Chapter XII: Introduction (9)

“After the destruction of the cervical portion of the sympathetic chain, and after the extirpation of the Gasserian ganglion in most animals, the mechanical stimulation of the tissues in the upper dorsal region did not produce any perceptible effects....

“Mechanical stimulation of the tissues near the second and third thoracic spines caused dilatation of the pupils and contraction of the vessels of the cranial mucous membranes.

“Inhibition, or the maintenance of an artificial lesion, caused dilatation of the vessels of the nasal mucous membranes and of the conjunctivæ. The eye ball was also somewhat congested. The pupils were dilated in this case also.”

The Nose and Throat in Eye Trouble

An examination of the eye would not be complete without a careful inspection of the =nose and throat=. The same nerve and blood supply that go to the eye is tied up so definitely with the nose and throat that when there are lesions of the nose and throat the eye is often affected secondarily. Just recently a case of =dacryocystitis= came into my office. After I had carefully examined her eye, spine, nose and throat, she informed me that she had been to three eye specialists before and not one of them had ever looked at her nose and throat, not to mention the spine. She had cervical and dorsal lesions, and =diseased tonsils=. The =inferior turbinate= on the side of the dacryocystitis was curled out so that it lay against the external wall of the nose almost if not altogether blocking the entrance of the =lacrymal duct= to the inferior meatus. This was evidently the predisposing cause of her dacryocystitis.

In =neuralgia= of the eye, =blepharitis=, =obscure pain=, =conjunctivitis= and often deeper troubles you will find a bad condition of the =nasopharynx=, such as adenoids, vegetations, pus pockets, adhesions in the fossa of Rosenmuller, contraction of the soft palate, disturbed relations of the septum and turbinates, sinus trouble, poor drainage, exostoses and polyps. In eye disease all these things should be discovered if they are present, in order to get best results and in order to make a careful diagnosis.

Examination of the Eye by Special Methods

The first thing after the family history, personal history, inspection of the eye and the osteopathic examination, is to find out how well the patient can see. To test the acuteness of vision certain test letters are used. Snellen’s Test Letters are good. The normal eye can read 3-8 inch letters at twenty feet. The test letters on the cards usually range in size to be read at 10, 15, 20, 30, 40, 50, 70, 100 and 200 feet. The most desirable distance is 20 feet. If at the distance of twenty feet he reads the 3-8 inch letters his acuteness of vision would be marked 20-20 or normal. Always use the distance between patient and chart as the numerator of the fraction and the number above the letters which he reads as the denominator. If he is twenty feet away, the numerator remains twenty and the denominator changes according to the line of letters seen on the test cards thus: 20-15, 20-30, 20-70, or 20-200 may express the vision. If the patient could not see the 200 feet letters at 20 feet he must be brought nearer, say 10 feet, for him to see the large letters; his vision would be 10-200. These fractions representing the acuteness of vision may be expressed in meters. Some charts have letters numbered that way.

If the vision is good enough for small objects to be clear, the near point should be taken. This would show the amount of accommodation of the eye. This is expressed in diopters.

A =diopter= is the unit of measurement of the =refractive= power of lenses. =Lenses= are numbered by their refractive power in diopters. A lens that has a curvature that will refract parallel rays of light and bring them to a focus at one meter distance is said to be a one diopter lens. This unit of measurement for the refractive power of lenses was proposed by Nagel in 1866. It soon became quite generally used.

The focal distance of a lens decreases as the strength of a lens increases. One diopter lens (written 1 D) has a focus of one meter (1 M) or 100 cm distance. A 2 D lens has a focal distance of ½ M or 50 cm. A 4 D lens has 25 cm focal distance and a ½ D lens has 100 cm ÷ ½ = 200 cm distance or 2 M. Trial cases have in them lenses varying in strength from .12 D or .25 D to 20 D of the spheric form. We will not discuss the trial case here.

Accommodation in the Eye

=Accommodation= in the eye is the ability of the eye to vary its focal point. When the normal eye (emmetropic) is at rest its focal point is at infinity so far as parallel rays are concerned. This is called the far-point or the “=punctum remotum=” (P. R.).

When the eye looks at letters twenty feet away it scarcely accommodates at all to get a focus, or so little that it may be disregarded in ordinary practice. Now if one brings fine print close to the eye he will find a point so close that it becomes indistinct. This point is the near-point of focus or the =“punctum proximum”= (P. P.). The range of accommodation is the difference between the refractive power of the eye when it is at rest and when the accommodation is exerted to the utmost, the difference between the P. R. and the P. P.

If one must accommodate one diopter to get a focus at one meter or forty inches distance, at thirteen inches or reading distance one must accommodate at least 3 D in order to see the letters clearly. If 3 D were the total of his accommodation he could not read at that distance but a few minutes; because the accommodation could not be held at its maximum for long at a time. Eye strain with its train of symptoms would result. Hence it is quite important to find the near-point or punctum proximum in order to judge in regard to eye strain in an emmetropic eye. If there is a refractive error, allowance for it must be made accordingly.

As a person gets older the accommodation in the eye becomes less and less until at 45 years of age he can only use 4 to 5 D of accommodation. This is so close to the amount required for reading that he has some eye strain. He begins to hold his paper farther away from him so he requires less accommodation. This condition we call “old sight” or =presbyopia.= An emmetropic eye at forty-five to fifty years of age requires a plus glass to make up for some accommodation in reading.

Frequently there are latent disturbances of equilibrium of the extrinsic muscles of the eye. This is =heterophoria.= If it is a latent convergence it is =esophoria=; if a latent divergence it is =exophoria=. The latter is more frequent. Hyper- and hypophoria are used for upward or downward tendencies. Normal muscular balance is =orthophoria=.

