Casey Albert Wood.

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1 '.'



THE VIM.UTR\n



THE COMMONER

DISEASES OF THE EYE

How to Detect and How to Treat Them.



FOR STUDENTS OF MEDICINE



With '_'»')(> Illustrations, many of t hem original, of which
seven are colored plates.



CASEY A Wool). CM.. M.D., D. C. L.

Professor of Clinical Ophthalmology in the University of
Illinois; Professor of Ophthalmology in the Post Graduate
School, Chicago; Ophthalmic Surgeon to St. Luke's Hos-
pital, Chicago; Consulting Ophthalmologist to the Emerg-
ency and St. Anthony's Hospital, Chicago; Ex-Chairman
of the Ophthalmic Section, American Medical Association;
Fellow of the American Academy of Medicine; Mifglied
der Oj>hthalmologischen Gesellschaft, etc.



THOMAS A. WOODRUFF, M.D.. CM., L. R.C.P.. London.

Professor of Ophthalmology in the Post Graduate Medical
School, Chicago; Ophthalmic Surgeon to St Luke's Hos-
pital and Dispensary and St. Anthonv de Padua Hospital,
Chicago; Fellow of the American Academy of Medicine:
Editorial Secretary of the Ophthalmic Record: Mitglied der
Ophthalmologischen Gesellsckaft, etc.




CHICAGO:

G. P. ENGELHARD & COMPANY,

1904.



Co yright 1804,
BY G. P. ENGELHARD & CO






PREFACE.

Some years ago one of us ventured to write a
short treatise entitled Lessons in the Diagnosis
and Treatment of Eye Diseases. In the present
volume it is intended to amplify this work so
that it shall consider ophthalmology from the
standpoint of the physician in general practice.
It is proposed, mainly by describing only the
commoner diseases of the eye (never using a tech-
nical term when a simpler word is available), by
numerous illustrations, synopsis-headings, and a
complete reference-index, to popularize a study
that is too often considered difficult and unprofit-
able.

We are well aware that the conduct of the busy
practitioner toward such ocular affections as
occur in his practice usually differs from his
treatment of most other diseases. The acquire-
ment of even a moderate degree of knowledge re-
specting diseases of the eye — especially those re-
quiring the use of the ophthalmoscope — necessi-
tates considerable study and frequent chances for
observation. The every-day routine of practice
affords neither opportunities for the one nor time
for the other, and it is not, therefore, surprising
that such cases are usually referred to a confrere
who makes a special study of them.

While one must admit the advantages that, on
the whole, accrue to both patient and medical man






8 COMMONER DISEASES OK THE EYE

from such a disposition of this class of maladies,
it is not without its drawbacks.

There is a fairly well-defined and important
group of diseases, affecting various parts of the
visual apparatus, whose signs and symptoms are
especially prone to be overlooked or misinterpreted
by the general practitioner simply because he has
abandoned the inspection of the eye. In this
group are some that call for recognition in tones
so loud that they ought to be detected at once by
any man who will use his ordinary powers of
observation, while others require stricter atten-
tion upon the part of the observer. Many of
them, too, are by no means simple matters. When
not recognized and promptly treated by the sur-
geon, they go on, in the ordinary course of events,
either to a more or less rapid destruction of the
organ itself, or to considerable impairment of its
function. The claims which the study of this
particular set of diseases makes upon the profes-
sion become all the more urgent when one reflects
that in every instance an early diagnosis ma\ be
correctly made by the exercise of the same quality
and amount of care and intelligence which are
commonly brought to the investigation, let us sa\ .
of affections of the lungs and uterus.

It is not claiming too much, we are sure, of
the student of medicine that he should have al
least a fairly intimate knowledge of the eye signs
and symptoms of disease in general. Chapters



on this important subject have been carefully
prepared and profusely illustrated, especial stress
being laid upon those evidences of systemic in-
volvement that the ocular structures so commonly
exhibit.

For the additional assistance of the student
a table of contents, giving the headings of each
chapter, as well as a cross (reference) index,
have been provided so that any subject treated in
this handbook may be readily consulted.

