Front matter
-
THIS BQOK 15 THE GIFT OF
3 1924 104 224 757
Preface To The Second Edition
It has afforded me no small gratification that the first edition of this work should have met with so very favorable a reception, both by the profession at large, and by the British and Foreign Medical Press ; and especially that it should have been deemed worthy of being translated into French and German, in both of which languages it will be published in the course of this year.
Stimulated by such encouragement, I have endeavored to render the second edition as complete as possible, and have made numerous additions, incorporating all the important facts elucidated by the most recent researches, so that the work might be brought up to the latest date.
16, Sayille Row, May, 1870.
Preface To The First Edition
"Within the last few years the want has often been expressed of an English treatise on the diseases of the eye, which should embrace the modern doctrines and practice of the British and Foreign Schools' of Ophthalmology, and should thus enable the practitioner and student to keep up with the knowledge and opinions of the present day.
I now venture to lay before the Profession a work which I trust may be deemed, to a certain extent, worthy to meet this desideratum. Whilst I have endeavored to enter fully into all the most important advances which have been lately made in Ophthalmic science, I have not contented myself with simply recording the views of others, but have sought in most instances to make myself practically conversant with them, so that I might be able, from my own experience, to form an independent and unbiassed opinion as to their relative value. The vast and peculiarly favorable opportunities which I have had at Moorfields of studying all phases and kinds of eye-disease, as well as the great benefit which I have enjoyed of witnessing the practice and operations of my colleagues, have most materially assisted me in the possibility of doing this.
In preparing this work, I have steadily kept one purpose in view, viz., to make it as practical and comprehensive as possible, and I have, therefore, entered at length into an explanation of those subjects which I have found to be particularly difficult to the beginner. I have, on purpose, occasionally repeated important points in diagnosis and treatment, in order to render each article, to a certain extent, complete in itself, so as to obviate the necessity of the reader having constantly to refer to other portions of the book for explanation or information. Moreover, I have thought that this would prove of great convenience to those who may desire to consult and study certain subjects, without being obliged to peruse the greater portion of the book.
The subjects of "Injuries to the Eye," and of "Congenital Malformations of the Eye," have assumed such considerable dimensions,
Vlll PREFACE.
that I have been obliged to treat of them somewhat briefly, and would, therefore, refer the reader, who seeks for fuller information, to special treatises upon these affections. Of these, I would particularly recommend the following excellent works: "Injuries of the Eye, Orbit, and Eyelids," by Mr. George Lawson ; " Verletzungen des Auges," by Drs. Zander and Geissler; and the "Malformations and Congenital Diseases of the Organs of Sight," by Sir "William Wilde.
My best and warmest thanks are due to my colleagues at the Eoyal London Ophthalmic Hospital, Moorfields, and more especially to Mr. Bowman, for their constant kindness in permitting me to have free access' to their cases, and for affording me much valuable information and advice upon all subjects connected with Ophthalmology.
Owing to the great liberality of my friend Dr. Liebreich, and of his publisher. Mr. Hirsehwald of Berlin, I have been able to illustrate this work with 16 excellent colored ophthalmoscopic figures, which are copies of some of the plates of Liebreich's admirable "Atlas d'Ophthalmoscopie."
As very frequent reference is made to certain Ophthalmic periodicals, I have used the following abbreviations : —
It. L. 0. H. Rep. signifies " Royal London Ophthalmic Hospital Reports," edited by Messrs. Wordsworth and Hutchinson (Churchill).
A. f. 0. signifies " Archiv fur Ophthalmologie," edited by Profs. Arlt, Donders, and Von Graefe (Peters, Berlin).
Kl. Monatsbl. signifies " Klinische Monatsblatter der Augenheilkunde," edited by Prof. Zehender (Enke, Erlangen).
The following symbols are also frequently employed in the course
of the work: — , means range of accommodation; r, punctum
remotissimum (far point); p, punctum proximum (near point); oo (= 0), infinite distance; ', foot, ", inch, '", line.