Cause the patient to fix on an object about thirteen inches away with both eyes; push a sheet of paper in front of one eye and watch behind the paper, the eye thus covered. If heterophoria exists the eye will move slightly from its point of fixation since it no longer sees the object. In orthophoria it will remain fixed as long as the other eye sees the object; the innervation to the different muscles is properly distributed.

A Maddox rod found in any complete trial case may be placed before one eye. Have the patient fix on a candle flame, say twenty feet away. The flame appears drawn out into a luminous line. This line can not be fused with the candle flame as the other eye sees it if there is heterophoria. The amount and kind of disturbance is somewhat indicated by the distance and direction of the luminous line and the flame. The exact amount can be measured by the use of a prism that will cause them to fuse.

Next the patient should be taken to the dark room and a careful inspection of the anterior segment of the eye should be made with oblique illumination. First use the unaided eye, then use a lens that magnifies. The 20 D plus lens from your trial case will suffice for the magnification. Note the transparency or lack of it in the cornea and crystalline lens; the depth of the anterior chamber and the appearance of the pupil and iris. Now we are ready for the ophthalmoscopic examination.

=The Ophthalmoscope.=—This is an instrument that commands great respect. Any one who is interested in eye troubles must have and use the ophthalmoscope if he expects to be efficient in diagnosis, upon which, of course, intelligent treatment must forever depend. One must try and try again in order to become proficient in the use of the ophthalmoscope.

A Schematic Eye is of great assistance to a beginner who does not have clinics or patients on whom to practice. Such an eye with full directions can be obtained at almost any optical goods store. It will make the study of ophthalmoscopy easy and interesting. The pupil can be regulated to any size and the eye can be made short (hyperopic), long (myopic) or normal (emmetropic) for study.

The efficient use of the ophthalmoscope makes the diagnosis of internal diseases of the eye as easy as the diagnosis of external diseases of the eye. Only some rare conditions will puzzle, and that is true of any part of the anatomy.

The ophthalmoscope is a simple instrument; its chief function is to illuminate the interior of the eye. The value of ophthalmoscopic findings depends on their correct interpretation by the examiner.

The ophthalmoscope has a mirror to reflect the light into the eye. It has two discs on which are mounted convex (plus) and concave (minus) lenses. The larger disc has seven plus and eight minus lenses. To these may be added the lenses in the smaller disc making many combinations.

A drop of a 2% solution of cocaine or homatropine may be used as a mydriatic where one can not otherwise see clearly the fundus. If no mydriatic is used a somewhat weak illumination should be employed in order not to arouse the accommodation to much activity and make the pupil small. If there is any opacity in the media a strong illumination should be used. The room should be dark; the darker the better.

There are two methods of using the ophthalmoscope. The =indirect= and the =direct= methods. One is more useful at one time and the other at another time. By the indirect method we view the whole field of the fundus more readily but less in detail. With the ophthalmoscope before his eye the examiner’s face is twelve to fifteen inches from that of the patient. When the “=red reflex=” of the eye is seen a plus 13 or 16 D lens is interposed near the patient’s eye. This magnifies the field. The image is inverted. As a rule it is best seen with a +4 D lens in the aperture of the ophthalmoscope.

This method is especially more satisfactory in high degrees of myopia and astigmatism. The =optic disc= is the objective point. One may see a retinal vessel first; this should be followed to its emergence from the disc. From this point view all parts of the fundus by having the patient look in different directions. This is better by the indirect method than for the examiner to vary his position.

The direct method of ophthalmoscopy is better for detail work and in all cases except high degrees of myopia and astigmatism. It is also better in determining errors of refraction. The patient looks straight across the room. For a beginner it may be essential to dilate the pupil, hence the schematic eye as suggested.

If the examiner has a refractive error, he should wear his own glasses or correct by throwing in front of his eye proper lenses in the ophthalmoscope. Face the patient and sit on the side of the eye to be examined. Use left eye to examine the patient’s left eye and right eye for the patient’s right. Examiner and patient keep both eyes open. The examiner may not be able to suppress the image of his other eye and may have to close it part of the time. Catch the “red reflex” some 15 to 18 inches away and move close to the patient’s eye. The “red reflex” color varies with the error of refraction, the transparency of the media, the degree of pigmentation and the size of the pupil. A blood clot will make it redder, some exudates will make it gray or yellow.

The examiner may approach as close as half an inch from the eye to be examined. Find the optic disc and examine all points of the fundus from it. Rotate in glasses to correct the patient’s refractive error if he has any. The strongest plus glass with which the fine retinal vessels can be clearly seen will represent the =hyperopia= of the eye. This is true only if the examiner’s accommodation is at rest. The weakest minus glass with which the fine retinal vessels can be clearly seen represents the =myopia=.

=A Normal Fundus.=—The color of the fundus is due to the blood vessels of the retina and choroid and the connective tissue of the choroid and sclera. Variation is due to the pigment. In the albino it is light pink. In the negro it is dark reddish. There are all gradations between the two.

The =optic disc= is the end of the optic nerve as it comes into the eye; it is circular in shape, pink in color, and sharply defined. It is about 1-16th of an inch in diameter; about 15° to the nasal side of the pole of the eye and slightly above the horizontal. There may be a dark =choroidal ring= around the disc or part way around. There may also be a white ring caused by the sclera. As a rule there is a depression in the center of the disc out of which the retinal vessels emerge and spread out over the fundus.

The =fovea centralis= or point of clearest vision is located two and a half disc diameters to the temporal side of the disc. Around this is a circular area of light yellow, the =macula lutea=.

