ANOMALIES OF REFRACTION-A CASE OF CROSS

EYES.

BY R. O. COTTER, M. D., MACON, GA.

The subject of squint or cross-eyes, its causes, prevention and treatment, though belonging more appropriately in a journal devoted to ophthalmology, is a most important one to the general practitioner also. Convergent squint (eyes crossed inward) is largely caused by hypermetropia; practically the antero-posterior diameter of the eyeball is too short. Parallel rays cannot come to a focus on the retina, but focus behind it. The muscles of accommodation cannot make the lens sufficiently convex to do its work. An artificial lens is needed, and a properly adjusted convex glass in front of the eye does the work by aiding the lens of the eye.

Authorities-DeWecker and others—place the proportion of hypermetropia existing in internal squint at 75 to 85 out of every 100 cases. On the other hand, in divergent squint (eyes turned outward) there is generally myopia-near-sightedness. Here the antero-posterior diameter of the ball is too long, and concave glasses are needed to prevent the rays converging too far in front of the retina. Divergent squint, however, being so much less common than convergent, I will only speak of the latter variety in this article.

Convergent squint, when caused by hypermetropia, rarely ever manifests itself until the child begins to use its eyes for near objects, at say four to seven years of age. In the effort to read or see close objects it is necessary to increase the convergence of the visual lines to aid the power of accommodation, and the internal rectus muscle participating so frequently in this act, the parents of the child pretty soon notice that it is becoming crosseyed. They then either stop the child from its studies or do worse, and follow what has been the unfortunate but too common

advice of the family physician, "let it alone, as the child will outgrow it," until finally the child will become worse and worse cross-eyed. The worst crossed eye will become useless finally, because we must not lose sight of the fact that they soon learn to suppress the image in the crossed eye, and do not use the eye. And furthermore, even in after years when the squint has been operated upon, they still retain the ungainly habit of ducking the

head to one side.

In the large majority of these cases if, in the beginning, the child's eyes had been properly examined and the error of refraction shown up by the ophthalmoscope, and the child been supplied with proper glasses, the eyes would not have become crossed; nor would any operation have been necessary.

Astigmatism, a still more complicated error of refraction, may still further complicate the case. In astigmatism there is irregularity of curvature of some one, or perhaps more than one, meridian of the cornea. This must be corrected by properly applied cylindrical lenses. The scientific management of these cases of errors of refraction calls forth the very highest skill of the oculist, and the successful results obtained are justly regarded as far finer work than the most brilliant handling of the knife. I had the pleasure of spending two months of the past summer attending the clinics of Drs. C. R. Agnew, Pomeroy and Webster at the Manhattan Eye and Ear Infirmary in New York city. I was charmed by the splendid success of these conservative ophthalmologists, especially on this very point. It was a very common sight to see in their clinics young children being relieved of a beginning squint by simply wearing skillfully adjusted glasses.

return.

Of course, if the squint has become established, we must operate; yet it is a very important point to look for the anomaly of refraction, and fit them with glasses also, or the squint may The following among some recent cases of young crosseyed hypermetropes whom I have operated upon will illustrate: This young lady is aged fourteen and is still at school. She had always had trouble in using her eyes for close work, and both eyes had been crossed since her seventh year. The right

eye was very badly crossed. Examination with the ophthalmoscope showed her not only to be very hypermetropic in one eye and slightly myopic in the other, but she was also astigmatic in both eyes, making quite a complicated anomaly of refraction. I operated very freely upon both eyes. By freely I mean that a long conjunctival cut was made, and the sub-conjunctival tissue was freely loosened over the muscle. The operation was instantly successful; but, after two or three weeks, one eye showed signs of again turning inward, when I fitted her with the proper spherical combined with cylindrical glasses, and directed her to wear them constantly. Her vision was thereby improved from 2 and to respectively, or normal, and 3. She now pursues her studies easily and with straight eyes.

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HOW THEY PRACTICE IN INDIA.-An Indian physician was holding forth the other day to some of his brothers of the craft in England. "You sairs in the West," he said, “do not understand the practice of medicine. In my country, if a rajah with nothing of sickness sends for me, I go and I say, 'Sair, your case is a bad one; you will be worse before you are better.' I give him some medicine and I go away. The next day I go again, and I find him heaving like a sea-sick mandarin, and wishing that the son of his mother had never seen the light. 'Sair,' I say, 'I told you so; you have passed a great crisis. There is no more need of medicine. Another sun will see your cure complete.' I then collect my fees, and I go away. When I have cured a few more rajahs I shall come again to your country and take a villa on your little river Thames, with the green turf sloping down to the waterside.”—Ex.

Clinic Reports.

A CASE OF HYPERTROPHY OF THE NYMPHÆ.

BY VIRGIL O. HARDON, M. D.,

LECTURER ON OPERATIVE GYNECOLOGY, SOUTHERN MEDICAL COLLEGE, ATLANTA, GA.

S. U., colored, age 33; menstruation commenced at 14 and has always been normal. Married at 20, had one child a year, after marriage; never pregnant since. No specific history, but had gonorrhea ten years ago. Health has always been good, with the exception of recurrent attacks of pelvic inflammation, which were relieved by rest and medical treatment. (Probably exacerbations of a chronic salpingitis from the old gonorrhea.) Relief was sought for a tumor on each side of the vulva, which had appeared and grown to its present size within a year, and which interfered with locomotion, micturition and coition.

Examination showed an enlargement of both nymphæ, as shown in the accompanying cut. The surfaces were rough and rugose and the mucous membrane was converted into a thick skin, which was as deeply pigmented as the true skin, the patient being a dark mulatto. There was no pain, tenderness, ulceration or excoriation of the parts. The remainder of the vulva was perfectly normal. The clitoris was not involved in the hypertrophy. The case was regarded as one of elephantiasis of the nymphæ.

The patient was very anxious to be rid of the tumor, not because of the pain and inconvenience occasioned by it, but rather from an æsthetic point of view. The unsightly growth was an eyesore to herself and to her husband.

Accordingly, on the 9th of August, with the assistance of Dr. C. C. Greene, the patient was etherized and with scissors the nymphæ were removed in toto. The wound was closed with carbolized. silk sutures and union took place readily by first intention.

A microscopical examination made by Dr. Henry Wile, of this city, showed that the condition was not that of elephantiasis, but of conversion of the mucous membrane into true skin with marked hypertrophy of all its structures. His report upon the specimen is as follows:

"Under a power of 75 diameters the epidermis is seen to be loosely attached to the papillary structure of the skin, and in a state of desquamation from exposure. In some places a complete separation is noticed. The cells of the rete show decided pigmentation, and this is most marked in the layer which is next to the papilla of the corium. The papilla of the corium present a swollen condition and are the seat of a lymphoid cell infiltration which extends downward into the deeper layer of the corium in the form of streaks, apparently in the line of the ascending capillaries. The corium is greatly thickened and is the seat of inflammatory change, which is marked by variously sized groups or aggregations of lymphoid cells, especially in the neighborhood of the blood-vessels.

Under a power of 200 diameters the layers of epidermis are seen to be in a state of desquamation. The strata are separated