f::$»:. ^Tmi1-'^..^. PLATE I. HORIZONTAL SECTION OF THE RIGHT HUMAN EYE. [Magnified four diameters.) A PRACTICAL TREATISE ON THE DISEASES OF THE EYE. BY WILLIAM MACKENZIE, M. D., SURGEON OCULIST IN SCOTLAND IN ORDINARY TO HER MAJESTY; LECTURER ON THE EYE IN THE UNIVERSITY OF GLASGOW, AND ONE OF THE SURGEONS TO THE GLASGOW EYE INFIRMARY. TO WHICH IS PREFIXED, AN AMTOMICAL INTRODUCTION EXPLANATORY OF A HORIZONTAL SECTION OF THE HUMAN EYEBALL. BY THOMAS WHARTON JONES, F.R.S., PROFESSOR OF OPHTHALMIC MEDICINE AND SURGERY IN UNIVERSITY COLLEGE, LONDON, AND OPHTHALMIC SURGEON TO THE HOSPITAL. WITH ONE HUNDRED AND SEVENTY-FIVE ILLUSTRATIONS. FROM THE FOURTH REVISED AND ENLARGED LONDON EDITION. WITH NOTES AND ADDITIONS, BY ADDINELL HEWSON, A.M., M.D., ONE OF THE SURGEONS TO WILLS HOSPITAL FOR DISEASES OF THE EYE; LECTURER ON SURGERY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, ETC. ETC. PHILADELPHIA: BLANCHAED AND LEA. 1855. WW nss Entered according to the Act of Congress, in the year 1855, by BLANCHARD AND LEA, in the Office of the Clerk of the District Court of the United States in and for the Eastern District of Pennsylvania. PHILADELPHIA: T. K. AND P. G. COLLINS, PRINTERS. t EDITOR'S PREFACE. Notwithstanding the very recent appearance of a new American edition of Mr. Lawrence's Treatise on Diseases of the Bye, containing the valuable notes and additions of its distinguished editor, the publi- cation of an American edition of Dr. Mackenzie's work needs no apology, for it indisputably holds the first place abroad amongst the valuable systematic treatises published there on diseases of the eye, and "forms, in respect of learning and research, an encyclopaedia unequalled in extent by any other work of the kind, either English or foreign."1 Numerous new wood-cuts have been inserted, and such additions have been made, as, it is hoped, will prove acceptable to the American reader. They relate chiefly to matters of a practical'character, and are embraced in brackets, with the initial H. appended. Amongst them will be found a short account of the ophthalmoscope, and the various conditions which have thus far been revealed by its use, and to which the author has scarcely alluded. ADDINELL HEWSON. Philadelphia, 289 Walnut St. 1 Dixon on Diseases of the Eye, London, 1855. ADVERTISEMENT TO THE FOURTH EDITION. In the present edition, a large amount of new matter has been added, and an attempt made, as far as the author's opportunities have served, to notice every material advance in the pathology and treatment of the diseases of the eye, which has been made during the last fourteen years. For most of the additional wood-cuts with which the work is now illus- trated, the author has been indebted to Dr. John Ritchie Brown. In the present edition, care has been taken to introduce, under each head, the most remarkable synonymes; and to give references to the works where the best figure of each disease may be found. The following is a list of the authors chiefly referred to, for such illustrations :— Ammon, Friedrich August von, Klinische Darstellungen der Krankheiten und Bildungs- fehler des menschlichen Auges. 3 Theile. Berlin, 1838, 1841. Beck, Karl Joseph, Abbildungen von Krankheitsform aus dem Gebiete der Augenheil- kunde. Heidelberg und Leipzig, 1835. Beer, G. Joseph, Lehre von den Augenkrankheiten. 2 Biinde. Wien, 1813, 1817. Boter, Lucien-A.-H., Recherches sur l'Ope'ration du Strabisme. Paris, 1842, 1844. Dalrtmple, John, Pathology of the Human Eye. London, 1852. Demours, A. P., Traite" des Maladies des Yeux. 4 Tomes. Paris, 1818. Deveegie, M. N., Clinique de la Maladie Syphilitique. 2 Tomes et Atlas. Paris, 1826, 1833. Dieffenbach, J, F., Ueber das Schielen und die Hielung desselben durch die Opera- tion. Berlin, 1842. Eble, Burkard, Ueber den Bau und die Krankheiten der Bindehaut des Auges. Wien, 1828. Grafe, Carl Ferdinand, Die epidemisch-contagiose Augenblennorrhoe Aegyptens in den Europiiischen Befreiungsheeren. Berlin, 1823. Hooper, Robert, Morbid Anatomy of the Human Brain. London, 1828. Jones, Thomas Wharton, Manual of the Principles and Practice of Ophthalmic Medi- cine and Surgery. London, 1847. Muller, J. B., Die neuesten Resultate iiber das Yorkommen, die Form und Behand- luno- einer ansteckenden Augenliederkrankheit unter den Bewohnern des Niederrheins. Leipzig, 1823. Panizza, Bartolomeo, Annotazioni Anatomico-Chirurgiche sul Fungo Midollare dell' Occhio. Favia, 1821. Sul Fungo Midollare dell' Occhio, Appendice. Pavia, 182G. VI ADVERTISEMENT. Rittericii, Friedrich Thilipp, Jlthrliche Beitr'tige zur Vcrvollkommnung der Augcn- heilkunst. Erster Band. Leipzig. 1827. Saunders, John Cunningham, Treatise on some Practical Points relating to the Dis- eases of the Eye. London, 1811. Scarpa, Antonio, Trittato delle principali Malattie degli Occhi. 2 Tomi. Pavia, 1816. Sichel, J., Iconographie Ophthalmologique. Paris, 1852. Sokmmerrixg, Wilhelm, Bcobachtungen, iiber die organischen Vcriinderungen imAuge nach Staaroperationen. Frankfurt am Main, 1828. Tkavers, Benjamin, Synopsis of the Diseases of the Eye. London, 1820. Vetch, John, Practical Treatise on Diseases of the Eye. London, 1820. Walton, H. Haynes, Treatise on Operative Ophthalmic Surgery. London, 1853. Wardrop, James, Essays on the Morbid Anatomy of the Human Eye. 2 vols. Lon- don, 1819, 1818. Weller, Carolus Henricus, Icones Ophthalmologics. Fasciculus T. Lipsice, 1824. Willis, Robert, Illustrations of Cutaneous Diseases. London, 1841. To the author of a treatise on a professional subject, involving the minute observation and description of a particular class of diseases, it must afford no small gratification that three large editions of the original work have been exhausted; that it has been reproduced by a transatlantic press; and has been deemed worthy of being translated and published in the three best known languages of modern Europe, German, French, and Italian. Such an unexpected reception affords assurance that the labor of many years has not been altogether misspent. To the translation of this work into French by MM. Laugier and Hichelot, from which the Italian translation has been made, it is necessary particularly to refer, on account of what must be regarded as an act of injustice to the numerous authorities referred to in the work, as well as to the readers of the French and Italian translations, and to the author himself. The translation of MM. Laugier and Richelot is executed with great care and success; but the bibliographical references are entirely omitted. By this means, the reader is prevented from referring to the proper authorities for many of the facts stated; the original authors who have recorded many of these facts are deprived of the share of credit which is justly due to them ; and it may hap- pen that many things may be credited to the author of these pages, by the French and Italian readers, which in the original English works are faithfully ascribed to those from whose works the facts have been taken. Glasgow, 27th September, 1851. CONTENTS. Anatomical Introduction, Explanatory of a Horizontal Section of the Human Eyeball .... I. Protective Parts or Tunics of the Eyeball Sclerotica Cornea . Choroid II. Parts Subsidiary to the Perfection of the Eye as an Optical In strument . - Iris Pigment Membrane III. Specially Sensitive Parts Optic Nerve Retina . IV. Dioptric parts, refractive media, or lenses Vitreous Body ...... Crystalline Body, comprising the Lens and its Capsule . Ciliary Zone and Canal of Petit Aqueous Humor ..... Postscript. General Plan of Distribution of the Bloodvessels of the Eyeball A Short Account of the Ophthalmoscope .... DISEASES OF THE EYE. Chapter I. Diseases of the Orbit I. Injuries of the Orbit ..... § 1. Contusions on the Edge of the Orbit \ 2. Fractures of the Edge of the Orbit § 3. Fractures of the Walls of the Orbit, attending Fractured Skull ...... § 4. Fractures of the Walls of the Orbit, attending Fractured Bones of the Face ..... \ 5. Orbit Fractured by a Blow on the Eye \ 6. Counter-Fractures of the Orbit § 7. Penetrating Wounds of the Walls of the Orbit \ 8. Incised Wounds of the Orbit \ 9. Gunshot Wounds of the Orbit Yin CONTENTS. fage Osteo-Sarcoma of the II. Periostitis, Ostitis, Caries, and Necrosis of the Orbit § 1. Acute Periorbita . \ 2. Chronic Periorbitis § 3. Curies and Necrosis of the Orbit III. Periostosis. Hyperostosis, Exostosis, and Orbit, and Cysts in its Parietes § 1. Periostosis § 2. Hyperostosis \ 3. Exostosis . § 4. Osteo-Sarcoma § 5. Cysts in the Parietes of the Orbit IV. Dilatation, Deformation, and Absorption of the Orbit, from Pressure \ 1. Pressure on the Orbit from within the Orbit \ 2. Pressure on the Orbit from the Nostril § 3. Pressure on the Orbit from the Frontal Sinus § 4. Pressure on the Orbit from the Maxillary Sinus § 5. Pressure on the Orbit from the Sphenoid Sinus \ 6. Pressure on the Orbit from the Cavity of the Cranium Chapter II. Diseases of the Secreting Lachrymal Organs . I. Injuries of the Lachrymal Gland and Ducts II. Lachrymal Xeroma or Xerophthalmia III. Epiphora ....... IV. Inflammation and Suppuration of the Lachrymal Gland \ 1. Inj/itmmation and Suppuration of the Glandules Congregatx \ 2. Inflammation and Suppuration of the Proper Lachrymal Gland V. Chronic and Specific Enlargements of the Lachrymal Gland \ 1. Hypertrophy of the Glandulac Congregatx . § 2. Hypertrophy, Chloroma, Scirrhus, and Medullary Fungus of the Lachrymal Gland VI. Encysted Tumor in the Lachrymal Gland VII. Encysted Tumor in the Vicinity of the GlanduliB Congregatse and Lachrymal Ducts . VIII. True Lachrymal Fistula . IX. Morbid Tears X. Sanguineous Lachrymation. Hemorrhage from the Lachrymal Gland XI. Dacryoliths or Lachrymal Calculi in the Lachrymal Ducts I. II. Chapter III. Diseases of the Eyebrow and Eyelids Injuries of the Eyebrow and Eyelids § 1. Contusion and Ecchymosis \ 2. Poisoned Wounds . \ 3. Burns and Scalds . \ 4. Incised and Lacerated Wounds Phlegmonous Inflammation of the Eyelids III. Erysipelatous Inflammation of the Eyelids IV. Phlebitis of the Eyelids . V. Carbuncle of the Eyelids VI. Malignant Pustule of the Eyelids VII. Syphilitic Ulceration of the Eyelids VIII. Syphilitic Eruptions affecting the Eyelids of Infants IX. Cancer of the Eyelids contents. X. Inflammation of the Edges of the Eyelids, or Ophthalmia Tarsi XI. Herpes affecting the Eyelids XII. Porrigo Larvalis affecting the Eyelids XIII. Vitiligo affecting the Eyelids XIV. Abscess of the Meibomian Glands XV. Obstruction of the Meibomian Apertures XVI. Meibomian Calculi XVII. Hordeolum . . XVIII. Phlyctenula and Milium of the Eyelids . XIX. Warts on the Eyelids XX. Sycosis affecting the Edge of the Eyelid XXI. Horny Excrescences on the Eyelids XXII. Tumors in the Eyebrow and Eyelids \ 1. Chalazion, or Fibrinous Tumor \ 2. Molluscum, or Albuminous Tumor . § 3. Encysted Tumor \ 4. Fibro-plasiic, or Sarcomatous Tumor Tylosis, or Callosity of the Eyelids Nsevus Maternus, and Aneurism by Anastomosis, of the Eyebrow and Eyelids .... ffidema of the Eyelids Emphysema of the Eyelids Twitching, or Quivering of the Eyelids . Morbid Nictitation Blepharospasm .... Palsy of the Orbicularis Palpebrarum and Muscles of the Eyebrow Ptosis, or falling down of the Upper Eyelid \ 1. Ptosis from Hypertrophy . \ 2. Congenital Ptosis . § 3. Traumatic Ptosis § 4. Atonic Ptosis § 5. Paralytic Ptosis Lagophthalmos .... Ectropium, or Eversion of the Eyelids § 1. Eversion from Inflammation and Strangulation § 2. Eversion from Excoriation § 3. Eversion from a Cicatrice . § 4. Eversion from Caries of the Orbit . Trichiasis and Distichiasis Entropium, or Inversion of the Eyelids . Ankyloblepharon Madarosis .... Phtheiriasis of the Eyebrow and Eyelashes XXIII. XXIV. XXV. XXVI. XXVII. XXVIII. XXIX. XXX. XXXI. XXXII. XXXIII. XXXIV. XXXV. XXXVI. XXXVII. XXXVIII. Chapter IV. Diseases of the Tunica Conjunctiva I. Foreign Substances adhering to the Conjunctiva II. Dacryoliths, or Lachrymal Calculi, in the Sinuses of the Conjunctiva III. Injuries of the Conjunctiva \ 1. Mechanical Injuries \ 2. Burns and other Chemical Injuries IV. Subconjunctival Ecchymosis V. Subconjunctival Emphysema X CONTENTS. VI. Subconjunctival Phlegmon VII. Subconjunctival (Edema . VIII. Pterygium IX. Pinguecula X. Warts of the Conjunctiva XI. Polypus of the Conjunctiva XII. Nanus Maternus of the Conjunctiva XIII. Fungus of the Conjunctiva XIV. Conjunctival and Subconjunctival Tumors Chapter V. Diseases of the Semilunar Membrane, and Caruncula Laciiry malis ....••• I. Inflammation of the Semilunar Membrane and Caruncula Lachry malis . . . . • II. Polypus of the Caruncula Lachrymalis . III. Narvus Maternus of the Caruncula Lachrymalis IV. Encanthis .... V. Lithiasis of the Caruncula Lachrymalis . Chapter VI. Diseases of the Excreting Lachrymal Organs I. Injuries of the Excreting Lachrymal Organs \ 1. Injuries of the Puncta and Lachrymal Canals g 2. Injuries of the Lachrymal Sac \ 3. Injuries of the Nasal Duct II. Acute Inflammation of the Excreting Lachrymal Organs III. Chronic Inflammation of the Excreting Lachrymal Organs IV. Fistula of the Lachrymal Sac . V. Caries of the Bones around the Lachrymal Sac and Nasal Duct VI. Relaxation of the Lachrymal Sac .... VII. Mucocele of the Lachrymal Sac .... VIII. Relaxation of the Puncta Lachrymalia and Canaliculi IX. Eversion of the Puncta Lachrymalia X. Obstruction of the Puncta Lachrymalia and Canaliculi . XL Obstruction of the Nasal Duct .... XII. Dacryoliths, or Lachrymal Calculi, in the Excreting Lachrymal Passages XIII. Polypus of the Lachrymal Sac Chapter VII. Diseases of the Ocular Capsule, and of the Areolar and Adipose Tissues of the Orbit I. Injuries of the Orbital Areolar Tissue II. Eftusion of Blood into the Orbital Areolar Tissue III. Phlegmonous Inflammation of the Orbital Areolar Tissue IV. Inflammation of the Ocular Capsule V. Exophthalmos, or Protrusion of the Eye from the Orbit \ 1. Simple Exophthalmos \ 2. Anaemic Exophthalmos VI. Protrusion of the Orbital Adipose Substance Chapter VIII. Intraorbital Tumors . I. Sobd and Encysted Tumors in the orbit . II. Osseous Tumors in the Orbit tage 2eye, are fasciculi of microscopical primitive fibrils, enclosed in a neurilemma or cellular sheath, and the whole enveloped in a general neurilemma. The neurilemmata of the fibres cease as the nerve penetrates the sclerotica, whence arises the constric- tion of the nerve at that place, and the appearance commonly described under the name of cribriform lamina of the sclerotica. There, free from neurilemma, the optic nerve passes through a well-defined opening in the choroid, to join the retina. About the third of an inch from the sclerotica, the optic nerve is perforated obliquely from below, by the central artery and vein of the retina (18), which run in a canal in the axis of the nerve, to gain the interior of the eye. Retina. The retina (20) is a transparent expansion of nervous substance, situated within the pigment membrane lining the choroid, continuous behind with the XXX anatomical introduction. The yellow spot of the retina occupying the axis of the eye; and the en- trance of the optic nerve, with the arteria centralis retinae on the inner side of the axis.—After Soem- merring. optic nerve, which, at the place of junction, forms a slight prominence (10), called papilla conica, and terminating anteriorly at the ora serrata, or place of transition of the choroid into the ciliary body. At the place corresponding to the antero-posterior axis of the eyeball, and ^th of an inch on the temporal side of the entrance of the optic nerve, the retina presents a transparent point (21), and is, for the extent of y^th of an inch all round, of a yellow color. These appearances, which are found only in the eye of man and the monkey tribe, were discovered in 1191, by S. T. Soemmerring, who, supposing the transparent point to be actually a perforation of the retina, called it foramen retince cenlrale, and the yellow border, limb us luteitsforaminis centralis. In this situation the retina is, on dissection, always found raised into a small fold, which extends from near the temporal side of the optic nerve, transversely outwards for about |th or ith of an inch. The bloodvessels of the retina, usually quite distinctly seen, are ramifications of the central artery and accom- panying vein. The retina is of very complex intimate structure. Ac- cording to the latest researches, it comprises five different kinds of elements, disposed in successive strata, viz: proceeding from without inwards, 1. stratum bacillosum, 2. stratum granulosum, 3. stratum gangliosum, 4. stratum fibrillosum, and 5. stratum limitans. The stratum bacillosum consists of columnar bodies, of a peculiarly clear substance, about yyVu-th 0I" au *ncn l°n£ an(l TTiiooth of an inch thick, ar- ranged side by side, and vertically to the surface of the retina ; so that if a bit of the retina, together with the corresponding portion of the vitreous body, be carefully removed from the eye, disposed on a glass plate with the outer surface of the retina uppermost, and examined with the microscope, the outer and thicker ends of the columnar bodies are seen arranged like minute tessel- lated work. Interspersed through this tessellated-looking surface at intervals, the wider the further forward the part of the retina which is ex- amined, we observe spots, as if two or three columns were wanting (Fig. ix.). These spots are owing to the presence of thicker but shorter columns, which, towards the subjacent stratum, are swollen out into fusiform or spigot-shaped bodies. From the inner ends of these fusiform dilatations of the thicker, as well as from the inner ends of the thinner columns, delicate filamentary prolongations are said to extend through the other strata of the retina towards its inner surface. By the action of water the structure of the stratum bacillosum, both as a whole and in its component columns, is speedily and remarkably altered. The change of the stratum as a whole, consists in its detachment from the rest of the retina, and that in a continuous film, but of much greater superficial ex- tent than the surface from which it has separated. In this state, it constitutes what was first observed and described by Dr. Jacob, and has since been usually demonstrated under the name of membrana Jacobi. In regard to the change in its component parts, we observe, that the columns readily become variously distorted, and at last acquire the form and appear- ance of very pale globules, held together by the same uniting medium as that by which the rods are in their natural state held together. It is to this change that the great increase of superficial extent is owing, which the stratum bacil- losum, now altered into Jacob's membrane, presents. Its natural condition above described, was first discovered by Dr. Hannover, ANATOMICAL introduction. xxxi of Copenhagen. The prolongations of its component columns, through the subjacent strata, towards the inner surface of the retina, were subsequently pointed out by Dr. H. Midler, and confirmed by Dr. Kblliker, in the human eye. To the stratum bacillosum succeeds a layer of nuclear-like bodies, stratum granulosum, connected with the inward prolongations of the columnar bodies. The bodies of which this layer consists, measure from 3 ^oth to joVoth of an inch in diameter. After this comes a layer of ganglionic corpuscles, with filamentary processes {stratum gangliosum). Then we have the layer composed of the primitive fibrils of the optic nerve (stratum fibrillosum). These fibrils, which are very delicate, spread out in a radiating direction from the entrance of the optic nerve. The fibrils are at first collected in fasciculi, which by frequent inter- change of fibres form plexuses with much-elongated meshes. In proceeding forward, the meshes gradually become wider, and the fibres more dispersed. The mode of termination of the fibrils has not been with certainty deter- mined. [They seem to consist of the gray nerve matter alone j and it is probable, as Todd and Bowman observe, that none of the white substance of Schwann enters into the component parts of the retina.