THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES LOGIN BROS. A HANDBOOK OPHTHALMIC SCIENCE AND PRACTICE. BY HENRY E. JULER, F.R.C.S. JUNIOR OPHTHALMIC SURGEON TO ST, MARY S HOSPITAL; SENIOR ASSISTANT SURGEON AND PATHOLOGIST TO THE ROYAL WESTMINSTER OPHTHALMIC HOSPITAL; FORMERLY CLINICAL ASSISTANT AT THE ROYAL LONDON OPHTHALMIC HOSPITAL, 3I00RFIELDS. WITH ONE HUNDRED AND TWENTY-FIVE ILLUSTRATIONS. PHILADELPHIA: HEITRY C. LEA'S SON & CO. 1884. DORNAN, PRINTER. AMERICAN PUBLISHERS' NOTE. In presenting to the profession in this country an edition of a treatise on Ophthalmology which has been so favorably received abroad, it is only necessary for the publishers to acknowledge their indebtedness and call attention to the valuable additions of Dr. Charles A. Oliver, of this city; among which might be mentioned the description of a new astigmatic disk, with an explanation of its use, and important material in the shape of results and conclusions derived from his re- searches as to the comparative effectiveness of the different mydriatics, as well as the equivalents in English inches where the metrical index is used in the original. A selection of the test-types of Jaeger will also be found in addition to those of Snellen, at the end of the volume. It is, therefore, confidently hoped the work will be found to meet fully the requirements of all those who desire to possess a reliable guide in this branch of the science of medicine. Philadelphia, November, 1884. PREFACE. In the preparation of the following work, it has been my endeavor to produce concise descriptions and typical illustra- tions of all the important affections of the eye. With one exception, the colored plates have all been taken from cases met with in the course of clinical work, chiefly at the Royal Westminster Ophthalmic Hospital, St. Mary's Hos- pital, and the Royal London Ophthalmic Hospital, Moorfields. With regard to the drawings of these and the other illustra- tions, I have received valuable suggestions and assistance from Mr. E. Noble Smith. The chapter on Refraction has been jointly written by my colleague Mr. Adams Frost and myself, and that on color- vision is entirely his work. My best thanks are due to my friend and colleague, Mr. Anderson Critchett, for the kind waj^ in which he has allowed me to make use of any cases coming under his, or our joint, care at St. Mary's Hospital, and for many valuable practical suggestions as to diagnosis and treatment. VI PREFACE. I also have to thank Dr. E. J. Edwardes for considerable help in the chapter on the Optic Nerve and Retina, more especially with regard to the views of Continental writers. Finally, I am indebted to Mr. Adams Frost and Mr. Arthur K. "Willis for their valuable help and suggestions in passing the book through the press. 77 WiMPOLE Street, Cavendish Square, W. 1884. CONTENTS. CHAPTER I. THE EYELIDS. PAGE Anatomy and physiology — Ophthalmia tarsi — Hordeolum — Chalazion — Dermoid cyst — Nsevi — Xanthelasma — Epithelioma (Rodent ulcer) — Papilloma — Molluscum contagiosum — Sarcoma — Chancre — Gumma — Blepharospasm — Ptosis — Trichiasis — Entropion — Ectropion — Epican- thus — Injuries — Wounds — Burns — Ankylohlepharon — Symblepharon . 17 CHAPTER II. THE LACHRYMAL APPARATUS. Anatomy and physiology — Diseases of the lachrymal gland — Hypertrophy ■ — Sarcoma — Extirpation — Cysts — Fistula of gland — Displacement of puncta — Slitting up canaliculus — Probing — Obstruction of canaliculi and of nasal duct — Abscess of lachrymal sac — Fistula of sac . . 45 CHAPTER III. THE CONJUNCTIVA. Purulent conjunctivitis — Gonorrhoeal ophthalmia — Ophthalmia neonatorum — Muco-purulent conjunctivitis — Granular conjunctivitis — Phlyctenular conjunctivitis — Membranous conjunctivitis — Pterygium — Pinguecula — Amyloid degeneration — Xerosis ........ 62 CHAPTER IV. THE CORNEA. Anatomy and physiology — Oblique focal illumination — Inflammation — Interstitial keratitis — Punctate keratitis — Vascular keratitis (Pannus) — Peritomy — Inoculation — Jequirity ophthalmia— Phlyctenular kera- titis — Suppurative keratitis — Abscess — Onyx — Hypopyon — Ulcers (su- perficial, deep, serpiginous) — Paracentesis — Saemisch's operation — Opacities of the cornea — Tattooing — Transplantation — Deposits — An- terior staphyloma — Enucleation of the eye — Artificial eyes — Conical cornea — Wounds — Foreign bodies — Tumors — Epithelioma — Sarcoma . 84 Vm CONTENTS. CHAPTER V. THE SCLEROTIC. PAGE Anatomy and physiology — Canal of Schlenini — Ligamentum pectinatum — Capsule of Tenon — Sclerotitis — Episcleritis — Contusions — Rupture — Wounds 125 CHAPTER VI. THE TUNICA VASCULOSA. The iris and pupil — The ciliary body — The choroid — The lymphatics of the eye — Iritis — Serous iritis — Plastic iritis — Suppurative iritis — Posterior sj-ncchia — Cyelitis — The normal fundus — Choroiditis (serous, plastic, disseminated) — Pseudo-glioma — Purulent choroiditis — Sjphilitic cho- roido-retinitis — Central choroiditis — Myopic crescent — Posterior staph j-- loma — Tubercle of choroid — Rupture of choroid — Sympathetic irrita- tion — Sympathetic ophthalmitis — Tumors — Gummata — Miliary Tu- bercle — Sarcomata — Congenital aflections — Irideremia — Coloboma — Persistent pupillary membrane — Iridectomj' — Iridodesis — Iridotomy . 130 CHAPTER VII. THE OPTIC NERVE AND RETINA. Anatomy and physiology of the optic nerve — Ophthalmoscopic appearance of the optic disk — The physiological cup — Sclerotic ring — Anatomy and physiology of the retina — Appearance of retina — Hypera^mia of the disk — Optic neuritis (Papillitis) — Optic nerve atrophy — Optic nerve hemorrhages — Opaque nerve fibres — Ischsemia of the retina — Embolism of the retinal arteries — Retinal hemorrhages — Retinitis — Albuminuric retinitis — Diabetic retinitis — Leucocythnemic retinitis — Syphilitic reti- nitis — Pigmentary retinitis — Detachment of retina — Glioma of retina — Pseudo-glioma 180 CHAPTER VIII. AMAUROSIS, AMBLYOPIA, AND SOME FUNCTIONAL DISORDERS OF VISION. Amaurosis — Tobacco amblyopia — Amaurosis in Infancy — Hemiopia — Hys- terical and cerebral hemianivsthesia — Night-blindness — Malingering . 219 CHAPTER IX. THE VISUAL FIELD AND THE PERIMETER. The visual field — The perimeter — Scotomata — The blind spot — McUardy's perimeter — Priestley Smith's perimeter — Importance of perimetry — Field of fixation— The angle alpha 229 CONTENTS. IX CHAPTEE X. COLOR-VISION AND ITS DEFECTS. (By W. Adams Frost, F.R.C.S.) PAGE Solar spectrum — Complementary colors — Young's theory — Young-Helm- holtz theory — Hering's theory — Congenital defects of color-vision — Total color-blindness — Complete blindness for one of the fundamental colors — Incomplete blindness for one of the fundamental colors — In- complete blindness for all three — Methods of testing color-vision — Holmgren's wools — Thomson's arrangement of Holmgren's wools — Frequency of color-blindness ......... 243 CHAPTER XL THE CRYSTALLINE LENS. Anatomy of lens — Suspensory ligament — Cataract — Varieties of cataract — Causes — Symptoms — Treatment — Artificial pupil — Solution — Needle operation — Linear operation — Suction operations — Extraction of the entire cataract — Preliminary iridectomy — Flap operation — Von Graefe's linear operation — Modifications of von Graefe's operation — Accidents and complications of extraction — Extraction of the lens in the capsule — Pagenstecher's operation — Macnamara's operation — After-treatment — Spectacles — Opaque capsule — Dislocation of the lens .... 262 CHAPTER XII. THE VITREOUS HUMOR. Anatomy — Muscse volitantes — Opacities in the vitreous — Degenerative changes — Abnormal fluidity — Synchisis scintillans — Foreign bodies — The electro-magnet — Cysticercus — Pseudo-glioma — Hemorrhages . 302 CHAPTER XIII. GLAUCOMA. Symptoms — Premonitory — Increased tension — Cupping of disk — Pulsation of vessels — Contraction of visual field — Varieties — P:ithology — Treat- ment — Secondary glaucoma ......... 309 CHAPTER XIV. ERRORS OF REFRACTION. Section I. — Optical Principles. Laws of refraction — Refraction at parallel surfaces — Refraction through a prism — Refraction at single spherical surface — Refraction through a biconvex lens — Images formed by spherical lenses — Spherical aberration — Chromatic aberration .......•• 327 CONTENTS. Section //.—The Eye Considered as an Optical Instrument. Construction of the eye — Donders's schematic eye— Frost's artificial eye — Accommodation and presbyopia— Optical defects of the eye — Visual angle and visual acuteness — Snellen's test-types 337 Section III. — The Errors of Refraction. Myopia. Definition — Symptoms — Pathology — Prevention . . . 346 Hyperynetropia. Definition — Far- and near-points — Symptoms . . 351 Asiigmatistn. Refraction at an astigmatic surface — Varieties of Astig- matism — Vision in simple astigmatism ....... 355 Section IV. — Lenses Used in Testing Refraction : the Ophthalmoscope. Trial lenses — Trial frame — Ophthalmoscopes — Direct ophthalmoscopic ex- amination — Indirect method — Difficulties to be overcome . . . 357 Section V. — Methods of Estimating Refraction. i. Testing by trial lenses— ii. Other subjective tests — iii. Testing by direct ophthalmoscopic examination — iv. Testing by indirect method — v. Testing by mirror alone at a distance — a. Fundus-image test — b. Shadow-test 367 Section VI. — General Considerations. Use of mydriatics — When full correction should be ordered — Whether glasses should be worn constantly — Correction of presbyopia . . 405 CHAPTER XV. affections of the ocular muscles. Anatomy and physiology — Associated movements — Strabismus (false, para- lytic, concomitant) — Angular measurement of strabismus — Operations for strabismus — Nystagmus — Affections of the intraocular muscles . 410 CHAPTER XVI. DISEASES OF THE O BIT. Cellulitis — Acute abscess — Chronic abscess — Periostiti> — Distention of frontal sinus — Exophthalmic goitre — Tumors — Pulsating exophthalmos — Injuries and foreign bodies ......... 435 Appendix 447 Jaeger and Snellen's Reading Tyi'es 449 Large Test-types 455 Index 459 CHROMO-LITHOGRAPHIC PLATES. FIG. 1. Epithelioma of Eyelid 2. Epithelioma of Cornea 3. Epithelioma of Cornea To face p. 26 1. Ciliary Kegion (normal) 2. Corneal Corpuscles and Nerve Fi- brils 3. Anterior part of Cornea 4. Section of Ulcer of Cornea 5. Section of Cornea in Pannus To face p. 84 1. Pannus 2. Pterygium 3. Local Keratitis 4. Interstitial Keratitis 5. Punctate Keratitis 6. Ulcer of Cornea (healing) 7. Phlyctenular Conjunctivitis 8. Plastic Iritis 9. Severe Plastic Iritis 10. Posterior Synechias 11. Hypopyon 12. Blood in Anterior Chamber To face p 90 1. Sarcoma of Cornea 2. Cells from Tumors 8. Sarcoma of Choroid 4. Section of Choroid 5. Structure of Lens 6. Lens Fibres To face p. 124 1. Section of Ciliarj^ Region in Iritis Serosa 2. Section of Ciliary Eegion in Iritis Plastica 3. Section of Ciliary Region in" Iritis Suppurativa To face p. 143 1. Normal Fundus 2. Normal Fundus To face p. 150 1. Disseminated Choroiditis 2. Disseminated and Central Choroi- ditis To face p. 154 1. Myopic Crescent 2. Posterior Staphyloma with patches of Choroidal Atrophy To face p. 158 1. Section through Optic Disk — J^or- mal 2. Section through Optic Disk — Optic Neuritis 3. Section through Optic Disk — Optic Neuritis To face p. 182 1. Section of Retina — Normal 2. Section of Retina — Hemorrhagic Retinitis 3. Section of Retina — Albuminuric Retinitis To face p. 184 Xll CHROMO-LITHOGRAPHIC PLATES. FIG. 1. Physiological Cup 2. Hyperaemia of Optic Disk To face p. 192 1. Neuro-retinitis 2. Neuro-retinitis with Hemorrhage To face p. 193 1. Visual Field — Optic Atrophy 2. Visual Field — Hemiopia To face p. 222 1. Visual Field — Normal 2. Visual Field — Commencing Optic Atrophy To face p. 232 1. Atrophy of Optic Nerve 2. Atrophy of Optic Nerve and Retina | ]. Visual Field— Chronic Glaucoma To face p. 197 2. Visual Field— Pigmentary Keiinitis To face p. 238 1. Opaque Nerve Fibres 2. Opaque Nerve Fibres \ 1-13. Tests for Color-blindness To face p. 201 To face p. 256 1. Embolism of Central Artery of lletina 2. Eupture of Choroid To face p. 202 1, 2. Dislocation of Lens 3, 4. Pyramidal Cataract 5, 6. Lamellar Cataract 7, 8. Cortical Cataract 1. Albuminuric Retinitis with Hcmor- 9, 10. Nuclear Cataract rhages 2. Renal Peri-arteritis with Hemor rhages To face p. 200 ^- ^^'S^t Glaucoma Cupping 2. Deep Glaucoma Cupping 1. Pigmentary Retinitis I Tofacep.ZW 2. Pigmentary Retinitis (advanced) ' To face p. 210^ 1_4. Microscopic sections of Ciliary 11, 12. Posterior Polar Cataract To face p. 266 1. Detachment of Retina 2. Detachment of Retina 1. Pseudo-glioma 2. Glioma of Retina 3. Glioma of Retina 4. Glioma of Retina To face p. 212 To face p. 216 Region and Optic Disk in Pri- mary Glaucoma To face p. 319 1. Appearance of the Disk in Astig- matism 2. Appearance of the Disk in Astig- matism To face p. 393 LIST OF ILLUSTRATIONS. FIG. 1. Section through Upper Eyelid 2. Compressing Forceps for Eyelid . 3. Section of Dermoid Cyst 4. Compressing Forceps . 5. Subcutaneous Ligature for Trichiasis 6. Arlt's Operation for Entropion, 7. 8. Streatfeild-Snellen Operation for Entropion 9. Adams's Operation for Ectropion, 10, 11. "Wharton Jones's Operation 12, 13. Dieffenbach's Operation . 14. Symblepharon .... 15. Lachrymal Apparatus . 16. "VVeber's Canaliculus Knife 17. Probes for Nasal Duct . 18. Probe in First and Second Positions 19. Syringe for Lachrymal Sac . 20. Caiiulas f:lit and morning after each cleansing with the alkaline solution. Hordeolum (stye) is an inflammation of one of the sebaceous glands of the ciliary follicles at the margin of the lid. Cause. — There is generally some constitutional derangement. Over-use of the eyes, especially in hypermetropes, and expo- sure to cold winds are exciting causes. Symptoms and Pathology. — It begins as a circumscribed red patch; the redness and swelling soon extend to the neighboring parts, sometimes to an alarming extent. Pain is sometimes very severe. At the end of three or four days a 3'ellowish point appears at the centre of the swelling, generally around the base of one of the lashes; this indicates that suppuration has taken place, and that the abscess will point externally. Several of these styes may occur at the same time, or there may be successive crops of them. Treatment must be constitutional as well as local. The general health should be improved by exercise in the open air, ' and the administration of good food, and tonic medicines, such as iron and quinine, or bark and ammonia. Great benefit is often derived from the internal administration of small doses of sulphide of calcium, a ^ or ^ grain in the form of a pill immediately after meals three times daily. They should be continued for at least a week or ten days after the disappear- ance of the styes. Over-use of the eyes should be avoided. Locally, the pain will be much relieved by frequent fomentation with warm water, or the application of bread-and-water poultice. An antiphlogistic lotion should be prescribed, to be used warm (F. 27) ; and a pad of cotton-wool can be soaked in this and placed over the eye in the form of a compress once or twice daily for five minutes at a time. When pointing has com- menced, the cure is accelerated and the pain relieved by an incision. Chalazion (Meibomian cyst, tarsal tumor) is a small tumor situated in the substance of the tarsus. Cause. — Obstruction of the excretory duct of a Meibomian gland. Syntptoiiis and Pathology. — The tumor is more commonly situated in the upper lid than in the lower ; several ma^- occur CHALAZION. 23 at the same time. They vary in size, their diameter ranging from three to ten millimetres. Each consists of a chronic hypertrophy of the deep portion of a Meibomian gland, con- taining accumulated secretion which is sometimes liquid and puriform, sometimes solid, homogeneous, and composed of sebaceous substance. The tumor is generally hard and spheri- cal, fixed to the tarsus, but not to the skin. On everting the eyelid, a bluish discoloration is observed; this is due to thin- ning of the tissues beneath, and corresponds to the position of the tumor. It develops slowly, and maj- cause no inconve- nience for several months, but, if left alone, it often inflames, and sometimes suppurates, pointing generally through the con- junctiva, but occasionally externally. In this way it may finally disappear by contraction. Trealiaent. — The tumor must be removed by surgical means. In the majority of cases it is best to operate from the Fig. 2. — Compressing Forceps for Eyelid. inside of the lid, but when there is pointing outwards the in- cision mu§t be made through the skin, and in the same direc- tion as the fibres of the sphincter orbicularis muscle. The nature of the operation should vary according to the character of the tumor; if this has fluid contents, it will be sufficient to make a crucial incision through the conjunctiva of the everted lid, and to scoop out the contents with a curette. The cavity often fills with blood after the operation, but this becomes ab- sorbed in about ten days. When the tumor has thick walls and solid contents extirpation is the only remedy. This may be done by fixing the eyelid in compressing forceps (see Fig. 2). If operating through the skin, the solid blade must be passed under the lid and the ring-blade made to encircle the tumor. An incision must then be made over the tumor, parallel to the edge of the eyelid, through the skin and subcutaneous tissues 24 AFFECTIONS OF' THE EYELIDS. until the tumor is visible, this is then transfixed by a tenaculum, or seized with an artery forceps, and carefully dissected out with a small scalpel. If removed from within, the solid blade of the compressing forceps must be placed outside, and the ring-blade inside the lid, which can then be easily everted with the instrument attached to it, and the extirpation proceeded with as before. Sutures are not required. Dermoid cyst is congenital, and contains epithelial structures. Syinptoiiis and Pathology. — It is a painless, uninflamed, spheroidal mass, situated generally at the outer angle of the orbit, on a level with the outer end of the eyebrow. Less fre- Skin-like structure Hair-follicle Connecti%"e tissue Fat-cells /<3K& Fig. 3. — Section of Dermoid Cyst. quently it occurs at the inner angle above, and is then to be approached with caution, as this is sometimes the position of meningocele, which is a congenital affection, having the same relation to the cranium and brain which spina bifida has to the spinal column and cord — i e., incomplete development of the bone, with protrusion of the dura mater, in the form of a sac containing fluid. The meningocele can usually be emptied on pressure; it also has a slight impulse, and is less movable. A dermoid cyst cannot be emptied, it is more or less movable, it is non-adherent to the skin; sometimes it is hard, sometimes semifluctuant on pressure. It is found beneath the orbicularis NuEVUS. XANTHELASMA. 