Arthur Nathaniel Alling.

Diseases of the eye and ear. A manual for students and practitioners online

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ome Series



DISEASES



OF THE i

EYE AND EAR i


ALLING 1


GRIFFIN


;5



PEDERSEN



^ JOHN K. MORRIS, M. IX

^be (IDebical Epitome Series,
DISEASES OF THE EYE AND EAR.

A MANUAL FOR STUDENTS AND PRACTITIONERS,

BY

ARTHUR N. ALLING, M.D.,

Clinical Professor of Ophthalviology in the Yale University, Depanment
of Medicine, New Haven, Connecticut,

AND

OVIDUS ARTHUR GRIFFIN, B.S., M.D.,

lAite Demonstrator of Ophthalmology and Otology, University of Michigan, and
Oculist and Aurist, University Hospital, Ann Arbor, Michigan.

SERIES EDITED BY

VICTOR COX PEDERSEN, A. M., M. D.,

Instructor in Surgery and Anesthetist and InstruMor in Anestliesia at the New York Poly-
clinic Medical School and Hospital ; Genito- Urinary Surgeon to the Out-Paiient
Departments of the New York and the Hudson Street Hospitals ;
Anesthetist to the Roosevelt Hospital.




I LEA BROTHERS & CO.,

PHILADELPHIA AND NEW YORK.



Entered according to Act of Congress, in the year 1905, by

LEA BROTHERS & CO.,

In the Office of the Librarian of Congress. All rights reserved.






Klectbotyped by press of

WESTCOTT & THOMSON, PHILAOA. WM. J. DORNAN, PHILADA.



Ass



r

AUTHORS' PREFACE, t: i^ ^ , ^^



In the following pages, the authors have endeavored to
present the subjects of Ophthalmology and Otology in as
clear, thorough, and interesting a manner as the limited space
would permit. Of necessity and intentionally, only the
cardinal facts have been mentioned, since their experience
as teachers has impressed the writers with the fact that a
complex consideration is confusing to the beginner, but that
after the fundamental principles have been mastered, the de-
tails of a more extensive work are readily acquired. While
the matter has been prepared primarily for the use of the
student, it is believed that it will prove of equal service to
the practising physician in the management of his cases. To
render the text more effective, numerous illustrations have
been employed, which should be carefully studied in con-
nection therewith. That the work might present a general
resume, the authors have consulted the principal authorities,
to whom they acknowledge their indebtedness for many of
the views contained herein.

New Haven, 1905. A. N. A.

Ann Arbor, 1905. O. A. G.

i 285



EDITOR'S PREFACE.



In arranging for the editorship of The 3Iedical Epitome
Series the publishers established a few simple conditions,
namely, that the Series as a whole should embrace the entire
realm of medicine ; that the individual volumes should au-
thoritativ-ely cover their respective subjects in all essentials ;
and that the maximum amount of information, in letter-
press and engravings, should be given for a minimum price.
It was the belief of publishers and editor alike that brief
works of high character would render valuable service not
only to students, but also to practitioners who might wish
to refresh or supplement their knowledge to date.

To the authors the editor extends his heartiest thanks for
their excellent work. They have fully justified his choice
in inviting them to undertake a kind of literary task which
is always difficult — namely, the combination of brevity, clear-
ness, and comprehensiveness. They have shown a consistent
interest in the work and an earnest endeavor to cooperate
with the editor throughout the undertaking. Joint effort of
this sort ought to yield useful books, brief manuals as con-
tradistinguished from mere compends,

5



6 EDITOR'S PREFACE.

In order to render the volumes suitable for quizzing, and
yet preserve the continuity of the text unbroken by the
interpolation of questions throughout the subject-matter,
which has heretofore been the design in books of this type,
all questions have been placed at the end of each chapter.
This new arrangement, it is hoped, will be convenient alike
to students and practitioners.

V. c. p.

New York, 1905.



V



^ JOHN K. MORRIS, M. ft
CONTENTS.

THE EYE AND ITS DISEASES.

CHAPTEK I.

PAGES

Examination of the Eye and its Appendages .... = . 17-31

^ CHAPTER II.
Diseases of the Lacrymal Apparatus . . . 31-36

^

CHAPTER III.
Diseases of the Lids = ..-,,. 37-48

CHAPTER IV.
Diseases of the Conjunctiva . , . . , » . 49-64

CHAPTER V.

Diseases of the Cornea » . » . . , 64-75

CHAPTER VL

Diseases of the Sclera 76-78

CHAPTER VII.

Diseases of the Iris 78-84

7



8 COjSTENTS.

CHAPTEK VIII.

