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 retina and be seen equally well. The letters on Snellen's card, which is usually employed, are all of a size determined upon the principle just stated and properly numbered for the distance at which they are placed in the angle. Method of Recording Acuity of Vision. — Each eye should be tested separately. With the card placed in a good light ^t a distance of 20 f^et from the patient, the smallest VISION. 27 letters which can be read are noted. The number over these, which denotes the distance in feet or metres at which they should be read, forms the denominator of a fraction whose numerator is the distance of the card from the patient — generally, as stated, 20 feet or 6 metres. Example : If the number of the line of smallest letters read is 40, the record will be V. = f^. When vision is too poor to be tested with letters, the distance at which fingers may be counted should be noted. Or, vision may be reduced to perception of light (p. 1.) or may be nothing (V. = 0). For the illiterate, forms such as the spots of playing-cards or familiar objects may be employed instead of letters. Near Point. — A card for the purpose of testing vision at Fig. 3. The visual angle. the near point is constructed upon the same principles, but various sizes of printers' type are usually employed (Jaegei'^s). The record is made for the number of the type read and nt the reading distance, 12 to 14 inches. The ability to change the refractive power of the dioptric media of the eye is called the accommodation, and lies in the action of the ciliary muscle, which in contraction relaxes the tension on the suspensory ligament of the lens, and the latter by its inherent elasticity becomes more convex, especially as to its anterior surface, and thus enables the focus for a near object to fall upon the retina. The test for the accommodation consists in observing the nearest point to the eye at which the print remains clear. Field of Vision* — The area of more or less distinct vision 28 EXAMINATION OF THE EYE AND ITS APPENDAGES. which is available about the object of fixation (6) {indirect vision) is called the field of vision. The angular distances at which objects can be seen on all sides, or the limits of the field of vision, are approximately : on the temporal side 95 degrees, nasal 65 degrees, above 65 degrees, below 70 degrees. Fig. 4. Field of vision of ri^ht eye as projected by the patient on the inner surface of a hemisphere, the pole of which forms the object of regard : T, temporal, and N, nasal side ; W, boundary for white ; B, for blue ; R, for red ; G, for green. Half-diagram- matic. (Landolt.) Rough estimates may be made by requiring the patient, with the other eye closed, to look steadily at the observer's oppo- site eye at about 1 foot distant, while the points at which the hand or some white object can be followed on all sides are noted and compared with the observer's field. Another method consists in placing the patient before a blackboard oooo 29 Perimeter. The examination may be made with the carrier which moves along the semicircle, or the test-objects may be carried along this by means of dark disks attached to a long handle, each disk containing in its centre the test-object. The pMtient's chin is placed in the curved chin- rest; the notched end of the upright l)ar is brought into contact with the face, directly beneath the eye to be examined, whicli attentively fixes the centre of the semicircle. The other eye should be covered, preferably with a neatly adjusted bandage. The record chart is inserted at the back of the instrument, and, by means of an ivory vernier, the examiner is enabled to mark exactly with a pencil tne point on the chart corresponding to the position on the semicircle at which the patient sees the test-object. The various marks are then joined by a continuous line, and a map of the field is obtained. and tracing with a piece of chalk the limits of the field while the eye is fixed upon a point directly in front. For exact 30 EXAMINATION OF THE EYE AND ITS APPENDAGES. measurements an instrument called the perimeter is employed. It consists essentially of a rest for the chin and a semicircular metal or hard rubber arc of about 1 foot radius, so fixed that when the head is placed in the rest the eye to be examined will be in the centre of the arc. The arc may be turned about on an axis which is a line drawn between the eye and the centre of the arc lying directly in front of and on a level with the eye. By revolving the arc about and passing a white object on it away from the central point, upon which the eye is fixed, the whole field may be covered. The field for one eye is called the monocular field of vision ; the field common to both is called the binocular field. One should observe concentric contraction of the field of vision, irregular contraction, and isolated defects (scotomata). When there is no vision in the defective part of the field, the scotoma is absolute; when the vision is diminished, relative. If one- half of the field is defective, the condition is known as hemi- anopsia. This is due to causes local in the eye or to lesions in the chiasm, optic tracts, optic radiation, or cortex of the occipital lobe. II. Color-sense. — A defect in the color-perception may be either congenital or acquired. In the latter case the defect may be only central (central color scotoma). The best method of testing color-perception is by the use of skeins of colored worsted (Holmgren's test). A red skein is laid on a table, and the patient is required to choose others which resemble it in color. For railroad and marine employees tests are also made with lanterns which show colored lights (Thomson's or Williams' lanterns). Colors are not seen so far from the point of fixation as white — i. e., the field for colors is smaller. Green has the smallest field ; then red, blue, and white in the order named. III. Light-sense is the pow'er of the eye to appreciate varia- tion in the intensity of illumination. An instrument called a photometer may be used in measuring differences of illumi- nation. Diseases such as retinitis may affect the light-sense. Muscles. — Only the external muscles of the eyeball are in- cluded under this caption. Although the methods of detect- mSEASES OF THE LACHRYMAL APPARATUS. 31 ing error of motility will be referred to later, it is well to test the action of the muscles roughly at this point. The excur- sion of each eye, while following the finger in every direction, should be tested and limitations noted (paralysis or paresis). There should be no deviation of either line of vision from the object of fixation (strabismus). If one eye is covered with a card and the other eye fixed upon any object, there should be no deviation of the covered eye, and it should make no movement when uncovered (cover- test for insufficiency). Both eyes should fix upon the same object and the two images should fuse (binocular vision). If both eyes do not fix upon the same object, double images are likely to result (diplopia). QUESTIONS. Describe the method of examining the conducting lachrymal apparatus. State points to be observed in examining the lids, conjunctiva, and sclera. What is oblique illumination ? Give the forms of conjunctival discharge and of congestion of the eyeball. Describe examination of the cornea, anterior chamber, iris, and lens. Explain the four methods of using the ophthalmoscope. Describe the fundus. Give test of tension. Describe method of testing the acuity of vision at distance and at near point. What is the field of vision? How is color-sense tested ? Give superficial tests for the ocular muscles. CHAPTER II. DISEASES OF THE LACHRYMAL APPARATUS. Diseases of the lachrymal apparatus are classified as dis- eases of the secreting and diseases of the conducting por- tions. DISEASES OF THE SECRETING PORTION. The secreting portion consists of the lachrymal gland, in- cluding the accessory gkmd of Rosenmuller. The lachrymal gland is rarely the subject of disease. 32 DISEASES OF THE LACHRYMAL APPARATUS. Acute nonsuppurative inflammation (dacryoadenitis), some- times called '^ mumps," and acute suppuration (abscess), do occasionally occur. It may also be involved in a chronic inflammation, causing hypertrophy. A cystic distention of one of the ducts (dacryops) is also described. Tumors of the lachrymal gland are not unknown — e. g., carcinoma, sarcoma, cysts, tuberculosis, and syphilis. It may become prolapsed downward, when it may be seen and felt. Fistula is of rare occurrence. DISEASES OF THE CONDUCTING PORTION. The conducting portion consists of the punctay canaliculiy lachrymal saCj lackrymal (nasal) duct Malposition or stenosis (atresia) of the puncta or canaliculi may be congenital. The most common condition, however, is displacement of the puncta by turning out of the lids (ectropion), so that they do not lie against the eyeball. This is produced by thickening of the lid in chronic diseases, re- laxation in old age and in facial paralysis, or by cicatricial contraction after traumatism. Foreign bodies, as an eyelash, leptothrix, or calcareous deposits and wounds may occlude the lumen. Symptoms. — The natural result of stenosis or malposition is epiphora — the patient complaining of a watery eye, tears flowing on the cheek, especially in wind or in cold weather. Treatment. — For congenital as well as acquired stenosis treatment is often unsatisfactory. If the punctum alone is affected, it may sometimes be opened, enlarged, or dilated with success. For malposition, due to hypertrophy of the lid, treatment consists in astringent applications to the con- junctival surface, such as nitrate of silver, 1 to 2 per cent, solutions. DISEASES OF THE LACHRYMAL SAC. The lachrymal sac has a small inlet through the canaliculi and an outlet through the nasal duct. Mechanical interfer- ence with the flow of tears from the sac into the nose tends CHRONIC DACRYOCYSTITIS. 33 to distention and disease of the sac. The diseases of the sac are classified as (a) Chronic catarrhal dacryocystitis ; later (6) Acute suppurative dacryocystitis {cibscess of the lachrymal sac) may supervene. CHRONIC DACRYOCYSTITIS. Synonym. — Blennorrhoea of the lachrymal sac. Definition. — A chronic catarrhal inflammation of the mucous lining of the lachrymal sac. Etiology. — The underlying cause is stricture of the nasal duct, usually accompanying nasal diseases, such as catarrh, polypi, or traumatic disturbance of the bone, with damming back of the tears and distention of the sac (mucocele). The stricture is generally either at the upper or the lower end of the duct. The mucous membrane of the sac thus becomes diseased from the presence of the accumulated discharge. Subjective Sjrmptoms. — The patient complains of epiphora and troubles referred to the lids, which come from the ever- present complicating chronic conjunctiv^itis. Objective Ssmiptoms. — The distended sac may be seen and felt as an elastic tumor. When pressure is made upon it, the contents usually pass out through the puncta, or are forced into the nose through the stricture of the nasal duct. The lids are red, swollen, showing more or less discharge at the edge from the conjunctivitis and blepharitis, and the caruncle is swollen. Course. — Such a condition in the sac may exist for years, but abscess is always liable to occur, and the disease does not tend to improve. In long-standing cases necrosis of the ad- joining bone may ensue. Diagnosis. — The epiphora and discharge of mucopurulent fluid through the puncta on pressure over the sac make the diagnosis unmistakable. Palliative treatment consists in the instillation of astrin- gents — e. g.j zinc sulphate (0.3 per cent.) or alum (0.5 per cent.) — immediately after emptying the sac by pressure, and in treating the primary nasal disease especially in the region of o — hi. ii. 34 DISEASES OF THE LACHRYMAL APPARATUS. the opening of the nasal duct. The sac may be syringed with astringent sohitions, such as nitrate of silver (0.5 to 1 per cent.). Operative Treatment. — I. Slitting the canaliculus and cut- ting the stricture in the nasal duct are accomplished as fol- lows : A small, narrow, probe-pointed knife (canaliculus- knife), with a long, slightly curved shank, is introduced usually into the lower punctum. After entering with the point downward, the knife is turned in a horizontal direction and passed along the canaliculus, with the cutting edge in- ward toward the eyeball, while the lid is drawn in the oppo- site direction with the finger and held quite taut. The knife should be passed through the lachrymal sac until it meets the lachrymal bone. With the point pressed against the bone, the handle should be raised until vertical, and the canaliculus thus fully slit, while the point is pushed down through the Fig. 6. Weber's canaliculus-knife. nasal duct into the inferior meatus of the nose. The direc- tion of the knife should be toward the groove between the ala of the nose and the cheek. The injection into the sac of a solution of adrenalin chloride (1 : 10,000) and cocaine hydro- chlorate (2 per cent.) will facilitate the operation by their vaso- constricting action. Immediately after withdrawing the knife the whole tract must be syringed with a mild antiseptic solu- tion, such as boric acid (3 per cent.). The next step consists in passing a probe (usually the largest possible) through the nasal duct into the nose, and allowing it to remain in place for a few minutes. Bowman, Theobald, and Weber probes are the common styles, and they vary in diameter from 1 to 4 mm. To prevent the stricture from reforming, the probing should be continued at first every other day, and later, at longer intervals, for several weeks or months, depending on the character and behavior of the stricture. The operation and ASSCSSS OF THE LACHRYMAL SAC. 36 probing are painful, and the results are not always satisfac- tory, at least as far as the epiphora is concerned, although the slitting of the canaliculus alone will usually prevent danger of abscess. In infants operative measures should be under- taken cautiously, since many cases recover under palliative treatment. II. The introduction into the nasal duct of lead or silver styles which are left in place indefinitely was formerly much practised. III. In obstinate cases and in those where operative pro- cedures on the eyeball are contemplated and infection feared, Fig. 7. Bowman's probes in position. (Reeve.) the sac should be destroyed. It is exposed by a skin incision and cauterized or dissected out. The epiphora is not dis- tressing, but excision of the lachrymal gland has been advo- cated. ABSCESS OF THE LACHRYMAL SAC. Synonyms. — Purulent dacryocystitis ; Phlegmon. Definition. — Acute suppurative inflammation of the sac and surrounding tissues. 36 DISEASES OF THE LACHRYMAL APPARATUS. Etiology. — Chronic dacryocystitis is always the forerunner of abscess. Infection is the immediate cause. Pathology. — The pyogenic germs which are always present in the sac may excite acute inflammation in the sac and walls, with the same pathogenesis as elsewhere in the body. Subjective Symptoms. — The patient who has been troubled with epiphora or dacryocystitis is suddenly attacked with severe throbbing pain in the region of the sac. Objective Symptoms. — The skin becomes red, tense, swollen, and tender. The lids also are swollen, and there may be constitutional disturbances. If not incised, the abscess points and bursts on the skin surface and may leave a permanent fistulous tract connecting with the sac. Diagnosis. — The involvement of the lachrymal sac is estab- lished by the situation of the abscess and the history of epiphora, but the condition might be mistaken for abscess of the lid or for processes involving the bone in the vicinity. Prophylactic treatment consists in treating the dacryocystitis. Active Treatment. — When the abscess is forming, hot fo- mentations or poultices are indicated. When the tumor softens, it should be promptly and freely incised through the skin and the cavity syringed and packed with gauze. The wound is then dressed daily on general surgical principles. If excessive granulations form, they may be treated by scraping or by nitrate of silver stick. When all reaction has subsided, the canaliculus should be slit and the nasal duct probed if possible, in order to prevent recurrence, which is liable to take place. QUESTIONS. What lesions may occur in the secreting portion of the lachrymal apparatus? What are the causes, symptoms, and treatment of malposition or stenosis of the puncta and canaliculi? How are diseases of the lachrymal sac divided ? What are the causes of chronic dacryocystitis ?' What are the symptoms and complications? Describe the palliative and operative treatment. Describe abscess of the lachrymal sac. What results may follow stricture of the nasal duct? DISEASES OF THE LIDS. 37 CHAPTER III. DISEASES OF THE LIDS. BLEPHARITIS MARGINALIS. Synonyms. — Blepharitis ciliaris ; Tinea tarsi ; Blepharo- adenitis. Definition. — A chronic inflammation of the edge of the eye- lids accompanied by congestion, thickening, ulceration, and formation of crusts and scales. Etiology. — The underlying cause is often a conjunctivitis with improper care in cleansing the roots of the lashes where the discharge collects. Errors of refraction are indirectly responsible in some cases. Other causes are improper mode of life, depression in the general health, late hours, smoke, and dust. It complicates lachrymal disease and may follow the exanthemata. Dermatological Classification. — The disease assumes the form oi (a) sehorrhwa, where the sebaceous glands are affected, form- ing scales or yellow crusts ; (h) sycosis, in which case there is suppuration in the hair-bulbs ; (c) eczema, being often asso- ciated with eczema of the face in children. Clinical Classification. — The disease is commonly divided into ulcerative and nonulcerative blepharitis. Ssrmptoms. — The congestion along the roots of the lashes is often the only symptom (hypersemia marginalis). This comes and goes at the least provocation, such as eyestrain, late hours, exposure to wind, etc. In more marked form there will be formation of scales and crusts (squamous blepharitis). In other cases minute pustules (pustular blepharitis) are found, and when these rupture, hard crusts and scabs form, under which ulcerations are found (ulcerative blepharitis). Course. — The disease, which is most common in children, extends over many years and ultimately results in complete loss of the eyelashes (madarosis), with the edge of the lid thickened and everted (tylosis). 38 DISEASES OF THE LIDS. Treatment, which is tedious, consists in correcting errors of refraction, reforming the mode of life, and attending to con- stitutional disturbances. Local Treatment. — Strict cleanliness should be observed. The edges of the lids must be washed with soap and water or solutions of borax or bicarbonate of sodium until free from crusts. Ointments may then be applied, such as the following : ^, Hydrargyri oxidi flavi, 0.15; Petrolati, 10.00. M. et ft. ung. Sig. — Rub on the edge of the eyelids every night. One may also use ointments of hydrargyrum ammoniatum (1 per cent.), hydrargyrum rubrum (1 per cent.), or ichthyol (5 per cent.). In ulcerative cases nitrate of silver solutions (1 to 2 per cent.) or even the stick of nitrate of silver are indicated. When pustules form about the hair-follicles, the cilia should be pulled out. Astringents such as zinc sulphate (0.3 per cent.) or nitrate of silver (1 per cent.) should be used to cure the complicating conjunctivitis. HORDEOLUM. Synonym. — Stye. Definition. — An acute circumscribed suppurative inflam- mation beginning in the glands at the margin of the lid. Etiology. — The presence of blepharitis, disturbances of digestion, impaired vitality, and eyestrain. The immediate cause is infection with pyogenic germs. Pathology. — On account of the numerous glandular struct- ures, the edge of the lid is a favorable place for the entrance of infection. It is also liable to slight abrasions by rubbing. Symptoms. — Itching and burning sensations followed by a red and swollen area at the edge of the lid. Later the abscess forms, points, and discharges. There is often extensive oedema of the lid out of proportion to the size of the lesion. Course. — Styes run their course in from three days to a week or more, and are often repeated one after another. At times CHALAZION. 39 one will not reach the suppurative stage, but become aborted or remain as a hard swelling (" blind stye "). Treatment. — The digestive tract should be treated and con- stitutional treatment instituted. Bits of ice held against the beginning stye may abort it. Ointments of red or yellow oxide of mercury (1 per cent.) may be applied. Later hot fomentations will encourage suppuration. Early incision will cut short the course. CHALAZION. Synonyms. — Tarsal tumor ; Meibomian cyst. Definition. — A chronic affection of the Meibomian glands with the formation of a hard swelling in the lid. Fig. 8. Chalazion. (Reeve.) Etiology. — Chalazia are regarded by some as due to infec- tion, but in many cases the direct cause is the stoppage of a Meibomian duct and the accumulation of discharge in the gland. Pathology. — The process seems to be a chronic inflammation with the production of granulation-like material originating in the Meibomian gland. Under the microscope these tumors 40 DISEASES OF THE LIDS. in the typical stage show scant connective-tissue stroma with many round cells and without true capsule. Subjective Symptoms.— The patients usually have little com- plaint except on account of the appearance of the swelling. The inflammatory symptoms which may occur at the begin- ning and the roughened condition of the lid occurring later may create more or less irritation. Objective Symptoms. — A chalazion appears as a round or elongated tumor varying in size up to that of a walnut. It is firmly adherent to the tarsal cartilage with the skin usually freely movable over it. On the conjunctival aspect a dark spot generally shows in the tarsus. Course. — A chalazion may begin with symptoms of horde- olum and later lose inflammatory signs, or may appear Fig. 9. Desmarres' chalazion forceps. without inflammation. At times the adjoining tissue is in- volved in chronic inflammatory infiltration. Later the centre of the chalazion breaks down into a clear or yellowish fluid, and the degeneration continues until the whole mass becomes a cyst with thickened walls. Generally the fluid escapes through a spontaneous opening on the inner aspect of the lid. This soon closes, and about it granulations form sometimes as large polypoid masses. Chalazia are likely to be multiple and their course is protracted. They often spontaneously disappear. Treatment. — Hot fomentations may be tried with massage. Radical treatment consists in curetting or in excision. In the former procedure, a vertical incision is made on the inner ENTROPION, 41 or conjunctival side, and the granulation-masses are thor- oughly scraped out with a small sharp- or serrated-edged spoon (Meibomian scoop). The sac refills with blood, which is absorbed in a few days. This operation may require repe- tition. A more satisfactory method consists in making a liberal incision under aseptic conditions through the skin over the tumor parallel to the edge of the lid. The mass may then be dissected out, using the knife and scissors. The chalazion with the region of the lid about it should be clamped oif by an instrument (Desmarres' clamp) consisting of a horn plate and a ring on opposite arms like a forceps. This will pre- vent troublesome hemorrhage and fix the tumor. One or more stitches are generally desirable after the bleeding has stopped. An antiseptic powder, as iodoform or aristol, may be used as a dressing and covered with court plaster. ENTROPION. Definition. — A condition in which the edge of the eyelid is turned inward against the eyeball. Etiology. — The common cause of entropion is cicatricial contraction of the palpebral conjunctiva {cicatricial entropion). This is generally produced by trachoma, but may be due to wounds or burns. Entropion may also be due to a spasmodic condition of the orbicularis of the lower lid in elderly people with lax condition of the soft parts (spasmodic entropion). A similar condition appears in children when there is great photophobia such as accompanies ulcers of the cornea. Symptoms. — The most serious consequence of entropion is the brushing of* the lashes against the eyeball (trichiasis), which leads to irritation and congestion of the eyeball and ulceration of the cornea. Treatment. — For spastic entropion, if temporary, the skin of the lid can be pulled down toward the cheek by adhesive plaster or may be folded by taking a long stitch. In trichiasis with the presence of only a few inturned lashes, these may be pulled out at intervals or destroyed by electrolysis. But in marked cases of cicatricial entropion operative treatment is 42 DISEASES OF THE LIDS. indicated. The simplest method consists in excising an ellip- tical piece of skin of the lid and closing the opening with sutures (Graefe's operation). This procedure is applicable to mild cases, and may also be applied to persistent spastic entro- pion. For marked cases many different operations have been employed. They are for the most part variations of the fol- lowing procedures : An elliptical piece of skin is excised from the lid with the underlying muscle. If there is much in- curving of the tarsal cartilage, a wedge-shaped groove is cut horizontally in the middle of the tarsus and sutures are passed through the skin and cut edges of the tarsus (Streatfeild-Snellen's Fig. 10. Jaesclie-Arlt's operation for trichiasis: 1, intermarginal incision; 2, 3, positions of the second and third incisions, between which the integument is removed. (Czermak.) operation). Instead of grooving the tarsal cartilage, a good effect is obtained by splitting the margin of the lid length- wise, being careful to leave all the cilia and hair-bulbs on the outer flap. This may be left to granulate, but the skin wound is sutured (Jaesche-Arlt's operation). A narrow strip of skin (Hotz) or mucous membrane (Van Millengen) without a pedicle may be fitted into the groove at the lid margin and will attach itself. In connection with the above operations it is of great advantage at times to lengthen the palpebral fissure at the outer canthus (canthoplasty). This is done by a single cut with the scissors and by passing sutures between the cut edges of the conjunctiva and skin. ECTROPION— PTOSIS. 43 ECTROPION. Definition. — A rolling out of the lid — the opposite of en- tropion. Etiology. — This condition is largely due to thickening of the conjunctiva and margin of the lid, or to cicatricial con- traction of the skin following wounds, burns, ulceration, or caries of the orbital margin. It also occurs from relaxation of the lid in elderly persons or in paralysis of the orbicu- laris. Symptoms. — Ectropion is unsightly, exposing as it does more or less of the conjunctiva. Epiphora, chronic conjunc- tivitis, and irritation are complained of. The lower lid is the more frequently affected. Treatment. — When recent, moderate in degree, and due to hypertrophy of the conjunctiva, applications of nitrate of silver (1 to 4 per cent.) to the conjunctival surface may give relief. In advanced and marked cases the hypertro- phied tissue may be excised. When ectropion is due to cicatricial contraction, relief is obtained only from some form of operation. Snellen's operation consists in passing a suture with two needles, each of which is entered inside the lower lid and comes out through the skin on the cheek, leav- ing a loop on the conjunctival surface. The ends are then tightly tied on the cheek, and the cicatricial bands, w^hich result, tend to roll the lid inward. In marked cases a plastic operation, generally by the use of sliding flaps, is necessary in order to relieve the tension of the cicatrix on the lid. Short- ening the palpebral fissure by joining together a portion of the upper and lower lids at the outer canthus (tarsorrhaphy) may be advisable. PTOSIS. Definition. — A drooping of the upper lid. Etiology. — Ptosis may be due to paralysis or insufficiency of the levator palpebrse. It occurs either in the congenital form, when it is usually bilateral, or in the acquired form, when it is generally unilateral. In the latter case especially, it may 44 DISEASES OF THE LIDS. be associated with paralyses of other muscles supplied by the third nerve, such as are due to syphilis or diseases of the brain. There are still other cases due to mechanical causes, such as increased volume of the lid with trachoma, tumors, etc. Forceps injuries at birth are not unknown as a cause. Symptoms. — The upper lid will cover the pupil in marked ptosis, and the patient will attempt to raise the lid by contrac- FlG. 11. Panas' operation : A, A', central sutures ; B, B', lateral sutures. (Nettleship.) tion of the frontalis muscle, holding the head well back, thus giving the characteristic expression. Treatment. — If ptosis is due to paralysis or to mechanical causes, the constitutional and local measures may avail. If the ptosis is permanent, and especially in the congenital cases, operative procedures are indicated. The underlying principle involved in nearly all the operations is the attempt to connect the upper lid more directly with the occipitofrontalis muscle, iNSVniES OF TSE LtDS. 45 and thus exaggerate the action of that muscle in raising the lid. The simplest method (Graefe's operation) is to excise an elliptical piece of skin with the underlying tissue of the lid and suture the cut edges of the wound. The Pagenstecher opera- tion consists in using a suture with two needles, each of wliich is passed from the edge of the lid up under the skin and brought out near the eyebrow. The ends are then tied, and the cicatricial bands, which form along the lines of the sutures, serve to connect the lid with the frontalis muscle. These two methods are applicable only to the mild cases, and are not always highly satisfactory. The Panas method con- sists in dissecting a flap of skin from the upper lid in the Fig. 12. Panas' operation, after. (Nettleship.) form of a tongue which points upward. This is drawn up with sutures underneath the undermined skin of the eyebrow. INJURIES OF THE LIDS. Wounds. — Especial danger attends wounds of the lids from the fact that disturbance in their function of covering the eyeball is serious. All wounds should be carefully sutured on 46 DISEASES OF THE LIDS. both the conjunctival and skin side. They heal kindly, as a rule. Burns. — When extensive, burns are likely to cause contrac- tions and adhesions, resulting in entropion, ectropion, or sym- blepharon. MISCELLANEOUS DISEASES OF THE LIDS. Emphysema. — An inflation of the subcutaneous tissue of the lids with air takes place when air is forced through a fracture of the walls of the orbit, which establishes a communication with the nose or accessory sinuses. The appearances are those of simple oedema, but a peculiar crackling sensation is experi- enced on palpation. The history of an injury and violent blowing of the nose confirm the diagnosis. It disappears under a bandage. Ecchymosis (Black Eye). — The settling of blood in the lid after contusion is favored by the loose subcutaneous tissue. In fractures at the base of the skull it occurs in the lower lid. Treatment. — Ice applications in the first few hours should be followed by hot fomentations. CEdema of the lids is a symptom common after injuries, insects' bites, inflammatory action, like hordeolum or dacryo- cystitis, and occurs as angioneurotic oedema, from urticaria, in myxoedema, nephritis, cardiac disease, or is idiopathic. It may be associated with severe conjunctivitis and deep-seated inflammations of the eyeball and orbit. Abscess of the Lid. — Generally traumatic. Should be in- cised when pus has formed. Syphilis only rarely appears on the lids. It may occur as chancre, mucous patch of the conjunctiva, gumma, or tertiary ulcer. Lupus is found on the lid, and vaccine ulcers are de- scribed. Blepharospasm is an involuntary contraction of a part or whole of the orbicularis muscle. Varieties. — It occurs as clonic or tonic spasm. In its sim- TUMORS OF THE LID. 47 plest form it appears as a fibrillary twitching of a part of the lid which sometimes annoys and alarms the patient. It may take the form of continual winking (nictitatio). This usually occurs in children as the result of irritation from the con- junctiva and is often choreic in nature. Spasmodic contractions of the orbicularis are also associated with tic douloureux, or may be of hysteric origin. Blepharospasm may also appear in diseases producing irri- tation, such as phlyctenular keratitis. Lagophthalmos is a condition in which the lids can not be completely closed, and is due to exophthalmos, injuries, par- alysis of the orbicularis, or contractions of the lid. Phthiriasis Ciliorum. — Pediculi pubis occasionally deposit eggs on the lashes and the insects themselves will be found buried in the lid margin. Diseases of the Skin of the Lid. — The skin is the seat of various diseases, such as erythema, eczema, erysipelas, herpes zoster, and syphilis. Epicanthus is a congenital deformity in the form of a fold of skin which extends from the inner end of each eyebrow to the side of the nose, covering the inner canthus and giving the appearance of a very broad bridge of the nose. It may be accompanied by ptosis. Treatment consists in removing a piece of skin from the bridge of the nose. Coloboma of the lid is a congenital defect of rare occur- rence. It is a cleft in the lid similar to cleft-palate and hare- lip. It may also be traumatic origin. TUMORS OF THE LID. Varieties. — Beside chalazion and hordeolum a number of benign tumors are found on the lid, including verruca (wart), molluscum contagiosum, xanthelasma, dermoid cysts, milia, vascular tumors, cutaneous horns, and small transparent cysts at the edge of the lids (glands of Moll). Molluscum contagiosum appears as a rounded elevation formed by the hypertrophy of a sebaceous gland and duct. 48 DtSEAsm OF WE LWS. On top will be found a pit out of which cheesy material may he pressed. They sometimes reach a considerable size. Xanthelasma is a chamois-skin-colored, flat, slightly ele- vated tumor of connective tissue with fatty degeneration involving the whole skin. It occurs usually on the upper lid of elderly persons. It should be thoroughly excised and the wound closed with sutures. Vascular Tumors. — Angiomata in the form of nsevus tel- angiectasia or cavernoma should be treated by electrolysis or excised. Malignant Tumors. — Sarcoma is rarely seen. Carcinoma in the form of rodent ulcer is found in elderly individuals. It begins as a small elevation, which breaks down into an ulcer, perhaps at first not malignant. The ulceration increases indefinitely, sometimes healing in places. Treatment. — Thorough excision, going well into the healthy tissue, should be practised unless the condition has advanced too far. It is often necessary to replace parts of the lid which are thus sacrificed by sliding flaps or by flaps with pedicle from the forehead, cheek, or temple (blepharoplasty). The use of caustics should generally be avoided. The A^-ray, Fin sen light, and radium promise usefulness in certain of these cases. QUESTIONS. Name the principal diseases of the lids. Mention the varieties and treatment of blepharitis marginalis. State the differential diagnosis between hordeolum and chalazion. Give the treatment for each. What are the causes of ectropion and entropion, and the treatment of each ? Define and state the causes and treatment of ptosis. Wliat conditions of the lids are due to traumatism ? Mention the common benign and malignant tumors of the lids. Describe forms of blepharospasm. Define lagophthalmos, epicanthus, and coloboma. To what cutaneous affections may the lids be subject? DISEASES OP THE COMtlNCTlVA, 40 CHAPTER IV. DISEASES OF THE CONJUNCTIVA. CONJUNCTIVITIS (OPHTHALMIA). Classification. Conjunctivitis Catarrhal . | Au"^*'- I Chronic. pi, J Ophthalmia neonatorum, \ Gonorrhoeal conjunctivitis. Granular. . Trachoma. Phlyctenular. Membranous I ^™"irV ( Diphtheritic. ACUTE CATARRHAL CONJUNCTIVITIS. Synonyms. — Acute mucopurulent conjunctivitis ; Acute con- tagious conjunctivitis ; " Pink-eye.'