25 muscle, and is often firmly attached to the periosteum; some- times it extends deeply into the orbit. On microscopic examination it is generally seen to contain structures resembling the skin and its appendages, such as hair-follicles, hairs, connective tissue, fat, etc. (see Fig. 3). It develops slowly, but is usually seen during childhood. It causes but little inconvenience beyond the deformity. The treatment consists in early excision. A good large in- cision must be made over the tumor, which should then be well cleared from the surrounding tissues. This should if pos- sible be done without rupturing the tumor, otherwise the white sebaceous contents immediately escape, and the thin walls are afterwards difiicult to find. Nsevi occur in the eyelids. They are similar in appearance and structure to those of other parts. Like dermoid cysts, they occasionally extend into the orbital cavity. Treatment is the same here as in other parts, but preference should be given to those methods by which the destruction of the surrounding healthy tissues can be reduced to a minimum, on account of the deformity produced by subsequent cicati-iza- tion. For this purpose I have found the galvano-puncture most valuable. Xanthelasma (vitiligo) is characterized by the presence of yellowish patches, or nodosities, in the skin of the eyelids. The upper lid is most frequently attacked, but both may be simul- taneously affected. The patches first appear near the inner angle and spread outwards parallel to the edges of the lids, being always elongated in form. They occur most frequently in women of middle age. The condition is due to proliferation of certain granular cells, some of which are pigmented, which appear normally in the deep parts of the skin of the eyelid ; besides this the sebaceous glands of the part are hypertrophied, and their epithelial cells are filled with molecules of fat. Their presence causes no pain or inconvenience; but when numerous and of considerable size they are cosmetically objectionable, and the patient may desire to have them removed. This can be easily done by raising them with forceps and using a pair of curved scissors. Sutures are not generally required, and no scar is perceptible after the operation. 26 AFFECTIONS OF THE EYELIDS. Epithelioma (rodent ulcer, rodent cancer, flat epithelial can- cer, cancroid) is the most frequent of malignant growths affect- ing the eyelid. S(/n)ptoms and Pathology. — It seldom appears before the age of forty. It most commonly attacks the skin at the inner angle of the lower lid just below its free edge, but it may occur in other parts of the eyelids. It first appears as one or more small hard nodules, which the patient describes as a " pimple ; " this sooner or later becomes covered with a yellowish incrusta- tion beneath which the skin is found to be excoriated. At tliis stage it causes but little inconvenience; the patient is in the habit of wiping away the scab from time to time, but finding that it does not heal, he presents himself to the surgeon, and it is at this period of the disease that we generally see it. It now presents a brownish exudation, which is hard and dry, and consists of inspissated sanio-purulent matter; beneath this is an ulcerated surface, which at first may be little more than an excoriation, and may appear to heal up for a time, but soon breaks out again, and becomes deeper with hardened edges and purulent secretion. It may remain indolent, or only occa- sionally irritable, for months or even years, without making visible progress, either in surface or depth: but sooner or later it will take on a rapid action, destroying not only the skin but the deeper parts of the eyelids, the connective tissues of the orbit, the cornea and o-lobe of the eve, and finallv the bones of the face. This disease is called rodent ulcer by many English writers, and is regarded by them as the mildest expression of a malignant disease — chiefly because of the long indolent stage, during which there is no pain, and no infiltration of the neigh- boring lymphatic glands; but as soon as the active stage has commenced, and the deeper tissues have become affected, the pain grows intense, the lymphatics in the neighborhood of the parotid gland are affected, and the destruction of tissue is so rapid that the term " mildness " is no longer applicable. Microsropy. — If the tumor be immersed in Miiller\s fluid until it is sufficiently hard for section, and then cut vertically just at the junction of the tumor with the healthy skin, and stained with logwood, it will in many cases be found to consist ,Nt«' f^ .iCfv. althy irjtefimertt m0^ " /. * ■ -'^ ■^' ,M ¥]<;. 1. — Eiiithelionia of lower eyelid. , about .'>o diam. .^v- V -Epiih,elioma whh'rie$ts! ^' ^^^j - Cmjumilyal ItJ^ep Corneal hssue. Fin. 2. — Epithelioma uf cornea. ^ about j.') diaii /^C.^/ ' M^m^m^ M^ - i J r- ■ - ^^ ffi^^r' '^^i^^iS'' Fig. :i. — Portion of tmiior of Fig. !?. > about l'!'! diaoi. To /nee /.. 2f.. EPITHELIOMA, PAPILLOMATA. 27 of ingrowths of epithelial cells; these are very abundant, and in the deeper layers typical "nests" composed of concentric rings of flattened cells may often be seen — such an appearance, in fact, as is represented in Figs. 2 and 3, opposite page 26, which shows an epithelioma of cornea. Very often, however, there is chronic inflammation of the part, so that the new growth is infiltrated with leucocytes, which absorb the staining fluid so readil}-, and are so abundant, that all other cells and tissues are obscured. Fig. 1, opposite page 26, represents a section from an epithelioma of over twenty years' standing, in which this abundant ingrowth of epithelium is very evident. The diagnosis of epithelioma from tertiary syphilitic ulcer is sometimes diflicult. As a rule, however, there is more cica- tricial tissue around the latter, which is often multiple, and yields to the proper treatment for syphilis. The treatment consists in the effectual removal of all the dis- eased tissue. This may be done in various ways, either by the knife or the thermal cautery. The method I have found most successful is that of scraping away all the diseased tissue by means of a small steel scoop, in a manner wdiich was first pointed out to me b}' my friend and colleague, Mr. Malcolm Morris. The patient is ansesthetized, and the whole surface, as well as the thickened edge of the patch, is thoroughly scraped away. This is attended with considerable hemorrhage, and is a rather tedious process, but its success in arresting this malig- nant afiection is marvellous. Patients are often very reluctant to submit to operative in- terference, and will sometimes allow the disease to advance until it is too late to aflbrd relief. They should be warned of the great danger of such neglect. In severe cases it is well to apply chloride of zinc paste (F. 38) to the surface of the wound after removal. Even in those cases in which the disease has been allowed to proceed beyond hope of permanent recovery, the removal of the diseased tissues by the knife or thermal cautery, and the subsequent application of chloride of zinc paste to the surfaces of the wound, appear to afford great relief from pain, and even to check the progress of the disease. Papillomata (warts) are occasionally found on the edge of the eyelid, and upon the conjunctiva. Thej- should be snipped off 28 AFFECTIONS OF THK EYELIDS. with curved scissors, taking care to cut well below their bases. Horny growths are also sometimes seen, and should be treated in a similar manner. Molluscum contagiosum is an affection of the sebaceous glands which atiects the eyelids and face as well as other parts of the integument. Symptoiiis and Pathology. — It begins as one or more hemi- spherical prominences of a whitish appearance varying in diameter from two to five millimetres, and is more commonly seen toward the inner part of the lower lid and cheek than in other parts. It consists of a hypertrophy of a sebaceous gland, the contents of which are composed of epithelial elements. The gland sometimes becomes inflamed, when the tumor will have a reddish appearance, and may go on to suppuration. It is pos- sible that the affection is contagious, but there is not much evi- dence of such being: the fact. Ireatment. — Each tumor must be transfixed through its base with a small scalpel and divided, its contents should then be evacuated either by squeezing between the thumb-nails or with forceps. Sarcoma of the conjunctiva is a rare affection; when it does occur it is usually pigmented, and sometimes almost black; its favorite situation is on the ocular conjunctiva near the cornea, whence it spreads to the lower cul-de-sac and lower lid. Free excision of the affected tissues is the onlj- hope for the cure of this malignant growth, which is liable to recur after all efforts have been made to remove it. Lipoma and Fibroma of the eyelid are very rare. They pre- sent the same characters here as in other regions. Indurated Chancre sometimes occurs on the eyelids. It is accompanied by much swelling. The glands of the parotid region are also indurated. Gummata occasionally occur in the eyelids, their seat of election being usually at the outer part of the upper lid. The induration is sometimes accompanied by swelling of the surrounding tissues of the lid, and more or less redness. The}' are accompanied by other symptoms of constitutional syphilis. Tertiary syphilitic ulcers also occur on the eyelids: when BLEPHAROSPASM. 29 more than one ulcer is present thej are easily recognized, but when occurring singly, with indurated edges and of slow increase, they are frequently difiicult to distinguish from epithelioma. The history of the case as to previous syphilitic infection and duration of ulcer must be ascertained. Local application of iodoform, or black wash, combined with the internal administration of iodide of potassium, will here be productive of early improvement, which at once conlirms the diagnosis. Blepharospasm (involuntar}' spasmodic contraction of the orbicular muscle) is mostly associated with photophobia. It is sometimes of the tonic kind, in which there is complete and continued closure of the eyelids, with inversion of the lashes against the corneal surface, thus causing great irritation of the cornea, and, by the constant pressure upon the globe, setting- up troubles in the intraocular circulation which are very pre- judicial to vision. Sometimes the spasm is of the clonic variety^ in which the contractions of the sphincter last from a few seconds to a minute, then ceasing entirelj" for a few seconds, but to return again with the same intensity. In other cases there is a severe spasm lasting for several hours and then dis- appearing entirely. Blepharospasm is usually due to irritation of some branch of the fifth nerve which, reflected through the facial nerve to the sphincter orbicularis, causes its contraction. Hence it is often caused by a foreign body inside the lids, an ulcer of the cornea, iritis, carious teeth, and other lesions in parts which are sup- plied by the fifth nerve. Another common cause is catarrhal conjunctivitis in children. It occasionally follovi's operations upon the eye, especially cataract extraction. It is sometimes due to errors of refraction. The treatment must be chiefly directed to the cause of the irritation. In the great majority of the cases the cornea is ulcerated, although the loss of tissue is often so superficial and so slight that it can only be observed by focal illumination. In such cases the proper treatment will be pointed out under the head of Corneal Ulcers. The division of the structures at the outer canthus by means of scissors is advised by some sur- geons. When the spasm is not caused by ocular lesions, the 30 AFFECTIONS OF THE EYELIDS. treatment is less certain. Graefe found a '■'"point of election" in certain cases, that is, a point where pressure upon the part woukl cause cessation or diminution of" the spasm. This point of election is difficult to find, its most common position is just opposite the exit of the infraorhital nerve on the cheek. The continuous current is sometimes very benelicial, the positive pole being placed behind the mastoid process and the negative passed along the surface of the lid. Ptosis is a drooping of the upper eyelid. It may be complete or partial. When complete., the eyelid covers the whole surface of the globe, and cannot be raised by any ettbrt on the part of the patient. When partial, more or less of the surface of the cornea is exposed to view, and some elevation can be produced by volun- tary eftbrt. It produces very unsightly deformity in either case. Causes. — The most frequent is paralysis of the third nerve (motor oculi), of which it is often one of the first symptoms. Traumatic lesions involving injury of the levator palpebrse. Hypertrophy of the upper lid itself may exist as the result of chronic inflammation, erysipelas, or tumors. Ptosis may be congenital, and is then usually associated with defect in the other ocular muscles, and affects both the eyes. Treatment must necessarily vary as the cause of the afiection. When it is due to paralysis of the third nerve, the cause of that paralysis should be carefully sought for. This may be due to intracranial disease, as 'gumma of the base of brain, cerebral tumor; to tumors or' other disases of the orbit, as exostosis, sarcoma; to general diseases, as syphilis, gout, or rheumatism. Of internal remedies, especially in cases in which syphilis is the cause of the nerve lesion, the iodide of potassium is one of the most reliable. It should be given three times daily, after food; the dose being gradually increased from 3 to 15 or 20 grains, and its administration continued for several \veeks after the cure of the patient. In recent cases, resulting from defective innervation, counter-irritants, such as slight blisters, iodine liniment, or compound camphor liniment, applied to the temporal region may be of some benefit. Electricity in the form of the continuous current is sometimes of great assistance in conjunction with other remedies. The positive pole should be applied to the forehead, the negative pole to the eyelids. PTOSIS. 31 the ej'es being closed. Six or eight couples are sufficient. The application should be made daily for five minutes at each sitting. "When internal and local remedies fail to improve the deformity, an operation for excision of a portion of the orbic- ular muscle from the upper lid is recommended with the object of diminishing its force, and consequently of increasing that of its antagonist, the levator palpebra*. The operation is ver}' easily performed, as follows: The upper lid is secured in the compressing forceps (Fig. 4). A longitudinal incision is made along the whole length of the lid about five millimetres from its free edge, the skin is cut through and dissected upwards so as to expose the fibres of the orbicularis muscle; these are then seized with forceps and a strip of about five millimetres width excised with scissors. Four or five sutures are then to Fig. 4. — Compressing Forceps. be introduced, each suture being passed through the upper and low-er portions of the divided muscle as well as the skin. The amount of muscle removed should be proportionate to the severity of the ptosis. The mere excision of a strip of integu- ment from the upper lid is of no use. Dr. H. Pagenstecher's o-peration for ptosis was brought before the notice of the International Congress b}' him in 1881. It claims to bring the action of the occipito-frontalis muscle to I)ear upon the upper lid by means of a subcutaneous cicatrix. It is performed as follows : I. Operation for complete ptosis. — A needle armed with a thick thread is introduced beneath the skin about 2 cm. above the supraciliary edge, and 2 mm. to the outer side of its middle line. It is then guided downwards and inwards beneath the skin, and brought out about the middle of the upper lid close to its ciliary margin. The ends of the thread are then tied in a knot, and moderate tension is made. The tension is gradually increased day by day, so as to make it cut its way through the 32 AFFECTIONS OF THE EYELIDS. skin, by drawing it tighter. The inflaniniatory symptoms are comparatively slight. The scar is not extensive. One ligature generally suffices, but two may be required. 