The test-types of Jaeger may be obtained from the Secretary of the Royal London Ophthalmic Hospital, Moorfields, and those of Snellen from Messrs. Williams and Norgate, Henrietta Street, Covent Garden.
16, Saville Row,
December, 1868.
CONTENTS,
Introduction
PAGE
E version of the Upper Eyelid — The mode of ascertaining the degree of Intra-ocular Tension — The examination of the Acuteness of Vision — Mode of examining the Field of Vision — Diplopia — The Compress Bandage— The Artificial Leech— The Eye-douche .... 17-32
Chapter I. DISEASES OP THE CONJUNCTIVA
Hypersemia of the Conjunctiva — Catarrhal Ophthalmia — Purulent Ophthalmia— Gonorrhceal Ophthalmia — Ophthalmia Neonatorum — Diphtheritic Conjunctivitis — Granular Ophthalmia — Acute Granular Ophthalmia — Chronic Granulations — Phlyctenular Ophthalmia — Exanthematous Ophthalmia — Xerophthalmia — Pterygium — Symblepliaron — Ankyloblepharon — Injuries of the Conjunctiva — Tumors of the Conjunctiva, etc 33-107
Chapter II. DISEASES OP THE CORNEA
Pannus — Phlyctenular Oorneitis — Fascicular Corneitis— Suppurative Corneitis — Non-Inflammatory Suppurative Corneitis — Ulcers of the Cornea — Diffuse Corneitis — Opacities of the Cornea — Arcus Senilis — ■ Conical Cornea — Kerato-globus — Staphyloma of the Cornea and Iris — Injuries and Wounds of the Cornea 108-164
Chapter III. DISEASES OF THE IRIS
Hypersemia of the Iris — Inflammation of the Iris — Functional Disturbances of the Iris — Tremulousness of the Iris — "Wounds, etc., of the Iris — Tumors of the Iris — Congenital Anomalies of the Iris — Iridectomy— Iridodesis — Corelysis — Iridodialysis — Changes in the contents, etc., of the Anterior Chamber — Irido-choroiditis — Sympathetic Ophthalmia 165-327
X CONTENTS.
Chapter IV. DISEASES OP THE CILIARY BODY AND SCLEROTIC
PAGE
Inflammation of Ciliary Body— Injuries of Ciliary Region— Episcleritis—
Anterior Sclerotic Staphyloma— Wounds and Injuries of the Sclerotic 228-237
Chapter V. DISEASES OF THE CRYSTALLINE LENS
Cataract — Lamellar Cataract — Cortical Cataract — Nuclear Cataract — Traumatic Cataract — Capsular Cataract — Flap Extraction — Removal of the Lens in its Capsule — Linear Extraction — Scoop Extraction — Von Graefe's Operation, etc.' — Reclination — Division of Cataract — Operations for Lamellar Cataract — Operations for Traumatic Cataract — Removal of Cataract by a Suction Instrument — Sperino's Treatment of Cataract by Paracentesis — Operations for Capsular Cataract — Dislocation of the Lens 238-311
Chapter VI. THE USE OF THE OPHTHALMOSCOPE
Theory of the use of the Ophthalmoscope — Ophthalmoscope of Liebreich, Coccius, Zehender [and Loring] — Fixed Ophthalmoscope of Liebreich — Binocular Ophthalmoscope of Giraud-Teulon — Aut-ophthalmoscope — The Examination with the Ophthalmoscope — The Examination of the Actual Inverted Image — The Examination of the Virtual Erect Image — The Ophthalmoscopic Appearances of Healthy Eyes — The Optic Disk — -The Ophthalmoscopic Appearances of Diseased Eyes . 312-344
Chapter VII. DISEASES OF THE VITREOUS HUMOR
Inflammation of the Vitreous Humor — Opacities — Foreign Bodies, etc., in
the Vitreous — Persistent Hyaloid Artery 345-359
Chapter VIII. DISEASES OF THE RETINA
Hyperemia of the Retina — Retinitis, Idiopathic and Parenchymatous — Retinitis Albuminurica, Lucsemica, Syphilitica, Apoplectica, Pigmentosa— Detachment of the Retina — Epilepsy of the Retina — IschaBmia Retinae — Embolism of the Central Artery of the Retina — Hyperesthesia of the Retina — Tumors of the Retina — Atrophy of the Retina — Cysts in the Retina 360-408