^ Definition. — An acute catarrhal inflammation, especially of the palpebral conjunctiva, characterized by congestion, swell- ing, and mucopurulent discharge. Etiology: — Exposure to wind, dust, and smoke, or presence of irritating foreign substances. Koch- Weeks bacillus, pneu- mococcus, streptococcus, staphylococcus, and Morax-Axenfeld diplobacillus are responsible for infection in different cases. It may be associated with the exanthemata. Occurs in epi- demic form, especially in spring and fall. Varieties. — A number of varieties exist, but clinically they may be classed under two heads : simple and infectious^ the latter being generally due to the Koch- Weeks bacillus and called acute epidemic conjunctivitis. Subjective Symptoms. — Patients complain of stiffness of the lids, photophobia, epiphora, burning, and sensations of a for- eign body. There is no actual pain, but considerable discom- fort, especially in the evening. Objective Symptoms. — The lids are swollen and red. The 4— E. E. 50 DISEASES OF THE CONJUNCTIVA. conjunctiva of the globe is more or less deeply congested, and that of the lid is thickened, congested, and rough. Occasionally there are subconjunctival hemorrhages. The mucopurulent discharge is collected at the roots of the lashes or lies on the surface of the conjunctiva. The lids are stuck together in the morning. The vision is only slightly affected by the mucous discharge on the surface of the cornea, which is otherwise clear, although minute ulcerations of the cornea are occasion- ally seen. Diagnosis is easily made by the presence of mucopurulent discharge, deep congestion involving the conjunctiva (espe- cially palpebral), clear vision, and absence of pain. Differen- tial diagnosis will be found under the head of acute glau- coma. Course. — The disease usually attacks one eye a few days in advance of the other. The first stage of congestion lasts a few hours or a day, and is followed by the stage of discharge, which continues a few days to a week or more. Most cases recover quickly, but the greatest danger is in chronic con- junctivitis and blepharitis remaining as sequelae. Prophylactic Treatment. — As epidemic conjunctivitis is con- tagious, and often attacks a whole family, the promiscuous use of towels, etc., should be avoided. Active Treatment. — In the first stage applications of gauze or cotton taken directly from ice are indicated, together with a wash, such as boric acid solution (3 per cent.), chlorine water (50 per cent.), or formaldehyde (1 : 5000). In addition to this, when the discharge appears, astringents are called for, such as applications of nitrate of silver (1 per cent.). An efficient prescription is as follows : 1^ Zinci sulphatis, 0.10; Alum, 0.15; Aqua? destill., 25.00. M. Sig. — One drop into eye twice or three times a day. The lids should be anointed with vaselin at night to pre- vent sticking with discharge. The common practice of apply- CHMONIC CATARRHAL CONJUNCTIVITIS. 51 ing poultices of tea-leaves or bread and milk is to be con- demned, and the eyes should not be bandaged. CHRONIC CATARRHAL CONJUNCTIVITIS. Definition. — A chronic catarrhal inflammation usually con- fined to the palpebral conjunctiva. Etiology. — May follow an acute conjunctivitis. It is caused by dusty atmosphere, night work, and late hours ; may be due to eye-strain from errors of refraction or improper use. It may be associated with nasal catarrh or with constitutional disturbances, such as rheumatism and gout. Subjective Symptoms. — There is complaint of burning, smarting, itching, sensations of a foreign body, blurring, lachrymation, photophobia, dryness, heaviness, sleepiness, and discharge, which sticks the lids together in the morning. Objective Symptoms. — The palpebral conjunctiva varies in appearance from slight injection to deep congestion, and the surface may be studded with granulations or cheesy deposits (lithiasis), and be more or less thickened. The edges of the lids are hypersemic, and there is watery or mucopurulent dis- charge, with excoriations of the skin, especially at the outer and inner canthus. Occasionally a white flocculent discharge will be found, which is chemically a soap, with sodium as a base. Course. — The disease, which is extremely common, runs a protracted course, being subject to exacerbations at intervals. Both eyes are usually aflPected. Systemic Treatment. — Unfavorable conditions should be corrected. Local measures consist in the use of astringents. In mikl cases boric acid in saturated solution, zinc sulphate (0.3 per cent.), alum (0.5 per cent.), tannic acid (1 per cent.), chlorate of potassium (0.3 per cent.), tine, opii (50 per cent.), or pro- targol (5 per cent.), may be tried. In marked or obstinate cases applications of silver nitrate (1 to 2 per cent.), every day or every other day, are indicated. Daily application of alum crystal is an excellent remedy. ^N^asal catarrh should 62 PTSEASES OF THE CONJUNCTIVA. be treated. The disease Is often intractable, and frequent changes in treatment are desirable. CHRONIC FOLLICULAR CONJUNCTIVITIS. Synonym. — Follicularis. Definition. — A chronic disease of the palpebral conjunctiva, characterized by the presence of hypertrophied follicles, with few or no inflammatory signs. Etiology. — Common in youth, especially in strumous chil- dren who live under unfavorable hygienic surroundings. It may be infectious. Pathology. — The " follicles '' are masses of lymphoid tissue resembling true trachoma granules. Subjective symptoms are those of mild, chronic catarrhal conjunctivitis. Objective Symptoms. — The granulations appear as small, round, pale elevations, confined to the fornix and nasal por- tion of the lower lid, and to the conjunctiva at the edge and over the extremities of the tarsal cartilage of the upper lid. Diagnosis. — Follicular conjunctivitis is difficult at times to differentiate from trachoma, and is regarded by some as be- longing to the same category. (See Trachoma.) Treatment is the same as for simple chronic conjunctivitis. OPHTHALMIA NEONATORUM. Synonyms. — Purulent conjunctivitis in the infant; Acute blennorrhoea ; Gonorrhceal conjunctivitis in the new-born. Definition. — A severe conjunctivitis in the new-born, usually due to the gonococcus of Neisser and characterized by puru- lent discharge. Etiology. — While mild cases of conjunctivitis in the new- born may be occasioned by less virulent forms of infection from the parturient canal or from outside causes, and are generally classed under this head, the majority of the severer cases are due to gonococcus infection. Symptoms. — The first symptoms are swelling and redness, y OPHTHALMA NEONATORUM. 53 usually of both eyes, occurring the second or third day after birth. Very soon the discharge begins to appear, and shortly becomes creamy pus, which runs from the eye when the swollen lids are parted. As the disease advances the con- junctiva of the lids is thickened, red, and velvety, and that of rhe eyeball is oedematous. Complications. — If the pus is allowed to remain in the con- junctival sac, the cornea may become hazy and ulcers appear. if an ulcer perforates, the iris is likely to be caught in the opening and in the resulting scar (adherent leucoma). The cornea, weakened by inflammation, may later bulge and pro- duce anterior staphyloma. Or, the whole eye may become involved in an inflammation which results in its destruction. Course. — The disease lasts from two to six weeks, often leaving chronic conjunctivitis. Prognosis. — If seen before corneal ulcerations set in, the vast majority of these cases recover. Treatment. — Ophthalmia neonatorum is a prolific cause of blindness, and its nature, prevention, and treatment should be thoroughly understood. Prophylaxis. — In public institutions and at times in private practice the Crede method should be employed. It consists in dropping a 2 per cent, solution of nitrate of silver into the conjunctival sac of the infant at birth. Salt solution should be used immediately afterward. Tlie frequency with which an active catarrhal conjunctivitis foUow^s the use of 2 per cent, solutions of nitrate of silver has led to the employment of 1 per cent, strength in the hands of many observers. The prophylactic value is equally great and the undesirable secon- dary catarrh of the conjunctiva is much less common than with the original CrMe strength. Such practice has greatly reduced the percentage of ophthalmia neonatorum in lying-in hospitals. It is well also to douche the vagina and cleanse the eyes of the new-born with a mild antiseptic solution, such as boric acid (3 per cent.). Active Treatment. — When the disease is established, ener- getic treatment should be instituted. The lids should be gently separated and the discharge flushed out with distilled 54 DISEASES OF THE CONJUNCTIVA, water, salt and water, boric acid solution (2 to 3 per cent.), or permanganate of potassium (1 : 3000), care being taken not to touch the cornea with the cotton or dropper. Cleansing must be done at least every hour, day and night. Squares of folded gauze or masses of absorbent cotton should be taken cold from a block of ice and laid over the eyes and constantly changed. The conjunctiva should be brushed with a 2 per cent, solution of nitrate of silver and neutralized with salt solution once every day. Protargol or argyrol (5 to 25 per cent.) may be substituted. The generous use of vaselin be- tween periods of cleansing is an excellent procedure. In corneal complications atropine (1 per cent.) may be necessary. Attentive nursing is the greatest desideratum. The attend- ants should be warned of the contagious character of the dis- ease for their own protection. GONORRHCEAL CONJUNCTIVITIS. Synonyms. — Blennorrhoea ; Purulent conjunctivitis in the adult. Definition. — A severe and serious purulent inflammation of the conjunctiva due to the presence of the gonococcus. Etiology. — The gonococcus of Neisser. It is not difficult to see how the conjunctiva may be infected by the patient. That the disease is not more prevalent must be due to the normal resisting power of the healthy conjunctiva. A separate class of cases resembling this disease is a purulent conjunctivitis in young girls with vaginal discharge which is not gonorrhoeal. Symptoms. — The patient, who generally has a gonorrhoeal urethritis, presents himself with great swelling and tension of the eyelids, more or less purulent discharge escaping between the lids. The conjunctiva is swollen and thickened. There is little pain but great discomfort. The cornea soon shows infiltration, and ulcers form. These perforate, leading to destruction of the eye or at best deep corneal opacities. Course. — One eye is usually first affected and the other only escapes by careful protection. The disease lasts from two to six weeks and leaves a chronic conjunctivitis with TRACHOMA. 55 thickened granular and congested conjunctiva (chronic blen- norrhoea). Prognosis is decidedly grave. The majority of the well- established cases result in loss of or in serious damage to the eye involved. Prophylactic Treatment. — Individuals with gonorrhoea should exercise the greatest care to prevent infection of the eyes. The healthy eye must be covered by a watch-glass framed with surgeon's plaster and closely applied about the eye (BuUer's shield). Active treatment of the disease is entirely similar to that of a severe case of ophthalmia neonatorum. Metastatic Gonorrhceal Conjunctivitis. — Cases of gon- orrhoeal urethritis complicated by systemic infection mani- festing itself as arthritis may suffer from conjunctivitis of metastatic origin. There is little or no discharge, but small corneal ulcers sometimes appear. TRACHOMA. Synonyms. — Granular conjunctivitis; Granulated lids; Egyptian ophthalmia. Definition. — A moderately contagious disease in which the palpebral conjunctiva is occupied by new tissue, usually in the form of small elevations, which after a prolonged exist- ence pass over into cicatrices. Etiology. — The disease belongs to the lower classes, among whom sanitary conditions are poor and cleanliness is not strictly observed. It is not unlikely that the origin of the disease is a microorganism, but its existence has not been established. It is more common among certain races — e. g., Jews and Irish. Pathology. — The trachoma granulations are composed of lymph-corpuscles with scanty connective-tissue stroma and incomplete capsule. They are imbedded in the conjunctiva. Trachoma is commonly classified as follows : I. Papillary trachoma, in which the conjunctiva is hyper^ 66 DISEASES OF THE CONJUNCTIVA. trophied and folded, forming granulations (papillae) especially over the tarsal cartilages. The appearance is velvety or coarsely granular. This form occurs also after blennorrhoea and from other causes. It is not, properly speaking, true trachoma. II. Granular, follicular, or true trachoma, appears as round, transparent bodies (granules, trachoma follicles), especially in the fornices. Each granule is a mass of lymph-corpuscles, without true capsule. III. Mixed form, where the two are associated. This is the most common. Symptoms. — The disease is divided into three stages ; I. Onset. II. Full development. III. Cicatrization. Fig. 13. Typical granular lid and beginning cicatrization, with pannus. (Berry.) I. The onset may be acute^ subacute^ or chronic. a. Acute Onset (Acute Trachoma). — An uncommon form, in which there are rapid swelling, redness, and irritation of the lids. The conjunctiva is much thickened, red, and granular (papillae), and there is considerable mucopurulent or purulent discharge. This condition resembles severe acute conjunctivi- tis, or even gonorrhoeal conjunctivitis. 6. Subacute Onset. — The conjunctiva is moderately swollen, deeply congested, and roughened. As the swelling disappears the true granules are seen. TRACHOMA. 67 c. Chronic Onset (Noninflammatory Trachoma). — There is little or no discomfort. The lids may appear slightly swollen. On everting the lower lid masses of granulations roll out from the fornix, and the upper lid shows a tarsus covered with granulations, and the retrotarsal fold will be found filled with traclioraatous masses. Congestion is usually absent. II. Stage of Full Development. — The disease usually as- sumes the mixed form with papillae and granules. There is considerable irritation, lachrymation, photophobia, and slight mucopurulent discharge. The tarsal cartilages are covered with coarse and fine granulations, and the fornices are filled with trachoma masses. The conjunctiva is moderately con- gested and thickened. This condition may exist for years with exacerbations, but gradually passes over into the cicatri- cial stage. III. Stage of Cicatrization. — White or bluish areas or lines (cicatrices) begin to appear among the granular masses, and by degrees the conjunctiva presents a shining surface streaked with white cicatricial bands. The fornices are practically obliterated in extreme cases, and the conjunctiva becomes dry (xerosis). During the periods of full development and tmnsition complications make their appearance. Palpebral Complications. — The inevitable contraction which follows when granulation-tissue is converted into cicatricial tissue is accompanied by disastrous results in the eye, for the shrinking of the inner surface of the lids bends the tarsal cartilage and rolls the margin of the lid inward (entropion), and the lashes sweep over the cornea (trichiasis). Corneal Complications. — A superficial vascular keratitis (pan- nus) appears w^ith ulcerations and infiltration, especially on the upper half of the surface of the cornea, with bloodvessels running down over the cornea from the conjunctiva above. Pan n us may cover the whole cornea and leave dense opacities seriously affecting the vision. Ulcers may be deep and per- forate. Deeper complications may appear in the form of iritis, cyclitis, and even panophthalmitis, from which phthisis bulbi results. 58 DISEASES OF THE CONJUNCTIVA. Course. — Trachoma is essentially a chronic disease, often beginning in youth and continuing for years. . Differential Diagnosis. — Chronic follicular conjunctivitis and trachoma sometimes resemble each other. The former occurs in youth. The granulations are small, round, in rows, occur- ring especially on the nasal half of the conjunctiva of the lower lid and edge and extremities of the cartilage of the upper lid. The disease is amenable to treatment and the granulations disappear without leaving a trace. Trachoma, on the contrary, is a progressive disease, lasting for many years. The granulations are, as a rule, larger, less prominent, more uniformly distributed, and at last disappear, leaving cicatrices. Prophylactic Treatment. — Children in schools and asylums should be protected against this common contagious disease. Individual towels and handkerchiefs should be provided, and cleanliness enforced. Cases should be, to a certain extent, isolated. Medicinal Treatment. — The sovereign remedy is sulphate of copper. The crytals should be rubbed over the diseased portion of the lids every day or every other day, not forgetting to go well under the tarsal cartilage into the retrotarsal fold of the upper lid. The eyes should be immediately bathed with cold water. Nitrate of silver (1 per cent, solution) is a good substitute for short periods. If applied too long, it will cause permanent staining of the conjunctiva (argyrosis, argy- ria). Tannin and glycerin (60 grains to the ounce) is of slight value. Also, mercuric chloride (1 : 1000) may be used. Applications of yellow oxide of mercury ointment (1 per cent, for home treatment) are useful in later stages. Atropine may be necessary in corneal and iridic complications. Surgical treatment consists in mechanically crushing the granulations. The roller-forceps of Knapp is generally used for this purpose. The granulations are caught between two grooved rollers and their contents squeezed out, as in a wringer. The operation should be thoroughly performed under a general anaesthetic. The lids should be treated with applications of copper sulphate for some time after the expres- PHLYCTENULAR CONJUNCTIVITIS. 59 sion. The operation is indicated in noninflammatory trachoma and in many cases with well-marked granulations. Other for- ceps sometimes employed are those of Noyes and Prince. Grattage is a method in which the granulations are broken by rnbbing with a stiff tooth-brush. It should be used with care. PHLYCTENULAR CONJUNCTIVITIS. Synonyms. — Scrofulous ophthalmia ; Eczematous conjuncti- vitis. Definition. — A disease characterized by the development of small papules or pustules on the bulbar conjunctiva. Etiology. — The disease occurs in strumous children and in those w^ho are ill-fed. It is allied to eczema in its nature and often is associated with it on the face. It is rarely seen in the adult. It is commonly accompanied by nasal catarrh. The same lesions occur on the cornea (phlyctenular keratitis). It is probably due to a micro5rganism. Subjective Symptoms. — The child complains very little if the phlyctenules are not near the cornea. There is some pho- tophobia, irritation, and lachrymation. Objective Symptoms. — On the bulbar conjunctiva will be found one or more elevations in the form of papules or pus- tules surrounded by a circumscribed area of congestion. Later the pustules may break down and form ulcers. A favorite site is at the margin of the cornea. It is then clinically known as phlyctenula marginalis. Phlyctenules often form in rapid succession, each lasting a week or more. Relapses are common. General Treatment. — Since this disease is a manifestation of constitutional derangement, tonics such as iron, quinine, and cod-liver oil are indicated. Proper food, exercise, and fresh air are prescribed. Local Treatment. — Once or twice a day a small quantity of yellow oxide of mercury ointment (1 per cent, in vaselin) should be placed inside the lids and thoroughly rubbed about w^ith the lids closed. Atropine (0.5 per cent, solution) should 60 DISEASES OF THE CONJUNCTIVA, be ordered if the cornea is affected. Calomel may be dusted into the eye. The nose should receive appropriate treatment. MEMBRANOUS CONJUNCTIVITIS. Membranous conjunctivitis is a rare disease. Two forms are described under the heads of croupous and diphtheritic. Croupous conjunctivitis is the more common variety, and may occur as a complication in severe forms of conjunctivitis in children, complicating infectious diseases, or as the result of superficial burns. It presents a membranous deposit which if removed leaves a bleeding surface. Treatment is same as for gonorrhoea! conjunctivitis. Diphtheritic conjunctivitis is a rare affection due to the Klebs-Loeffler bacillus. The reaction may be comparatively slight but usually the lids are greatly swollen, reddened, tense, and stiff. A dirty yellow diphtheritic membrane is found on the conjunctiva when it is possible to evert the lids. Constitutional symptoms of diphtheria are present. The necrosis following the infiltration of the conjunctiva results in a granulating surface which cicatrizes and deforms the lid. The cornea and whole eye are likely to suffer. Treatment. — Cases should be isolated and the other eye pro- tected. Diphtheritic antitoxin should be employed. Locally the treatment is the same as for gonorrhoeal conjunctivitis. INJURIES OF THE CONJUNCTIVA. Foreign bodies frequently lodge on the palpebral con- junctiva. Wounds and burns with lime, acids, or metals occur. The contraction which follows extensive destruction of the conjunctiva, or the uniting of adjacent surfaces of the conjunctiva of the eyeball and lid, produces adhesions which are known as symblepharon. It may be partial at the fornix or in the form of bands, leaving the fornix free, or it may completely unite the lid to the eyeball. MISCELLANEOUS DISEASES OF THE CONJUNCTIVA. 61 Treatment. — If symblepharon is simply cut and the lid freed from the globe, it is impossible to prevent recurrence. Sliding flaps of healthy conjunctiva should be made to cover the cut surfaces and prevent reattachment. Flaps of skin or mucous membrane without a pedicle are rarely successful. The most favorable cases are the bands which allow a probe to be passed around through the fornix. MISCELLANEOUS DISEASES OP THE CONJUNCTIVA. Spring Catarrh. — Synonyms. — Vernal catarrh; Spring catarrh ; Saemisch spring catarrh ; Conjunctivitis sestiva. Definition. — A peculiar, uncommon disease characterized by the presence of nodular masses about the periphery of the cornea and extending a little on to it, associated with hard, flat, pale granulations on the conjunctiva of the upper lid. Etiology is unknown. Symptoms. — The disease appears either with circumcorneal lesion or granulations on the lid alone or both together. It usually occasions very little discomfort except some irritation, photophobia, and sensation of a foreign body. It occurs in the spring, summer, and autumn, but nearly or entirely disap- pears in the winter. As the corneal lesions are all confined to the periphery they do not affect the vision, and after recovery usually no traces are left. Treatment is unsatisfactory except in relieving irritation. Xerosis is a term applied to two different affections. The name is used to designate : I. The condition of dryness seen in advanced cicatricial contraction of the conjunctiva such as occurs after the ravages of trachoma (atrophy of the conjunc- tiva, parenchymatous xerosis). Treatment of this condition is of no avail. The term also applies to : II. A disease which shows white plaques on the surface of the bulbar conjunctiva (epithelial xerosis), due probably to the presence of xerosis bacillus. This membranous, greasy appearing deposit may be scraped off. In infants (infantile xerosis) it is associated with maras- 62 DISEASES OF THE CONJUNCTIVA. mils and usually complicated by indolent ulcers of the cornea. These latter cases always end fatally. Treatment in adults consists in scraping off the membrane and applying antiseptics, such as mercuric chloride (1 : 1000). Pterygium. — Definition. — A superficial membranous growth having its base near the inner or outer canthus and extending with its point toward the centre of the cornea. Etiology. — This growth is formed of hypertrophied con- junctival tissue and thought in some cases to be an extension of the Pinguecula (page 63). Symptoms. — The patient complains very little except when the pterygium is well advanced toward the centre of the cornea and astigmatism is produced or the vision cut off. "^^^^^]^V^-^"^ Pterygium. (Fnchs.) The wing-like membrane occurs most often on the nasal side, may be on the temporal, but is very rare above or below. When progressive, it is thick and somewhat congested. When nonprogressive, it is dry, thin, and nonvascular. Pseudopterygium is somewhat similar in appearance, but produced by burns or ulcers. Course. — It extends over many years and may sponta- neously cease advancing at any time. MISCELLANEOUS DISEASES OE THE CONJUNCTIVA, 63 Treatment. — Surgical treatment is necessary. If the pte- rygium is dissected off the cornea, which may readily be done, and then cut off, it will recur. It is necessary to cover the loss of tissue on the conjunctival surface with a conjunctival flap which will extend to the edge of the cornea. An effec- tive method (transplantation) consists in dissecting off the pterygium from the cornea and sclera, leaving the base attached and burying its apex beneath the undermined con- junctiva below. Pinguecula is a small yellow elevation in the ocular con- junctiva usually on the nasal side and near to the cornea. It is a hyaline degeneration of the conjunctiv^a and is of common occurrence in middle and late life. Occasionally it becomes inflamed. No treatment is required. Tuberculosis of the conjunctiva is uncommon. Primary lesions have been recorded. Secondary affections in the form of nodules or ulcerations occur and are occasionally asso- ciated with nasal disease. Parinaud's disease somewhat resembles tuberculosis of the conjunctiva. It is accompanied by enlargement of the pre- auricular and cervical glands with constitutional symptoms. It is a rare disease. Syphilis of the Conjunctiva. — Chancre and Gumma are of rare occurrence. Amyloid conjunctivitis is characterized by waxy masses in the fornix. Ecchymosis of the conjunctiva is extravasation of blood beneath the conjunctiva due to rupture of bloodvessels. Caused by traumatism, paroxysms of coughing, as in whoop- ing-cough, and spontaneously in elderly persons wdiose blood- vessels are sclerosed. No treatment is necessary. L3rmphangiectasis of the Conjunctiva. — Clusters of transparent blisters in the bulbar conjunctiva due to dilata- tion of lymph-spaces. Chembsis of the Conjunctiva. — (Edema of the bulbar conjunctiva occurring in violent inflammatory conditions of the eye. Pemphigus of the Conjunctiva. — Bullae form, and are 64 DISEASES OF THE CORNEA, followed by cicatricial tissue which destroys the whole con- junctiva. "Essential shrinking" of the conjunctiva is an allied process. The conditions are extremely rare. Tumors of the Conjunctiva. — Cyst, angioma, dermoid, lipoma, fibroma, papilloma, epithelioma, and sarcoma have been described. QUESTIONS. Give the classification of conjunctivitis. Give the differential diagnosis between acute conjunctivitis, iritis, and glaucoma. Describe the treatment of acute catarrhal conjunctivitis. Describe chronic catarrhal and chronic follicular conjunctivitis. Give definition, etiology, symptoms, complications, and treatment of oph- thalmia neonatorum. Describe gonorrhceal conjunctivitis. What are the varieties of trachoma ? Give the pathology, the stages, the complications, and differential diagnosis between trachoma and follicular con- junctivitis? What two forms of membranous conjunctivitis occur? Define spring catarrh, xerosis, pterygium, symblepharon, and Pinguecula. Mention other rarer diseases of the conjunctiva. What microorganisms cause diseases of the conjunctiva? What is the prognosis for the various diseases of the conjunctiva? CHAPTER V. DISEASES OF THE CORNEA. ULCER OF THE CORNEA. Definition. — Superficial loss of substance accompanied by more or less infiltration of adjacent cornea. Etiology.— Depression in the general health is an under- lying cause, or there may be poor nutrition of the cornea itself. Ulcers are more common among the poorer classes. Thev often begin in an abrasion produced by a foreign body. May be associated with diseases of the conjunctiva or lachrymal apparatus. Pathology. — The process is a necrosis of the superficial layers of the cornea due to infection. Among the micro- organisms which have been found are staphylococcus, strepto- VLCER OF THE CORNEA. 65 coccus, pneumococcus, Morax-Axenfeld bacillus, gonococcus, and aspergillus. Varieties. — A broad distinction may be made between simple or nonprogressive ulcers and infected or progressive ulcers. Simple ulcers are small, may follow abrasions with clean foreign bodies, are amenable to treatment and not asso- ciated with deep-seated complications. They are due to some mild form of infection. Infected ulcers, on the contrary, may follow injuries with dirty foreign bodies, often resist all treatment, tend to spread, and are accompanied by complica- tions. They are due to some active form of infection — e. g., pneumococcus. The important clinical varieties are : Phlyctenular ulcer (see Phlyctenular Keratitis). Traumatic idcer. Following abrasions or wounds. Serpent ulcer (Saemisch ulcer). An infected ulcer with advancing crescent-shaped edge. Dendritic ulcer. An infected ulcer branching in shape, and superficial. May be malarial in origin. Ring ulcer. Attacking the periphery of the cornea and sometimes completely encircling it. Indolent ulcer (absorption ulcer). Shows little or no inflam- matory signs. Occurs in the aged, in marasmic infants, and in debilitated subjects. Catarrhal ulcer. Accompanying catarrhal conjunctivitis. Subjective Symptoms. — The patient complains of photo- phobia, lachrymation, sensations of foreign body, more or less pain especially in infected ulcers. There is defect in vision w^hen the ulcer is over the pupil. Objective Symptoms. — The eyeball shows a ring of pink congestion about the cornea (circumcorneal), together with more or less congestion of the conjunctiva. Ulcers vary greatly in appearance, but in general with oblique illumina- tion show a superficial loss of substance in the cornea with a gray opacity (leucocyte infiltration) in the adjacent tissue. The form of the ulcer may be irregular, circular, crescentic, dendritic (branching), or punctate. Course. — Simple ulcers usually heal kindly in a week or 5— E. E. 66 DISEASES OF THE CORNEA. two by throwing off the necrotic tissue and replacing it with connective tissue. Infected ulcers may progress by spread- ing superficially, by undermining healthy tissue with an ad- vancing edge or in branching lines. Or, they may sink Fia. 15. ' *' fl fek H^ K> Corneal ulcer. (Sichel.) deeply into the substance of the cornea and even perforate. Sometimes the progress is by colonies, which break out in all directions. When the healing process has begun, bloodvessels Fig. 16. Hypopyon, seen from the front, and in section, to show that the pus is behind the cornea. (Nettleship.) will often be found running inward from the periphery of the cornea. Complications. — Opacities of the cornea are the inevitable result of filling of the ulcer with connective tissue. The effect on the vision depends on their density and situation. ULCEB OF THE CORNEA. 