11. Operation for partial ptosis is a modification of the above. A strong thread is armed with a needle at each end. One needle is then introduced beneath the skin of the upper lid parallel to its ciliary border for about 1 mm. or 2 mm. At the point of exit the same needle is again introduced and carried beneath the skin, but over the tarsus, and again brought out about 2 cm. above the supraciliary arch and 2 mm. external to its middle line. The second needle is then introduced at the point of entry of the first needle, directed upwards, and brought out at the same point of exit above the supraciliary arch. The two threads are then tied together and moderately tightened, thus forming a subcutaneous ligature, which must be left a longer or shorter time, and in extreme cases may be allowed to cut its way out entirely. By this means a subcutaneous cicatricial baud is produced, which. Dr. Pagenstecher main- tains, will transmit the action of the occipito-frontalis to the upper lid. Trichiasis, Distichiasis, and Entropion, are all modifications of the same affection of the eyelids. In trichiasis, the eyelashes are inverted so as to rub against the surface of the o^lobe ; the number of the lashes which are thus turned in varies from one, two, or three, to the whole number. In distichiasis, there appear to be supplementary rows of cilia developed, which are also incurved; this development is generally attended with more or less thickening of the free edge of the eyelid. In entropion, there is inversion of the lid as well as the cilia. The amount of inversion varies from a slight incurvation to complete reduplication, so that the cilia are in contact with the upper cul-de-sac. Entropion may be acute (spasmodic) or chronic. The acute form is common in old people after an operation on the eye. The chronic is usually due to cicatriza- tion of the inner surface of the lid. Causes. — The most common cause of all these affections is chronic granular conjunctivitis, which, having been imper- fectly cured, has been followed by contraction of the conjunctival surface of the lid. Sometimes thev are due to contraction of TRICHIASIS. 33 the sphincter orbicularis. They may be the result of injuries of the conjunctiva, lacerations, burns, etc. Treatmmt. — For trichiasis: (1) when the number of incurved cilia is small they may be removed by epilation forceps. Each lash should be tirmly seized close to its base and pulled out steadily. They will probably recur after a few weeks, and may be subjected to the same treatment. In case of a third or fourth recurrence, some method of destroying the incurved lashes should be adopted. Various methods are employed for this purpose. Those of Gaillard and of Herzenstein consist in surrounding the roots of the incurved lashes by a tight sub- cutaneous ligature of fine silk, thus causing ulceration and obliteration of the follicles of the cilia. Operation. — The eye being protected by a horn spatula, a needle which can be armed near its point with the ligature (see Fig. 5), is introduced at the margin of the eyelid just below the lashes which are to be strangulated, say at a, and passed subcutaneously to a point (b) two or three millimetres above; the ligature is secured at b, and the needle withdrawn, it is then rethrcadcd and passed subcutaneouslj- from b to c. The Fig. 5. — Subcutaneous Li^iiture for Trichiasis. two ends of the ligature at a and c have now to be tightly tied together so as to include the offending lashes, and its ends cut short. Water dressing should be applied, and the ligature allowed to come away of its own accord. (2) The galvano-puncture has been successfully used in 3 34 AFFECTIONS OF THE EYELIDS. destroying aberrant lashes of tins description by Dr. Benson, of Dublin. (3) In more severe cases of trichiasis the whole ciliary margin of the eyelid should be shifted away from the cornea. Arlt's method of doing this is as follows: A small double- edffed straight knife is inserted at one or other end of the eve- FiG. 6. — Lines of Incision in Arlt's Operation. lid between the cilia and the Meibomian ducts, and its point is made to come out through the skin about two millimetres above the lashes. It is then made to cut its way along the whole length of the edge of the lid (see Fig. 6), and thus forms a bridge of tissue containing the lashes only. A second incision is now made from the two extremities of the first, curving up- wards to the extent of three or four millimetres. This tbrms a semilunar flap on the upper lid which must be dissected oft". The bridge of skin containing the cilia has now to be shifted upwards, and its upper edge attached by sutures to the skin of the lid, its lower edge being left free. Simple water dressing is all that is necessar}'. Another method of dealing with extensive trichiasis is that of scalping. The whole ciliary margin of the lid is dissected away. The practice is becoming obsolete. Entropion, (1) when spasmodic^ is generally relieved by excis- ing a strip of the skin and orbicularis muscle from the whole length of the lid, parallel to its margin. The width of the flap to be removed must vary according to the laxity of the OPERATIONS FOR ENTROPION, 35 tissue, which is generally great in these cases. The edges of the wound are united by sutures, and water dressing applied. (2) When chronic it may be treated b}- either of the following methods : A. By Arlt's method of transplanting the ciliary border, which is the same as that just described for trichiasis (Fig. 6, p. 34). B. By Streatfeild's operation for " grooving " the tarsus. This is best described in Mr. Streatfeild's own words : " The lid is held with compressing forceps (Fig. 4, p. 30), the flat Ijlade passed under the lid, and the ring fixed upon the skin so as to make it tense, and expose the edge of the lid. An incision with Upper flap Groove in cartilage Lower flap Figs. 7 and 8. — The Streatfeild-Snellen Operation for Entropion. the scalpel is made of the desired length, just through the skin, along the palpebral margin, at the distance of a line or less, so as to expose, but not to divide, the roots of the lashes; and then just beyond, them the incision is continued down to the cartilage (the extremities of this wound are inclined toward the edge of the lid); a second incision, further from the pal- pebral margin, is made at once down to the cartilage in a simi- lar direction to the first, and at the distance of a line or more, and joining it at both extremities; these two incisions are then continued deepU' into the cartilage in an oblique direction toward each other. With a pair of forceps the strip to be excised is seized, and detached with the scalpel."^ Three sutures are then introduced as follows: A small curved needle, armed 1 R. 0. H. Keports, vol. i. p. 125. 36 AFFECTIONS OF THE EYELIDS, with tine silk, is passed first through the lower edge of the skin wound, then through the upper edge of the groove in the tarsus, and the two ends tied tightly together. The upper edge of the skin wound is thus left free, and unites very well without sutures.. Tliis operation gives excellent results. It has been slightly modified by Snellen, who makes the groove in the cartilage rather higher up, and uses a different form of suture. Three sutures are used (see Figs. 7 and 8). A fine silk suture is passed through the upper edge of the groove in the tarsus for about one millimetre. It is armed at each end with a needle; these needles are then passed through the lower edge of the skin wound, just above the cilia; their distance a[)art should be about four millimetres. All the sutures being similarly introduced, a glass bead is passed over the end of each, and they are all tightened together by gentle traction, and then each suture tied. Ectropion is that condition in which the eyelid is everted and its conjunctival surface exposed. It most commonly afi:ectsthe lower lid. It may be partial or complete, and the eversion may cause displacement of the lower punctum lachrymale, drawing it so much away from the globe as to prevent the tears from entering it. The exposed conjunctiva is always more or less thickened. Causes. — An acute form of ectropion, due to tumefaction of the conjunctiva, is sometimes met with in ophthalmia neona- torum, in which the lids become everted on the orbicularis muscle being called into action, as in crying, etc. Chronic forms are generally caused by cicatrices of the skin of the eyelid or neighboring parts following wounds, burns, scalds, abscess, ulceration, etc. Treatment must vary with the cause of the eversion. 1. In the acute form efforts must be made to reduce the inflammation of the conjunctiva by leeches, scarification, com- presses of lint dipped in iced water, or even the excision of a portion of the mucous membrane with scissors. 2. When there is persistent eversion of the lower punctum lachrymale the lower canaliculis should be slit up and kept open. OPERATIONS FOR ECTROPION. 37 Dr. Argyll Robertson's method is well suited for cases of ectropion of the lower lid in old people, in whom the conjunc- tiva is thickened and the tissues of the face lax. Each end of a stout ligature, armed with a needle, is passed from without inwards through the margin of the ej'elid, the punctures being about a centimetre apart. In this way a loop is left externally parallel with the edge of the lid. Each end is then thrust through the lower cul-de-sac and made to emerge upon the cheek well below the eyelid. The operator now takes a piece of sheet-lead, shaped and moulded to resemble the normal tarsus, this he places in the conjunctival cul-de-sac, beneath the ligatures, so that on tight- ening the latter, the lid is moulded to the lead, and lead and eyelid are together drawn toward the eye. A stout piece of drainage-tube is now placed beneath the external loop, and the ends of the ligature tied over it below ; this prevents the skin being cut, and by its elasticity allows a certain amount of swelling to occur. After about ten days th^ ligatures are cut and removed, when a considerable improvement, and often a complete cure, will be found to have been etiected, 3. When the edge of the lid has become elongated as well as everted Adam's operation may be performed. This consists Fig. 9. — Adam's Operation for Ectropion. in removing a triangular wedge from the whole thickness of the lower lid (see Fig. 9). The base of the triangle must be at the edge of the lid; its width may vary, according to cir- 38 AFFECTIONS OF THE EYELIDS. cumstanoes, between 5 and 10 mm. The sides of the triangle should be from 10 to 20 mm. The edges of the wound are brought together by a tine pin, and secured by one or two sutures. This operation is often more advantageously per- formed near the outer cauthus. 4. AVhen the eversion is due to contraction of neighboring cicatrices on the face, the nature of the operation must depend upon the site and extent of the lesion, and much scope is often afFordL'd for the exercise of ingenuity on the part of the surgeon. In all such cases no plastic operation should be attempted until the skin of the affected part has as far as possible re- covered from the injury. It sometimes requires six months or more for the hardness and thickening of the skin and sub- cutaneous tissue to pass away. The variety of plastic opera- tions performed for ectropion is very great ; those of Wharton Jones and of Dieifenbach will serve as examples. Wharton Jones's Operation. — The eye is to be protected by a horn spatula placed beneath the lower lid. A Y-shaped (Fig. 10) #^ Ftg. 10. — Wharton Jones's Operation. I First Stage.) Fig. 11.— (Final Stage. incision is to be made with a small scalpel, including as far as possible the cicatricial tissue; the flap thus formed is to be dissected from the subjacent parts sufficiently to enable the lid to be pressed upwards to its normal position. There then OPERATIONS FOR ECTROPION, 39 remains a raw surface, which is to be covered by bringing together the edges of the V-shaped wound by means of tine pins in such a manner that the V-shaped incision becomes Y-shaped (see Figs. 10 and 21). In Dieffenbach's operation the diseased tissue is dissected away by a triangular incision, which has its base at the lower 6. Fig. 12. — Dietfenbach's Operation for Ectropion. (First Stage.) Fig. 13.— (SeeonJ Stage.) lid ; a flap of skin of equal size is then marked off from the immediate neighborhood (see Fig. 12). This is loosened by careful dissection and then glided on to the recently exposed surface beneath the lower lid. It is then kept in position by line harelip pins and sutures, as shown in Fig. 13. In slight cases the surface from which the new skin has been removed soon becomes covered over by growth from the edges of the wound; but when a large surface is thus exposed, skin grafts should be made from other parts of the body. Wolfe's Operation. — The operation for the transplantation of skin en masse in the treatment of ectropion and other deformi- ties of the eyelids has been somewhat extensively practised during the last few years. Professor "Wolfe, in his recent work," speaks very favorably of this method, which he brought before the notice of the profession in 1875. Since that time a 1 Diseases and Injuries of the Eye, by J. R. Wolfe, M.D. 1882. 40 AFFECTIONS OF THE EYELIDS. number of successful cases have ])een reported. It is particu- larly valuable in all cases in Avhicli skin is required to replace cicatricial tissue, sucli as that which so often follows burns of the check and eyelids. The operation is long and tedious; like all blepharoplastic procedures, it requires great care and ingenuity on the part of the surgeon. 1. The mucous membrane is to be pared from the margins of both eyelids, and the raw surfaces thus produced are to be brought into a[tposition and united by four line silk sutures, in order to produce temporary ankyloblepharon. The eyelashes should, if possible, be undisturbed. 2. The affected eyelid is then to be liberated from the cicatricial tissue by an incision through the skin along its whole length, parallel to, and about 2 mm. from, its ciliary border. The contracted skin is then to be loosened by subcutaneous incision, so as to form a semihmar raw surface, or, if quite deformed and useless, it had better be dissected away. The bleeding from the surface thus exposed is to be entirely stopped. 3. Apiece of skin of similar shape and about one-third larger in each diameter of the exposed surface is now to be carefully dissected from some other part of the body of the patient, or of another person. The inner side of the arm, the front of the forearm, the front of the leg, and the foreskin are all convenient parts for this dissection, which should be made as far as possible without removing subcutaneous connective tissue and fat. Before detaching the flap of skin which is to be transplanted, it is well to pass three or four sutures into different points at its margin, otherwise it shrivels up in such a manner that it cannot be opened out without diiiiculty and loss of time. The same sutures can be used to secure it in its new position. The object of making the flap so much larger than the surface is that it contracts immediately after removal, as well as after union. As soon as removed it is to be transposed, and secured in its new position by numerous tine silk sutures. 4. Various methods of dressing are recommended. Pro- fessor AVolfe recommends the application of lint soaked in hot water for a few minutes after the operation, and Anally dressing with warm moist lint covered over with dry lint, gutta-percha tissue, and bandage. The plan I have adopted with success is SKIN-GRAFTING FOR ECTROPION". 