PAGES

Diseases of the Pupil . . , 84-86

CHAPTEK IX.

Diseases of the Ciliary Body , . 86-88

CHAPTER X.
Diseases of the Lens ....,, 88-99

CHAPTER XL

Diseases of the Vitreous 99-100

CHAPTER XXL
Diseases of the Retina ....,,.. 101-108

CHAPTER XIII.
Diseases of the Choroid 109-111

CHAPTER XIV.
Diseases of the Optic Nerve 112-115

CHAPTER XV.

Diseases of the Orbit < o . . 116

CHAPTER XVI.

Diseases of the Eyeball 117-119

CHAPTER XVIL
Glaucoma 120-124

CHAPTER XVIIL
Sympathetic Ophthalmia . 125-127



CONTENTS.
CHAPTER XIX.



PAGES



I Refraction = 127-135

CHAPTER XX.
The Muscles of the Eye 135-142



THE EAE AND ITS DISEASES.

CHAPTER I.
Anatomy and Physiology 143-162

CHAPTER 11.

Examination of the Patient 162-178

I CHAPTER HI.

Diseases of the Auricle and External Auditory Meatus 178-196

CHAPTER IV.
Diseases of the Middle Ear 196-242

CHAPTER V.
Diseases of the Internal Ear 242-246



^ JOHN K. MORRIS, M. D.

THE EYE AND ITS DISEASES.



CHAPTER I.
EXAMINATION OF THE EYE AND ITS APPENDAGES.

Lachrymal Apparatus. — Under favorable conditions the
edge of the lachrymal gland may be felt as it lies in its fossa on
the upper outer wall of the orbit, back of the orbital ridge.
Enlargement, tumor, or prolapse should be made out. The pres-
ence of excess of tears in the conjunctival sac (epiphora, stilli-
cidium) is indicated by a watery line along the edge of the
lower lid and at the inner canthus. Attention should be
turned to the conducting apparatus, and the small openings
(puncta) on the margin of each lid near the inner canthus
should be found open and lying against the eyeball. The
region overlying the lachrymal sac is next examined for red-
ness and swelling. The finger, with the ball turned toward
the nose, is pressed firmly over the lachrymal sac, and at the
same time the puncta are watched to observe the escape of
discharge, which would indicate that the lachrymal (nasal) duct
is closed. By introducing the point of a lachrymal syringe into
the lower punctum, solutions may be forced into the lachrymal
sac and out again through the upper punctum, if it seems
desirable to determine the patency of these channels. The
character of the fluid may also be observed with reference to
the presence of abnormal secretion in the lachrymal sac.

Lids. — The width and length of the opening between the
upper and lower lids (palpebral fissure) should be observed,
as well as any drooping of the upper lid (ptosis).

The thin skin covering the eyelids should then be examined
2— E. E. 17



18 EXA3IINATI0N OF THE EYE AND ITS APPENDAGES.

for any disease which may occur there, and for oedema, swell-
ing, or redness.

The margins of the lids should receive a thorough inspec-
tion. Note the number and character of the cilia, as well as
their direction, being sure that no fine lashes are turned in
against the eyeball (trichiasis), and that there is" not a double
row of lashes (distichiasis). Note the presence of redness,
swelling, discharge, scales, crusts, watery cysts, ulcers, tumors,
pediculi, or ova. If the upper or lower lid is found rolled
inward, so that the margin is turned against the eyeball, the
condition is called entropion. When the margin is turned
outward, showing more or less of the conjunctiva, it is known
as ectropion.

One should next investigate the inner surface of the upper
lid by turning. This is accomplished by seizing the eye-

FlG. 1.




Desmarres' lid-retractor.



lashes with a firm hold between the thumb and finger of the
left hand, with the thumb below. The patient must then
look down, and any smooth instrument, preferably about the
size of a match, should be pressed into the skin just under the
edge of the orbital ridge. If this instrument is pressed down,
folding the skin before it, while the eyelashes are pulled up
outside the folded skin, the lid will turn, and may be held in
place for inspection by the thumb, which is conveniently
present. The inner surface of the lid should be examined
as to the condition of the conjunctiva, congestion, thickening,
granulations, or points of discoloration.

The inner surface of the lower lid may be examined by
placing the finger well up to the edge and pulling down while
the patient looks up.

To make satisfactory examination of the lids and eyeball



CONJUNCTI VA- SCLERA . 19

in young children the head must be held face up between the
surgeon's knees and the lids pried apart by the fingers or by
the use of lid-retractors. (See Fig. 1.)