67 If a deep ulcer perforates into the anterior chamber, there is danger of the iris being caught in the resulting scar, in which case the condition is called adherent leucoma. The cornea weakened by ulceration may later bulge, forming staphyloma, which may or may not contain the prolapsed iris. In infected ulcer a quantity of pus is sometimes seen in the lower part of the anterior chamber (hypopyon). This is com- posed of cells thrown off from the iris and endothelial layer of the cornea as the result of irritation. At times, also, pus will accumulate on the substance of the cornea (formerly called onyx), which may break down into an abscess. Iritis is a common complication of infected ulcers. Iridocyclitis and even panophthalmitis may follow, with destruction and shrinking of the eye (phthisis bulbi). Diagnosis. — The presence and extent of the loss of substance may be visibly demonstrated by the use of a drop of 2 per cent, solution of fluorescin, which stains the exposed area a bright green. An ulcer may be known from an old opacity by the presence of circumcorneal congestion, subjective symp- toms, loss of substance, or roughened surface of the cornea. Preventive Treatment.— After abrasions of the cornea a mild antiseptic should be given in the form of eye-drops — boric acid, saturated solution, or mercuric chloride (1 : 5000). In removing a foreign body aseptic instruments should be em- ployed. Complicating conjunctivitis or dacryocystitis should be treated. Constitutional Treatment. — It is important to treat the gen- eral condition if infected ulcers are associated with debility, syphilis, or improper mode of life. Local Treatment. — Atropine (1 to 2 per cent.) should be instilled three to six times a day. Eserine is sometimes of use, but tends to produce iritis. Hot fomentations, re- peated according to the severity of the case, and an anti- septic should be prescribed, such as boric acid (3 per cent.), permanganate of potassium (1 : 3000), or chlorine water (50 per cent). Indolent, phlyctenular, and healing ulcers should be stimulated by rubbing in the eye yellow oxide of mercury ointment (1 per cent, in vaselin). Calomel or iodoform may 68 DISEASES OF THE GOttNEA. also be dusted into the eye. If there is much irritation, holo- caine (1 per cent.) may be instilled. A pressure-bandage is indicated unless there is much conjunctival discharge. In infected ulcers more energetic treatment is required to arrest the infection. In addition to the above the base and edges should be scraped with the eye under cocaine (5 per cent.), and nitrate of silver (1 per cent.) or tincture of iodine (full strength) should be applied by means of cotton on an appli- cator once a day or once every other day. The actual cautery, such as a red-hot strabismus- hook or electrocautery, may be tried. The application should be in tlie form of numerous punctures at the edge of the ulcer. If hypopyon is present, it is sometimes wise to split the ulcer into the anterior chamber with a knife (Saemisch operation). Dense opacities left after ulcerations are sometimes conspicuous, and may be tattooed by the introduction of India ink with needle-pricks. An artificial pupil may sometimes be made through the iris if the pupil is covered by the opacity. INTERSTITIAL KERATITIS. Synonym. — Diffuse parenchymatous keratitis. Definition. — A chronic inflammation involving the paren- chyma of the cornea, characterized by deep-seated opacities and circumcorneal congestion. Etiology. — The common form of this disease a])pears in children and is due to congenital syphilis. It rarely occurs in acquired syphilis. It has been known to occur in utero. The disease may also be due to malaria, rheumatism, gout, tuberculosis, and rickets, or may be idiopathic. Pathology. — The cornea normally has no bloodvessels, and inflammatory action consists in infiltration of leucocytes, al- though occasionally in this disease a deep-seated vasculariza- tion may take place at the periphery. Subjective Symptoms. — The patients complain of moderate pain, photophobia, and poor vision. Constitutional Objective Symptoms. — Congenital syphilis is usually easily recognized in other parts of the body by char- INTERSTITIAL KERATITIS. 69 acteristic signs, such as the so-called Hutchinson teeth. The incisors of the permanent set are small, furrowed from side to side, peg-shaped, narrowed, and notched at the extremity. The face, especially at the angles of the mouth and forehead, is scarred and wrinkled from early, even intra-uterine, ulcer- ations. The head is large and square. The lymph-glands are enlarged. The bridge of the nose is flat, and there are chronic aural and nasal troubles. Local Objective Symptoms, — The opacities of the cornea may begin at any point, but usually at the periphery as a thin, gray cloud. The opacities spread and often completely cover the cornea, becoming at times a dense white or yellowish and mottled. Deep-seated bloodvessels will enter from the sclera and produce a dense red spot called " salmon patch.'' The surface of the cornea is sometimes dull and rough and " steamy." There is little or no tendency to ulceration, although it is possible for the cornea to weaken and bulge, forming staphyloma. Course. — Both eyes are usually affected, although it may be at different times. The disease occurs between the ages of five and fifteen, though sometimes seen as late as thirty years. It is slow in its course, lasting from two months to a year or more. The opacities clear often to a remarkable degree, but in severe cases the vision is more or less impaired. Relapses are common. Complications in the form of inflammations of the uveal tract (iritis, cyclitis, and choroiditis) often occur in severe cases. Internal Treatment. — Mercury and iodide of potassium, in doses suited to the age of the patient, are indicated, although the cases of congenital syphilis may do as w^ell with tonics, such as iron and cod-liver oil, with out-of-door life. Local Treatment. — Atropine (1 per cent.) should be instilled three times a day during the active period, and hot fomenta- tions applied regularly for at least fifteen minutes four times a day. Stimulation by rubbing in the yellow oxide of mer- cury ointment is of value, if there is not too much irritation. Dark glasses should be worn. Injections of normal salt solu- tion under the ocular conjunctiva (subconjunctival injections) 70 DISEASES OF THE CORNEA. may be tried. In acquired syphilis energetic antisyphilitic treatment is necessary. PHLYCTENULAR KERATITIS. Definition. — The disease is of the same nature and due to the same causes as phlyctenular conjunctivitis. Varieties. — a. Fascicular keratitis. An ulceration whicli presents a curved, advancing edge of infiltration with a bunch of bloodvessels passing to it from the corneal edge. This often continues across the cornea and leaves a row of perma- nent opacities, b. Multiple ulcers, with more or less super- ficial vascularization. Symptoms. — The young patient suffers greatly from photo- phobia and buries the head in the pillow. There is tonic blepharospasm, and the lids are separated with difficulty. Treatment. — Atropine (1 per cent.) t. i. d. Yellow oxide of mercury ointment (1 per cent.) rubbed in at night. If there is great blepharospasm, the face may be plunged into a basin of cold water. Constitutional treatment is the same as for phlyctenular conjunctivitis. STAPHYLOMA. Synonym. — Ectasia. Definition. — A bulging of the cornea or sclera, not due to swelling or thickening of the tissues. Staphyloma occurs in cornese which have been the subject of disease which has weakened their resisting power to internal pressure, such as ulcerations, abscesses, or injuries. It is called partial or total staphyloma depending upon the extent of the cornea involved. When total and very prominent, the lids can not close. The eye is usually blind from previous inflammation, and some- times the eyeball itself is shrunken. Treatment. — For total staphyloma, operation consists in abscission of the protrusion and suturing the edges together ; this is done for cosmetic reasons. The operation is usually safe, although serious inflammation has been known to follow. KERATOCONUS. 71 KERATOCONUS. Synonym. — Conical cornea. Definition. — A peculiar disease consisting in gradual bulg- ing of the transparent cornea into a conical form with the apex at or near the centre. The process may begin at any period of life, but usually in youth, progresses slowly for many years without signs of inflammation, and may become stationary at any time. Symptoms. — The patients complain of increasing defect in vision. On examination, in marked cases the conical form of the cornea is very evident, especially when viewed from the side. In slight cases a reflex from the window is greatly Fk;. 17. Conical cornea. (Dalrymple.) distorted by lengthening on every side from the apex of the protrusion. The change in the curve of the cornea creates a high degree of astigmatism and myopia. A gray opacity may appear at the apex of the cone and ulcerate. Treatment. — The progressive character of the condition must be established by extended observation. If nonpro- gressive, strong cylinders often greatly improve the vision and should be carefully selected. If progressive, treatment should begin at once, and consists in destroying a portion of the cornea at the apex of the cone in the hope that the contraction 72 DISEASES OF THE CORNEA. following will flatten the protrusion. The best method is to burn deeply with the electric cautery, using a small electrode with a flattened end. INJURIES OF THE CORNEA. Abrasions. — The anterior epithelial layers of the cornea are easily torn off by a foreign body. If the object is clean, the cells will reform in a few hours under a bandage. If ih^ abrasion is infected by the foreign body or by bacteria already in the conjunctival sac, an ulcer will result, which may lead to disastrous consequences. The pain, photophobia, and lach- rymation are quite intense after an abrasion, owing to exposure of the nerves. Treatment. — An antiseptic, such as mercuric chloride (1 : 5000) or boric acid (saturated solution), should be pre- scribed and the eye bandaged. Burns of the cornea may be by hot w^ater, steam, metals, acids, and alkalies. If superficial, being aseptic, they heal quickly ; if deep, the scars may affect the vision. Treatment. — Atropine (1 per cent.) and a bandage are indi- cated. FOREIGN BODIES. The cornea, on account of its soft structure and its exposed position, is a favorite lodging-place for foreign bodies, such as particles of dust, cinders, coal, emery, and steel. For the detection of a foreign body it is necessary to use the oblique illumination and sometimes a magnifying-glass in addition. Treatment. — The eye should be thoroughly anaesthetized by dropping in a solution of cocaine (4 per cent.) or holocaine (1 per cent.) twice with ten minutes' interval. The eyelids should be spread apart with the fingers or with a speculum, and the foreign substance picked out of the cornea by the use of a sterilized blunt spud or foreign-body needle. Great care must be exercised not to injure the cornea more than is abso- lutely necessary. Some foreign bodies, especially emery and bits of steel, may be quite deeply buried, and must be attacked carefully yet boldly. If the cornea should be per- MISCELLANEOUS DISEASES OF THE CORNEA. 73 forated and the foreign body lie partly in the anterior cham- ber, it must not be pushed further in. An eye drop of boric acid (saturated solution) should be prescribed and the eye bandaged. PERFORATING WOUNDS OF THE CORNEA. Wounds which open the anterior chamber and allow the aqueous to escape are likely to be complicated by falling in of the iris (prolapse of the iris). If the wound is not ijifected and not too extensive or contused, it will heal in a few days, and when the iris is not prolapsed only a scar will result. This may or may not affect the vision, according to its situation. If there is prolapse of iris, the healing will not be so rapid, and danger of subsequent inflammation will be incurred. A fistulous opening may remain, which may also happen in perforating lUcers. Treatment. — The wound should be cleansed with an anti- septic solution (bichloride of mercury 1 : 5000), which should be continued, together with atropine (1 per cent.) and light pressure-bandage. Ice applications may be employed during the first day or two to control reaction. Treatment of the prolapsed iris is important. If the wound is clean and the case is seen within forty-eight hours of the injury, the iris should be pulled through the wound with iris- forceps and cut off close to the cornea with scissors. The cut edges of the iris must be carefully replaced within the anterior chamber by a spatula. If the wound is infected, the iris should not be cut, since this procedure exposes the tissues to infection, which otherwise they might escape. If the case is over forty-eight hours old, adhesions to the wound have formed, which render separation of the iris difficult, and to leave the cut edges of the iris in the wound opens a path for infection to the interior of the eye. MISCELLANEOUS DISEASES OF THE CORNEA. Superficial Keratitis. — Synonym. — Vascular keratitis. Definition. — A term used to signify a superficial inflamma- 74 DISEASES OF THE CORNEA. tion such as that which complicates trachoma, otherwise known as pannus. It is characterized by the presence of bloodvessels and infiltration on the surface of the cornea. Treatment consists in attacking the trachoma, but in severe cases the bloodvessels may be cut off by scraping the periphery of the cornea, or the galvanocautery may be used for the purpose. Vesicular Keratitis. — A number of diseased conditions of the cornea presenting vesicle formations are classed under this head. Herpes cornese is a peculiar recurrent eruption of small vesicles on the surface of the cornea lasting for a few hours and accompanied by sensations of a foreign body, pain and irritation, which pass away when the vesicle ruptures. It sometimes follows an abrasion or injuries of the cornea. Keratitis Bullosa. — Characterized by large bullae, occur- ring usually in a diseased eye. Herpes Zoster Ophthalmicus. — When herpes affects the fifth nerve, it may attack the cornea as well as the skin of the face. The corneal eruption usually leaves scars. Treatment of vesicular keratitis is in general similar to that of ulcer of the cornea. Filamentous Keratitis. — Shows threads attached at one end to an ulceration. Keratitis profunda is a deep-seated central interstitial keratitis occurring in the adult and sometimes confounded with keratitis of specific origin. The cause is generally un- known, but it may be due to exposure, rheumatism, or malaria. Local treatment is same as for interstitial keratitis. Sclerosing keratitis accompanies scleritis as a dense white permanent opacity resembling the normal sclera. Treatment is the same as for scleritis. Ribbon-shaped Keratitis. — Synonjrm. — Transverse cal- careous film. Definition. — A grayish-white band extending horizontally across the cornea. It is hard to the touch of an instrument, since it contains lime. It occurs in eyes which have been diseased or are degenerated. MISCELLANEOUS DISEASES OF THE CORNEA. 75 Treatment consists in scraping off the film. Neuroparalytic keratitis is due to lesion of the trigeminus which cuts off the nerve-supply of the cornea. Characterized by anaesthesia, ulcerations, and necrosis caused by trophic changes and undetected foreign bodies. Posterior punctate Keratitis. — Synonym. — Descemitis. Definition. — A condition in which minute deposits occur on the lower part of the posterior surface of the cornea in the form of a triangle with the base down. It is a manifestation of disease of the uveal tract — L e., iris, ciliary body, or choroid (see Serous Iritis). Superficial punctate keratitis is characterized by numer- ous small elevated opacities of the anterior layers of the cornea accompanied by congestion and irritation of the eye. Tumors of the cornea are of rare occurrence. They are found mostly at the limbus, and dermoid fibroma, papilloma, epithelioma and sarcoma have been described. Pigmentation of the Cornea. — The cornea may be stained with blood-pigment (hsematin, hsematoidin), or from the pres- ence of iris or steel in the eye (siderosis). Arcus Senilis (Gerontoxon). — A zone of opacity at the periphery of the cornea, but with a narrow zone of clear cornea between it and the sclera. It is a fatty degeneration, and gen- erally found in elderly persons. QUESTIONS. Mention the varieties of corneal ulcers. Give course, complications, and treatment. Describe interstitial keratitis. Describe phlyctenular keratitis. Define other forms of keratitis. Define staphyloma and keratoconus. State rule for treatment of prolapse of iris in perforating wounds of the cornea. What is arcus senilis? What antiseptics are used in treating the cornea ? 76 DISEASES OF THE SCLERA. CHAPTER VI. DISEASES OF THE SCLERA. SCLERITIS. Definition. — A localized inflammation charact€rized by the presence of more or less elevated, congested, and discolored patches in the sclera. Etiology. — The disease occurs in adults who are the sub- jects of constitutional disorders, such as syphilis, rheumatism, malaria, gout, or tuberculosis. It may be idiopathic. Varieties. — Episcleritis: Involves the superficial layers of the sclera. Scleritis proper: Where the whole depth is affected. A clinical variety of episcleritis is a mild recurrent form called episcleritis fugax. The elevated patches of spe- cific origin may be called gummatous scleritis. Sjrmptoms. — I. Episcleritis. There is usually only a moder- ate amount of pain, photophobia, and irritation. A bright-red or violet, slightly elevated patch appears on the sclera not far from the cornea. The congestion is seen to be formed, not alone by the conjunctival vessels, but by those of the sclera underlying. There are frequent relapses. II. Scleritis. This is a more serious form. There may be considerable pain, tenderness, photophobia, lachrymation, and general irritation. There are elevated, red, yellow, or violet areas in the sclera, which, recurring, may extend about the whole cornea. The deeper structures — iris, ciliary body, and adjacent cornea — are often involved. Complications. — Scleritis, iritis, keratitis, and cyclitis — a process affecting the anterior segment of the eyeball — is known as anterior uveitis. When the sclera and cornea alone are affected, it is called sclerokeratitis. The sclera may be thinned by inflammation and bulge from internal pressure, producing staphyloma. Glaucoma may ensue Patches of scleritis leave permanent dark-bluish spots at the site of the lesion, which should not be confounded with congenital pig- mentation. STAPHYLOMA-INJUBIES OF THE SCLERA. 77 Constitutional treatment should be given according to the established cause. In idiopathic cases sodium salicylate, gr. x three or four times a day (although some advocate very large doses), or potass, iodide, gr. x t. i. d., is indicated. Local Treatment. — Hot fomentations. Atropine (1 per cent.), t. i. d. Subconjunctival injections of salt solution or bichloride of mercury (1 : 5000) may be tried. STAPHYLOMA. Definition. — A bulging of the sclera not due to thickening. It occurs after scleritis ; also in diseases of the choroid and ciliary body accompanied by high tension, or in weakening of the cornea or sclera after injury. It appears as dark bluish elevations (sometimes called ectasiae). Posterior staphyloma is a bulging of the sclera about the optic nerve, and is associated with high myopia. (See page 132.) Treatment. — For anterior and equatorial staphyloma with increased tension iridectomy may be indicated ; but if the eyes are destroyed by inflammation and are unsightly or painful, enucleation is necessary. INJURIES OF THE SCLERA. The sclera, with the cornea, is exposed to injury from for- eign bodies. Injuries with blunt objects may produce rupture of the eyeball, which, beside the lacerated wound usually near the cornea, is often accompanied by internal injuries, such as rupture of the iris, dislocation of the lens, detachment of the retina, rupture of the choroid, or intraocular hemorrhage. The eyeball is soft and the vision is seriously affected. Rup- ture of the sclera, without break of the conjunctiva, is pos- sible. Incised wounds, when large, are accompanied by more or less loss of vitreous and prolapse of the ciliary body and choroid. The greatest danger beside that arising directly from the injury is from infection, which may produce an iridocyclitis or panophthalmitis, both of which may end in 78 DISEASES OF THE IBIS. shrinking of the eyeball (phthisis bulbi). When the wound is in a zone occupying about one-fourth of an inch outside the periphery of the cornea (known as the " ciliary region '' on account of the fact that the ciliary body lies beneath it), the injury has a further significance. Such a wound, followed by a chronic iridocyclitis, gives the conditions which may produce sympathetic disease in the other eye — sympathetic ophthalmia. If a foreign body is retained within the eye, the case is further complicated. (See page 118.) Treatment. — Small wounds should be treated with pressure- bandage, an antiseptic (bichloride 1 : 5000), and atropine (1 per cent.). In extensive wounds, say over 10 mm., sutures should be passed through the scleral edges of the wound and others through the conjunctiva. These wounds sometimes heal remarkably well. If the ciliary body or choroid is prolapsed, it should be cut off. When an injury has evi- dently completely destroyed the eye, it should be enucleated at once. QUESTIONS. What are the varieties of scleritis? Describe each. Define staphyloma of the sclera. Give differential diagnosis between episcleritis and phlyctenular conjuncti- vitis. Describe injuries of the sclera and give treatment. CHAPTER yil. DISEASES OF THE IRIS. IRITIS. Varieties. — In point of duration and severity iritis may be divided into acute, subacute, and chronic. As regards etiology, into syphilitic, rheumatic, gonorrhoeal, traumatic, tuberculous, secondary, sympathetic, and idiopathic. On a pathologic basis, into plastic, serous, and purulent. ACUTE PLASTIC IRITIS. 79 ACUTE PLASTIC lEITIS. Definition. — An inflammation of the iris, characterized by congestion, small pupil, and posterior synechiae. Etiology. — The disease occurs in the secondary stage of syphilis — /. e., from the second to the eighteenth month — and is rarely seen in the tertiary stage. Rheumatism is the next most frequent cause. It may occur with gonorrhoeal rheu- matism, but not usually at the same time. It may appear in diabetes, gout, or from traumatism, or may be idiopathic. It may also be secondary to inflammation of adjacent tissues — e. g., in keratitis or scleritis. Pathology. — The iris is congested, swollen, and infiltrated with round cells. There is an exudate of round cells, fibrin, and pigment-cells, which fills the anterior chamber and glues the edge of the pupil and back of the iris to the anterior cap- sule of the lens. Subjective Symptoms. — The patient complains of more or less severe pain in the eye, forehead, and temple, especially in the early hours of the morning. There are fear of light and lachrymation. The vision is affected, and there may be some constitutional symptoms. Objective Sjrmptoms. — On examination the lids are found to be swollen and red. The eyeball shows the typical circum- corneal or ciliary congestion, with some congestion of the con- junctiva. The cornea under oblique illumination is seen to be hazy, and under careful examination the posterior surface will often be found studded with minute dots. The anterior chamber is cloudy, and there may be some deposits in the lower part. Rarely blood may be seen in the anterior cham- ber. The anterior surface of the iris has lost its fine and delicate details. It looks muddy, and has changed to a dirty color as compared with the other eye. The pupil is small, and scarcely moves to stimulus of light. It is more or less filled with cloudy exudate. If a drop of a mydriatic, such as atropine (1 per cent), be instilled, the pupil will show irregular dilatation on account of the fact that at dift'erent points the pupillary edge of the iris is held to the lens by 80 DISEASES OP THE iRtS. exudate (posterior synechise). If these be torn oif by the action of the mydriatic, it is common to find a ring of pig- ment corresponding to the position of the edge of the iris before treatment was begun. On account of the hazy condi- tion of the media the fundus is usually obscured. A form of the disease known as spongy iritis occurs especially after injuries and operations which open the anterior chamber. It is characterized by a gelatinous sharply defined mass of exudate in the anterior chamber, which resembles a partly opaque, dislocated lens. It often disappears with great rapidity. Course. — The disease may occur at any time of life, but is uncommon in children, except as a secondary condition. It begins acutely and lasts from one to six weeks. Prognosis. — When seen early, the prognosis is excellent if proper treatment is carried out. There is a tendency to recurrence. Complications. — If the disease is severe, there may be formed numerous synechiae and more or less deposit in the pupillary area. If the blocking of the pupil is complete, it is known as occlusion ; if the synechise completely bind down the iris yet leave the pupil clear, the condition is called exclusion. In the latter circumstances circulation from behind the iris through the pupil is impeded, and the iris bulges forward into the anterior chamber, except at the pupillary edge ; hence the name crater-shaped pupil (iris bombQ. Glaucoma is likely to follow, and the condition must be relieved by iridectomy. After repeated attacks of iritis the iris may become atrophic and immovable. Cataract may also form. Adjacent tissues may be involved in the inflammatory process, and the condi- tions are designated by the following terms, which are self- explanatory : iridocyclitis, iridochoroiditis, keratoiritis, ante- rior uveitis. (See page 76.) In syphilitic iritis yellow nodules form at the pupillary margin or at the periphery. Gummata may develop in tertiary syphilis. Diagnosis. — The pain, especially at night, the ciliary conges- tion, muddy iris, small pupil, and especially posterior syne- chise establish the diagnosis. u- ACUTE PLASTIC IMIS. 81 Differential Diagnosis. — See Acute Glaucoma. Treatment. — Patients should be kept in a darkened room, and, if the attack is severe, in bed. Constitutional treatment should be instituted according to the cause. Syphilis must be treated energetically with mercury protiodide (^ gr.), bichloride (^V gr-)> inunctions of blue oint- ment, or hypodermatic injections of bichloride. Potassium iodide may also be given (gr. x, increased). In rheumatic cases it is well to give the patient a saline cathartic at the beginning of the treatment, followed by salicylates, such as sodium salicylate, 30 to 60 grains daily. In idiopathic and gonorrhoeal cases salicylates are also indicated. Morphine may be necessary to quiet pain. Local Treatment. — Dry or moist heat should l)e applied. In severe cases leeches may be placed near the outer can- thus. Atropine is most essential (1 per cent, solution), and should be dropped into the eye three to six times a day, depending on the severity of the attack and the ease with which the pupil is dilated. A local toxic effect is sometimes noticed in the form of conjunctivitis, swelling and redness of the lids. In this case scopolamine (1 per cent.) or duboisine (1 per cent.) may be substituted. Atropine also sometimes produces a granular conjunctivitis resembling trachoma (papil- lary conjunctivitis). Disagreeable effects from absorption are at times noticed — dryness of the tongue and constitutional effects, as flushed face, dizziness, and rapid pulse. Small doses of morphine and pilocarpine are then indicated. Chronic Plastic Iritis. — Iritis may assume the chronic form, most commonly in elderly rheumatic subjects. The exacerbations are frequent, but usually not severe ; however, each attack thickens the pupillary membrane, and finally leads to occlusion, glaucoma, and loss of the eye. Under this head may be included the iritis of sympathetic ophthalmia (page 125). Treatment. — Chronic iritis is best treated by atropine, anti- rheumatic remedies, and by making an iridectomy. 6— E. E. 82 DISEASES OF THE lEIS. SEROUS IRITIS. Synonyms. — Keratitis punctata posterior ; Descemitis ; Aquocapsulitis. Definition and Symptoms. — Serous iritis is the term used to describe a condition in which the eye shows only slight ciliary congestion ; numerous deposits of various sizes on the pos- terior surface of the cornea, which occupy the lower half of the cornea in a triangular shape, with the base down at the periphery and the apex at the centre of the cornea ; also a deep anterior chamber and somewhat enlarged pupil. This condition is now known to be a serous inflammation of the uveal tract, including the posterior layer of epithelial cells of the cornea, the iris, ciliary body, and probably the choroid. Treatment. — Atropine must be used with caution, owing to glaucomatous tendencies. General treatment is the same as for plastic iritis. Purulent Iritis. — Purulent iritis is defined as a purulent inflammation, the result of infection, generally following per- forating injuries, but may occur as a metastatic process in infectious diseases; often associated with purulent processes in the deeper structures — choroid and vitreous. Hypopyon is present. TUBERCULOUS IRITIS. Varieties. — Tuberculosis rarely attacks the eye, but may occur in the iris under two forms. I. Isolated tubercles, which appear as yellow tumors usually at the periphery of the iris. They gradually increase in size, with slight inflammatory symptoms. They involve the cornea and deeper structures, finally destroying the eye. Spontaneous absorption has been known to occur. 11. Miliary tuberculosis of the iris is the other form. It presents the signs of acute iritis without much pain. The surface of the iris is studded with small yellow- ish-gray elevations (tubercles). Infiltration of the eye with tuberculous tissue usually supervenes, and the eye is lost. Cases of spontaneous recovery are not uncommon. The dis- ease of the eye is undoubtedly always secondary to tuber- culous deposits in other parts of the body. INJURIES AND TUMORS OF THE IRIS. 83 Treatment is the same as of other forms of iritis, with proper constitutional treatment. Enucleation may be thought ad visible in advancing cases to prevent general infection. INJURIES OF THE IRIS. Concussion of the eyeball may produce a dilatation of the pupil, sometimes irregular. This is due to paralysis of the sphincter pupillse. It generally disappears. The pupillary edge may be torn in the form of one or more rents, or the iris may be separated at the periphery from its root, leaving a clear space (iridodialysis). It may be entirely torn from its attachment (traumatic irideremia). Perforating wounds are usually accompanied by injury of the lens and other structures. Wounds of the cornea are often complicated by the falling in of the iris (prolapse), the treatment of which has been described (page 73). A small foreign body passing through the cornea and iris leaves a perforation which is of diagnostic value in reference to the presence of a foreign body in the eye. The greatest danger from wounds is from infection, which, if it reaches the iris, usually produces purulent iritis. When the lens is dislocated or absent, the iris, being without support, will tremble with every movement of the eye (tremulous iris, iridodonesis). In some injuries, and occasionally after extraction of cataract, with loss of vitreous, a part of the iris may be folded back upon itself, thus enlarging the pupil in that part (retroflexion). TUMORS OF THE IRIS. Apart from the syphilitic and tuberculous tumors of the iris already described, tumors of the iris are of rare occur- rence. Sarcoma, usually melanosarcoma, occurs at any age, but usually in middle life. Melanoma is a benign, nonprogressive pigmented tumor. Cysts. — Transparent or true cysts of the iris may be con- genital, but are usually traumatic. They may occur from the presence of a foreign body (transplantation cyst). 84 I>ISEAS£:S OF THE PUPIL. Differential Diagnosis of Tumors of the Iris. — Tubercles occur in youth at the periphery of the iris, secondary to other tuber- culous disease ; bright yellow or gray color, with an occasional vessel running over the surface ; associated with serous iritis ; gradually infiltrate the surrounding tissues ; may disappear ; rupture through limbus. Gummata. — Occur in middle life in the tertiary stage of syphilis ; dark yellow color at the pupillary edge or at the periphery ; break down or absorb. Sarcomata. — Dark, usually ; middle and late life ; lower part of the iris ; vascular ; rarely burst through the cornea ; pro- gressive. Cysts. — Transparent ; usually following injury. Congenital Defects of the Iris. — The iris is rarely entirely wanting at birth {irideremia, aniridia). A part of the iris from the periphery to the edge of the pupil may be congeni- tally absent (colohoma of the iris). This occurs in the inferior nasal quadrant. The pupil may be irregularly placed (cor-ec- topia) or multiple (polycoria). There may be remnants of the pupillary membrane stretching across the pupil (persistent pupillary membrane). CHAPTER VIII. DISEASES OF THE PUPIL. PHYSIOLOGY. Contraction. — The contraction of the pupil is caused by the action of the sphincter pupillse. I. If light falls upon the retina, the pupil contracts by reflex action. The course of the impulse starting in the retina and ending in the contrac- tion of the sphincter is as follows : From the retina it travels through the optic nerve and optic tract to the anterior corpus quadrigeminum (probably). From there the pupil- fibres pass by Meynert's fibres to the centre of the sphincter pupillse in the third nerve nucleus. Here the reflex is started, which passes out to the eye by the third nerve and its ciliary PHYSIOLOGY. 