41 to apply first a piece of goldl)eater's skin, then a dossil of drj lint, and over these a large pad of dry and warm cotton-wool and a bandage. The dressings should be carefully removed once daily. The eyelids can remain united for a longer or shorter period, according to the nature of the case. When their union is considered to be no longer conducive to the pre- vention of eversion of the lid, they can be carefully separated by incision with a sharp scalpel on a grooved director. Skin-grafting has, in my experience, been of greater utility than either of the foregoing operations. The plan I adopt is to loosen the unhealthj' skin by subcutaneous section, and to shift it upwards so as to liberate the eyelid from its traction. If the tissue is very much diseased, I remove it altogether by dissection. Water dressing is then applied for one or two •daj's to the exposed surface, with the object of inducing a con- dition of healthy granulation. As soon as the surface looks red and clean I make numerous small grafts of skin from some other i)arts of the patient's body, preferably from the front of the forearm. In order to detach these grafts from the forearm I pass a flat surgical needle just beneath the true skin, so as to raise a bridge of about 2 mm. This bridge is cut through at each end by small thin scissors, and can be transferred to the raw surface, ^o scar is left on the arm, nor is there any great pain caused by the process. The more grafts thus made the greater is the success of the operation. If the first batch does not succeed, other attempts must be made. As soon as the grafting is completed a piece of goldbeater's skin is placed over the patch, then a piece of dry lint, and this is secured by good strapping. The patient should remain as quiet as possible after the operation, and should be cautioned not to rub the part should it be irritable. The strapping and lint should be care- fully removed once daily, and the condition of the grafts examined through the transparent goldbeater's skin. The grafts at first have a white sodden appearance, but on the second or third day they become pink, and increase rapidly in all directions. Epicanthus is a congenital deformity in which a crescentic fold of skin projects in front of the inner canthus. It is generally symmetrical, giving a broad appearance to the root 42 AFFECTIONS OF THE EYELIDS. of the nose. By pinching up the skin at the root of the nose the epicanthus can be made to disappear. It generally im- proves as the child grows and the bones of the face become developed. Vision is not interfered with. Operative inter- ference is seldom required except for cosmetic purposes, and should not be adopted during childhood. When required, it is simply necessary to remove an oval flap of skin from the median line over the root of the nose, the size of which must vary with the extent of the deformity, and to bring the edges of the wound together by sutures. Contusions are very common, and may vary from slight red- ness to severe cutaneous and subcutaneous ecchymoses (" black- ayo"). They are not unfrequently accompanied by other more serious lesions of the globe, or of the orbit. The absorption of the ecchymosis in " black-eye " is often hastened by the use< of cold-water compresses or of evaporating lotions. Wounds when incised or lacerated should have their edges brought into exact apposition by tine sutures. Great attention should be given in these cases to the position of the puncta lachrymalia, as the slightest eversion of these from the globe is sufficient to interfere with the natural flow of tears. When wounds are penetrating, the condition of the globe and of the orbit should be carefully examined. They heal with great rapidity. A pad of lint and a light bandage should be applied in either of the above cases. Burns and scalds of the eyelids require similar treatment to that employed in other parts of the body. In case of destruc- tion of tissue great care should be exercised to keep the lids from uniting to each other by their edges (ankyloblepharon), and to prevent the ocular and palpebral portions of the con- junctiva from becoming adherent (symblepharon). Burns from quick-lime are of frequent occurrence; the eyelids should be well everted and carefully washed with cotton-wool and water, a little castor oil and atropine should then be dropped into the palpebral aperture, and a compress of lint and a light bandage applied. The eye should afterwards be examined daily, and any adhesions broken down with a probe. Ankyloblepharon signifies the adhesion of the ciliary margins of the eyelids. It may be congenital or acquired, complete or SYMBLEPHARON. 43 partial. It often accompanies and is produced by the same cause as s3'mblepharon. The adhesion is rarely so complete as to involve the entire edges of the lids; it usually only occupies their outer half; even in the most complete cases a small opening usually exists near the inner canthus, through which the tears and mucus can escape. The treatment consists in di- viding the cicatricial structures which hold the lids together. To do this a grooved director should first be passed behind the lids, and the incision made with a small scalpel. Symblepharon is the abnormal adhesion of the ej'elids to the globe. It is usually caused by burns or injuries, but occasion- ally follows granular and diphtheritic conjunctivitis. Symble- pharon may be partial, consisting of one or more bands ot Fig. 14. — Symblepharon (after Anderson Critchett). cicatricial tissue extending from the conjunctiva of the lid to that of the globe, and thus forming a bridge of tissue, be- neath which a probe can be passed; or it may be complete, that is, the entire surface of the affected portion of the lids becomes united to the globe. The lower lid is most commonly adherent; in severe cases this becomes united to the cornea, thus producing great deformity, limitation of the upward and lateral movements of the globe, and partial or total loss of vision (see Fig. 14). Treatment. — In the simpler forms of partial symblepharon, where only a band of cicatricial tissue extends from the palpe- bral to the ocular conjunctiva, and where a probe can be passed beneath, it is usuallj^ sufficient to snip away the adhesion close to both surfaces with scissors, and to keep the raw surfaces from uniting by separating them with a probe every day. 44 AFFECTIONS OF THE EYELIDS. When more extensive adhesions exist we must have recourse to otlier procedures. 1. Teale's operation consists in the dissection of the adherent lid from the globe, so that the latter can move freely in all directions. This done, the neighboring healthy conjunctiva is utilized, by dissection and stretching, so as to form flaps to cover the ocular, and, if possible, the palpebral surfaces. Nu- merous fine silk sutures are used to draw the edges of the new flaps together. Various modifications of this operation are performed l)y difJerent surgeons. 2. Professor Wolfe has introduced an operation for trans- plantation en masse of portions of conjunctiva from the eye of a living rabbit, in lieu of transferring portions of conjunctiva from one part to another of the same eye. He thus describes the operation:^ "I put the patient and two rabbits under chloroform, one of the latter being kept in reserve in case of accident. I then separate the adhesions, so that the eyeball can move in every direction. !N"ext, I mark the boundary of the portion of the conjunctiva of the rabbit which I wish to trans- plant, by inserting four black silk ligatures, which I secure with a knot, leaving the needles attached; these black ligatures in- dicate also the epithelial surface, which would be very difficult to distinguish after separation, I take from the rabbit that portion of the conjunctiva which lines the inner angle covering the 'membrana nictitans,' and extending as far as the cornea, selecting this on account of its vascularity and looseness. The ligatures being put on the stretch, I separate the conjunctiva to be removed with scissors, and transfer it quickly to replace the lost conjunctiva palpebrae of the patient, securing it in its place by means of the same needles, and adding two stitches, or more if requisite. Both eyes are then covered with a band- age and dry lint. For the first forty-eight hours- the conjunc- tiva has a grayish look, but it gradually loses that appear- ance, and, with the exception of some isolated patches here and there, becomes glistening, in some parts looking not unlike conjunctival thickening. These patches gradually decrease until the whole assumes a red appearance. Should any irrita- tion set in, I apply warm water fomentations." ^ Loc. cit. CHAPTER II. AFFECTIONS OF THE LACHEYMAL APPAEATUS. ANATOMY AND PHYSIOLOGY — DISEASES OF LACHRYMAL GLAND INFLAMMA- TION — HYPERTROPHY' — SARCOMA — EXTIRPATION — CYSTS FISTULA OF GLAND— DISPLACEMENT OF PUNCTA — SLITTING UP CANALICULUS — PROBING — OBSTRUCTION OF CANALICULI AND OF NASAL DUCT — ABSCESS OF LACH- RY'MAL SAC — FISTULA OF SAC. Anatomy and Physiology. — The lachrymal apparatus consists of the lachrymal gland and its excretory ducts, the lachrymal canalieuli, the lachrymal sac, and the nasal duct. The lachrymal gland is placed in the upper and outer part of the orhit, a little behind its anterior margin. It consists of a large superior and a small inferior portion. The larger portion is about 2 cm. in length, 1 cm. iu breadth, and 0.5 cm. in thickness ; it is lodged in a depression in the orbital plate of the frontal bone, to Avhich it adheres by librous bands. The smaller portion is separated from the larger by connective tissue; it is closely adherent to the back of the upper eyelid, and is covered on its ocular surface by conjunctiva (see Fig. 15). From both portions of the gland there proceed numerous small ducts — the lachrymal ducts — varying from seven to four- teen in number; they run obliquely under the conjunctiva, and open by separate oritices into the fornix conjunctivae at its upper and outer part. The lachrymal gland is similar in structure to the salivary glands, consisting of acini, which contain cuboidal cells having a large nucleus. In the centre of each acinus the duct begins. The nervous mechanism of the lachrymal gland is very complex. A flow of tears may easily be excited in a reflex 46 AFFECTIONS OF THE LACHRYMAL APPARATUS. manner by stimuli applied to the conjunctiva, the nasal mucous membrane, the tongue, the optic nerve, etc. : and in a direct manner by the emotions. Fig. 15. — Dissection of the Lachrymal Apparatus The lachrymal canaliculi are two in number, situated on the margin of each lid, at the inner angle. Each commences by a small aperture, the punctum lachrymale, which may be seen situated on a slight eminence (papilla). The upper canal is rather smaller than the lower, it first ascends and then turns downwards and inwards, to the lachrymal sac. The lower canal lirst descends, and then runs horizontally to the sac. They unite just before reaching the sac. Near the punctum the diameter of each canaliculus is about 0.5 mm., just beyond this it becomes suddenly dilated to 1 mm., and for the remaining two-thirds of its course it is about 0.6 mm. Its walls are ex- tremely thin, and are lined by pavement epithelium. The lachrymal sac is the upper dilated portion of the passage which conveys the tears from the lachrymal canals to the cavity of the nose. It is situated in a deep groove formed by the lachrymal and superior maxillary bones. Its upper end is closed and rounded, and its lower part tapers off into the nasal duct. On its outer side and rather anteriorly it receives the canaliculi. INFLAMMATION OF THE LACHRYMAL GLAND. 47 In front of it are the tendo palpebrarum and some fibres of the orbicular muscle. It is composed of fibrous and elastic tissue, and adheres closely to the bones. It is lined by ciliated epithelium. The nasal duct extends from the lachrymal sac to the inferior meatus of the nose. The osseous canal is formed by the supe- rior maxillary, the lachrymal, and the inferior turbinated bones. This is lined by a tube of fibrous membrane, continuous with that of the lachrymal sac, and is similarly lined with ciliated epithelium. At the entrance into the inferior meatus there is sometimes an imperfect valvular arrangement of the mucous membrane. The length of the duct varies with the develop- ment of the face. Its direction is downwards, and slightly out- Avards and backwards. The lachrymal secretion is a faintly alkaline fluid containing about one per cent, of solids, of which a small part is proteid in composition. It passes by the lachrymal ducts into the sac of the conjunctiva, where it serves to moisten the anterior part of the eye. Its exit from the sac of the conjunctiva is efl'ected by the act of winking, which takes place at frequent intervals. In tins act of closure of the lids not only is there contraction of the palpebral portion of the orbicularis, but also of those fibres which are in front of the lachrymal sac; thus, the palpe- bral fissure being closed, the tears are pressed successively through the puncta lachrymalia, the canaliculi, the lachrj-mal sac, and the nasal duct into the inferior meatus of the nose, where they are evaporated by the act of respiration. Diseases of the Lachrymal Gland. Inflammation of the lachrymal gland (dacryo-adenitis) is ex- tremely rare. It may be acute or chronic. In the acute form there are great swelling and redness of the upper lid, especially toward the outer angle of the orbit. The swelling may be so great as to displace the globe downwards and inwards, in which case the upward and outward movements of the e^e are aftected. The conjunctiva is injected, and frequently there is chemosis. Pain is severe, of a throbbing nature, and increased on pressure. It may terminate by resolution, it may go on to suppuration, or it may become chronic. 48 AFFECTIONS OF THE LACHRYMAL APPARATUS. The formation of abscess is indicated by increased local red- ness, swelling, and intensification of the throbbing pain. In chronic inflammation of the gland there is also consider- able swelling, but the other symptoms of the acute form are less severe. Digital examination in the region of the gland shows it to be distinctly enlarged, but there is less redness of the skin of the eyelid, little or no chemosis, pain is slight, and not of a throbbing nature; and there is scarcely any tenderness on pressure. Causes. — Dacryo-adenitis, whether acute or chronic, is gen- erally caused by injury to the parts in the region of the gland. It may be the result of chronic conjunctivitis. Treatment. — In the early stage the acute form of inflamma- tion should be combated by energetic antiphlogistic measures, such as the local application of several leeches, frequent hot water fomentations, emollient compresses bandaged on and kept warm by a large pad of cotton-wool. When suppuration is evidently established, a free incision should at once be made by plunging a scalpel into the most prominent part of the swelling, the point of the knife being carefully kept away from the globe ; the incision should, if possible, be made through the conjunctiva, so as to avoid the formation of a lachrymal fistula; but if there is pointing through the skiu of the upper lid, this must be the point of election. When the affection is chronic any patent cause of the affection should be as far as possible removed. The application of an ointment of mercury and belladonna to the surrounding surface may be useful. Hypertrophy of the lachrymal gland has been occasionally seen, but is very rare, most of the cases described under this name being probably sarcomata. It is characterized by the presence of a circumscribed, nodular, somewhat elastic tumor in the region of the gland. It is not painful or tender, nor is there any marked swelling of the upper lid. It occurs in young subjects, and has been seen shortly after birth. It always in- creases, though its growth is usuall}' slow. The edge of the tumor can be distinctly felt beneath the orbital ridge, as it gradually extends over the upper part of the globe. Pathology. — These tumors do not present the microscopic characters of simple hypertrophy of gland tissue. Those which EXTIRPATION O P^ THE LACHRYMAL GLAND. 49 I have examined have presented the appearance of fibro-sar- coma or adeno-sarcoma. Treatment of a palliative nature may at first be tried; iodide of potassium may be given internally, and absorbents applied locally to the surface: but the tumor will generally be found to increase, in which case extirpation of the whole mass is the only reliable remedy. Operation for extirpation of the lachrymal gland. — The patient is to be fully ansesthetized in the supine position upon a moderately high table. The instruments required are a small scalpel, a horn spatula, a vulsellum forceps, curved scissors, toothed forceps, and artery forceps. The operator should stand on the patient's right, his assistants on the patient's left. The upper lid is to be drawn down until the lower edge of the eyebrow becomes on a level with the edge of the orbit. An incision is then made parallel Math the eyebrow and quite close to its lower part, extending from the middle of the upper edge of the orbit as far as its outer angle. All struc- tures are to be divided down to the periosteum. The fibrous tissue of the palpebral ligament will now be exposed, and must be carefully divided close to the edge of the orbit with scissors or scalpel. The lachrymal gland, if large, will now present itself to view; if small, it will be found deeply seated in the lachrj-mal fossa; in either case, it must be firmly seized with the vulsellum forceps and dissected from its surrounding con- nective tissue wdth scissors. The dissection should be besfun from the orbital surface of the gland. In clearing it from its ocular relations great care should be taken to avoid laceration of the levator palpebrce muscle. The edges of the wound are to be brought together by fine silk or catgut sutures, and a light compress of dry lint applied. The antiseptic method of operating is very desirable here. Cysts of the lachrymal gland sometimes occur. They are mostly due to obstruction of the excretory ducts, but some- times are caused by hydatids. When present they may be felt as a small tumor of from 1 cm. to 2 cm. diameter in the upper and outer angle of the orbit. On raising the upper lid they may often be recognized by their transparency beneath the conjunctiva. 