CONTENTS. XI
Chapter IX. DISEASES OP THE OPTIC NERVE
PAGE
Hyperemia of the Optic Nerve — Inflammation of the Optic Nerve — Atrophy of the Optic Nerve — Excavation of the Optic Nerve — Pigmentation of the Optic Nerve — Tumors of the Optic Nerve — Opaque Optic Nerve Fibres 409-433
Chapter X. AMBLYOPIC APPECTIONS
Amaurosis— Amblyopia — Hemeralopia — Color Blindness — Simulation of
Chapter XI. DISEASES OP THE CHOROID
Hyperemia of the Choroid — Serous Choroiditis — Disseminated Choroiditis — Sclerotico-choroiditis Posterior — Suppurative Choroiditis — Colloid Disease of the Choroid — Tubercles of the Choroid— Tumors of the. Choroid, Sarcoma, Carcinoma — Formation of Bone — Coloboma of the Choroid — Rupture of the Choroid-^Heniorrhage from the Choroid — Detachment of the Choroid 463-499
Chapter XII. GLAUCOMA
Acute Inflammatory Glaucoma — Chronic Inflammatory Glaucoma — Glaucoma Simplex— Secondary Glaucoma- — Ophthalmoscopic Symptoms of Glaucoma — The nature and Causes of the Glaucomatous Process — Prognosis of Glaucoma, etc 500-535
Chapter XIII. THE ANOMALIES OP REFRACTION AND ACCOMMODATION OF
THE EYE.
The Refraction and Accommodation of the Eye' — Optical Lenses, etc. — Mechanism of Accommodation — Negative Accommodation — The Range of Accommodation — Myopia — Presb3'opia— Hypermetropia — Astigmatism — Aphakia — Paralysis, Spasm, and Atony of the Ciliary Muscle— Spectacles — Difference in the Refraction of the two Eyes 536-598
PA HE
Xli CONTENTS.
Chapter XIV. AFFECTIONS OF THE MUSCLES OF THE EYE
Actions of the Muscles of the Eye— Paralysis of External Rectus— Paralysis of the Third Nerve— Paralysis of the Internal, Superior, and Inferior Recti— Paralysis of the Inferior and Superior Oblique- Nystagmus— Strabismus — Convergent Strabismus— Divergent Strabismus—Operations for Strabismus, Von Graefe's, Critchett's, Liehreich's — Muscular Asthenopia 599-657
Chapter XV. DISEASES OF THE LACHRYMAL APPARATUS
Diseases of the Lachrymal Gland — Stillicidium Lacrymarum — Inflammation of the Lachrymal Sac— Blenorrhcea of the Sac — Stricture of the Lachrymal Passages — Fistula of the Lachrymal Sac . . . 658-681
Chapter XVI. DISEASES OF THE ORBIT
Inflammation of the Cellular Tissue — Periostitis — Caries and Necrosis — Inflammation of the Capsule of Tenon — Exophthalmic Goitre — Tumors of the Orbit — Vascular Tumors of the Orbit — Effusion of Blood — Emphysema — Pressure upon the Orbit from Neighboring Cavities — Wounds and Injuries of the Orbit — Excision of the Eyeball .-The Application of Artificial Eyes 682-725
Chapter XVII. DISEASES OF THE EYELIDS
ffidema and Inflammation of the Eyelids — Syphilitic and Exanthematous Affections — Blepharitis Marginalis — Ephidrosis and Chromhydrosis — Hordeolum — Tumors of the Eyelids — Nsevus Maternus — Ptosis — Paralysis of the Orbicularis — Blepharospasm — Trichiasis and Distichiasis — Entropium— Ectropium— Injuries, Wounds, etc., of the Eyelids 726-783
Appendix
Mode of Examining the Field of Vision — Treatment of Chronic Granulations— Treatment of Symblepharon — Phlyctenular Corneitis — Treatment of Ulcers of the Cornea — Treatment of Conical Cornea — Treatment of Total Staphyloma of the Cornea and Iris — Leprous Tubercle of the Cornea — Inflammation of the Iris — Treatment of Inflammation of the Iris — Treatment of Irido-choroiditis — Operations for Cataract — Operation for Secondary Cataract — New Demonstrating Ophthalmoscope of Brudenell Carter 785-800
Selections from the Test-types op Jaeger and Snellen . . 813-821
LIST OF ILLUSTRATIONS.
