AMBLYOPIA TRICS. 
BY 
GEORGE M. GOULD, A.M., M.D., 
OPHTHALMOLOGIST TO THE PHILADELPHIA HOSPITAL. 
FROM 
THE MEDICAL NEWS, 
December 31, 1892. [Reprinted from The Medical News, December 31, 1892.] 
AMBLYOPIATRICS.1 
By GEORGE M. GOULD, A.M., M.D., 
OPHTHALMOLOGIST TO THE PHILADELPHIA HOSPITAL. 
The fact that no name exists for the therapeutics 
of amblyopia in the cases in which the defect is 
ascribed to “disuse,” and coexisting either with 
squint, muscular insufficiency, or a high degree of 
ametropia and probably of anisometropia, leads to 
the astonishing fact that the desire or the attempt 
to cure amblyopia does not exist on the part of 
ophthalmologists. If a child with one weak and 
deformed leg is brought to the orthopedic surgeon, 
he does not say, “ Oh, well, the child has one good 
leg, let it get on with that alone.” If a finger or a 
hand is injured, does a surgeon ignore its needs and 
congratulate himself and the patient that the rest 
of the fingers or the other hand is all right ? But it 
is a literal truth that an argamblyopic eye (/. <?., 
one amblyopic from disuse) brought to the oculist 
is dismissed without care and without attempt at 
cure. In no text-book with which I am ac- 
quainted are either principles or rules laid down 
to govern the treatment, and no hint is given 
that any treatment is desirable. Not only so, but 
1 Read before the Philadelphia County Medical Society, 
December 28, 1892. 2 
positive instructions are laid down that, carried out, 
prevent the weakened eye from ever regaining its 
lost power. It is as if the surgeon should say of a 
lame leg : Strap it up out of the way ; it can't work 
with the other, or as well as the other; let it go. 
Listen to this extract from the latest text-book on 
ophthalmology, fresh from the press: 
In anisometropia we give the same glasses for 
BOTH EYES, OR CORRECT ONLY ONE EYE AND PLACE A 
PLANE GLASS BEFORE THE OTHER.—Fuchs, Text-book 
of Ophthalmology. 
I set this sentence out in capital letters, as display- 
ing as much ophthalmologic error and therapeutic 
sin as could easily be gathered into so many 
words. Another popular treatise puts it this way : 
“ For the class of patients whose ocular discrepan- 
cies \anisometropia\ are so great that they always 
use only one eye, nothing is to be done save to aid 
as perfectly as possible the working member in case 
it needs assistance. The other is to be left to purely 
ornamental functions.” 
Any number of such quotations could be added 
were it necessary to show that the established con- 
viction and practice of the ophthalmologic profes- 
sion is not only to completely ignore the need and 
the duty of treatment of argamblyopia, but even to 
so further handicap eyes thus afflicted by measures of 
anti-therapeutics as to render recovery impossible, 
and even to increase the defect. 
In square and absolute opposition to this I con- 
tend that every amblyopic eye is a sick eye, and 
that it is the physician’s first duty to cure, whether 
it be eyes, or legs, or bodies. 3 
Our impotent willingness to permit such a lazj 
method of non-treatment is a distinct reproach and 
discredit to us. It is simply untrue that patients 
with anisometropia will not permit a proper and 
helpful correction of each eye. In some 2500 
cases occurring in private practice, I have found 
none such except two or three who had simple 
myopia in one eye and approximate emmetropia in 
the other. But, for obvious reasons, in such cases 
there is no amblyopia, and they are, therefore, out 
of the count. Of course, correction of anisome- 
tropia may be inconvenient and even uncomfortable 
to the patient for a short time, but could one ex- 
pect the abnormal habits and weakened organs of a 
lifetime to resume normality in a few days? Do 
orthopedic surgeons thus treat the consequences of 
spinal curvature or talipes? Instead of the supine 
let-alone policy we should seek to save and to heal 
and to strengthen. Instead of non-response to 
treatment and inability of the patient to wear 
binocular correcting glasses, I have, in fact, been 
delighted and astonished to witness how soon re- 
sponse comes, and how short or non-existent is the 
period of discomfort. The weakened, almost 
blinded eye, soon reacts to the spur of kind, intelli- 
gent helpfulness, and, as month by month one 
watches these eyes irfiprove and gather strength, 
one feels the pride and pleasure of the true physi- 
cian in his true work. I have never failed to find 
such reaction even in the most hopeless cases of 
argamblyopia. 