—H.] Lastly, a homogeneous membrane forms the inner superficial boundary of the retina (membrana limitans). In regard to the disposition of the above elements of the retina at the cen- tral point and limbus luteus : At the central point the stratum granulosum is absent. In the situation of the yellow spot the smaller columnar bodies are wanting, the large spigot-like bodies alone form this part of the stratum bacillosum. Here, also, the optic fibrils are few, and form no continuous layer between the ganglionic stratum and membrana limitans. The capillary network of the retina, is seated partly in the fibrinous stra- tum, but chiefly in the ganglionic. The branches of the central artery and vein of the retina, proceeding to and from the capillary network, are seated under the membrana limitans. IV. Dioptric Parts, Refractive Media, or Lenses. Vitreous Body. The vitreous body (22) is a transparent gelatiniform mass, situated imme- diately within the retina, and filling the middle and back part of the interior of the eyeball. It presents a concavity in front, called fossa hyaloidea, into which the crystalline body is received. The vitreous body consists of a very delicate and transparent enclosing membrane, called the hyaloid (23); nu- merous processes of which are considered to extend into the interior, like the sectors of an orange according to Dr. Hannover, enclosing spaces in which a watery fluid, called the vitreous humor, is contained. This fluid slowly drains away when the vitreous body is punctured, and is found, under the microscope, to contain a few colorless cells. In old age the membranous septa tend to disappear, so that, in operations for the extraction of cataract for example, a more or less considerable quantity of vitreous humor is apt to be suddenly evacuated. [Brucke's view was that the vitreous body resembled an onion, and was composed of concentric lamellae, separated from each other by a gelatiniform fluid, but the reagent he employed to develop these lamellae (solut. of acetate of lead) Bowman has proved could produce the same appearance, no matter in what direction the section was made, and yet no true lamella could be de- tected. The same objection will also hold good, in part at least, against XXX11 anatomical introduction. Hannover's view; for although Bowman has confirmed his observations in the foetal vitreous humor, he has not been able to, in the adult eye ; for there the septa formed by Hannover's reagent (chromic acid) cannot be proved to be true membranes. It is possible, however, that as these septa tend to dis- appear in advanced life, that the specimens examined by Bowman were not such as to allow us to draw any positive inference as to the total absence of such a structure at any period in adult life. Kblliker's view is, that in early life it presents a condition of things analogous to embryonic cellular tissue, but that subsequently all traces of such development entirely disappear and it becomes a kind of mucus, more or less consistent in its character. The crys- talline body varies very much in form, consistency, transparency, and color, at different periods of life. In the foetal state it approaches in form a sphere, is quite soft, pinkish in color, and not entirely transparent. In adult, it pre- sents the conditions described above, but in old age it becomes flattened, dull, or less transparent, tough and dense in structure, and of a yellowish hue.—H.] Crystalline Body, comprising the Lens and its Capsule. Fig. The crystalline body (21, 28, 29), as above said, lies in the hyaloid fossa of the vitreous body. It is a double /' \ convex lens about 270ths 0I> an ^ncn i*1 diameter, and half as \^2-^j much in thickness at its axis. Its anterior surface is less /i<^^S\ convex than its posterior, the radius of the convexity of the * \ former (a, Fig. x.), being much the same as that of the > ! cornea, i. e. {jjths of an inch; the radius of the convexity of the latter (b, Fig. x.), /0ths of an inch. At its cir- V.. _ __..''' cumference it is thick and rounded, as is represented in the section. The axis of the crystalline body does not lie exactly in that of the eyeball, but a little to the nasal side, corresponding to the middle of the pupil. The crystalline body comprehends the lens (21) and capsule (28, 29). The capsule of the lens is a transparent, elastic, but easily lacerable, homo- geneous membrane, somewhat resembling the membrane of Descemet. Its anterior wall (28) is thicker than its posterior (29). The posterior wall lies close upon the vitreous mass, and the union between them is intimate, though capable of being dissolved by maceration. On the inner surface of the ante- rior wall there is a layer of tessellated epithelium, first demonstrated by Dr. YVerneck, of Salzburg. The lens, which increases- inconsistence from without inwards, is composed of tubular fibres (b), filled with a clear viscid substance [albu- minous in its character, readily coagulated by nitric acid, and speedily dissolved in caustic al- kalies,—H] They are flat, being about 3 oViyth of an, inch broad and TB^o0th of an inch thick, and their transverse sec- tion is hexagonal. This is just such a form as tubular fibres, closely aggregated together and stratified, necessarily assume. [In the lens of the ox these fibres present a finely serrated edge, and in the codfish lens this serration is still more marked, a. Cells connecting the body of the lens to its capsule (hu- man). 6. Fibres of the lens, with slightly sinuous edges (hu- man), c. Ditto from the Ox, with finely serrated edges, d. Ditto from the Cod; the teeth much coarser.—Magnified 320 diameters. anatomical introduction. xxxiii (c, d, Fig. xi)—H.] The fibres, thus aggregated together, are so arranged and disposed that they extend, say from about the middle of the anterior surface, turning round the circumferential edge, towards the middle of the posterior surface; in fact, something like the lines of longitude in the maps of the world. It is to be remarked, that the fibres do not converge to points on the anterior and posterior surfaces, but to radiating clefts, filled with a transparent homo- geneous-like substance. Though there are no actually distinct layers, the fibrous structure is separable by dissection in concentric strata, which are denser the nearer they are to the centre of the lens (Fig. xii. a). Betwixt the lens and capsule, a fluid called liquor Morgagni, has been said to exist; and indeed, if the capsule of the lens of a sheep's eye, a day or two after death, be punctured, a liquid escapes ; but this is a post-mortem- accumulation, arising from the aqueous humor having passed through the cap- pa^^dMdef aio'gtf Ce sule by endosmosis, and mixed with the detached iutenor planes, as weii as into inner epithelium of the capsule and soft outermost Krnow!snified S*diameters- part of the lens. Ciliary Zone and Canal of Petit. Around the circumference of the crystalline, as it lies embedded in the vitreous body, the hyaloid membrane is, for the breadth of \\ka of an inch, raised up into radiating folds. This is what is called the zonula ciliaris, or zonula Zinnii (25). It is the counterpart of the ciliary body of the choroid, with which it is dovetailed, the folds and intervening depressions of the two structures being received into each other. At the place where the ciliary body of the choroid and ciliary zone of the hyaloid begin posteriorly to be thus dovetailed with each other, the retina terminates in a serrated edge ; but branches of the retinal bloodvessels extend forward. In separating the ciliary body from the ciliary zone, some fragments of the pigment membrane of the former generally remain adherent to the latter, and hence the ciliary zone has been considered merely as an impression of the ciliary body, and called halo signatus. Besides the folds of the hyaloid, the ciliary zone comprises in its structure peculiar fibres, something like those of elastic tissue, which extend from its posterior margin to the capsule of the lens. To the corona formed by the aggregate of these fibres, the name orbiculus capsulo-ciliaris has been given. The united folds of the ciliary zone and ciliary processes, overlap the cir- cumference of the lens in front, but do not adhere to it, there being betwixt them a ring of transparent hyaloid, called zonula lucida, broader on the tem- poral than on the nasal stde. Around the circumference of the crystalline body there is a space which may be inflated into the form of a beaded ring, by blowing through a punc- ture in the zonula. This is the canal of Petit (26), which is usually consi- dered as being formed by a separation of the hyaloid into two layers, one pass- ing behind the capsule of the lens, adhering to it and lining the hyaloid fossa; the other, that which forms the ciliary zone, being inserted into the circum- ferential part of the capsule of the lens. 3 XXXI v ANATOMICAL INTRODUCTION. Aqueous Humor. This watery fluid, examined under the microscope, is found to contain in suspension, a few colorless cells. The form of the aqueous humor is deter- mined bv that of the compartment in which it is contained (30, 31). This compartment is bounded in front by the cornea, behind by the crystalline bodv, and at its circumference by the ciliary processes and ligament; and is subdivided by the iris into the anterior (31) and posterior (30) chambers of the aqueous humor, communicating with each other through the pupil (13). The depth of the whole aqueous humor, from the posterior surface of the cornea, through the pupil, to the anterior surface of the crystalline, is rather more than yLth of an inch. From the membrane above referred to, as investing the uvea or the pos- terior surface of the iris, a continuous surface may be traced over the free extremities of the ciliary processes, and from them to the circumference of the capsule (15). [The whole chamber of the aqueous humor has been supposed by many to be lined by a continuous, a true serous, membrane, and called by them the membrane of the aqueous humor, but no such structure has yet been detected by the microscope. The existence of a membrane passing over the anterior surface of the iris to connect the membrane of Descemet with the pigment membrane of the uvea has not been demonstrated ; neither has the presence of any such structure on the anterior surface of the capsule of the lens ; and Bowman, as was observed before, even denies the existence of an epithelial layer on the anterior surface of the iris, though this is disputed by Kolliker, who describes, very minutely, the structure of such a covering. It seems impossible to reconcile the difference between these two eminent Anatomists and Microscopists; one states he has never been able to detect such a struc- ture : the other, an equally high authority, not only asserts its existence, but has described its character.—H] In the preceding sketch, the curvatures of the refractive media have been spoken of as if spherical, but they are in reality not so. The curvature of • the cornea appears to be ellipsoidal, with the long axis not exactly in the direction of the incident rays, but slightly inclined from before backwards and to the temporal side. The curvatures of the aqueous humor which, as a whole, has something of the form of a meniscus, depend on those of the pos- terior surface of the cornea and anterior surface of the lens. As to the curva- tures of the lens, that of its anterior surface is ellipsoidal, with the lesser axis in the direction of the incident rays, while that of its posterior surface appears to be hyperbolical. The curvature of the hyaloid fossa of the vitreous body corresponds with that of the posterior surface of the crystalline, while the posterior curvature of the vitreous body corresponds with the concavity of the retina, which is probably ellipsoidal. Postscript. General Plan of Distribution of the Bloodvessels of the Eyeball. To give a correct idea of the distribution of the bloodvessels of the eye- ball, it would be necessary to make a few preliminary observations on its development. Of the different constituents of the eyeball, the retina, which, along with the vitreous body, is the fundamental part of the posterior segment, origin- ally a diverticulum from the brain. These parts receive their supply of blood from the central vessels of the retina. ANATOMICAL INTRODUCTION. XXXV The central artery of the retina, as already said, enters the eyeball through the substance of the optic nerve, and divides into two sets of branches; one set, which is a persistent one, to the retina, as already explained; another set, to the vitreous body, as well as to a structure which exists in front of the vitreous body, in the early -stage of formation ; namely, the vascular cap- sule of the lens presently to be described. The latter set of branches has merely a temporary existence. Their trunk, which is the third branch of the central artery of the retina, and called the central artery of the vitreous body, divides, on entering the hyaloid canal (24) of that body, into the central artery, properly so called, and circumfer- ential branches. The ramifications of these vessels are dispersed throughout the vitreous body, anastomosing with each other. The central artery having given off its ramifications, passes out from the vitreous body, at the middle part of the hyaloid fossa, in which the crystalline body is seated. There the artery enters and ramifies in a capsule enclosing the crystalline body, not the capsule of the lens, formerly described as struc- tureless, transparent, and non-vascular, but the vascular capsule just now referred to as having a temporary existence only. This vascular capsule appears to be originally an involution of the skin. From the point where the artery enters the middle of this capsule, it radi- ates towards its circumference and from thence turns round to its anterior wall. At the circumference corresponding to the zonula ciliaris, these vessels anastomose with the vessels of the zonula; these again, being in connection with, or derived from the retinal vessels and the circumferential branches of the vitreous body, perhaps also in connection with the vessels of the ciliary body. With the development of the eye, the vascular capsule of the crystalline body grows in a greater ratio than does the crystalline body itself; its ante- rior part coming to line, though not adhering to the walls of the aqueous chamber. The iris not having yet been developed, the aqueous chamber is not hitherto divided into anterior and posterior chambers. When, however, the iris does sprout out, it soon comes into contact with, and adheres to this vascular capsule of the crystalline, in such a way that the anterior wall of the capsule closes to the pupil, constituting what is known by the name of the pupillary membrane; the rest of the capsule constituting what is called the capsulo-pupillary membrane, extending backwards from the pupil through the posterior chamber, to be continued into the posterior wall, which still lies between the hyaloid fossa and the crystalline body. The iris having joined the vascular capsule of the crystalline in the manner now explained, its vessels shoot into that membrane, and anastomose with its original vessels. The iris continuing to grow, its pupillary or small ring shoots forth beyond the point where the first formed part of the iris, or the ciliary ring, joined the vascular capsule of the crystalline; and this in such a way that the point of the junction in question comes to be on the anterior surface of the iris where the ciliary joins the pupillary ring; the edge of the pupil thus exists quite free. Such is the vascular distribution of the retina and humors, in the early stage of the formation of the eye. The vascular distribution in the choroid is the same as we have already described it to be in the fully formed condition. In regard to the cornea, it owes its vascularity to ramifications from the anterior ciliary and conjunctival vessels. It is thus perceived that the parts of the eyeball, through which, when the organ is fully formed and called into use, the rays of light have to pass on their way to the retina, are in the early stage of formation interwoven with XXXV1 ANATOMICAL INTRODUCTION. bloodvessels. These bloodvessels are necessary for the full development of the organ; but this having been accomplished, a smaller number of vessels is sufficient to minister to its nutrition, and these are dispersed in parts of it through which the rays of light are not required to pass. Vessels which are distributed in parts through which the rays of light are required to pass on their way to the retina, become obliterated ; the cornea thus ceases to be vascular; the pupillary membrane, contingently with the obliteration of its vessels, disappears. This disappearance usually occurs before birth, or about the eighth month. Coincident with this, the pupillary ring of the iris, which was before small, acquires its full development. The capsulo-pupillary membrane, the other part of the vascular capsule of the crys- talline body, has in like manner disappeared; this disappearance having occurred before that of the pupillary membrane, no traces of it remaining. As is the case with regard to the'cornea, the bloodvessels of the vitreous body become obliterated, the body itself remaining and drawing the materials for its nutrition from the bloodvessels of the neighboring parts. Thus the cornea, in its fully formed state, is nourished from the vessels of the neighboring parts of the conjunctiva and sclerotica. The aqueous humor appears to be supplied by transudation from the vessels of the ciliary processes. The lens never was vascular, but at first surrounded by a vascular membrane, and it continues to receive nourishment from the vascular network of the zonula Zinnii. The whole posterior surface of the vitreous body being in contact with the vascular layer of the retina, the vessels of which are persistent, is from it supplied with nourishment, as also from the ciliary zone on its lateral part, anteriorly. The non-vascular layers of the retina are nourished from the vascular layer. The non-vascular membrane of the pigment has its supply from the capillary network on the inner surface of the choroid. Scale of the English inch and its division into tenths. __________I__________l__________I----------- I_______ Scale of the Parisian inch and its division into twelfths or lines. 2 t * /i # DESCRIPTION OP THE PLATES. REFERENCES TO THE HORIZONTAL SECTION, PLATE I. 1. Sclerotica. 2. Sheath of the optic nerve, a continuation of the dura mater. 3. Circular venous sinus of the iris. 4. Proper substance of the cornea. 4'. Conjunctiva extending over the cornea. 5. Membrana fusca or arachnoidea oculi. 6. Membrane of the anterior chamber of the aqueous humor. Of the two dotted lines, the short one points to the membrane of Descemet, the long to the supposed continuation of that membrane over the anterior surface of the iris. 1. Choroid. 8. Annulus albidus, or ciliary muscle. 9. Ciliary ligament. 10, 10'. Ciliary body, consisting of (10') a pars non-plicata, and (10) a pars plicata formed by the ciliary processes. 11. Ora serrata of the ciliary body, and anterior limit of retina. 12. Iris. 13. Pupil. 14. Membrane of the pigment. 15. Delicate membrane lining the posterior chamber of the aqueous humor. 16. Stratum bacillosum of retina, or membrane of Jacob. 11. The optic nerve surrounded by its general neurilemma. 11'. The fibres of the optic nerve, consisting of fasciculi of primitive tubules. 18. Central artery of the retina. 19. Papilla conica of the optic nerve. 20. Retina. The situation of its membrana limitans is indicated by a dotted line. 21. Central transparent point of the retina, or foramen central e of Soem- merring. 22. Vitreous body. 23. Hyaloid membrane. 24. Canalis hyaloideus. 25. Zonula ciliaris. 26. Canal of Petit. 21. Crystalline lens. 28. Anterior wall of the capsule of the lens. 29. Posterior wall of the capsule of the lens. 30. Posterior chamber of the aqueous humor. 31. Anterior chamber of the aqueous humor. 3* XXXV111 DESCRIPTION OF THE PLATES. EXPLANATION OF PLATE II. Fig. 1. Crystalline capsule, extracted entire. See p. 191. 2. Glaucomatous lens, as seen by transmitted light. See p. 841. 3. Four varieties of entohyaloid spectra ; a. pearly spectra; b. watery spectra; c obscurely defined insulo-globular spectra; d. sharply defined insulo-globular spectra. See p. 888. 4. Cvsticercus cellulosae in anterior chamber. See Case 423, p. 1010. 5. Cysticercus cellulosae in anterior chamber. See Case 424, p. 1011. 6. Cysticercus cellulosae, removed from the eye in Case 423, magnified about six diameters. 