The subject of ophthalmoscopy has been touched upon somewhat in detail because of its great importance to the general practitioner. Every osteopathic physician should know the ophthalmoscope well enough to recognize the ordinary lesions inside the eye. When we take up pathological conditions of the eye we will have occasion frequently to refer to the ophthalmoscopic appearance. Without the use of this instrument all of our clinical field research on internal diseases of the eye is valueless. Many have told me they have cured cataract with osteopathic treatment, some say they have cured specific neuroretinitis with no sequelæ, others testify to opacities and blindness from various causes. Invariably we ask if they used the ophthalmoscope in their diagnosis and with it watched the progress of the case. Almost invariably the answer is “no, it looked like it,” “the symptoms indicated it,” or “Dr. so and so, an oculist diagnosed it as such.” Fellow Osteopaths! we can not base our claims on this kind of data. With a little study and practice the ophthalmoscope can be mastered. Not till then can we get reliable statistics on internal diseases of the eye in our case reports. Osteopathy has much to reveal to us in this field and for the sake of the science and our patients we appeal to every one to do the work here set forth.

Diseases of the Eye

OSTEOPATHIC MANIPULATION FOR EYE DISEASES

A general correction of lesions should be made in order to give perfect alignment and equilibrium. Lesions that affect the nerve and blood supply will be found from the fourth thoracic to the occiput; more often at the occiput, atlas and axis in the cervical region and the second and third thoracic in the dorsal region including the ribs.

Correction of these lesions must have specific attention in every case of eye disease that shows any tendency to chronicity or in repeated eye disease and exacerbations.

A thorough upper spinal treatment to insure good mobility of all joints and establish freedom of fluids and forces is recommended.

The =nose=, _throat_ and =sinuses= should be examined for pathology. If the tonsils and pharynx are not normal the cotted index finger should be introduced into the mouth until the anterior pillar of the fauces is reached. A mouth gag may or may not be used. Massage the tonsil through the anterior pillar then move to the top and press down on the tonsil with a pumping motion. Repeat this from below the tonsil and posteriorly. Slip the finger under the soft palate and stretch it thoroughly. Clean out any adhesions and vegetations in the vault of the nasopharynx and fossa of Rosenmuller. Stretch the pillars of the fauces by pressing down on each side at the root of the tongue.

If the sinuses are diseased they should be drained. If the nose is diseased and has abundance of secretion, first use irrigation for cleanliness.

Manipulation in the nose will be of great benefit in some eye diseases as pathology there frequently has an important bearing on diseases of the eye. The nose is often too narrow and contracted. The first inch of the nose is muscular and cartilaginous; it is of even more importance to dilate the nose in contractured conditions than it is the sphincters at the lower end of the rectum. The great benefit derived from rectal dilatation has been recognized for years.

In dilating the contracted nose a wide blade nasal speculum may be used. The cotted and oiled little finger may be used where it is properly adapted in size. The dilating can be done with practically no pain and no damage to membranes or other tissues. It should not be extended beyond the cartilaginous and muscular part. Manipulation of the turbinates and tissue further back may be done if needed, by the use of instruments. The Edwards turbinate adjuster instrument (Aloe Co., St. Louis) or the Ruddy Nasal Third Finger (Sharp and Smith, Chicago) are the best instruments so far devised for this operation.

A thorough stretching of the =eyelids=, manipulation of the =eye ball= and the points of the fifth nerve are indicated in many diseases.

The lids may be stretched by pulling them from side to side. The cotted forefinger well oiled (sterile vaseline) may be slipped into the conjunctival sac back of either lid and with the thumb on the outside the lid may be massaged or stretched in any direction. The points of the fifth nerve may readily be influenced at their respective exits about the orbit. The eye ball and deeper contents of the orbit can be profoundly treated by pressing the finger into the orbit above, below and at the sides of the bulb and pushing it in all directions as far as possible. The Ruddy eye finger instrument was devised for this deep manipulation of the orbital and bulbar structures. It is of high value. One finger may be laid on the closed eye and with a tapping motion with the other hand a vibration or oscillation of the orbital structures may be had. This is a useful treatment.

The wise selection and skillful use of these various methods of treatment for the eye will solve most of our difficulties.

This short survey of osteopathic methods will aid us in the more specific discussions to follow.

Neuralgia

A considerable number of people seem to be subject to attacks of pain in one or both eyes. These attacks of pain come at varying intervals; in some cases several times a day, in others as far apart as one or two weeks. The pain will suddenly start almost without warning and with very little provocation, and last from one to twenty-four hours. It is very severe and the patient frequently thinks something terrible is wrong. Something terrible is wrong so far as his comfort is concerned. But in these cases to which I am referring there is no organic trouble with the eye. The patient does not need glasses. There is no sign of inflammation. Vision is not disturbed. Local examination of the eye with the ophthalmoscope reveals that the fundus of the eye is normal. There is no symptom connected with the eye except pain, occasionally accompanied by a slight redness. I have had several cases in my own practice and my attention has been directed to cases of other physicians.

These cases differ from _tic douloureux_ in that there is no muscular spasm. In fact, motor nerves do not seem to be involved. The involvement seems to be largely in the =fifth cranial nerve=, usually the supraorbital, or other smaller branches of the ophthalmic division of the fifth cranial. Sometimes we note slight dilatation of the pupil with more or less congestion. This would indicate an involvement of the sympathetic branch to the eye.

The lesions discovered in these cases have been a subluxation of the occiput upon the atlas or an upper cervical lesion and frequently some involvement at the second dorsal. There has been noted also trouble in the nasopharynx such as contractures of the muscles of the soft palate and adhesions in the fossa of Rosenmuller.