Many of the illustrations are original with us,
while a number are borrowed from well known
text-books and treatises, to the publishers of
which we are greatly indebted for their use.

The chapters on the relations of ophthalmology
to general medicine will be found to resemble in
treatment the section devoted to that subject in
the text-book on Diseases of the Eye edited by
Drs. Hansell and Sweet, because they were both
written by the same hand.

Casey A. Wood,
Thomas A. Woodruff.

Chicago, March i, 1904.



10 PREFACE TO THE SECOND EDITION



PREFACE TO THE SECOND EDITION.

The early exhaustion of the First Edition ot"
this manual affords an opportunity for correct-
ing a few errors in the text and adding to it >c\ -
oral observations and illustrations that, it is be-
lieved, will increase the value of the book to stu-
dents and practitioners.

Many new cuts have been prepared especially
for this work, from original drawings and photo-
graphs, by the well-known Chicago author-artist.
Dr. |. I'. Burkholder.

C. A. W.
T. A. W.

Chicago, September t. 11)04.



CONTENTS



11



TABLE OF CONTENTS. Page

Chapter I.

METHODICAL EXAMINATION OF THE EYE.

Inspection of the eye — How to evert the lids —
Has the patient "crossed eyes" or squint?
— Has he ulcer of the cornea? — How to
examine the eyes of children without hurt-
ing them— The pupil reflexes— The oblique
illumination with a lens— The tension or
hardness of the eyeball — How to determine
the visual acuity or amount of sight — Test
types for distant and near vision — How to
measure the field of vision with the perim-
eter — Color vision and color blindness
and how to test them 23-56

Chapter II.

THE NORMAL, THE FARSIGHTED, THE SHORT-
SIGHTED AND THE ASTIGMATIC EYE.

The normal or emmetropic eye — The abnormal
or ametropic eye — The differences between
these lie mainly in their shape and size —
How the eye focuses or accommodates —
Presbyopia or old sight — The path of
visual sensations from the retina to the
brain — Hypermetropia or farsight, due to
abnormally small eyes — Aphakia, absence
or loss of the lens — Myopia or shortsight,
in which the eyeball is enlarged — How
abuse of the eyes causes the eye-coats to
stretch — Astigmatism, or abnormal shape
of the cornea or crystalline lens — The as-
tigmatic chart — How to correct with
lenses errors of refraction resulting from
these abnormal conditions 57-80



12 COMMONER DISEASES OF THE EYE

Chapter III. I'v i

THE MEASUREMENT OF AMETROPIA — THE FIT-
TING OF OLASSES — THE OPHTHALMOSCOPE.

Objective and subjective methods of measur-
ing the refraction — The "test case" used
for the subjective determination of ame-
tropia — Fitting of glasses not an easy
task — Symptoms of eye strain — The oph-
thalmometer, or measurer of corneal as-
tigmatism — The ophthalmoscope and how
to use it — Its value in the diagnosis of
ocular disease — Why it should be in the
hands of every physician — Skiascopy,
retinoscopy or the "shadow test" the best
objective means for measuring refractive
errors — How to employ it in the various
kinds of ametropia 81-102

Chapter IV.

THE COMMONER DISEASES OF THE EYELIDS.

'1 ne anatomy of the lids — How they protect,
lubricate and cleanse the front of the eye-
ball — The tarsus, the cilia and the Meibo-
mian glands — "Black eye" — Styes — Chala-
zion or Meibomian cyst and how to re-
move it — Blepharitis — Eczema of the lid
edges — Entropion — How to do a can-
thoplasty — Other operations for entropion
and trichiasis — Ectropion and operations
for its relief — Ptosis, or drooping of the
upper lid, and how to treat it — Lagoph-
thalmus — Symblepharon K);{ 186



CONTENTS



1::



Chapter V. Page

THE COMMONER DISEASES OF THE CONJUNCTIVA.