1. Neck and head of cysticercus cellulosae, removed from the eye in Case 424, magnified about twelve diameters. PLATE II. Fig. 4. Fig. 5. Fig. 1. Fig. 3. Fig. 6. Fig. 7. ■d Fig. 2. *J~** 3723473� A SHORT ACCOUNT OF THE OPHTHALMOSCOPE. [When we look into an eye which is healthy, and particularly that of a young person, the pupil presents a dark appearance, as though the bottom of the eye was black. This evidently does not arise from the color of the tissues themselves in that part, for the retina is grayish white and quite transparent, and beneath it is the choroid, a bright vascular tissue, covered with brown pigment cells, whose color is, however, too light to produce the phenomenon in question. How, then, can we explain this dark appearance of the bottom of the eye ? In the beginning of the last century, Mery, having accidentally immersed a cat in water, observed, whilst the animal was in that condition, he could very readily perceive the bottom of its eye, and even the bloodvessels of its retina and choroid. But he gave no explanation of what he observed. Five years afterwards, Lattere repeated the experiment, and showed that our inability to perceive the bottom of the eye, arose from the refractive power of the cornea and lens, and that in this experiment of Mery, the refraction of the water neutralized this power, and caused the rays of light reflected from the cat's retina, to come to a focus, and produce an image on the retina of the experimenter's eye. About ten years since, Kussmaul demonstrated by dissection, that our inability to see the bottom of the eye was due to refraction. He took a sheep's eye, and on removing the cornea, found that the bottom of the eye still appeared black, but when he removed the lens, he had no difficulty in observing the retina. Here is positive proof of the influence of the lens ; but that the cornea also exerts an influence on the phenomenon in question, is evident from the fact that the bottom of the eye still appears black in cases where the lens has been removed, as in the operation for cataract. Although the retina is transparent, it is also brilliant and capable of reflect- ing, and does reflect some of the rays of light which impinge upon it; and these rays, on being reflected, pass out through the crystalline and cornea in precisely the same direction as that in which the incident rays enter; they are subjected to the same refraction, and finally come to a focus at the point of origin of the incident rays. "From this," as Dr. Williams observes, "it follows that we could see the retina of an individual only when he looked attentively at our own eye, which, in this case, would be the luminous point. But it is clear that the quantity of light which our own eye can project, is too feeble to illuminate the bottom of the eye explored, and in attempting to look into the interior of that eye by the aid of ordinary daylight, we should xl A SHORT ACCOUNT OF THE OPHTHALMOSCOPE. only intercept with our head the rays which should illuminate the cavity. Placed in this manner in the shade, the pupil will naturally appear black." To Prof. Helmholtz, of Koenigsberg, is due the credit of first devising an instrument, by which a sufficient amount of light can be thrown into the eye to enable us to see clearly its interior structures. His eye speculum consists, essentially, of a tube, with one end bevelled to an angle of 50° to its axis, on which is fastened the reflector of four parallel and highly polished slips of glass; the other end is cut square to the axis, and has adapted to it an eye- piece, containing a biconcave lens and diaphragm. An accident suggested this invention to Helmholtz. His friend, Von Erlach, who wore spectacles, observed one day, whilst conversing with an acquaintance, that the eye of the latter became illuminated when the rays of the light from a neighboring window were reflected by his glasses into this person's eye—hence the probable reason of Helmholtz using plate glass as the reflector in his ophthalmoscope. The accompanying diagram will ex- /; Fig. xiii. plain the principle of his instrument. The luminous rays emanating from the light at A, impinge on the reflector of glass B—they are (some of them) re- flected by it into the eye, and, by the A refractive power of the cornea and lens, come to a focus, and illuminate the retina. The retina reflects some of them back, and these passing out in precisely the same direction in which they en- tered, meet the reflector, which some of them penetrate, and would converge to a focus at D, and thus produce no dis- tinct image of the patient's retina on that of the observer. Hence the neces- sity, in this instrument, of the biconcave C lens, which will bring them to a focus at E, the retina of the observer. Since Helmholtz's instrument was first made known in 1851, Coccius Meyerstein, Follin Epkens, and many others, have invented instruments but little different from it in principle. In some a plain mirror, with a hole in it, has been substituted for the reflector of plate glass ; in others, a biconvex lens has been added, to condense the light as it falls on the reflector; in others, the same means has been employed when either the eye of the observer or that of the patient was short-sighted, to converge the rays as they enter or pass from the latter. The simplest form of eye speculum yet proposed, is that described and claimed as original by Anagnostakis. Although, on the authority of an informant of "Mr. Dixon, we learn that Prof. Graeff showed this very instru- ment, or one precisely like it, to Dr. Anagnostakis, when he was in Berlin, in 1853, some time before the publication of his paper on this subject. It con- sists of a small concave mirror, about 2 inches in diameter, with a focal dis- tance of four and a half inches. In the centre of this mirror there is a small hole, of a quarter of an inch in diameter. This mirror, mounted on a handle, and protected on its plated surface by a sheet of blackened copper, consti- tutes the apparatus described by Anagnostakis, but except in persons who are short-sighted, a distinct view of the deep seated structures of the eye can- not be obtained by it, without the aid of a biconvex lens of two and a half inch focus. A SHORT ACCOUNT OF THE OPHTHALMOSCOPE. xii Ruete's Ophthalmoscope consists of a mirror analogous to the one just described, but of ten inch focus, and a biconvex lens, placed before the patient's eye, to increase the convergence of the rays reflected from the mirror. Mr. Dixon has proposed to fix the mirror into a spectacle frame, to be worn by the observer, so that both his hands may be free, and enabled, with- out assistance, to command the movements of the patient's lids with one hand, whilst with the other he can use the magnifying glass. He also suggests the use of mirrors of a focus corresponding to the distance of distinct vision of the observer. We have, on these suggestions of Mr. Dixon, made for ourselves an extempore instrument, at a very trifling cost, by plating with tin-foil and mercury one side of a common bi-convex lens, having selected for the purpose a lens of such con- vexity as would, when plated, produce a mirror of a focus to suit our own eye. This mirror we covered with dark paper through which and the plating we made a hole of about the fifth of an inch in diameter, and then mounted the mirror in one side of a common iron spectacle frame, having placed in the other a plane glass, so that the instrument would balance itself on the nose. Fig. xiv. The principle of these forms of the Ophthalmoscope can be perceived at a glance by reference to the dia- gram (Fig. xiv.). The rays of light divergent from A, impinge on the mirror, B C, which is to be so placed before the eye, D, to be ob- served, as to reflect them, in a con- vergent manner, into its interior, and illuminate the structures there. This illumination can be readily appreciated through the hole in the mirror at E. The original instrument of Helmholtz has not proved as efficient a one as is desirable in examining the retina ; its illumination is not sufficient to give a clear view of the parts it is intended to expose. This objection can not, however, be urged against some of the improved forms of the instru- ment, particularly those of Jager and Meyerstein ; but these, in common with many others, are so complicated in their construction, that we give a decided preference for the simple mirror and lens over all of them. The mode of using the instrument___All examinations with the eye specu- lum require to be conducted in a dark room, and it is also necessary that the pupil of the eye to be examined should be well dilated by the solution of atropia. A steady-burning, broad-flamed lamp will be found to be the best means of illuminating the reflector. Some recommend that the light should be placed to one side of the patient's face, and on the same plane with his and the observer's eye. This may undoubtedly be the best position for it in some instruments of a fixed angle of reflection, and may be even essential for their proper adjustment, but is not necessary where the simple concave mirror is employed. In using this we would decidedly prefer the lamp placed behind the patient's head, and so elevated that its rays will just clear his forehead to reach the observer's eye ; for no matter where the light may be, we must, to throw the reflected rays into the patient's eye, compensate for the obliquity of the rays incident on the mirror, by giving a corresponding obliquity to the position of this reflecting surface. Hence, when the light is in the position we advocate, by elevating ourselves above the horizontal plane of the patient's eye, we will approach nearer the horizontal plane of the lamp, and thus dimi- nish the angle of the incident rays, and this position will require much less Xlii A SHORT ACCOUNT OF THE OPHTHALMOSCOPE. obliquity of the reflector to illuminate the eye to be observed than is necessary where the light is at the side. The next step after arranging the position of the patient and the source of illumination, is to throw the reflection on the eye to be explored. This is done bv turning the reflecting surface to the light, and then gradually changing its position until its reflection appears on the eye to be observed. The observer is now to apply his eye close to the orifice of the speculum (if he has not been looking through it before), and watching carefully the reflection, he is to move his head with the instrument back or forward, until the reflecting light appears about the size of the reflecting surface. The patient is then to be directed to keep his eye slightly inverted, perfectly steady, and wide open ; its interior will then present a reddish hue, but none of the deep-seated structures will probably be recognizable. It is evident, then, that the proper focal adjustment has not yet been obtained. By slightly moving the head and instrument, or by interposing a biconvex lens, this will be rec- tified. We prefer introducing the lens here, as it has afterwards to be used. If this does not make apparent the deep-seated structures, the head and re- flector are not yet in their proper position, and must be moved nearer to, or further from, the patient's eye, until the observer can distinctly detect red ves- sels on the yellowish-red ground of the retina and choroid. If the patient's eye is inverted, as we said it should be when the lens and speculum are pro- perly adjusted, the light will, in all probability, fall on a brilliant white circle which is the entrance of the optic nerve, and from the centre of this circle there will be readily seen two larger vessels, an artery and vein, passing up over the surface of the retina, and a similar set passing downwards over the same structure. This white circle has a diameter of one-fourth of an inch, and the contrast between it and the bright choroid shining through the retina surrounding it, is very striking. It is important that the whereabouts of this entrance of the optic nerve should be sought for at the very first, as it is a valuable landmark, and its detection affords great facility in investigating the other parts ; for here the illumination is brighter, being on a white surface, and the bloodvessels are larger and more readily detected. Consequently, the observer becoming familiar with their appearance, will have much less diffi- culty in detecting them in situations not so favorable for their observation. Should the patient's eye be too much or not at all inverted, the light will fall on the surface of the retina, and the appearance presented will be that of a yellowish-red surface marked with streaks of darker red. Those dark streaks are the larger bloodvessels, and by following them in the direction in which they increase in diameter, in other words, towards their origin, the observer will readily reach this landmark of the entrance of the optic nerve. Some have spoken of the facility with which they could, with the ophthalmoscope, see the pulsation in the larger arteries of the retina. The ability to detect such a phenomenon seems to us, however, rather doubtful. We believe the only mode of distinguishing the artery from the vein is by the darker color of the latter. To follow up one of these vessels in order to reach the entrance of the optic nerve, it is much better that the observer should move the instru- ment, the lens, and his own eye, rather than keeping these fixed to direct the patient to change the position of the eye under observation, for the latter cannot appreciate the character or exact amount of motion required to throw the light on the point sought after, and in attempting to do so, he will not unfrequently disturb completely the whole adjustment. Sometimes it will be only necessary to change the position of the convex lens to bring distinctly into view the parts we wish to observe. We need but remind the beginner of the fact, that the lens, from its peculiar property, must be moved in the opposite A SHORT ACCOUNT OF THE OPHTHALMOSCOPE. xliii direction to that in which the part is, which he desires to bring into proper focus, precisely as the microscopist has to move an object which he wishes to trace under the field of his instrument. The vessels coming out from the optic centre were stated to consist of two pairs. One, an artery and vein, passing upwards in a more or less vertical direction; the other similar in character, but passing downwards. This is the course they generally take ; they will sometimes be found to vary. It is exceedingly difficult to trace them very far, from the fact that the red- dened surface over which they run makes it impossible to distinguish their minuter branches; and the iris completely intercepts the view of their final distribution. The bottom of a healthy ;eye presents, as was just observed, a yellowish red color ; this color is brighter in the immediate vicinity of the optic centre than on the periphery of the retina. The tint will also be found to vary in different eyes—being lighter (more yellowish) in those who are fair than in those who are dark and florid; showing that the intensity and character of the color are influenced by the pigment layer of the choroid. Close to the inner side or the entrance of the optic nerve, the color will be observed to be darker at one point. This Helmholtz attributes to the shadow of the semilunar fold of the retina. When the patient looks directly at the eye of the observer, and thus brings the axis of the two eyes in the same line, the yellow spot of Soemmerring will come into view; the retina here is of a grayish yellow color, entirely free from any admixture of red; and has no bloodvessels on its surface. As regards the value of the ophthalmoscope in the diagnosis of deep- seated disease of the eye, it might justly be supposed, from what has been said of this instrument, that it would not only be indispensable in the inves- tigation of all such diseases, but that with it there should be no difficulty in detecting the slightest pathological change in any of these structures, and in determining the exact character of the disease present, without any regard to its subjective symptoms. A great deal more, however, has been expected of, and claimed for the instrument, than it is capable of accomplishing, in the present state of its construction. In the first place, the great concentration of light which it produces in the eye, renders its employment highly injurious, even for a few moments of time, in the incipient stages of disease. In cases where it can be endured, its em- ployment for any length of time sufficient to detect all the changes which have taken place, produces an excited and unnatural condition of the structures which are the subject of investigation, and might readily lead the observer astray in his diagnosis. In cases of more confirmed disease, it might not give rise to such annoy- ances and serious consequences ; but would the investigation be of any value in such cases ? Are they not generally incurable ? Granting such to be the case, here will be found the great value of the instrument; for it, and it alone, will often enable us to set aside, as Mr. Dixon justly observes, "as positively hopeless, a large number of cases formerly termed ' amaurotic,1 or ' nervous,1 which were assumed to be still curable, because their real nature could not be demonstrated." "We now know," he says, "that total disintegration of the vitreous body, detachment of the retina from its connection with the choroid, and other equally hopeless conditions of structures essential to vision, may exist without any alterations being produced in the outward appearance of the eye. In enabling us, therefore, to appreciate these conditions, the ophthalmoscope has proved of immense value." Xliv A SHORT ACCOUNT OF THE OPHTHALMOSCOPE. We would refer those who wish to study the subject more fully than the limits of the present work will admit of, to the following :— Helmholtz—Beschreibung eines Augenspiegel zur Untersuchung der Netzhaut ine lebenden Auge. Berlin, 1851. Ruete—Der Augenspiegel und das Optometer. Gottingen, 1852. Coccius—Ueber die Anwendung des Augenspiegel nebst Angabe eines neuen Instru- mentes. Leipzig, 1853. Anagnostakis—Essai sur l'Exploration de la Re"tine et des Milieux de l'CEil sur la vivant a moyen d'une nouvelle Ophthalmoscope. Paris, 1854. Van Trigt—Der Augenspiegel, seine Anwendung und Modificationen nebst Beitragen zur Diagnostik inneren Augenkrankheiten. Nach dem Holliindischen mit Zusiltzen bear- beitet von Dr. C. H. Schauenberg, Docenten au der Universitilt zur Bonn. Lahr, 1854. Ed. Jagee—Ueber Staar und Staaroperationen nebst anderen Beobachtungen und Erfah nungen aus seines Vaters, Dr. Friedrich Jiiger, K. K. Prof. &c. und aus der eigenen Ophthalmologischen Praxis. Wien, 1854. Ruete—Physikalische Untersuchung des Auges on Dr. C. G. Theodor Ruete. Tab. viii. Leipzig, 1854. T. Wharton Jones—Report on the Ophthalmoscope. British and Foreign Med.- Chirurg. Review, for Oct., 1854, p. 549. E. Williams, M.D.—The Ophthalmoscope. Med. Times and Gazette, July 1, 1854, p. 7. I. Hays's edition of Lawrence on Diseases of the Eye. Blanchard & Lea. 1854. C. Bader, M.D. and Bransbt Roberts, Esq.—On the Means of Diagnosing the In- ternal Diseases of the Eye. Aug., 1854. Britisli and Foreign Medico-Cbirur. Rev., for April, 1855, p. 501. James Dixon—A Guide to the Practical Study of Diseases of the Eye. London, 1855, p. 7. Christopher Johnston, M. D.—Report to the Medical and Chirurgical Faculty of Maryland, published in the proceedings of that Society for 1854, p. 45. Baltimore, 1855.—H.] A PRACTICAL TREATISE ON THE DISEASES OF THE EYE. CHAPTER I. DISEASES OP THE ORBIT. SECTION I.—INJURIES OF THE ORBIT. In considering the injuries of the orbit, it is impossible to avoid noticing the effects produced on the investments and contents of this cavity; or, in treating of wounds penetrating the walls of the orbit, to pass over in silence the injuries which, in this way, the brain and other surrounding organs may sustain. Cases occur, indeed, in which it is doubtful, to the injury of what particular part, without, within, or beyond the orbit, the effects which arise ought to be attributed. Amaurosis, for example, one of the chief conse- quences to be apprehended from wounds of the orbit, appears sometimes to be owing to injury of the branches of the fifth nerve exterior to that cavity; in other cases, to injury of the optic or other nerves within the orbit, or of the eye itself; and, in other cases, to injury of the brain. § 1. Contusions on the Edge of the Orbit. Blows, falls, and similar accidents are apt, especially in scrofulous children, as I shall explain more fully in the next section, to excite inflammation, running into suppuration, and affecting the periosteum, and even the sub- stance of the bones forming the edge of the orbit. From blows on the edge of the orbit, particularly its upper edge, we must be prepared, however, to meet occasionally with still more serious conse- quences than an affection of the bone or its periosteum. Effusion of blood within the cranium, concussion of the brain, or inflammation of its substance, or of its membranes, may be excited by such an injury; and, while we are perhaps confining our fears to the state of the bone, or of the soft parts which cover it, changes may be going on within, which shall suddenly prove fatal. Case 1.—Henry II., King of France, was struck, in a tilting-match, above the right eyebrow. The skin was torn across the forehead to the external angle of the left eye, iu the substance of which there stuck several small bits of the shivered lance. There was no fracture. The injury proved mortal on the 11th day. On opening the head. Pare" found a quantity of blood effused between the dura and the pia mater, under the middle 4 50 FRACTURES OF THE EDGE OF THE ORBIT. of the occipital bone ; and the substance of the brain at that place changed in color and consistence.^ ^^ ^ ^^ ^ & ^^ ^ had ^ k with pewter quart over the left eye, and had thus received a wound about an inch and a half long, laying bare the bone She died on the 26th day from the receipt of the injury On dissection, the dura mater under the wound was found detached, and slightly spotted with matter, the anterior part of the left hemisphere of the brain in a state of suppuration, and some fluid matter lying on the anterior and left fossa cerebri. Case 3.