then introducing instruments from the upper orifice of the duct; more
especially in cases where the swelling and pain are considerable.
The instruments employed for dilatation of the passage are tubes and
styles. The tubes are made either of silver or gold, of equal calibre
throughout, and of the same length as the passage. For some time
after their introduction they cause much irritation; this gradually
diminishes, and the wound heals over them. But, according to my
experience, the effects are not satisfactory. The irritation which
they at first occasion generally subsides, but abscess again occurs,
with much swelling, and it becomes necessary to remove the foreign
body. Again, the tube sometimes becomes obstructed by thickening and
concretion of the discharge, and then, when it is necessary to remove
it, the process is found to be by no means an easy one; a free incision
is required; a screw must be fastened into the tube, or, when that
cannot be accomplished, the foreign body must be laid firmly hold of
with strong forceps; altogether the extraction is very painful, and
often extremely tedious. In short, the practice of introducing tubes
does not appear to be founded on sound surgical principles.
After extensive and impartial trial of both the tubes and style, I
decidedly prefer the use of the latter. On the point of the bistoury
being fairly lodged in the lachrymal duct, a probe is passed along it;
the knife is then withdrawn, and the passage is gently dilated by the
probe. The probe again is followed by the style, which should be made
of silver, of the same thickness throughout, of the same length as the
duct, and with a flattened head placed obliquely to the body of the
style. The size of the style should be at first small, and gradually
increased. The irritation caused by the first introduction is in many
cases very severe, but the parts soon accommodate themselves to the
presence of the foreign body; the pain and swelling diminish, as also
the discharge. If a large style be pushed forcibly in at first, violent
inflammatory action will ensue, and much mischief may be produced.
After irritation has gone off, the tears pass readily down in the
nose by the sides of the style, according to the laws of capillary
attraction, little or no fluid escapes from the external opening, the
wound contracts around the instrument, and, its head being covered with
black wax, no deformity is produced. The instrument should be removed
from time to time, cleaned, and replaced. When, by the continued use of
styles gradually increased in size, the duct has been dilated to its
full extent, and appears restored to a sound condition, the instrument
may be withdrawn, and afterwards introduced only occasionally. The
external aperture, which has become fistulous from the long presence
of the foreign body, then begins to contract, and, on its completely
closing, the tears continue to follow their usual course, and the
disease is overcome. But sometimes a small fistulous aperture remains,
and there appears to be a disposition towards the renewal of the
affection; in such a case, a small style, not exceeding a thin gold
probe in diameter, should be introduced every evening, and retained for
some hours: this causes little or no inconvenience to the patient, and
insures the permeability of the canal.
Such is the method by which a permanent cure may often be obtained, and
which, in my opinion, is preferable to the use of tubes. If these are
to be employed, they should, as already mentioned, be nearly of equal
calibre throughout; the external opening must not be allowed to close
for a considerable time after the introduction of the instrument; and
the tube must be kept pervious for some time by a style introduced
through it. But by these means, which are essential for the success of
the practice, the main advantage arising from the use of a tube, viz.,
little irritation being produced at first, and the parts being allowed
to close soon over it, are completely done away with.
The practice of perforating the os unguis never can be required; it is
cruel, unnecessary, and unsurgical.
Sometimes the lachrymal passages are entirely destroyed. In such cases,
it has been found that no great inconvenience arises from their
obliteration, as the lachrymal gland ceases, in a great measure, to
secrete fluid, and the conjunctival secretion, after having performed
its office, evaporates from the surface. In truth, the lachrymal gland
always enjoys long periods of repose, and is only called into active
exercise of its functions occasionally, as the eye in its ordinary
condition is sufficiently lubricated by secretion from its conjunctival
covering.
The treatment of fistula lachrymalis, as has been well remarked
by an eminent author, must be varied and regulated according to
circumstances;—by the degree of obstruction in the duct, by the state
of the coverings of the sac, of the sac itself, and of the subjacent
bone, and by the general state and habit of the patient.
[Illustration]
_Encanthis_ is a tumour situated in the corner of the eye. The
caruncula lachrymalis appears to be the original seat of the disease,
at least it is involved at an early period. The growth is at first
small, and appears to be simple enlargement of the caruncle: it is of a
reddish colour, and its surface is studded with numerous granulations.
