and not only in transverse, but also in longitudinal sections, and that the vessels present in their course a much more characteristic representation of the cribriform fascia than the connective tissue. This histological structure of the lamina cribrosa, dependent upon the vascular anastomosis, is of great importance from a pathological standpoint. The few small branches of the posterior ciliary vessels do not all pass directly into the optic nerve, in order to anastomose with the central retinal vessels, but some pass backward between the two sheaths of the nerve and here form a rich network of blood-vessels. The scleral vascular circle is formed by an anastomosis between the branches of the short posterior ciliary arteries and minute vessels, which come directly from the brain and run along the surface of the inner sheath of the optic nerve to the sclera. In addition to all these networks, there is still another between the inner sheath of the nerve and the nerve itself, which anastomoses intimately with the vessels supplying the nerve fibrils.

Leber in a recent paper (Archiv für Ophthalmologie, XVIII, 2) calls attention to the following points, viz:

I. The central artery and vein of the retina supply not only the retina and optic papilla, but also in connection with the vaginal vessels, that portion of the nerve-trunk in which they run.

2. The vessels of the optic nerve-trunk always run within the meshes of connective tissue by which the nerve is traversed.

3. The relations of the branches of the vascular circle of the sclera are, with some slight modifications, a repetition of the relations of the vaginal vessels of the optic nerve-trunk.

4. The lamina cribrosa, optic papilla, aud a small portion of the retina are supplied both by the central vessels and ciliary vessels.

All this discussion of the vascular supply of the retina, choroid and optic nerve, is of very great interest, not only when we have to do with a question of true anastomosis, as in the diagnosis of a simple embolus of the central artery of the retina, but also in all cases of inflammatory affections of the deeper tissues of the eye. In this matter of asthenopia with a congested fundus, it seems to me of special importance as a means of explaining the great development or enlargement of vessels seen by the ophthalmoscope. The constant strain upon the choroid, due to the contraction of the longitudinal fibres of the ciliary muscle, must necessarily cause an increased flow of blood to the parts, while the coincident ever-progressive hypertrophy of the fibres themselves, due to continuous action, would of itself tend to the same end.

As regards the treatment of these cases of asthenopia, I think we may safely say that we can do a great deal. In my experience the most obstinate cases to deal with are those in which there is no error of refraction, and in which the exciting cause has been simply long continued abuse of the eyes. The first thing to be done is to look carefully into the acuity of vision, both for the distance and for ordinary near-work. If we find that the vision for the distance is not normal, that is, if the patient cannot read Snellen XX at twenty feet, then we should try whether the vision can be improved by spherical glasses. We can thus generally satisfy ourselves of the existence of hypermetropia or myopia, and if the latter, determine its degree. With hypermetropia it is

somewhat more difficult, as the patient frequently refuses a weak convex glass, and yet there may be considerable latent hypermetropia present, particularly if he be young. Having determined the vision for the distance, we should try the patient upon Jæger's or Snellen's test-types for reading, and we shall generally find that there is more or less limitation of the accommodation, and this almost always occurs in a hypermetrope. The near-point will be found to have receded from the eye, and thus to have approached the far-point. We should next examine into the condition of the muscles of the eye, and note whether the excursive movements of the globe are normal. Test the power of convergence, and if the trouble has lasted for any length of time, an insufficiency of one or both internal recti will be discovered, so that when an object is brought to within a certain distance of the eyes, one eye diverges or turns outwards. But sometimes this is not noticeable, and yet the patient tells you that he sometimes sees double. We must then resort to the use of prisms, and by placing one with the base upwards or downwards before one eye, and telling the patient to fix an object like the flame of a candle or a black dot upon white paper, vertical diplopia is immediately produced. The patient will then tell you that the objects do not stand vertically, but that there is also a lateral displacement, and then by placing a series of prisms with the base inwards before the same eye, we at last find one which brings one image directly over the other, and this is the measure of the insufficiency. Finally comes the ophthalmoscopic examination with its revelations.

The first step in the treatment is to ensure the stoppage of all work, The patient must be informed of

the danger of continuing work, and to make sure of this, atropine should be instilled thrice daily for from two to four weeks. This paralyzes the ciliary muscle, sets the accommodation completely at rest, and thus aids in stopping the increased congestion. As the pupils are now widely dilated, a pair of blue or smoked glasses should be constantly worn, and a leech should be applied to each temple, and if necessary repeated once every week. If there be much hyperæsthesia of the retina, the lactate of zinc may be given in five grain doses three times a day, and it is better to give it in pill-form combined with iron and quinine. If the intraocular congestion be very marked and venous pulsation present, the heart's action will generally be found to be accelerated, and digitalis is then indicated, in small doses. Attention should be paid to the general health, bathing and exercise should be advised, and the bowels kept regularly open. After three or four weeks the symptoms will generally have disappeared, the congestion of the fundus will have subsided, and the atropine may now be discontinued. If the patient be hy

permetropic the proper glasses should then be ordered, and in about two weeks the blue glasses may be laid aside and work be recommenced. And now comes in play what is called the muscular gymnastic exercise of the eyes, or "Dyerizing," to coin a word from the name of Dr. Dyer, of Philadelphia, who recommended the plan to be described. The patient should be told to put on his glasses and read for from two to five minutes in the morning, and the same length of time in the afternoon, and no longer. The next day this time should be increased one minute, and so he should go on for several days, increasing each day by one minute.

After a time the increase may be raised to five minutes each day until finally the patient finds that he can use his eyes for a number of hours continuously. He should carefully avoid working by gas or lamp-light for some time to come, and if possible should change his occupation for another that does not tax the eyes so much, as he is liable to a return of the asthenopia on slight provocation.

1615 Washington Avenue.

ON TETANUS AND TETANOID AFFECTIONS, WITH CASES.

By R. ROEMER, M. D., St. Louis, Mo.

[Continued from page 309]

The internal use of opium is advantageously combined with large doses of camphor, as in the case of Van Bibber. Professor Rochester has reported two successful cases of strychnia poisoning in which he relied upon camphor, and asks the question, "might it not possibly be successfully used in cases of traumatic and idiopathic tetanus?"