Conjunctiva. — The method of examining the palpebral con-
junctiva has just been described. Tlie transition of the pal-
pebral into the ocular conjunctiva (retrotarsal fold, fornix, cul-
de-sac) should not be overlooked. AYhen the upper lid has
been turned, the edge of the tarsal cartilage must then be
raised by a blunt instrument.

The ocular (bulbar) conjunctiva is easily accessible, and con-
gestion, thickening, oedema (chemosis), and tumors noted. By
using pressure with the edge of the lid it will be seen that the
conjunctiva is loosely attached to the eyeball, except about
the cornea, where it is adherent by a narrow zone (limbus).
Presence of lesions in this locality should be noted.

Conjunctival Discharge. — The student must learn to distin-
guish the various forms of discharge found in the conjunc-
tival sac :

a. Watery (tears, epiphora). — Found in stenosis of con-
ducting apparatus, etc.

b. Mucous. — Mucilaginous, but clear. Example, chronic
conjunctivitis.

c. llucopnrident. — Tenacious, white or yellow — as in acute
and chronic conjunctivitis.

d. Purulent. — Creamy. Runs out of the eye when the lids
are separated — as in gonorrhoeal ophthalmia.

Congestion of the Eyeball. — a. Coiijimctival. — This form
may be easily distinguished by the fact that the vessels are
movable with the conjunctiva over the eyeball. Found in
conjunctivitis.

b. OHiaiy or Oircumcorneal. — A fine vessel congestion most
intense about the periphery of the cornea. Pink or viola-
ceous in color. Due to irritation or inflammation in cornea,
iris, or ciliary body.

c. Scleral — Conjunctiva movable over it. May be local-
ized fine-vessel congestion or general in form of large vessels
which perforate the sclera. In scleritis or glaucoma.

Sclera. — The sclera may show congestion, localized swell-



20 EXAMINATION OF THE EYE AND ITS APPENDAGES.

ings, bulging (staphyloma), or areas of discoloration due to
scleritis or congenital.

Oblique Illumination. — Although the further examination
is partly carried on by daylight, the method of oblique illumi-
nation in a dark room next comes into use. A double convex
lens of about 2.5 inch focus is held so that the image of the
artificial light (an Argand burner is best), which should be at
least 2 feet away, is " played '' upon the eye. The impor-
tance of this manoeuvre is very great. Another lens may be
used to magnify the illuminated field. Special instruments
have been devised for this purpose, called corneal microscopes.

Cornea. — The anterior surface of the cornea should be
carefully examined by oblique illumination for irregularities,
bloodvessels, foreign bodies, ulcers, blisters, depressions, and
opacities. One may observe the reflection of a window when
the patient is facing it, and note distortions in its outline by
moving the eye.

The deeper layers of the cornea should be examined for
opacities. A dense white opacity (leucoma), whether super-
ficial or deep, or a moderately thick cloud (macula), may be
easily discerned by daylight, but a faint opacity (nebula) is
best seen by oblique illumination. The posterior surface should
be scrutinized for opacities, usually punctate.

Sensibility of the cornea may be tested by brushing the sur-
face with a wisp of cotton. Normally this is resented by a
quick reflex.

Anterior Chamber. — The depth of the anterior chamber
should be noted — i. 6., the distance between the posterior
surface of the cornea and the anterior surface of the iris and
lens. The clearness of the aqueous humor should be noted as
well as the presence of pus and exudate (hypopyon) or blood
(hyphaema).

Iris. — The anterior surface of the iris should be observed
carefully and compared with the other eye. The muddy dis-
coloration from congestion which is accompanied by loss of
detail in the fine markings of this surface, as well as masses
of exudate, tumors, or pigment-spots, will be recognized with
a little experience. Quivering of the iris when the eye is



PUPIL— ORBIT. 21

moved (iridodonesis or tremulous iris) is sometimes seen
wlien the lens is absent or dislocated.

Pupil. — The pupil should be circular and nearly in the
centre of the iris. Great variation in size is possible under
normal conditions. It is sometimes desirable to record its
size, which may be done by comparing with an instrument
which has numerous circular apertures of measured diameter
(pupillometer). The reaction of the pupil to light may be
roughly tested by alternately covering and uncovering the
eyes with the hands before a window. A better way is to
throw the light by oblique illumination in and out of the
pupil in the dark room. The pupil into which the light is
thrown should contract (direct action), but tlie otiier should
do so as well (consensual action). When the patient looks
from a distant to a near object, the pupil should also contract
(reaction to accommodation and convergence).