Anatomy— Hyperemia of the conjunctiva and
its treatment— Acute conj unctivitis— The
various infections of the conjunctiva and
their bacterial causes— The pneumococ-
cus, Koch-Weeks bacillus, streptococcus,
staphylococcus, gonococcus, Morax-Ax-
enfeld diplobacillus and other sources of
conj unctivitis — "Pink eye" — The treat-
ment of infectious diseases of the con-
junctiva—Ophthalmia Neonatorum the
commonest and most serious eye disease
of infancy— How to treat it— Gonorrheal
conjunctivitis in the adult 13 ' 166

Chapter VI.

THE COMMONER DISEASES OF THE CONJUNCTIVA.

(Continued)
Follicular conjunctivitis and its treatment-
Trachoma, the most serious form of
granular lids— How it produces blindness

Its many complications — Treatment —

"Spring" catarrh— Phlyctenular conjunc-
tivitis and its treatment— Pterygium, its
cause and treatment— Pinguecula 167-186

Chapter VII.

THE COMMONER DISEASES OF THE CORNEA.

Anatomy and physiology— Ulcer of the cornea
generally due to removal of protecting
epithelium and subsequent infection — The
pneumococcus— Deep ulcer— Hypopyon—
Perforation of the cornea— Treatment-
Serpent or spreading ulcer— Ring ulcer at



ii commoner diseases of the eye

Pagi

the margin of the cornea — Neuroparalytic
ulcer — Herpes of the cornea — Phlyctenu-
lar keratitis, a common disease of child-
hood — Treatment of the foregoing — In-
terstitial or parenchymatous keratitis — It
occurs mostly in children and is due to
syphilis or struma — Punctate keratitis, a
sign of disease of the choroid or ciliary
body — Opacities of the cornea and their
treatment — Nebula, macula and leucoma —
Artificial pupil — Optical iridectomy — Irid-
otomy — Tatooing the cornea — Conical
cornea and how to treat it 187-230

Chapter VIII.

THE COMMONER DISEASES OF THE IRIS.

Anatomy and physiology — What produces the
color of the iris — The pupil — The uveal
tract — Acute iritis — Usually due to
rheumatism or syphilis — Posterior syn-
echia, or adhesions of the iris to the
lens — How to distinguish iritis from con-
junctivitis — Treatment of iritis very sat-
isfactory if given early — Cyclitis or in-
flammation of the ciliary body ^:!l-044

Chapter IX.

GLAUCOMA — HOW TO DISTINGUISH THE VARIOUS
INFLAMMATORY DISEASES OF I UK. EYE.

Primary glaucoma — An affection of the in-
traocular drainage system — The acute
form of the disease — Liable to be mis-
taken for supraorbital neuralgia — The
practitioner should always he on the look-
out for it — Symptoms of acute glaucoma



contents 15

Page
— Hardening of the eyeball — Chronic
glaucoma — The lesions in this disease- —
Treatment — Scleritis and episcleritis — An
easy method of diagnosing the commoner
forms of inflammation of the eye — How
to decide whether the inflamed eye is a
serious or a simple matter 245-208

Chapter X.

THE COMMONER DISEASES OF THE LACHRYMAL
APPARATUS.

The course of the tears from the ducts of the
lachrymal gland to the inferior nasal
meatus — The anatomy of the lachrymal
apparatus — Difference between epiphora
and lachrymation — Acute and chronic
dacryocystitis practically always due to
obstruction of the lachrymal passages —
Diagnosis, symptoms and treatment of
lachrymal stricture — Passing lachrymal
probes — The lachrymal syringe — Extirpa-
tion of the sac and removal of the lach-
rymal gland 269-284

Chapter XI.

CATARACT AND OTHER AFFECTIONS OF THE
CRYSTALLINE LENS.

The crystalline is suspended from the ciliary
body behind the lens, in front of the
vitreous — Dislocation of the lens — Apha-
kia or absence of the lens — The various
kinds of cataract — The senile variety the
commonest and most important — Hard
and soft cataract— The lens an epith-
elium structure within an unyielding cap-



16 COMMONER DISEASES OF THE EYE



Page



sulf. grows heavier, larger and less trans-
parent with age — Diagnosis of cataract —
Operations for removal — Iridectomy —
Contraindication for operation — Extrac-
tion of senile cataract — After treatment.. 285-316



Chapter XII.