—A man received a wound 18 lines long, above the right eyebrow. On the third or fourth day, fever and sleeplessness came on; the edges of the wound became tender and swollen; the patient vomited bile ; he fell into a state of delirium ; his abdo- men was painful, especially the right hypochondrium. The symptoms grew speedily worse, locked-jaw supervened, and the man died on the /th day. A large quantity of pus was found beneath the pericranium, in contact with the falx, and on the tentorium; the surface of the brain was highly injected, and of a darker color than natural; the liver large, and its peritoneal covering thickened ; the intestines contracted, and present- ing here and there spots of purulent exudation.3 Consequences not less serious have been known to result from injuries of a similar sort, received at the lower edge of the orbit. Thus Petit relates a case of palsy of the left side, and death, from suppuration in the right hemi- sphere of the brain, consequent to a wound at the lower edge of the right orbit, close to the exit of the infra-orbitary nerve, which, however, did not appear to have been injured.4 Contusion of its temporal edge has been sometimes followed by the growth of encysted and other tumors within the orbit. These effects, however, as well as inflammation of the various parts contained within that cavity, and the formation of exostoses, excited by the same cause, will require separate consideration hereafter. § 2. Fractures of the Edge of the Orbit. The only recent instance of this injury I recollect to have seen, was from a blow with the end of a long piece of wood, which struck the lower edge of the orbit, and separated a fragment, which I concluded to be the anterior angle of the malar bone. The fractured piece moved at first easily under the finger, in different directions, but became united in the course of a few weeks. No bandage was applied ; but cases may occur in which, the eyelids being previously closed, compresses might be judiciously employed, with a roller round the head, to keep the fractured portion of the edge of the orbit in contact with the bone from which it had been separated, till the process of reunion should be completed. r Case 4.—A butcher was leaping from a barrel to the ground, and not observing a flesh- hook which hung close by him, it caught him by the middle of the left orbitary arch, and fairly took the piece of bone with it, tearing, of course, the integuments and the eyebrow. The wound healed in such a way as to leave the lid peaked up in the middle, so that the patient could not completely close the eye, which consequently was exposed to frequent attacks of inflammation. During one of these he consulted me, several years after the accident. The deficiency of the bone was very perceptible, and added to the deformity produced by the lagophthalmos. The ophthalmia was puro-mucous, and soon subsided under the use of a solution of nitrate of silver. Case 5.—Dr. Scott relates5 that a soldier, riding into the town of Douglas, Isle of Man, in a December night, was caught by the hook of an iron lamp-supporter, which, fixing beneath the superciliary ridge of the right orbit, tore away that part of the bone, and wounded the brain. He recovered perfectly in about four weeks. Case 6.—Biermayer6 records the case of a boy who, being struck with a stone at the inner angle of the eye, was, on the 5th day after the injury, seized with tetanus, and died in a few hours. On dissection, a small portion of the nasal process of the superior maxillary bone was found lying loose in the abscess at the seat of the injury, and in con- tact with one of the branches of the infra-orbitary nerve. Of fractures of the edge of the orbit extending into the frontal or maxil- lary sinus, or into the ethmoid cells, the consequence sometimes is that, on SKULL AND ORBIT FRACTURED. 51 blowing the nose, air, passing through the fracture, is introduced into the cellular membrane of the eyelids, which suddenly become swollen, and crepi- tate under pressure. In such cases, of which I shall have occasion again to speak under the head of Emphysema of the Eyelids, it is scarcely necessary to open the integuments with the lancet, to let the air escape. Its presence is of no moment; but the patient should avoid blowing his nose till the fracture is consolidated. § 3. Fractures of the Walls of the Orbit, attending Fractured Skull. Fractures of the skull not unfrequently penetrate into one or both of the orbits; and it is worthy of observation that, if the roof of the orbit be broken in this way, it is apt to be attended by laceration of the dura mater, and injury of the anterior lobes of the cerebrum, which rest upon the orbits. Suppose that this is the case, while at the same time a fracture with depres- sion is present, we shall say on the temple, and that this fractured piece of the skull is raised into its place by the operation of trepan, the patient will, in all probability, not be relieved; the symptoms of pressure on the brain, or of inflammation within the head, will most likely remain as before, and death follow, contrary, perhaps, to what might have been expected, if the fractured temple had been the sole injury. It will probably be only on dis- section that, in such a case, the cause of death will be discovered. Case 7.—Sir George Ballingall7 has recorded a case of compound fracture of the os frontis, in which, after the depressed pieces of bone were removed, the patient instantly recovered his senses, and answered questions rationally. He soon lapsed, however, into a comatose state, and died within 48 hours of the receipt of the injury. On dissection, the fracture was found to extend backwards, through both orbitary plates of the frontal bone, and to pass across the ethmoid behind the crista galli. Opposite to the fissures in the roof of each orbit, the dura mater was found lacerated to a considerable extent, and portions of brain protruding. The anterior lobes of the brain were disorganized and broken down ; and there was a distinct appearance of purulent matter upon the tunica arachnoidea covering each hemisphere of the brain, although the patient had survived the accident for so short a time, lost a considerable quantity of blood from the wound, and manifested no inflammatory symptoms. In cases of fractured skull extending to the orbit, it sometimes happens that portions of the walls of this cavity are so completely separated, that they easily come away, either in dressing the wound, or in raising the depressed pieces of the skull. The mere circumstance of a portion of bone being loose, is not sufficient ground for removing it; for, if its surfaces are still attached to the membranes with which they are naturally in connection, it may be susceptible of reunion ; but if the bone be extremely shattered, and pressed partly through the dura mater, we are warranted in extracting the Joose pieces. Case 8.—Cheselden8 communicates a case of this kind, which occurred in the practice of Mr. Cagua, in which five splinters of the cranium, depressed into the substance of the brain, were extracted, the largest piece comprehending part of the orbitary plate of the frontal, of the great wing of the sphenoid, and of the suture which connects the external angular process of the frontal to the superior angle of the malar bone. Pieces of the substance of the brain followed the removal of this splinter; yet the patient, a boy of ten years of age, perfectly recovered. Case 9.—A similar case, also terminating favorably, is recorded9 by Dr. Klein, in which several large portions of the frontal bone were removed ; the roof of one of the orbits was completely loose; a wide hiatus, separating the ethmoid from the neighboring bones, ran down towards the basis of the skull; and considerable portions of brain were discharged. Case 10.—I was consulted, in October 1842, by a man whose right eye was totally amaurotic, and lay depressed and everted in its orbit. On passing the hand over the forehead, the right portion of the frontal bone presented a triangular elevation, showing the scat of a former fracture. Six months before, he had received a severe blow on the right temple, but no fracture was then detected. He lay insensible for 14 days after the 52 FRACTURES OF THE ORBIT. accident. The bone was exposed to the extent of an inch. All the symptoms of con- cussion of the brain followed. The right eye projected ^f™"*'?*^™*' pressure of effused blood within the orbit. Now it had retreated. I considered it likely that there had been fracture of the orbit. S 4 Fractures of the Walls of the Orbit, attending Fractured Bones of the s Face. Of this sort of accident it may be sufficient to give the following illustra- tion :— Case 11.—John Lewis, aged 11, had his face crushed by the wheel of a carriage, and the bones of the nose and cheek fractured. He lay with little appearance of sensibility, but understood and replied to questions when roused. He had no paralysis ; but it was thought that some convulsive twitches occasionally took place on the left side, lhere was ecchymosis about both eyes, and some laceration under the left, and about the nose. He died on the 6th day after the injury. On removing the scalp, several patches of ecchymosis were seen between it and the calvaria ; the largest of these was situated at the posterior part of the head. At these spots, the scalp scarcely adhered to the calvaria, but elsewhere it did so with consider- able firmness. The internal surface of the dura mater was of a light red; between it and the arachnoid, on the left side, there was a pretty generally diffused layer of puri- form lymph of a light yellow color with a tinge of green, which adhered partly to the dura mater, and partly to the arachnoid. It dipped down between the hemispheres, but was wholly confined to the left side of the falx. At the under part of the left anterior lobe, a portion of brain of about the size of a shilling was softened to the depth of about half an inch ; and a few minute ecchymosed spots, such as are usually met with in lace- rated brain, were visible at this part. There was very little laceration of the dura mater, but a portion of the left orbitary plate of the os frontis appeared to have been pushed inwards, so as to bruise the brain at the part above mentioned. The fracture was con- tinued through the sphenoid bone by the side of the left cavernous sinus, and at this part there was a considerable quantity of extravasated and coagulated blood beneath the dura mater.10 § 5. Orbit Fractured by a Blow on the Eye. The following case, related" by Duverney, has sometimes been referred to as an example of this sort of injury ; but it may fairly be doubted if, in this instance, the fracture of the orbit was actually produced through the medium of the eyeball. Case 12.—A gentleman had his left eye crushed to pieces by a blow from a stone, and the orbit beaten in upon the brain. After the first shock till his death, which happened on the 7th day, his faculties remained entirely unimpaired, insomuch that some of his medical attendants pronounced it impossible the brain should be injured. On dissection, the cranium was found filled with brain in a softened state, mixed with fragments of bone. The whole substance of the brain, even to the cerebellum, was changed by dis- ease. The anterior part of the sella Turcica was found broken. § 6. Counter-Fractures of the Orbit. Fractures of the orbit sometimes take place, by what the French call contre-coup,12 in consequence of blows or falls on the forehead, or even on the occiput. Cate 13.—Bohnius13 opened the body of a man who died in consequence of a blow with a stick, close to the right eyebrow. At the part struck there was an ecchymosis, but no wound ; beneath the ecchymosis, the bone was sound and entire ; but in the roof of the orbit there was a fissure, an inch and a half long, running towards the sella Turcica, and the corresponding portion of the dura mater was ruptured. After a fall or blow on the head, should an extravasation of blood appear in the upper eyelid, without its having received any contusion, it may be suspected that a counter-fracture of the upper wall of the orbit has taken place ; if in the lower eyelid, that the floor of the orbit is broken.14 It can be but seldom, if ever, that such fractures can be positively pronounced to exist, till after death. Indeed, it is of comparatively little importance to PENETRATING WOUNDS OF THE ORBIT.—EXTERNAL WOUNDS. 53 know of their existence during life, as they do not admit of any particular treatment, and as our attention will be directed chiefly to the concussion and consequent inflammation of the brain, by which counter-fractures are attended. § 1. Penetrating Wounds of the Walls of the Orbit. The smoothness and mobility of the eyeball, together with its smallness, compared with the size of the cavity in which it is placed, and its firm resist- ance, compared with the looseness of the parts interposed between it and the orbit, serve to explain how pointed bodies, thrust against this organ, are very apt to leave the eyeball uninjured, and to penetrate deep into the orbit, or even passing through its walls, to enter one or other of the neighboring cavities. The nasal and cranial sides of the orbit, from their situation and extreme thinness, are especially liable to be thus injured. Perforation of the orbitary plate of the frontal bone, in particular, is an accident to which the attention of the surgical student is early and forcibly drawn. The thinness and fragility of that plate, the readiness with which the brain maybe reached through it, and the instantaneousness with which death has been known to follow, are among the earliest points impressed on the mind of the young anatomist, Thus Mr. John Bell, after attributing the thinness of the orbit- ary plate to "the continual rolling of the eye," with which that plate never comes into contact, and by which, therefore, it cannot be thinned, tells us that "it is the aim of the fencer; and we have known in this country," adds he, "a young man killed by the push of a foil, which had lost its guard."15 Yarious effects may follow a penetrating wound of the orbit, and we may find the patient in one or other of very different states. The weapon may have been immediately withdrawn after the injury was inflicted; or the foreign body may still be fixed in the wound, and is to be extracted; or it may have sunk so deep that it cannot be laid hold of. As for the effects of the injury, they may be slight and transient, or violent and immediately dangerous, or prolonged for a length of time. It is evident, that a dagger, or other weapon, directed outwards, so as to break through the suture between the malar and sphenoid bones into the temporal fossa, or directed downwards, so as to shatter the floor of the orbit, and enter the maxillary sinus, will not be productive of the same amount of dangerous consequences as when the instrument of injury traverses the os planum of the ethmoid, or the orbitary plate of the frontal, or fractures the sphenoid where it gives passage to the optic nerve. I shall treat of gunshot wounds of the orbit separately; but I may here remark, that their effects correspond so far at least with those of common penetrating wounds, that from both we may occasionally expect hemorrhage, extravasation of blood, blindness, strabis- mus, syncope, vomiting, coma, convulsions, palsy, and even death, as imme- diate effects ; and, as remote effects, fever, delirium, suppuration, caries, exfoliation of bone, and the like. In all such injuries, paralytic symptoms are most likely to arise from hemorrhage into the cavity of the cranium ; fever and delirium indicate inflammation of the membranes; rigors, suppura- tion ; coma, convulsions, and dilated pupils, abscess of the brain. 1. Trifling appearance of external wound.—A weapon, penetrating through the orbit, may strike deep into the brain, and yet so small an external wound be present as shall be apt to excite little or no suspicion of danger. Case 14.—Ruysch relates the case of a man who was wounded in the left orbit, with the end of a stick, not particularly sharp. The injury appeared of little importance; yet the patient died soon after receiving the wound. The magistrates appointed Ruysch to examine the body, in order to discover the cause of the sudden death. Externally, he observed a slight degree of ecchymosis at the upper part of the eye; but on removing 54 SITUATION AND EXTENT OF FRACTURED ORBIT. the calvaria, he found that the wound had penetrated to a considerable depth into the brain.l6 Case 15.—Peter Borel mentions a still more remarkable case, of a man who was wounded with a sword in the left orbit. Thinking that the wound had not penetrated deep, he merely covered it with a plaster; after which he walked two leagues, and ate and drank heartily with his companions, exactly as if he had been well, being affected with no pain. Next morning he was found dead. The skull was opened, when the wound was found to have penetrated to the cerebellum.17 Such cases18 sufficiently show how carefully our examination ought to be conducted, and how cautiously our prognosis delivered, when a wound appears to have penetrated towards the roof of the orbit. In the following case, symptoms of danger supervened early, and were treated with the appropriate remedies, although unfortunately without success:— Case 16.—A man was brought into the London Hospital, 12th Apru\1832, with a lace- rated wound of the right upper eyelid. He stated that, while working on board a ship discharging coals, a hook used for raising the coals caught him by the eye, so that he was elevated to the height of several feet. His companions, observing what had hap- pened, suddenly let go the rope, so that the poor fellow fell heavily on the deck. He immediately withdrew the hook himself. On his admission to the hospital, he did not appear to be suffering from any serious injury. The eyeball was uninjured, and no fracture could be detected. His respiration was natural; his pulse 76, full, but not more than might have been expected in a robust man; pupils obedient to the light; no pain in the head. He was bled to the extent of twenty ounces ; a cold lotion was applied to the forehead; and two grains of calomel were ordered to be given every second hour. He passed a quiet night. Next morning, his pulse was 74, full, but free from hardness. He had very little pain in the head. His bowels had been opened three times. Twelve leeches were applied to the forehead, and the calomel continued. Symptoms of compression of the brain came on very suddenly at six in the evening. His breathing became stertorous; pupils contracted, and insensible to the stimulus of light; pulse 52, and laboring; he could not be roused by any noise. At this time, a quantity of blood, mixed apparently with cerebral substance, to the amount of about two ounces, escaped from the wound. He was again bled to the extent of twenty ounces; the blood cupped and buffy. Twelve leeches were applied to the temple. He lingered in this state until two o'clock next morning, when he died. The orbitary plate of the frontal bone was found to be completely smashed, and a con- siderable portion of the anterior lobe of the right hemisphere of the brain wanting, it having escaped through the wound.,9 2. Differences in situation and extent of fractured orbit.—It is worthy of remark, that it is not the orbitary plate of the frontal bone alone which is apt to be fractured, when the weapon is directed towards the roof of the orbit; and that we are in some degree enabled to judge of the violence employed by the hand which held the weapon, even by the mere situation of the fracture, which, in fatal cases, is detected on dissection. The following case of fatal wound of the brain through the orbit and ethmoid bone, is quoted by Bonetus:— Case 17.—A countryman, about 55 years of age, was asked by one who met him to step out of the way ; but, as he was carrying a heavy burden at the time, he could not do so, and therefore refused. The other, provoked at this, struck the countryman vio- lently over the shoulders with a whip ; and, when the whip broke, thrust the sharp end of the broken shaft of the whip in the countryman's face. Not apprehending any dan- gerous effects from the blows which he had received, the countryman, with his burden on his back, trudged along after his cart, which was loaded with wood, for nearly a quarter of a mile, till he arrived at the wood market, when he instantly dropped down dead. Schmid was appointed to inspect the body. On examining the head externally, he found that the sharp end of the stick had penetrated at the inner canthus of the right eye. He endeavored to ascertain with the probe whether the wound had reached the brain ; but he could not, on account of the narrowness of the wound. Having opened the cranium, the brain and its membranes at first view appeared sound ; but, on raising the anterior part of the oerebrum, the nasal extremity of the falx was observed to be SITUATION AND EXTENT OF FRACTURED ORBIT. 55 injured, and it was found that the wound had penetrated into the third ventricle, in which lay a considerable quantity of clotted blood.® Case 18.