4 50 AFFECTIONS OF THE LACHRYMAL AITAKATUS. Irealmeiif. — Simple puncture through the conjunctiva is sometimes suUicient to establish a cure, but it is better to remove a small portion of the wall of the cyst in addition to the puncture. Some surgeons prefer to pass a ligature of silk through the cyst, Avhich is gradually tightened, and iinally ulcerates through ; others recommend extirpation of the lach-. rymal gland. Fistula of the lachrymal gland is usually the result of injury or of abscess. A small opening exists in the skin near the upper and outer angle of the orbit through which the tears almost constantly escape. The flow of tears through this abnormal passage may be increased by irritation of the conjunctiva. Treatment. — The edges of the opening will sometimes unite by the application of solid nitrate of silver every few days, or by the introduction of a wire of the thermal cautery at a dull red heat. These measures may be assisted by previously establishing an artificial opening into the sac of the conjunc- tiva by the introduction of a seton in the region of the lachry- mal ducts. Some cases are obstinate and require ultimate extirpation of the gland. Affections of the drainage system may be classified as those of the puncta lachrymalia, those of the canaliculi, and those of the lachrymal sac and nasal duct. In each of these affections lachrymation, or overflow of tears (epiphora), is a troublesome symptom, Avhich is always aggravated by exposure of the eye to cold or wind, or by any cause which would increase the secretion of the lachrymal gland. Displacement of the punctum of the lower lid is a not unfre- quent cause of lachrymation. It occurs in elderly people in whom the orbicularis muscle has become relaxed, so that the lower lid, with its punctum, falls away from its proper apposi- tion to the globe. The punctum is often drawn outwards in cases of ectropion. Treatment. — This must vary with the cause of the eversion, and its degree. If the punctum cannot be restored to its proper position, the best method of restoring conduction of the tears into the lachrymal sac is by slitting up the lower canaliculus, so that thev mav enter its channel nearer the sac. 1) I S P L A C E :\t E N T OF THE P U N C T U M , 51 Operation for slitting up the lower canaliculus. — No anses- thetic is required, except in the case of children and persons of nervous temperament. The patient is to be seated on an ordinary chair with the head thrown back, so that « the face looks toward the ceiling. The operator is to stand behind the chair. The lower lid is to be tensely drawn downwards and outwards, and slightly everted by the thumb of one hand (Fig. 18), while with the other hand the probe-point of Weber's canaliculus knife (Fig. 16) is introduced vertically. When the knife has well entered the canaliculus its point is to be directed inwards, and slightly backwards in the direction of the lachry- mal sac, until it reaches the inner wall. The edge of the knife during its passage is to be turned toward the conjunctiva, so as to divide the canali- culus close to the muco-cutaneous junction. When the knife has thus reached the inner wall of the sac, it must be boldly brought up from the horizontal to the vertical position, the eyelid being still kept tensely drawn outwards by the opposite thumb. Thus the whole length of the canaliculus is divided quite into the sac. Several other methods of slitting up the canali- culus are adopted. A line grooved director (Crit- chett's) is passed through the canaliculus, along which a fine knife is passed into the sac. Fine scissors are sometimes used, one blade of which is passed into the canaliculus. Various modifications of the knife represented in Fig. 16, such as Bowman's, de Wecker's, Liebreich's, and others, are used. It sometimes happens that the punctum is very small, and wall not admit the probe-point of the knife; in these cases a fine coni- cal probe should be first introduced, by which means it may be sufficiently dilated to admit the knife. Obstruction of the lower canaliculus is not unfre- quent. It may be caused by inflammation of the mucous membrane extending from the conjunctiva, or by the presence of a foreign body such as an eyelash. It is sometimes Fig. 16.— Weber's Canaliculus Knife. 52 AFFECTIONS OF THE LACHRYMAL APPARATUS. due to chalky concretions, und is often the result of cicatrix fol- lowing burns, and lacerated wounds. The upper canaliculus is less frequently attected, except in the^ase of wounds and burns. Treatment. — This must vary as the cause of the obstruction or obliteration. When a foreign body or concretion is present it should, if possible, be removed with fine forceps. When its removal is found to be impracticable, the canaliculus should be slit up. There is sometimes a difficulty in finding any opening into the canaliculus. In this case careful search should be made in the region of the punctura with a fine conical probe ; this will sometimes find an entrance when no aperture is visible, and should then be forcibly passed in the direction of the canali- culus, so as to dilate it sufficiently for the reception of the knife. Mr. Streatfeild has an ingenious method of finding the canal in these cases. Having first slit up the upper canaliculus, he passes a piece of bent silver wire through this into the lower one. When no opening can thus be found, a minute aperture should be made in the direction of the canal at its middle third; this can be done with a fine knife or scissors, and will affi)rd greater facility of entrance than incision of the tissues about the punctum. A very frequent point of obstruction is just at the entrance to the lachrj-mal sac. This is indicated by the movement of the whole lower lid when the knife or probe is pressed toward the sac. Firm pressure in the inward and slightly backward direction will generally overcome this resistance. Stricture of the nasal duct is the most common affection of the lachrymal apparatus. Cause. — The original cause of this aff"ection is frequently difficult to make out. It appears in man}' cases, however, to commence by extension of catarrhal inflammation of the lining membrane of the nose. It is possible for it to be caused by extension from the conjunctiva through the lachrymal sac, but more frequently it is the obstruction which causes the con- junctivitis. In strumous and syphilitic subjects, periostitis of the bones forming the nasal canal is a frequent cause of obstruc- tion by extension of inflammation to the fibro-mucous lining. It may also be caused b}' injury to the nasal bones, and by the existence of carious teeth in the upper jaw. Pressure, causing STRICTURE OF NASAL DUCT. 53 more or less obliteration of the canal by tumors of various kinds, as fibro-sarcoma, myxoma, and exostosis developed in the upper jaw, the antrum, or the nasal fossa, is not uncommon. The seat of the stricture is usually at the upper part of the tube just below its junction with the lachrymal sac, but it may be situated anywhere in its course. The symptoms of stricture of the nasal duct are very variable. In some cases the only observable departure from the normal condition is an overflow of the tears, which is increased by ex- posure to cold wind or bright light. There may be little or no inflammatory redness of the conjunctiva. The puncta lachry- malia and canaliculi are found to be quite patent, and in their normal position. There is no perceptible tumor in the region of the lachrymal sac. On making firm pressure with the finger over the region of the sac, there may be no regurgitation of its contents; more frequently, however, there is some reflux of a viscid secretion through the canaliculi, which may be quite clear and colorless, or may be more or less purulent, but is always of a more tenacious character than the tears. In the majority of cases, however, there is distinct swelling of the lachrymal sac (chronic dacryo-cystitis, mucocele, blennorrhcea). The amount of sw^elling varies from a mere fulness to an abso- lute protuberance of the skin just below the internal palpebral ligament. Firm pressure with the finger over this will usually cause the dispersion of its contents either upwards through the canaliculi, or downwards through the nasal duct. The nature of this liquid varies according to the gravity of the lesions of the sac; it may be simple mucus or muco-pus, or even pus. Lachryraation is troublesome, causing irritation and redness of the conjunctiva and eyelids. The swelling is usually free from pain and devoid of tenderness, even on pressure ; it is localized, and increases but slowly. It is, however, liable at any time to take on an active state of inflammation and suppuration, thus constituting abscess of the lachrymal sac, in which the symp- toms are altogether more severe. The swelling now becomes suddenly' increased, and of a tense, brawny nature. The root of the nose, the lower part of the frontal region, the upper part of the cheek, are oedematous; the eyelids, also, are frequently infiltrated. The skin over the region of the lachrymal sac and 54 AFFECTIONS OF THE LATHRVMAL APPARATUS. the surrounding parts is of a dusky-red color. There are in- tense local pain and heat in addition to the redness and swell- ing. General symptoms, such as pyrexia, rigors, and even .vomit- ing, may occur. This kind of inflammation of the sac never terminates in resolution; suppuration lirst takes place inside the sac, forming an abscess, which soon perforates its walls, setting up inflammation of the surrounding cellular tissue. Perforation of the wall of the sac is attended by a diminu- tion of the pain, which, although it does not disappear, be- comes greatly lessened in intensity. Then commence the more serious inflammation and swelling of the tissues around the sac and in its vicinity, leading to the formation of abscess, which, if untreated by surgical interference, usually terminates by pointing through the skin about 1 cm. below the lower punctum lachrymale. This opening gives exit at first to purulent matter, which gradually decreases as the inflamma- tion and swelling subside. It may heal up of its own accord, but generally remains as a fistula of the lachrymal sac, giving exit at first to the purulent matter, then to muco-pus mixed with the tears, and finally to the tears alone, which ought to have passed down the nasal duct. The diagnosis of swelling of the lachrymal sac is easily made when there is but little inflammatory trouble. Its situation, its history and accompanying lachryination, its more or less complete disappearance on firm pressure, serve to distinguish it from other tumors of this region. When inflammation is severe, it may at first simulate erysipelas of the eyelids, but in abscess of the sac we have seen that the redness is most intense over the seat of inflammation, and shades oflf and becomes simple oedema of the surrounding parts, that there is always a history of lachrymation, and generally of tumor of the sac. In erysipelas the redness is equal all over the swell- ing, its outer edge is seen to spread to surrounding parts, and there is no history of previous lachrymation or tumor. It may also be difficult to say whether an abscess at the inner angle of the eye had its commencement within or outside the sac. Here again the previous history' of overflow of tears and of tumor of the sac are useful aids to diagnosis, and all doubt can STRICTURE OF NASAL DUCT. 55 often be dispelled by pressure over the swelling, when a regur- gitation takes place through the puncta lachrjmalia. Stricture of the nasal duct also gives rise to the development of serious lesions of the cornea, conjunctiva, and eyelids. After prolonged obstruction a chronic inflammation of the conjunc- tiva is often established. This may spread to the edges of the eyelids, causing blepharitis and even ulceration. The cornea also often becomes affected with superficial, ill-detined, grayish- white opacities and ulcers. An}^ operation involving wound of the cornea, such as that of iridectomy or extraction of cata- ract that might be performed under this condition of lachryma- tion, would be seriously interfered with ; the wound healing but slowly, if at all, and suppuration being very easily provoked. Treatment must be directed to the permanent cure of the stricture. I. When there is no abscess of the sac, but only swelling, or even only lachrymation, the lower canaliculus should be slit up in the manner indicated on page 51, and a probe should be passed through the stricture at once. It should be passed again within forty-eight hours to prevent the closing up of the canali- culus, and the operation should be repeated twice or thrice a week until lachrymation has ceased, and all symptoms of ob- struction have disappeared. Even then it is well to continue the probing once a week for a few times. The kind of probe used is a matter of little importance so long as it is of the right calibre, and is passed in the proper Fig. 17. — Set of Probes for Nasal Duct. direction — viz., downwards and rather outwards and back- wards. Many varieties of probes are now in use. The original probes of Bowman were straight; they were about 12 cm. long and six in number, the largest, 'Ro. 6, being about 1 mm. in diameter. These are now^ altered in shape and size; instead of 56 AFFECTIONS OF THE LACHRYMAL APPARATUS. being straio-ht they are curved in opposite directions toward each end, and instead of being of equal calibre throughout they are bulbous toward each extremity, as shown in Fig. 17. These larger probes number from 1 to 8, ISTo. 1 being about Fig. l!^. — Probe in First and Second Position?. 1 mm. across the bulb, Xo. 8 about 3.5 mm., and the remainder of intermediate sizes. There are numerous other varieties of probes which it is not necessary to describe. The mode of introducing- the probe is similar to that of intro- STRICTURE OF NASAL DUCT. 57 ducing the canaliculus knife (see Fig. 18). It is passed horizon- tally along the canaliculus until it reaches the inner wall of the lachrymal sac, the lower lid being kept tense by the thumb of the opposite hand. The probe is known to be well inside the sac by the resistance offered by the lachrymal bone, and by the absence of dragging on the skin of the lower lid. The end of the probe being kept in contact with the inner wall of the sac, it must now be brought from the horizontal to the vertical position and pushed down the duct. The direction of the duct, as we have seen, is downwards and slightly backwards and out- wards; pretty firm pressure can be made in this direction. I usually commence with a probe of 2 mm. diameter; if this passes easily, I try the next size larger; if it does not pass with- out great force, I try smaller sizes until one is found which will pass through the stricture. It seldom happens that a stricture is so tight that it will not admit a probe of 0.5 mm. diameter. Thus we are enabled to form an estimate of the extent and the nature of the constriction. One of three methods can now be adopted, viz. : 1. Gradual dilatation, by slightly increasing the diameter of the probe used at each sitting. 2. Bapid dilatation, by the passage at one sitting of a probe of 2.5 mm. to 3.5 mm., and continuing this practice at after-sittings. 3. The incision of the stricture by means of a knife, and the subsequent passage of probes. This is of great service in very tight strictures. The best knife for this purpose is that of Stilling. It is introduced into the lachrymal sac in the same way as the probe, and then forced dow'n in the direction of the duct two or three times in succession, the blade being turned in different directions at each passage, after which probes of 1 mm., 2 mm., or 3 mm. can be passed. Other knives, such as those of Bowman and Weber, can be used for this purpose, but, owing to their brittleness and delicacy, their blades are apt to be left in the stricture. II. When there is abscess of the sac, and a fistula has not yet formed, an immediate effort should be made to give free exit to the pus. This should, if possible, be effected by slitting up one of the canaliculi; if, however, the swelling is so great as to prevent this, a puncture should be made by thrusting a small scalpel through the skin 1 cm. below the inner canthus, the 58 AFFECTIONS OF THE LACHRYMAL APPAKATUS. direction of the cut being downwards and outwards. When a iistula has been established b\' ruptui'C of the abscess, or when the abscess has been opened by incision and the swelling has subsided, the lower canaliculus should be slit up so as to establish a free exit for any pus that may yet be retained in the sac or may be afterwards formed. Probing must now be attempted, but should there be any difficulty of introduction to the nasal duct, it is well to wait a few days for subsidence of inilammatcr\' swelling of the mucous membrane of the sac and duct. Then a small probe can generally be introduced, and gradual or rapid dilatation or incision by Stilling's method may be performed. These inflammations of the sac, whether chronic or acute, very frequently yield to treatment by dilata- tion only; but in some cases, especially in those in which there has been much suppuration, the cure is often accelerated by local astringents. An excellent astringent and antiseptic for this purpose is to be found in a 2 to 4 per cent, solution of pure boracic acid. It should be injected into the sac by means of a syringe, the nozzle of which (Fig. 19, 8) can be easily Fig. 19. — Syringe for Injecting Lachrymal Sac. introduced, or the whole length of the duct can be treated by the use of a canula (Fig. 20, b) which is flrst passed down the duct in the same way as a probe, then attached to the syringe by the connecting tube d, and then gradually withdrawn as the solution is injected. Other solutions than that of boracic acid can be used for this purpose, such as those of alum, sulphate of zinc, and lapis divinus of the same strength. Solution of nitrate of silver of strength h per cent, is beneficial in some cases. It sometimes happens that there is a tendency to closure by cicatrization of the entrance to the sac, which renders the in- STRICTUEE OF NASAL DUCT. 59 troduction of the probe difficult at each sitting. In such a case the insertion of a small silver or lead style of the shape shown in Fig. 21 is very convenient. A probe should first be passed to ascertain the length of the duct, and a style of proper length being chosen, its upper end should be bent at right angles to the extent of 4 mm. or 5 mm. It is then introduced so that its lower end rests on the floor of the nose, and its upper bent C li Fig. 20. — Canulas for Injecting Na^al Duct. portion lies in the groove of the open canaliculus. After its introduction it must be watched lest the parts become inflamed, in which case it must be removed and reinserted after a few days; if the parts remain quiet, it can be allowed to remain for several weeks, and will be found to be of great service, the lachrymation being often improved even whilst the patient is wearino; the stvle. This method is also useful in ordinarv cases Fig. 21.