IIU. COMMONER INJURIES OF THE EYELIDS, CON-

rUNCTTVA, IRIS, CORNEA. LENS, SCLERA

AND CHOROID.

Injuries to the lids frequently seen — What
a nstitutes a "black eye" — How to treat
it — Incised and other wounds of the lids
— Injuries of the conjunctiva — Symbleph-
aron — Burns and other injuries of the
cornea and now to manage them — Con-
tusions of and blows upon the eyeball —
Hyphemia — Iridodialysis or rupture of
the iris — Dislocation of the lens — Deep
injuries to the eye, such as rupture of the
choroid — Rupture of the eyeball — Sym-
pathetic ophthalmia may follow penetrat-
ing wounds, especially of the ciliary re-
gion — Injuries of the cornea and how to
deal with them — The electro-magnet the
most useful means for the extraction of
iron and steel from the interior of the
eyeball Migratory, or sympathetic, oph-
thalmia due to infection of the second eye
by microbes and toxins from the injured
eye 817 340



CONTENTS • 1 '

Chapter XIII. Page

HOW TO PRESERVE THE EYESIGHT— THE FUNDA-
MENTALS OF OCULAR HYGIENE.

A knowledge of the principles of ocular
hygiene necessary to every well informed
physician — Care of children's eyes —
Stupid pupils often children that are half
blind or half deaf— At what age shall a
child be sent to school ?— The building of
school houses and the arrangement of the
rooms— Measurements and lighting of the
ideal or standard schoolroom — Window
shades, blackboards, seats, desks and
schoolbooks should be chosen with due
regard to the pupils' eyesight — What
colors should be used in painting the
schoolroom? — The hygiene of adult eye-
sight — The illumination of offices, public
buildings and private houses — The posi-
tion of the reading lamp — When to avoid
the use of the eyes for reading — Dotted
veils a cause of eye-strain — Rules for arti-
ficial illumination 341-3f.6

Chapter XIV.

THE COMMONER DISEASES OF THE OPTIC NERVE,
ITS PERIPHERAL AND CENTRAL CON-
NECTIONS.

The retina an expanded layer of optic nerve
tissue — The structure and important parts
of the retina — The retinal circulation —
The physiology of peripheral vision — The
blind spot of Mariotte— The orbital and
intracranial divisions of the optic nerve
and their cerebral relations — The cortical



18 commoner diseases of the eye

Page
center for sight occupies the sides of the
calcarine fissure in the occipital lobe— Eye
signs of brain tumor — "Choked disk" and
its meaning— Its value very great as a
symptom of brain disease — Eye signs
of meningitis— Blindness from epidemic
c< rebrospinal meningitis — Pseudo-glioma
— Ocular symptoms of multiple sclerosis
and tabes dorsalis — Argyll-Robertson
pupil — Hereditary ataxia or Friedreich's
disease 357-374

Chapter XV.

OPHTHALMOLOGY IX GENERAL MEDICINE AND
S l RGERY.

Why the student of general medicine should
study the eyesigns of disease — The ex-
treme importance of ocular symptoms in
gi nrral diagnosis — The eye symptoms
(toxic amblyopia) set up by indulgence
in tobacco and alcohol, by lead poisoning
and by methyl alcohol — The treatment of
toxic amblyopia — Ocular rheumatism —
The eye signs of gout, gonorrhea,
measles, syphilis, dyspepsia and diseases
of the reproductive organs — Affections of
the eye in tuberculosis, simple anemia,
leukemia, hemorrhages, nasal diseases and
diseases of the ear ; '"-' 386

Chapter XVI.
che ocular complications of certain sys-
temic DISEASES.
The ocular lesions that accompany or follow
smallpox, e. g., ulcer of the cornea— The



contents 19

Pack
oculomuscular pareses of diphtheria — The
eye complications of influenza, malaria,
typhoid fever, rickets and diseases of the
vascular system— Retinal pulsations in
aortic insufficiency — Retinal embolism and
thrombosis 387 396

Chapter XVII.