86 fibres. The contraction to light of the pupil of the eye illumi- nated is called the direct action, but the other pupil also con- tracts at the same time. This is called the consensual action. It is explained by the fact that the pupillary fibres of the optic nerve probably suffer semidecussation at the chiasm as well as the visual fibres. There is also a communication between the two corpora quadrigemina and between the third nerve nuclei. II. The pupil contracts not only to light, but also to convergence and accommodation. It seems probable that the three centres for convergence, accommodation, and pupil-contraction, though independent, are stimulated simulta- neously by the voluntary impulse for adjustment of the eyes for the near point. Dilatation. — The presence of a dilator muscle is still in doubt. The elasticity of the posterior membrane and vaso- motor action are probably in part active in dilatation. Dila- tation is under the control of the sympathetic system. The centre is in the medulla and the course is down the spinal cord to the seventh and eighth cervical and first dorsal roots, through the cervical sympathetic, carotid, and cavernous plexus to the eye. Physiologic dilatation is produced by irritation of sensory nerves and by psychic conditions such as fright or anger. Size of the Pupil. — There is no standard size so varied are the influences acting upon the pupil. In middle life, with moderate illumination and the accommodation at rest, it is from 4 to 4.5 mm. in diameter. In children it is larger than in the adult. Pathology. — The state of dilated pupil is called mydn- asis ; of contracted pupil, 7nyosis. Bearing in mind the physiology, it will be readily seen that mydriasis may be produced by (a) paralysis of the third nerve or those fibres going to the sphincter pupillse, or by (6) stimulation of the sympathetic fibres or the dilator fibres. On the other hand, myosis may be produced by (a) paralysis of the sympathetic fibres or (6) irritation of the third nerve. Hence we have : Mydriasis . | P^'^lyt!"; Mvosis . . | Paralytic. y \ Spasmodic. " ( bpasmodio. 86 DISEASES OF THE CILIARY BODY. Paralytic mydriasis will be produced by lesions involving the third nerve or its centre, such as tumors, locomotor ataxia, disseminate sclerosis, hemorrhages, or injuries ; also by lesion of the optic nerve or tract and by paralysis of the sphincter. Spasmodic mydriasis may be due to high intracranial pressure, spinal irritation, mental excitability. Paralytic Myosis. — Diseases of the upper portion of the spinal cord. Tumors or wounds involving the cervical sympathetic. Spasmodic Myosis. — Meningitis in the early stage. Irri- tation of the third nerve or centre by lesions in the vicinity. As a reflex from irritation in the eye, as from a foreign body. The so-called Argyll-Robertson pupil does not contract to light, but does contract to accommodation. It is principally found in locomotor ataxia. Hippus is the alternate contraction and dilatation of abnor- mal amplitude. QUESTIONS. What is the classification of iritis? Give the etiology, pathology, symptoms, complications, and treatment of acute plastic iritis. Define serous iritis. Name two forms of tuberculous iritis. What is iridodialysis? Iridodonesis ? Irideremia? Mention the tumors of the iris. Name the congenital defects. Describe the physiologic contraction of the pupil to light. What are the direct and the consensual actiou of the pupil to light? Explain contraction to accommodation. Explain physiologic dilatation. What are the pathologic states of contracted and dilated pupil? Give examples of each. What is the Argyll-Robertson pupil ? CHAPTER IX. DISEASES OF THE CILIAEY BODY. CYCLITIS. The ciliary body is in close anatomic relations on the one side with the iris and on the other with the choroid. It is not strange that it should be rarely alone affected. INJURIES OF THE CILIARY BODY. 87 Varieties. — Cyclitis is usually divided into plastic, serous, and purulent. ACUTE PLASTIC CYCLITIS. Definition. — This disease is characterized by pain in the ciliary region, circunicorneal congestion, and tenderness over the ciliary body. There are usually some opacities in the anterior part of the vitreous. Glaucoma is not an uncommon complication. If the iris is involved, the symptoms of iritis are added. When the choroiditis accompanies the cyclitis, patches of exudate may be seen if the vitreous opacities will allow inspection of the fundus. Tiie causes are the same as in acute iritis. If the disease is severe, the prognosis is bad, for permanent blocking of the pupil may occur and permanent opacities of the vitreous may result. Chronic Plastic Cyclitis. — Definition and Symptoms. — Usually the iris is involved. There are occlusion of the pupil and formation of exudate in the vitreous back of the lens, which tends to organize and draw together the ciliary body. The periphery of the iris is retracted. Such a chronic irido- cyclitis of traumatic origin may produce sympathetic oph- thalmia. Serous cyclitis is the same as the so-called serous iritis, and is described under that head. PURULENT CYCLITIS. Definition. — Usually the whole uveal tract is involved in the purulent inflammation — iris, ciliary body, and choroid. This condition is generally due to a perforating injury, but may occur as a metastatic condition, as in nasal disease or meningitis (see Purulent Choroiditis). Treatment of cyclitis is the same as for iritis. INJURIES OF THE CILLA.RY BODY. The ciliary body lies behind a zone which surrounds the cornea, and is ^boiit one-fourth of an inch wide ("danger 88 DISEASES OF THE LENS. zone"). Perforating wounds in this region, followed by chronic iridocyclitis, give the conditions which cause sympa- thetic ophthalmia. Wounds with or without prolapse of the ciliary body should be treated according to the rules laid down under injuries of the iris. TUMORS OF THE CILIARY BODY. Sarcomata, usually melanosarcoma, are of rare occurrence. Tubercles, gummata, and cysts have been reported. These may grow into the vitreous or may present in the anterior chamber at the periphery of the iris. QUESTIONS. Define plastic, serous, and purulent cyclitis. What importance have wounds in the ciliary region? CHAPTER X. DISEASES OF THE LENS. CATARACT. Definition. — An opacity of the crystalline lens or its capsule. Varieties. — Cataracts may be divided into polar, anterior and 'posterior (including capsular), zonular, senile, and traumatic. Cataracts may also be classified as stationary (polar and zonu- lar) and progressive (senile and traumatic). When a cataract forms without known connection with other disease of the eye, it is called primary. If associated with glaucoma, iridocycli- tis, tumors, etc., it is called secondary. ANTERIOR POLAR CATARACT. Sjmonym. — Pyramidal cataract. Definition. — Under oblique illumination a small round dense opacity is seen at the anterior pole of the lens. This is often elevated above the level of the anterior capsule (although the capsule passes over it). It also extends som^- POSTERIOR POLAR AND ZONULAR CATARACT. 89 what into the sul)stance of the lens. An opacity of the cornea will also generally be found near the centre. Etiology. — Anterior polar cataract may be congenital or acquired. It usually originates from the contact of the lens with the posterior surface of the cornea after the perforation of an ulcer in infancy or in utero. Fig. 18. Anterior polar cataract, seen from the front and in section. (Nettleship.) Symptoms. — There may be little interference with vision on account of the fact that the opacity is so near the nodal point. Treatment is not necessary. POSTERIOR POLAR CATARACT. Definition and Symptoms. — May be somewhat similar to anterior polar cataract in appearance. The congenital form appears as a small white round opacity, and is due to the remains of the point of contact of the hyaloid artery, which extends in foetal life from the optic nerve through the vitreous to the posterior surface of the lens. A minute dot is very common on the posterior capsule in normal eyes, and is of similar origin. An acquired form is associated with intraocular disease. Cataracts beginning in the posterior cortex or upon the posterior capsule are often found associated with choroidal disease, and may clear. ZONULAR CATARACT. Definition. — Zonular or lamellar cataract consists of one or more opaque zones, which surround a clear nucleus and leave an outside or cortical zone clear. Symptoms. — By oblique illumination the opacity may be seen to be lamellar in structure, often with striae running out 90 DISEASES OF THE LENS. into the clear cortex. The extent and density of the opacity are subject to considerable variation. These cataracts are, almost without exception, stationary. Congenital cataract may also show complete opacity of the lens. A punctate and a stellate form about the nucleus exist. Etiology. — Generally congenital ; sometimes in children who have suffered from convulsions in infancy and in rachitis. There is an hereditary tendency. Treatment depends upon the extent of the opacity. If the central opacity is less than the size of the medium pupil, and if atropine, by dilating the pupil, allows sufficient vision Fig. 19. Discission of cataract. (Juler.) through the clear cortex thus exposed, an iridectomy to pro- duce artificial pupil will be the proper treatment. The ad- vantages of this method of treatment are that the accommo- dation is left intact, and no glasses need necessarily be worn. If the opacity is too extensive to obtain clear vision through an artificial pupil, the lens should be removed by absorption. The operation for absorption by needling (discission) is per- formed as follows : The pupil is dilated by atropine. The j)atient, if too young for self-control, should be put under a general anaesthetic. The cornea should be entered by a knife- needle which has a short, narrow blade and a long shank. A horizontal incision is then paade through the ^nt^rior capsule SENILE CATARACT. 91 and somewhat into the lens substance. It should be about 4 mm. in length. A vertical cross -incision may also be made if desired. The aqueous humor entering into the lens substance swells and gradually dissolves it. If the swelling is too rapid, glaucoma may ensue, in which case the lens must be let out through a corneal incision. A second and sometimes a third needling is necessary before the lens is completely absorbed. A strong convex lens must then be worn to re- place the crystalline lens. Iritis may rarely complicate the operation. SENILE CATARACT. Etiology. — Although cataracts under this category may occur at an earlier period, the vast majority are found after fifty years of age. They are most frequent among the aged ; in fact, elderly persons are likely to show some, practically stationary, opacities at the periphery of the lens. There are usually no causes to assign for senile cataracts. They appear equally in all conditions of life, although constitutional dis- eases, such as diabetes and tendencies tow ard sclerotic changes, are known to favor their development. Pathology. — Between the ages of thirty and forty the lens begins to harden at its centre, forming what is known as the nucleus. The size of the nucleus increases with age. Cata- racts are produced during the process of nucleus-formation by the irregular shrinking of the fibres and the collection of fluid within spaces thus formed. Degeneration of the fibres and coagulation of the fluid follow, producing opacities. The choroid, especially at its periphery, is at times found aff'ected during the formation of cataract. Subjective Symptoms. — The patient complains of blurred vision, flashes and streaks of light, dark spots, and double or multiple vision. There is never any pain directly due to cataract. There is sometimes eye-strain, due to imperfect sight. Sometimes the first subjective symptom is the ability to read without glasses (second sight). This is due to the increased refracting power of the lens from swelling. Objective Symptoms. — 1. In the early stages {incipient cata- 92 DISEASES OF THE LENS. ract) an opacity may be found at the centre of the lens (nuclear), or radiating spiculse may be seen in the cortex (cortieal), or again a homogeneous or mottled opacity may appear through- out the whole lens. These changes may be best made out with the dilated pupil by oblique illumination, in which case the opacities appear white, or by the ophthalmoscope, in which case they appear black against the red reflex from the fundus. In elderly persons a brownish-red appearance with- out decided opacity may often be made out, especially in the centre of the lens. This is due to sclerosis (sclerosed cataract). Such a lens may appear almost black when extracted (cata- racta nigra). II. As the ripening process advances (immature cataract), the lens becomes more extensively opaque and at the same time increases in size (cataracta tumefacta). This swelling of the lens is manifest in the decreased depth of the anterior chamber — i. e., the iris is pushed toward the cornea. The reflex from the fundus is gradually lost and the opacity becomes quite evident in daylight. At times it has a streaked, glistening appearance (asbestiform). III. The cataract then gradually shrinks to its normal or somewhat less than normal size. It is fully opaque and "ripe" (mature cataract). A sclerosed cataract never becomes opaque, but translucent, and vision is never entirely lost. IV. If allowed to remain, the cortex slowly softens (hypermature cataract) and may become fluid, leaving the hard nucleus to float about (3Iorgagnian cataract), or the lens may become flat (disciform) or calcify. Course. — The progress of senile cataracts is slow. A num- ber of years usually pass before maturity is reached. They may become stationary at any time. They probably never actually improve, although a few such instances have been reported. The rapidity of progress is usually difficult to estimate by one examination, but in general sharply outlined cortical and well-defined punctate opacities are stationary. Diff'used blurred opacities are progressive. In senile cataract both eyes are affected sooner or later, although it often hap- pens that one eye may become fully mature before the other eye is materially changed. Pro^osis, — The points to be noticed before expressing ap SENILE CATARACT. 93 opinion as to the suitableness of a cataract for operation are as follows: The eye should be free from evidence of disease as far as one is able by external examination to exclude it — i. e., dacryocystitis, conjunctivitis, corneal affections, signs of iritis, such as synechise (cataracta accreta)^ The anterior chamber should be of normal depth. The pupil should react to light. There should be a homogeneous white or gray opacity immediately back of the pupil, with no shadow from the edge of the pupil except in cases of sclerosis already men- tioned. A candle carried on all sides of the patient while the eye is fixed, should be properly located by him (projection good). The tension of the eyeball should be normal. If the above examination of the eye prove satisfactory, the cataract is ripe, and in all probability vision, after operation, will be good. 95 per cent, of success is an average showing. It is of some importance to inquire of the patient as to the condition of the vision before the cataract appeared and if the eye were injured. Treatment. — There is no control over the progress of lens opacities. Massage and electricity within justifiable limits have no appreciable effect. If both eyes are equally advanced and the vision considerably reduced, artificial ripening may be resorted to. The safest method consists in making a small opening into the anterior chamber and gently stroking the anterior surface of the lens with a spatula which is introduced through the opening. Sometimes an iridectomy (preliminary) will hasten the ripening process. If a senile cataract has proved suitable for operation by the method of examination explained, it can be removed only by extraction, which is performed as follows : Combined and Simple Extraction. — The skin about the eye should be washed with soap and water, and the lids, especially at the roots of the lashes, thoroughly cleansed. Cocaine hydro- chlorate (4 per cent.) or holocaine hydrochloride (1 per cent.) is instilled two or three times at intervals of five minutes. Be- fore beginning the operation, the eye is flushed with normal salt solution, bichloride of mercury (1 : 5000), or boric acid solution (3 per cent.). The patient should lie on the back, if 94 DISEASES OF THE LENS. possible in bed, and the daylight or artificial illumination arranged to illuminate the eye fully. The operator should stand back of the patient's head. The lids are kept apart by Fig. 20. Fixation forceps. inserting a speculum, and the conjunctiva just below the cornea is firmly seized with the fixation forceps held in the left hand (when operating on the right eye). The cataract knife (Graefe), with the edge upward, is introduced at the juncture Fjg. 21. Eye speculum. of the cornea and the sclera on the temporal side a little above the horizontal meridian of the cornea. It is passed across the anterior chamber in front of the iris and pupil, and brought out at a corresponding point on the opposite side (counter- FiG. 22. ^^^=-C Cataract knife. puncture). As soon as the point is seen outside the eye, the knife should be made to cut upward as it advances, always keeping the incision in one plane at the sclerocorneal junction. SENILE CATARACT. 95 One or two movements of the knife forward and backward will finish the section. Such a section will include nearly Fig. 23. The corneal section in cataract extraction. Puncture and counterpuncture have been made. The section will pass in its whole extent exactly throus:h the transparent margin of the cornea, the knife remaining in the same plane through- out. Slightly modified from de Schweinitz. (Ellett.) one-half the periphery of the cornea, but should be somewhat smaller if an iridectomy is to be made. Some operators prefer to finish the section more in the cornea by turning the blade Fig. 24. Iris forceps. Fig. 25. Lens scoop. forward ; others, more in the sclera, forming a flap of conjunc- tiva, by turning the knife back toward the equator of the eye. The next step (which is omitted in the so-called simple extraction) is the iridectomy. While an assistant holds the fixation forceps, the operator, entering through the wound 96 DISEASES OF THE LENS. with closed ms forceps, seizes the iris near the pupillary edge and pulls it out through the wound. A piece is then cut off with the scissors, close to the eye. When the iridectomy is performed, the operation is called the combined method. The next step (which follows the section in the simple ope- ration) is the capsulotomy. The capsulotome is entered from the temporal side, and the capsule is opened by a number of scratches either in the pupillary area or above the edge of the pupil under the iris. If properly done, the lens will be seen to come forward toward the cornea. The fixation forceps is then carefully removed and, with a spoon, pressure is made at the lower edge of the cornea toward the centre of the eye- ball. If the force is gradually increased, the lens will enter and open the wound, slowly dilating the pupil, and will be delivered. When the equator of the lens has passed the wound, the pressure should be somewhat relaxed and the spoon should be passed over the cornea, following the lens out. The speculum is then carefully removed. Some ope- rators prefer to remove the speculum and extract the lens by pressing the lower lid against the eyeball at the lower edge of the cornea. Cortical matter remaining behind should be worked out by using the lower lid against the cornea. The pupil should be made round with a spatula by freeing the iris from the wound, and the spatula should be passed along the edge of the wound to assure proper apposition. If an iridectomy has been made, the cut edges of the iris must be freed from the wound. A light bandage is placed over both eyes and the patient kept absolutely quiet on the back in bed. No injury should be allowed to happen to the eye by any movement of the head or hands. On the following day it is customary to inspect the eye, and if, in case of simple extrac- tion, the iris is found caught in the wound (prolapse), it should be drawn out with the iris forceps and cut off. A drop of atropine (1 per cent.) should be instilled at each daily dressing. Bandages may be left oif the other eye in four or five days, and from the one operated on about the seventh day. The patients are not allowed to leave the hospital before two weeks. SENILE CATARACT. 97 Accidents and complications liable to occur are improper place and size of the incision, difficult delivery due to adhe- sive lens, small incision, or imperfect opening of the capsule. There may he rupture of the suspensory ligament and pro- lapse of vitreous due to too large incision, too much pressure, patient squeezing the lids, or to frail suspensory ligament. In the after-treatment there may occur striated keratitis (usually harmless), prolapse of iris, iritis beginning generally after the third day, iridocyclitis resulting in destruction of the eye, suppuration of the wound, intraocular hemorrhage, or injury from hitting the eye. After- cataract. — The capsule out of which the lens is taken in many cases is left as a more or less opaque membrane aci'oss the pupil (secondary cataract). At any time after the eye has become free from congestion or irritation this may be cut with a knife-needle (discission-knife) by making a large crucial incision. Two needles entered on opposite sides of the cornea are sometimes employed. If there are tough bands, they may be cut with small scissors, as those of de W'^ecker. Glaucoma rarely occurs after these operations. The loss of the refracting power of the eye by removing the lens — a con- dition known as aphakia — must be made good by wearing a strong convex lens (cataract glass) in order to obtain the best vision. Usually about +10 D. is required. Often some astig- matism is also present. Traumatic Cataract. — If the lens capsule is opened, the aqueous enters and produces swelling and opacity of the lens. Traumatic cataract may also occur from contusion without perforating injury. In this case the suspensory ligament is generally ruptured, or, in rare cases, the capsule. Rupture of the capsule in a patient under thirty-five may be followed by gradual and complete absorption of the cataract. In injured and diseased eyes the lens may calcify. Treatment. — Traumatic cataracts should be treated accord- ing to the principles already laid down, by absorption or ex- traction, depending upon the age of the patient. 7— E. E. 98 DISEASES OF THE LENS DISLOCATION OF THE LENS. Definition. — The lens may be displaced partially (sublux- ation) or completely (luxation) from its position behind the iris by rupture of the suspensory ligament, by which it is attached in its capsule at its equator to the ciliary body and ciliary processes. Etiology. — Congenital, secondary to pathologic changes, or traumatic. I. Dislocation may be backward, upward, downward, or to the side in the vitreous chamber. The displaced edge may often be seen with the ophthalmoscope as a curved black line in the pupil. Every movement of the eye will shake the lens and the iris will tremble (iridodonesis or tremulous iris). II. The lens may be dislocated partly through the pupil or entirely into the anterior chamber. In the latter case, when it is clear it is difficult to see. Glaucoma usually supervenes. III. The lens may be dislocated through a wound in the sclera, and lie under the conjunctiva. A dislocated lens is likely to become cataractous. Treatment. — If inflammation or glaucoma occur, the lens should be removed after the usual cataract incision, either by the use of a fenestrated spoon or by pressure. CONGENITAL AFFECTIONS. Beside those mentioned the following occur : ^ Lenticonus Posterior. — A rare congenital affection con- sisting of a bulging of the centre of the posterior surface of the lens. Lenticonus anterior is extremely rare. Coloboma is a rare condition, in which part of the lens is absent. QUESTIONS. Define and give classification of cataract. Explain anterior and posterior cataract. Define and give rules for the treatment of zonular cataract. What are the etiology and pathology of senile cataract? Describe four stages in the development of senile cataract. Describe the examination of the eye for the determination of fitness for operation. DISEASES OF THE VITREOUS. 99 What is artificial ripening ? Describe the operation for extraction of cataract. What is an after-cataract ? Describe traumatic cataract. In what directions may the lens be dislocated? Mention congenital afiections of the lens. CHAPTER XI. DISEASES OF THE VITREOUS. The vitreous humor should be perfectly clear to all objec- tive methods of examination, but subjectively floating opaci- ties (muscae volitantes) may always be seen if properly searched for. They are the source of considerable annoyance to ner- vous individuals. They are shadows thrown on the retina by the vitreous cells. OPACITIES OF THE VITREOUS. Opacities vary in form, character, and origin. They inter- fere more or less with vision. They may be either fixed or floating. In the latter case the vitreous is fluid in consist- ence (synchysis) . The ophthalmoscope is used in the exami- nation of the vitreous. Fixed Opacities. — One is the remains of the hyaloid artery in the canal of Cloquet. This appears as a band extending at varying distances from the optic nerve into the vitreous, even to the posterior capsule of the lens. Other fixed opaci- ties are bands or membranes of connective tissue, which may be congenital or the result of organization of inflammatory exudate. Floating opacities may be dust-like and fill the whole vitreous (characteristic of syphilis), or large masses, bands or membranes secondary to inflammation of the ciliary body, choroid, or retina, to hemorrhage, injury, or to degeneration of the vitreous. Degenerative changes occur in high myopia, old age, exhaustion from depressing disease, menstrual dis- orders, systemic disturbances, or may be idiopathic. 100 DISEASES OF THE VITREOUS. Synchysis scintillans is a peculiar condition in which the vitreous is filled with numerous scales which reflect the light as brilliant floating spots. These are cholesterin crystals. Treatment. — If any constitutional disease may be made out, it should be treated. If the cause of the vitreous opacities is inflammation in the adjacent tissues, attention should be given to this. SUPPURATIVE INFLAMMATION OF THE VITREOUS. Synonym. — Purulent hyalitis. Etiology. — Pus in the vitreous may be due to infection from perforating wounds, or may be of metastatic origin from men- ingitis, infectious diseases, or from ear or nose. It may follow inflammations of the uveal tract, or occur spontaneously in debilitating diseases. Symptoms. — The cornea, aqueous, and lens are clear, but a yellow reflex is obtained back of the lens. A few pos- terior synechise may be found. If the disease is advanced, the eye will be soft and the periphery of the iris will be drawn back by traction on the ciliary processes from within. Such a condition may be mistaken for glioma of the retina, and is sometimes called pseudoglioma (see Glioma of the Retina). When the process is acute and severe, it is known as panophthalmitis, or abscess of the eye, in which case the w^hole eye and surrounding orbital tissue are involved. Treatment. — If the inflammatory conditions subside, it is not necessary to perform enucleation for pseudoglioma. In panophthalmitis, hot fomentations and incision into the eye to evacuate pus are indicated. Enucleation has been followed by meningitis. QUESTIONS. What are miiscfe volitantes ? What are the forms of opacities of the vitreous ? Define synchysis scintillans. Describe suppuration of the vitreous and give treatment. What is pseudoglioma ? DISEASES OF THE RETINA, 101 CHAPTER XII. DISEASES OF THE RETINA. Andemia and Hyperaemia of the retina occasionally occur as the result of local or general conditions, but the varia- tions may be considerable within physiologic limits. Retinitis. — Simple, albuminuric, syphilitic, and pigmented varieties of retinitis occur. Eetinitis is often associated with choroiditis (chororetinitis) or with inflammation of the optic nerve (neuroretinitis). SIMPLE RETINITIS. Etiology. — The causes are often obscure. There is com- monly some constitutional disturbance — e. g., arteriosclerosis, anaemia, leukaemia, malaria, etc. Cases may be due to albu- minuria, syphilis, or diabetes; but such causes generally pro- duce eiiaracteristic appearances, which will be described under S(^parate heads. Subjective Symptoms. — The patient complains of impaired vision and blurs in the field of vision and flashes of light. There may be photophobia and distortion of objects (meta- morphopsia). Objective Symptoms. — There may be found only slight dis- turbance of the retina, such as dilated veins, tortuous vessels, and a few hemorrhages ; or, in more marked cases, a cloudy fundus, dilated and distorted vessels buried in the swollen retina, with numerous flame-like hemorrhages, and the out- line of the nerve is blurred. The disease may be unilateral or bilateral. The duration is usually several months. Treatment. — The eyes should be protected from light and strain. Mercury, or potassium iodide, sodium salicylate, and diaphoretics may be given. Hemorrhagic Retinitis. — A form of simple retinitis in Avhich hemorrhages are the most striking feature. It is most common in elderly people with apoplectic tendencies du^ t9 102 DISEASES OF THE RETINA. arteriosclerosis. Thrombosis of the retinal veins may occasion hemorrhages with dilated veins. At times hemorrhage occurs between the retina and vitreous (subhyaloid). ALBUMINURIC RETINITIS. Definition. — A distinct type of retinitis accompanying acute or advanced chronic nephritis. Usually bilateral. Etiology. — The cause is nephritis, usually chronic inter- stitial. It also occurs in Bright's disease of pregnancy and Fig. 26. Albuminuric retinitis. Granular kidney. Note hard-edged "asterisk" exuda- tion at macula, and the punctate and linear hemorrhages, (Posey and Wright.) in acute nephritis. Diabetes is the cause of a somewhat simi- lar condition in the retina. The only subjective s3anptom is interference with vision. This is sometimes surprisingly slight in cases showing marked RETINITIS PIGMENTOSA. 103 fundus changes. Patients with nephritis are subject to attacks of temporary blinchiess of uraemic origin, with or without retinitis. By ophthalmoscopy there may appear the signs of simple retinitis — swelling, tortuous vessels, Fiemorrhages, and, in addition, shining white patches scattered through the fundus, and a peculiar arrangement of glistening white dots around the macula. This is a stellate figure formed by radi- ating lines. Pathology. — The white patches are due to fatty degeneration of the retinal elements and to exudate. Prognosis. — Retinitis in chronic nephritis is a late mani- festation, and the patient is not likely to live more than two years after the appearance of the eye lesion. Temporary im- ])rovcment may occur, especially when the disease assumes an acute or inflammatory exudative form. Treatment. — No local treatment is of use. When the dis- ease appears in ^ pregnancy, the question of producing prema- ture labor is a grave one. If the retinitis is marked and occurs before the seventh month, it may be wise to induce labor. If after the seventh month, and mild, it is better to wait. SYPHILITIC RETINITIS. Etiology. — Occurs in the second stage of acquired syphilis and in the congenital form. Subjective symptoms are the same as for other forms of retinitis. Objective Symptoms. — The ophthalmoscope shows dust-like opacities in the vitreous — a pecnliar bluish-gray haze over the retina, about the disk and macula, and streaks of white exudate along the vessels. Course. — The course is chronic, leading to choroiditis and atrophy of the optic nerve. Treatment. — Antisyphilitic. Should be energetic, and if begun early may be successful. RETINITIS PIGMENTOSA. Definition. — A disease chamcterized by a prolonged course, beginning in youth and prolonged for ^ears. There is loss 104 DISEASES OF THE RETINA. of vision, especially in subdued light, as in the twilight or evening (night blindness, nyctalopia). There is a peculiar arrangement of the retinal pigment into masses of irregular shape, mostly with branching projections. These appear first at the periphery, later approach the nerve. The field of vision becomes gradually narrowed. The nerve and retina become atrophic, and the bloodvessels of the retina much reduced in calibre. There is a strong hereditary tendency, and consanguinity in parents is an element. EMBOLISM OF THE CENTRAL ARTERY OF THE RETINA. Definition. — Plugging of the central artery, or more rarely a single branch. Etiology. — There may be heart lesion or obliterating endarte- ritis of the retinal vessels. Symptoms. — There is sudden blindness in one eye without pain or other symptoms. The retina in a short time begins to assume a foggy appearance (oedema), especially near the centre of the fundus. A cherry-red spot is found at the macula. The arteries are small and the veins contain little blood. Later the circulation may be restored, the blood returning at times in broken columns. Atrophy of the retina and nerve usually results. Occasionally central vision is preserved, which is due to the existence of a branch of the central artery com- ing off back of the location of the embolus (or of a branch from the ciliary arteries), supplying the macular region. Treatment. — Massage is recommended. DETACHMENT OF THE RETINA. Synonym. — Ablatio retinae. Definition. — Separation of the retina from the choroid, leaving behind the layer of retinal pigment. Etiology. — This may occur from the extravasation of blood or serum, or from the presence of exudate or new growth. It may also occur from the traction of bands of connective tissue in the vitreous, The ordinary form occurs as a complication DETACHMENT OF THE RETINA. 