—A man, standing at the head of a horse which had fallen in the street, was suddenly struck in the face, upon the animal raising itself unexpectedly. The blow was so violent that he was thrown down by it, but not stunned. He was of opinion that it was not the head of the horse, but some part of the harness that had struck him. There was a bleeding wound between the left eye and the nose, about an inch long, dividing the lachrymal canal and palpebral tendon. A probe was introduced to the depth of three- quarters of an inch into the wound, in the direction of the inner wall of the orbit, but without the bone being felt. The left eye was uninjured. The right eye, without any perceptible injury, had entirely lost the power of vision. Its pupil was dilated to the utmost; and, although its common sensibility, as well as its different motions, was per- fect, a lighted candle held close before it caused no contraction of the pupil, nor any sensation of light. The patient answered questions promptly and clearly, and evinced no symptom of injury extending to the brain, except that he complained of a little headache. The bones of the nose were examined, but no crepitus could be felt; neither was there any ecchymosis to indicate injury on the right side. Delirium, however, and stupor supervened on the following day; and, as these symptoms were attributed to meningitis, the patient was bled, purged, and treated with repeated doses of calomel and antimony. In the evening, convulsions came on; the left arm and leg were stiff and contracted, while the right extremities were in constant motion; the pupil of the right eye was now found to be contracted. As the patient could no longer swallow pills, calomel was laid on the tongue; a blister also was applied to the nape of the neck. The left side and extremities became subsequently paralytic, while the right were tranquil. He died con- vulsed on the 5th day after the accident. On dissection, the brain and its membranes were found loaded with vessels, and there was a copious deposit of lymph between the arachnoid and the pia mater, over both hemispheres. A large accumulation of serum, with purulent matter diffused in it, was present in both lateral ventricles. The whole lower surface of the anterior lobes was adherent to the dura mater, by means of coagulable lymph. The optic nerves being exposed, the right was seen to be torn completely through, or its ends joined only by delicate membrane, close to the foramen opticum. The base of the brain, from the medulla oblongata to the chiasma, was thickly covered with a layer of lymph, which obscured the roots of the nerves. In the posterior part of the right anterior lobe, close to the injured part of the optic nerve, and approaching to the anterior cornu of the late- ral ventricle, the brain was bruised, softened, and ecchymosed. The cause of the lacera- tion of the brain and tearing across of the optic nerve was found to be a fracture of the cerebral plate of the ethmoid bone, with part of the sphenoid forming the roof of the foramen opticum. The fractured fragment of bone was found loosely attached by dura mater to the fore part of the sella Turcica, above the right cavernous sinus. On intro- ducing a probe into the external wound, it could be made to pass, by a slight degree of management, into the crushed part of the ethmoid, and to appear within the skull. It was evident, therefore, that the object by which the blow was inflicted, must have been pointed ; that it entered the orbit, so as to strike the os planum, and force it inwards; and that the force being communicated at the same time upwards, the blow had the effect of fracturing the cerebral plate of the ethmoid, and lacerating the optic nerve on the opposite side.21 Case 19.—On the 20th December, 1819, I assisted at the examination of the body of a man who, the evening before, had instantaneously dropped down dead in a scuffle on the street, after receiving a penetrating wound of the orbit, with the pointed end of an umbrella. Considerable bleeding had taken place from the nose and mouth. The upper eyelid was swollen and livid, and the conjunctiva elevated by extravasated blood. Just over the tendon of the orbicularis palpebrarum, a penetrating wound easily admitted the little finger to the bottom of the orbit, between its nasal side and the eyeball. A frac- ture of the orbit was felt with the end of the finger. On opening the head, much dark fluid blood was found effused into the cavity of the tunica arachnoidea, and some between it and the pia mater. The dura mater was seen to be perforated by a lacerated wound, just under the edge of the boundary of the middle fossae of the basis of the cranium, formed by the little wing of the sphenoid bone. The brain behind the wound of the dura mater was lacerated, and a small portion of it separated from the rest. On removing the dura mater, the fracture, which had been seen, indeed, immediately on lifting the brain, was displayed completely to view. The little wing of the sphenoid was separated by the fracture from the frontal bone, in the course of the sphenoidal suture. The frac- ture extended through the orbitary plate of the frontal from behind forward for about half it.* length; but what was much more remarkable, the comparatively thick and strong portion of the sphenoid, which completes the posterior part of the roof of the ">G HEMORRHAGE—SUPPURATION — CONVULSIONS. orbit, was broken across at its inner extremity; proving, along with the state of the dura mater and brain, the great degree of force with which the instrument of death had been driven against the hapless victim of a drunkard's fury. I may mention, that the optic nerve and eyeball were entire, the cornea clear, and the humors and retina uninjured.22 3. Hemorrhage.—Although hemorrhage, more or less profuse, must attend all accidents of the kind now under consideration, I know only of one recorded case, in which a fatal result was to be ascribed entirely to the loss of blood. Case 20.—In a scuffle, a nailer drew a red-hot iron nail-rod from the fire, and thrust it against the eye of a man, aged 28 years, who immediately fell heavily, and remained in- sensible for a short time; but, after having been carried home, became quite conscious, and vomited a large quantity of blood. When Dr. Little saw him next morning, he found a trifling wound of the left upper lid, immediately under the internal orbital angle of the frontal bone, not presenting any of the characters of a recent burn, and already united. The lid was swollen and black from ecchymosis, and was closed over the eye, which was intact and uninflamed. The face was pale, voice weak, and general aspect that of a person who had lost a large quantity of blood. Pulse 50, full, soft, and regular. His intellect continued unaffected, and he had a desire for food. Pupils regular and con- tractile. He was purged, and on the second day after the accident was bled at the arm on account of headache. On the fourth day, he began to void bis urine in bed, and lost the power of his left leg, and partially of his left arm. Till the fourteenth day, he seemed to improve; his pulse steadily at 50; he was free from pain; his mind active ; his ap- petite keen ; but still passing urine involuntarily, and his left extremities paralytic. On that day, he was seized with a violent and sudden epistaxis, evidently arterial, immedi- ately after which coma supervened, and in three hours he was dead. The dura mater and subjacent arachnoid were perfectly normal. No serum in the ventricles. On raising the anterior lobes of the cerebrum, a large clot of blood, about three ounces in weight, was found lying on the orbital plate of the frontal bone. On re- moving this coagulum, an oval breach, with sharp and ragged edges, and about half an inch in its longest diameter, was exposed, involving the orbital plate of the frontal bone and cribriform plate of the ethmoid, and terminating at the side of the crista galli. Not a drop of matter had been formed, either within the skull or in the course of the wound, which had quite healed externally. The vessel from which the fatal hemorrhage had issued could not bo discovered. Dr. Little thought it probable, that it had been the an- terior artery of the cerebrum, and considered that the same vessel had given origin to the blood which the patient had swallowed and afterwards vomited, and, either by the separation of a slough or the disengagement of a coagulum from its orifice, had finally caused death. There are many remarkable circumstances about this case The permanent pulse of 50; the occurrence of paralysis on the 5th day, without any new symptoms directly af- fecting the head ; the contemporaneous improvement in the general state of the patient up to the day of his death ; the freedom of the brain from injury; the absence of in- flammation ; and the cause of pressure, as detected on direction, existing on the same side as the paralysis; all deserve particular attention.25 4. Suppuration—Convulsions.—The cases which I am now about to quote, serve at once to confirm what is proved by some of the preceding ones, namely, that at the first there may be nothing alarming, except the suspicious situation of the wound; exemplify a symptom which has ever been regarded as an exceedingly dangerous, if not fatal, one in injuries of the brain, namely, convulsions ; and illustrate, in accidents of this kind, both the date and the effects of suppuration. The earliness with which matter is formed by the tunica arachnoidea, in cases of wounded brain, is strikingly proved by the case already quoted from Sir (}. Ballingall's Clinical Lecture. With regard to the convulsions arising from irritation of the brain, and which not unfrequently appear immediately or very soon after a severe in- jury of the head, it may be observed, that they are probably the effect rather of pressure from fractured pieces of bone or effused blood than of any change in the cerebral structure, and are attended with comparatively less danger than those caused by disorganization consequent on inflammation. The latter usually occur along with strabismus and coma, some time after the PALSY. 5T setting in of the symptoms called secondary, from their occurring days or weeks after the injury, and are almost invariably the forerunners of death. Case 21.—A soldier was brought to the hospital at Brest, at eleven o'clock in the even- ing, having been wounded with a pitchfork, at the middle of the left upper eyelid. The wound was oblique, about three lines in length, and appeared to implicate only the skin and orbicularis palpebrarum; there was very little blood discharged ; the eyelid was dis- tended, and the conjunctiva inflamed. The apparent simplicity of the wound, the good- ness of the pulse, and the free exercise of all the functions, led to a favorable prognosis; the patient asserted that he had experienced nothing particular at the moment of the in- jury, and had scarcely been stupefied by it. Compresses dipped in brandy and water were applied over the wound. The patient rested during the night; next day, he was quite lively, walking about in the wards, complaining only of slight pain in the wound, and even eating with appetite. The same day, at seven in the evening, he was seized with convulsions, which were supposed by his attendants to be epileptic. The day after, he was kept from food, and bled at the arm ; the convulsions returned, and he was bled at the foot. Vomiting, uneasiness, agitation, and delirium came on; the pulse became small and contracted; cold sweats succeeded, and the patient died at two o'clock next morning. On dissection, the eyelids were found oedematous, and the wound had already closed. On cutting through the upper eyelid and orbicularis palpebrarum, a circumscribed collec- tion of pus was found in the orbit, between its roof and the levator palpebrae superioris. This collection of pus communicated with the cranium, through the orbitary plate of the frontal bone, which had been penetrated by one of the prongs of the fork. After remov- ing the eyeball, the inferior wall of the orbit was found fractured, and depressed almost completely into the maxillary sinus. This fracture is compared by M. Massot, the nar- rator of the case, to the depression which might be produced on the surface of an egg, by pressing it inwards with the thumb. On removing the calvaria, the dura mater was seen to be penetrated over the hole made by the fork in the roof of the orbit. The dura mater appeared in a morbid state at that place, the anterior fossae of the basis of the cranium were covered with pus, the anterior lobes of the cerebrum were in a state of suppuration, and the rest of the brain healthy. M. Massot thinks it probable that, when the fork was pushed through the orbit into the cranium, the eyeball being fixed and vio- lently pressed between the fork and the floor of the orbit, the thin plate of the superior maxillary bone could not resist this pressure, but sunk by the continued action of the fork upon the eyeball.24 5. Palsy.—Wounds penetrating the upper or inner side of the orbit are sometimes productive of paralytic affections, from the effusions of blood within the cranium to which they give rise. The palsy is generally, but not always, on the opposite side of the body to that which has been injured. The upper and lower extremity, and the sphincter of the bladder, are most apt to be paralyzed. The paralytic affection sometimes occurs instantly after the injury ; in other cases, not for several days. The effusion of blood ceasing, the patient may survive; and slowly, as the blood is absorbed, the palsy may disappear. The effusion continuing, or being renewed, after having ceased for a time, coma and death are likely to supervene. Case 22.—The son of Gen. E., a student at the Polytechnic School in Paris, received, in fencing, the end of the foil. through the roof of the orbit, and became hemiplegic on the opposite side of the body. The eye was saved.25 Case 23.—Thomas Hale, aged 35, was assisting in hay-making. A scaffolding had been erected at the side of the hayrick; and while his companion, a man named Joslyn, was in the act of throwing some hay upon it, the pitchfork missed the hay, and struck Hale in the right eyebrow. Instead of drawing the pitchfork out, Joslyn, under the impression that he had caught the hay, thrust it farther in, the one prong entering Hale's orbit, while the other glanced over the outside of his head. When the prong was withdrawn, which was accomplished with difficulty, Hale turned to leave the field, having the impression that his eye had been driven out of his head; but he had not proceeded more than five or six yards before he fell, his left side crippling under him. In other respects he recovered; but the palsy continued, the fingers of the left hand being contracted, and the left foot swinging about, although he became able, in the course of some months, to walk at the rate of a mile in 30 minutes. Dr. Roe, who published26 the case, had given a trial to strychnia internally, and to electro-magnetism, without any very striking improvement. Hale continued to taste, smell, and see as well as ever. 58 FOREIGN BODY STILL IN TnE ORBIT. Case 24 —A case of this kind is also recorded by Mr. Geach.87 Ho does not, indeed, say that the wound penetrated into the brain, but merely that the instrument of injury struck against the inner side of the orbit; leaving it a matter of doubt whether the para- lytic symptoms which followed, were attributable to effusion within the cranium, or to a still more direct injury of the brain. The instantaneousness with which the patient, in this ease, fell on receiving the injury, looks very like the effect of a wound of the brain; while, on the other hand, the slowness of the pulse and the hemiplegia, are more the symptoms of pressure from effused blood Even, however, on the supposition that the small sword with which the wound was inflicted, had not penetrated through the ethmoid bone into the brain, the case becomes only the more remarkable ; as it would lead us to conclude, that a wound of the bones of the orbit, without perforation, might be attended by rupture of vessels within the cranium, and consequently with pressure on the brain, and paralysis. At the time when Mr. Geach drew up his account of the case, the para- lytic arm and thigh were recovering, but slowly, their power of flexion and extension. 6. Foreign body still in the orbit.—In all the instances to which I have hitherto referred, the weapon, whatever it was, was instantly withdrawn on the injury being inflicted; but we must be prepared to meet with cases where the foreign body which has been driven through the walls of the orbit, still remains in the wound. In such cases, we instantly proceed to its removal; for there very soon follows such a degree of swelling as might prevent us from accomplishing the extraction without great difficulty, if at all: and were the weapon left, what could we expect but destructive inflammation of the eyeball, of the orbit, of the surrounding parts, and, among these, of the brain ? Case 25.—A laborer thrust a long lath, with great violence, into the inner canthus of the left eye of another laborer. It broke off quite short, so that a piece nearly two inches and a half long, half an inch wide, and above a quarter of an inch thick, remained in his head, and was so deeply buried that it could scarcely be seen or laid hold of. He rode with the piece of lath in him above a mile, to Barnet, where Mr. Morse extracted it with difficulty; it sticking so hard, that others had been baffled in attempting to remove it. The man continued dangerously ill for a long time: at last he recovered entirely, with the sight of the eye and the use of its muscles; but even after he seemed well, upon leaning forwards, he felt great pain in his head.28 In the days when javelins and arrows formed principal weapons of war, many difficult cases of this sort must have occurred. Albucasis shortly relates two which had come under his care. In the one, an arrow entered at the nasal side of the orbit, and was extracted under the ear. The patient re- covered, without any permanent injury of the eye. In the other case, a Jew was struck with a large unbarbed arrow from a Turkish bow, under the lower eyelid. It had sunk so deep that Albucasis reached with difficulty the end of the iron, where it stuck upon the shaft. This patient also recovered with- out any serious effect.39 Yery great force may sometimes be necessary for extracting a foreign body, which has been driven through the walls of the orbit. Park's successful case"1 is well known, in which he was obliged, with a pair of farrier's pincers, to tear away from the Duke of Guise the broken end of a lance, which, entering above the right eye, and towards the root of the nose, penetrated as far as the space between the ear and the nape of the neck, tearing and destroying vessels and nerves in its course, as well as fracturing the bones. Case 26.—Percy had under his care a fencing-master, who in an assault received so furious a thrust from a foil on the right eye, that the weapon penetrated nearly half a foot into the head, and broke short. The man fell down in a state of insensibility, and very soon the supervening swelling was so great as to conceal the foreign body. In order to lay hold of it, Percy opened and evacuated the contents of the eyeball. His forceps not being strong enough, he sent to a clock-maker in the neighborhood, and borrowed from him a pair of screw-pincers, with which he laid hold of the broken end of the foil, and thus succeeded in extracting it. The fencing-master died some weeks after, more from the consequence of intemperance than of the injury.31 Commenting on this case, Percy recommends, that we should rather re- DANGERS AFTER FOREIGN BODY IS REMOVED. 59 move the eyeball, than leave large foreign bodies in such a situation; and refers, in support of this practice, to a case related by Bidloo, in which a splinter of wood was left to come away from the orbit by suppuration. The eye burst at last, after the most dreadful pain and after the other eye had been threatened with destructive sympathetic inflammation. Case 27.— Sabatier notices32 an instance of wound with a knife, through the upper eye- lid, with injury of the neighboring edge of the frontal bone. It was not, he says, till after four hours' work, that the surgeon succeeded, by means of a hand-vice, in tearing away the portion of the knife-blade which remained in the orbit, on account of its pro- jecting so little from the wound. The patient complained of severe pain, as if one had been tearing out his eye. No ill consequence followed; the cure was speedy, and without any affection of sight. 1. Dangers after foreign body is removed.—We must not imagine that, on withdrawing the foreign body from the orbit, the danger is over. Destructive inflammation of the eye, or even fatal inflammation of the brain, may follow, as in the case I have just quoted from Percy : nay, the patient has been known suddenly to expire, immediately after the foreign body was removed. Case 28.