PIG.
1. Upper eyelid everted ....
2. Mode of everting the upper eyelid
3. Mode of examining the eye by oblique illumination
4. Mode of examining the eye by oblique illumination
5. Mode of examining the visual field - 6. Mode of examining the visual field
7. Diagram for demonstrating the punctum caecum
8. Diagram explanatory of homonymous diplopia .
9. Diagram explanatory of crossed double images .
10. Diagram explanatory of action of pi-isms
11. Liebreich's bandage ....
12. Liebreich's bandage applied
14. The eyelids in purulent ophthalmia
15. Chemosis in purulent ophthalmia .
16. The eyelids in gonorrhoeal ophthalmia
17. Chemosis in early stages of gonorrhoeal ophthalmia
18. Ophthalmia neonatorum ....
19. The palpebral conjunctiva in granular ophthalmia
20. Pterygium tenue .....
21. Pterygium crassum ....
22. Szokalski's operation for pterygium
23. Symblepharon .....
24. Mr. Teale's operation for symblepharon .
25. Mr. Teale's operation for symblepharon .
26. Mr. Teale's operation for symblepharon .
27. Ankyloblepharon .....
28. The spud . ...
29. Mr. Haynes Walton's gouge
30. Dermoid tumor of the conjunctiva
31. Dermoid tumor of the conjunctiva
32. Dermoid tumor of the conjunctiva
34. Phlyctenular corneitis ....
35. Ulcer of the cornea ....
36. Prolapse of the iris ....
37. Paracentesis cornese ....
38. Notched teeth of congenital syphilis
39. Notched teeth of congenital syphilis
40. Partial leucoma .....
XIV
LIST OF ILLUSTRATIONS.
HO.
41. Knife for removing deposits of lead
43. Kerato-glpbus ....
44. Partial staphyloma of the cornea (side view)
45. Partial staphyloma of the cornea (front view)
46. Total staphyloma of the cornea
47. Operation of excision of staphyloma
48. Mr. Critchett's operation of abscission of staphyL
49. Beer's cataract knife
50. View of eye after Mr. Critchett's operation of abscission
51. Knapp's operation for staphyloma
52. Iritis
53. Iritis with irregular pupil and lymph near margin
54. Iritis with occlusion of the pupil .
55. Iritis with slender adhesions to the capsule
56. Serous iritis ....
57. Mr. Laurence's pupillometer
58. Rupture of the continuity of the iris
59. Rupture of the iris at its great circumference
60. Double pupil caused by laceration of the iris
61. Cyst of the iris
62. Coloboma iridis
63. Weiss' stop speculum
64. Straight keratome .
65. Bent keratome
66. Straight iris forceps
67. Curved iris forceps .
68. Iris scissors bent on the edge
69. Iris scissors curved on the flat
72. Iridectomy (Mr. Bowman's modification)
73. Iridectomy (Mr. Bowman's modification)
74. Appearance of the eye after iridectomy .
75. Broad needle ....
76. Diagram illustrating iridodesis
77. Broad cilia forceps ....
78. Canula forceps ....
79. Pupil after iridodesis
80. Artificial pupil made by incision of the iris
81. Tyrrel'shook ....
82. Spatula hook ....
83. Cysticercus in the iris .
84. Microscopic view of cysticercus .
85. Appearance of the eye in sympathetic ophthalmia
88. Annular staphyloma
90. Diagram showing how dilatation of the pupil in cataract improves the
LIST OF ILLUSTRATIONS.
