tures. A firm compress bandage was applied 
until the next day, Avhen the sutures were re- 
moved, and a eollyrium of sulphite of soda, 
three grs. to the 5j, ordered to be dropped in 
the eye daily. 
The eye healed remarkably well; the patient 
returning home the week after. 
August 1st following he returned to this city 
to have the upper tumor removed, as it had given 
him pain and appeared to have increased since 
the previous operation. The operation was per- 
formed in the same manner as in the previous 
one, except that the patient was not etherized, 
he preferring not to be at this time. 
The tumor first operated on had given him 
no trouble since, and looked remarkably well. 
There was no appearance of its returning. By 
microscopic examination both tumors were found 
to be of cancroidal formation. In this case the 
patient was given an unfavorable prognosis as 
to a permanent cure, but as long as the sight 
remained good in the eye, the removal of the 
cancroid growths at once, if they should reap- 
pear, was advised ; if the sight should be lost 
the eyeball should be enucleated immediately. 
It is now five months since the last operation, 
and he writes me that the eye is doing well, 
neither tumor having returned, although the 
vision in the eye is not so perfect. 
Cancroid tumors on the cornea are rather rare, 
and being of a malignant character their return 
may be expected, but in what time it is impos- 
sible to say. In the Klinische Monatsblatter fur 
Augenheilkunde, vol. vii, 1869, I reported a case 
where I removed a cancroid tumor from the 
sclero-corneal border of the eye of a gentleman 
in this city, 69 years old, which had not returned 
at that time, two years after the operation. 
boring conjunctiva was somewhat injected, and 
three or four large vessels extended to each tu- 
mor. Both were firmly attached to the cornea 
and sclerotica underneath them, and were very 
sensitive to the touch. Both had the appear- 4 
Removal of Large Foreign Bodies from the 
Eyeball. 
Michael C., sot. 32, machinist, of Wilmington, 
Del., came to my clinic at the Philadelphia Eye 
and Ear Infirmary, March 7th, 1872, with the 
right eyeball inflamed, swollen, much disorgan- 
ized and very painful, and with the report that 
three days previously he had received an injury 
from a piece of iron bolt flying against the eye. 
Upon lifting the lid a lai*ge incision across the 
cornea and outer side of the sclerotica was seen, 
with the edge of something black pi-oti*uding. 
With a probe it was found to be hard and metal- 
lic. Taking this for the piece of iron it was 
grasped by the forceps and drawn out. It was 
a piece from the head of a bolt chipped off by 
the hammer in riveting. It measured 11 m.m. 
wide and 3 m.m. thick, weighing 19| grains. 
W. II. Y., set. 50, machinist, of Philadelphia, 
came to my clinic at the Wills’ Ophthalmic Hos- 
pital, March 4, 1873, with the left eye much 
swollen and inflamed. On the upper lid there 
was an incision extending from the edge xxp 
about one-half of an inch, with two sutures 
therein to bring the edges of the wound together. 
The history of the case was, that the day before 
a piece of iron had flown and cut his eye. He 
went immediately to a neighboring physician, 
who saw nothing but the cut through the lid and 
put the sutures in. He was the next day ad- 
vised by his friends to come to this hospital. 
On lifting the lid an incision through the cor- 
nea and inner side of the sclerotica was seen, 
with the wound in the latter gaping. Taking a 
probe to see how far the wound extended, I felt 
a hard substance. Introducing a pair of for- 
ceps, I grasped and drew out from the inside 
of the ball a piece of iron measuring 21 m.m. 
long, 10.} m.m. wide, and 3 m.m. thick at the 
top, while the lower edge was tapering and as 
sharp almost as a razor. Its weight was 20 
grs. Instant removal of the ball was advised, 
for fear of sympathetic trouble in the other eye, 
but the patient would not consent thereto and 
left the hospital. 
From the Medical and Surgical Reporter, March 7, 1874. 
Iritis, with Gelatinous Exudation into the 
Anterior Chamber. 
ish, translucent, gelatinous mass, apparently 
issuing from or attached to the edge of the iris. 
It looks as if the lens had been dislocated for- 
ward and become slightly opaque. 
April 8. The exudation has increased in size 
and thickness. The hemorrhagic spots on the 
iris still visible. 
April 10. The gelatinous exudation has in- 
creased so as almost to fill the anterior chamber, 
and is as opaque as a cataractous lens. The 
vision is reduced to distinguishment of a bright 
light only. A very narrow rim of the iris is 
visible. 
April 15. The exudation remains as when 
last seen. There is considerable hemorrhage 
into the anterior chamber. The pain in the eye 
much less. 
April 19. The hemorrhage into the anterior 
chamber absorbed, and the exudation less 
opaque. No pain in the eye nor over the brow. 
The process of absox-ption has begun. 
May 8. The whole of the semi-transparent 
coherent mass is absorbed. The anterior cham- 
1 ber is clear. The iris still discolored and di- 
J. P., set. 22, came to my clinic at the Wills' 
Ophthalmic Hospital, March 27th, 1873, with 
iritis, R. E. The inflammation, with pain, came 
on a few days previously, but thinking it would 
pass away he took no notice of it at once. The 
pupil was irregularly contracted; the iris swol- 
len ; considerable peri-corneal injection ; vision 
cloudy; pain severe. He had had gonorrhoea 
two or three times, but never had a chancre. 