And first, a prefatory word as to the new coin- 
ages that, with some trembling, I have ventured to 4 
strike: The needed word amblyopiatrics, or the 
therapeutics of amblyopia, explains itself, but it 
seems surprising that scholarly ophthalmologists 
should have continued to use the tautologic bar- 
barism, amblyopia exanopsia. According to its 
Greek roots amblyopia can mean nothing but 
dimness or dulness of the eyes or of vision ; and ex- 
anopsia can mean only, from absence of sight. The 
combined term, therefore, is literally and absurdly 
enough this : dimness of sight due to want of sight, 
or, lessened visual power from failure or absence of 
visual power. There is no hint in the etymology 
of the supposed meaning, amblyopia from disuse (of 
the eye). It seems clear that we should drop such 
a term and make use of some one that will express 
what we mean and desire. In Greek we have Ipyov, 
meaning function, htpyeia, activity of function, of 
which the opposites are, hpy6q and apyia. A well- 
formed and significant compound for disuse-ambly- 
opia, would, therefore, be argiamblyopia, contracted 
naturally to argamblyopia. 
I have no desire to enter into the vexed question 
as to whether the muscular anomaly or ametropia 
precedes and causes the amblyopia, or whether the 
reverse is the case. When the patient appears in 
the oculist’s office, the two facts are (at least often) 
presented at the same time, and our task is at once 
the very practical one of therapeutics, the question 
of etiology being of minor or theoretic importatance. 
There is, however, a very suggestive illumination 
thrown back upon the question of etiology by the 
practical results of intelligent and persistent thera- 
peutics. When large numbers of amblyopic eyes 5 
recover their lost acuteness of vision by means that 
permit and necessitate their functionalization, the 
dogmatism of authorities and the negligence of 
oculists receive a suggestive comment amounting 
to refutation, both of the theory and of the sadly 
common resultant practice, that the amblyopia is 
cerebral or that it is the causal agent of the muscu- 
lar or ametropic anomaly. Almost without excep- 
tion, my cases teach me that amblyopia is argam- 
blyopia. (It goes without saying, of course, that 
amblyopia due to fundus-lesions and media-lesions 
are out of the count.) And when such improve- 
ment of vision follows the removal of the ametropic 
or heterophoric hindrance it, ipse facto, justifies the 
acceptance of the theory of effect-amblyopia im- 
plicit in the word coined. 
But whether the one theory or the other be the 
true one, the therapeutic sin of not attempting to 
bring back the lost power of these handicapped 
and half-ruined eyes, is a sin that cries out against 
us. The number of persons going about, and going 
on to the age of cataract-possibility, with such' eyes, 
is surprisingly large. Whether with growing prac- 
tice one sees more patients, or whether such argam- 
blyopic patients, neglected by others, drift into 
one’s hands, one is amazed at the frequency of the 
fact, and that instead of heroic effort to save, there 
has usually been pursued a no-policy of the most 
atrocious and let-alone indifference. Now this 
policy of laisser-aller is to me incomprehensible, 
unethical, antimedical, and impolitic, and the object 
of this writing is to protest against it and to offer 
proofs that it is in all these ways wrong. “ Far from 6 
telling me how to save the bad eye, my doctor never 
suggested that it could or need be saved”—that 
gives the hint of the impolitic policy. “I now 
have cataract in my best eye, and the other has 
been no good for many years ”—that should deeply 
sting the heart of the negligent physician—if he 
could hear it. 
The practice may partially be a conscious or un- 
conscious result of what I believe the false teaching 
that the amblyopia is cerebral or idiopathic, or is 
the cause of the coexistent strabismus or insuffi- 
ciency, or again of the still more execrable teach- 
ing to correct the ametropic defect of one aniso- 
metropic eye, leaving the other to go to the dogs. 
The functionalization of argamblyopic eyes con- 
sists, of course, in three things: i. The correction 
of the ametropia; 2. The reinstatement of the 
muscular balance, if imbalance exists ; 3. Exercise. 
As to the correction of the ametropia, there are a 
number of peculiar difficulties and problems. These 
each refractionist will overcome and answer accord- 
ing to his teaching, his habit, or his intelligence. 
Assuredly no hard-and-fast rule will suffice, nor can 
such a rule be even approximately formulated. 
Each case will be a study in itself, requiring the 
most accurate discrimination of judgment, and the 
finest delicacy of testing. In an eye of which the 
neurologic elements and the cerebral centers are 
certainly weakened and partially atrophied, the 
failure to hit exactly the right kind, degree, or 
precise proportion of help required, foredooms at 
once to failure. The very breath of life in such an 
eye is trembling between endeavor and renuncia- 7 
tion. A shade of over-correction or of under-cor- 
rection, a slightly misplaced axis of astigmatism, a 
misplaced or maladjusted spectacle, a touch at the 
wrong place, the lack of a wee-bit of help at the 
right place—anything except the right thing—smothers 
the little remaining power of recuperation, and 
proves a tiny load too great for the tiny forces to 
lift. We are here dealing with infinitesmals, and 
the keenest and swiftest perception will win where 
a less subtle discrimination will fail. 