XV
FIG.
01. Diagram showing how dilatation of the pupil in cataract improves the sight ....
92. Morgagnian cataract
93. Flap extraction by the upper section
94. Flap extraction by the lower section
95. Sichel's knife 96 Flap extraction by the superior section
97. The pricker
98. Graefe's cystotome
99. Passage of the lens through the corneal
100. Mode of making the corneal flap .
101. Probe-pointed secondary knife
103. Weber's lance-shaped knife
104. Diagram illustrating Weber's operation for cataract
105. Mr. Critchett's scoop ....
106. Mr. Bowman's scoop ....
107. Mr. Bowman's scoop (another form)
108. Von Graefe's cataract knife
109. The line of incision in modified linear extraction
110. The line of incision in modified linear extraction
111. Diagram illustrating Liebreich's operation for cataract
112. Bowman's fine stop needle
113. Hays's knife-needle ....
114. Hays's knife-needle (magnified view)
115. Diagram showing how dilatation of the pupil in cataract improves the
sight ....
116. Diagram showing how dilatation of the pupil in cataract improves the
117. View of the artificial pupil made by iridectomy
118. View of the artificial pupil made by iridodesis ,
119. Mr. Teale's suction curette
120. Mr. Bowman's suction syringe .
121. Extraction of chalky cataract
122. Partial dislocation of the lens
123. Complete dislocation of the lens into the anterior chamber
124. Dislocation of the lens beneath the conjunctiva.
125. Diagram illustrating the reflection of light from the eye
126. Diagram illustrating the principle of Helmholtz's ophthalmoscope
127. Diagram illustrating the ophthalmoscopic examination of the actual in
verted image
128. Diagram illustrating the ophthalmoscopic examination of the virtual
erect image ....
129. Ophthalmoscope of Liebreich . . ■
130. Ophthalmoscope of Coccius
131. Ophthalmoscope of Coccius (original form)
132. Ophthalmoscope of Loring
133. Diagram illustrating the mode of action of Giraud Teulon's binocular
ophthalmoscope
134. Section of the binocular ophthalmoscope of Messrs. Laurence and
Heisch ....
XVI
LIST OF ILLUSTRATIONS.
FIG.
135. Diagram illustrating the optical action of the same
136. Manner of using the binocular ophthalmoscope
137. Diagram illustrating the optical action of Giraud-Teulon's aut-ophthal
138. Ophthalmoscopic examination of the actual inverted image
139. Diagram illustrating Mr. Bowman's operation for subretinal effusion
140. Glioma retinae .......
141. Fungus hsematodes of eye .....
142. Microscopical appearance of glioma ....
143. Diagram showing the decussation of the fibres of the optic nerve
144. De Wecker's trephine ......
145. Diagram explanatory of the focus of a biconvex lens .
146. Diagram explanatory of the focus of a biconvex lens . .
147. Diagram explanatory of the secondary axis of a biconvex lens
148. Diagram illustrating the mode in which a biconvex lens forms an
image of an object in front of it
149. Diagram illustrating how a biconvex lens magnifies
150. Diagram illustrating the course of rays of light passing through a hi
concave lens .......
151. Diagram illustrating the mode in which the reverse image of an object
is formed upon the retina .....
152. Diagrammatic eye of Listing .....
153. Diagram illustrating the visual angle ....
154. Diagram illustrating the effect of accommodation
155. Diagram illustrating myopia .....
156. Diagram illustrating hypermetropia ....
157. Diagram illustrating the changes which the eye undergoes during ac
commodation .......
158. Diagram explanatory of the ophthalmoscopic appearance of a myopic
159. Diagram explanatory of the ophthalmoscopic appearance of a hyper
metropic eye .......
16,0. Diagram illustrating the focal distance in the vertical and horizontal meridian in astigmatism .....
161. Diagram illustrating the focal distance in the vertical and horizontal
meridian in astigmatism
162. Diagram illustrating the focal distance in the vertical and horizontal
meridian in astigmatism .....