Lens. — Tlie lens may be examined partially by daylight,
or better by oblique illumination, as far as the size of the
pupil will admit. The more complete examination as carried
on with the ophthalmoscope will be described later. Its
fixity of position should be determined. Dislocation (luxa-
tion) is evidenced by iridodonesis or by obtaining a view of
its edi>;e, which is never seen under normal conditions.
Opacities (cataract) on the anterior or posterior surface (polar
or (capsular) or in the lens-substance are noted. A moderate
amount of haze in advanced life, often quite brownish (sclero-
sis), is normally present and compatible with useful vision.

Vitreous Humor. — That part of the vitreous chamber
which lies just back of the lens is accessible by daylight and
oblique illumination, and should be perfectly clear. When
filled with exudate, involved by a new growth or retinal
detachment, these may be made out. The deeper parts of
the vitreous are examined with the ophthalmoscope.

Orbit. — The finger should be passed about the bony edge
of the orbit and pushed well back inside about the eyeball for
the detection of tumors and irregularities. If orbital disease
is suspected, the nose and accessory sinuses should be inves-
tigated.



22 EXAMINATION OF THE EYE AND ITS APPENDAGES,

Eyeball. — Note the position of the eyeball as to undue
prominence (exophthalmos, proptosis) or recession into the
orbit (enophthalmos), and as to whether it is pushed to one
or the other side. Also whether the eyeball is larger (megal-
ophthalmos) or smaller (microphthalmos) than the normal size.

Fig. 2.




Loring's ophthalmoscope.

Ophthalmoscope. — Ophthalmoscopy is a difficult art, and
the beginner is advised to embrace every opportunity to
perfect himself. The principle underlying the use of the
ophthalmoscope should be thoroughly mastered. The reasons
why the pupil appears dark and no view of tlie background
(fundus) may be obtained under ordinary circumstances ar^



OPHTHALMOSCOPE. 23

two : first, because light which enters the eye is reflected back
to its source ; and secondly, because there is little internal
reflection on account of the pigmented background. The
])roblera of getting in the path of the light returning from
the interior of the eye might be simply solved by holding a
hollow tube in a candle-flame. Through this the pupil will
appear luminous. Or, if a hole is made in the centre of a
mirror and the light reflected into the pupil, the observer's
eye, placed at this aperture, will see the fundus illuminated
in the same way. This is essentially an ophthalmoscope.

The modern complete or refracting ophthalmoscope con-
sists of a revolving disk, near the circumference of which is
arranged a series of apertures filled with lenses of various
strengths. These are made to pass back of the aperture in a
concave mirror. Suitable support for the disk and mirror
with handle make up the instrument.

There are four methods of ophthalmoscopy for diagnosis of
lesions :

I. A strong lens in the disk, say +16 D., is turned behind
the aperture. An Argand burner is placed on a level with
the patient's eye, on the same side of the head, so that the
shadow of the temple falls on the tip of the nose. The ob-
server approaches the patient on the same side as the light,
while reflecting it into the eye and looking through the aper-
ture with the same eye as that observed. By this method the
cornea, lens, and anterior part of the vitreous may be studied
in great detail with magnified image.

II. With no lens behind the aperture, at a distance of about
12 inches, the light is reflected into the eye. The pupil
appears luminous, but the details of the fundus can not be
seen. If there are opacities in the cornea, lens, or vitreous,
they will appear as black spots in the brilliant pupil.

The localization of any opacity may be determined with
some accuracy by the following method : If the observer's
eye is moved so that the opacity which he sees lies nearly in
line, let us say, with the lower edge of the pupil, when the
patient's eye is turned upward the opacity, if it lies hack of the
pupil, will disappear behind the iris, or if it lies in front.



24 EXAMINATION OF THE EYE AND ITS APPENDAGES.

it will appear to move "upward from the edge of the pupil.
The principle of parallax is here involved.

The behavior of the opacity with reference to a brilliant
point of light which is the reflex from the anterior surface of
the cornea, and which is referred to a point just back of the
posterior pole of the lens, may be observed in the same way.

The vitreous should be carefully scanned for fixed or float-
ing opacities while the eye is moved about. Lesions in the
vitreous may be located and followed at different depths by
bringing into place convex lenses of the ophthalmoscope.

III. The details of the fundus may now be investigated
by what is known as the direct method or the method of the
erect image. The patient and the light should be placed
as just described, and the upper edge of the ophthalmoscope
placed on the supraorbital ridge of the observer with the chin
held down. The light is reflected into the pupil of the
patient^s eye and the observer approaches very near. If the
accommodation is relaxed by an attempt to look at a distance
with both eyes open, the fundus will come into view, if the
refraction of both the patient and observer is normal. . The
erect image thus seen will be magnified about 15 times.