It often attains a very considerable size; and, on account of its
propinquity to the lachrymal passages, is accompanied with watering of
the eye, the puncta being either involved in the growth, or compressed
or displaced by it. Sometimes the whole inner corner of the eye,
from the margin of the cornea to the inner junction of the eyelids,
is occupied by the granulated swelling; and in such cases it is not
uncommon for the tumour to extend itself outwards, in the form of
a lunated appendage, on the under surface of each lid; thereby the
motions and functions of the ball are much impeded, and a prominent
deformity is occasioned. In most instances the growth seems to be
a simple enlargement of structure, and is of a benign nature; but
sometimes it is firm, hard, of rather a livid hue, with a smooth slimy
surface, and is decidedly malignant,—enlarging, and gradually involving
the surrounding parts.
Cancerous ulceration, attacking and destroying the eyelids, and the
parts around the ball of the eye, often commences in the situation
of the caruncle, or in a wart on the edge of the lid. Cancer, though
a rare and uncommon disease of the eyeball, frequently seizes on the
appendages of the eye, extending rapidly in all directions, and often
completely detaching the ball by ulceration. Warty tumours also occur
on the conjunctiva of the lids, or of the ball, and are inconvenient as
a source of much irritation to the neighbouring parts, even though of a
benign nature in themselves.
Extirpation, by means of a small pointed knife, or curved scissors, is
the only means to be relied on for the cure of such warty tumours, and
of encanthis. The growth must be fixed and pulled outwards with a small
hook, and carefully dissected away; the eyelids, and, if necessary,
the ball of the eye, being kept fixed with the fingers, or by means of
a speculum: the fingers are generally sufficient, and more convenient
than any instrument. If from the appearance of the parts, and from
induration surrounding the tumour, malignant action has evidently
taken place or is dreaded, then the incisions must be made wide of the
base of the swelling. For malignant, open, and extensive ulcerations,
nothing can be done farther than to allay the pain, and soothe the
constitutional disturbance. On the whole, encanthis is a rare disease;
however, I have seen, and operated on, several instances of it.
[Illustration]
_Encysted Tumours of the Eyelids._—These occur beneath the conjunctival
lining of either the upper or under lid, but most frequently in the
former. They form rapidly, but seldom attain any very considerable
size; and may be found to contain, along with glairy fluid, a mixture
of pus, or curdy matter. The contents, however, are generally glairy,
rarely atheromatous. The cysts are very thin and adherent, and the
tumour projects externally, forming a dusky red elevation of the
integuments. They cause considerable deformity, watering of the
eye, and stiffness and difficulty in moving the lids. On everting
the eyelid, the contents of the tumour are seen shining through the
distended conjunctiva, and present a bluish appearance. They are seldom
single, and are not remediable but by operation. It is improper to
attempt their extirpation from without, as there is a certainty of
cutting completely through the eyelid, the inner covering of the cyst
being merely attenuated conjunctiva. The lid is to be everted, and
an incision made into the prominent and thin cyst with the point of
a cataract knife; the contents can then be readily scooped out with
the end of a probe. It is impossible to dissect out the tender cyst
entire, and, when this is attempted, the cure can seldom be permanent.
If, after incision and discharge of the contents, nothing farther is
done, the disease will almost certainly return, in consequence of the
remaining cyst reassuming a secreting action. The only effectual and
radical cure is the application of a finely-pointed piece of caustic
potass to the interior of the cyst, after discharge of the contents and
cessation of bleeding. The cyst is thereby completely destroyed. A slip
of soft lint, dipped in oil, is interposed betwixt the lid and eyeball,
for an hour or two, in order to protect that delicate organ from the
caustic. The wound suppurates and heals kindly, and no mark is visible,
the incision having been made from within. I have had no instance of
return of the disease since adopting this practice; and I have operated
on many which had been previously treated by other and ineffectual
means. The laceration of the cyst with a pointed probe is sometimes
followed by a permanent cure, but it cannot be depended upon.
_Closure of the Eyelids_ may be either congenital, or a consequence
of injuries, as burns of the parts. The closure may be complete or
partial. In general it is partial, though perhaps extensive; and the
adhesions can be readily separated by the point of a knife, or small
probe having been previously introduced beneath; or a small and narrow
probe-pointed bistoury may be conveniently used for the purpose. In the
after-treatment means must, of course, be taken to prevent the lids
from again adhering.