Misplacements of the uterus have also been found in some cases.

Treatment

Nearly all these cases are curable with from one week to six weeks treatment. Of course the treatment must be intelligently directed after a correct diagnosis as to the cause. The cause can usually be removed. One case to which my attention has been directed was that of a woman about forty years of age who had very severe pains. With all the local treatment of the eye and otherwise she got practically no results until she had replacement of the uterus, which brought immediate relief. Other cases have no trouble on that kind but have lesions of the cervical region and on correction of these lesions the neuralgia disappears. Other cases have had the nasopharynx cleaned out by the finger operation and the stretching of the soft palate which relieved the neuralgia immediately or in a few days. Numbers of cases have been to medical physicians and had various eye remedies administered locally with no permanent benefit. Of course the treatment was administered at the wrong place.

The ramifications of the sympathetic and fifth cranial nerves are so complex and far-reaching that we must keep in mind that one or more of many causes for the trouble may exist and be quite remote from the seat of the pain.

Diseases of the Eyelids

Occasional factors are bee stings or insect bites, which completely occlude the palpebral fissure. We may have some palpebral edema from lid abscesses, chalazion, hordeolum, dacryocystitis, panophthalmia and so forth. In =hemorrhagia subdermalis= there is so much spongy tissue beneath the skin about the eye that the blood extends easily and far. The red tint will soon change to a reddish blue and then become dark, what is known as a black eye (ecchymosis). This frequently results from a blow. The skin is sharply attached around the orbital margin by tense connective tissue so the area of the hemorrhage is limited to the region of the orbit. There may be spontaneous rupture of some of the vessels by hard sneezing or coughing, especially in young children. In older people it may indicate a fragile condition of the vessels, arteriosclerosis or some trouble with the kidneys. The diagnosis of the eye condition is not difficult but the cause of the hemorrhage in that region might be investigated further. Local treatment is of some value in these conditions. They may be soothed by cold compresses. In bee stings and insect bites use an alkaline compress. Manipulation about the eye and osteopathic treatment of the neck with a view to directing a better circulation to that region will aid much.

Herpes Zoster Ophthalmia

This affection of the supraorbital branch of the fifth cranial nerve may extend to the eyelids. It may not go beyond the stage of blistering and redness with some edema. However, it is possible for it to become gangrenous and even extend to the conjunctiva and cornea. I had one case of herpes zoster gangrenosa of this region. There were several gangrenous spots as large as a dime on the forehead and extending down in the region of the eyelid. The process extended to some extent on the cornea and in healing left a condition of irregular astigmatism.

=Treatment.=—The prognosis in herpes zoster is always favorable under osteopathic treatment. Lesions of the cervical region will almost invariably be found interfering with the sympathetic connections of the fifth cranial nerve causing the trophic disturbance to the region. Osteopathic treatment applied to these conditions will always hasten normalization. The affected part might be kept covered with some soothing lotion to keep the skin soft.

Hordeolum

This is commonly known as a =sty=. It is due to suppuration of the =glands of Zeiss=. It is a harmless affection but causes pain and inconvenience.

=Diagnosis.=—Swelling and pain with a small inflammed nodule in the palpebral margin is quite diagnostic.

=Treatment.=—The circulation is obstructed in this region. The effort should be made to open the circulation before pus has formed. This can frequently be done and the hordeolum aborted by carefully picking up the eyelid and rolling the nodule between the fingers. This will cause some pain but if it is kept up for a moment or two about every hour through the day with an occasional thorough treatment of the neck the sty will usually be aborted. If pus forms it should be opened as soon as it points and then the squeezing and rolling process may be employed again, which will aid rapidly in the freeing of the circulation.

Chalazion

This is a =Meibomian cyst= in the eyelid. It shows as a circumscribed swelling on the inner side of the lid. It frequently becomes large enough to produce some deformity of the lid. A chalazion is movable on the tarsal cartilage. It is a chronic condition and the cyst may become as large as a bean. There may be more than one in the same lid.

=Treatment.=—When a chalazion is small and not of long standing it can frequently be cured by osteopathic treatment. Introduce the finger into the conjunctival sac under the lid, and with the thumb externally, grasp the chalazion between the finger and thumb; roll it thoroughly. Squeeze and massage it two or three times a week for awhile. This, combined with a thorough treatment of the neck, will result in a cure. If at the end of six weeks the condition has not disappeared surgery should be resorted to.

Blepharitis

This is an inflammation of the eyelid. It is either =acute= or =chronic= according to the cause. Acute blepharitis may be due to heat or injury. Chronic blepharitis affects the glands of the lid causing a perversion of the secretions. There is usually the formation of crusts and scales. This condition is known as =blepharitis sicca=. In some cases infection will form little pustules at the roots of the cilia. There is soreness and aching. There may be photophobia. The nasal region may be involved. Osseous lesions of the cervical region are usually present. Refractive errors frequently exist in these cases. Occupation or environment may expose to dust or wind sufficient to keep up the irritation.

=Treatment.=—Change environment. See that there is thorough cleanliness of the lid. Rub or pick away all scales. Use a bland ointment. Correct any cervical or upper dorsal lesions.

Ptosis

This is =congenital= or =acquired=. In congenital ptosis operation seems to be the only treatment. Acquired ptosis is amenable to treatment frequently. The cause is some lesion interfering with the passage of proper nerve force to the levator muscle of the lid. The lesion may be at the origin of the third nerve, at the cortical nucleus in the sigmoid gyrus or in the trunk of the third nerve, or a lesion of the muscle itself. Tumor, trauma, syphilis, sclerosis, hemorrhage, gout or rheumatism, or anything that will produce a peripheral neuritis are causative factors. Lesions of the cervical and upper dorsal by reflecting back upon the nerve centers may produce a ptosis.

