to bring the raw edges into contact, and retain them so; and, in most
cases, one or more points of interrupted suture are necessary. Adhesive
plaster may be at the same time applied, but of itself is insufficient
to effect permanent coaptation.
Wounds of the eyeball, however slight, require much attention, being
inflicted on an important and highly sensible organ, and there being
always a risk of destructive inflammatory action. If the breach of
surface be clean, simple, and superficial, rest of the parts will in
general be sufficient to effect a cure. Lacerated wounds, and such
as penetrate into the interior of the eyeball, cannot be expected to
heal without morbid action having been excited: inflammation must be
anxiously looked for, and actively combated as soon as it appears.
When a foreign body lodges in the wound, it must be early removed.
But in certain cases it is imprudent to attempt extraction of foreign
matter; as when a small shot, or other minute substance, has lodged
in the interior of the eyeball. In such circumstances we can only
adopt such measures as prevent and subdue morbid excitement. The
organ may remain little disturbed for a short period, but violent
inflammatory action soon occurs, and, though subdued for a time,
again breaks forth, and, by its successive attacks, may ultimately
destroy the eyeball. Frequently all endeavours to avert untoward
results are unavailing, and the functions of the organ are more or
less impaired—the cornea may become opaque, the iris may protrude, the
pupil may become irregular, contracted, or obliterated—the crystalline
lens may lose its transparency, amaurosis may occur from injury of the
retina, the humours may be evacuated, and the eye sink in its socket.
The entrance of a large foreign body into the orbit may displace the
globe, and cause it to protrude between the eyelids: in such a case
the body should be removed and the ball gently replaced; vision may be
soon regained; but, if the protrusion has been such as to cause much
stretching of the optic nerve, blindness more or less complete remains.
Fatal effects may follow wound of the eye, on account of the foreign
body, as a sharp-pointed instrument, penetrating the thin parietes of
the orbit, splintering the bone, and injuring the brain.
_Orbital Inflammation._—Inflammation seldom attacks the parts situated
between the orbit and the eyeball; but, when it does, the affection
is very serious. The action is very acute, and proceeds rapidly to
suppuration. The pain is excruciating, extends to the whole head,
accompanied with a sensation of extreme tension in the orbit, and is
much increased by the slightest motion of the eye: and from the matter
accumulating around the ball, and being confined to the unyielding
orbit, by the dense fibrous expansion which extends from the margin of
the orbit to the interior surface of the eyeball, the globe is pushed
forwards, and distends the lids. The palpebræ become erysipelatous,
and swollen by serous effusion. Violent inflammatory fever occurs;
and, as the disease advances, all the symptoms are aggravated, and
become almost intolerable. The globe is farther protruded, and the
retina is insensible to light. At length the accumulated matter makes
its way to the surface, and is discharged, giving great relief to the
patient, and permitting the protruded globe to regain its situation.
The inflammation seldom extends to the eyeball.
In the early stage of this affection, the most decidedly antiphlogistic
measures are imperiously called for. When fluctuation can be felt,
or when the symptoms indicate that suppuration has taken place,
whether fluctuation is perceptible or not, an early opening into the
affected part should be made through the dense orbital ligament. Thus
a free exit is allowed for the matter, the patient is instantaneously
relieved, and the extent of the local mischief is limited. It is unsafe
to wait for the spontaneous evacuation of the matter: such a process
is necessarily tedious, and, before it has been accomplished, the
orbital bones may have become diseased; they may have given way at
certain points, and the matter may have escaped within the cranium. The
artificial opening should always be free, and deep if necessary.
_Tumours in the Orbit._—Sarcomatous tumours occasionally form in the
cellular tissue of the orbit. They occur at all periods of life, and
may, by slow and gradual increase, cause the eyeball to protrude and
disturb its functions; or their growth is rapid, and accompanied with
great suffering. In some cases, the eye is made to protrude to a great
degree, and by the extension of the optic nerve vision is impaired;
in others, the patient is totally blind at the commencement of the
disease. Yet the eye may be displaced to no small extent without
amaurosis following. The optic nerve appears to bear a good deal of
extension without disturbance of its functions. The majority of tumours
in this situation are of rapid growth, their structure is soft and
medullary, they sooner or later furnish a fungus, and, though removed
at an early period, are generally reproduced. The exophthalmos is often
the first indication of such a growth, and it is sometimes greater in
the early part of the disease than afterwards, when the fascia passing
down from the edge of the orbit has given way. The malignant tumours
are most frequently met with in childhood, though morbid growths of a
bad kind form in the eyeball at different periods of life. They often
follow the infliction of a blow or wound. The patient’s sight speedily
declines, without any known cause; there is pain in the forehead,
temple, and eyeball; the ball protrudes, perhaps slightly, and at
first is not otherwise changed; but on careful examination a dimness
can be perceived deep in the eye. The opaque body approaches the pupil
and fills it, and may in this state be mistaken for disease of the
crystalline lens; but the tumour soon pushes forward the iris, and
fills the anterior chamber. It has an irregular surface covered with
flocculi. Blood-vessels are observed ramifying on it, and by this it
is distinguished from cataract, should the accompanying symptoms not
have previously convinced the surgeon of the nature of the disease.