— Style for Nasal Duct. in which the passage of the probe is inconvenient or impossible, owing to the patient living at a distance, or being unable to attend. The general health of the patient should be carefully looked after. Fresh air, good nourishing diet, tonic medicines, and local cleanliness are very important here as in other surgical afltections. When there has been great distention of the sac, 60 AFFECTIONS OF THE LACHRYMAL APPARATUS. its restoration is much facilitated by gentle pressure in the form of a compress and light bandage. In certain obstinate cases, in which overflow of the tears still persists after all the efforts above indicated have failed, the extirpation of the lachrymal gland is recommended. The re- moval of this organ (see p. 49) has been repeatedly performed without injurious results; and the operation is well spoken of by Lawrence, Abadie, and other surgeons. Obliteration of the lachrj-mal sac, by means of the actual cautery, strong caustics, as the potassa cum calce, chloride of zinc, etc., is also occasionally practised by some surgeons in obstinate ulceration of that organ, the sac being first laid open by a free external incision. I have never had occasion to re- sort to this heroic treatment. The above methods of treatment are strongly objected to by some surgeons on the grounds (1) that the lachrymal sac acts as an aspirator to the tears, and that its action as such is impaired by an artificial opening; (2) that the normal condition of the nasal duct is that of a capillary tube, or a system of such tubes, and that the passage of a probe of above 0.75 mm. or 1 mm. in diameter is likelj- to destroy this capillary action. Perhaps the best answer to these objections is to be found in the fact that so many eases are thus successfully treated by this method; and further, that those who condemn this practice in theory are frequently obliged to resort to it in practice, although they may content themselves with probes rather smaller than we are accustomed to use. Fistula of the lachrymal sac is a frequent result of neglected inflammation. It consists of a sinus extending from the sac to the skin just below (about 1 cm.) the inner cauthus. The opening is usually small, and gives passage to the tears and mucus, which ought to pass down the nasal duct. The skin and subcutaneous tissue in the vicinity of the fistula may be but little afiected, but are usually swollen and red; sometimes there is indolent ulceration extending: over a considerable area of the cheek. Treatment must first be directed to the stricture (p. 55). This being so improved that the tears can flow through the nasal duct, we may attack the fistula. In slight cases the applica- FISTULA OF LACHRYMAL SAC. 61 tion of simple astringents by means of a compress of lint is often sufficient. In old, inflamed, and ulcerated cases this is not sufficient. Various methods of promoting their healing are employed, such as paring the edges, the galvano-cautery, etc. I liave found the most speedy and efficient help in these chronic cases from the use of the lupus scoop. I first open up the canaliculus and nasal duct, and then proceed to scrape away all the red unhealthy surrounding skin as well as the ulcerated surface. The process is very painful, and requires an anaesthetic. When the scraping is effectually done there is considerable oozing of blood. Water dressing is applied, and the surface usually heals rapidly. To prevent or lessen cica- tricial contraction, I usually graft some patches of skin from another part of the bod.y in the same way as indicated on p. 40 ; this accelerates the healing of the wound. CHAPTER III. AFFECTIONS OF THE CONJUNCTIVA. THE VAKIKTIES OF CONJUNCTIVITIS — PTERYGIUM — PINGUECULA — AMYLOID DEGENERATION — XEROSIS — SARCOMA. Inflammations of the conjunctiva can be conveniently divided into the following live classes: 1. Purulent conjunctivitis: a, gonorrha'al ophthalmia; by ophthalmia neonatorum. 2. Maco-pundent conjunctivitis. 3. Granular conjunctivitis. 4. Phlyctenular conjunctivitis. 5. Membranous conjunctivitis. Purulent conjunctivitis (also called purulent ophthalmia, gonorrha?al ophthalmia, ophthalmia neonatorum, contagious ophthalmia, military ophthalmia, Egyptian ophthalmia). Causes. — The best known cause is indisputably that of the inoculation of the conjunctiva with certain pathological pro- ducts. Of these, the discharge from the urethra or vagina during an attack of acute or chronic gonorrhoea is a very com- mon example. It is remarkable that discharge from a very slight affection of the urethra will often set up a violent inflammation in the conjunctiva. This, no doubt, is due to the susceptibility of the recipient, and is also influenced by the previous condition of the eyelids, and of the general health. If a patient has been previously suflering from granuhn- con- junctivitis, a very slight cause is sufiicient to establish purulent inflammation. The discharge from an eye affected with puru- lent conjunctivitis is very liable to set up a similar and even more severe affection in a healthy eye, either of the same patient or of others. Hence the necessity of great caution and PURULENT CONJUNCTIVITIS. 63 cleanliness, both on the part of the patient and of the surgeon, and others who have to do with the patient. With regard to the period of the disease at which the discharge is most viru- lent by inoculation, Piringer^ has made some interesting ex- periments, from which he infers that for the first few honrs, whilst the secretion is serous, it is comparatively inoffensive, producing only a slight rauco-purulent affection, or no percep- tible efi'ect; that when suppuration has set in, the effect of the inoculation is much more powerful, producing in all cases puru- lent conjunctivitis, which is sometimes of the most violent and destructive nature; and that a step later, when suppuration has ceased and given place to serous exudation, the effect of inocu- lation is similar to that of the very early secretion. He also found that by dilution with water the most active and virulent pus rapidly lost its contagious properties. Muco-purulent conjunctivitis, when conveyed from one person to another, who is in a weak condition, may become entireh' purulent. The atmosphere is considered by some high authorities to be the means of the conveyance of contagious particles, and so placing them in contact with the conjunctiva; this theory is advanced in explanation of epidemic outbreaks such as occur in crowded dwellings, hospitals, barracks, etc. Careful inquiry, however, in such cases will generally elicit the fact that many facilities of direct inoculation are present, such as several children sleeping together, the use of a common towel, etc. Such outbreaks of the disease illustrate very well what has been said above as to the susceptibility to infection of pa- tients who have suffered from granular conjunctivitis; and in order to check such an outbreak in a school or similar institu- tion, it is essential, not only to isolate those actually suffering from purulent conjunctivitis, but also those who present the granular affection, lest the latter should themselves become foci of infection. Concerning the cause of this affection in the newly born (ophthalmia neonatorum"!, the prevailing opinion, and that in which I heartily concur, is that it arises from the introduction of purulent discharge from some part of the 1 Quoted by Abadie. Maladies des Yeux. Paris, 1876. 64 AFFECTIONS OF THE CON J L^ N CT I V A . genito-urinary tract of the motlier into tlic conjunctival sac of the infant shortly after parturition. The great frequency of purulent discharges from the os uteri in pregnant wonien is universally admitted; and it is easy to understand how this could come into contact with the eyelids during the passage of the head per vaginam, shortly after which the child opens its eyes. Hence the necessity of scrupulous care in washing the eyes of the newly born. Symptoms. — Purulent conjunctivitis usually commences in from one to four days after infection ; in some cases its progress is so rapid that it attains its maximum intensity in forty-eight hours. At first there is a gritty sensation in the eye; this is soon followed by pain, which sometimes becomes excruciating in character. The eyelids become red, infiltrated, and swollen to such a degree that they can only with difficulty be everted ; the palpebral conjunctiva is greatly congested and swollen; the ocular conjunctiva is also infiltrated, and forms an elevated ridge of chemosis all round the cornea, which in some cases is sulficiently prominent to overlap and conceal its peripheral portion. The discharge at first consists only of a serous fluid containing a few flocculi of pus, but it soon becomes thicker, and of a yellow or even greenish-yellow color. This purulent secretion fills the palpebral sac, and generally flows over on to the cheek; at times it is retained by the swollen lids, and causes great danger to the globe by the pressure thus exerted. The establishment of free suppuration is marked by immediate relief of pain and some diminution of swelling; this may lead the patient to consider his condition to be improving, but in reality the risk of serious and irreparable mischief commencing in the cornea is greater now than at any other period of the disease. The great danger of purulent conjunctivitis is lest the cornea should slough or become ulcerated. Ulcers vary in their position and depth; a very common situation is beneath the limbus conjunctivae; in whatever part of the cornea they occur, they are very likely indeed to lead to its perforation. When we come to treat of affections of the cornea, we shall see that a perforating ulcer from any cause may be followed by dangerous sequela?; but when the perforation takes place in the course of an attack of purulent conjunctivitis, we have the GONOERHCEAL OPHTHALMIA. 65 additional danger lest the suppuration should immediately extend to the whole eye. It occasionally happens that the peripheral ulceration, ex- tending round a large portion or the whole of the circumfer- ence of the cornea, so interferes with its nutrition that the whole membrane sloughs. When the swelling of the lids has subsided, the conjunctiva is found to have lost its normal smooth appearance, and to have become rough and rugose, presenting numerous papillae over its entire surface, more especially over the upper and lower culs-de-sac. After a variable time the discharge diminishes in quantity, becomes thinner, and finally gives place to a serous fluid con- taining a few flocculi of muco-pus. If untreated, this condition may become chronic, giving rise to deformities of the lids, such as trichiasis, entropion, ectropion, and to corneal affec- tions, as ulcers, pannus, etc. Gonorrhoeal ophthalmia is the most acute form of purulent conjunctivitis. It is caused by the introduction of the urethral discharge to the conjunctival sac, either directly by means of the hand, or indirectly by the use of a contaminated towel or pocket-handkerchief. It is more common in men than in women. The right eye is more frequently attacked than the left. Its progress is usually very rapid and severe ; from the outset there are acute pain, chemosis, and great swelling of the lids. If neglected or improperly treated, there may be total destruction of the cornea, from abscess, ulceration, or slough- ing, in the course of a few days. Ophthalmia neonatorum — the form of purulent conjunctivitis which attacks newly born children — is less virulent than the gonorrhoeal, but is sufiiciently destructive in its nature to require prompt and energetic treatment. Its probable cause has been already mentioned. Its sjmiptoms and complications are essentially the same as those of the gonorrhoeal and other forms of the aflfection occurring in adults, although somewhat less pronounced in degree. It usually occurs about the third or fourth day after birth. More blindness is caused by oph- thalmia neonatorum than by any other single aflection of the eyes ; but this is due solely to the fact that its treatment is 5 66 AFFECTIONS OF THE CONJUNCTIVA. frequently left to persons Avho are ignorant or incompe- tent. Treatment. — When not occurring in the newly born, the indications are : 1. To protect the healthy eye when only one is attacked. 2. To reduce the pressure upon the globe which is caused by the swollen lids and the retained purulent secretion. 3. To cut short the inflammatory process, and to restore the conjunctiva to its normal condition. 4. To treat the complications. 1. To "protect the healthy eye. — (i) The closed lids may be covered with absorbent cotton-wool, which is secured by col- lodion and a bandage or sticking-plaster. (ii) Buller's shield may be employed. This has the double advantage of giving the patient a certain amount of vision, and of enabling the surgeon to examine the eye without disturbing its dressings. It is constructed as follows : Take a watch- glass and two pieces of India-rubber plaster, one about ^h inches the other 4 inches square ; cut a round hole slightly smaller than the watch-glass in the middle of each piece of plaster. Then insert the watch-glass between the two pieces of plaster, and stick them together so as to form a small window. Now arrange the plaster by its free edge along the nose, forehead, and cheek, leaving only the lower and outer angle a little open for purposes of ventilation. 2. To reduce the pressure upon the globe. — In some cases the tension of the eyelids is so great that the cornea is in danger of strangulation from pressure. Under these circum- stances the lids should, if possible, be everted and their inner surfaces freely scarified. Incisions with a small, sharp scalpel should be made parallel to the edge of the everted lids from near the ciliary margin as far back as the fornix conjunctivae. Even the ocular conjunctiva may be benefited by a few radial cuts. The incisions should be sufiiciently deep to induce free hemorrhage. When it is found impossible to evert the eyelids, either of the following methods may be adopted: (1) Division of the outer canthus as far as the outer angle of the orbit. This can be done with a pair of strong, sharp scissors, or by means of a scalpel and a grooved director. (2) By vertical PURULENT CONJUNCTIVITIS — TREATMENT. 67 division of the upper lid as recommended by the late Mr. Critchett. A grooved director is first passed beneath the middle of the upper lid; a sharp-pointed bistoury is then inserted into the groove of the director, and made to perforate the lid at its upper part ; all the structures of the latter are then divided. The flaps thus formed can, if desirable, be stitched back. The hemorrhage following these scarifications, and even that of the division of the lids, is always beneficial in reducing the swelling and cutting short the inflammatory process. The incisions should be immediately followed by the copious use of tepid, slightly carbolized water, with the object of encouraging the local bleeding and thoroughly removing accumulated pus. This done, the closed lids should be kept constantly cold and wet by means of pledgets of lint dipped in iced water. The latter may with advantage contain J per cent, of carbolic acid; and the lint should be changed every half hour or so. Besides this, the inside of the lids must be frequently cleansed, say every one or two hours, by thorough washing with similar carbolized water. On the following day the congestion and swelling may still be so great as to render a second scarification advisable, or it may be better to cauterize the inner surface of the lids with strong nitrate of silver, and to continue the frequent ablutions and cold applications. 3. To cut short the inflammatory jwocess. — (i) The best and most effectual treatment consists in the application of solid nitrate of silver (F. 1) to the inner surfaces of the eyelids once in twenty- four hours, combined with the constant external application of iced carbolized water, and frequent ablutions of the conjunctival sac. The process is tedious, and requires the services of one or two nurses. The lids must be well everted and cleansed, and the caustic freely passed over the conjunctival surface.; they must then be again washed, in order to remove the superfluous silver nitrate before they are inverted. This should be repeated once in twenty-four hours, and in the in- terval the eyelids are to be everted, and the conjunctival sac well cleared of all accumulated secretion every one or two hours. Ice-cold applications should be kept constantly applied to the outside of the lids. This may be effected by a dry ice bag, or, better, by pledgets of lint dipped in iced carbolized 68 AFFECTIONS OF THE CONJUNCTIVA. (^ per cent.) water. It will be found that the lint requires changing every ten or fifteen minutes. Two or three days of such treatment usually suffice to re- duce the swelling, inflammation, and amount of discharge, after which the use of milder astringent applications, as the sulphate of copper or iodoform, may be substituted for the nitrate of silver; and the cold applications may be discontinued whilst a simple ointment is used to anoint the lids. (ii) When the above process cannot be thoroughly carried out, and when the aflfection is comparatively mild in degree, we may use a 4 per cent, solution of nitrate of silver to paint the conjunctiva, instead of the solid nitrate. It should be washed off again before the lids are inverted. The conjuncti- val sac should be thoroughly cleansed with | per cent, solution of boracic or carbolic acid every one or two hours, and the eyelids either anointed with simple ointment, or kept cool by wet lint. Iodoform has been recently used with great success in the treatment of purulent conjunctivitis. It can be best used in vaseline of 4 per cent, strength, and a very convenient and efficient way of applying it is by means of a glass syringe with a flattened nozzle (Bader's). By means of this the ointment can be introduced well into the upper cul-de-sac without evert- ing the lids. As the acute symptoms of purulent conjunctivitis subside, the discharge becomes diminished in quantity, then thin and muco-purulent, and finally ceases. The mucous membrane of the lids continues to be thickened and red; it is often very rough, and sometimes quite granular. The treatment at this stage must be similar to that for granular conjunctivitis. (iii) In ophthalmia neonatorum both eyes are generally at- tacked; even when one eye only is affected the use of Buller's shield is hardly applicable. The other eye should therefore be closed and secured from infection by cotton-w^ool, collodion, and strapping. The treatment here is the same in principle as in the adult; but, owing to the tender age and delicacy of the subject, it requires a few remarks as to detail. The sur- geon should always see the child at least once in twenty-four hours. In order to examine the eye, he, being seated, directs PURULENT CONJUNCTIVITIS — TREATMENT. 