105 of myopia of high degree. Traumatism is the next most fre- quent cause. Symptoms. — The patient complains of poor vision and de- fect in the field of vision corresponding to the detachment. The ophthalmoscope often reveals floating opacities in the vitreous. The detached retina appears as a wavy grayish or greenish-white membrane, over which the very dark-red retinal bloodvessels run in tortuous course. The retina Fig. 27. Detachment of the retina. (Jaeger.) usually floats about with the movements of the eye. A tear is sometimes seen. The tension of the eye is reduced. Prognosis. — These cases, especially if complicating myopia, get worse, and all vision is lost. The cases occurring as the result of traumatism are the most favorable, but the prognosis is always bad. Treatment. — In recent cases rest in bed for a number of weeks should be ordered ; also hypodermatic injections of 106 DISEASES OF THE RETINA. pilocarpine (gr. -^^ to produce sweating, every day or two. Puncture of the sclera over the detachment and subconjunc- tival injections are of questionable value. GLIOMA OF THE RETINA. Definition. — A malignant intraocular tumor occurring in early childhood or infancy, commonly before three years of age. Pathology. — Glioma springs from the granular layer of the retina, grows underneath the retina (exophytum), or on top of it in the vitreous (endophytum). It consists of blood- vessels, small round cells, and cells with protoplasmic proc- esses in scant stroma. Symptoms. — In the first stage there appears a shining white or yellowish reflex from the interior of the eye (formerly called "amaurotic cat's eye"). The eye is blind. A few bloodvessels may be seen on the mass in the vitreous. In the second stage (glaucomatous) the eye becomes hard by the growth of the tumor filling the interior. It is ])ainful and somewhat congested. Third stage. The new growth bursts through the eye and extends either backward into the orbit or forward toward the outside. Fourth stage. Metastatic growths appear in other organs. The otlier eye may be affected, and the child dies of cerebral complications or from exhaustion. Other children in the same family are sometimes affected. Differential Diagnosis. — The condition may be mistaken for purulent choroiditis (pseudoglioma). Glioma occurs in early childhood, with no history of injury or meningitis. Tumor often well defined, with rest of vitreous clear. Anterior chamber shallow and tension increased. Pseudoglioma may occur at any age ; follows injury or men- ingitis. Vitreous immediately and wholly filled with yellow- ish mass. Inflammatory signs appear early. The iris is bulging at the pupillary edge, but retracted at the periphery. Tension is minus. Treatment. — The eye should be enucleated at the earliest jTioipent, BARER FORiMS OF RETINAL DISEASE. 107 OPAQUE NERVE-FIBRES. Definition. — A congenital anomaly showing flame-like, glis- tening, white patches extending from the optic nerve into the retina. They are formed of nerve-fibres which have re- tained their medullary sheaths, normally lost as the fibres pass through the lamina cribrosa into the eye. INJURIES OF THE RETINA. Beside the diseases already mentioned as due to traumatism, contusions and wounds may occur. Commotio retinae (oedema of the retina) arises from contusions and shows defective vision and gray infiltration of the retina, especially in the macular region. RARER FORMS OF RETINAL DISEASE. Retinitis Proliferans. — Characterized by masses of con- nective tissue in the vitreous, which contain bloodvessels. Hemorrhages are undoubtedly the original lesion. Retinitis Circinata. — Presenting a white circle of exudate concentric with the macula. Retinitis Striata. — Showing white streaks of fibrous tissue in the retina. Angioid Streaks. — Black or brown striae, in deeper layer ; probably due to hemorrhages. Snow Blindness. — From exposure to brilliant light, such as from snow or electric light. There may be central sco- toma, macular changes, and retinitis. Amaurotic Family Idiocy. — Symmetric changes at the macula in infancy. A peculiar condition, showing a hazy area in the macular region, with a red spot in the centre. The disease is probably due to degeneration of ganglion-cells of the retina, following arrest of development of the nervous system. There is a strong hereditary influence. Jews are more prone to the disease (Jacobi). The children all die within a year or two, 108 DISEASES OF THE RETINA. AMBLYOPIA OR FUNCTIONAL DISEASE OF THE RETINA. In the ordinary acceptance of the term amblyopia is used to signify a defect in vision without discoverable lesion or refractive error. Amaurosis is a name which has fallen into disuse, but signifies total blindness from unknown causes. The forms of amblyopia are (I.) congenital, (II.) hysterical, (III.) simulated, and (lY.) toxic. I. Congenital Amblyopia.— Commonly associated with errors of refraction, especially hypermetropia and astigma- tism. In convergent strabismus the squinting eye is likely to be amblyopic. It is commonly believed that this is from nonuse (amblyopia ex anopsia). II. Hysterical Amblyopia.— Generally unilateral. Blind- ness may be partial or total. The field of vision is con- tracted, especially after repeated examinations. The fields for colors are reversed as to their order in point of size. III. Simulated Amblyopia.— Malingering is not unknown, and is attempted for various reasons. Generally blindness in one eye only is feigned. When a prism is placed over one eye, such patients will often acknowledge diplopia, and will find difficulty in walking, etc. IV. Toxic Amblyopia. — Under this head may be classed amblyopia occurring in uraemia, malaria, and poisoning with drugs, such as quinine, tobacco, and alcohol. Lesions, espe- cially of the nerve, are often developed. QUESTIONS. Mention the varieties of retinitis. Give the etiology, symptoms, and treatment of simple retinitis. What is albuminuric retinitis ? Give the etiology, symptoms, pathology, prognosis, and treatment. Describe syphilitic retinitis. Define retinitis pigmentosa. Explain embolism of the central artery of the retina. Give the etiology, symptoms, prognosis, and treatment of detachment of the retina. Give the four stages of glioma of the retina. Give the differential diagnosis between glioma and pseudoglioma. What are opaque nerve-fibres? What diseases may be produced by traumatism ? What constitutional diseases produce afiections of the retill^? P^scnbe the four forms of amblyopia. DISEASES OF THE CHOROID. 109 CHAPTER XIII. DISEASES OF THE CHOROID. The choroid is the vascular tunic of the eye and liable to inflammation. Its intimate connection with the retina makes their simultaneous involvement of common occurrence, although the entirely separate blood-supply renders disease of each distinctive. Varieties. — Exudative choroiditis, serous choroiditis, sup- purative choroiditis, and sclerochoroiditis posterior. EXUDATIVE CHOROIDITIS. Definition. — A disease characterized by localized patches of plastic inflammation, later producing atrophic areas. Pathology. — The exudate is a collection of round cells in the choroid and in the outer layers of the retina. Organi- zation of this exudate causes atrophy and disturbance in the pigment. Etiology. — Syphilis (congenital or acquired) is the most common cause, also general disorders of nutrition, and it may be idiopathic. Tuberculous deposits occur very rarely. Varieties. — Central, Occurs not infrequently in myopia, syphilis, and in elderly persons as a senile change. Dissemi- nate. Essentially chronic, characterized by scattered patches. Diffuse. Always accompanied by involvement of the retina and called chorioretinitis. Due to syphilis. Isolated. Some cases are characterized by isolated patches of exudate occurring in people as result of overexertion or idiopathic. Not due to syphilis. Runs a comparatively short course. Symptoms. — Gradual loss of sight is complained of, although the vision is sometimes good, with extensive changes. The field of vision may be contracted, and there may be scotomata. When recent, the diseased areas appear as irregular hazy, white or yellowish patches. Isolated hemorrhages may occur. In the stage of atrophy there are masses of pigment or white patches with or without rings of pigment about them. Opaci- 110 DISEASES OF THE CHOROID, ties of the vitreous and lens or atrophy of the optic nerve may complicate the case. Treatment. — Mercury, either internally or by inunctions, is beneficial even in nonspecific cases. Iodide of potassium in full doses or large doses of salicylate of sodium are of value. Serous Choroiditis. (See Serous Iritis.) SUPPURATIVE CHOROIDITIS. Definition. — This condition is practically the same as de- scribed under suppurative inflammation of the vitreous. On rare occasions in the course of infectious or wasting diseases the beginning of the suppurative process may be seen as foci of infection in the choroid. These quickly involve the whole interior of the eye in purulent inflammation. Treatment. — Unless the case may be aborted, which is prac- tically impossible, the eye is lost. SCLEROCHOROIDITIS POSTERIOR. Definition. — Consists in a slow process of atrophy of the choroid surrounding the optic nerve, especially on the side toward the macula. It complicates myopia, and is associated with bulging of the sclera in this place (posterior staphyloma). See page 132. TUMORS OF THE CHOROID. Sarcoma, gumma, tubercle, and secondary carcinoma are of rare occurrence. SARCOMA OF THE CHOROID. Pathology. — Melanosarcoma is the most common form. Symptoms. — First Stage. — The patient complains of blurred vision. A tumor will be seen in some part of the fundus. Over it other vessels beside those of the retina will be seen. The retina is often detached on one side. Second Stage. — The eyeball becomes hard and painful, and the vision is lost. QUESTIONS. Ill Third Stage. — The tumor involves the surrounding parts. It ruptures through the globe or extends backward through the optic nerve. Fourth Stage. — Metastatic growths appear. Diagnosis. — A tumor showing vessels beside those of the retina, with increase of tension. Prognosis. — Unless seen in the early stage, the prognosis is decidedly bad. Treatment. — Immediate enucleation, with the optic nerve cut well back. INJURIES OF THE CHOROID. Beside the direct laceration of the choroid in perforating injuries, it may be ruptured by contusions. Such a condition shows a curved white line of exposed sclera bordered with pigment usually concentric with the optic nerve. Treatment. — None is possible. CHOROIDAL HEMORRHAGE. Choroidal hemorrhage may occur from injury or from sudden relief of pressure in operations which open the eye- ball. CONGENITAL DEFECTS OF THE CHOROID. Goloboma is a defect in development owing to imperfect closure of the foetal cleft. It appears as a white area of ex- posed sclera, stretching usually from the optic nerve toward the ciliary body and iris, which may be involved in the same way. There are often irregularities in the surface of the area, wliich is bordered with more or less pigment. An uncommon form of coloboma is confined to the macula. Albinism of the eye is a condition of absence of pigment. QUESTIONS. Name the varieties of choroiditis. Name the varieties of exudative choroiditis. Describe four stages of sarcoma of the choroid. Describe rupture of the choroid and congenital defects. 112 DISEASES OF THE OPTIC NEHVE. CHAPTER Xiy. DISEASES OF THE OPTIC NERVE. The diagnosis of ansemia or liyperaemia of the optic nerve should be made with care, in view of variations within pliysio- logic limits. If the optic nerve is inflamed at its entrance into the eye, the condition is called optic neuritis, intraocu- lar neuritis, or papillitis. If the process is confined to the nerve behind the eyeball, it is known as retrobulbar neuritis. OPTIC NEURITIS. Definition. — An inflammation of the head of the optic nerve, characterized by congestion and swelling of the optic disk. Etiology. — Papillitis occurs in brain tumors, generally in the form known as '^ choked disk.^^ It is also caused by syphilis, Fig. 28. Ophthalmoscopic appearance of severe recent papillitis. Several elongated patches of blood near border of disk. (After Hughlings Jackson.) nephritis, rheumatism, ansemia, diseases of the vascular system, infectious diseases, and poisons, as well as diseases of the orbit ACUTE RETROBULBAn NEURITIS. 11^ and adjacent sinuses. Tuberculous and other forms of menin- gitis are the cause of descending neurntis. Pathology. — There is infiltration of white cells. The pa- thology of " choked disk '^ is yet unsettled, but this condition seems to be due to increased intracranial pressure, with disten- tion of the optic nerve sheath. Subjective Symptoms. — The patient complains of defective vision, which is, however, independent of the apparent sever- ity of the lesion, for marked cases may retain excellent vision. Objective Symptoms. — There are no external signs. With the ophthalmoscope the optic disk is congested or of whitish color. The edges are blurred and streaked. There is more or less swelling of the disk. The veins are distended and tortuous and the arteries small. There may be hemorrhages. The field of vision is usually defective. The neighboring retina is always involved to some extent, but there may be general retinitis (neuroretinitis). The disease is usually bilat- eral. In " choked disk '^ there is great swelling of the nerve (oedema), dilatation of vessels, and hemorrhages. Course. — The disease lasts for months. The inflammation may subside without after-effects, or the nerve may pass into a condition of atrophy (postneuritic). Treatment. — The treatment consists in giving attention to the cause, sweating with pilocarpine, potassium iodide, sodium salicylate, and rest in bed. ACUTE RETROBULBAR NEURITIS. Definition. — An inflammation of the orbital portion of the optic nerve. Etiology. — Syphilis, rheumatism, infectious diseases, pois- ons — e. g., methyl alcohol — and secondary to inflammation in the adjacent tissues. Pathology. — In most cases the inflammation is confined to the fibres which supply the macula. Symptoms. — Rapid loss of sight, orbital pain and tender- ness. There may be no intraocular evidence of disease or only appearances of moderate optic neuritis. Optic nerve 8— E. E. 114 DISEASES OF THE OPTIC NERVE. atrophy, especially on the temporal side of the disk, is likely to follow with central scotoma. Treatment. — Same as for optic neuritis. CHRONIC RETROBULBAR NEURITIS. Synonym. — Toxic amblyopia. Definition. — A disease characterized by gradual loss of vision and atrophy of the optic disk on the temporal side. Etiology. — Nicotine, especially combined with alcohol, is the most common cause. Lead, arsenic, bisulphide of carbon, and other poisons may also produce it. It occurs in middle and late life. Pathology. — The lesion is a chronic interstitial inflammation of the macular fibres of the nerve, which occupy the temporal side of the nerve at the optic disk, but pass into its centre further back in the orbit. Symptoms. — The patients find their sight gradually failing. There are diminution in central vision (central relative sco- toma) and defect in color perception . in a small area about the fixation point (central color scotoma). The ophthalmo- scope shows a decided pallor of the disk on the outer side and dilatation of the retinal veins. The disease aff*ects both eyes. Course. — It is of long duration, but never produces total blindness. Treatment. — Alcohol and tobacco should be absolutely cut off. Strychnine may be given to the physiologic limit; also potassium iodide. ATROPHY OF THE OPTIC NERVE. Definition. — A condition of the optic nerve characterized by degeneration and shrinking of its fibres, and showing a white or gray disk. Etiology. — Atrophy may be : a. Primary, idiopathic, or associated with diseases of the brain or spinal cord. There is an hereditary type, which affects members of the same family. It begins in youth, and gradually produces total blindness, b. Secondary to optic neuritis or diseases of the QUESTIONS. 115 choroid and retina and glaucoma ; also after injuries and compression. Pathology. — There is chronic interstitial inflammation, with atrophy of the nerve-fibres. Symptoms. — The patient has no symptoms except gradual loss of sight and perhaps contraction of the field of vision. The disk varies in appearance from the slightest degree of pallor to the most intense white or gray. In advaruced cases there will be noticed a depression in the centre of the disk, Avith sloping sides. The edges of the nerve are sharply de- fined, except when following optic neuritis. There are con- centric or irregular contraction of the field of vision and defects in color perception. Course is usually long. Treatment. — If any indications for general treatment can be found, they should be followed. Strychnine in full doses, preferably by the hypodermatic method, potassium iodide, arsenic, electricity, and massage, may be tried, but are of little value. Tumors of the Optic Nerve. — Fibroma, sarcoma, endo- thelioma, myxoma, tubercle, and glioma are known to occur. Hyaline bodies are found on the disk. CONGENITAL AFFECTIONS. Inferior Conus. — A congenital, white crescent, usually on the lower side of the nerve. Coloboma of Optic Nerve-sheath shows a depression on the lower side of the disk, due to absence of the sheath. QUESTIONS. state the two forms of hiflammation of the optic nerve. Describe acute and chronic papillitis; also retrobulbar neuritis. Give the etiology, symptoms, and treatment of atrophy of the optic nerve. What general diseases cause affections of the optic nerve? 116 DISEASES OF THE DEBIT. CHAPTER Xy. DISEASES OF THE ORBIT. PERIOSTITIS. Etiology. — Occurs, especially at the margin, from trau- matism, syphilis, rheumatism, tuberculosis, and extension from the neighboring sinuses. Symptoms are pain, tenderness, swelling, and perhaps ab- scess, with fistula and contracture, later producing cicatricial ectropion. Treatment. — Constitutional, hot applications, and incision. ORBITAL CELLULITIS. Definition. — Inflammation of the cellular tissue of the orbit, usually terminating in suppuration. Etiology. — Injuries, erysipelas, septicaemia, extensions from neighboring sinuses, and idiopathic. Sympt^^ms. — There may be constitutional disturbance, swell- ing of the lids, chemosis, exophthalmos, and perhaps panoph- thalmitis and meningitis. Treatment. — Hot applications, incision into the orbit if pus has formed. TUMORS OF THE ORBIT. Cyst, aneurism, angioma, osteoma, sarcoma, and carcinoma have been reported. Treatment. — Excision, with preservation of the eye if pos- sible. The operation of Kronlein (osteoplastic) consists in removing part of the outer wall of the orbit, and gives access to the orbit. The whole contents of the orbit are some- times removed in case of malignant disease (exenteration). QUESTIONS. Describe periostitis and orbital cellulitis. Give the treatment of tumors of the orbit. DISEASES OF THE EYEBALL, 117 CHAPTER XVI. DISEASES OF THE EYEBALL. EXOPHTHALMOS. Synonym. — Proptosis. Definition. — A condition in which the eyeball is pushed forward from orbital inflammation, hemorrhage, tumors, or in exophthalmic goitre. PULSATING EXOPHTHALMOS. Definition. — Protrusion, with pulsation of the eyeball and surrounding parts. A bruit is heard above the eye. Gener- ally due to traumatism causing communication iDetween the carotid artery and cavernous sinus. Treatment. — Tying the common carotid artery. EXOPHTHALMIC GOITRE. Synonyms. — Graves' disease, Basedow's disease. Definition. — A disease of the nervous system in which the heart action is accelerated, thyroid gland enlarged, and the eyes prominent. Subjective and Objective Symptoms. — The exophthalmos is partly only apparent on account of the widening of the pal- pebral fissure (Dalrymple's symptom). When the eyes are turned downward, the upper lid does not follow (Graefe's symptom). There is also infrequent winking (Stellwag's symptom). If the exophthalmos is extreme, the cornea suffers from exposure, since the lids can not be closed. Treatment. — Beside general treatment, thyroidectomy and sympathectomy have been tried. Enophthalmos is recession of the eyeball into the orbit. Usually traumatic and very rare. Anophthalmos is absence of the eyeball. It may b^ congenital. iSegalophthalmos is enlarged eyeball. 118 DISEASES OF THE EYEBALL. Microphthalmos is a small eyeball. Congenital. A shrunken eyeball resulting from extensive inflammation is known as phthisis bulbi. BUPHTHALMOS. Synonyms. — Hydrophthalmos ; Keratoglobus ; Congenital glaucoma. Definition. — A progressive enlargement of the whole eye, with increased tension. Begins in utero or in infancy. INJURIES OF THE EYEBALL. Contusions and wounds of the eyeball have been described under diseases of the various structures of the eye. FOREIGN BODIES WITHIN THE EYEBALL. Perforating wounds with retention of a foreign body are always serious injuries. Aside from the danger of infection carried in by the foreign body, or from the wound, the pres- ence of a foreign substance generally leads to destructive changes. Diagnosis. — The history, character of the wound, be- havior of the eye after the injury, and sometimes a view of the foreign body, will usually determine its presence in the eye. If the particle be iron or steel, a magnetic needle prop- erly adjusted, as in the sideroscope of Asmus, may be used. Or, when a large magnet is placed before the eye, pain is sometimes felt. The ;i'-ray has also been successfully em- ployed in localizing foreign bodies. Treatment. — If the foreign body be of wood, stone, brass, or glass, it should be removed with forceps, hook, or in any way possible. If magnetic, and in the vitreous, it may be removed through the original wound, through an incision in the sclerotic, or may be brought around the lens into the ante- rior chamber. For this purpose, a large magnet, such as that of Haab, is best employed, although smaller magnets are QUESTIONS. 119 sometimes of service, and may even be introduced into the wound. It is well to remember that small aseptic foreign bodies may become encysted and remain innocuous for many years. Even after successful extraction, degenerative changes are likely to occur after a considerable time. ENUCLEATION. This operation is performed under general anaesthesia. The conjunctiva is cut all about the edge of the cornea with scissors. Each muscle is then taken on a strabismus hook and cut close to the eyeball. A strong scissors, which is curved on the flat, is passed backward close to the eyeball on tiie nasal side until the optic nerve is felt. This is severed with one stroke. The eye is then easily freed from remaining adhesions. After cleansing with an antiseptic (bichloride of mercury 1 : 5000) the conjunctiva should be brought together with a purse-string suture. An artificial eye may be worn in two or three weeks. EVISCERATION (EXENTERATIO BULBI). A substitute for enucleation, having the advantage of leaving a better stump for an artificial eye. The eye is opened by excising the cornea, and the contents are scraped out, leaving only the sclera. A hollow sphere of glass or silver is sometimes introduced (Mules' operation), QUESTIONS. Define pulsating exophthalmos and exophthalmic goitre. What are the dangers of perforating wounds of the eyeball? How may the diagnosis of the presence of foreign bodies within the eye- ball be made? Give the treatment of foreign body witlnn the ej'^eball. Describe enucleation and evisceration. 120 GLAUCOMA. CHAPTER XYII. GLAUCOMA, Definition. — A disease characterized hy increase of intra- ocular tension. Varieties. — Acute inflammatory glaucoma, chronic inflam- matory glaucoma, simple glaucoma, and secondary glaucoma. ACUTE INFLAMMATORY GLAUCOMA. Predisposing causes are, age over forty, arterial sclerosis, high arterial tension, and hypermetropia. Exciting causes are physical and mental depression, in- somnia, and the use of a mydriatic. Pathology. — A current normally passes from the ciliary body, around the lens, through the pupil, anterior chamber, and ligamentum pectinati in the iris angle, into Schlemm's canal. Interference with this system of circulation, such as would be caused by blocking-up of the iris angle and cutting off the outflow, with or without increase in the secretion, will be followed by rise in intraocular tension. Upon this theory most explanations of glaucoma are founded. Prodromal Symptoms. — For a year or two the patient may complain of a failure of accommodation, which shows itself by the need of stronger glasses, or of occasional attacks of blurred vision and halos about the light. Symptoms of attack begin suddenly with a severe pain in the eye and head. There may be some temperature, nausea, and vomiting. The lids are swollen, the eyeball is deeply con- gested, cornea steamy and ansesthetic, anterior chamber veiy shallow, pupil dilated and oval in shape, and the iris dis- colored. The fundus can not usually be made out on account of the cloudiness of the media. Vision may be diminished in a few hours even to perception of light. Tension is very high. This attack lasts from a few hours to a few days; then all acute symptoms gradually subside, leaving the vision ACUTE INFLAMMATORY GLAUCOMA. 121 more or less permanently impaired. The other eye may be affected in a similar manner at any time. Recurrence. — After a few weeks or months the acute attack is repeated, and if no treatment is given, the eye later will pass into a condition of subacute or chronic glau- coma. Diagnosis. — Although acute glaucoma is not a common dis- ease, the importance of differential diagnosis is evident from the fact that if the condition is mistaken for iritis and atro- pine prescribed, the results will be disastrous. The follow- ing table will assist the student. It applies to acute condi- tions. Age Tension ..... Secretion .... Congestion . . . Cornea Anterior chamber Iris Pupil Pain Vision Treatment . . . Glaucoma. Over forty. Plus. None, or watery. (General, especi- ally scleral. Cloudy and steamy surface. Shallow. Discolored. Dilated, oval. Severe, continuous. Much reduced. Eserine, pilocarp- ine, iridectomy. Iritis. Any. Normal. None, or watery. General, especially circumcorneal. Cloudy. Unchanged. Unchanged. Discolored. Unchanged. Contracted, syn- Unchanged. echiae. Especially at night. None. Somewhat reduced Good. Atropine. ! Astringent. Conjunctivitis. Any. Normal. Mucopurulent. Conjunctival, espe- cially of lids. Clear. Prognosis. — After proper treatment, the results in acute glaucoma are usually satisfactory. It must be borne in mind, however, that the operation or after-treatment at times pre- cipitates an attack in the other eye. Treatment. — Persons over forty, complaining of rapidly failing accommodation, transient blurs, and halos should be kept under observation. In the acute attack the patient should be kept in bed and given a full dose of an opiate. Locally, eserine sulphate (0.5 per cent.) should be instilled at first every hour or two ; later, three to five times a day. 122 GLAUCOMA. But if the tension remains high and vision becomes worse, iridectomy should be performed as follows : A general anaes- thetic is necessary in acute glaucoma. After cleansing the eye, the speculum is adjusted. The fixation forceps are then Fig. 29. Keratome. placed in the conjunctiva below the cornea, and a lance-knife or bent keratome is introduced into the sclera above, about 1 mm. back of the clear cornea, and the point is passed into the anterior chamber over the iris. After withdrawing the knife, the iris forceps is introduced and the iris grasped near Fig. 30. Iridectomy for glaucoma. (De Weeker.) the pupillary edge and drawn out of the wound. The iris is then cut off with two snips of the scissors very near to the eyeball. The cut edges of the iris are replaced with a spatula, making the ideal keyhole iridectomy. Some operators use the Graefe cataract-knife for the incision. CHRONIC INFLAMMATORY GLAUCOMA. Definition and Symptoms. — After repeated attacks of acute glaucoma, or primarily, the tension may become permanently increased. There is more or less pain, enlargement of scleral vessels, shallow anterior chamber, oval, enlarged and immov- able pupil. Vision is reduced or destroyed. Later, when there is no. perception of light, very high tension, cataractous lens, wide pupil, and shallow anterior chamber, the condition is known as Absolute Glaucoma, SIMPLE GLAUCOMA. 123 SIMPLE GLAUCOMA. Synonyms. — Chronic noninflammatory glaucoma ; Glaucoma simplex. Etiology. — Age over forty. Hyperopic refraction, arterio- sclerosis, and high arterial tension. Pathology. — See Acute Inflammatory Glaucoma. Subjective Symptoms. — The only complaint from the patient is gradual decrease in vision and halos about artificial light. There is no pain, only occasionally a sense of pressure. Objective Symptoms. — The eye will be found free from con- gestion, except perhaps a few enlarged scleral vessels. The anterior chamber may or may not be shallow. The pupil may be normal and movable, or somewhat dilated. The lens and vitreous are clear. The optic nerve is atrophic, white or gray, and shows the characteristic condition known as " cupped disk." Just inside the scleral ring, which is broad, the nerve falls abruptly to a deeper level, and the bloodvessels will be seen dropping over this edge and appearing again at the bottom of the excavation. The arteries, if closely ob- served, will be seen to pulsate. The tension of the eye is increased, but not constantly, at times being quite normal. The field of vision is contracted concentrically, but more especially on the nasal side. There may be irregular con- traction in any part of the field, and even isolated scotomata. The acuity of vision is usually reduced, although in some cases the field is much contracted before the vision is affected. Course. — Both eyes are usually afi'ected at about the same time. The disease continues over a number of years. If no treatment is undertaken, it ends in absolute glaucoma. Diagnosis. — In some cases the appearance is very similar to atrophy of the optic nerve with excavation, and may only be distinguished by detecting increase of tension, which is not at all times present. In prescribing mydriatics such as atro- pine for a patient over fifty, the possibility of glaucomatous tendencies should be borne in mind, since these drugs tend to increase intraocular tension. Prognosis. — Although the prognosis is poor, the disease will 124 GLAUCOMA. usually be arrested, or at least the rapidity of its progress decreased by operation. The success of operative treatment is in general proportionate to the size of the field of vision. On rare occasions the eye operated upon will become more rapidly worse. Sometimes there is no effect. Increased ten- sion, with inflammatory signs, immediately after operation, is of rare occurrence. This latter condition is known as malignant glaucoma, and results in loss of the eye. Treatment. — Eserine (0.2 per cent.) t. i. d., or pilocarpine (1 per cent.) t. i. d., should be given as temporary palliative treatment. An iridectomy, broad at the base of the iris, should be performed, as already described. It may be done under cocaine. Sclerotomy as a substitute for iridectomy may be tried : The eye is entered with a Graefe knife, as for cataract incision, but the knife is withdrawn before the flap is completed (anterior sclerotomy). Or, the knife is entered well back in the sclera and the eye pierced behind the lens (posterior sclerotomy). Of late, excision of the superior cer- vical ganglion (sympathectomy) has been performed for the relief of glaucoma with some success. Secondary Glaucoma is generally due to mechanical causes, such as filling up of the iris angle, swelling of the lens, dislocation of the lens, hemorrhages, intraocular tumors, injuries, choroiditis, retinitis, and closure of the pupil. Hemorrhagic Glaucoma. — A form which appears after retinal hemorrhages of various origin. Its treatment is un- satisfactory, iridectomy being generally disastrous from the occurrence of further hemorrhages. QUESTIONS. Into what varieties may glaucoma be divided? Give cause, symptoms, and treatment of acute inflammatory glaucoma. Give differential diagnosis between acute glaucoma, iritis, and conjunc- tivitis. Give pathology, symptoms, diagnosis, prognosis, and treatment of simple glaucoma, SYMPATHETIC OPHTHALMIA. 