Has suffered from rheumatic pains in the limbs, 
and sore throat at times. 
A solution of atropia sulph., four grs. to the 
ounce, was ordered to be dropped into the eye 
three or four times daily, and ten grs. iodide of 
potassium, with one-twelfth gr. of bin. iodide of 
mercury and ten tr. colchicum, given in- 
wardly three times daily. 
March 29. Iris finely dilated, but color 
changed to a dirty yellow. Aqueous clear. 
April 5. Iris still finely and regularly dilated, 
but covered with hemorrhagic spots. The pu- 
pillary region is completely covered with a gray- 5 
lated. By ophthalmoscopic examination vitre- 
ous found to be quite clouded. Ordered hvdrarg. 
bichlor., one-sixteenth gr., three times daily. 
From this day on absorption went on rapidly, 
and the eye cleared up so as to give a vision of 
XL until 
•Tune 7. He returned with the eye again in- 
flamed. Much peri-corneal injection. Iris hori- 
zontally oval. Eyeball feels swollen, too large 
for the socket, painful to the touch. Great burn- 
ing pain in the eye. Anterior chamber clear, 
but cornea slightly infiltrated. Vision reduced 
to 20; four grain solution of atropia continued. 
Artificial leech applied to the temple, and fif- 
teen grs. iodide of potassium inwardly, three 
times daily. 
June 10. Eye much better. Iris well and 
evenly dilated. Pain relieved. 
•Tune 14. Eye still improving. Artificial leech 
again applied to the temple. 
From this time, under the above treatment, 
the eye improved, so that in about ten days there- 
after he went to work with vision of 1. 
The points of interest in this case are :— 
1st. The hemorrhagic spots on the iris. 
2d. The gelatinous exudation into the anterior 
chamber from the iris. 
3d. The primary cause, whether of syphilitic 
origin or not. 
The hemorrhagic spots were peculiar. When 
first noticed there appeared but three or four 
little globules of blood oozing out of and resting 
on the iris, no doubt held in position by still 
being under the epithelium of the iris. These in- 
creased in numbers, and some coalescing formed 
long oval spots, then passing through the epi- 
thelium fell to the bottom of the anterior cham- 
ber, forming a hyphaema. 
The first appearance of the gelatinous exuda- 
tion was immediately over the pupil, and ap- 
peared issuing from or attached to the inner 
edge of the iris; looking as if the lens was slip- 
ping through the pupil. 
From the symptoms of the sore throat and the 
cloudiness of the vision, I have no doubt that he 
had a urethral chancre at one of the times he 
says he was suffering from gonorrhoea, and that 
syphilis was the real cause of the disease, al- 
though at no time could I see a well defined 
gummy tubercle on the iris. 
Schmidt, of Marburg, is the first to have writ- 
ten upon this peculiar exudation from the iris 
into the anterior chamber. In 1869 he called 
the attention of Prof. V. Graefe to it, who said 
that he had seen but a couple of like casoft, but 
had made no particular notes thereof. 
In Schmidt’s paper he describes two eases 
which came under his care, but says nothing of 
syphilis as the primary cause, claiming it as a 
rheumatic affection. 
In looking over them and their treatment, I 
am inclined to think that there was really more 
syphilis than rheumatism at the foundation of 
the disease. In the last case he describes, he at 
first thought that it was a dislocation of the lens, 
with secondary irido-choroiditis, and to relieve 
the severe inflammation placed the patient un- 
der the inunction of ung. hydrargyri. Under this 
treatment, he says, he was surprised to see the 
exudation become reduced and absorbed. On 
the sixteenth day after the beginning of the treat- 
ment there was a little exudation of blood into 
the anterior chamber, which was again absorbed 
the second day after. He does not, however, 
mention anything about the appearance of little 
blood globules on the iris first, lie also found 
clouded vitreous as soon as an examination with 
the ophthalmoscope could be made. He does 
not say if he even inquired or examined for any 
previous syphilitic infection. His treatment 
was entirely anti-syphilitic, under which they 
recovered. 
Gunning, of Amsterdam, in 1872 published 
three cases of this peculiar exudation, in two of 
which he found syphilis the primary cause of 
the iritis, and one doubtful, “rheumatism” be- 
ing given. 
Kipp, of Newark, N. J., published a case in 
1873, in which syphilis was the primary cause. 
All the cases so far published have been 
males. In looking over these cases I am of the 
opinion that where this peculiar gelatinous exu- 
dation from the iris into the anterior chamber 
is found or takes place with iritis, that syphilis, 
either acquired or congenital, will be found in 
the patient. 
Granuloma of the Iris, Extending through 
the Cornea. 
G. S., set. 21, machinist, came to me Novem- 
ber 10th, 1866, to have his left eye examined, 
it having been injured some days previously 
by a ragged piece of iron nail butt flying against 
it. 