It is evident that such eyes must be nursed and 
encouraged, as it were, into convalescence. Frequent 
re-testings will be required; frequent adaptations 
to the changed conditions sure to follow ; watchful 
care if one weak part of the complex system fails to 
respond or temporarily gives way; constant read- 
justment of the spectacles following and stimulating 
the renascent powers, and meeting them with the 
precise modicum of lessened or increased aid—these 
and many such methods of guiding and guarding, 
must be kept in mind until full health is restored, 
and the convalescent eye enjoys and shares the labors 
of its fellow. 
In the same way the reestablishment of muscular 
coordination, still further complicating the problem, 
will be brought about according to the peculiarities 
both of the case and of the physician. 
But these questions having been settled, gym- 
nastics will remain as the very heart of the matter 
and crux of the difficulty. An eye the visual 
power of which has from disuse fallen to 20/c, let us 
say, and reduced to only the temporary holding of 
the image of Jaeger 14 or 18, will not participate in 8 
binocular vision, however perfect the image formed 
on the retina, or however balanced the muscles. It 
must be exercised, and gently forced to function. 
It is clear that the good eye must be temporarily 
thrown out of use, and the weakened brother put 
to work alone. The kind and the amount of exer- 
cise will again depend on the retained visual acute- 
ness of the eye to read print, large or small, and 
the retained power to continue this for a longer or 
a shorter period of time. Here again appears the 
necessity on the part of the physician of careful 
estimation by a trained judgment to give the proper 
instructions. 
But the final success will depend upon the patient’s 
persistence, patience, and cooperation. This co- 
operation will only be certainly gained by mak- 
ing him (or, if a child, his parents) thoroughly 
understand just what is desired, and the full signifi- 
cance of it all. To him it should be explained in 
detail and fulness, that exercise only develops func- 
tion ; that as years go by, non-exercise will still 
further and hopelessly ruin the eye ; and that as age 
approaches, the possibilities of danger to the good 
eye (always doubled if there be but one!) are 
greatly increased by the liability of cataract, of 
inflammation, of injury, etc. 
The method of monocular gymnastics in these 
cases will depend upon the interest of the patient, 
the age, occupation, etc. In children too small to 
wear glasses, or to wear the blinder willingly, I keep 
the good eye under continuous mydriasis for weeks, 
or even for a month or two. Some ladies prefer 
holding the fan, a bit of paper, etc., before the 9 
sound eye while exercising the weaker one. I have, 
during the past year or two, ordered the patient to 
get a disc of black rubber fitted with two hooks, so 
that it may be hung on the spectacle-lens in front of 
the good (unclosed) eye. Such discs are supplied 
by my opticians, who have prepared them in ac- 
cordance with my request. The patient is to read 
print of a size that can be easily distinguished, and 
only so long as signs of positive discomfort or weak- 
ness do not appear. Some patients can at first hold 
the image for but a few seconds. The shorter the ne- 
cessary duration of such periods the more frequently 
they should be undertaken. Some patients can read 
or work with the single eye for an hour or two with- 
out trouble. The plan that has proved of most 
service, and has been productive of the best results, 
is to use “the blinder” when eating the meals. If 
living at home, the extra blinder is left at the plate 
as a reminder, and the practice is excused by friends. 
It gives an hour or more of varied and easy exercise 
without loss of time or the annoyance of special 
attention to the matter. I have a patient, a jeweler, 
who works at his bench with his blinder, in all one 
or two hours a day, and whose power and vision have 
been greatly improved thereby. 
A certain proportion of cases do not report; a few 
get tired, or are indifferent to the matter. The fol- 
lowing cases illustrative of the method and of its 
results may be cited : 
Case I.—Mrs. H., nineteen years of age, has had 
severe and continuous headache from early child- 
hood, with gastric trouble, malnutrition, etc. Natu- 10 
ral vision is R. 20/xx; L. 10/cc. Mydriatic refrac- 
tion = 
R.—sph. 0.25 D,0+cyl. 0.50 D, ax. 900—20/xx-f. 
L.-f-sph. 2.50 D, 0—cyl. 5.50 D, ax. i8o°=:2o/xl. 
With muscular balance. 
After the return of the accommodation, and with 
the proper correcting glass, the left eye could read 
only Jaeger 14 at twelve inches. 