125 CHAPTER XVIII. SYMPATHETIC OPHTHALMIA. Definition. — A condition in which a healthy eye becomes the seat of a clestructiv^e inflammation transferred from the other eye, which has been the subject of a similar inflam- mation usually following a perforating injury of the eyeball. The injured eye is called the exciting eye ; the other, the sym- pathizing eye. Although sympathetic ophthalmia is a com- paratively rare disease, the possibility of its occurrence should not be overlooked on account of its terrible consequences. Etiology. — Children are more susceptible than adults. The type of inflammation in the exciting eye is usually a chronic plastic iridocyclitis. This is produced in the majority of cases by a perforating wound involving the so-called " danger zone," or ciliary region — a zone J inch wide about the cornea. There may or may not be retention of a foreign body within the eyeball. It may follow cataract extraction. The exciting eye may be one which has had a perforating ulcer of the cornea with incarceration of iris or ciliary body. Instances have been reported in which there was no evidence of per- foration, traumatic or otherwise. Eyes destroyed by purulent inflammation, as a rule, do not produce sympathy. Pathology. — The mode of transmission of the inflammation is still undecided. The theories are (a) irritation in the sym- pathizing eye, producing disturbances of nutrition and circu- lation, and, finally, inflammation through the agency of the intimate nerve relationship ; (b) transferrence of germs by means of communication through the optic nerve or sheath ; (c) transmission of infectious germs or toxins by means yet unknown. The last is the commonly accepted theory. Symptoms of the Disease in the Exciting Eye. — The eye is more or less congested and painful. It is tender in the ciliary region when pressure is made through the upper lid ; shows minus tension ; posterior synechise or pupil blocked with exudate. 126 SYMPATHETIC OPHTHALMIA. Symptoms of the Disease in the Sympathizing Eye. — There is a chronic inflammation involving the uveal tract (iris, ciliary body, and choroid). It may begin (a) with slight ciliary congestion, punctate deposits on Descemet\s membrane, deep and cloudy anterior chamber, slightly dilated pupil, a few synechise and opacities in the vitreous (so-called serous iritis) ; {b) or the disease may begin at once as a plastic irido- cyclitis with pain, ciliary tenderness, ciliary congestion, small and blocked pupil, opacities of vitreous, and later formation of bands and detachment of the retina and shrinking of the eyeball ; (c) the disease may also appear first as a neuro- retinitis. Course. — Sympathetic ophthalmia appears between the third week and the sixth month after the original injury. The extreme limits are two weeks and twenty or more years. The second eye is likely to be attacked during a period of active inflammation in the exciting eye. Although there are usually some symptoms of sympathetic irritation (see page 127) before the genuine attack sets in, it often appears without warning. The disease in the sympathizing eye runs a chronic course, with exacerbations. Prognosis. — Sympathetic inflammation once established leads to blindness in the vast majority of cases. Those ap- pearing as neuroretinitis are the most favorable. Treatment. — The enucleation of a suspected eye, if we can be assured that the sympathetic process has not begun, is a positive preventive, and should be practised in cases of hope- lessly extensive wounds. Further, an eye which has been the subject of an injury especially involving the ciliary body or containing a foreign body, and which shows signs of plastic iridocyclitis with ciliary tenderness and in-drawn scar, should be enucleated. Evisceration of the contents of the eyeball or section of the optic and ciliary nerves are advocated by some as a substitute for enucleation. When sympathetic ophthalmia is established, enucleation of the exciting eye is usually considered of no value — at all events, should not be performed if any vision remains in the hefraction, 127 exciting eye. After cessation of the disease the first eye may be the better. The patient shoukl be treated with rest in bed, mercury — either by inunctions or internally — and by diaphoretics. The eye should be kept under the influence of atropine and hot fomentations. If the inflammation finally subsides without shrinking of the eyeball, an attempt may be made to obtain a clear pupil by iridectomy or iridotomy, but it will usually close again. SYMPATHETIC IRRITATION. Definition. — This is a distinct affection apart from sympa- thetic inflammation. It is a neurosis, showing in the sympa- thizing eye photophobia, lachrymation, symptoms of asthe- nopia, impaired accommodation, and contraction of the field of vision. In its simplest form it may be produced by irrita- tion, such as arises from the presence of a foreign body on the cornea, or may appear when the exciting eye is one capable of producing sympathetic ophthalmia. These phe- nomena are likely to recur at intervals, and may be the pre- cursors of the true inflammation. Hence blind offending eyes should be removed. QUESTIONS. Define sympathetic ophthalmia. What is the mode of transmission from one eye to the other? Describe the disease in the exciting eye and in the sympathizing eye. What are the course and the prognosis ? Give the rules for enucleation of the offending eye. What is sympathetic irritation ? CHAPTER XIX. REFRACTION. SUBJECTIVE EXAMINATION. A test-case consists of lenses and prisms graded in strength. Lenses. — A lens is made of glass or crystal, with at least one surface curved, and has the power of refracting or changing the direction of rays of light. 128 REFRACTION. Prisms. — A prism is wedge-shaped, and bends rays of light toward its base. Prisms are numbered (a) according to the angle of the two sides ; or (6) by the amount of angular devia- tion of a ray of light, which is produced by the prism : the latter may be considered about one-half the former ; (c) devia- tion measured in one-hundredths of a given arc (centrad). Spherical Convex Lens. — Usually biconvex. Converges rays of light to a focus. When the entering rays are parallel, the distance from the optical centre of the lens to tlie focus is called the principal focal distance. The stronger or more convex the lens, the shorter the focal distance. Convex Cylindrical Lens. — May be represented by a section, cut in one plane, from a solid cylinder parallel to the axis of the cylinder. One surface would be plane, the other surface would have a convex meridian, and the other meridian at right angles to it — a straight line. The focus is determined for the meridian of greatest curvature, and is a line instead of a point. Concave Spherical Lens. — Usually biconcave. Diverges rays of light and has no real focus. The focal distance is found by extending the divergent rays backward until they meet. The same principles then apply as for convex sphericals. Concave Cylindrical Lens. — Corresponds to convex cylin- drical lens, but has one concave meridian. Numbering of Lenses. — Lenses are numbered according to two methods : 1. The inch system, which designates the strength by the inverse of the principal focal distance in inches : -^-q" signifies a lens whose focal distance is 20 inches. 2. The diopter (dioptry, dioptre) system. A lens with a focal distance of one metre is the unit. A lens of one-half this focal distance would be called 2 D. ; one-quarter of this distance, 4 D. One system may be converted into the other, approximately, by dividing the number of the lens, in either system, into 40 — e. g., 2 D. equals 20 inches, or, 10 inches equals 4 D. + sig- nifies convex, and — concave, lenses. Diagnosis with Lenses. — After recording the vision, as de- OBJECTIVE EXAMINATION. 129 scribed on page 26, if it is f J-, one may conclude that the patient is either emmetropic or hypermetropic. If a convex spherical lens is held before the eye and the vision still remains perfect, the eye is hypermetropic and the strongest glass ac- cepted measures the manifest hypermetropia. If no plus glass is accepted, the eye is probably practically emmetropic. If the vision is not equal to f^, and the cause is a refractive error, this is either myopia, astigmatism, or high hypermetropia. Concave spherical lenses should be tried, and if the vision is made perfect, the weakest lens measures the myopia. If not made perfect, convex and concave cylinders should be tried at all axes until vision is improved. The improvement of vision by cylinders shows the presence of astigmatism. OBJECTIVE EXAMINATION. Ophthalmoscope.— The direct method is employed. The observer must learn to relax his accommodation. The accom- modation of the patient usually relaxes under the examination, or a cycloplegic (atropine, 1 per cent., or homatropine, 2 per cent.) may be used. Hypermetropia is measured by noting the strongest convex lens of the ophthalmoscope through which the fundus may be clearly seen, and myopia by the weakest concave lens. Astigmatism gives a streaked appear- ance to the fundus. Each meridian may be measured, as is simple hypermetropia or myopia, by focussing upon the retinal vessels. With practice, the refraction may Jbe estimated with great accuracy. Skiascopy (Retinoscopy, Shadow Test).— A skiascope, or retinoscope, is a circular plane or concave mirror with a small central aperture. If the light is placed back of the patient, and the observer stands about 1.5 metres in front and reflects the light into the patient^s eye, the pupil will show a red reflex. When the reflected light is moved slowly from side to side, the red pupil reflex will appear to move either in the same or in the opposite direction. If the reflex, or the shadow which borders it, moves in the same direction, when a plane mirror is used, the eye is hypermetropic. If in the 9— E. E. 130 REFRACTION. opposite direction, the eye is myopic. The reverse is true if the concave mirror is used. By placing lenses before the patient's eye, one may determine the exact correction when there is no movement of the reflex. The different meridians of astigmatism may be separately measured in this way. Skiascopy is the most accurate method of determining refrac- tion. Ophthalmometer. — An instrument for the determination of variations in the curvature of the cornea by means of reflexes. As astigmatism is, for the most part, in the cornea, the instrument is of value in confirming other tests. INDIVIDUAL ERRORS OF REFRACTION. If parallel rays of light are brought to a focus on the retina, with the accommodation at rest, the refraction is normal and the eye is said to be emmetropic. If under these conditions the rays are not brought to a focus upon the retina, the eye is ametropia The varieties of ametropia, or errors of refraction, are (I.) hypermetropia, (II.) myopia, and (III.) astigmatism. Anisometropia is a term commonly employed to denote that one eye differs markedly from the other in refraction. I. HYPERMETROPIA. Synonym. — Farsightedness. Definition. — A condition in which, with the accommodation at rest, parallel rays of light fall behind the retina. Hypermetropia is a congenital defect, and never increases. The eyeball is too short in anteroposterior diameter for the refractive power of the media. Thus the focus falls behind the retina, but while the accommodation (see page 27) is strong, the focus may be brought forward. Ssrmptoms. — The patient complains of asthenopia, under which head are classed the symptoms produced by eye-strain : pain in the eyes, headache (especially frontal), blurring and running together of type, conjunctivitis, photophobia, tiring of the eyes, dizziness, etc. INDIVIDUAL ERMons OP HEPMACTION. 131 Tests. — When the vision is tested at a distance, it will be found perfect unless the patient has lost his accommodation, but he will see as well with a convex glass. The strongest convex lens through which the patient sees as well as without, measures the manifest hypermetropia. A cycloplegic such as homatropine hydrobromate (2 per cent, solution) dropped into the eyes three times during an hour, or atropine sulphate (1 per cent.) three times a day for three days, will paralyze the Fig. 31. Ck>rTection of hypermetropia. accommodation, and the vision will then fall below the nor- mal, because the patient can no longer use his accommodation and bring forward the focus upon the retina. The convex lens, which then gives him perfect vision, will be stronger than that for the manifest hypermetropia, and measures the exact refraction of the eye or total hypermetropia. The differ- ence between the manifest and total hypermetropia is called the latent hypermetropia. As one grows older, the accom- modation weakens, and the latent hypermetropia becomes less until about fifty or fifty-five, when the manifest equals the total, if it does not before. Example. — If a patient under forty has perfect vision at distance — e.g., |^ with each eye, and sees as well with +2 D. spherical, and with no stronger lens, he is said to accept +2 D., or to have manifest hypermetropia of that amount. If the eyes are put under the influence of atropine, his vision will be reduced to perhaps f^, but with +3.5 D. is brought to 1^. He thus has total hypermetropia +3.5 D. and latent + 1.5 D. Treatment. — In young persons it is well to examine the 132 REFRACTION, eyes with a cydoplegic. When the observer is skilled in the use of the ophthalmoscope, skiascope, and ophthalmometer, the use of cycloplegics becomes less necessary, especially in adults. In some cases, particularly those with muscular errors, it is best to give the correction for total hypermetropia (full correction). But since the distant vision will be blurred with these lenses when the effects of the atropine have passed, it is generally customary to correct the manifest error and a little of the latent, in addition. In children the glasses should be worn constantly. I71 adults they may be used only for close work if the error is not large. n. MYOPIA. Definition. — Myopia is a condition in which the focus for parallel rays of light falls in front of the retina. The antero- posterior diameter is too long. It is a diseased condition. Etiology. — Myopia may be congenital, but is generally acquired, beginning usually between the ages of eight and fifteen. In the latter form there may be hereditary predis- position, but improper use of the eyes is the direct cause. FiQ. 32. Correction of myopia. Complications. — There is bulging of the posterior segment of the eyeball (posterior staphyloma). In high degrees this is accompanied by a chronic inflammatory process (cho- roiditis), which produces changes in the fundus, especially at the macula and about the nerve. There is also a tendency toward hemorrhages in the fundus, detachment of the retina, ASTIGMATISM. 133 and opacities of the vitreous. Insufficiency of the internal recti is a common complication, and at times divergent stra- bismus occurs. Symptoms. — The young patient begins to complain, in school, of poor vision at a distance. There is usually no asthenopia. If the disease has reached a high degree, near work is held very close to the eyes. Tests. — The distant vision is found considerably reduced, while perfect at the near point. Concave spherical lenses bring the distant vision to normal if there are no complications. The weakest concave lens which gives perfect vision measures the myopia. Atropine is not so important as in hyperme- tropia, since there is a natural tendency to relax the accom- modation. Low degrees of myopia, how^ever, should be tested with a cycloplegic, because spasm of accommodation, or false myopia, is possible, and gives poor vision, improved by weak concave lenses. Course. — Myopia may increase through youth and reach a high degree before the twenty-fifth year. It is then called progressive. When rapidly progressive, it is known as malig- nant. Treatment. — Near work should be restricted, and the eyes used only under the most favorable conditions as to proper position at desk, illumination, etc. Attention should be given to the general health and exercise out-of-doors prescribed. For the lower degrees of myopia, it is commonly agreed that the full correction of the error should be worn constantly. In high degrees and in patients over forty, a w^eaker glass should be given for near work. The crystalline lens may be removed by absorption or extraction in myopia over — 15 D. This more or less exactly neutralizes the myopia. III. ASTIGMATISM. Definition. — ^A condition in which one meridian varies from another in refractive power. Astigmatism is largely in the anterior surface of the cornea. The corneal surface may be likened to that of the bowl of a spoon. Some astigmatism. 134 REFRACTION. may be present in the lens. There may be irregularities in the surface of the cornea (irregular astigmatism) ; but, in the ordinary acceptance of the term (regular astigmatism), the extremes of curvature are at right-angles to each other. The axis of the astigmatism, as of the cylinder which corrects it, is that meridian which is nearest the emmetropic. There is no one point as a focus for the astigmatic eye, but there are two foci — one behind the other, and each a line at right-angles to the other. Astigmatism changes only gradually through life. Varieties. — Simple hyperopic astigmatism: one meridian emmetropic ; the other, at right-angles, hypermetropic. Simple myopic astigmatism : one meridian emmetropic ; the other myopic. Compound hypermetropic astigmatism : one meridian hyper- metropic ; the other more hypermetropic. Compound myopic astigmatism : one meridian myopic ; the other more myopic. Mixed astigmatism : one meridian hypermetropic ; the other myopic. Symptoms. — There is complaint of poor vision, of seeing lines in one direction better than another, and of asthenopia. Tests. — The vision is affected according to the degree of the astigmatism, both for near and distance. Cylinders at the proper axis will give improvement in vision. Atropine should be used for the examination under the same conditions as in hypermetropia. A further subjective test is made with a card having lines which radiate in all directions from a common centre, like spokes of a wheel. The astigmatic eye will not see all the lines with equal distinctness, and cylinders can be tried at all axes until the lines appear alike. Treatment. — It is desirable to order as weak a cylinder as possible. ERRORS OF ACCOMMODATION. Presbyopia.^The near point of monocular vision (punctum proximum) is about two and one-half inches in the young child. This near point gradually recedes until between forty THE MUSCLES OF THE EYE. 135 and forty-five it is no nearer than fifteen inches, which is the average reading distance. When the near point of accom- modation recedes beyond this point and vision is not clear within this limit, the condition becomes unpleasant for read- ing, writing, and other near work, and is known as iweshyopui. If a patient at forty-five can accommodate to a point 14 inches from the eyes, he has a range of accommodation from infinity to a distance of 14 inches, or 2.75 D. If at fifty his near point is 30 inches, his range is only 1.25 D., and he needs a lens to give him the required ranges^ — i. e.y +1.50 D., which would make +2.75 D., or bring the near point to 14 inches. When he has no accommodation at fifty-five, he will need +2.75 D. for near work. QUESTIONS. What is a leas ? A prism ? Describe four varieties of lenses. How are lenses numbered ? Give rule for changing one system into the other. Describe the use of the ophthalmoscope, retinoscope, and ophthalmometer. Give method of subjective examination. Define hypermetropia. Explain the accommodation. What are manifest, total, and latent hypermetropia ? Give tests for hypermetropia. What is the treatment. Give the definition, etiology, complications, and treatment of mypopia. What is spasm of accommodation? Define astigmatism. State varieties and Describe presbyopia. CHAPTER XX. THE MUSCLES OF THE EYE. The physiologic action of the external muscles of the eye- ball is as follows : Internal rectus turns the eye inward (adduction). External rectus turns the eye outward (abduction). Superior rectus turn the eye upward and inward (ad- duction), and rotates the upper extremity of the vertical meridian inward (wheel rotation or torsion). 136 THE MUSCLES OF THE EYE, Inferior rectus turns the eye downward and inward, and rotates the upper end of the vertical meridian outward. Superior oblique rotates the upper end of the vertical meridian inward, and turns the eye downward and outward. Inferior oblique rotates the upper end of the vertical meridian outward, and turns the eye upward and outward. The monocular ^e/(i of fixation is the area outlined by the limits of movement of each eye when the head is at rest. Errors of motility comprise : I., Insufficiency ; II., Stra- bismus; and III., Paralysis. I. INSUFFICIENCY. Definition. — A condition in which one or more muscles are lacking in power, but in which binocular vision is main- tained in spite of the error. There is a tendency for the eyes to deviate, but this is controlled by constant effort. Etiology. — Temporary depression in the general health, overuse of the eyes, insufficient innervation or mechanical dis- advantage, such as malposition of muscular attachment. Varieties. — The following terms are used to describe the varieties of insufficiency : Orthophoria is the condition of normal balance. Hetefrophoria, imperfect balance or insufficiency. Exophoria, tendency for eyes to spread. Insufficiency of the internal recti. Esophoria, tendency to converge. Insufficiency of the ex- ternal recti. Hyperphoria, tendency for eyes to deviate vertically. In- sufficiency of superior or inferior recti. Symptoms. — Pains in the eyes, headaches, running together of print, diplopia, dizziness ; in general symptoms classed under the head of asthenopia. Tests. — (a) Some patients with heterophoria will sponta- neously or voluntarily allow the eyes to separate or many will develop diplopia when a red glass is held over one eye. (6) Cover-test (see p. 31). (c) Vertical diplopia or Graefe test consists in holding a prism of 8° or 10° with base down STRABISMUS. 137 over one eye. This throws the image of that eye upward over the image of the other. If the lateral muscles are in equi- librium the upper image will lie vertically over the other. The amount of esophoria or exophoria may be measured by a })rism Avith base out or in which brings the upper image over the under one. (d) Adduction and Abduction Tests. — If a prism is held horizontally over either eye with the base either in or out and eyes fixed on object twenty feet distant, hori- zontal diplopia will be produced ; but if the prism is not too strong, the two images will run together and fuse into one. The strongest prism with the base in through which the two images may be made to fuse measures the fusion power of the external recti (abduction). This should be about 7° or 8°. The strongest prism with base owf, through which the images fuse, measures the internal recti (adduction). This should be 20° or 30°. The latter test is often deceptive. The same method may be used to test the elevators and depressors by holding the base of the prism either up or down. Fusion power should be 3° or 4°. A phorometer is an instrument constructed to hold suitably prisms used for the tests just described. Treatment. — Attention should be given to the general health. Errors of refraction should be carefully corrected. If there is no improvement, so-called gymnastic exercises may be prescribed. The patient practises by fusing the images which are produced by the strongest prism, making fusion possible, with the base over the muscle to be strengthened. The results are sometimes gratifying, but not likely to be permanent. The constant use of a prism as an eyeglass may h6 of value in some cases. A prism of about one-half the error, if it is not too great, is generally suitable. If the case is not improved by the treatment above outlined, faithfully carried out operative measures are to considered. If the external recti show abduction over 12° with weak adduction, the external rectus of one eye may be severed by a complete tenotomy. If the external recti show abduction as low as 1° or 2° with adduction strong, th? internal rectus may be cut with 138 THE MUSCLES OF THE EYE. caution. If excessive effect is produced at the time of the operation, it may be limited by a suture. So-called partial tenotomies consist in cutting a portion of the tendon. They yield no permanent results. n. STRABISMUS. Synonym. — Squint. Definition. — A condition in which both lines of sight are not directed toward the same object of fixation. Varieties. — The common varieties are convergent strabismus (internal squint), where one eye is turned inward toward the nose ; divergent strabismus (external squint), one eye turns outward toward the temple. Deorsumvergent strabismus (downw^ard) and sursimivergent strabismus (upward) are uncommon. A strabismus is said to be concomitant when the angle of deviation between the two lines of sight remains the same for any point in the field of fixation equally distant from the eyes. Periodic y when the squint is not constant. Alternate, when either one or the other may be the squinting eye. CONVERGENT STRABISMUS. Etiology. — Generally appears between the ages of two and five. At first periodic, later constant. Hypermetropia is generally the refractive condition of the eyes. The squinting eye is often amblyopic (having poor vision). This is regarded by some as the result of nonuse (amblyopia ex anopsia), and therefore secondary. By others it is considered a congenital defect, and partly the cause of the strabismus. Symptoms. — The child does not complain of diplopia, except rarely at the beginning, because the image of the squinting eye is disregarded. Tests. — Measurement of the degree of squint may be made by noting the distance on the lower lid at which the centre of the cornea lies from the place which corresponds to that of the other eye. The angular deviation may also be measured by means of the reflex from the cornea by passing a candle along the arc of a perimeter. DIVERGENT STRABISMUS. 139 Treatment. — Nonoperative. — Convergent strabismus may be treated in very young children when it first appears by placing a cover over the better eye and forcing the child to use the squinting eye. It is important, when the child is old enough, that glasses should be worn to correct fully the errors of refrac- tion. There is usually hyperopia, or hyperopic astigmatism. Under such treatment a number of cases will recover. Operative treatment consists in performing tenotomy of the internal rectus of one or both eyes, and sometimes an advancement of the external rectus. Tenotomy. — The conjunctiva over the insertion of the ten- don is seized with a toothed forceps about 7 mm. from the edge of the cornea. A small opening is made with the scis- sors, exposing Tenon's capsule. This is opened in a similar Fig. 33. Tenotomy of an ocular muscle. (Veasey.) manner, and the tendon may then be caught up by passing a strabismus hook beneath it. The tendon should be completely cut close to the eyeball. A suture may be used to bring together the edges of the conjunctival wound. The opening in the conjunctiva and capsule is sometimes made at the edge of the tendon and the muscle cut by passing the scissors underneath the conjunctiva (subconjunctival tenotomy). The eifect of a tenotomy upon a squint is not always easy to predict with certainty. Remembering, however, that the edge of the cor- 140 THE MUSCLES OF THE EYE. nea should normally turn on either side to the inner and outer canthus, any decrease or increase of motility can be estimated. Such indications are the best guides for operation. If tenotomy of the internal rectus of the squinting eye does not produce sufficient effect, the other eye may be operated upon after waiting at least two months. At times, wlien the motility of the squinting eye is markedly deficient outward, advancement (see p. 137) of the internal rectus is indicated. As there is a tendency toward divergence in later years, it is safer to leave a little convergence. DIVERGENT STRABISMUS. Etiology. — May appear at any age. Often associated with myopia. Found after loss of vision in an eye from injury or disease and after faulty operation for convergent strabismus. Treatment. — In the majority of cases tenotomy of the external rectus will not suffice, but an advancement of the internal rectus is necessary in connection with it. Advancement. — The tendon of the opposing muscle is first cut. An incision is made over the tendon, and sometimes an elliptical piece of conjunctiva is excised. Tenon's capsule, thus exposed, is opened and the muscle raised upon two hooks. One suture is passed through the conjunctiva on the side of the wound farthest from the cornea, then through the middle of the muscle about ^ inch or more from its insertion. Two other sutures are then passed, one below and one above. The tendon is severed from its attachment to the eyeball and a piece cut off nearly down to the sutures. The first suture is then passed in a horizontal line under the conjunctiva on the corneal side, taking a firm hold on the episcleral tissue and coming out near the cornea. The other two are passed in the same way above and below. The sutures, when tied, will advance the muscle to produce the effect desired. Sutures should be left in place about seven days. PAUALtStS OF m^ OCULAR MtlSCLES. l4l ra. PARALYSIS OP THE OCULAR MUSCLES. Varieties. — Classification may be (a) according to the nerve affected. Tiie third nerve supplies all the muscles (including the sphincter pupillse, ciliary muscle, and levator palpebrse) except the external rectus and superior oblique, which are supplied by the sixth and fourth respectively; (6) according to the muscle paralyzed. Internal ophthalmoplegia is a term used to designate par- alysis of the intrinsic muscles, the sphincter, and ciliary muscle; and external ophthalmoplegia, paralysis of the ex- trinsic muscles ; total ophthalmoplegia, when both inti'insiG and extrinsic muscles are paralyzed. Etiology. — Paralysis may be congenitaly especially of the ex- ternal rectus and levator palpebrae (ptosis). In the acquired form, syphilis is the most common cause. Other causes are traumatism, locomotor ataxia, tumors, hemorrhages, and toxic conditions. Pathology. — The paralysis may be cortical, nuclear, in the nerve-trunk, or peripheral. Subjective Symptoms. — The patient suffers most from dip- lopia, dizziness, and confusion of vision. Objective Symptoms. — The excursion of the affected eye is limited. The head is held habitually away from the side of the paralyzed muscle in order to avoid diplopia. The character of the diplopia may be tested as follows : A red glass is placed over the paralyzed eye. The red image is called the false image. The false image appears to the patient to occupy a position, relative to the true image, which repre- sents the physiologic action of the muscle paralyzed. For example : if the right external rectus is paralyzed, there will be diplopia to the right of the median line, and the image of that eye will be to the right and on a level with the other image, which represents the action of the right external rectus — i. e., turning the eye to the right horizontally. The above rule will be found applicable to all cases except where secondary contractions have taken plnce Treatment. — In syphilitic cases mercury and iodide of 142 THE MUSCLES OF THE EYE, potassium should be given in full doses. In other cases sodium salicylate, mercury, iodide of potassium, and strych- nine. Sometimes, in mild cases, wearing of a prism will help to fuse the images. At times a cover must be worn over the paralyzed eye. Operations are usually unsatisfactory. NYSTAGMUS. Definition. — An involuntary oscillatory movement of the eyeball, usually from side to side (lateral nystagmus), occa- sionally up and down (vertical), or with wheel rotation (rotary). Etiology. — The condition is usually congenital and associated with poor vision. It is sometimes acquired when the eyes are used under poor illumination (miners' nystagmus). Treatment. — There is no treatment for the former. For the latter, change of occupation. QUESTIONS. What is the physiologic action of each of the ocular muscles? Define insufiiciency, and give terms used to describe varieties. Name four tests for heterophoria. Give the treatment for heterophoria. What are the common varieties of strabismus ? Give the cause, etiology, symptoms, and treatment of convergent stra- bismus. Describe operations for tenotomy and advancement. How may paralysis be classified ? Give rule for determining the muscle affected. What is nystagmus? ^ JOHN K. MORRIS, M. fX THE EAR AND ITS DISEASES. CHAPTER I. ANATOMY AND PHYSIOLOGY. For the convenience of study the organ of hearing may be considered as being composed of (1) a conducting apparatus — consisting of the auricle, external auditory meatus, merabrana tympani, ossicles, and the tympanum, together with the con- necting cavities of the Eustachian tube and the mastoid process — by means of which certain forms of ethereal vibra- tions are collected and transmitted inward to (2) a perceptive mechanism — divided into the vestibule, semicircular canals, and cochlea, with its filamentous terminations of the auditory nerve — through the agency of which the vibrations are recog- nized and the resulting stimulation is conveyed to the audi- tory centre of the brain and there interpreted as sound. A further clinical subdivision considers the conducting portion as being composed of an external ear (auricle and ex- ternal auditory meatus), a middle ear (membrana tympani, ossicles, and the tympanic cavity, with its connecting Eu- stachian tube and mastoid process), while the perceptive mechanism constitutes the internal ear or labyrinth. THE CONDUCTING APPARATUS. The External Ear. The Auricle. — To secure the best concentration and con- duction of the sound-waves, the external ear is an oval, funnel-shaped organ with the convexity of the auricle point- 143 144 ANATOMY AND PHYStOLOGT. ing inward toward the middle ear or tympanum. In struct- nre, with the exception of the lobule (Fig. 33), which is composed of a network of connective tissue interposed with globules of fat, the auricle or pinna consists of a convoluted, cartilaginous framework, attached to the temporal bone by ligaments and rudimentary muscles, and covered by a thin, firmly adherent reflection of the integument from the side of the head, preserving the ridges and depressions of the sub- Fig. 33. Auricle : A, helix ; B, antihelix ; C, tragus ; D, antitragus ; E, lobule ; F, concha : G, orifice of the external meatus. (Politzer.) structure, which are named as indicated in the accompanying illustration. The external auditory meatus is a canal, which leads from the concha inward about one inch and a quarter, termi- nates with a membrane which separates the external ear from the tympanic cavity (Fig. 34). The outer third of this passage, which is a prolongation inward of the auricle, is cartilaginous, and forms an angle with the inner portion, which is bony in the adult. Hence, the auricle must be pulled TME MIDDLE EAR 145 upward, hachwardy and outward to make the meatus straight, when examming the intenor of the canal or the terminating membrane. The inner two-thirds of the meatus is mem- branous in the infant, with the exception of the distal end, which is formed by a bony ring, the annulus tsrmpanicus, which with development gradually elongates outward, replac- ing the membranous passage and forming the osseous portion of the adult ear, which is about three-quarters of an inch in length. A prolongation inward of the skin of the auricle forms the lining membrane of the meatus, which is thin and firmly attached in the bony portion. In the cartilaginous part numerous hairs, together with sebaceous and ceruminal glands, are present, which normally prevent to a marked extent the entrance or retention of foreign bodies within the canal. The blood-supply of the auricle and the outer end of the meatus is derived from the superficial temporal and the pos- terior auricular arteries, while the bony portion of the canal is supplied with branches from the internal maxillary. The nerve distribution of the auricle is from the deep poste- rior auricular and auricularis magnus, while that of the ex- ternal auditory meatus is derived mainly from the auriculo- temporal branch of the inferior maxillary nerve. THE MIDDLE EAR. The Membrana Tympani. — Situated at the inner end of the external auditory meatus, and separating it from the tympanic cavity, is a pearly- gray, oval-shaped membrane, concave on its outer surface, and placed obliquely to the axis of the canal so that the upper and posterior portion is the least removed from the examiner (Fig. 34). Its structure consists of an outer dermal surface continuous with that of the meatus, a middle fibrous membrane, and an inner mucous covering, which is reflected from the lining membrane of the tympanum. Within these layers rests the long handle of the malleus, the outlines of which are faintly followed from above, downward, and backward to its termination at the centre of the mem- 10— E. E. 146 ANATOMY AND PHYSIOLOGY. brana tympani in a slight depression, umbo, from which point a triangular, glistening area projects downward and for- ward to the periphery of the membrane (Fig. 35). This cone of light, as it is termed, is a reflection of the rays from the surface of the membrana tympani, due to its smoothness, obliquity of position, and contour of surface. At the upper Fig. 34. Incus. \ I Malleus. I ' , \Slapes. ^-.