There was found a traumatic cataract, a long 
cicatrix across the outer half of the cornea, 
running at an angle of 150°, and extending out 
of the cicatrix there was a flat hammer-shaped 6 
fleshy tumor, lying in the cornea. Perception 
of light was good. 
out through the incision in the cornea before it 
had entirely healed. 
Congenital Hereditary Dislocation of Both 
Lenses. 
E. D., aged 28, residing in Lycoming county, 
Pa., was brought to my clinic at the Philadel- 
phia Eye and Ear Infirmary, January 13th, 
1872, for an affection of her sight, with the his- 
tory that ever since her birth she has had poor 
vision, never having been able to attend school, 
although she has made out to teach herself to 
read by the use of very large type. 
She is of normal stature and build, and al- 
ways enjoyed good health. The eyes are small, 
diameter of the cornea reduced. Iris dark hazel; 
pupils rather contracted. On fixation on any 
near object, the right eye deviates somewhat out- 
ward. Her vision is, large objects at ten to 
twelve feet without distinguishing them. With 
-j- 4 glass vision With + reads Jager’s 
test types, No. 6, at eight inches. 
In looking directly in the eyes a grayish- 
white cone-like projection is perceived coming 
from the lower and outer part of each pupil. 
The pupils being dilated by atropia (4 gr. so- 
lution), ophthalmoscopic examination showed 
dislocation of both lenses outwai'd and down- 
ward, and now opaque and shriveled, the line of 
vision being over them. 
There is also a singular involuntary spas- 
modic movement of both eyes and the brow. 
Every few minutes the brows would contract, 
and the eyeballs would roll upward and inward 
as far as the muscles could draw them, being a 
spasmodic contraction of the eorrugator super- 
cilii, and superior and internal rectii and infe- 
rior oblique of each eye. 
Upon questioning her why she did it, she re- 
plied that she was perfectly unconscious of any 
movement. 
She, and the lady with her, reported that the 
patient’s mother, sister and two brothers were 
affected with the eyes and sight just as she is ; 
and that the mother had three brothers and her 
father similarly affected. 
If this is so, it is a very remarkable case of 
hereditary abnormity of the eyes existing in so 
many members of one family. 
It is now a well established fact that there are 
persons born with the lenses of the eyes out of 
the natural position, or rather displaced from the 
normal situation, but still remaining within the 
ciliary processes, and sustained by the normal 
attachments. This condition, though rare, is 
2 
t 
The tumor was 6 m.m. long, 3 m.m. broad, 
and 2 m.m. thick, and was attached to a small 
round pedicle that passed through an aperture 
in the cornea, on the line of the cicatrix, and 
connected with the iris and spread out on the 
anterior capsule. The capsule was thickened 
and appeared quite vascular on that side. 
The iris had prolapsed into the wound of the 
cornea, and no doubt was lacerated at the time 
of the injury. The pedicle seemed to run along 
and was lying on the prolapsed iris. The iris 
was not inflamed, nor changed in color. 
There was no pain attending it, but much in- 
convenience at times by the lids, on closing, 
catching it and drawing it from its base. 
The history given was, that there was con- 
siderable pain and inflammation for a day or 
two after the injury, but it soon passed away, 
and a little fleshy spot showed itself on the eye, 
which continued increasing, and at the same 
time flattened out ufitil it had attained the size 
above mentioned, when he sought surgical ad- 
vice. 
I proposed the removal of the cataractous lens 
and the lower and outer part of the iris with the 
granuloma, but the patient would not consent 
to undergo the operation, so I cut the pedicle 
through close to the cornea, touched the point 
with caustic, and applied a firm compress band- 
age over the eye. 
I saw him several times in two to three 
months after, during which time there showed 
no disposition of its returning, and the eye re- 
mained in good condition. Since then I have 
heard nothing from him. He promised to come 
to me if it should grow again. 
Granulations proceeding from the iris and 
ciliary body after lacerating Avounds, do some- 
times form in the eye and produce more or less 
irritation. At times become large fungoid 
masses, destroy the eye by bursting through 
the cornea, and then shrink, leaving the bulb 
atrophied. 
In this case the granulation formed, and fol- 
lowing the track of the prolapsed iris, pushed often hereditary, and sometimes exists in several 
members of one family. 
The displacement, according to Stellwag, usu- 
ally takes place upward and inward. The above 
case deviating, however, from the usual rule, in 
the situation being downward and outward. 
The lenses in this position often remain trans- 
parent for years, perhaps through life, while in 
some, laminated cataract is developed. There 
is always great disturbance and difficulty in 
vision. If by contraction of the iris the rays of 
light pass through the edge of the lens lying in 
the pupillary region, the adjustment is myopic, 
and with some, astigmatism is combined ; while 
if the rays pass directly in, by, or over, or under 
the edge of the lens and not through it, it is 
adjusted as in aphakia (absence of lens), strongly 
hypermetropic. Occasionally, deviation of the 
optic axis takes place, that is, the eyeball turns 
in or out, up or down, from its normal position, 
to allow the rays of light to pass clearly and un- 
obstructed in through the most transparent part 
of the pupil, causing an accommodative strabis- 
mus ; as in the case above, the right eye deviated 
outward on fixation of objects.