163. Dr. Green's test object for detecting astigmatism
164. Javal's optometer .......
165. Thomson's optometer .....
166. Blackened disk for determination of astigmatism
167. Diagram showing hypermetropia and myopia . • .
168. The muscles of the eyeball .....
169. Linear measurement of squint ....
170. Mr. Laurence's strabismometer .....
171. Dr. Galezowski's binocular strabismometer
172. Diagram explanatory of diplopia in paralysis of the external rectus
173. Diagram explanatory of the difference in height of the double images
in paralysis of the external rectus ....
LIST OF ILLUSTRATIONS.
XV11
FIG.
174. Mr. Bowman's diagrammatic record of the extreme lateral movements
of the eye ........
175. Mr. Bowman's diagrammatic record of the extreme lateral movements
of the eye . . .
176. Finely pointed forceps
177. Probe pointed scissors, curved on the flat
178. Strabismus hook with bulbous point
179. Straight blunt-pointed scissors
180. Strabismus hook ....
181. Theobald's crochet hook
182. Von Graefe's test for insufficiency of the internal recti
183. Grooved director for slitting up the canaliculus
184. Mr. Bowman's probe (No. 6)
185. Weber's beak-pointed knife
186. Weber's graduated biconical sound
187. Dr. Hays's probe ....
188. Dr. Sailing's knife
189. Manfredi's speculum
190. Eversion of lid owing to necrosis of orbit
191. Ectropium the result of caries of the margin of the orbit
192. Ectropium the result of caries of the margin of the orbit
193. Ivory exostosis in the orbit ....
194. Cystic tumor of orbit .....
195. Scirrhus of the orbit .....
196. Present appearance of patient from whom the above bone was removed
197. Appearance of patient with medullary cancer of orbit
198. Appearance of same patient after operation
199. Aneurism by anastomosis in orbit
200. Appearance of patient with abscess of frontal sinus
201. Appearance of same patient after operation
202. Portion of hat-peg which was impacted in orbit
203. Blunt-pointed scissors curved on the flat
205. Cutaneous horn growing from lower lid
207. Horn spatula ......
208. Snellen's modification of Desmarres' clamp
209. Snellen's modification of Desmarres' clamp applied
210. Mr. Laurence's modification of Snellen's clamp
211. Diagram illustrating Herzenstein's operation for trichiasis
212. Diagram illustrating Arlt's modification of Jaesche's operation for trichi
213. Diagram illustrating Von Graefe's operation for trichiasis
214. Diagram illustrating Anagnostakis's operation for partial trichiasis of
upper lid
215. The same
216. The same
217. Spasmodic entropium
218. Entropium forceps
219. Another form of the same
220. Diagram illustrating Von Graefe's operation for spasmodic entropium
B
LIST OF ILLUSTRATIONS.
FIG.
221. Diagram illustrating Von Graefe's operation for spasmodic entropium
222. Diagram illustrating Von Graefe's operation for spasmodic entropium
223. Desmarres' forceps ......
226. Ectropium caused by cicatrix .....
227. Sir William Adams's operation for ectropium .
228. Appearance of the eye after Adams's operation for ectropium .
229. Diagram illustrating Mr. Wharton Jones's operation for ectropium
230. Appearance of the eye after Mr. Wharton Jones's operation for ectro
231. Diagram illustrating Dieffenbach's operation for ectropium
232. Appearance of the eye after Dieffenbach's operation for ectropium
233. Diagram illustrating Von Graefe's operation for ectropium
234. Blepharoplastic operation for ectropium . .
235. Method of fastening the flap in the blepharoplastic operation .
236. Dieffenbach's blepharoplastic operation for ectropium .
237. Dieffenbach's blepharoplastic operation for ectropium .
238. Vertical cut of tarsal edge of lower lid .
239. Operation for epicanthus ... .
240. Carter's perimeter ......
241. Teale's operation by transplantation for symblepharon
242. De Wecker's operation for total staphyloma of cornea and iris
243. Diagram illustrating line of incision in operation for cataract .
244. Lebrun's operation for cataract .....
245. Diagram illustrating line of incision in De Wecker's operation for
secondary cataract ......