=Treatment.=—Remedial measures according to indications. Cases due to osteopathic lesions as indicated will usually yield readily to treatment. Where there are other factors treatment must be varied accordingly.

Trichiasis

This is a condition in which part or all of the eye lashes turn inward and touch the eye ball, due to cicatricial contractions in the conjunctiva and tarsus. Many of the cilia are so small in these conditions that it is very difficult to see them. A loupe or a magnifying glass must be used in order to discover them.

=Dystrichiasis= is a condition where the cilia come in irregularly growing in all directions, some of them turning in toward the eye ball and causing irritation.

=Treatment.=—An epilatory should be used to extract all of the wild hairs. Care should be taken to get out the finest ones as they will frequently cause irritation if not removed.

Entropion and Ectropion

=Entropion= is a turning in of the eyelid and =ectropion= is a turning out. These conditions may be spasmodic and temporary. Entropion is more often due to cicatricial contraction in old blepharitis or trachoma conditions. In some cases the condition may be corrected by the use of strips of adhesive plaster. In cicatricial conditions operation is the rule. Spasmodic ectropion may be corrected sometimes by curing the conjunctivitis. Bandaging may be resorted to. In paralytic ectropion osteopathic treatment may serve to produce a complete cure. Operative procedure should be a last resort.

Diseases of the Lachrymal Apparatus Dacryocystitis

=Dacryocystitis= is an inflammation of the lacrymal sac. It is due to some lesion in the nose, malposition of the inferior turbinate or a poor blood and nerve supply to the lacrymal region as determined by cervical lesions. The sac becomes infected and we have a =dacryocystoblennorrhea.= Pus and tears are regurgitated into the eye through the puncta. There is irritation and the conjunctiva may become infected at any time, also the cornea. It is a dangerous and annoying affection.

=Treatment.=—Osteopathic measures have something to offer along this line. The medical idea seems to be completely surgical in recent years. The first and only thing to be done surgically is to obliterate the sac or dissect it out and curette the nasal duct, completely destroying the apparatus. Lancing does not affect a cure. By treating for a good nerve and blood supply to that region, the irrigation of the nose and a thorough squeezing of the sac each time with a view to forcing the solution in the sac down through the nasal duct into the nose, a cure may be effected in many cases. If these cases can be gotten before infection has taken place, in the state of epiphora or the backing up of the tears into the eye, thorough treatment along the lines just indicated will in nearly all cases result in a cure.

Boric acid solution should be used to wash out the sac when pus is present. The attempt should be made to force it into the nose. Probing properly done is of value in many cases. These cases should be followed up with great care.

Treat the neck thoroughly and spring the inferior maxilla.

Diseases of the Conjunctiva Conjunctivitis

The conjunctiva is a mucous membrane that coats the posterior surface of the eyelids and the anterior surface of the eyeball. It forms a sac, which is slit open in front in the line of the palpebral fissure.

The conjunctiva consists of three parts (1) the conjunctiva tarsi, the part on the lids; (2) the conjunctiva bulbi, the part on the eyeball, and (3) the conjunctiva fornicis, the part connecting the first and second; it is the retrotarsal fold or the region of transition, often called the fornix. The first part can be seen by everting the lids. It is adherent to the tarsus. It is covered with a laminated cylindrical epithelium. The membrane contains an abundance of lymphocytes similar to adenoid tissue. This increases with every inflammation of the conjunctiva. This is why =chronic conjunctivitis= often results in thickened lids.

The =blood supply= of the conjunctiva of the lids is from the muscular branches of the ophthalmic artery. The =nerve supply= is from the ophthalmic division of the 5th cranial and the sympathetic.

The bulbar conjunctiva continues over the cornea. It is covered with layers of pavement epithelium. Its blood supply comes from the posterior conjunctival vessels about the retrotarsal fold, and the anterior ciliary arteries which accompany the tendons of recti muscles; these two systems anastomose in the conjunctiva. Conjunctival injection or congestion shows a superficial net work of larger or smaller vessels that move with the conjunctiva. The color is scarlet or brick red. Ciliary injection occurs as a rose-red or pale violet zone around the cornea, spoken of as peri-or circumcorneal injection. It does not move with the conjunctiva and occurs more with diseases of the cornea, iris and ciliary body.

In the =etiology of conjunctivitis= a great variety of germs are considered by different writers. Collins and Mayo give a report of “germs found in normal conjunctiva.”

Bacillus Xerosis in 94% of normal conjunctivæ; Staphylococcus Albus in 79%; Pneumococcus in 9%; Diplobacillus in 6%; Staphylococcus Aureus in 6%; Streptococcus in 5%.

If this be true, and I do not doubt their statement, we are practically compelled to say that these germs at least are only secondary in the etiology of conjunctivitis. Just at this point osteopathy comes with its flood of light and makes it easily explainable why some conjunctivæ become inflamed while others do not, when all have germs present. The lesion disturbing the integrity of blood supply and nerve force to the eye is the primary cause while the presence of germs may be the aggravating cause. The lesion prepares the soil in which the germs thrive sufficiently to become an irritant. There are all gradations of this soil preparation. The more fertile the field (i. e. the more profound the effect of the lesion) the more virulent germ life may become; the resistance is proportionately less.