[Illustration]
[Illustration]
_Ectropion_, or eversion of the eyelids, may be produced, merely by
swelling of the conjunctival lining protruding the lid: or the lid may
be relaxed, and the conjunctiva may swell in consequence of repeated
inflammation of the parts, caused by frequent and careless exposure;
or the disease may be the result of contraction, by cicatrisation of
the integuments of the face, as after burns, extensive superficial
wounds in the neighbourhood of the eye, or the effect of periosteal
disease of the orbit. The affection may exist to a greater or less
degree, being in some instances scarcely visible, and not troublesome,
whilst in others, the eyelashes lie on the upper part of the cheek,
and the swollen granulated conjunctiva is exposed. The lower lid is
generally the one which is affected. The disease may exist in both
eyes, or only in one. In strumous habits both are frequently affected
in a slight degree; and the upper lid, too, is sometimes turned a
little outwards. When eversion is of long continuance, and complete or
almost so, the conjunctival covering of the ball of the eye, and of the
cornea, becomes dry and wrinkled; in short, the membrane completely
changes its character, and becomes cuticular. In a lad who laboured
eleven years under eversion of the upper and lower lids—arising from
abscess and exfoliation of the external angular process of the os
frontis, following a blow received when a boy—the conjunctiva was hard,
wrinkled, scaly, and exactly similar to cuticle: this change of the
membrane also extended over the whole cornea. The surface of the eye
had lost its lustre, and vision was much impaired, the patient being
able to distinguish only very bright objects. By such cases, continuity
of the conjunctiva with the outer layer of the cornea is beautifully
demonstrated.
Some of the most intractable of all cases of eversion are the result
of burns. The constantly increasing contraction of the cicatrix draws
either the upper or the lower lid far from its natural situation,
and produces frightful deformity. The tarsal cartilages are greatly
extended, and in any operation for the relief of the patient it is
necessary to remove a portion before the lid can be properly adapted.
Great inconvenience is caused by the state of eversion: the surface
of the eyeball is subject to inflammation, in consequence of being
insufficiently protected; the change of its investing membrane is
a serious evil; and in some cases the cornea becomes extensively
ulcerated, unusually vascular, and opaque.
When the conjunctiva only is in fault, the deformity is slight, and
the state of matters is readily ameliorated by excision of the relaxed
portion. This is done by sharp curved scissors. As the wound gradually
contracts, the eyelid is drawn inwards, and, on cicatrisation taking
place, the parts have become restored to their healthy condition. Care,
however, should be taken that too much of the swollen conjunctiva is
not removed, otherwise the subsequent contraction may cause inversion
of the lid. Combined with the above practice, relaxation of the lid
itself will in many cases be remedied by removal of a portion of it
in the form of the letter V, by means of a sharp-pointed bistoury:
the edges of the incisions are afterwards put together by a point
of interrupted suture. When eversion arises from a cicatrix of the
integuments, the part in fault may be divided; but a temporary benefit
only can be procured. For, during the healing of the wound, the parts
again contract; and, though a portion of the conjunctiva is at the
same time removed, the contraction internally will hardly counteract
that which is going on externally. In order fully to obviate the evil
of this contraction of the cicatrix in inveterate cases of ectropion,
a form of plastic operation may be successfully resorted to. The
cicatrix being dissected out, and the tarsal cartilage brought neatly
into position, a piece of integument from the temple or cheek may be
adapted, and a portion of a new eyelid formed. The parts may sometimes
be brought into a good position without the necessity of borrowing
any portion of integument. A V-shaped incision can be made, the apex
pointing downwards, so as to loosen the under lid; and after it has
been drawn upwards and put straight, the edges of the lower part of the
exposed space are united by suture.
[Illustration]
_Entropion_, or inversion, consists in the turning in of the tarsal
margins of the lids, and generally takes place during inflammation
and swelling of the conjunctival lining of the lid. During violent
inflammation of the lid the conjunctiva and integuments are much
swollen, and bulge out externally; by the projection the margin is
forced mechanically towards the ball, and entropion takes place. But
in this state of matters, should the lid be by any chance everted,
and not replaced, then the bulging is from the conjunctival surface,
and prevents the margin from regaining its former site, and permanent
eversion or ectropion occurs. In fact, inversion and eversion, like
phymosis and paraphymosis, exist from the same parts being put in
different relation to each other. More permanent entropion is caused by
the contraction which follows removal of tumours from the under surface
of the lids, or destruction of large portions of the conjunctiva. The
disease is most frequently met with in the upper lid.
_Trichiasis_ consists in a vicious bend of the eyelashes, or in a
supernumerary growth in the rows or numbers of individual cilia,
whereby they are inverted, and sweep the surface of the conjunctiva
covering the cornea; thus great distress is caused by the friction of
the hairs and edge of the lid on the sensible surface of the eyeball,
and inflammation is frequently kindled and kept up by the continued
irritation; it is accompanied by its usual distressing symptoms when
seated in that organ, and too often followed by a greater or less
number of untoward consequences. Sometimes only one or two hairs are at
fault; in other instances, the half of the eyelash grows inwards; and
sometimes there is a double row of cilia; one set being in the usual
position, while the other projects against the eyeball. If proper means
are not taken to remedy the evil, and moderate the irritation which it
produces, the cornea becomes thickened and changed in structure; and
vision, at first impaired and indistinct, may be entirely lost.