246. De Wecker's forceps scissors .....
247. Carter's demonstrating ophthalmoscope
248. Diagram illustrating the arrangement of Carter's demonstrating oph
thalmoscope ........
PAGE
798 798 799
COLORED OPHTHALMOSCOPIC PLATES. XIX
COLORED OPHTHALMOSCOPIC PLATES.
Plate I. to face p. 802.
Fig. 1. — The normal fundus oculi of a brunette. Fig. 2. — The normal fundus oculi of a blonde.
Plate II. to face p. 804.
Fig. 3. — Sclerotico-choroiditis posterior. Fig. 4. — Choroiditis disseminata syphilitica.
Plate III. to face p. 806.
Fig. 5. — Retinitis pigmentosa.
Fig. 6. — Retinitis albuminurica.
Plate IV. to face p. 808.
Fig. 7. — Retinitis apoplectica.
Fig. 8. — Embolism of the central artery of the retina.
Fig. 9. — Cysticercus in the vitreous humor. Fig. 10. — Detachment of the retina.
Plate VI. to face p. 812.
Figs. 11 and 12. — Atrophy of the optic nerve.
Figs. 13 and 14. — Optic neuritis.
Figs. 15 and 16. — Glaucomatous excavation of the optic nerve.
CORRIGENDUM.
Page 124, in line 24, for "Bals. peruv. 9 lbs. 6 to 10," read "Bals. perav. n 10—15."
A TREATISE
DISEASES OF THE EYE
INTRODUCTION.
In order to avoid unnecessary repetition in the course of this work, I think it advisable to give in this introduction a brief description of some of the more important and frequent modes of examination of the eye, as well as of certain remedies and appliances in common use in ophthalmic practice.
Eversion of the upper eyelid has frequently to be practised if the presence of a foreign body is suspected beneath it, or if certain remedies are to be applied to its lining membrane. Various contrivances have been suggested for facilitating this proceeding, but it is best done in the following manner: The patient being directed to look downwards, the surgeon seizes lightly the central lashes of the upper lid between the forefinger and thumb of his left hand, and draws the lid downwards, and somewhat away from the eyeball. He next places the tip of the forefinger of his right hand on the centre of the lid, about half an inch from its free margin. "With a quick movement, the edge of the lid is to be then turned over the tip of the forefinger (which should be simultaneously somewhat pressed downwards). By slightly pressing the margin of the everted lid backwards against the upper edge of the orbit, the whole retro-tarsal fold will spring into view, and the lid become fully everted. [Fig. 1.] In those exceptional cases in which the patient i^ very unmanageable, and forcibly contracts the orbicularis muscle, it may be necessary to use a probe, or the end of a quill pen or pencil, over which to turn the lid, instead of the fore- 2
INTRODUCTION".
finger. [Fig. 2.] But as a rule it is more convenient to employ the latter, as we may not always have a probe at hand, and as anything in the shape of an instrument frightens some patients, whereas we may often succeed in everting the lid with the finger, before they have even time to resist. The surgeon may also stand behind the patient, and steady the head of the latter against his breast, aud evert the lid from behind.
The oblique or focal illumination is in constant requisition for ascertaining the condition of the structures of the anterior half of the eyeball. By its aid we are enabled to examine, with great minuteness, the appearances presented by the cornea, iris, pupil, lens, and even the most anterior portion of the vitreous humor [and to detect foreign bodies in the anterior chamber, delicate false membranes in the pupillary space, minute deposits upon the iris and capsule of the lens, and slight nebulae of the cornea, which would often escape the observation of the unaided eye]. This mode of examination is to be thus conducted : A #lamp being placed somewhat in front and to one side of the patient, at a distance of from 2 to 2J feet (Fig. 3), and on a level with his eye, the light is concentrated upon the cornea or the crystalline lens by a strong bi-convex lens of 2 — 2J inches focus. The observer's eye
INTRODUCTION.
is then to be placed on one side of the patient, so as to catch the rays emanating from the eye of the latter. By shifting the cone of light from one portion of the cornea or lens to another, we may rapidly, yet thoroughly, examine its whole expanse and detect the slightest opacity. In order to gain a larger image, we may employ a second lens as a magnifying glass [which should be held directly in front of the patient's eye. (Fig. 4)]. Opacities of the cornea or lens will appear by the oblique illumination (reflected light) of a light gray or whitish color, whereas with the ophthalmoscope (transmitted light) they will appear as dark spots upon a bright red background.