—A laborer, aged 51 years, while cutting wood in a forest, stumbled over the root of a tree, and with the whole weight of his body drove the end of a file, which he held in his hand, against his left eye. The file broke across, and a portion of it remained in the orbit. The patient was carried, in a state of insensibility, to a small town some miles off, where three surgeons tried by turns, but in vain, to extract the foreign body, which, with the probe and the forceps, they felt distinctly, through the wound, beneath the mid- dle of the eyebrow. They enlarged the wound with the knife, and during three days made reiterated attempts at extraction; but the foreign body continued immovable. On the 4th day, the patient was brought to the surgical clinic at Prague. The eyelid was greatly swollen, and in the middle of it there was a triangular wound, with inverted edges. The eyeball was motionless, and was so pushed downwards and outwards that it almost lay on the cheek, carrying the lower eyelid before it. The cornea presented a more than ordinary degree of lustre. The patient was nearly comatose. Fritz endeavored, by means of strong pincers and polypus-forceps, to withdraw the foreign body, but these instruments bent under the pressure. At last, with a pair of small but very strong lithotomy-forceps, which he grasped with both his hands, he suc- ceeded in extracting the piece of the file. It was triangular, measured an inch and a half in length, and was denticulated to its point, which was blunt. The patient answered questions very slowly, or not all; his face was pale and sunk, his eyes were shut, and he lay motionless, except that he often raised his left hand to the left side of his head. Respiration slow; pulse oppressed and hard. The wound gaped widely; the eyelid, almost completely divided into lateral halves, was of a dark red color, and so much swollen as to allow only a small portion of the displaced eyeball to be seen. Notwithstanding the repeated use of venesection and of leeches, and constant cold applications to the eyes, the cornea filled with pus, and giving way about the 12th day, allowed the iris to protrude. The cornea was ultimately left in an opaque and atrophied state. The wound suppurated abundantly, and for some time a probe could be passed along it, in a direction backwards and inwards, beneath and through the orbitary por- tion of the frontal bone, to the depth of five inches, without causing pain. At length the wound closed, the upper eyelid remaining palsied. The patient's general health was per- fectly restored.33 Case 29.—A girl, 10 years of age, playing along with other children, near a cotton- spinning machine, fell upon one of the pointed iron spikes, 5 or 6 inches long, on which the bobbin is placed. This instrument penetrated to the depth of about 2 inches into the orbit, between the inner wall and globe of the eye, and then broke across, so that 2 or 3 lines' length of it projected above the level of the skin. Attempts were made to remove it; but so much difficulty was experienced, that these attempts were not persisted in. Ten days afterwards the piece of iron was found protruded to the length of 9 or 10 lines; a month afterwards, it was still more protruded ; in fact, it now held apparently so slightly, that it was laid hold of with the fingers and extracted. Scarcely had this been done, when the child was seized with convulsions, and died in a quarter of an hour. The sight had not been affected during the residence of the foreign body in the orbit, nor had its presence there excited any very marked symptoms. The child had always been able to go about.34 8. Eyeball dislocated.—It is important to observe that mention is made by different surgical authors, of the eyeball being dislocated, or pushed out of its 60 UNDETECTED WOUNDS OF ORBIT. socket by a foreign body thrust into the cavity, or traversing the sides of the orbit. Xow, in such cases, it is necessary not only to remove the foreign body, but to reduce the eye. This has sometimes been done with complete restoration of vision. By being dislocated, or pushed out of its socket, is to be understood, that the eyeball is extruded beyond the fibrous layer of the eyelids; that layer which is a continuation of the periosteum, and lies beneath the orbicularis palpebrarum. Of course, the optic nerve must be put on the stretch by such an accident, and the eyelids can no longer be made to close upon the pro- truded eyeball. Case 30—Mr. B. Bell relates a case, in which the eye was almost completely turned out of its socket, by a sharp pointed piece of iron pushed in beneath it. The iron passed through a portion of the orbit, and remained firmly fixed for the space of a quarter of an hour, during which period the patient suffered exquisite pain. He saw none with the dislocated eye; and the protrusion being so great as to lead to the suspicion that the optic nerve was ruptured, Mr. Bell doubted whether it would answer any purpose to replace it. He found, however, on removing the wedge of iron, which, being driven to the head, was done with difficulty, that the power of vision instantly returned, even before the eye was replaced. The eye was now easily reduced to its original situation; inflammation was guarded against, and the patient enjoyed perfect vision.35 9. Undetected wounds of orbit—Foreign body not removed.—The foreign body, by which a wound of the orbit has been inflicted, has in some cases been left unremoved, from the fact of its presence not having been suspected, or from the surgeon not having instituted a sufficiently strict examination of the wound with the probe; while, in other cases, it has been left in the orbit, or within the cavity of the cranium, from an impossibility of removing it with safety. The recorded instances of foreign bodies, driven through the orbit by mere manual force, and left within the cavity of the cranium, are but few. Nu- merous cases of gunshot wounds, however, in which the ball or other foreign body was left within that cavity are recorded; and it is evident that the effects, so far as the mere presence of the foreign body is concerned, must be much the same, whether it has passed through the orbit into the brain by manual or by explosive force. Death, under such circumstances, is almost certain to be the result, either immediately or in the course of a few days; although some remarkable cases have happened, of extraneous bodies lying for years in the very brain itself, without causing any apparent inconve- nience.38 Case 31.—A lieutenant in a Highland regiment, running in a dark night to escape a shower of rain, came in contact with an irritable old man, who made a thrust at him with an umbrella, the point of which struck him immediately beneath the left eyebrow. The wound was attended with so little pain or shock to the system, that the gentleman walked a distance of at least half a mile, to Sir Philip Crampton's house; and having mentioned the occurrence as one to which, however, he attached no importance, begged Sir P. to look at the wound on the eyelid, which still continued to bleed slightly. Sir P. found a wound of about three-fourths of an inch in length in the upper eyelid, exactly in the seat of the fold formed in this part by the action of opening the eye, and looking up. When the eyeball was so turned, there was no appearance of wound; but when the eyelid was drawn downwards, the wound gaped and showed the conjunctiva, which still completely covered the upper portion of the ball of the eye. Vision was quite unimpaired. The wound having been united by two points of suture, the patient took his leave and walked home. Sir P. called on him next morning, and found him at breakfast, making no complaint, but of some stiffness in the eyelid. Next morning at seven o'clock, Sir P. was called to him in a hurry, and found him in so strong convulsions, that it was with difficulty two persons were able to keep him from working himself out of bed. The convulsions continued, with short intervals of coma, till eight or nine o'clock in the even- ing, when he expired. At the post-mortem examination, it was found, that the brass ferrule of the umbrella, nearly two inches long, had penetrated the orbital plate of the frontal bone, and was lodged in the substance of the left hemisphere of the brain; it was imbedded in a thin INCISED WOUNDS OF THE ORBIT. 61 coagulum of blood, which extended into the left lateral ventricle; both ventricles contained a small quantity of bloody serosity.37 As to foreign bodies which have not touched the brain, but merely passed through one or other of the sides of the orbit, and are left remaining, they give rise to more or less irritation, destroy the bones more or less extensively, take different routes for their escape, but, in most instances, appear to pass either through the maxillary sinus, or by the spheno-maxillary fissure into the fauces, and are discharged in very various spaces of time. Case 32.—Marchetti had under his care a beggar, who, asking charity rather importu- nately one summer's day from a Paduan nobleman, this testy personage struck the beggar with the handle of his fan, in the inner angle of the eye, and with so much force, that a portion of the fan, three inches long, broke through the orbit, and sunk out of sight in the direction of the palate. When the man came to the hospital, Marchetti removed some small bits, which he found sticking in the angle of the eye, combated the inflamma- tion, allowed the wound to close, and dismissed the patient as cured. In three months he returned with a large swelling in the palate, which, when Marchetti cut into, his knife struck upon the handle of the fan, which he immediately extracted with a pair of forceps. The patient speedily recovered.38 Case 33.—Mr. White relates the case of a person, to whom it happened that, as he sat in company, the small end of a tobacco-pipe was thrust through the middle of the lower eyelid. It passed between the globe of the eye and the inferior and external circumfer- ence of the orbit, and was forced through that portion of the os maxillare which consti- tutes the lower and internal part of the orbit. The pipe was broken in the wound, and the part broken off, which, from the examination of the remainder, appeared to be above three inches, was quite out of sight or feeling, nor could the patient give any account of what had become of it. The eye was dislocated upwards, pressing the upper eyelid against the superior part of the orbit; the pupil pointed perpendicularly upwards, the depressor oculi was upon the full stretch, and the patient could see none with that eye. Mr. White applied one thumb above and the other below the eye, and after a few attempts at reduc- tion, it suddenly slipped into its socket. The man instantly recovered perfect sight, and suffered no other inconvenience than that of a constant smell of tobacco smoke in his nose for a longtime after; for, as he informed Mr. White, the pipe had just been used before the accident. About two years'afterwards, he called upon Mr. White, to acquaint him that he had, that morning, in a fit of coughing, thrown out of his throat a piece of tobacco-pipe, measuring two inches, which was discharged with such violence, as to be thrown seven yards from the place where he stood. In about six weeks he threw out an- other piece, measuring an inch, in the same manner, and never afterwards felt the least inconvenience.39 In illustration of the length of time which a foreign body may take in this way to escape, I may notice the following case, related in a letter to Horstius:— Case 34.—A boy of 14 years of age was struck by an arrow, while amusing himself in his play-ground. It stuck fast in the orbit; but the boy pulled it out, and threw it on the ground. A surgeon arrived, to whom the playfellows of the boy who was wounded showed the arrow, deprived of its iron point. With a probe the surgeon attempted to examine the wound; but, on the boy fainting, he desisted, so that the iron point was left in the orbit. The external wound healed, and the boy recovered; the eye remained clear and movable, but deprived of sight. This happened in the beginning of August 1594, and nothing more was heard of the iron point, till October 1624; when, after an attack of fever and catarrh with a great deal of sneezing, it descended into the left nostril, whence, taking the way of the fauces, it came into the mouth and was discharged. Dur- ing the whole thirty years and three months that it had remained in the head, it had not been productive of any pain.40 § 8. Incised Wounds of the Orbit. Sabre-wounds of the head have sometimes been attended by a cleaving of the orbit; and, in some rare instances, the orbit has been laid open, by an entire separation of part of its parietes, so as to expose its contents to view. The following cases illustrate this class of injuries of the orbit:— Case 35.—Marchetti shortly states the case of a German soldier, who was wounded in the forehead, with a broad and heavy sword. The frontal bone and the brain were 62 INCISED WOUNDS OF THE ORBIT. divided, down to the eyes, and the patient was immediately deprived of sight. ^In two months, he recovered from the wound, but continued blind, with the pupils clear. Case 36.—Edward Power received a desperate wound with a backsword, extending from the top of the frontal bone to the orbit of the left side, forming an extended and frightful chasm, in which were included the bone, membranes, and brain. The wound bled considerably, and was for nearly three hours exposed to the open air, the patient not having so much as a rag to cover it. Fever and inflammation of the brain might have been apprehended; yet by a couple of bleedings, and some other antiphlogistics, the man was completely cured in five weeks, without exfoliation, or the slightest ope- ration. ** The following case shows the propriety of attempting union by the first intention, even when part of the osseous parietes of the orbit is completely separated by an incised wound :— Case 37.—A young man received a wound with a cutting instrument, extending ob- liquely from the upper part of the left temporal fossa, across the root of the nose, to the right fossa canina. This wound divided the skin, the temporal branches of the portio dura, the anterior auricular muscle, part of the temporal muscle, orbicularis palpebra- rum, and corrugator supercilii, the frontal branch of the ophthalmic nerve, and the superciliary artery. These parts hanging over on the cheek, formed a flap, in which were also present a portion of the orbitary arch of the frontal bone and its external an- gular process, so that a portion of the cavity of the cranium was laid open, as well as the cavity of the orbit, exposing to view the globe of the eye, and the motion of the brain. The nasal nerve and artery, the pyramidal muscles, and, to a small extent, the bones of the nose, were divided; from the nose to the right fossa canina, only the skin was divided. The portion of brain laid bare appeared unhurt; the eye also seemed perfectly sound, none of its parts having been touched, except the levator palpebrse superioris, which, having been cut across in the middle, presented its anterior half in a state of re- laxation, and dragged downwards and forwards by the flap which lay upon the cheek. The patient had neither experienced any concussion, nor become insensible; but, when M. Ribes saw him, was in a state of considerable depression. A surgeon, who had been called before M. Ribes arrived, had already dressed the wound. Perhaps, in imitation of Magatus, who directs in such cases that a plate of gold or lead, drilled through with holes, be applied over the dura mater, and that the, edges of the wound be simply brought together, without supporting them by sutures, this surgeon had placed between the lips of the wound a bit of linen spread with cerate on both sides, in order to give vent to the suppuration, which no doubt would have followed; he had then brought the flap into its place, and supported it by a roller. M. Ribes removed the piece of linen, and brought the edges of the wound exactly together, retaining them by strips of adhesive plaster. In six weeks the patient was cured, without fever or suppuration. The eye, however, which had been exposed, became blind, and the upper eyelid re- mained motionless. Ten years afterwards, the eye still preserved its form and transpa- rency, but had shrunk in size. M. Ribes is of opinion, that the blindness in this ense was a sympathetic effect, produced upon the retina by the division of the branches of the fifth pair. He regards the retina, not as a mere expansion of the optic nerve, but as a nervous membrane into which enter branches of the great sympathetic, and of the ciliary or iridal nerves, as well as the fibrils of the optic nerve; whence injuries of the great sympathetic, or of the fifth pair, may, he thinks, produce blindness, although in the first instance the optic nerve has not been affected.43 Although the separated piece of the orbit appears to have united in this case, it sometimes happens that only the soft parts unite, while the bones continue divided. Of this, we have an example in the following case, related by Dr. Hennen :— Case 38.—An officer received, at the battle of Waterloo, a sabre-wound across the eyes, cutting obliquely inwards and downwards to such a depth as to admit of a view of the pharynx. One eye was destroyed; and the hiatus was so great, that it was neces- sary to support the upper jaw by morsels of cork put into the mouth in such a way as to act as fulcra, but admitting the passage of liquid nourishment. After the wound was dre*sed on the field, the patient was sent to Brussels, where he fell into the hands of a Belgian barber, who stupidly cut out the ligatures, removed the straps by which the lower portion of the face was kept in position, and 6tuffed the parts with eharpie. This was not removed for several days, after which the parts were again brought into apposi- tion by straps and bandages, but with great pain and consequent delirium. The patient recovered, granulations sprouting up at all points, and the soft parts uniting, but not the bones.41 DIRECTIONS OF PROJECTILES THROUGH THE ORBIT. 63 § 9. Gunshot Wounds of the Orbit. Gunshot wounds of the orbit, and wounds caused by other explosions, present much greater variety in their direction than any other wounds of this part. They also vary much in the depth, extent, and effects of the in- jury which they produce. 1. Exterior parts of orbit uninjured.—The superciliary ridge, and the other exterior parts of the orbit, are often the seat of gunshot injuries. Sometimes a ball traverses the outer wall of the orbit. In other cases, the person bending forward at the moment of receiving the wound, the ball passes through the superciliary ridge, whence it generally descends through the floor of the orbit into the maxillary sinus, or into the nostril, destroying the eye- ball in its course. The frontal sinus, when much developed, separates the two tables of the orbitary plate of the frontal bone, so as to form a cavity in which musket-balls have frequently been known to lodge. This is generally attended by depres- sion of the inner table, so as to render necessary the operation of trepan.45 The surgeons of former days refrained from trepanning these sinuses, partly from fear of an incurable fistula following the operation, partly from the diffi- culty of sawing through two plates of bone placed obliquely in regard to each other, without wounding the dura mater ; but the fear of a fistula is now laid aside, and the second difficulty is in some degree obviated, by employing two trephines, a large one for the external, and a smaller one for the internal table. In this way, a depression may be raised, or a ball, fixed perhaps in the internal table, or in the roof of the orbit, may be removed. Sometimes a ball has been left in the frontal sinus, whence it has slowly made its way. Case 39.—The French General T. received a ball in the left orbit, at Waterloo. After lacerating the eyeball, it traversed the superior internal wall of the orbit, and lodged in the frontal sinus. It remained there for 12 years, without producing any remarkable effects, after which time the patient awoke one night with the sensation of something falling into his gullet. It was the ball, which he immediately coughed out.46 2. Bones of orbit susceptible of reunion.—The bones of the orbit, shattered by a ball, are still, in some cases, susceptible of reunion, and ought not, therefore, to be hastily removed, although they are felt to be loose after an injury of this kind. The copiousness with which all the parts of the face are supplied with blood, communicates to its bones a power of recovery, greater than that usually found in the osseous system. Case 40.—Poneyes had under his care a soldier, in whom a musket-ball had shattered the anterior part of the frontal sinuses, the upper part of the bones of the nose, and the right orbit towards the inner angle. « He fell instantly on receiving the wound, vomited soon after, became insensible, and bled at the nose. Poneyes removed the portion of bone forming the frontal sinuses, leaving the bones of the nose and the injured portion of the orbit loose. The posterior part of the frontal sinuses was not fractured. Delirium came on with drowsiness; but after the patient was repeatedly bled, those symptoms ceased. The loose pieces of bone reunited, and cure was completed in two months and a half.47 3. Different directions of projectiles through the orbit.