The symptoms may be for a time palliated by plucking out the faulty
hairs, abstracting blood from the loaded vessels, and subsequently
using ointments or collyria,—the best of which, perhaps, is the
solution of nitrate of silver. In some cases it may be necessary to
employ counter-irritation, as blistering the nape of the neck; and in
all the general health must be strictly attended to. Other means may be
required, and will be mentioned when treating of chronic ophthalmia.
The permanent cure of the disease is effected either by removal or by
destruction of the roots of the cilia. The whole edge of the eyelid,
or the offending part of it, is removed with a sharp narrow bistoury,
the operator steadying the parts by laying hold of the cilia with the
fingers of his left hand. It is necessary to remove the mere edge only,
the cilia and their roots, and not the whole of the tarsal cartilage,
as has been proposed.
Inversion of the lid, from contraction of a cicatrix in the
conjunctiva, may be counteracted, by destroying with caustic, or
removing with cutting instruments, a portion of the outer integuments,
corresponding to the internal cicatrix. Forceps with broad points
are used for taking up a fold of the skin, and an oval portion is
then excised with a knife or scissors, cutting instruments being
less painful and more precise than caustics. Of the latter, the
sulphuric acid has been particularly recommended for this purpose.
The contraction of the wound releases the cilia from the power of the
internal cicatrix, and the parts are restored to their healthy state.
[Illustration]
The term _Pterygium_ is employed to denote a thickened and vascular
state of part of the conjunctiva. The diseased portion is generally of
a triangular form, commencing at the inner corner of the eye, extending
towards the cornea, gradually diminishing in breadth, and terminating
in a sharp apex, either at the margin of the cornea, or somewhere
between its margin and centre. The thickening is seldom great, but the
vessels which traverse the thickened part are numerous, enlarged, and
tortuous—are, in fact, varicose. The base of the pterygium is always
on the circumference of the eye, generally at the inner corner, and
its apex is seldom, if ever, situated beyond the centre of the cornea:
frequently the sclerotic conjunctiva alone is affected. The motions of
the eye are little disturbed by the disease, but vision is materially
impaired when a considerable part of the cornea is covered. Pterygium
is in general single, but sometimes, though very rarely, there are two
or more pterygia in one eye; and, in such cases, the patient’s vision
is seriously affected, in consequence of the apices of the different
pterygia uniting and coalescing on the cornea, and investing the
greater part of that organ with a thick and dark shade. When several
occur, they sometimes unite throughout their whole extent, and cover
the half or more of the eye. This disease is very common amongst
negroes and persons residing in equatorial climates.
When the pterygium is of considerable size, extending over the cornea,
the only remedy is excision. The apex of the web is laid hold of and
pulled outwards by forceps or a hook, and the whole diseased part is
then carefully dissected off with scissors, the incisions commencing
at the apex, and being carried on to the base. The wound gradually
contracts; and though an opaque cicatrix must form on the corneal
surface, the speck is of much less dimensions than the space formerly
occupied by the pterygium. If the web be thin and not exceedingly
vascular, it may be sufficient to make a semicircular section of it
transversely, by means of a hook and scissors, between its base and
the margin of the cornea; its growth is thereby arrested, and there
is a probable chance of its beginning to diminish, and ultimately
disappearing. When it is small, and so situated as to cause no
impairment of vision, it is prudent and good practice not to interfere
with it at all.
DISEASES OF THE EYEBALL are numerous, and various in their nature. Some
are acute, others chronic; and their attack is either sudden, or slow
and insidious. Most of them are attended with pain and other annoying
symptoms, and some cause loss of vision. Some are cured by internal
means; others require surgical operations; and the cure is either
complete and permanent, or palliative and temporary. Some destroy the
organ, and others, still more malignant, cause extinction of life. All
require much attention and care.
_Of Ophthalmia, or Inflammation of the Eye._—The symptoms and
appearances of ophthalmia vary much according to the particular
texture or textures affected. They require to be minutely attended
to, that the treatment may be varied in such a way as to obviate any
bad consequences which may be threatened. The great importance of the
organ, and the danger to its structure and functions which is likely to
occur from any other termination of the affection than resolution, must
never be lost sight of.
We shall first treat of inflammation of the more external parts of
the ball, an affection generally less dangerous than inflammation of
the interior, but at the same time of more frequent occurrence, and
produced by slighter causes.