=Conjunctivitis= is =classified= for convenience in study, diagnosis and treatment as follows:

(1) Catarrhal, (a) acute, (b) chronic, (c) follicular; (2) gonorrhoeal; (3) ophthalmia neonatorum; (4) trachoma; (5) diphtheritic; (6) eczematosa (phlyctenulosa); (7) vernalis; (8) tubercular; (9) traumatic. This is the clinical classification after Fuch.

Treatment of Conjunctivitis

In order to give the best care in these cases it is quite essential that both the primary and secondary causes be given attention. Some good =germicide= or =antiseptic= is to be used with intelligence. This is in harmony with the great principles of antisepsis and cleanliness taught by osteopathy from its inception. The use of the microscope in the =bacteriology= of conjunctivitis aids in more definite diagnosis and the selection of a proper germicide. For the Koch-Weeks bacillus, the pneumococcus and the influenza bacillus silver nitrate 1% or a 25% solution of argyrol is used; for the diplo bacillus (Morax-Axenfeld) zinc sulphate 1 gr. to the ounce is almost a specific.

A good way to prepare the zinc prescription would be:

Boracic acid and water oz. 1.

Zinc sulphate gr. 1.

The boric acid and water of course being a saturated solution. Apply one drop to each eye about four times a day. If one can not have the use of the microscope to make specific the diagnosis, the zinc solution may be alternated with the argyrol as the germicide. Ice cold applications are good in many of these cases.

Catarrhal Conjunctivitis

=Acute=.—mostly affects the conjunctiva of the lids in the light form. If severe it invades the bulbar conjunctiva. There is redness and swelling and increased secretion which dries at night upon the edges of the lids and glues them together. The eyes are better in the morning and worse toward evening. =Corneal ulcers= and =iritis= may arise as complications. Chronic inflammation may result.

=Etiology.=—Textbooks on the eye give =bacteria= as the chief cause; some scarcely mention anything else. After discussing how the bacteria get there and multiply, they usually bring in some statement to indicate that in many cases no bacteria can be found in the secretions from the conjunctiva. These latter are unaccounted for in the etiology.

=Catarrhal conjunctivitis= is non-specific in its origin.

The great science of osteopathy will fill in the missing links to works otherwise very exhaustive on the eye.

If the cause is due only to a passing irritant as dust, smoke, pollen or wind the disturbance may vary from hyperemia only, to a severe attack of conjunctivitis. Fuch says the majority of cases are produced by bacteria, but THAT IN NOT A FEW CASES OF CONJUNCTIVAL CATARRH THE EXAMINATION OF THE SECRETIONS FOR BACTERIA PROVES NEGATIVE. He also says that the usual course of the disease is from eight to fourteen days, but NOT INFREQUENTLY THERE REMAINS A CONDITION OF CHRONIC CATARRH PROTRACTED OVER A LONG TIME; THAT NOT INFREQUENTLY THE NORMAL CONJUNCTIVAL SAC CONTAINS PATHOGENIC GERMS.

Some authors divide the =etiology= into (1) specific, (2) non-specific. The first they account for by irritants due to dust, heat, smoke, metal, pollen, cold, wind, glare of light, eye strain from overwork of the eyes, ametropia and chronic alcoholism. The second they account for by germ life, most often the Morax-Axenfeld diplobacillus or the Koch-Weeks bacillus, the latter germ being found in the so-called “pink-eye.” It is contagious. This is one condition for which the zinc sulphate (½% to 2% solution) is almost a specific.

No doubt the irritants and the bacteria mentioned, with others, do cause much of our catarrhal conjunctivitis and that one who fails to consider properly the local conditions in practice will be sadly lacking in best results.

On the other hand many cases, treated for local conditions only by very competent men who used the best antiseptics and germicides, have very indifferent results. The acute condition would continue and gradually become chronic. From observation, study and experience there are causes aside from local irritants, ametropia, bacteria, syphilis, rheumatism or measles. There is some disturbance to the integrity of the =spinociliary sympathetic arc=. In many cases of eye disease note lesion and tenderness at the upper dorsal, the removal of which will cause improvement of the eyes. Many cases of eye strain can be relieved by correction of the first, second or third dorsal, and the use of glasses made unnecessary.

Irritation of the eye will cause more or less tension of the muscles at the second and third dorsal, and stimulation of the tissues near the second and third dorsal spines will cause dilatation of the pupils and contraction of vessels of the cranial mucous membranes; which means vasomotor, secretory and trophic disturbances.

It follows then that an =osteopathic lesion= at the second or third dorsal will cause or tend to cause disease of the eye. There may be all gradations in the effect produced, the lighter being mere tendency, while again it may be enough to set up profound vasomotor, secretory and trophic changes in and about the eye. The first effect of the lesion may be stimulatory, and later, inhibitory. The normal resistance of the eye would be lowered and naturally, local irritants, bacteria and ametropia would have a more profound effect. This will explain how one can develop conjunctivitis in the absence of a local irritant with no bacteria present, and no eye strain.

All of these causes, or any number of them, may be acting together, and each more virulent because of the influence of the other.

=Lesions= of the =occipito-atlantal= joint or any of the cervical articulations may cause eye disturbance. There are no efferent ramicommunicantes in that region and the course of the physical disturbance must be greater in proportion to the eye trouble produced, than at the upper dorsal. It is important however to make a close examination of the entire cervical region in eye trouble.