If not interfered with, the cornea ulcerates, a fungus appears, often
grows with great rapidity, and may either furnish not a drop of blood,
or bleed profusely. The eyelids are œdematous and permeated by large
venous branches. Abscesses form around; the lymphatics of the neck are
involved; and the patient succumbs. The original tumour may possess the
usual structure of medullary sarcoma, may be of a melanotic nature,
or may contain a mixture of both; or it is of harder consistence,
containing cells filled with bloody, glairy, or other fluid. The
whole coats of the eye are seldom involved: part remains sound, but
compressed and disfigured by the morbid mass, and the humours are
either absorbed or discharged.
Circumscribed tumours, exterior to the ball, and surrounded by a
cellular cyst, may be removed by careful and cautious dissection,
without injury to the important parts. A free incision is made along
the edge of the orbit, in the course of the fibres of the sphincter
oculi. The tumour is exposed, laid hold of with a hook or small
vulsellum, and separated from its attachments by a knife, the edge of
which is directed towards the new growth. A man, aged 26, had laboured
under blindness with exophthalmos for eighteen months. A tumour could
be felt above the eyeball, which I dissected out, along with the
lachrymal gland, to which it adhered. It was of medullo-sarcomatous
structure, and of the size of a plum: at one point it contained a mass
of coagulated blood. After its removal, the eye resumed its place and
functions. The patient remains well; but such favourable cases are rare.
If the affection be more extensive, it may be necessary to remove
all the contents of the orbit: but, in disease involving the entire
structures, there is little chance of the patient remaining free from
it: it almost uniformly returns, as is also the case whenever the
disease has commenced in parts of the eyeball. The optic nerve is
often affected at an early period: its cut surface is unsound; and
from this, again, springs a fungus which grows rapidly. But under many
circumstances the surgeon is not only justified in removing the orbital
contents, but called upon to do so. The operation, though cruel and
painful, need not be tedious. The commissure of the eyelids is divided
with the point of a bistoury, and the forepart of the ball laid hold
of firmly and deeply with a vulsellum—that is, forceps provided with
a double hook at each extremity of the blades. A straight bistoury
is then entered at the margin of the orbit, pushed down to the base,
as near as possible to the entrance of the optic nerve, and carried
round the tumour rapidly, the blade towards the handle being made
to move more quickly than the point. The nerve is cut across, and,
after the removal of the morbid mass, the cavity is sponged out and
examined. The lachrymal gland, and other soft parts, particularly if
altered in texture, are raised with a hook, and removed by means of
curved scissors. In young subjects, and in adults, when the disease
is far advanced, the parietes of the orbit are thin, softened, and
attenuated by pressure: the knife should therefore be used cautiously,
and it is, perhaps, safer to finish excision with a narrow, curved,
and probe-pointed bistoury, after having penetrated to the bottom of
the orbit with a sharp-pointed knife: all other curious and crooked
knives are useless. Bleeding is restrained by charpie, pressed firmly
and quickly into the cavity, and supported by compresses and bandage;
but, before introducing the dossils, all coagula and fluid blood should
be carefully sponged out. Afterwards, excited vascular action, with
pain in the head and wound, may in some subjects require abstraction
of blood, the exhibition of purgatives and antimonials, and immediate
removal of the dressings, followed by fomentation and poultice. When
matters proceed favourably, the charpie is removed gradually as
suppuration advances, and the granulations are supported with light
dressing, either dry, or moistened with some slightly astringent
lotion. The discharge will gradually cease, and the granulated surface
cicatrise under the level of the eyelids. In such circumstances the
deformity may be remedied, after the parts have become quiet, by the
adaptation of an artificial eye of enamel, made so as to resemble
exactly the other eye. It is worn without inconvenience, removed at
night like artificial teeth or a wig, and cleaned and replaced in
the morning. Such a substitute is also useful when the humours have
been evacuated, or the organ destroyed, by injury or the effects of
inflammation. Too frequently the morbid growth is reproduced, and that
rapidly. It may be restrained by escharotics, the red oxide of mercury,
potass, acetate of lead, acids, or the actual cautery; but the patient
is thereby put to much pain without a chance of ultimate benefit.
It is too true, that the hopes of a cure, after the extirpation of the
eyeball for malignant disease, are defeated by the prior existence
of a similar affection within the cranium. In the majority of cases,
death has occurred from tumours of greater or less extent, along the
course of the optic nerve, or their tract: behind the commissure, and
extending to the optic lobes and even cerebellum.