Monocular exercise was ordered. In three months 
all headache had disappeared, the distant vision of 
the left eye, both at near and distant range, equal- 
ling that of the right eye. 
Case II.—Miss M., aged twenty, had the follow- 
ing defect: 
R.-|-sph. 0.75 D, 0+ cyl. 0.75 D, ax. i.25°=2o/l. 
L.-j-sph. 0.50 D, 0+ cyl. 3.50 D, ax. 1. i5°=2o/c. 
Careful instructions as to ocular gymnastics has 
improved the vision in four months to R. 20/xx ; L. 
20/L 
Case III.—Mrs. R., aged fifty-one, had the fol- 
lowing refractive error : 
R. 20/xxx -f sph. 0.37 D, = 20/xx. 
L. 10/cc -)- sph. 3.00 D, 0 -j- cyl. 1.00 D, ax. 90° 
= 20/cc. 
With the left eye the patient could read only the 
large-print “ Scripture leaflets ” hung in rooms—the 
only thing I could get for her of sufficiently large- 
sized letters with which to exercise the eye. One 
year later, after more or less exercise of this eye 
alone, she was able to read Jaeger 12, slowly. 
Case IV.—Miss R., aged twenty-five, under homa- 
tropine was found to have the following error of 
refraction: 
R.—sph. 3.00 D, 0—cyl. 0.50 ax. 1500— 2o/lxx-|-. 
L.—sph. 7.00 D, 0—cyl. 0.50 ax. i8o°=2o/lxx. 11 
Eight months later the vision was: R. 20/xx ? 
L. 20/xL. 
Case V.—Mrs. K., aged forty-five, had 20/xL 
vision in the right eye, with a compound myopic 
astigmatism twice as great in this eye as in the left. 
There were six degrees of exophoria. Proper cor- 
rection of all ametropia and insufficiency with mon- 
ocular exercise relieved the life-long sick-headache, 
etc., and in five months the vision of the left was 
brought to the normal. 
Case VI.—Miss S., thirty-five years of age, had 
had frontal headaches all her life, and, with much 
near-work, ptosis of the left lid. Refraction was: 
R.— sph. 1.50 D, Q 4" cyl- 5-°° D, ax. 105° = 
20/LXX. 
L. -(- cyl. 1.25 D, ax. 8o° = 20/xx. 
Five months later, after the monocular course of 
gymnastics, all headache and ptosis had disappeared, 
and the vision of the right eye was 20/xx ? 
Case VII.—Mr. P., twenty-five years of age, was 
found to have the following refraction : 
R.— sph. 0.25 D, 3 + cyl. I'°° D, ax. 1250 — 
20/xx. 
L. -f- sph. 0.75 D, Q -f- cyl. 3.00 D, ax. 1800 — 
20/LXX. 
He had been wearing a plane glass. After myd- 
riasis had passed off he could, with proper correc- 
tion, barely read with the defective eye Jaeger 10. 
Three months later he read Jaeger 4, with ease. 
Case VIII.—Miss M., forty-six years of age, gave 
a history of a lifetime of sick-headaches, once or 
twice a week, with anorexia, anemia, etc. She was 
wearing: 
R.— sph. 3.00 D, 3— cyl. 2.25 ax- 1800. 
L.+ sph. 0.75. 12 
This had been given her for constant use, although 
her age was forty-six, and she was employed at 
writing all day. I found that her refraction was : 
R.— sph. 2.50 D, Q — cyl. 5-0° D, ax. 165° = 
2o/lxx. 
L.-J- sph. 0.37 D, = 20/xx. 
Hyperphoria of 30. 
A few months after correcting the ametropia, 
presbyopia, and hyperphoria, with monocular exer- 
cise of the right, the vision in that eye had im- 
proved to 20/xL, and all the reflex symptoms men- 
tioned had disappeared. 
Case IX.—A little girl of nine was greatly 
afflicted with night-terrors, somnambulism, head- 
ache, anorexia, nervousness, etc. Her refraction 
was as follows : 
R.-)-sph. 0.75 3+ cyl. 5-°° D, ax. ioo°= 20/LXX. 
L.-f-sph. 1.00 0+ eyl- 5-°° D, ax. 85°= 20/c. 
The blinder was ordered for the right eye, with 
daily exercise of the left alone in reading large- 
print toy-books, in playing, etc. The right eye 
soon recovered a normal acuity, but it took nearly 
a year of watchful care and exercise to bring the 
left to 20/xx? 
Case X.—Mrs. A., has had constant frontal head- 
ache for the past five years, culminating in parox- 
ysms of sick headache every few days. When a girl 
at school she had “numb spells,” “ blind spells,” 
etc. I found : 
R.-f- sph. 3.50 Q -j- cyl. 1.00 ax. 150°= 20/cc. 