—Balls passing di- rectly backwards through the orbit, are generally fatal, from entering the brain ; whereas, those which enter the orbit obliquely, though generally de- structive of vision, either by striking the eyeball, or dividing the optic nerve, very frequently leaving the brain untouched. A ball passing transversely, or with only a slight degree of obliquity, through one or both orbits, proves fatal, if the cribriform plate of the ethmoid is fractured, the shock communi- cated by the crista galli to the brain and its membranes being followed by cerebritis and meningitis. Dr. John Thompson mentions a case, in which the ball entered nearly in 64 BALLS TRAVERSING BOTH ORBITS. the middle, between the frontal sinuses, passed across the left sinus, and seemed to lodge in the cavity of the orbit, producing blindness, with groat swelling of the'eve, and of the parts surrounding it. In another case, where the millet entered "the face on the upper and left side of the nose, and passed out anterior to the right ear, the patient was affected with amaurosis of the right eye. The left eve was similarly affected, in a case where the ball entered the n»nt side of the nose, and came out in front of the left ear. In one case the hall entered at the inner angle of the left eye, and passed out in front ot the lett ear. In another, the ball entered above the inner angle of the right eye, ana passed out of the right ear. In both these cases, the eye of the side on which the ball passed was destroyed. In one case, in which the ball entered the right eye, and passed out midway between the left eye and ear, the lett eye was affected with amaurosis.4!* Case 41 — Wepfer* has recorded the case of a person, accidentally shot by his fellow- traveller, while resting on the ground. The ball entered a little below the lobe of the ri«rht ear, and passing behind the angle of the jaw, above the roof of the palate, and behind the root of the nose, traversed the left orbit, and made its exit through the upper eyelid. The eyeball was forced from its place, so that it hung out of its socket, with the cornea in a state of laceration ; and at the same time a portion of the frontal bone was separated from the rest of the orbit. Blood was discharged from both apertures of the wound, and from the nostrils and mouth ; and for some days it flowed whenever the patient made any exertion. In the course of the cure, no pus came from the nose or mouth. The patient had no convulsions. He was always able to swallow, although at first he found it difficult to masticate, or to open his mouth. The right eye and the neighboring parts were ecchymosed for a number of days. From the aperture caused by the exit of the ball, laudable pus was copiously discharged; an abscess forming above the inner angle of the eye, an incision was made into it, above an inch in length, and kept open until some loose fragments of the frontal bone came away; after this it closed. At first the eyeball was not only extruded from the orbit; but the muscles, lachrymal gland, and fatty cellular substance were exposed to view. Pus was discharged, but not very copiously, from the orbit; the eye retreated into its place ; and a thick fold of conjunctiva being removed with the scissors, the parts healed. Purulent matter was copiously discharged from the aperture near the angle of the jaw, which was kept open for 18 weeks, till some fragments of bone came away; after which the patient perfectlv recovered, but with the loss of his eye. Case 42.—At the battle of Pultusk, a cannon-ball striking and giving impetus to a bayonet, the latter penetrated the right temple of a soldier, at the distance of two fingers' breadth behind, and a little above the orbit; and taking a direction forwards and down- wards, traversed the left maxillary sinus, whence it protruded to the length of 5 inches. The surgeon, on the field of battle, tried in vain to extract the bayonet; but a comrade, making him sit down on the snow, and putting his foot on the wounded man's head, drew it out with both his hands. The patient recovered in three months, with the loss of the right eye.50 4. Balls traversing both orbits.—Many instances are recorded of balls passing through the orbits from temple to temple. Case 43.—Heister relates51 a case of this sort. The person recovered; only he became blind the very moment he received the shot, and remained so ever after. The entrance and exit of the ball were exactly in the angle which the zygoma makes with the process of the malar bone going up to join the frontal, and of course the ball must have passed through the posterior part of each orbit, probably dividing the optic nerve and the muscles of both eyes, without wounding either the eyeballs or the brain. The eyes appeared quite clear, and without inflammation, but fixed, and totally deprived of sight. In such wounds, many different parts are exposed to injury; and by the subsequent effects we may sometimes determine what structures have actually suffered. The outer and inner walls of the orbit will be reduced to splinters, and, perhaps, the cribriform plate of the ethmoid; the temporal muscle and its aponeurosis, numerous nervous filaments from the portio dura, and from the three divisions of the fifth nerve, and numerous branches of tlie external and internal maxillary artery, will be divided; while the nerves within the BALLS TRAVERSING BOTH ORBITS. 65 orbit, as well as the muscles of the eye and the branches of the ophthalmic artery, will suffer more or less severely. A gunshot wound which traverses both orbits, must be regarded as less dangerous than one in which the ball does not pass so directly across from one side of the head to the other; but either from being directed backwards in its course, enters the brain, or from its force being partially spent, lodges among the bones. Speaking of the wounded before Mons, in 1709, Heister states that, for the most part, those who had received a wound only in one temple, died either immediately, or soon after. Dr. Thomson tells us that he saw from eight to ten patients, after the battle of Waterloo, in whom musket-balls had passed behind the eyes from temple to temple. In all of them, there was great swelling, pain, and tension of the head and face. He mentions, that a careless examination would have led one to suppose that, in these cases, the balls had entered the cavity of the cranium; and remarks, that cases of this kind are recorded, in which the blindness which followed is supposed to have been produced by the balls in- juring the inferior part of the anterior lobes of the brain; but that, most probably, in such cases the brain is untouched. In one case observed by Dr. Thomson, where the ball had passed behind the eyes from temple to temple, one eye was destroyed by inflammation, and the other affected by amaurosis. In another case, where the ball had taken pre- cisely the same direction, both eyes were affected with amaurosis, without any inflammation being produced. He remarks that, in some of the patients in whom amaurosis had followed, there was reason to believe, from the course which the balls had taken, that the optic nerves were divided; but that in a considerable proportion of those so affected, it was obvious that the balls had not come into contact with those nerves. Various instances also occurred, in which the bullet, penetrating through both eyeballs, had passed behind the bridge of the nose, and left it unbroken. In one of the cases, in which the ball had passed below and behind the eyes, the patient was affected, at the end of some weeks, with painful spasms in the, face, which, in their severity and mode of attack, bore a resemblance to tic douloureux.52 Case 44.—A case by Valleriola is often quoted,53 of a soldier through whose head a ball passed from temple to temple, entering by the left, and coming out a little higher on the right side. Apoplectic symptoms followed, from which he recovered; but he remained blind and deaf. Case 45.—In one of the engagements between the French and the Algerines, in 1830, a French corporal received a ball through the orbits. It entered an inch behind and six lines above the external angular process on the right side, and came out at the point diametrically opposite. The patient presented symptoms of concussion of the brain, and Dr. Baudens54 was of opinion that the anterior and inferior surface of the cerebrum was injured. Although gunshot wounds are not in general attended by much hemorrhage, the patient, in this instance, was covered with blood, which flowed from the temples, and still more from the nostrils. When he arrived at the ambulance, he was in a state of syncope, which served to arrest the bleeding. The face was considerably swollen, and especially the naso-orbitary region. The splinters were removed; the wounds were washed, dressed, and covered with large compresses wrung out of cold water. These were continued for six days, as well with the view of preventing inflammation within the head, as of retarding the flow of blood. Dr. Baudens did not wish to arrest the bleeding altogether, as it contributed, he thought, to the safety of the patient. During the first fifteen days, there was occasional delirium ; but this symptom was moderated by cold applications to the head, along with the abstrac- tion of blood by cupping between the shoulders. A multitude of small maggots formed in the orbits aud nostrils. Fearing they might penetrate to the brain, Dr. Baudens de- stroyed them by a weak solution of corrosive sublimate. Among the effects of this injury, the following are particularized by Dr. Baudens. A feather pushed into the nostrils produced no sensation ; but any sharp body was distinctly felt. This organ, although not entirely deprived of sensibility, was not affected by any annoying itchiness from the presence of the maggots. The cornere became opaque, and 5 66 BALLS LEFT WITHIN THE CRAM I'M. were destroyed, so that the eyes sunk. The sense of smell was lost, and the sensibility of the palate was blunted. The intellect was weakened. The patient preserved the memory of what had happened to him previously to the injury; but, alter this, nut even the incidents of the evening could be recalled on the following morning. He was not aware of the extent of his misfortune, and still cherished the hope of being restored to sight. The wounds were cicatrized two months after the receipt of the injury. 5. Balls sometimes extracted from the orbit; in other cases left nnrcmort'd.—. A ball which has penetrated through one or other of the sides of the orbit may, in some cases, be detected and extracted. In other cases, it cannot be extracted, nor its course ascertained; so that, if the individual survives, it must be left to make its way out by the fauces, or by some other route. Even grains of small shot, traversing the walls of the orbit, or fixing in them, should be traced, and, if possible, extracted. Left in the substance of the bones, they are apt to give rise to exostoses. In those cases in which a musket-ball is left, we must lay our account with long-continued and severe pain, caries, exfoliation of the bones, deep-seated formations of matter, sloughing of the mucous membranes, puffy swellings on the surface towards which the ball is approaching, and a very tedious recovery. Sinuses form, in such cases, before the ball makes its exit, and continue after it has escaped; and to dry them up is generally attended with danger. We must wait till the parts within have become healthy, and then the sinuses will close of themselves. Case 46.—Dr. Hennen mentions55 the case of a soldier, who was brought to him some weeks after being wounded, for the purpose of having a ball extracted, which gave him excessive pain, impeded his respiration and deglutition, prevented his speaking distinctly, and kept up an irritation in his fauces, attended with a constant flow of saliva, and a very frequent inclination to vomit. On examination, it was found to be lodged in the posterior part of the fauces, forming a tumor behind, and nearly in contact with the velum pendu- lum. It had passed in at the internal canthus of the eye, fracturing the bone. Although blindness was the instant effect, the globe of the eye was not destroyed; and the remaining cicatrice, and the very inflamed state of the organ, were the only proofs that an extra- neous body had passed near it. Case 47.—One of the most remarkable cases of a ball penetrating through the orbit, and making its way out of the head, is that of Dr. Fielding, who was shot at the battle of Newberry, in the time of the Civil Wars. The ball entered by the right orbit and passed inwards. After 30 years' residence in the parts, and a variety of exfoliations from the wound, nose, and mouth, and the formation of several swellings about the jaw, it was at last cut out near the pomum Adami.56 Case 48.—A soldier of one of Napoleon's armies was struck just above the left orbit by a musket-ball; but, as a fellow soldier fell dead at the same time by his side, he be- lieved the ball had rebounded from his own head and killed his comrade. For more than 24 years he was subject to violent pains in the left eye, and in the head; and this eye projected much from the orbit. The surgeons under whose care he was placed from time to time, believing his story of the rebounding of the ball, afforded him little or no relief. In 1837, he came to the hospital at Verona, when Dr. De Borsa, on examining the case, came to the conclusion, that the projection of the eye, which commenced soon after the accident, could be caused only by the persistence of the foreign body in the orbit, as any exfoliation of bone which the blow might have occasioned, would, in the course of so many years, have been discharged or absorbed. A portion of bone was, therefore, removed from the orbit by the trephine. The track of the ball was found ossified, excepting at a small aperture, whence issued from time to time a little fluid. After the bone was removed, the ball was felt, by means of a probe, at the back of the orbit, and extracted by means of a forceps. The eye now retreated into the orbit, and, after some weeks, became atrophic. The violent pains were quite re- lieved, and the patient lived for five years, to die then of pleuro-pneumonia. On examina- tion, it was found that the cranial cavity had not been penetrated by the trephine ; but opposite to where the bone had been removed, was a deposit of osseous substance.57 6. Balls or other foreign bodies, passing through the orbit, left within the cranium.—Although it generally happens that gunshot wounds of the orbit, penetrating into the brain, prove immediately mortal, yet, in some rare cases, BALLS TRAVERSING THE BRAIN. 67 the ball or other foreign body has been known to remain within the cranium for a length of time, without producing much disturbance. Case 49.—Petit related in his lectures the case of a soldier, who received a musket- shot in the inner angle of the eye. It seemed a very simple wound, and healed under the common hospital treatment. The man thinking himself cured, determined to leave the hospital, although advised by the surgeon to remain some time longer. Scarce had he reached the door when he was seized with rigors, obliged to return, and died in two days. On dissection, the ball was found lodged under the sella Turcica and optic fora- mina. An abscess was present in the brain.58 Case 50.—Dr. Hennen mentions59 the case of a French soldier, wounded at Waterloo. The ball entered the right eye ; the left, though not in the slightest degree injured to ap- pearance, became completely blind. Dr. H. felt under the zygoma, and all along the neighborhood of the wound, but in the puffy state of the parts could not detect the course of the ball. The patient himself was confident it had gone into his brain. He returned to France convalescent. In contrast to the cases in which a very small injury of the brain, through the orbit, has been followed by instant death, may well be placed those in which such a substance as the breech of a gun, a piece of iron measuring up- wards of three inches in length, and weighing more than three ounces, has been projected through the frontal bone into the brain, and been extracted, in one case, two months, and in another twenty-seven days after the accident. In the first of the cases referred to, Mr. Waldon's, the roof of the orbit seems to have been destroyed; as through it one of the screw-pins of the lock was extracted. The patient died three days after the extraction of the breech from the brain.60 In the second case, Dr. Rogers's, the patient recovered with the loss of an eye.01 7. Balls or other foreign bodies passing through ihe orbit, and at the same time traversing the brain; loss of substance of the brain, in gunshot and other wounds of the orbit.—The effects of such wounds must, in general, be similar to those described in the following case by Wepfer, in which it is surprising that death did not ensue more speedily. Still more remarkable are those in- stances, in which gunshot and other explosive wounds, traversing the orbit and the brain, have been followed by recovery. Case 51.—A huntsman, says Wepfer,62 holding the upper end of his gun with his hand, accidentally touched the trigger with his foot. The piece went off, and two balls enter- ing by the right side of the lower jaw, traversed the left orbit, and made their exit through the left parietal bone, near the lambdoid suture. The left eye was driven from its orbit. The patient's mind seemed entire, and he moved all his limbs till the close of the 4th day. At that time he began to sing; but an hour or two before death his speech became indistinct, although he still testified by nods that he understood what was said to him. He began to toss about hie arms, as if in pain; short fits of a convulsive kind came on; he raved during the night; and died on the 5th day. During life, a copious ichorous discharge took place from the aperture in the jaw. On dissection, the course of the ball through the brain was traced from the parietal bone to the neck of the orbit. and was observed to be filled with the same sort of ichor as had flowed from the jaw during life. * The following case of recovery from a gunshot wound traversing the orbit and the cranium, in several respects resembles Mr. Cagua's case of fractured *orbit, referred to at page 51:— Case 52.—A lad of 17 years of age was wounded by a musket-ball, which, passing from below upwards, penetrated through the upper lip, the right nostril, and the roof of the orbit into the cranium, whence it escaped at the upper part of the frontal bone near to the sagittal suture, where it made a large wound of the integuments, with loss of sub- stance. Such a degree of swelling came on as made the head frightful. An incision was made over the wounded part of the orbit, whence, at the first dressing, there came out a portion of both substances of the brain, in bulk about the size of a small hen-egg. The eye was exceedingly swollen, especially the upper eyelid, into which an incision was made, to give issue to the blood which was supposed to be there extrava- sated: but, instead of blood, there came out a splinter of bone and a portion of both substances of the brain, nearly equal to a third of the portion which had formerly come 68 PART OF THE ORBIT SHOT AWAY. away. The wounds were dressed lightly, and the patient was repeatedly bled. Some small portion of brain was again discharged. On the 4th day, the brain appeared to l>e in a state of suppuration ; on the 5th, the discharge became very considerable, r rom the time that he had been bled, the patient continued j.retty well till the 11th day. Next day he was more feeble. On the 13th day, the matter from the brain which had been discharged both from the wound above and from that below, was in part retained, and the patient fell into a state of drowsiness and general depression. M. Bagieu, who treated the case, having anew examined the wounds with minute atten- tion, removed a large piece of loose bone from the upper part of the skull. The patient did not appear to be relieved by this, but became worse till the 16th day, when every one ex- pected him to die. M. Bagieu remarked, that on pressing the skin where he had removed the piece of bone, pus oozed out, which made him suspect that there was an accumulation of matter at that place. Led by this idea, he removed the skin, and some portions of dura mater, so as freely to re-establish the discharge. The pulse rose, the patient was next day able to speak, and afterwards the suppuration slowly subsided. About the 19th day, the fleshy parts began to granulate, and the wound on the upper part of the head was soon covered over. It was otherwise with that of the eyelid, where supervened a considerable fungus, occasioned by the splinters separating from the neighboring bone. In spite of cutting and burning this fungus, it was found necessary to wait patiently till all these splinters had come away; after which the excrescence was easily destroyed, the wound closed, and the patient recovered completely.63 Still more remarkable, in some respects, are the two following successful cases:— Case 53.