< — Semi-circular CanaU. Vestibule. Cochlea. A front view of the organ of hearing (right side). (Gray.) end of the handle is observed a yellowish-white projection, short handle of the malleus, from which point thin folds of membrane pass antra-supra-posteriorly to the upper wall of the canal, constituting the membrana flaccida or Shrapnell's membrane. The membrana tympani not only serves as a protection to the delicate structures within the tympanum, but also receives the sound-vibrations from without and trans- mits them to the ossicular chain of the middle ear. THE MIDDLE EAB. 147 The Tympanum. — Just beyond the membrana tjmpani, which forms the greater part of its outer wall, is situated, within the petrous portion of the temporal bone, the tym- panum, an irregular cavity having its greatest diameters antra-posteriorly and supra-inferiorly, with an inward depth of about one-eighth of an inch to the promontory from the drum membrane (Fig. 36). The upper portion of this cav- FiQ. 35. The normal membrana tympani (right ear) : 1,-membrana flaccida ; 2, long handle ; 3, cone of light ; 4, membrana vibrans ; 5, umbo ; 6, short handle. ity, the attic, lies immediately below the middle lobe of the brain, separated from it by a thin layer of bone, which forms the roof of the tympanum. The lower portion of the tym- panic cavity is termed the atrium. The floor, narrower than the roof and pierced by the Jacobson nerve, rests just above the jugular fossa. The outer wall, formed largely by the membrana tympani and the annulus tympanicus, into which bony ring the membrane is inserted, contains the Glaserian fissure, the iter chordae posterius, and the iter chordae ante- rius, the latter two being the openings through which the chorda tympani nerve enters and emerges from the tympanic 148 ANATOMY AND PHYSIOLOGY, cavity in its course across the inner surface of the drum mem- brane between the long handles of the malleus and incus (Fig. 36) on its way to the submaxillary gland. Separating the tympanum from the internal ear, the inner The middle and internal ear : 1, membrana tympani ; 2, long process of malleus : 3, chorda tympani nerve ; 4, short process ; 5, tendon of tensor tympani muscle ; 6, malleus ; 7, ligament ; 8, attic ; 9, incus ; 10, facial nerve ; 11, vestibule ; 12, stapes ; 13, auditory nerve ; 14, Eustachian tube ; 15, cochlea ; 16, promontory ; 17 atrium (right ear, anterior view). wall presents the following points of interest, as illustrated in Fig. 37 : (1) The fenestra ovalis, which opens into the vestibule of the internal ear, but is occupied, in the recent state, by the foot-plate of the stapes (Fig. 37). (2) The fenestra rotundum, closed by a thin membrane (membrana tympani secondaria), beyond which lies the cavity of the scala tympani of the cochlea. (3) The promontory, a convexity of the inner wall, formed THE MIDDLE EAR. 149 by the first turn of the cochlear spiral, which is situated just beyond the inner wall (Fig. 36). (4) The Aquaeductus Fallopii, a small canal through which the facial nerve passes, marked by a bony ridge along the supraposterior part of the inner wall. (5) The Pyramid, a bony, cone-shaped projection, which contains the stapedius muscle. Fig. 37. Chorda tympani View of inner wall of tympanum (right ear). (Gray.) The anterior wall, which is interposed between the carotid canal and the tympanum, presents the tympanic orifice of the Eustachian tube, canal for the tensor tympani, and the proc- esses cochleariformis, which is a thin, bony partition separating the two canals, while the posterior wall, which has the greatest height, reveals in its upper portion a passage, antrum, through which the vault of the tympanum, attic, communicates with the cells of the mastoid process, situated posteriorly. The Ossicles. — Connecting the membrana tympani with the fenestra ovalis of the inner wall, an ossicular chain, consisting of the malleus, incus, and stapes, serves to transmit the vibra- tions imparted to the drum membrane across the tympanic <5avity to th^ labyrinth or intern^ e^r. Fig, 38 illustrates 150 ANATOMY AND PHYSIOLOGY. very well the general shape, relative size, and position of the bones. The malleus consists of (1) a headj which articulates with the incus ; (2) a neckj constricted portion below the head ; (3) a long process, handle or manubrium, which is embedded in the layers of the membrana tympani ; (4) a short process, processus brevis, which presents at the upper end of the manubrium ; and (5) a processus gracilis, which lies in the Glaserian fissure. Fig. 38. ocessus brevis. ■ Os orbiculare. Head, Crura. The small bones of the ear, seen from the outside. (Gray.) The incus, which resembles in outline a molar tooth, has (1) a body, which articulates with the malleus ; (2) a long process, which articulates with the head of the stapes; (3) a short process, which has a ligamentous attachment at the lower edge of the antrum on the posterior wall of the tympanum. The stapes, as its name indicates, is stirrup-shaped, and presents (1) a head, which articulates, as shown above ; (2) a foot-plate, which occupies, in the recent state, the fenestra ovalis, being attached to the surrounding bony wall by an intervening annular ligament ; and (3) the crura, which con- nect the head and the foot-plate. The Joints and Ligaments of the Ossicles. — The ossicles are held in articulation and suspension within the tympanic cavity by means of ligaments, which, however, permit freedom of ossicular vibration in the normal state ; but in certain diseased conditions the ligaments about the articulations become thick- ened^ so that the joints assume o, stifFefte(} or ^v^n ankj^lose^ THE MIDDLE EAR. 151 condition, which interferes markedly with the ease of mobility, thus lowering the function of hearing even to inaudition if the process be sufficiently extensive. The Eustacliian Tube.— With an opening in the anterior wall Fig. 39. G H I A Eustachian tube and tympanic cavity (right ear, viewed from within): A, mem- brana tyrapani ; B, head of the malleus ; C, lower end of the handle of the malleus : D, body of the incus ; E, .short process of the incus ; F, tensor tympani muscle ; G, pharyngeal opening of the tube; H, isthmus of the tube; I, tympanic opening of the tube. (Politzer.) of the tympanum (Fig. 89), an osseous canal passes, from this point, inward, forward, and downward through the petrous bone, when it merges into a cartilaginous canal, which termi- nates in a funnel-shaped protuberance, with a slit-like orifice, 152 ANATOMY AND PHYSIOLOGY. located in the nasopharynx, just back of the inferior turbinated body (Fig. 53). At the junction (isthmus) of the cartilaginous and osseous portions, the canal has a diameter, in the recent state, of about one-twelfth of an inch, which gradually increases toward the tympanic and pharyngeal ends, where it measures one-eighth to one-quarter of an inch, the slit-shaped orifice of the latter being greatest in the vertical direction. This condition results from the fact that the cartilaginous portion, which forms the inner two-thirds of the Eustachian tube, is not composed throughout of cartilage ; the lower two-thirds of the anterior wall, together with all of the inferior, is membranous, inter- mingled with muscular fibres of the tensor palati. Hence, the slit-shaped lumen of the cartilaginous portion of the tube is normally obliterated in most cases through contact of the anterior membranous wall with that of the posterior, excepting the upper portion of the lumen, which remains patent because of its cartilaginous wall, thus preserving the passage at this point, though it may be obliterated by an inflammatory sw^ell- ing of the lining mucous membrane. During the act of swal- lowing, the tensor palati and the levator palati muscles open the pharyngeal portion of the Eustachian tube by drawing the anterior membranous wall forward and elevating the inferior portion of the tube, which acts increase the antra-posterior diameter of the passage and permit the entering air to reach the tympanic cavity, thus equalizing the atmospheric pressure upon the internal and outer surfaces of the membrana tym- pani, and favoring its freedom of vibration. The Lining Membrane of the Middle Ear. — The mucous mem- brane of the tympanum, which is continuous with that of the nasopharynx through the Eustachian tube, is thin, cili- ated, and slightly vascular in character. It not only forms the lining investment of the tympanic cavity, but also extends to the spaces of the mastoid process through the intervening antrum, and forms a covering of the ossicles, intratympanic muscles, and ligaments. The resulting reduplications or folds of the mucous membrane are of special interest in in- flammatory conditions of the tympanum, and especially those in th^ at^iCj which ^re large an^ numerous, as thej^ form yery THE CUDDLE EAR. 153 favorable conditions for the development and retention of an infective process, as will be shown later. In the tympanic })ortion of the Eustachian tube the lining membrane is also thin, smooth, ciliated, and firmly adherent, while in the car- tilaginous extremity it assumes the thick, vascular, and loosely attached character of the nasopharyngeal mucous membrane, through which route inflammatory conditions of the latter frequently extend to the tympanic cavity. The Intratympanic Muscles. — Only two muscles, the tensor tympani and the stapedius, are present within the ear. The tensor tympani (Fig. 36) obtains its origin from the upper wall of the Eustachian tube and the sides of the canal through which it passes ; emerges from the orifice of its canal just above the Eustachian opening ; curves around the projecting processus cochleariformis at nearly a right angle ; crosses the tympanic cavity ; and makes its attachment to the inner border of the long handle of the malleus just below the neck. The stapedius muscle originates within the bony canal of the pyramid (Fig. 37), and forms an insertion into the neck of the stapes through an intervening tendon. The action of the tensor tympani alone draws the drum membrane inward, thus rendering it more taut, and also forces the foot-plate of the stapes inward, thereby increasing the intralabyrinthine pressure, while the action of the stape- dius muscle is antagonistic to the action of the former, as it tends to draw the foot-plate outward, the posterior margin serving as a fulcrum, thus lessening the labyrinthine tension. It is therefore probable that the function of these muscles is to preserve an uniformity of pressure within the labyrinth under the varying conditions of atmospheric force and inten- sity of sound. The Arteries. — The blood-supply of the tympanum is derived mainly from (1) the tympanic branch of the internal maxil- lary, which enters the cavity through the Glaserian fissure, supplying the anterior wall and the tympanic end of the Eustachian tube, and anastomosing at the periphery of the membrana tympani with the stylomastoid branch of the pos- terior auricular ; (2) the superficial petrosal from the middle 154 ANATOMY AND PHYSIOLOGY. meningeal, which reaches the attic through the petrosquamous suture, and is distributed to the roof of the tympanum, the mal- leus and incus, and the inner wall through which, according to Pulitzer, "vascular connections are kept up between the middle ear and the labyrinth'^ ; (3) the tympanic branch of the internal carotid, which anastomoses with the tympanic and Vidian branches of the internal maxillary upon the floor and inner wall of the tympanum. In addition to the supply indicated above, the Eustachian tube receives the pharyngeal Fig. 40. Vertical (sagittal) section of the mastoid process and the osseous meatus : a, mas- toid cells ; 6, posterior wall of the osseous meatus ; c, anterior wall of the osseous meatus. (Politzer.) branch of the external carotid, a few small branches from the internal carotid, and the descending palatine and pterygo- palatine branches of the internal maxillary artery. The Nerves. — Through the otic ganglion the trifacial sup- plies the tensor tympani, a filament from the facial innervates the stapedius muscle, while the lining membrane of the tym- panum and the Eustachian tube receives its supply from the tympanic plexus. Trie Mastoid Process. — Immediately behind the auricle (ind THE PERCEPTIVE MECHANISM. 155 somewhat inferiorly is located a large, rounded, bony pro- tuberance, at the lower tip of which the sternocleidomastoid muscle forms an attachment. Its inward structure is usually composed of a varying number of pneumatic spaces or cells, irregular in size and shape (Fig. 40), which freely communi- cate with each other through openings in their intervening walls and also with the tympanic cavity through the antrum. Some mastoids are formed almost entirely of air-cavities, while others contain but few or no spaces, which is usually true of the infantile process, but with development the chambers are gradually formed and enlarged. In the child the inner wall of the mastoid, which separates the air-cavities from the lateral or sigmoid sinus of the brain, is quite thick, while the opposite outer wall is thin and often imperfect. Hence, in- flammatory conditions within the mastoid rarely extend in- ward to the meninges in the youthful patient, but tend to pass outward through the opposite wall, a circumstance which is indeed fortunate. The anatomical conditions are reversed in the adult, though the firmer and harder structures form a strong barrier to the passage of infection inward. Since the mucous membrane lining the pneumatic spaces of the mastoid is continuous with that of the tympanic cavity through the antrum, infective processes of the tympanum frequently ex- tend backward and involve the chambers of the mastoid process. The lateral sinus, which courses along the inner wall of the mastoid, the meninges of the brain, which are separated from the antrum by only a thin lamina of bone, and the facial nerve in its passage through the aquaeductus Fallopii, are structures of special importance to be considered in inflamma- tory conditions and surgical procedures. THE PERCEPTIVE MECHANISM. The Internal Ear. Just beyond the inner wall of the tympanum a group of osseoqs cavities and curving canals receive the peripheral enc}-? 156 ANATOMY AND PHYSIOLOGY. organs of the auditory nerve through which the sound-vibra- tions imparted from without are recognized and conveyed to the brain. This labyrinth, so termed from its complexity of shape, consists of an osseous portion (vestibule, semicircular canals, and cochlea) within which a membranous portion (utricle, saccule, semicircular passages, and scala media), filled with a fluid, forms a loose inner lining, being separated from the bony walls by an intervening perilymph. The Bony Labyrinth. The Vestibule. — This cavity, which forms the greater part of the internal aural chamber, is an oval, bony space about one-quarter of an inch in diameter, and is situated imme- diately beyond the internal wall of the middle ear, with which it communicates in the late state through the fenestra ovalis. The anterior part of the inner wall of the vestibule presents above an oval depression, fovea hemi-elliptica, and below, a small round excavation, fovea hemispherica, into which fila- ments of the auditory nerve enter through minute foramina in the inner wall, while the posterior portion of the vestibular cavity reveals the aquseductus vestibuli, which passage con- nects with the subdural space. In front the vestibule be- comes the scala vestibuli of the cochlea (Fig. 41), while pos- teriorly the semicircular canals communicate with the vestibule by five openings. The Semicircular Canals. — Three small bony passages emerge from the posterior aspect of the vestibule, follow a nearly circular course through the osseous tissue, and terminate in a dilated portion, ampulla, where they again commu- nicate with the cavity. One of the canals passes upward, and is termed the superior semicircular canal ; another, the poste- rior semicircular canal, runs both vertically and backward ; while the shortest of the three, the external semicircular canal, takes an outward and backward course. The former canals possess at one end a common opening into the ves- tibular chamber. The Cochlea, — Situated antra-inferiorly to th^ v^stibule^ with ^tni: PERCEPTIVE mechanism. 16? which it communicates, and internally to the promontory which is formed by its first turn, a spiral canal, which re- sembles that of a minute snail-shell, is formed in the petrous bone, constituting the cochlea (Fig. 42). It consists of a conical central axis, the modiolus, around which a tapering spiral canal makes two and one-half turns, ending in an apex which points outward and forward, while the base of the Fig. 41. Opening of aqueductus vestibuli. Bristle passed through foramen rotunduni. Opening of aqueductus cochleae. The osseous labyrinth laid open (right ear). (Gray.) cochlea faces the internal auditory meatus. Winding around the modiolus from the base to its apex, a thin bony plate, lamina spiralis ossea, projects from the central axis outward, midway across the lumen of the canal (Fig. 44), where it joins, on its lower edge, a lamina spiralis membranosa or membrana basilaris from the opposite side, thus dividing the spiral canal into two passages — the scala vestibuli above and the scala tym- pani inferiorly, which communicate at the apex of the cochlea 158 ANATOMY AND PHYSIOLOGY. through a small foramen. The former passage enters the vestibule, Avhile the latter communicates with the tympanum in the late stage through the fenestra rotundum, which is normally occupied by the membrana tympani secondaria. Through several canals in the base of the modiolus, blood-ves- sels and bundles of the cochlear branch of the auditory nerve are distributed to the scalae. Within the canalis spiralis modioli, which tunnels around the modiolus near the junction of the bony lamina spiralis, rest the enlarged terminations, ganglia spirala, of the cochlear branch, from which filaments Fig. 42. Section of the osseous capsule and of the modiolus of the cochlea with the lamina spiralis ossea : a, internal auditory meatus ; b, modiolus. (Politzer.) pass through minute canals in the spiral lamina to the organ of Corti, which is situated upon the membranous lamina spiralis. The Membranous Labyrinth. As indicated previously, the membranous labyrinth con- sists of a series of fibrous pouches and tubes, filled with an endolymph, which form a loosely attached inner lining of the bony labyrinth, from the walls of which it is separated by an intervening perilymph. Hence, the outlines of the mem- branous labyrinth resemble those of the osseous portion (Fig. 43). The Utricle. — This oblong sac forms the greater part of the THE PERCEPTIVE MECHANISM, 159 vestibular portion of the labyrinth, and occupies the posterior part of the bony vestibule, forming an attachment to the inner wall in the fovea hemi-elliptica. Within the utricle at this point there is a macula acustica with its specialized protoplasmic cilia, which receive neural filaments from the auditory nerve. Posteriorly the utricular cavity communi- cates with the membranous semicircular canals. The Saccule. — This globular pouch lies antra-inferiorly to the utricule in the fovea hemispherica near the mouth of the Fig. 43. ^Ampullce Canalis Reuniens The membranous labyrinth. cochlea. A macula acustica is also present in the saccule at the point of its attachment in the hemispherical depression, from the bottom of which tiny nerve-filaments enter the macula. No communication is demonstrable between the utricle and the saccular cavity, though the latter joins that of the scala media through a minute passage, the canalis reuniens. The Membranous Semicircular Canals. — In number and shape these correspond to the bony canals which they line, and become continuous with the utricular cavity, as indicated 160 ANAlVMT A^D PHYStOLOQY. in Fig. 43. In the ampullae there occur the cristae acusticae, vvliich are similar to the specialized areas of the utricle and saccule and also receive filaments from the auditory nerve. The Scala Media or Ductus Cochlearis. — This triangular membranous passage, which traverses the entire length of the spiral canal of the cochlea, is a subdivision of the outer por- tion of the scala vestibuli, formed by the membranous spiral Fig. 44. Section through the first turn of the cochlea of a newborn infant: S,c.v, scala ves- tibuli ; Sc.i, scala tympani ; k, lamina spiralis ossea ; ft, lamina basilaris ; I, liga- mentum spirale ; JR, membrana vestibularis ; Dc, ramus cochlearis ; o, Corti's organ ; m, Corti's membrane ; n, fasciculus of the ramus ; g$, ganglia spirale. From a prepa- ration in the author's collection. (Politzer.) lamina or membrana basilaris, ligamentum spirale, and the membrane of Reissner (Fig. 44). Upon the basilar mem- brane rests the remarkable perceptive mechanism of Corti. In general the organ of Corti, as it is termed, consists of a ridge of polymorphous cells (Fig. 45), formed by two rows of modified columnar, epithelial cells, which, separated at the base, incline toward each other and interlock at the top, forming an archway within which a minute triangular pas- THE PERCEPTIVE MECBANISM. IGl Sage, tunnel of Corti, is enclosed. Upon either side of tliis epithelial arch rests a group of specialized neuro-epi- thelium, from the top of Avhich minute cilia project into the lumen of the canal, which is filled with a thin fluid. Be- yond this group the modified cells gradually merge into the epithelial layer of the membrana basilaris. From the gan- glia spirala, tiny neural filaments may be traced to the ciliated epithelia through minute passages in the osseous spiral lamina. Extending from an epithelial thickening upon the upper edge of the bony lamina spiralis, a membrana Corti projects to the Fig. 45. Terminal filaments of the cochlear nerve, with Corti's orfjan, as found in the human subject: o, lamina spiralis ossea, with the nerve-bundle of the ramus coch- learis ; pi, lamina spiralis membranacea; H, tooth of Huschke (crista spiralis); C, inner rods of Corti : C", outer rods of Corti ; r, lamina reticularis : Z. Corti's cells ; D, Deiter's cells; //), inner hair-cells ; oh, four outer hair-cells; e, radiating tunnel fibres of the ramus cochlearis passing to the cells of Corti ; k, cells of the sulcus spiralis interior; CI, Hensen's supporting cells; cm, Corti's membrane; vs, vas spirale ; tr, ligamentum spirale. (Politzer.) ligamenfcum spirale of the outer wall, thus separating the organ of Corti from the rest of the scala media. The Arteries of the Lab3rrinth. — The vestibular and cochlear branches of the internal auditory artery form the chief blood- supply of the internal ear, through anastomosis with the tympanic plexus through the internal wall of the tympanum, as previously quoted from Politzer. The Auditory Nerve. — After a division in the internal auditory meatus the auditory nerve is distributed to the laby- rinth through its two branches : the vestibular nerve, which through its three subdivisions sends filaments to the maculae 11— E. E. 162 EXAMINATION OF THE PATIENT. of the utricle, saccule, and semicircular canals; while the cochlear nerve, which traverses the modiolus, ends with the ganglia spiralis, from which a large number of minute fila- ments terminate in the ciliated cells of the organ of Corti. Thus the sonorous vibrations imparted to the membrana tympani from without are transmitted across the tympanic cavity by the ossicular chain, which, impinging upon the fluid contents of the labyrinth, sets in harmonious motion the cilia of the organ of Corti, from which the impulse through the intervening auditory nerve reaches the auditory centre of the brain and is there interpreted as sound. QUESTIONS. Give the classification of the organ of hearing. What is the general direction of the auditory canal ? Describe the anatomy of the tympanic cavity. What important structures are associated with the mastoid ? What is the function of the Eustachian tube? Name the subdivisions of the internal ear. Describe the scala media and the organ of Corti. Give the physiology of hearing. CHAPTER II. EXAMINATION OF THE PATIENT. HISTORY OF THE AFFECTION. When a patient presents himself for consultation regard- ing an ear trouble, the problem which confronts the physician is the determination of the cause, location, and extent of the aifection. The first procedure, then, should be the elicitation of a complete history as to the probable etiology, symptoms, and duration of the disease, remembering that inflammatory conditions of the nasopharynx, resulting from either local or systemic disorders, are the usual cause of aural disturbances. Specific information should be obtained as to the presence of impaired function, pain, tinnitus, discharge, and vertigo. From these data alone a diagnosis may frequently be made, but PHYSICAL EXAMINATION. 163 a thorough physical and functional examination by the fol- lowing methods will frequently reveal the presence of an unsuspected condition. Too much emphasis can not be laid upon the importance of details in aural work, both in the examination and treatment of the conditions present, for therein only lies the secret of obtaining successful results. PHYSICAL EXAMINATION. Inspection of the External Parts. — In the examination of the aural region the physician should note the condition of the auricle, the orifice of the external auditory meatus, the parotid gland in front, and the mastoid process behind. Spe- FiG. 46. Head mirror. cial attention should be directed to the latter, as it is always liable to be involved in inflammatory conditions of the tympanum. A comparison of the part should be made with that of the opposite side, especially if malformations or swell- iyigs be suspected, or a tenderness of any portion be elicited by palpation. Condition of the Meatus and Membrana Tympani. — To exam- 164 EXAMINATION OF THE PATIENT. ine these structures properly requires a bright illumination, which may be either natural or artificial, though the latter is to be preferred because of its uniformity of light ; a reflecting mirror (Fig. 46) attached to a headband so that the hands may be free to manipulate the auricle and the necessary instru- ments ; and a speculum (Fig. 47) to separate the sides of the cartilaginous meatus, thus permitting the light which is reflected from the mirror to be directed into the canal. In the introduction of the speculum the curved direction of the meatus, as previously indicated, may be straightened, in the adult, by drawing the auricle upward, backward, and out- ward, while in the child the auricle should be pulled down- ward and backward, thus separating the upper and lower walls, which are membranous and frequently lie in contact. Fig. 47. Gruber's speculum. When instrumental examination of the canal is made with either the speculum or the probe, a reflex cough is sometimes produced, which may be so marked as to interfere seriously with the proper inspection of the interior of the meatus. As the speculum enters, the examiner should note within the canal the size of the lumen, its shape, length, condition of the lining epithelium, amount of cerumen, and the number and arrange- ment of the hairs, as all may be factors in the production or aggravation of a pathological condition within the meatus or even the tympanum. Extending across the distal end of the canal will be seen the membrana tympani, which presents normally a pearly gray appearance. From its antra-superior aspect will be ob- served the faint outlines of the long liandle of the malleus as it extends downward and backward between the outer dermal PHYSICAL EXAMINATION. 165 layer and the inner mucous cov^ering of the membrane, ter- minating in a slight depression, umbo, at the centre (Fig. 48). At the upper extremity of the long handle, the short process, resembling in appearance a small pustule, is distinctly outlined, from which point the lower folds of the membrana flaccida may be followed anteriorly and posteriorly to the wall of the meatus. The cone of light, which occupies the antra-inferior quadrant of the drum membrane normally, may be displaced, Fig. 48. The normal membrana tympani (right ear) : 1, membrana flaccida ; 2, long handle ; 3, cone of light ; 4, membrana vibrans ; 5, umbo ; 6, short handle. distorted, or even absent, due usually to an inward bulging, retraction of the membrana tympani, resulting from an im- proper aeration of the tympanic cavity through a partial or complete occlusion of the Eustachian tube ; though an out- ward curving of the membrane, resulting from the pressure of a fluid within the tympanum, may also cause the cone of light to disappear. The points in an inspection of the tympanic membrane to be specially observed are its color, position, evenness of surface, and cootinuity of structure. The usual alterations in color 166 EXAMINATION OF THE PATIENT. are produced by an infJammatory condition within the meatus or tympanum, when the membrane assumes a tint ranging fi'om a slight pinkish flush to that of an angry, dark, red- dened, injected condition, while formations of atrophic areas, cicatrices, and calcareous deposits produce whitened areas in the membrane. The deviations of the normal position are traceable to either a tubal obstruction or tympanic adhesions to the inner wall of the tympanum, when the drum mem- brane is forced inward, or a fluid, serous or purulent, within the middle ear, when the membrane will bulge outward if the Fig. 49. Siegel's otoscope, with rarefler. intratympanic pressure be sufficient. Atrophic areas, various deposits, ulcerations, polypi, and granulations, together with internal adhesions, are the common disturbing elements of the evenness of surface. An interruption in the continuity of structure results either from an inflammatory condition, per- foration, or ulceration, a blow upon the auricle leading to rupture, or from a surgical procedure, incision, for therapeutic or exploratory purposes. Atrophic areas and adhesions of the membrana tympani to intratympanic structures are diagnosed, in questionable in- stances, by the aid of the Siegel otoscope (Fig. 49), with which the air in the external auditory meatus may be rarefied, when it will be observed, while inspecting the drum head through the instrqnient, that with each movement of the piston PHYSICAL EXAMINATION. 