IV. The Indirect Method or the Method of the Inverted
Image. — The light is thrown from the ophthalmoscope, held
at a distance of about 18 inches, with a -f 3 D. lens before the
aperture.

With the other hand the lens used for oblique illumination
(+lo D.) is held about 2 inches from the patient's eye. An
inverted image will form between the object lens and the
ophthalmoscope. It is magnified about 5 times.

Choice of Method. — The method of the erect image is to be
preferred for closer examination since the enlargement is
greater but the field is small. The use of the ophthalmosco[)e
for determining errors of refraction will be described under
the head of Errors of Refraction.

The Fundus. — The ophthalmoscope opens to one's view a
little more than the posterior hemisphere of the internal sur-
face of the eyeball. It is often desirable to use a mydriatic to
facilitate the examination, Homatropine hydrobromate (2 per



THE FUNDUS. 25

cent.) or euphthalmin (5 per cent.) are the most suitable for this
})urpose. In carrying out a complete examination of the fundus
the two landmarks which should be first found are the optic
nerve (optic disk, papilla) and the macula (yellow spot). The
former appears as an oval pinkish-white disk. A pit with
sh)ping sides is in the centre (physiological excavation), with
the mottled appearance of the lamina cribrosa at its bottom.
A white ring of varying breadth (scleral ring) surrounds the
disk, and outside of this more or less pigment (choroidal ring).
From the nerve comes the central artery of the retina as a
single trunk, or already divided, and it then divides and sub-
divides on the retina. The veins follow in general the same
course as the arteries. The color, amount of blood-supply,
sharpness of outline, and swelling of the disk shoukl not esca])e
notice. The presence of an excavation with sharp sides, over
which the vessels seem to fall (cupped disk), may denote glau-
coma. The other landmark — the macula — which is very diffi-
cult to see when the pupil is small, is an area of deeper color
than the surrounding fundus, and shows a pit in its centre
with a bright reflex (fovea centralis). An examination can not
be thorough without a careful investigation of this region,
whose integrity is so necessary to perfect vision. The retinal
vessels should be followed from the nerve over the fundus
and changes in them noted. The general appearance of the
fundus is variable with the amount of pigment, depending on
the complexion of the individual. When the retinal pigment
is plentiful, a dark-red, mottled background is presented for
the retinal vessels ; when scanty, the choroidal vessels as
well are seen as a network either lighter or darker than the
background of choroidal pigment. Remembering that the
retinal vessels are in the nerve-fibre layer, wiiich is practi-
cally the inner layer of the retina, that the retinal pigment is
the outer layer of the retina, and that the choroidal vessels lie
in the choroidal pigment, the depth of any lesion may be made
out from these landmarks. The fundus should be searched in
all directions for lesions — such as blood in spots, splashes, or
large areas, white patches of exudate, degeneration, or of ex-
posed sclera. Black masses of pigment — retinal or choroidal.



26 EXAMINATION OF THE EYE AND ITS APPENDAGES.

Tension. — The proper way to test the hardness of the eye-
ball is by making the patient look down, and delicately, with
the two first fingers, press through the upper lid until the
eyeball is felt. By alternately pressing with either finger
while the other finger is held fixedly in contact with the eye-
ball as the surgeon gets the ^' sense of fluctuation '^ a judgment
of the tension is obtained.

Degrees of Tension. — An eye that is somewhat harder than
the normal is described as having tension, T. +1. Decided
rise of tension is recorded as T. +2 ; stony hardness as T. +3.
Conversely, T. — 1, T. — 2, T. — 3, denote varying degrees of
softness. Instruments for recording the degree of tension
have been devised, but are of little practical value.

Vision. — The sense of sight is divided into : I. Form-sense
(acuity of vision) ; II. Color-sense ; and III. Light-sense.

The form-sense may be classified as (a) direct or central
vision, and (6) indirect or peripheral vision.

I. Acuity of Vision. — Distance. — In order to record with
exactness the acuity of («) direct or central vision the employ-
ment of letters has been found the most practical test. The
universal method is to determine the smallest letters which
the patient can read from a card containing letters of various
sizes placed at a given distance. The construction of such
a card is based upon the assumption that, with average
acuity of vision, a patient should normally recognize a letter
at any given distance when the height and breadth of that
letter subtend an angle of 5' of arc, the apex of which
angle is at the patient's eye. In other words, if two lines are
made to diverge from the eye forming an angle between them
of 5', letters fitted between these lines at different distances
will vary in size, but will all form the same size image on the


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