[STRABISMUS.
Strabismus, or squint, as it is vulgarly designated, may be defined
to be an aberration from the natural direction of the optic axes, by
which the consent between the eyes is destroyed, and vision more or
less impaired. The resulting deformity varies in different cases,
from the slightest possible cast to the most disagreeable obliquity.
The affected organ may be turned inwards or outwards, upwards or
downwards, according to the muscle upon the derangement of which
the squint depends. When the eye is directed inwards, it constitutes
what is called convergent strabismus; if, on the other hand, it
inclines outwards it is said to be divergent. The upward and downward
obliquities have not received any particular names. As might be
supposed, these different forms of strabismus do not occur with equal
frequency. On the contrary, two of them are so rare that I have not
yet met with an instance, though I have examined the eyes of a very
considerable number of persons labouring under this infirmity. These
two forms are the upward and downward, both of which, but especially
the latter, are so seldom witnessed that their occurrence may well be
doubted, except as the result of external violence.
The most common variety of strabismus by far is the convergent, in
which the eye is directed inwards, or inwards and upwards. Of 536
cases collected from various sources by a writer in the Philadelphia
Medical Examiner, 506 were of this description, a proportion which
fully accords with my own but more limited observation. The degree of
obliquity may be very moderate, or so great that when the person looks
directly forwards with the sound eye the cornea of the other shall be
almost entirely concealed at the inner canthus. It is worthy of remark,
that in this form of the lesion, at least so far as my own experience
goes, the organ rarely, if ever, inclines downwards, but nearly
constantly somewhat in the opposite direction.
Next in point of frequency is the divergent form, which, however, is
comparatively rare. Of 866 cases reported in the work above alluded
to, it was noticed only forty-four times; and thus far I have myself
seen only three or four examples of it. The eye in this variety of
strabismus is seldom drawn out very far, nor is it so apt to be
attended with the same amount of upward obliquity as the convergent.
It seems to be the general sentiment of writers on strabismus, that, in
the great majority of cases, only one organ is affected. Thus, in the
article in the Philadelphia Examiner, before adverted to, it is stated
that the distortion occurred 459 times in one eye, and only 47 times
in both. Dr. Dix, of Boston, in a small treatise on strabismus, makes
a similar remark. Of 50 cases which fell under his notice, the lesion
is said to have been limited to one eye in 36. Now I am convinced from
a good deal of experience that nothing can be more unfounded than this
opinion, which is to be deprecated the more because it is calculated to
lead to very serious errors in practice. I unhesitatingly assert, that
in nearly all instances, at least of convergent squint, both organs are
implicated, though not in an equal degree. Usually—perhaps always—one
is more affected than the other, which the patient, therefore, regards
as his good eye, as it is the one which he constantly employs in
viewing objects. Nor is it surprising that this should be the case,
when we recollect the remarkable sympathy existing between these
structures, and the fact that when one eye is diseased the other is
very liable to take on morbid action also. Amaurosis of one eye is very
often followed by a similar malady of the other, and the same is true
of cataract and some other affections. In the natural state there is a
perfect agreement between the optic axes, produced by the harmonious
action of the straight muscles, but when this consent is destroyed,
as it is in strabismus, the eyes lose their parallelism, and the
distortion in question is the consequence.
As was previously intimated, one eye is commonly more affected than the
other, and this, if I mistake not, will be found to be the left, though
it is impossible, in the existing state of the science, to indicate
the proportion. Mr. Lucas thinks that the proportion in favour of the
left eye is as three to two; Dr. Phillips of Liège, on the other hand,
maintains that the right organ is more frequently involved than the
other. It rarely happens that both eyes become deranged simultaneously;
on the contrary, one generally squints first, and after a while the
lesion begins in the other, the interval being probably very short.
Whether strabismus occurs with equal frequency in both sexes, is still
an unsettled question. Of thirty-two cases on which I have operated,
only five were females, whereas in the fifty cases published by Dr.
Dix, of Boston, only nineteen were males, thus exhibiting a most
remarkable disparity in reference to this point. The difference, if
any, is perhaps not great either way, and, as it is of no practical
importance, it need not be pursued any farther here.
The exciting causes of this affection are numerous and diversified. One
of the most frequent is imitation. Nearly one-seventh of all the cases
that occur are probably induced in this manner. Hence our schoolrooms
may be regarded as a fruitful source of mischief, one cross-eyed child
being often the cause of strabismus in many others, merely from that
habit of imitation to which the young are so much addicted. Ophthalmia,
by whatever cause induced, is another, and that a very common source
of this distortion. I have seen repeated instances of this kind, and
many others are mentioned by authors. Convulsions, eruptive diseases,
such as measles and scarlet fever, hooping-cough, derangement of the
digestive organs, injury on the eye, and difficult dentition, may all
be enumerated as so many causes of the lesion in question. Frequently
it arises without any assignable reason, and when the individual is in
the most perfect health. Occasionally it is congenital, or, what is
more probable, makes its appearance within a few days after birth.