What has been said on the osteopathic causes of acute catarrhal conjunctivitis applies with equal force to chronic and =follicular concatarrhal conjunctivitis.=

What has been said on the osteopathic causes of =acute= catarrhal conjunctivitis applies with even greater force to the =chronic= form. The great variety of local irritants may account for acute conjunctivitis, and does in most instances; but in chronic conjunctivitis local irritants are more often secondary or incidental while the osteopathic lesion with its effect upon the =bulbo-spino-sympathetic= ciliary arc is the =fundamental= cause. Of course some continuous local irritant, e. g., an uncorrected refractive error, excessive light, heat, dust or germ life in the environment may cause a chronic conjunctivitis. Other causes may be retracted lids (lagophthalmus) leaving the eyeballs too prominently exposed; turning in of the cilia (entropion, trichiasis or dystrichiasis) which impinge upon and irritate the bulbar conjunctiva. =Chronic blepharitis= may spread to the palpebral conjunctiva and then the bulbar. Foreign bodies in the eye, or infarction of Meibomian glands may be causes. The diplobacillus (Morax-Axenfeld) is the most common germ in chronic catarrhal conjunctivitis.

=Symptoms and Course.=—In mild cases the redness is only moderate. The conjunctiva is smooth and not swollen. Old cases have hypertrophy with thickening. There was a small girl who came into the office recently who had the conjunctiva of the lids decidedly swollen with some hypertrophy. Her eyes were glued shut with pus every morning. Pus pockets were forming along the follicles of the cilia and on the direct edge of the lid. Her troubles started a year ago and got gradually worse. A few osteopathic treatments were given during three months (she was irregular in coming) and argyrol, 20%, used locally. All pus and debris were cleared off the lids and conjunctiva each time. The swelling all left and the thickening became inconsiderable; the eyes looked almost clear. On pressure there was tenderness at the right side of the second dorsal. No mechanical lesion was apparent there but in treatment that region was thoroughly loosened.

The subjective symptoms are usually worse at night; pain, heaviness of the lids; feeling of a foreign body in the eye; burning; itching and dryness in many cases.

This condition is one of the most frequent of eye diseases in adults; may be senile catarrh in advanced age. It is frequently complicated with blepharitis, ectropion, epiphora and ulcerations of the cornea.

=Treatment.=—The osteopathic treatment depends on the findings in the osteopathic examination. No case of chronic catarrhal conjunctivitis should be treated without a thorough examination of the whole spinal, rib and innominate mechanism. Careful and detailed adjustment should be made of any lesions that might disturb the ciliary arc, the other nerve connections, the blood supply or the body equilibrium.

This does not mean that local treatment of the eye should be neglected in any way. Any measure that will aid in getting rid of local pathology as quickly as possible should be ours. Where there is abundant secretion, silver nitrate 1% to 2% solution put on the conjunctiva with a brush when the lids are turned, or argyrol 20% to 25% dropped into the eye are among the best antiseptics for local use. If the diplobacillus is present zinc sulphate ½% solution is indicated.

The nose, nasopharynx and pharynx should never be overlooked in this disease.

Follicular Conjunctivitis

=Follicular conjunctivitis= is of catarrhal origin. It is characterized by the presence of follicles. There may be only a few or a great many. If numerous they are often in rows on the palpebral conjunctiva. Microscopically they show as circumscribed masses of adenoid tissue. In this they resemble the granules of =trachoma=. Sometimes cases persist for years with little or no inflammatory symptoms. On account of the follicles this disease is frequently confused with trachoma.

We have heard numbers of well meaning conscientious osteopathic physicians testify to curing cases of trachoma with a short course of osteopathic treatment with no pathology remaining. We are absolute believers in the effectiveness of osteopathic treatment and want to give it full credit for doing all it will; but here we want to enter a plea to the profession that we need more discrimination and definiteness in our diagnosis. Technique is being emphasized and we say Amen! It is proper for us to be thoroughly competent in technique but diagnosis should be made just as emphatic because scientific technique depends upon diagnosis for each individual case.

=Differentiation= of follicular conjunctivitis from trachoma.

=Follicular conjunctivitis= occurs (1) chiefly in the young; (2) the follicles are smaller, more sharply limited, project more above the conjunctiva, are often in rows, and oval in shape; (3) the disease clears up with no bad after effects often without any treatment and the tendency is to ultimately get well; (4) it never leads to shrinking of the conjunctiva, to pannus or other destructive sequelæ; (5) it can arise without contagion and is not considered contagious although, like trachoma, it does attack large numbers of people who are confined in a small place.

=Trachoma.=—(1) It seldom occurs in children; (2) the follicles are larger, do not have sharp outlines, are less prominent under the conjunctiva, are round in shape and never in rows; (3) tends to lead to more or less pathology and seldom recovers spontaneously; (4) scar tissue becomes a product of the inflammation in the conjunctiva and leads to shrinking of the conjunctiva, causing in turn entropion and trichiasis. Pannus is the sure result of unarrested cases as there is a tendency to infection of the cornea from the infected conjunctiva moving over it and remaining in contact; (5) trachoma has been proved to be contagious. Trachoma bodies which are considered the infective agent have been isolated.

The use of atropine in some instances will cause a follicular catarrh which clears up on stopping the use of the poison.

Parinauds “Infectious conjunctivitis” has granulations but almost always occurs in only one eye and is accompanied with constitutional symptoms.

=Treatment of Follicular Conjunctivitis.=—The treatment should be directed against the inflammation. The trophicity of the nerve terminals to the conjunctiva may be altered by osteopathic lesions.

Suggestions under chronic catarrhal conjunctivitis apply here. If there is no inflammation the follicles tend to disappear, leaving no trace of pathology, hence a few osteopathic treatments of the lids and the cervical region will hasten normalization.

Gonorrheal Conjunctivitis

This disease is sometimes called =purulent ophthalmia= or =acute blennorrhea=, It is caused from an infection of the conjunctival sac with the gonococcus of Neisser. Contact with soiled fingers or linen may transfer the germ.