167 in rarefaction and condensation there will he a corresponding outward and inward excursion of the whole membrane with an evenness of surface ; but in the atrophic areas the bulg- ing will be greater than that of the rest of the membrane ; while with internal adhesions, areas will be seen where the mobility is restricted or lost, corresponding to the point of attachment. Examination of the Nasopharynx. — As previously noted, the nasal and pharyngeal passages should be carefully examined in all aural disturbances where an inflammatory condition may exist, as an involvement of the tympanum frequently results from extension of an inflammatory process through the Eustachian tube. The respiration should be free through the nares, which often are narrowed by an hypertrophic con- dition of the turbinal mucous membrane, though the turbinate bone itself may be enlarged congenitally or through disease. Malformations of the septum, comprising deviations, spurs, thickenings, will also frequently sufficiently impede the influx of air to account for a chronic congestion, if not inflammation, of the mucous membrane in and about the pharyngeal orifice of the Eustachian tube. In an examination of the pharynx the usual etiological factors observed are an hypertrophic, granular or follicular pharyngitis, enlargement of the faucial tonsils, or adenoids in the pharyngeal vault. For details in the examination and treatment of these conditions, consult the volume on Diseases of the Nose and Throat of this series. Examination of the Eustachian Tube. — While making the physical examination of the nasopharynx, the condition of the Eustachian orifice should be noted and the surrounding structures scrutinized for the presence of polypi, enlarged lymphatics, posterior septal and turbinal deviations, together with thick, tenacious discharges, any one or all of which are capable, as are also hypertrophic faucial tonsils, of mechan- ically obstructing the lumen of the pharyngeal meatus. To determine the patency of the Eustachian tube the follow- ing methods are in vogue, by means of which air may be forced through the tube into the tympanic cavity, when, if the passage be partially or completely occluded, the functiou 168 EXAMINATION OF THE PATIENT. of audition will be correspondingly improved thereby, pro- viding there be no organic lesions of the conducting or perceptive mechanisms. While employing any of these procedures, the physician should use the auscultation tube (Fig. 50), one end being placed in the examiner's external auditory meatus, while the other rests in the patient's meatus, by means of which additional information is gained as to the size of the lumen, presence of fluid, and the amount of press- ure necessary to drive the air through the canal. By this method alone is the operator often certain that the entering air has reached the tympanum, when the impact of the air- current will be heard against the membrana tympani, and Fig. 50. Auscultation tube. the resulting outward movement of the patient's drum head will produce an inward excursion of that of the examiner's, which he can easily feel. The Valsalva Method. — This procedure consists of an attempt at forced expiration while the nose and mouth are held firmly closed, thus forcing the air through the passage of least resist- ance, the Eustachian tube. This method should be used only in determining the permeability of the tube or the mobility of the membrana tympani and ossicles, and should not be taught the patient to be used at will as a therapeutic means of re- lieving the stenosis of the canal, as the resulting congestion incident to its employment tends to aggravate an existing in- jection of th^ twb?il ^nd tympanic mucoiis membraqc, A PHYSICAL EXAMINATION. 169 relaxed condition of the membrana tympani or ossicles also not infrequently follows its repeated and forcible use. The Politzer Method. — In using this mode of inflation the patient is directed to take a sip of water from a glass and retain it within the mouth until instructed by the physician by word or sign to swallow. The nozzle of a Politzer air- bag (Fig. 51) is placed snugly into one nostril, while the other is held firmly closed. The patient then swallows at the given signal, and the air-bag is simultaneously compressed, when. Fig. 51. Politzer bag, with glass inhaler attached. if the soft palate rests tightly enough against the pharyngeal wall, the air makes its passage up the Eustachian tube into the tympanum, as may be heard by the auscultation test. Instead of employing the act of swallowing to close the pharyngeal space, the patient may be instructed to forcibly pronounce the word " hook,'' prolonging the " k " sound, or markedly distend the cheeks in an attempt at forced expira- tion, when the air-bag may be used as previously indicated. The compression of the air-bag should always be guarded until the accessary forc^ of inflation is learned^ otherwise^ if the tube 170 EXAMINATION OF THE PATIENT. be patent and a strong compression made, tlie forcible entrance of the air into the tympanic cavity will be attended with great discomfort, if not actual pain, and frequently vertigo is thus momentarily produced by the sudden outward move- ment of the foot-plate of the stapes, which lowers the intra- labyrinthine pressure. Rupture of the membrana tympani has resulted from the presence of these conditions, attended with atrophic areas in the drum membrane, which are, of course, points of weakened resistance. The Principles of Catheterization of the Eustachian Tube. — Before attempting to employ the catheter, the operator should examine the nasal cavity for any obstructions that may inter- fere with the passage of the catheter ; and to render the pro- cedure less objectionable to the patient, a 4 per cent, solution of cocaine may be sprayed into the nostrils or preferably applied directly by means of a cotton-tipped applicator unless the patient Fig. 52. Blake's Eustachian catheter. has an idiosyncrasy against the drug. Whether a metallic or hard-rubber catheter should be employed is a matter of per- sonal choice and experience. For his own use the writer prefers the silver probe-pointed instrument as devised by Blake (Fig. 52), w^hich permits of changes being made in its curvature by bending and its sterilization by means of steam. These catheters come in four different sizes, to fit the various- sized orifices of the Eustachian tube, but No. 2 is the size most frequently employed. For the inflation of the tube after the catheter has been placed in the Eustachian orifice, an ordinary atomizer-bulb should be attached to the funnel-shaped end of the catheter, before its introduction, by means of a small flexible inter- vening rubber tube about one foot in length. Otherwise, if the bulb were connected after the passage of the catheter, the necessary manipulations would be liable to displace th^ patheter an4 discomfort the patient verv much, PHYSICAL EXAMINATION. 171 The Technique of Catheterization of the Eustachian Tube. — Seated or standing in front of the patient, the examiner places the fingers of the left liand upon the patientAs forehead, while with the thumb the end of the nose is forced upward. With the other hand, while the patient is holding the bulb, the Fig. 53. Vertical section of the nasopharynx, with the catheter introduced into the Eustachian lube : A, inferior turbinated bone : B, middle turbinated bone ; C, supe- rior turbinated bone ; D, hard palate ; E, velum palati ; F, posterior pharyngeal wall ; G, Rosenmiiller's fossa ; H, posterior lip of the orifice of the Eustachian tube. (Politzer.) operator introduces the probe-pointed extremity into the nostril with the curved portion directed downward and resting upon the floor of the nasal cavity. The catheter is gently pushed along the inferior meatus until the curved ^^tremity reaches the postpharyngeal w^all, when the cath^ 172 EXAMINATION OF THE PATIENT. eter may be introduced into the Eustachian orifice by one of two courses : (1) It is now rotated directly inward and brought forward until the curved portion rests against the posterior end of the septum. The catheter is so turned that the probe end describes a semicircle, passing downward along the posterior surface of the soft palate and finally coming to a rest directly outward with the ring of the funnel end pointing toward the external auditory meatus, when the probe end will pass, with some manipulation, into the mouth of the Eustachian tube. (2) After the catheter has reached the pha- ryngeal wall the instrument is withdrawn slightly and rotated so that the curved end passes from below to a position almost directly outward toward the ear to be inflated. The extremity in the hand is then elevated and carried toward the opposite side, when the probe end will encounter the side of the pharynx just back of the Eustachian protuberance. The catheter is now withdrawn carefully, when the probe end will be felt to impinge against the posterior lip of the orifice, and then, with a little added traction, pass over the lip into the funnel-shaped orifice of the Eustachian tube (Fig. 53), impart- ing a definite sensation to the experienced hand. The catheter is again rotated upward so that the curved extremity points, as indicated by the position of the ring, toward the outer canthus of the eye on the corresponding side of the head, while the fun- nel end of the instrument is carried toward the opposite side, which forces the inner extremity into the lumen of the pha- ryngeal orifice. The connecting bulb is now compressed by the right hand, while the left retains the catheter in position. With the auscultation tube, the examiner listens for any diag- nostic signs as the air passes through the tube into the tympanum. As to which is the preferable method of inflation, Politzera- tion or catheterization, will depend wholly upon the condi- tion of the nasal cavity and the lumen of the Eustachian tube, together with the experience of the operator with either mode. The advantages of the former are : its ease of appli- cation, its utility in obstructed nasal passages, nonliability of injuring the tubal or nasal uiucous jnembmne^ and its prefer^- TESTS OF HE AMINO, 173 ble use in children and nervous individuals. With catheter- ization^ however, the following favorable points are observed : one ear only may be inflated ; amount of force to open the tube can be definitely ascertained ; the process may be repeated without annoyanc^e to the patient ; its success depends wholly upon the operator; medicated vapors and applications may be made directly to the tubal mucous membrane through the catheter, while slender bougies or probes may be introduced into the Eustachian canal thereby, affording an additional method of diagnosis and treatment of obstructions within the tube. TESTS OF HEARING. Having completed the physical examination of the aural structures, the physician should next determine carefully the functional condition of the organ of hearing, and record his findings for future reference in noting the course of the dis- ease and the results of treatment. Quantitative Tests of Hearing. — In determining how much the function of audition has been impaired, it is only necessary to ascertain at what distance a sound of given intensity and pitch is heard and compare it with that of the normal ear. While employing the various procedures, the patient's eyes should be closed to eliminate the imagination of hearing, and the organ not under the test should be stopped by the moist- ened finger of the patient or with a tight plug of cotton, so that only one side will perceive the sound. As impairment of hearing for conversation is usually the first symptom recognized in aural disturbances, the examiner should note to what extent the hearing is affected in this direction by speaking in an ordinary or w^iispered tone of voice. It is well to employ short and varied phrases instead of sentences, as the patient will often construct the latter by catching a few of the words only, and it is equally important that the patient does not see the face of the speaker, as some individuals become very adept in reading the motion and position of the lips. Impairment of Hearing for Sounds. — A watch or small 174 EXAMINATION OF THE PATIENT clock may also be employed as a test by holding it beyond the normal distance of hearing and gradually approaching the ear until the ticking becomes audible. A stop-watch is preferable, as the test may be interrupted and thus tri(;k the patient. As the pitch and loudness of the sound emitted by different Avatches or the human voice vary markedly, Politzer devised an instrument (Fig. 54) termed an acoumeter, which practically produces an uniformity of quality and in- tensity, by which means different observers may compare results; but, unfortunately, its intensity of click, which is heard at 45 feet by the normal ear, is too marked for Fig. 54. Politzer's acoumeter. the detection of slight alterations in function. In these in- stances the watch or tuning-fork offers a more delicate and reliable method of testing. In recording the findings of a quantitative test, a note may be made of the distance at which the instrument is heard ; but preferably the results should be designated by a fractional term, which will indicate at a glance the amount of defect as compared with that of the normal ear. For instance, if the tick of a given watch be heard at 60 inches normally, and the patient perceives the sound at 30 inches, then the fraction |f would indicate defi- nitely the state of his hearing, and would be understood by other observers in the same line of practice. TESTS OF HEARtm. 175 Qualitative Tests of Hearing. — In testing the quality of per- ception the physician will find that there is a quite definite range of hearing with the normal ear, which may be altered by diseased conditions of either the conducting or the percep- tive apparatus. There is a point below which the ear can not hear lower placed sounds, while for the high tones a corre- sponding limit is reached beyond which the sounds become inaudible. These dividing-lines between audition and deaf- ness are designated as the lower and upper limits of hearing respectively. By ascertaining their positions, which are nor- mally placed at 16 and 32,500 tone-vibrations per second, and determining the duration of perception by air and bone conduction, the examiner is thereby enabled to decide whether the difficulty be located in the conducting or the perceptive mechanism, as these points are fairly constant in the normal Fig. 55. c < o MEYROWITZ. (fl - Blake's tuning-fork. state, but are characteristically altered in disorders of the middle or internal ear. For instance, if a Blake tuning-fork (Fig. 55) making 512 single vibrations per second were held before the external auditory meatus, it would be heard normally for 30 seconds or more, providing a corner of the fork were not directed toward the canal, when the vibrations would be inaudible ; but with the handle of the fork placed firmly against the mastoid bone, about one inch directly back of the external auditory meatus, the duration of perception would approxi- mate is seconds. Thus the duration of air conduction is normally about twice that of bone transmission. This pro- cedure has been named the Rinne test, in honor of the scien- tist who first observed the above relationship of air and bone conduction. When the vibrating-fork is held before the meatus, the vibrations are imparted through the intervening 176 EXAMiNATiON OF THE PATIENT. air to the membrana tympani, and thence to the labyrinth through the ossicular chain. Hence, if there be any obstruc- tion to its freedom of passage — e. g., a foreign substance occluding the external auditory meatus, or a restriction of the mobility of the drum head or the ossicles by the presence of adhesions or a fluid within the tympanum — the duration of hearing by air conduction will be correspondingly dimin- ished. With the liandle directed against the mastoid bone, the sound-vibrations of the instrument reach the perceptive organ through the substance of the bone, thus eliminating the conducting apparatus ; and if the nervous mechanism of the labyrinth, the auditory centre of the brain, or the connect- ing auditory nerve be affected, the duration of bone conduc- tion will be limited, the amount depending upon the extent of the lesion. Occasionally in hypersesthetic conditions of the nervous system the duration and range of audition appears greater than normally observed. Theoretically the duration of air and bone conduction for all musical sounds present between the lower and upper limits of hearing should be ascertained in a complete test ; but, practically, tuning-forks tuned to C, making 128, 256, 512, 1024, and 2048 single vibrations per second respectively, furnish a very complete diagnosis. The lower limit is tested by means of a large tuning-fork (Fig. 56), which records 26 to 64 v. s. per Fig. 56. Denche's large tuning-fork. second, while the upper limit is determined with sufficient accuracy by the use of the Galton whistle (Fig. 57), wliich is capable of giving from 3500 to theoretically 84,000 v. s. per second, though the Konig rods give the more complete test^ TESTS OF HEAHtm. 177 but require too much time for routine use. Another phe- nomenon of aural perception has been designated as the Weber test, which is observed with the handle of a vibrating fork resting upon the skull in the median line, either upon tlie vertex, forehead, or the maxillary region, when, if the external auditory meatus be closed by the finger, the sound will be heaj'd more distinctly upon the corresponding side. Thus, clinically, if there be an impairment of the hearing in Fig. 57. Galton's whistle. one ear only, or the two sides be unequally affected and the patient recognizes the vibrations as louder in the deafened ear, these facts indicate that an obstruction exists in the con- ducting apparatus of the same side, which may be a foreign body in the meatus, adhesions of the membrana tympani or ossicles, or fluid within the tympanum if the Eustachian tube be patent. Were the sound heard more distinctly upon the better side, this would point to an impairment of the percep- tive mechanism of the more deafened ear. This method, therefore, should precede the Rinne test in a systematic ex- amination of the hearing. In general, then, with lesions of the conducting apparatus, the duration of air conduction is shortened (bone transmission remaining normal), while the lower tone limit is raised. In affections of the internal ear, a diminution of duration for both air and bone conduction is shown, but the latter is relatively more reduced, while the upper limit is lowered, its amount depending upon the extent of the alterations in the labyrinthine nervous mechanism. From the data obtained in the physical and functional examination of the aural structures, the cause, location, and 12— E E. 178 DISEASES OF THE AUHICLE AND MEATUS. extent of the aifection may be determined, when the physician will be in position to consider properly the methods of treat- ment. QUESTIONS. What points are to be elicited in the history of a case ? What structures are inspected in a physical examination ? Describe the appearance of a normal membrana tympani. What points should be observed in its inspection ? «, Describe the Politzer method of inflation. Give the technique and advantages of catheterization. Name the different methods of testing the hearing. What is meant by the lower and upper limits of hearing? What is Einne's test ? What is Weber's test? What is the utility of the qualitative tests? What instruments are necessary to make these tests ? What are the characteristic alterations indicative of involvement of the middle ear ? Of the labyrinth ? CHAPTER III. DISEASES OF THE AURICLE AND EXTERNAL AUDITORY MEATUS. MALFORMATIONS. Signifioance. — Occasionally among those who present them- selves for consultation regarding aural troubles, the physician will note instances of congenital defects in the auricle or the external auditory meatus, which may exist without the knowl- edge of the patient, especially when the malformation is not marked. These freaks of Nature are sometimes associated with perversions of mind and nervous system, and are thus looked upon by many observers as stigmata of degeneration. While it is true that many cases occur apparently substan- tiating this belief, the most aggravated forms of malformation may exist without any signs of impaired mentality. Common Abnormalities of the Auricle. — Among the usual deviations from normality may be mentioned the excessively large or small auricle, abnormality of position or attachment, supernumerary ridges or fossae, deformities or absence of the SEBACEOUS CYSTS 179 tragus, rudimentary or cleft lobule, indentations of the helix, and mixed conditions. Common malformations of the meatus frequently appear with those of the auricle, especially when the latter involve the structures about the orifice of the canal. Exostoses in the bony portion, cartilaginous spurs in the outer meatal passage, very small lumen (atresia) — which may be round, but is usually slit-shaped — or even complete stoppage or absence of the canal are conditions that may be occasionally met. Of course, when the malformations markedly diminish the lumen of the meatus, deafness of various degrees will add to the dis- comfort of the individual. Treatment. — Regarding the advisability of surgical pro- cedures for cosmetic effects, it may be said that much may be accomplished for the amelioration of the deformity by skilfully executed plastic operations which have for their purpose the removal of superfluous structures. As to the conditions of atresia and absence of the meatus, it is a generally accepted fact that surgical interference is often disappointing on account of the formation of cicatrices and granulation tissue, which tend to undo an otherwise brilliant result. These cases, there- fore, should be referred to the specialist for treatment. SEBACEOUS CYSTS. Synonyms. — Steroma ; Wen ; Atheroma. Definition. — A sebaceous cyst is a noninflammatory, rounded — either soft or hard — elastic tumor, varying in size, which is produced by the distention of a sebaceous gland by its retained secretions. Etiology. — Irritation of the mouth or duct of the gland from mechanical or inflammatory sources, thickened secretions which can not be discharged from the gland, and hyperse- cretion. Symptoms. — The tumor is usually located in the lobule, though it may occur at any point upon the surface of the auricle. In the external auditory meatus the cysts develop in the cartilaginous portion, where the glandular structures 180 DISEASES OF THE AUmCLE AND MEATUS. are usually confined. The tumor gradually enlarges without pain or discomfort unless appearing in the bony portion of the canal, which is rare. Attaining a certain size, it frequently remains stationary in its growth for an indefinite period unless irritated, when the secretion is liable to be increased . The only interference with the function of the ear occurs when the tumor attains such a size in the meatus as nearly or completely to occlude the lumen, producing varying degrees of deafness, which occasionally is altered by movement of the jaws, when the lumen of the meatus is changed. Treatment. — After producing anaesthesia of the part by means of Schleick^s injections or any other local anaesthetic, the tumor is removed by a careful dissection so that the sac or distended gland is not ruptured, otherwise its complete removal will be difficult, and unless this is accomplished the cyst is liable to recur. A less preferable method is the incision of the sac, evacuation of the contents, and destruction of the secreting walls by means of caustics. HiEMATOMA AURIS. Synonyms. — Atha^matoma ; Blood tumor. Definition. — Hsematoma auris is a bluish-red swelling of the auricle, due to an eifusion of blood between the cartilage and the perichondrium. Etiology. — This disorder is frequently the result of a blow upon the auricle or pulling of the ear, which ruptures a blood- vessel or separates the cartilage from the perichondrium, into which space the blood flows. Spontaneous rupture of athe- romatous arteries, formation of fissures or cavities in the carti- lages, proliferation of bloodvessels, and new growths are also recognized as etiological factors. Symptoms. — Following a traumatism of the auricle, or occurring spontaneously, a tumefaction suddenly makes its appearance upon either side of the auricle, although it usually occurs upon the anterior surface, attended by a painful sensa- tion at the site of the swelling and a feeling of warmth. The pain is sharp and stabbing in character, due to the forcible PERICHONDRITIS AURICULJE. 181 separation of the tissues by the sanguineous effusion. On account of its frequent occurrence among the insane, it is claimed by some authorities that instances of spontaneity are traceable to local trophic changes, resulting from intercranial lesions. Others attribute its appearance in the demented to ill treatment or injury of the part by the attendants. The (contents of the swelling frequently disappear by absorption, but may become purulent in character, attended with inflam- matory symptoms. Should the swelling extend to or involve the meatus sufficiently, the hearing will be lowered from the occlusion of the canal, although this is unusual. Treatment. — In order to reduce the swelling, cold soothing compresses may be applied for a time, wdien, if the tumefac- tion does not abate, an incision should be made at the most prominent point and the contents evacuated, following strict antiseptic procedures in the after-treatment. If the tumor be small, resolution may occur without interference. The patient should be warned that deformity of the auricle is liable to result from the cicatricial contractions consequent upon this affection, especially if the effusion of blood has been extensive. PERICHONDRITIS AURICULAE. Definition. — An acute inflammation of the perichondrium. Etiology. — May follow hsematoma auris as a complication ; often results from traumatism or frost-bites of the auricle. Symptoms. — With the gradual appearance of an inflamma- tion of the auricle, a bright-red swelling, which may occur at any point, slowly makes its appearance, attended with severe pain and a feeling of heat in the affected area. The serous effusion between the cartilage and the perichondrium, which accounts for the enlargement, may become so extensive as to involve the entire auricle, obliterating the ridges and fossae as the perichondrium is dissected from the cartilaginous frame- w^ork. Later the serous contents of the tumor may become purulent in character, which adds to the gravity of the condi- tion. If left to itself, spontaneous evacuation of the fluid will result from perforation, followed with great deformity. The 182 DISEASES OF THE AURICLE AND MEATUS. diiferential diagnosis of perichondritis from hsematoma rests upon the fact that in the latter the swelling which results from an effusion of blood appears suddenly and unattended with inflammatory conditions, while the perichondritic exu- date is serous and produces its enlargement gradually, follow- ing a previous inflammatory state. Treatment. — Practically that of hsematoma auris. ECZEMA. Synonyms. — Salt rheum ; Moist tetter ; Milk crust ; Scalds Definition. — -Eczema is an acute or chronic, multiform, in- flammatory disease of the skin, characterized by the forma- tion of vesicles, papules, or pustules attended with infiltration and thickening of the epidermis, and terminating in a desqua- mation or a seropurulent discharge with the formation of crusts. Etiology. — The causes of this dermatitis are : (1) predispos- ing constitutional disorders, among which may be mentioned rheumatic tendencies, dyspepsia, constipation, mental and physical exhaustion, and the neuroses of functional or organic origin ; and (2) local causes producing irritation of the skin, such as excessive heat or cold, strong soaps, acids, alkalies, injuries of the skin, which in the case of involvement of the external auditory canal frequently results from foreign bodies being introduced into the meatus with the intention of scratch- ing the skin or removing the ear wax, inspissated or impacted cerumen, and irritation by a chronic discharge from the tym- panum. Symptoms. — The most pronounced symptom is the itching, pricking, or burning sensation which first calls attention to the part, congestion of the region affected, presence of an exudate, formation of crusts, thickening of the skin, develop- ment of fissures, and desquamation. If the meatus be aifected, the hearing may be altered mechanically by the presence of crusts, discharges, desquamations, or swelling of the skin, which might obstruct the lumen of the canal sufficiently. Treatment. — In general remove the local and predisposing DIFFUSE EXTERNAL OTITIS. 183 systemic causes, advise hygienic and dietetic measures, apply locally soothing and protective medication in the acute form, and stimulating ointments in the chronic state. Removal of the crusts is best accomplished by an oily preparation. For details of treatment consult a work on diseases of the skin, as eczema in this region does not differ from that affecting any other part of the body. Care should be exercised that the membrana tympani be not injured by either the medication employed or the instruments used in its application. DIFFUSE EXTERNAL OTITIS. Occurrence. — This form of inflammation of the external auditory meatus may occur either as an acute or chronic affec- tion which involves, as its name implies, the greater portion, if not the whole, of the meatal lining membrane, gradually merging into the surrounding epithelium. Synonyms. — Otitis externa diffusa acuta ; Diffuse inflamma- tion of the external ear. Etiology. — As an idiopathic affection, the disease is rare. Usually it results from pathogenic microbic infection which enters through abrasions of the skin produced by traumatic influences, foreign bodies introduced into the canal, irritation by discharges from the tympanic cavity, or the instillation of improper fluids into the meatus, and secondary to furun- cular inflammations of the epithelium. Symptoms. — The symptoms are especially marked when the disease involves the osseous portion of the canal and the sur- face of the membrana tympani. Beginning with an itching sensation, a violent, radiating pain soon follows, which is in- creased by movements of the jaws, manipulation of the auri- cle, and lying upon the affected side. Tinnitus and deafness may supervene. The inflammation first makes its appearance as a congestion of the cutis, followed by marked s-welling and infiltration ; development of a serous or purulent discharge which softens the cuticle ; exfoliation of the whitened, mace- rated dermal layers, leaving an angry, excoriated surface which is extremely sensitive ; ulcerations of the membrana 184 DISEASES OF THE AURICLE AND MEATUS. tympani may develop and result in perforation ; granulations may spring from an ulcerative process of the meatal wall ; or necrosis of the bony meatus may affect the unfortunate indi- vidual. In the chronic form there may occur an itching of the skin, slight degree of pain, varying amount of discharge, and desquamation which may obstruct the canal by the ex- foliated debris, attended with a lowering of the aural func- tion. Keflex cough is also thereby occasionally produced. Diagnosis. — Inspection of the meatus and membrana tympani reveals the swollen, infiltrated condition of the skin, the dis- charge, and the whitened, exfoliating layers of the epithelium, which microscopically show the presence of micrococci or aspergillus fungus. This condition might be confounded with that resulting from a purulent discharge from the tympanum, but in the latter instance inspection would reveal the presence of a perforation of the drum head, which would indicate the nature of the affection. Prognosis. — In the idiopathic cases the inflammation sub- sides in the course of a few days, while in those due to a traumatic origin the resolution is usually delayed because of the complicating ulcerations and attending granulations, which are not only slow in healing, but tend to the formation of strictures and atresia of the canal. Treatment. — In the acute form, if the inflammation be mild, antiseptic and protective measures will usually suffice; while if the inflammatory conditions be marked, the patient should be put to bed, a saline purgative given, a hypodermic admin- istered if necessary for the relief of the pain, the canal syringed with warm solutions of boric acid (saturated), bichloride of mercury (1:8,000), or carbolic acid (1:40), artificial leech and cupping applied in front of the tragus or immediately behind the auricle as is indicated, and the application of an ice-bag or coil to the mastoid. If the swell- ing does not abate within a day or so, scarification or incision of the infiltrated tissues extending down to the bone will prove beneficial, especially in the early stage. After the canal has been dried insufflations of boric acid powder are recommended. In the chronic form, after cleansing the canal ACUTE CIRCUMSCRIBED EXTERNAL OTITIS. 185 with antiseptic solutions, applications of nitrate of silver solu- tion (1 ; 24 or stronger), instillation of boric-alcohol (1 : 20), or diachylon ointment may be used. If the alcoholic solu- tion does not remove the granulations, they may be de- stroy e