HEADACHE FROM EYE STRAIN — OCULAR HEAD-
ACHE — THE OCULAR SIGNS OF CERTAIN
GENERAL DISEASES.

Headacne from eye strain very common —
Nearly always a frontal headache — Causes
of ocular headache— How to distinguish
an eye headache from others that resem-
ble it— Treatment of it— Exophthalmic
goitre, Graves' or Basedow's disease —
The eye signs very important and valu-
able in diagnosis — The ocular signs in
epilepsy — Migraine not an affection of the
visual apparatus although it usually pre-
sents characteristic eye symptoms — The
ocular signs of hysteria — Reversal of the
color field — Hysterical amblyopia — Mon-
ocular diplopia — Hysterical photophobia
and blepharospasm — Traumatic hysteria —
The eye symptoms of Bright's disease —
Albuminuric retinitis — The ocular signs
of diabetes — Diabetic cataract — The com-
moner tumors of the eye — Glioma
retinae 397-424

Chapter XVIII.

THE COMMONER DISEASES OF THE EYE MUSCLES.

Anatomy and physiology — The rotation cen-
ter of the eyeball — Six orbital and two



20 commoner diseases of the eye

Page

intraocular muscles — How to memorize
their nerve supply as an aid 10 the diag-
nosis of cerebral and spinal lesions —
Heterophoria and its meaning — The
various forms of muscular imbalance —
Tests for and treatment of heterophoria —
Squint or strabismus — How it differs
from paralysis of the eye muscles — Con-
vergent and divergent squint— Symptoms
and treatment — Tenotomy and advance-
ment of the external ocular muscles —
Paresis and paralysis of the eye muscles
— Double vision and vertigo the chief
symptoms — Syphilitic and rheumatic le-
sions the chief causes — Peripheral and
central forms of the disease — Tabes and
diphtheria — Treatment — Nystagmus and
its causes 42fr-450

Chapter XIX.

Mil COMMONER PATHOGENIC BACTERIA THAT

INVADE THE EYE.
Numerous bacteria, pathogenic and benign,
inhabit the normal conjunctival sac —
Slight traumatisms or local irritations
permit them or their toxins to invade the
tissues beneath the protecting epithelium
— They constitute an important cause of
ocular inflammations — The staphylococ-
cus — The streptococcus — The gonococcus
of Neisser the special cause of gonorrheal
conjunctivitis in adults and in ophthalmia
neonatorum — Tne pneumococcus the spe-
cial bacterium of spreading ulcer of cor-
nea — The Koch-Weeks bacillus responsi-
ble for "pink eye" — It is doubtful whether



CONTENTS



21
Page



451-456



the trachoma bacillus has been isolated-
Mixed infections— Toxins often as viru-
lent as the bacteria that excrete them—
The environment of much importance in
determining the virulence of bacteria...-

Chapter XX.

REMEDIES COMMONLY USED IN OPHTHALMIC
PRACTICE.

Local blood-letting-Leeches, natural and art-
ificial—The application of dry and moist
heat _ This remedy mostly used in deep-
seated inflammation of the eye— The use
f C old— Moderately cold applications m
superficial ocular inflammation-Massage
of the lids over the eyeball— Subconjunc-
tival injections— How to irrigate the eye
—The use of the medicine dropper— How
to instill single drops— Poultices rarely
useful in eye diseases-The "rest cure" as
applied to the eyes-Protective glasses,
goggles and bandages— Their various
forms and how to apply them— Mydri-
atics and cycloplegics— Cocain, atropin,
euphthalmin and homatropin— Atropin
and other powerful cycloplegics— Miotics
and their uses— Holocain, cocain and
other local anesthetics— Silver nitrate,
argyrol and protargol— Zinc and copper
sulphates— Boric acid, formalin, bichlor-
ide, and other disinfectants— Dionin— Su-
prarenal capsule and its extracts— The
yellow oxide of mercury and its oint-
ments—The preparation of the patient in
ophthalmic operations 457-491



METHODICAL EXAMINATION OF TF.E EYE



123



CHAPTER I.