=Symptoms.=—Within 12-48 hours after inoculation the first symptoms of redness and irritation occur. This is soon followed by much swelling and tension of the lids and chemosis of the conjunctiva. There is much pain and a copious discharge of pus coming from beneath the lids. At first the pus is yellow or yellowish green.

Later the symptoms begin to subside; there is less tenseness and heat; the lids can be more readily everted and the discharge ceases after 6 or 8 weeks. The puckered conjunctiva becomes rough and granular.

In these cases the =prognosis= is always grave; more so than in ophthalmia neonatorum. The eye is almost always marred in some way. One of the great dangers is involvement and destruction of the cornea. If the cornea becomes hazy soon after symptoms begin it is not a good omen. =Ulcers= will likely form and then there is a tendency to puncture the cornea. In mild cases the cornea may escape without injury. In severe cases it is likely to ulcerate. If it perforates, the anterior chamber is emptied and the iris prolapses into the perforation; adhesions take place and there is healing with reformation partially of the anterior chamber. An adherent leucoma is the result with practical loss of vision. There may be a bulging of the cornea known as anterior staphyloma. The iris and ciliary body may become involved, causing iritis and cyclitis, or the whole inner structures may be affected making a =panophthalmitis= with =atrophy= of the eyeball.

The cornea is affected by the infective material direct or the nutrient vessels to the cornea at the limbus may be obstructed by the extreme swelling and pressure.

=Complications= of arthritis, rhinitis, septicemia and endocarditis may arise. If there is none of these, at least there is a general debilitated condition which needs attention.

=Treatment.=—The treatment should be =local= and =constitutional=, The diagnosis should be made quickly from the history, symptoms microscopically, and local cleansing begun at once and followed diligently. Excessive discharge should be wiped away with cotton. The conjunctival sac should be thoroughly irrigated every hour or oftener if necessary to keep it clean. This is to be done day and night. A saturated solution of boric acid may be used, or corrosive sublimate one grain to the pint, or permanganate of potassium solution 1-5000. The irrigation should be followed by the free use of argyrol 25%. This procedure will keep the eye clean and be the means often of saving the cornea from destruction and the eye from blindness.

If there should be ulceration of the cornea a drop of atropine ½% should be used in the eye often enough to keep the pupil dilated and the ciliary body at rest.

Osteopathic physicians no less than other physicians should not neglect this local, careful, persistent, antiseptic cleansing of the eye in such cases. The osteopathist can do more. He is not limited to antisepsis even in this kind of work, however important it might be. The unaffected eye should be carefully protected. Buller’s shield should be used.

The osteopath should give thorough treatments to the neck and the fifth nerve.

Supporting treatment to the system according to indications should be given e. g., bowels, kidneys, nerves, muscles, joints as in constipation, nephritis, neurosis, rheumatism, arthritis, endocarditis, septicemia, rhinitis etc.

Ophthalmia Neonatorum

This is an =acute purulent conjunctivitis= in the new-born. Neonatorum comes from a junction of the Greek word Neos—new, to the Latin word natus—born; new-born. This disease is the bugbear to the obstetrician. He must always be on the lookout for it and act promptly in order to save sight. Every general practician should make a careful study of this disease if he expects to treat children.

Sixty to seventy percent of conjunctivitis neonatorum is due to the infection with the gonococcus of Neisser. It usually comes from a gonorrheal discharge from the genitals of the mother. The nurse or anyone who handles the baby might be the agent in the transmission of the infection.

The disease is not always of gonorrheal origin. Some cases are due to the pneumococcus, streptococcus, diplobacillus or one variety of staphylococci.

Thus there are two varieties or types of ophthalmia neonatorum; a severe type which is =gonorrheal= or specific and a mild type which is non-specific.

In some states there is a law which requires the use of silver nitrate in the eyes of all babies at birth. Every baby’s eyes should be thoroughly washed at birth, with boric acid and where there is the least suspicion of gonorrhea silver nitrate 1% or argyrol 25% should be used. A routine use of one of the silver salts would be good practice.

=Symptoms.=—Gonorrheal cases begin usually the third day after birth, non-gonorrheal, on the fifth or sixth day. Both eyes are usually involved, one worse than the other. The lids swell much. There is chemosis of the conjunctiva which may put the cornea in a pit. The discharge is abundant. It is yellow or greenish yellow.

The disease gradually declines and the discharge ceases in six to eight weeks. The conjunctiva is thickened and looks granular. May be some cicatricial changes.

The chief danger is to the cornea, more so if it becomes hazy the first two days. Corneal lesions seldom occur in non-specific forms.

If the cornea is involved perforation is likely, with a general inflammation of the eyeball (panophthalmitis) followed by atrophy (phthisis bulbi).

Complications such as rhinitis, meningitis, endocarditis and general septicemia may occur.

=Diagnosis= is made from the onset, character, symptoms and course with the use of the microscope.

=Prognosis.=—Delayed or improper treatment in these cases will likely be fatal to sight as sloughing of the cornea will occur. With prompt and proper care the prognosis is favorable.

=Treatment.=—Mild cases (non-specific) are treated in the same manner as simple conjunctivitis. In severe cases (specific) clean the eye carefully and apply cold compresses of gauze 15 to 20 minutes at a time every hour or two. Keep the gauze on a block of ice and change every few minutes. If the cornea is involved heat may prove more satisfactory. There must be constant removal of the discharge. Wipe away the excess and irrigate freely with boric acid at least every hour day and night and more often if necessary. After each washing use a solution of argyrol 25%. Once a day silver nitrate 1% solution may be used and washed out with a salt solution.

If the cornea should ulcerate the treatment need not be altered.