It is supposed that strabismus is occasionally hereditary. This is
doubtful; for if we sometimes meet with cross-eyed children whose
parents, one or both, are similarly affected, it by no means proves
that the distortion was transmitted to them in the manner of certain
maladies. It only shows a coincidence, which may be explained, in
most instances, on the assumption that the children have acquired
the obliquity by imitation, or by some other cause, not that it was
entailed upon them previously to birth. In the same manner we may
satisfactorily account for the existence of strabismus in several
members of the same family, of which a remarkable instance has recently
come under my own observation. Of three brothers, one has three
children affected with it, another two, and a third one. The parents
have all sound eyes, and so have the uncles and aunts, except one,
on whom I operated successfully several months ago. Last autumn I
operated for cataract on three children belonging to a gentleman from
Mississippi, who informed me he had six others at home, of whom three
were affected with strabismus. Both parents, as well as their immediate
relatives, are free from the affection.
Strabismus essentially consists in a contracted state of one or more
of the muscles of the eye. This, as was before intimated, is commonly
the internal rectus. The shortening, varying according to the extent
of the squint, is always attended with a corresponding elongation of
the opposite muscle, so that it gradually loses, either in whole or
in part, its antagonising influence. How this affection is brought
about, in the first instance, is still unknown, though it is probable
that it depends upon some lesion of the nerves which supply the
muscles of the eye, rather than upon any actual lesion of these fleshy
bundles themselves. Be this as it may, when the resultant distortion
is permanent, the affected muscle, from being constantly engaged in
holding the eye in its unnatural position, acquires a corresponding
degree of development, in accordance with a law of the animal economy
that, in proportion as an organ is exercised, will be its size and
strength. The more frequent occurrence of convergent strabismus is
owing, doubtless, to the fact that the internal straight muscle is not
only larger and stronger than the others, but that it is inserted much
nearer the cornea, deriving thus two important mechanical advantages.
One of the most disagreeable effects of strabismus is the deformity
to which it leads, rendering the individual an object of constant
observation and ridicule. Were this confined to infancy and childhood,
it would be of comparatively little consequence, but when we reflect
that it continues through life, and that it is a source of incessant
mortification, the influence which it exerts upon the temper and
disposition of the sufferer must often be of the most unhappy kind. A
still more serious effect, however, is the impairment of the vision
of the affected eye, which, never entirely absent, sometimes amounts
nearly to a total loss, from the insensibility of the retina, which is
sometimes as complete as in confirmed amaurosis. In another series of
cases the person is myopic, or sees objects only at a short distance.
In some instances, again, there is double vision, or objects appear
indistinct, and run as it were into each other, the image painted on
the retina being confused and imperfect.
The distortion in question can be remedied only by a surgical
operation, it having no tendency to a spontaneous cure. On the
contrary, it generally manifests a disposition to increase,
particularly in children of a nervous, excitable temperament. In fact,
the very worst forms of squint I have ever witnessed were in persons
of this description. The question then arises, at what age ought we
to operate? My opinion decidedly is the sooner the better. Provided
the child be in good health, and not under one year of age, I would
not hesitate a moment to resort to the knife for its relief. And why
should we? The operation itself is not particularly painful, and if it
be done at an early period it will commonly be necessary to perform
it only on one eye, whereas if it be postponed until the age of ten
or twelve, as some have suggested, we shall not be able to effect a
cure without dividing the corresponding muscle of the opposite side.
Moreover, the sight in the meantime will become considerably impaired,
the retina will lose its insensibility, and the individual be an object
of ridicule and insult; all of which may thus be obviated. But it may
be urged that a resort to the knife at this tender age will be both
difficult and dangerous; difficult, because of the struggles of the
little patient, and dangerous, because of the great susceptibility of
the nervous system. In regard to the first of these points, it may
be stated that the resistance, however great, may be easily enough
surmounted by proper management; and, as it respects the latter,
that it has been vastly overrated. Operations much more severe are
frequently performed even at a much earlier period. I have seen the
primitive carotid artery successfully tied in an infant of less than
six months; and I have myself repeatedly operated, with similar
results, for harelip, and that too in the very worst forms of that
malformation. I do not, therefore, in these objections, see sufficient
reason for deferring the division of the affected muscle.
The instruments which I employ for the operation, are two lid-holders,
a double sharp-pointed hook for fixing the eye, a pair of dissecting
forceps for pinching up the conjunctiva, and a scalpel or pair of
scissors. The surgeon should also be provided with two or three small
sponges and a basin of cold water.