L.-f- sph. 1.00 0 -(- cyl. 0.75 ax. 1500— 20/xx. 
Persistent exercise with the blinder brought pro- 
gressive increase of visual acuteness and power. 
The reading ability descended through all the sizes 
of letters from Jaeger 18 to Jaeger 8, and from 13 
ability to hold the image for only a few seconds, 
until now, seven months since beginning, she can 
read ordinary print with the right eye for a half- 
hour, and distant vision at the last visit was 20/LXX, 
with improvement still in progress. The headache, 
anorexia, ill-health, etc., have entirely disappeared. 
Case XI.—A girl of ten years of age, anemic, 
with ocular and forehead-pain, was refracted on 
April 16, 1892 : 
R. 20/LXX -f sph. 1.00 O + cyl. °-25 ax- 9°° — 
20/xxx. 
L. 20/cc -f- sph. 1.25 O -f- cyl. 0.37 ax. 90° = 
20/LXX. 
With esophoria. 
With the prescribed exercise of the left eye, the 
vision in six months had reached 20/xxx, and will 
doubtless soon be equal to that of the other. 
Case XII.—A lad of seventeen, with a high de- 
gree of compound hyperopic astigmatism in the 
right, and 20/Lxx vision, while the left had perfect 
vision, and a low degree of the same refractive 
error. The blinder treatment has brought vision in 
the right eye to 20/xx ? in six months. 
Case XIII.—The last case I shall refer to is an 
instructive one. A gentleman of forty-six years 
has had severe ocular trouble and headache all 
his life, but for the past twelve years, these and 
other symptoms have been excessive, and he has 
reason, if he but knew it, to preach some useful 
lessons to ophthalmic specialists. One of these gen- 
tlemen, who prides himself on prescribing by oph- 
thalmoscopic examination alone, fitted him with 
glasses twelve years ago, but with the most heroic 
endeavor he could not wear them. Vertigo was at 
this time, and for six years, so pronounced that it 
was a source of daily wretchedness. Then came the 14 
turn of the graduated tenotomist, but the vertigo 
was worse and mental confusion became so great 
that pronounced cerebral disease was diagnosticated 
by physicians. He feared insanity, and was so 
haunted by suicidal mania that he had to take daily 
precautions to obviate the thought and the circum- 
stances that might lead to its execution. This went 
on for years. A firm will has kept the upper hand 
through all these years. The patient describes his 
symptoms as “ panic-feelings and palpitation of the 
brain,” with extreme nervousness and nausea. The 
headache has been less of late. Lastly, a famous 
oculist told him to go to an optician and get what- 
ever glasses should be given to him there. These 
he has been wearing for reading—what little he can 
do ! They are simple plus spherical 3.00 D lenses, 
the same for each eye ! 
After hours of careful work I find his true refrac- 
tion to be: 
R.-)-sph. 2.00 D,0-j- cyl. 2.00 ax. 400—20/xL. 
L.-f-sph. 1.50 D,C+ cyl. 1.00 ax. 9o°=2o/xxx-|-. 
With some exophoria and hyperphoria. 
With the right eye alone he can hold an image of 
Jaeger 10 but a second or two, the letters then 
“ jump ” and fade. 
When one thinks of the lifetime during which the 
poor eyes and the cerebral centers of the last case, 
for example, have struggled and begged for a bit of 
intelligent help; when one analyzes the peculiar 
defect that would not let either eye renounce vision ; 
when one considers the fact that a strong healthy 
masculine will has fought against this frightful evil, 
and preserved its defective mechanism so well; or 
what would have been the result in a woman—when 
one ponders over these and many such related things, 15 
one is pained with sympathy, and indignant at the 
failure to help. 
The age of the patient, of course, has a great deal 
to do with success of treatment in all these cases, and 
one fact stands out with clearness: the younger the 
age at which the treatment is begun the better. 
Reaction is prompt in the young, and every added 
year of failure, and wrench, and wreck, makes the 
task ever more difficult. 
I have had something like fifty of these cases, and 
many had previously passed through the hands of 
others unbenefited. It would therefore appear that 
the duty to “fight for a bad eye” is at present 
not at all recognized. Every such case is pathetic 
with dumb pleading for a simple bit of help that 
it should be at once our highest duty and privi- 
lege to give. Moreover, to prevent disease is even 
greater than to cure it, and if taken early in life in 
no branch of medicine is intelligent prevention of 
intolerable evil so possible and so beautifully result- 
ful as in painstaking and skilled refraction-work. The Medical News. 
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