69 the nurse to place the child's head between his knees, which are protected by a towel. He then first cleanses the eyes by douching with pellets of cotton-wool and carbolized tepid water; next he thoroughly everts both the eyelids and cleanses them; then he applies, not the solid stick, but a 4 per cent, solution of nitrate of silver by means of a camel's-hair brush to the whole of the mucous membrane of the lids, and particularly to that of the upper cul-de-sac; he then again washes away the superfluous nitrate by douching with the carbolized water, and finally closes the lids. Having done this he raises the upper lid by means of Desmarre's retractor (Fig. 22), in order to Fig. 22.— Lid Retractor. examine the condition of the cornea. If there are signs of inflammation or ulcer of this structure, a few drops of atropine solution should be applied. Finally he anoints the edges of the lids with simple or iodoform ointment, and instructs the nurse or mother of the child to cleanse the eyes thoroughly every hour with tepid carbolized water (| per cent.). 4. To treat the complicatio?is. — When cases are seen in the very early stage, and can be properly treated, the inflamma- tory process can generally be subdued before the cornea or the deeper structures are aft'ected. AVhen the cornea is found to present signs of inflammation, abscess, or ulcer, some atropine solution, 1 per cent., should be dropped into the palpebral aperture after each dressing. The iris in such cases is very likely to be inflamed, and this will tend to dilate the pupil and so prevent the formation of adhesions (synechise). The existence of lesions of the cornea does not contraindicate the treatment above described ; but in the case of ulcers, especially when deep, greater care is required in everting the lids, lest the pressure upon the globe should cause perforation of the ulcer. "Where perforation of the cornea is imminent, it may be advisable to perform para- 70 AFFECTIONS OF THE CONJUXCTIVA. centesis of the anterior chamber toward the periphery of the cornea, with the view of reducing intraocuLar tension, and so preventing the rupture. When the conjunctivitis has sub- sided, the corneal lesions can be treated according to the rules given under tlie head of Ulcers of the Cornea. Muco-purulent conjunctivitis (catarrhal ophthalmia) is of very frequent occurrence. Causes. — Contagion, sudden exposure to cold, irritating particles of dust in the atmosphere, aftections of the eyelids, as trichiasis, entropion, ectropion, and obstructed lachrymal ducts, are all causes, as also are errors of refraction, especially hypermetropia and hypermetropic astigmatism, in which con- stant exercise of the accommodation tends to induce hyper- emia of the conjunctiva. The secretions of muco-purulent conjunctivitis are themselves contagious, and it is usual to lind various members of the same household simultaneously or suc- cessively attacked. The contagious nature of the aifection renders an outbreak in large communities of great importance. Cases should be isolated, and strict cleanliness enforced, not only to prevent actual contact of the discharge with the eyes of others by means of towels, etc., but also to prevent the atmosphere becoming charged with particles of secretion; a precaution which is especially necessary in the case of schools of the poorer class, where the dormitories are often over- crowded and ill-veutilated. This form of ophthalmia is much more common among the poor than the well-to-do, although the latter class is by no means exempt from the malady-. It also occurs in the exanthemata of childhood, especially measles. Si/mp(oms. — This aftection presents itself under many dif- ferent aspects. (1) In the milder cases we find only slight redness of the palpebral conjunctiva and of the fornix con- junctivae, hypersecretion of mucus, sticking together of the lids on awaking in the morning, and a more or less gritty feeling in the eyes. (2) In the severer cases these symptoms are exaggerated; the mucous membrane of the lids and fornix is not only in- jected, but perceptibly swollen; and there is some injection of the ocular conjunctiva. In addition to hypersecretion of mucus, MUCO-PURULENT CONJUNCTIVITIS. 71 we iincl flocculi of muco-pus floating in the lower cul-cle-sac. The adhesion of the eyelids on awaking is more marked, and the edges of the lids are covered with a yellowish incrustation of inspissated muco-pus. (3) A few cases are much more severe, and are often diflfi- cult to distinguish from purulent conjunctivitis. In fact, there is no sharp line of demarcation between the two aflections, since cases of every intermediate degree of severity are met with. The chief diagnostic signs are the amount of oedema- tous tension of the lids and the character of the discharge. When muco-purulent conjunctivitis is attended with redness of the circumcorneal zone, it becomes important to distinguish it from other affections in which the same symptom exists. The chief of these are iritis, episcleritis, and keratitis. (a) In muco-purulent conjunctivitis the redness, at first, is super- ficial, and chiefly confined to the conjunctiva. If the ocular conjunctiva be moved up and down by pressure of the finger through the lower lid, the injected vessels will be seen to move with the mucous membrane. The redness of the ocular con- junctiva is always accompanied by redness of the fornix con- junctivae, and generally of that of the lids. The redness is not localized in patches. The iris is clear and bright, the pupil active, and the cornea clear. (b) In iritis the circumcorneal zone of redness is deep-seated, and is not accompanied by redness of the fornix and palpebral conjunctiva. The injected vessels, being chiefly situated be- neath the conjunctiva, do not move with the latter. The iris is less brilliant than normal, and at times is much altered iu color. The pupil is sluggish or inactive. The vision is im- paired. (e) In episcleritis the congestion is of a deep red color; it is subconjunctival and localized — that is, it does not invade the whole circumcorneal zone, but appears in patches, which are usually situated opposite the palpebral fissure, near the outer edge of the cornea. (d) In keratitis the injected vessels are deep-seated and fixed. The redness is most marked in the circumcorneal zone. The transparency of the cornea is always more or less diminished. 72 AFFECTIONS OF THE COxNTJUNCTI V A. Treatment. — Any general predisposing causes should be as far as possible removed. Any error of refraction should be at once corrected by spectacles. When due to a local cause, such as trichiasis, entropion, stricture of nasal duct, etc., these should be cured by appropriate treatment. In the mildest forms of class 1, the use of any mild astringent (Formulae Nos. 5, 8, 9, 14), to be dropped into the palpebral aperture three times daily, or used in the form of a lotion, together with the anoint- ing of the lids with a simple ointment at night, is sufficient to arrest the disease. In class 2 it is necessary to inculcate strict cleanliness and caution with regard to the discharge. The eyes should be washed four or five times daily with tepid water and cotton-wool; after this astringent lotions should be applied, as for class 1, or a piece of cotton-wool may be soaked in the lotion and applied over the closed eyelids for ten or fifteen minutes at a time in the form of a compress. The edges of the lids should be constantlj^ anointed with simple ointment to prevent adhesion, When the swelling and discharge are severe, as in class 3, the above rules as to treatment still apply ; but I do not hesitate to evert the lids and apply a 4 per cent, solu- tion of nitrate of silver to their inner surface once daily. This must, of course, be well washed away before inverting the lids. Granular conjunctivitis (trachoma, follicular conjunctivitis, granular ophthalmia). Causes. — The chief cause of this affection is contagion. This view is substantiated by the fact of its prevalence in pauper schools in past and even present times, also in prisons, bar- racks, and other places where there are crowded communities having facilities for the conveyance of the unhealthy secretions from eye to eye by means of towels and otherwise. Cases do occur, however, which appear to be spontaneous, no source of infection appearing to be within the patient's reach. In all cases, whether produced by contagion or otherwise, the subjects of the aftection appear to have been predisposed to it by ill-feeding, over-fatigue, bad ventilation, and other debili- tating causes. It is rarely seen in the better classes of society. Symptoms and Pathology. — This disease first appears in the form of numerous small, grayish, hemispherical, semi-trans- parent elevations, having a great resemblance to boiled sago GRANULAR CONJUNCTIVITIS. 73 grains (follicular granulations). These usually appear first in the upper and lower culs-de-sac, and thence spread to the lower and upper lids. This granular appearance, from which the malady derives its name, differs from pathological "granu- lation-tissue," inasmuch as the mucous membrane is not ulcerated, and the submucous tissues have a characteristic ar- rangement. Beneath the mucous, membrane we find these elevations to be composed of aggregations of lymphoid cells, those nearest the surface having undergone partial fatty de- generation. In the superficial part there is but little inter- cellular substance, but toward the base we find more or less connective-tissue formation, with small branches of blood- vessels. After the follicular granulations have existed some time the adjacent papillae become hypertrophied, and the whole lid assumes the rough villous appearance which is often left Fig. 23. — Everted Granular Lids. after catarrhal or purulent conjunctivitis (papillary granula- tions) (see Fig. 23). As time goes on, the connective-tissue element increases, and thus converts the papillfe and sub- mucous tissue of the whole lid into a dense fibrous structure, which finally contracts and undergoes changes resembling those of cicatrices. The attack may be acute or chronic. There is a more or less copious muco-purulent secretion, gritty feeling as of sand in the eye, and photophobia. Sooner or later the cornea begins to suffer from the friction and irritation of the granular lids, and becomes ulcerated; or, more frequentl}", its 74 AFFECTIONS OF THE CONJUNCTIVA. superficial la^'ers become opaque and vascular, which latter condition is known as pannus. Follicular granulations may he classified into three chief groups: (a) Simple forms, in which there is but slight redness of the free edges of the lids, a feeling of grittiness in the eyes, and an increase in the secretion of mucus. On everting the lids, however, we find fine granulations disseminated over the conjunctiva, mostly in the position of the upper and lower culs- de-sac. The conjunctiva over the tarsi is often free, or the granulations may be seen creeping over their borders near the outer canthus. The submucous tissues are but little affected. [b) In a second class of cases the granulations constitute a diffuse infiltration of the conjunctiva of the culs-de-sac and of the palpebrte. The mucous membrane is greatly thickened, and presents a grayish, gelatinous appearance. The edges of the lids are reddened; the mucous secretion is much increased, and often semi-purulent. Besides this, there soon supervene increased lachrymation, photophobia, and lesions of the cornea — pannus, ulceration, etc, (c) llalignant. — In a third group may be placed a still more grave and troublesome class of cases, viz., those in which the granular affection extends to the ocular conjunctiva, and even to the cornea; whilst the whole inner surface of the eye- lids is infiltrated and thickened with villous-looking hyper- trophies of the mucous and submucous tissues, which bleed on the slightest touch, and which are so extensive as to cov^er up the upper and lower culs-de-sac when the lids are everted. The whole episcleral and corneal surfaces become filled with tortuous bloodvessels, and the cornea becomes quite opaque and fleshy-looking. There may be superficial, deep, or even perforating ulcer. The iris also may be inflamed by continuity of tissue. The most discouracjinsr feature of this malignant form of granular conjunctivitis is its obstinate progress from bad to worse. The inflamed tissues do not return to their normal state, but all appear to undergo an ultimate fibroid. degenera- tion, similar, in fact, to the cicatricial contraction which follows true ojranulatins: ulcers of the skin. Thus the mucous mem- GRANULAR CONJUNCTIVITIS — TREATMENT. 75 brane becomes thin and shrunken and tightly adherent to the tarsi, and the latter become shrunken and incurved. Treatment must in all cases be general as well as local. The general treatment consists in placing the patient under the best possible hygienic conditions. Good and plentiful nourishment, exercise in the open air, and well-ventilated sleeping accommodations are essential adjuncts to local treat- ment. Change of air or a sea voyage is frequently of great assistance. The eyes should be protected from bright light and from dust by smoked glasses. The patient should avoid as far as possible over-fatigue of the eyes, especially by artificial light. Tonics, such as iron, quinine, cinchona, and cod-liver oil, should be administered. Parrish's food, Easton's syrup, and similar forms of medicine are beneficial. The local treatment consists in the application of astringents or caustics (F. 4, 8, 24, 33) to the inner surfaces of the lids and the culs-de-sac at regular periods. In the use of these remedies it is important to bear in mind the delicate structure of the mucous membrane we are dealing with, and to realize the fact that our object is to restore it to its proper condition and function, and not to destroy it altogether. 1. Whe)i the granular conjunctivitis is free from purulent discharge, the safest and perhaps the most efficient remedy is the daili/ application of a crystal of sulphate of copper. The lids should be everted (see Fig. 23), and a smooth crystal of this substance or of the lapis divinus (F. 33) applied to the surface of all the granulations, and especially to the upper cul-de-sac. These surfaces should then be lightly washed with cotton-wool and water, and the lids restored to their position. The appli- cations should be repeated every twenty -four hours witliout remission until the granulations have disappeared, and even then they should be continued twice a week for several weeks. Should there be a lull in the apparent improvement by this daily application, it is well to substitute the weak nitrate of silver crayon (F. 4) for the copper every third or fourth day, always remembering to wash away the superfluous salt before returning the eyelids. With these efforts, combined with attention to the improve- 76 AFFECTIONS OF THE CONJUNCTIVA. ment of the general health, there are few cases that will not yield to treatment in from five to ten weeks, especially when seen in the early stage. Unfortunately, however, this method is too elaborate to be carried out in any but private cases, the demand of time being greater than either the physician or the patient can aftbrd to give. It remains therefore either to teach the patient to apply the remedy himself, or to instruct some friend how to do it for him. No doubt other remedies, such as the lapis divinus (F. 33), the glycerine of tannin, or the solution of tannin in syrup, would be equally beneficial if constantly applied. The subace- tate of lead in solution or in powder is recommended by some surgeons ; but knowing the facility with which lead becomes reduced, and deposited upon the cornea even in the slightest abrasions of that structure, and being also aware of the great frequency of these abrasions or ulcerations in trachomatous afifections, I never employ this reniedv. 2. When there is considerable furulent discharge in addition to the granular condition, the treatment should be similar to that prescribed for the severer forms of muco-purulent con- junctivitis. The granular surface of the eyelids and culs-de- sac should be first cleansed with water and cotton-wool, then painted with a 2 per cent, solution of nitrate of silver (F. 6), and again immediately washed, and the edges of the lids anointed with a simple ointment. This should be repeated every twenty-four hours until the discharge is diminished, when it may be replaced by a 1 per cent, solution of the same, or by the crystal of sulphate of copper. 