METHODICAL EXAMINATION OF THE

EYE.

Inspection of the eye.— How to evert the lids.— Has
the patient "crossed eyes" or squint?— Has he ulcer
of the cornea?— How to examine the eyes of chil-
dren without hurting them.— The pupil reflexes.—
The oblique illumination with a lens.— The tension
or hardness of the eyeball.— How to determine the
visual acuity or amount of sight.— Test types for
distant and near vision.— How to measure the field
of vision with the perimeter.— Color vision and color
blindness and how to test them.

just as one studies the conditions under which
the healthy lungs and heart subserve their re-
spective functions before proceeding to an in-
vestigation of the departures from health to
which these organs are subject, so it is well
to make a study of the normal eye. The physi-
cian should cultivate this habit of observation
in the case of the visual apparatus particularly,
because so much information as to its condi-
tion — whether normal or abnormal — can always
be learned by simple inspection.

To be of the greatest value, such an examina-
tion should be methodical and every case should
be examined in the same order. Of course,
where the patient's condition is so obvious that
it would be mere waste of time to follow out
a program including all the parts of the eye, this
rule may be modified ; but it is the safest to run



84 COMMONER DISEASES OF THE EYE

over the whole ground, so far as possible, in the
great majority of instances.

The common and probably the best plan that
can be adopted is that of proceeding from with-
out inward, bearing in mind, meanwhile, as
many as possible of those diseased conditions
which one might expect to find in the particu-
lar locality under examination.

The objective examination of the eye should
be begun by carefully inspecting the superficial
structure and parts surrounding that organ.
The patient is to be seated in a chair facing a
window through which a good illumination can
be obtained.

The lids are to be examined for any irregu-
larity in their outline, for distended vessels,
edema, thickening, redness or tumors (such as
cysts) of the Meibomian glands (Chalazia) —
and for scales, crusts or ulcerations along their
margins (blepharitis). It should be noted if
they are in close apposition to the eyeball, and
whether their margins turn out (ectropion), or
turn in (entropion), or if there is inability to
close the lids (lagophthahnus) , or drooping of
the upper lid (ptosis).

The cilia or eyelashes should next be in-
spected to see if any are misplaced, or if they
curve inward (trichiasis). The position and
permeability of the puncta should be ascer-
tained. Pressure should be made over the



METHODICAL EXAMINATION OF THE EYE



25



lachrymal sac in the endeavor to squeeze out
through the puncta any fluid (mucus or pus)




Everting the Lower Lid.



that may be retained therein. It should be noted
if the conjunctival sac contain any secretion,



26 COMMONER DISEASES OF THE EYE

and if so whether it is mucous or purulent;
whether the tears accumulate in the corner of
the eye, overflow and run down over the cheeks
(epiphora).

For a thorough examination of the mucous
lining of the lids and eyeball (conjunctiva),
the former should be (.verted and their inner
surfaces inspected for any undue redness,
roughness or other abnormality.

The lower lid is everted by placing the tip
of the thumb upon the skin near its margin and
drawing it downward, at the same time pressing
backward, and telling the patient to roll the
eyeball upward.

The eversion of the upper lid is somewhat
more difficult, and is accomplished in the fol-
lowing manner. The patient is told to look
dozen during the whole time required for evert-
ing the lid. The surgeon stands behind the
operating chair. The forefinger of the left hand
is placed upon the upper lid just below the eye-
brow and the lid drawn by the finger tip up and
away from the eyeball in such a manner that the
cilia point upward. The eyelashes are then
grasped by the thumb and forefinger of the oppo-
site hand, without touching the globe. The pa-
tient is now directed to continue looking down-
ward, the lid is drawn dozen and away from the


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