The method of examining the eye with the ophthalmoscope will be found described, at length, in the section upon the ophthalmoscope.
The mode of ascertaining the degree of intra-ocular tension is as follows : The patient being directed to look slightly downwards, and gently to close the eyelids, the surgeon applies both his forefingers to the upper part of the eyeball behind the region of the cornea. The one forefinger is then pressed slightly against the eye so as to steady it, whilst the other presses gently against the eye, and estimates the amount of tension, ascertaining whether theglobe can be readily dimpled, or whether it is perhaps of a stony hardness, yielding not in the slightest degree even to the firm pressure of the finger. The beginner will do well to make himself thoroughly conversant with the normal degree of tension, by the examination of a number of healthy eyes, and then, if he should be at all in doubt as to the degree of tension in any individual case, he should test the tension of the patient's other eye (if healthy), or that of some normal eye, so as to be able to draw a comparison between them. If there is much oedema of the lids, or conjunctival chemosis, or if the eyes are small and deeply set, it may be difficult accurately to estimate the degree of tension.1
I would call particular attention to the signs which Mr. Bowman has devised for the designation of the different degrees of tension of the eyeball, as they will be found most useful, not only in practice, but also in the reporting of cases, or in the preservation of an accurate record of the state of tension.
Mr. Bowman introduced this subject to the attention of the profession in 1862, in his admirable paper " On Glaucomatous Affections, and their Treatment by Iridectomy," read before the Annual Meeting of the British Medical Association,2 in which he says, " I have long paid special attention to the subject of tension of the globe, and particularly since it has assumed so much additional importance in the last few years. I have found it possible and practically useful to distinguish nine degrees of tension ; and, for convenience and accuracy in note-taking, have designated them by special signs. The degrees may be thus' exhibited : — 3
" T represents tension (' t ' being commonly used for ' tangent,' the capital T is to be preferred). Tn, tension normal. The interrogative, ?, marks a doubt, which in such matters we may often be content with. The numerals following the letter T, on the same line, indicate the degree of increased tension ; or if the T be preceded by — , of diminished tension, as further explained below. Thus : —
" T 3. Third degree, or extreme tension. The fingers cannot dimple the eye by firm pressure.
" T 2. Second degree, or considerable tension. The finger can slightly impress the coats.
" T 1. First degree, slight but -positive increase of tension.
" T 1 ? Doubtful if tension is increased.
" Tn. Tension normal.
1 In order, if possible, to estimate the degree of intra-ocular tension with extreme nicety, instruments, termed tonometers, have been devised by Von Graefe, Donders, Dor, etc. It must, however, be admitted that the results obtained by them were not sufficiently accurate to render them preferable to the palpation by the fingers. But more lately Monnik has invented a tonometer, which appears to answer well, and which is constructed on the principle of indicating the depth to ' which a minute pin, connected with the instrument, is pressed into the sclerotic, and also the force employed to produce the depression. For a further account of it, vide Kl. Monatsbl. 1868, p 364, and Annales d'Oculistique, 1869, p. 68.
"- British Medical Journal, Oct. 11, 1862, p. 378.
3 " Since this paper was read I have simplified the signs, with the concurrence of my friend, Professor Donders, in order to adapt them for general use. The simplified form has been substituted above."
INTEODUOTION'. 21
" — T 1 ? Doubtful if tension be less than natural.
" — T 1. First degree of reduced tension. Slight but positive reduction of tension.
" — T 2 ) Successive degrees of reduced tension, short of such
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