3. If the patient is unable to attend for treatment more than once or twice a week, and is unable to get the sulphate of copper applied at home, I find it more effectual to use the strong form of nitrate of silver crayon (F. 1) at each interview, and to prescribe an ointment of yellow oxide of mercury for use at home (F. 24), directing the patient to introduce a small quantity into the palpebral aperture twice daily. When granulations have become excessively large it may be well to excise them at once before commencing treatment by astringents or caustics. Dr. Wolfe, of Glasgow, states that he finds very beneficial results from the combination of scarifi- PHLYCTENULAR CONJUNCTIVITIS. 77 cation of the granular surfaces, and the subsequent application of a solution of tannin in simple syrup. Some surgeons recom- mend the excision of the upper cul-de-sac of the conjunctiva as a radical cure for granulations. MM. Galezowski and Richet report very favorably of their results of this practice. I have performed this operation about a dozen times in con- junction with peritomy, and from this limited experience I consider it to be beneficial as regards the granulations. 4. In the malignant forms of this disease the results of treat- ment are most unsatisfactory. Here again the benefits of good constitutional treatment cannot be over-estimated. The local remedies must depend upon the condition of the con- junctiva. Daily applications, either of astringents or caustics, as the case may indicate, will do much to mitigate the results which would supervene were the disease left to itself. Phlyctenular conjunctivitis (also called pustular, scrofulous, strumous, and herpetic conjunctivitis) is characterized by the presence of one or more small vesicles attacking the sclerotic portion of the conjunctiva (see Fig. 7, opposite p. 90). Each is at first small, conical, and well defined ; it seldom measures more than from 1 to 2 mm. across the base. Its contents are at first clear and transparent, but soon become yellowish, in- dicating the formation of pus. Sometimes it becomes solid in texture, forming a somewhat hard prominence. The sur- rounding conjunctiva is swollen and injected, and there is fre- quently a triangular leash of enlarged bloodvessels, having its apex at the phlyctenula and its base toward either the inner or the outer canthus. The number of these phlyctenulae varies from one to five or six. One or two will appear by preference at the sclero-corneal junction, although they may be entirely corneal, or entirely in the sclerotic portion of the conjunctiva, or they may occupy any of these positions simultaneously ; when, however, more than two occur, they generally appear in successive crops. So long as the corneal portion of the con- junctiva is not simultaneously afi:ected, there is little or no in- convenience beyond a pricking sensation, increased secretion of mucus, and more frequent blinking than normal. As soon, however, as the cornea is attacked (phlyctenular kera- titis), even though it be near the periphery, there is increased 78 AFFECTIONS OF THE CONJUNCTIVA. lachrvmation, and photophobia may be so great as to cause blepharospasm (p. 95). In some cases these pustules are ac- companied by a more extended inflammation of the conjunc- tiva, presenting the combined symptoms of muco-purulent and phlyctenular conjunctivitis. This aiiection is common in children up to the age often or twelve years, but may occur at any period of life. It is fre- quently accompanied by impetigo of the face and head. The subjects are generally anaemic, badly nourished, and live in crowded and ill-ventilated dwellings. Prognosis and Treatment. — So long as the corneal conjunctiva is unaffected, the phlyctenulae break down after a few days, leaving a superficial ulcer, which rapidly heals, and the con- junctival redness disappears. The disease, however, shows a great tendenc}' to recurrence. The process of healing is assisted by the use of mild astrin- gents, such as the yellow oxide of mercury ointment (F. 24), the solution of boracic acid (F. 14), and other simple astringents. Constitutional treatment is also important. A wholesome diet and good hygienic conditions should be prescribed ; also plentiful exercise in the open air, and the internal administra- tion of tonic medicines — Parrish's food, cod-liver oil, decoction or tincture of cinchona, etc. ; also sulphide of calcium in -^^ gr. doses every few hours. Membranous or diphtheritic conjunctivitis is comparatively rare in this country; nevertheless, a good number of cases have been recorded, and in Germany, where the graver forms of the affection appear to be of more frequent occurrence than in Great Britain and France, the subject has received consider- able attention. A. von Graefe^ endeavored to arrange these cases into two classes : {a) The diphtheritic, in which in the first stage there are brawny swelling of the lids, a pale, bloodless condition of the conjunctiva, a very adherent whitish membrane, and a thin, scanty discharge. (6) The pseudo-membranous, or croupous, in which there are a slightly adherent pellicle of exudation, a succulent con- 1 A. von Graefe, Arch. f. Oph., I., i. 1G8, 1854. MEMBRANOUS COX JUNCTI VITIS. 79 junctiva, which bleeds easily when touched, and more or less mueo-purulent or purulent discharge. He admitted, how- ever, that cases intermediate between these two classes do sometimes occur. De Wecker' also draws a line of demarcation between what he terms croapal and diphtheritic conjunctivitis. Professor Tweedy- also maintains the classical distinction between membranous and diphtheritic affections. I fully acknowledge the extreme severity of the majority of those cases which are directly traceable to diphtheria; yet some of these are of a milder type and less pernicious in their results than others of the so-called membranous conjunctivitis, in which, beyond the condition of the conjunctiva, no symptom of diphtheria can be found. I have made microscopic examina- tions of both the diphtheritic and the membranous forms of conjunctivitis.* In each the conjunctiva is thickened by infil- tration, consisting chiefly of leucocytes; toward the surface these are so thick and numerous that nothing else is visible. Deeper down the bloodvessels are completely occluded by similar cells, no red blood-corpuscles are visible; even in the deepest parts these leucocytes are very numerous, occupying the interstices between the connective tissue. In some of the chronic cases the white, caseous-looking substance, which can be separated with forceps, presents a semicrystalline appear- ance, simulating cholesterine. This condition of an opaque, whitish, adherent membrane, with more or less solid infiltra- tion of the ocular or palpebral conjunctiva, may occur in con- junction with throat diphtheria; it may be the result of inoculation with diphtheritic discharge from another person; it may occur as one of the sequelae of an acute illness, or during the course of an attack of scarlet fever; or it may supervene in a case of simple muco-purulent or purulent con- junctivitis, especially when strong caustics are too freely applied. For these reasons I am inclined to think with Mr. Nettleship,* that we should abandon the distinction between ■diphtheritic and membranous conjunctivitis. 1 Therapeutique Oculaire. ^ Lancet, 1880, vol. i. pp. 125, 282. 3 See Ophthal. Soc. Trans., vol. iii. p. 1. * St. Thomas's Hospital Reports, vol. x., 1880. 80 AFFECTIONS OF THE CONJUNCTIVA. Tliere are man}' degrees of severity in this affection, varying from a simple patch of a few millimetres diameter of slow increase, and unattended by constitutional disturbance, to that condition in which the whole of the palpebral and ocular con- junctiva is involved, causing rapid destruction of the cornea, and attended by considerable pyrexia, with severe pain in the eyes, the temples, and the head. Treatment. — In the severe and acute forms active measures must be taken to reduce the local inflammation, to prevent the destruction of the cornea by pressure of the swollen conjunctiva, and to support the constitution of the patient. Unfortunately, all the means we possess are too frequently futile in preventing partial or complete sloughing of the cornea. The application of caustics is generally regarded as increasing the danger. Jacobson recommends the use of iced compresses continuously applied; the effect, however, should be watched, and if the symptoms do not improve, or should appear to be aggravated, they must be substituted by hot fomentations, which may with advantage contain a small percentage of carbolic or salicylic acid. A few leeches may be applied to the temple, or to the lids, if the patient can afford the loss of blood. Moderate scarification of the mucous surfaces may also be of great benefit, and even the division of the outer canthus may be efiective in relieving the globe from the bad results of com- pression, and in favoring the local applications. With regard to constitutional treatment, some surgeons recommend the , administration of mercury till slight salivation is produced. Others prefer a tonic and supporting plan of treatment by the copious use of nutrient foods, iron, quinine, ammonia, bark, etc. In the milder and chronic forms the exudation should be, as far as possible, peeled off" dailj'; the surface should then be treated with some astringent, such as the lapis divinus, once daily, or with lotion of quinine (2 per cent.), or of salicylic acid at frequent intervals. Pterygium is a thickened condition of a part of the ocular conjunctiva. It usually commences opposite to the aperture formed by the opened eyelids, and is more common on the nasal than on the temporal side of the cornea, although it raa}^ occupy both these positions in the same eye, or even in both PTERYGIUM. 81 eyes, at the same time. Each patch appears in the form of a triangle, of which the apex is directed toward, or encroaches upon, the cornea, the sides being free and formed by a double fold of the mucous membrane, under which a probe can be easily passed. Its color is general!}^ so similar to that of the conjunctiva that it usual!}' passes unnoticed until it attacks the cornea (see Fig. 2, opposite p. 90) ; sometimes, however, it becomes vascular in structure, and then has a bright red color. It varies greatly in thickness and in the rapidity of its growth. In some cases it continues for many years with- out apparent increase; in others, especially those of the vascu- lar kind, the increase may be rapid. In the majority of cases it causes but little or no inconvenience; but when the thick- ening is great the conjunctiva is liable to inflammatory at- tacks. So long as the growth does not extend lo the front of the pupillary aperture, the vision is unafiected; but after it has reached this region, the vision decreases in proportion to the extent of the pterygium. Pterygium is thought to be caused by persistent exposure of the conjunctiva to irritating substances, and to commence as a small abrasion or ulcer opposite the sclerno-corneal junction. It is most common in those who have travelled or spent some years in hot, dusty countries, and in stonemasons and others who are exposed to irritating substances. Treatment. — When the cornea is only slightly or not at all involved, and when the increase is evidently slow — that is, where increase is imperceptible during six or twelve months' observation — no treatment is called for. Where increase is evident, and the pterygium has com- menced its march upon the cornea, its removal by operation should be at once resorted to. This can be effected by (1) transplantation, (2) excision, or (3) ligation. 1. Transplantation (Desmarre's operation). — The lids being separated by a speculum, the pterygium is seized with forceps and dissected completely away from the cornea and the con- junctiva as far as its base. The lower flap of the incision formed in the ocular conjunctiva by the removal of the ptery- gium is now enlarged by an incision of several millimetres in length, made parallel to the lower margin of the cornea. The QJ, AFFECTIONS OF THE CONJUNCTIVA. conjunctiva is then dissected away from the globe to an extent sufficient to receive the pterygium beneath it. The pterygium is then twisted under this flap of conjunctiva and fastened in its new position by one or two fine silk sutures. Finally, the cut edges of the conjunctiva are brought into apposition by similar sutures. The dissection can be made w^ith curved scissoi-s or a Beer's cataract knife. An excellent little knife is used for this pur- pose by Mr. Anderson Critchett. It is rounded at its extremity, and the cutting edge is continued a short way up the back of the blade. It is made by Weiss. This method gives very satisfactory results; the transplanted conjunctiva soon becomes shrunken and imperceptible. 2. Excision is performed in a manner similar to the first stage of transplantation, the mass being cut away at its base by two incisions meeting at the commissure. The edges of the wound are brought together by fine silk sutures. 3. Ligation is performed by transfixing the base of the ptery- gium by several silk ligatures and tying them tightly in such a manner as to involve the whole of the base of the growth, which soon sloughs, and can be removed with forceps. Pinguecula is a small whitish or yellowish-white tumor of from 1 mm. to 4 mm. diameter, situated in the ocular con- junctiva close to the cornea, and opposite the palpebral fissure. It more commonly occurs on the temporal than on the nasal side of the cornea, but it frequently comes on both sides and in both eyes. It involves the whole thickness of the conjunctiva, with which it moves when the latter is displaced. It is more common after middle age than before that period ; also in per- sons who are exposed by their occupation to irritating vapors and substances. Microscopically, pinguecula consists chiefly of condensed cellular tissue; the epithelial layer of the con- junctiva is thickened, and the bloodvessels are obliterated. It causes no trouble or inconvenience; after attaining a certain magnitude it remains stationary. As a rule, no treatment is required, but no harm would be done by its removal. Amyloid degeneration of the conjunctiva. — This is a rare afl'ection, in which there is a soft, gelatinous-looking iiyper- trophy of the conjunctiva, unattended by inflammation or pain. XEROSIS. 83 It appears first to attack the sclerotic portion of the conjunc- tiva, and thence to spread to that of the palpebrpe and the cornea. According to Leber, amyloid degeneration is a purely local malady ; it may come on as a primary affection of the conjunctiva, or it may be consecutive to chronic granular con- junctivitis. The process consists in the development of amy- loid corpuscles or trabecule, which are situated in a clear, liquid matrix, and are enclosed in a special membrane, con- taining numerous nuclei. The corpuscles and trabeculse give a decided amyloid reaction when treated witli iodine and sul- phuric acid. Xerosis is a very uncommon form of disease, which is charac- terized by a peculiar drj-ness of the conjunctiva, giving it a shrivelled, skin-like character, in consequence of atrophy of its tissue, and obliteration of its secretory elements. Its treat- ment is very unsatisfactory. The application of glycerine and bandaging is advised as a palliative. M. Oilier, of Lyons, has found benefit from keeping the eyelids closed for man}- months. In order to eftect this he pares the edges of the lids, and brings them together by sutures, so as to produce symblepharon. CHAPTER IV. DISEASES OF THE CORNEA. ANATOMY — INFLAMMATION — PHLYCTENULAR KERATITIS — INTERSTITIAL KERA- TITIS VASCULAR KERATITIS — PUNCTATE KERATITIS — ULCERATIVE AND SUPPURATIVE KERATITIS — LEUCOMA — STAPHYLOMA. Anatomy and Physiology. — The cornea is nearly circular in shape, and is quite transparent ; its arc extends to about one- sixth of the circumference of the globe. It has a smaller radius of curvature than that of the sclerotic, and so projects forwards beyond the general surfiice of curvature of that mem- brane. In the cornea (Fig. 1, on the opposite page), we find from before backwards the anterior epithelium, Bowman's mem- brane, the substantia propria, the posterior elastic lamina, or Descemet's membrane, and the endothelium. The anterior epithelium is of the stratified pavement variety, arranged in several layers, the deepest of which is composed of columnar cells, each with an oval nucleus; then follow two or three layers of pol^-hedral cells, each with a spherical nucleus; lastly, there are two or three layers of fiattened cells, each with a discoid nucleus. This epithelium is continuous with that of the conjunctiva, from which it difters in being thicker and more transparent (see Fig. 3, on the opposite page). Bowman's membrane is the transparent homogeneous-looking anterior part of the substantia propria. It is considered by some high authorities to be a distinct and almost structureless membrane, but recent researches show that it only differs from the rest of the lamellee in containing fewer lacunse and corneal corpuscles. The substantia propria is continuous with the sclerotic ; it Ca7ial tifgcTilcmm. ^Jtrtiie- Fig. 1. — Ciliarj- region (normal). X about 40 diain. Fig. 2. — Corneal Corpuscles and nerve fibrils. X •♦50 diani. (After Klein and Xoble Smith.) TTrf^f (if Corneal Vleer- Troir^iili nnlris. — ^amuai's mtvibn -SuiafaKf.ra jiivpriit. , Fig. '•'>. — Anierior part of human cornea. X about i!50 diam. (.\fter Klein and Xoble .Smith.) >:^ -Cilia, y hody Fig. 4. — Perforating ulcer of cornea. X about l>h