— Nicholas Joseph Brune, aged 17, wishing to unload a musket, began by ex- tracting the balls with the common screw used for that purpose, but was foiled in at- tempting to remove the paper and the powder. He tried in vain to make the piece go off, priming it repeatedly for that purpose. At last, he resolved to bring the thick end of the ramrod to a strong heat, and introduce it into the barrel of the gun. The instant this was done the powder exploded, and the ramrod was driven against the inner part of Brune's right orbit, where the os unguis is united to the nasal process of the superior maxillary bone. Directing its course upwards and backwards, it came out by the right side of the superior angle of the occipital bone, to the length of ten inches. On hearing the explosion, the father in terror ran to the assistance of his son, who had fallen to the ground. He instantly raised him, and, seizing the thick end of the ramrod with both his hands, drew it out of his head. About two ounces of blood flowed from the two openings, whence escaped also some portions of brain. A surgeon dressed the wounds, enjoined abstinence, but did not bleed. No bad symptoms occurred, except that the right eye became violently inflamed, and was lost. A considerable quantity of pus came from the wounds, and between the 3Cth and 52d days, some small exfoliations were discharged. Three months after the accident, the cicatrization was complete. Professor Ansiaux afterwards repeatedly examined the patient, and exhibited him to his pupils. His health was perfect, and he was able to labor at hard work.64 Case 54.— Phineas P. Gage, 25 years of age, was charging with powder a hole drilled in a rock, for the purpose of blasting. It is customary when filling the hole to cover the powder with sand. The charge having been adjusted, Gage directed his assistant to pour in the sand ; and at the interval of a few seconds, his head being averted, and supposing the sand to have been properly placed, he dropped the iron bar as usual upon the charge, to consolidate it. The assistant had failed to obey the order; and the iron striking fire upon the rock, the uncovered powder was ignited, and an explosion took place. Gage was at this time standing above the hole, leaning forward, with his face slightly averted; and the bar of iron was projected directly upwards through his head, and high into the air. The wound thus received, was oblique, traversing the cranium in a straight line from the angle of the lower jaw on the left side to the centre of the frontal bone above, near the sagittal suture. The iron weighed 134; lbs.; it was 3 feet 7 inches in length, and 1J inch in diameter. The end which entered first was pointed, the tapering part being seven inches long, and the diameter of the point £ inch ; circumstances to which, perhaps, the patient owed his life. It was picked up at a distance of some rods from the patient, smeared with brains and blood. Notwithstanding considerable hemorrhage and loss of cerebral substance, the patient recovered in the space of about two months, the left eye remaining amaurotic, and inca- pable of being turned outwards or upwards, and the upper eyelid in a state of ptosis.__ In the course of the cure there occurred no signs of compression, concussion, nor inflam- mation of the brain. The case was treated by Dr. Harlow, and is ably commented on by Professor Bio-clow.65 8. Part of the orbit shot away.—The temporal angle of the orbit is pecu- INJURIES OF THE ORBIT. 69 liarly exposed to this accident. Occasionally a considerable portion of the face, along with the lower edge, or the floor of the orbit, is destroyed; and yet recovery may follow. Even the roof has been so shattered, that it re- quired to be removed ; yet life has been preserved. Case 55.—Captain M., aged 38, a Freneh officer engaged against the Algerines, was wounded by a musket-ball, on the 1st of April, 1836. It entered at the lower external part of the base of the orbit, and came out behind the ear, carrying away the malar bone, with the exception of a part of its superior surface, and of its superior and infe- rior angles, which, notwithstanding their being quite loose, Dr. Baudens66 did not re- move. All the soft parts, as far as the ear, were lacerated, and presented a dreadfully contused wound, the bottom of which corresponded to the temporal fossa. By gently introducing his finger along the groove of the wound, Dr. B. withdrew some small splinters of bone, mixed with large clots of blood. He replaced the shattered bones which were still adherent, and preserved carefully the envelops of the globe of the eye, the humors of which had been evacuated, in order to obtain a stump, movable by the muscles of the eye, upon which a glass eye might afterwards be placed. Having pared the edges of the wound, he brought them together by stitches. The cure went on during two months ; there were no cerebral symptoms ; distressing tinnitus aurium was removed by local bleedings; the suppuration was not great; the edges of the wound united perfectly, leaving a linear cicatrice; there was no exfoliation. Case 56.—Guibon, aged 30, on the 10th December, 1830, received a wound by a case- shot, on the right inferior part of the frontal bone. The wound was contused and rag- ged, with splinters of bone driven in above the orbitary arch. All the splinters were re- moved, and a large portion of the roof of the orbit was extracted; there was a loss of cerebral substance ; but no loss of feeling, motion, or intellect. The cure was well ad- vanced by the 2d January.67 Case 57.—Louis Vaute" was struck obliquely on the face with a cannon-ball, which took away almost the whole of the lower jaw, and three-fourths of the upper. The two upper maxillary bones, the bones of the nose, the vomer, the ethmoid bone, both malar bones and zygomata were broken to pieces ; the soft parts corresponding to those osseous por- tions destroyed; the right eye burst; the tongue cut across; the fauces, and posterior apertures of the nostrils completely exposed, as well as one of the glenoid cavities. Such was the state of the wound, that the comrades of this soldier had laid him in a corner of one of the French hospitals at Alexandria, in the belief that he was dead. Indeed, when Larrey first saw him, the pulse was scarcely to be felt, and the body cold and without the appearance of motion. As he had taken nothing for two days, Larrey's first care was to administer to him, by means of an oesophagus tube, some soup and a little wine. His strength was re-ani- mated ; he raised himself, and testified by signs the most lively gratitude. Larrey washed the wound, removed the foreign substances which adhered to it, cut away the soft parts which were in a state of disorganization, tied several vessels which had opened in doing so, and brought the flaps together, as much as possible, by stitches. He also united by stitches the two portions into which the tongue had been divided. He covered the whole excavation with a piece of linen with holes cut in it, and dipped in warm wine, and then applied fine charpie, compresses, and a bandage. Every three hours, a little soup and some spoonfuls of wine were given with the gum-elastic tube and funnel. The dressings were frequently renewed, on account of the flow of saliva and other fluids. Suppuration was established, the sloughs separated, the edges of the enormous wound approached each other, and the parts which were brought together adhered ; 35 days after the injury, the man was in a state to be moved, and ultimately cicatrization was completed. After having been fed during the first 15 days through the tube, he was able to take nourish- ment with a spoon. The patient returned to France : and 11 years afterwards, when Larrey published his work,68 was alive, and in good health, in the Hotel des Invalides. He could even speak so as to make himself understood, especially when the large opening into his face was co- vered with a gilt silver mask. I have thus attempted to classify and illustrate the different injuries to which the orbit is liable, and the various effects which those injuries are apt to produce. There remain only two topics, on which I wish to say a few words. 1. Prognosis.—It is evident, from the cases which have been passed in review before us, that although, in general, immediate death is the conse- quence of an injury extending through the orbit to the brain, yet this is not 70 INJURIES OF THE ORBIT. always the case ; but that in some instances life has been prolonged for seve- ral days, and that in others the patient has completely recovered. Putting aside the important question, whether or not large vessels have been ruptured and blood extravasatcd, it is probable, that it is not so much the absolute amount of injury to the brain, as the suddenness with which it is inflicted, which renders wounds of the brain so generally fatal. AYe have ex- amples of disorganization of very considerable portions of the brain proceed- ing slowly, and yet life prolonged for years; while in perforation of the roof of the orbit, the smallest wound of the brain may prove immediately mortal. Pathologists generally attempt to explain the sudden and fatal effects of such wounds of the brain, by telling us, that thereby the heart, or the organs of respiration, are instantly deprived of the nervous energy necessary for con- tinuing their functions. But how it happens that death takes place instanta- neously in some cases of this sort, while in others the person suffers so little from sudden and severe injury of the brain, but lingers, like Mr. AValdon's patient with the gun-breech in his head, or recovers, like Mr. Cagua's, M. Bagieu's, and Dr. Harlow's patients, we cannot tell, any more than we can explain how one man shall have a limb carried off or shattered to pieces by a cannon-ball, without exhibiting the slightest symptom of mental or corporeal agitation, while deadly paleness, violent vomiting, profuse perspiration, and universal tremor, shall seize another on the receipt of a slight flesh wound. To say that all this depends on differences in nervous susceptibility, is only to repeat the fact in other words, not to explain it. 2. General Treatment.—In regard to the general treatment of injuries of the orbit, it is plain what that ought to be ; namely, quiet and rest; a spare diet; bloodletting, if the reaction demands it; opiates; laxatives; gentle diaphoretics; a mercurial pill occasionally, if the liver becomes irregular in its action, as from confinement it is very apt to do ; great cleanliness in regard to the injured parts; emollient cataplasms and soft light dressings, frequently renewed. We must not neglect the use of bloodletting, but we must beware of em- ploying this remedy too soon or too profusely. We must not omit to examine the injured parts frequently, in order, if there be any piece of exfoliated bone or foreign substance keeping up irritation, that it may be withdrawn, and as soon as the sloughs have separated, and the inflammation diminished, we must draw the edges of the wouud together, and keep them as nearly as possible in contact with one another; but, on the other hand, we must avoid too much poking and intermeddling, or attempting prematurely to close up the issues, by which matter and foreign substances may have still to escape. In some cases, it will be necessary to divide the soft parts, or even to apply the trephine, in order to allow an exit to extravasated blood, evacuate puru- lent matter, or remove depressed or detached pieces of bone. All other things being equal, the cure proceeds more favorably when there is a free outlet to the fluids extravasated or secreted in consequence of the wound. A simple fissure, with effusion of blood, being followed by inflammation, is often more dangerous than a fracture, with splinters, and even loss of part of the brain. 1 (Euvres d'Ambroise Pare1; Liv. x. cap. 9; Petit, in GSuvres diverses de Louis; Tome ii.p. Paris, 1607. 41 ; Paris, 1788. 2 Observations on Wounds of the Head, p. ' Duncan's Annals of Medicine, vol. i. p.358. 107 ; London, 1766. Edinburgh, 1796. 3 Quoted from the Journal de Mfidecine de e Musaeum Nosocomii Vindobonensis, p. 45; Corvisart, Dec, 1808, by Ansiaux, Clinique Chi- Vindobonaa, 1816. rurgicale, p. 48 ; Liege, 1829. 1 Clinical Lecture in the Royal Infirmary of 4 Nouveau Systeme du Cerveau, par F. P. du Edinburgh, March, 1828, p. 5. INJURIES OF THE ORBIT. 71 * Philosophical Transactions for 1740; Vol. xii. Part ii. p. 495. 9 Giafe und Walther's Journal der Chirurgie und Augenheilkunde ; Vol. ii. p. 192 ; Berlin, 1821. 10 Bright's Report of Medical Cases; Vol. ii. p. 36; London, 1831. 11 Memoires de I'Academie Royale des Sci- ences, Annee 1703, p. 355; Amsterdam, 1738. 12 Chopart, Memoire sur les Lesions de la Tete par Contre-coup, p. 1; Paris, 1771. 13 De Renunciatione Vulnerum, p. 168; Lip- friae, 1755. 14 See the French translation of this work, by MM. Laugier and Richelot, p. vii. Paris, 1844. 1 i Bell's Anatomy,Vol. i. p. 49; London, 1811. The thinness of the orbitary plate, like the thin- ness of the middle of the os ilium, or scapula, must be regarded as the natural constitution of the bone, and not at all as the effect of pressure by the brain, or rolling of the eye. 16 Ruyschii Observationum Centuria; Obs. 54; Ainstelodami, 1691. 17 Petri Borelli Historiarum et Observationum Centuria II, Obs. 19; Francofurti, 1676. 18 See a similar case by Diemerbroeck, in his Anatome Corporis Humani, p. 637 ; Ultrajecti, 1672. 19 Lancet, May 12, 1832, p. 190. 40 Joannis Schmidii Miscellanea; quoted by Bonetus in his Sepulchretum, Tom. iii. p. 380; Lugduni, 1700. 21 Medical Gazette, Vol. xxvii. p. 587; Lon- don, 1841. 22 See a similar case in Bright's Reports of Medical Cases, Vol. ii. p. 611; London, 1831. 23 Dublin Quarterly Journal of Medical Sci- ence ; Vol. xii. p. 226 ; Dublin, 1851. 24 Journal I carry. This is the reverse of the last disease ; for the tears are secreted and dis- charged too abundantly, and too frequently. Like xeroma, however, epiphora may be regarded rather as a symptom than as a disease in itself. Diagnosis.—Epiphora, or excessive lachrymation, must not be confounded with stillicidium lachrymarum. The difference is, that the latter arises merely from some incapability in the excreting parts of the lachrymal organs to remove the tears and the mucus of the conjunctiva, after they had done their duty; while epiphora is a disease of the secreting lachrymal organs, or an over-discharge of tears. Causes.—Any mechanical or chemical irritation, applied to the conjunctiva, a particle of dust, for example, on the inside of the upper eyelid, or a grain of salt intruding into the eye, instantly produces a discharge of tears, or epiphora. This is the natural means employed to wash away the foreign body, or to dilute the chemical substance. Inflammation of the eye, or eyelids, and especially phlyctenular inflamma- tion of the conjunctiva (the disease commonly known by the name of scrofu- lous ophthalmia), is an extremely frequent cause of epiphora. We observe that the subjects of the last mentioned disease, if they attempt to open the eye, are affected with instant epiphora and spasm of the orbicularis palpe- brarum. We can be at no loss to explain the connection between the eyelids, conjunctiva, and lachrymal gland, when we recall to mind that the lachrymal nerve, a branch of the first division of the fifth nerve, having passed through the lachrymal gland, spends its ultimate branches in the conjunctiva, orbicularis palpebrarum, and skin of the upper eyelid.1 In many cases of scrofulous conjunctivitis, the redness is slight, perhaps scarcely an enlarged vessel is to be seen on the surface of the eyeball, and as yet no phlyctenulse have made their appearance; but the epiphora, and intolerance of light, are acute. Epiphora is occasionally a symptom of disordered digestion, especially in children, and of worms in the intestines. Indeed, even when connected with scrofulous ophthalmia, we may regard both the ophthalmia and the epiphora as originating, in many cases at least, in improper food, and in disorder of the digestive organs. It may also be made a question, whether phlyctenular ophthalmia is not sometimes the consequence of lachrymation in children; the inordinate flow of tears being excited by the pain which accompanies teething, and by other causes. Profuse attacks of epiphora often attend hysteria and hypochondriasis, and are associated in such cases with exagge- rated feelings of affliction and mental depression. In such cases, all the symptoms are confirmed and aggravated, if recourse is had to dram-drinking. Treatment.—Before prescribing any remedy, general or local, for epiphora, let us assure ourselves that it depends on no mere mechanical irritation of the eye, such as that of an inverted eyelash, a particle of dust imbedded in any part of the conjunctiva, or minute growth on the internal surface of either eyelid. We seldom require to prescribe for epiphora alone. I have known it com- pletely and permanently removed by an emetic. A regulated diet, purgatives followed by tonics, and occasionally antacids, will be found highly useful, in removing some of the more common causes of the disease. A mixture of rhubarb and supercarbonate of soda repeated every day, or every second day, and followed up by a course of the sulphate of quina, is a plan of treat- ment which I have often found effectual. Of local remedies, the most useful. are the vapor of laudanum, and the 124 INFLAMMATION AND SUPPURATION OF THE LACHRYMAL GLAND. lunar caustic solution. Into a cup of boiling water, a teaspoonful of lauda- num is mixed, the cup held under the eye, the eyelids opened, and the vapor allowed to come into contact with the conjunctiva. The eye is then bathed with the mixture by means of a bit of old linen. This may be done twice or thrice a day. A tincture of belladonna, used in the same way as the lauda- num, is also serviceable. In some cases, nothing relieves more the irritability of the conjunctiva, on which epiphora so much depends, than a solution of from two to four grains of lunar caustic in an ounce of distilled water, dropped on the eyeball with a camel-hair pencil, once or twice a day. Blisters are useful in epiphora. They are perhaps more likely to be so, when applied before the ear, or on the temple, as they will then act more directly on the branches of the temporal nerves, which anastomose with the lachrymal nerve. 1 Soemmerring, Abbildungen des menschli- ternarum Oculi Humani Descriptio; g 162; cben Auges. p. 44; Tab. iii. Fig. 5; Frankfurt Lipsiae, 1810. am Main, 1801. Rosenmiiller, Partium Ex- SECTION IV.—INFLAMMATION AND SUPPURATION OF THE LACHRYMAL GLAND. § 1. Inflammation and Suppuration of the Glandulce Congregates. This is by no means an uncommon affection; and having somewhat the appearance of a hordeolum or stye, it often passes as such. The external angle of the eyelids is swollen, red, and painful; and if the upper lid is raised, several of the acini of the glandulae congregatae are seen to be en- larged. In the course of a few days, one or more of them point and dis- charge pus, on the inside of the upper or lower lid, close to the commissure. Sometimes, on pressure, a long thread of matter may be seen oozing from one of the lachrymal ducts. Considerable pain attends the suppuration of the glandulse congregatse, and not unfrequently there is chemosis of the con- junctiva of a whitish color, with puriform secretion from the membrane. The causes are similar to those of hordeolum. In one case, I found that a hog's bristle, lodged in the upper sinus of the conjunctiva, had brought on this affection. I admitted a boy as a patient at the Glasgow Eye Infirmary, who, in consequence of a blow with a stone, was affected with swelling and redness of the upper eyelid towards its outer extremity; the eyebrow was elevated, and the eyelid depressed ; and on raising the eyelid, a considerable fleshy projection was seen between the inside of the eyelid and the eyeball, which I considered to be the inferior portion of the lachrymal gland in a state of inflammation. - Warm fomentations, and a small poultice of bread and warm water, con- tained in an oiled bag, generally form the treatment. Leeches are seldom demanded; the disease is generally too far advanced before we see it, to admit of resolution by cold applications; and the lancet is rarely required to evacuate the matter. § 2. Inflammation and Suppuration of the proper Lachrymal Gland. The glandula innominata, or superior portion of the lachrymal gland, is liable to become inflamed, constituting, from the size of the part affected and the deepness of its seat, a much more serious disease than the one now described. Children of a scrofulous constitution are the general subjects of this affection, which is by no means a common one. Symptoms.—Pain in the seat of the gland, and increasing fulness above INFLAMMATION AND SUPPURATION OF THE LACHRYMAL GLAND. 125 the external angle of the eyelids, are the first symptoms which are remarked. By and by, a red and tense swelling rises at the upper outer angle of the orbit; the upper lid can be raised with difficulty, if at all; the conjunctiva is inflamed, and the eyeball is pushed forwards from the orbit. When the inflamed gland is enlarged to the utmost, the sympathetic swelling of the neighboring cellular substance and the chemosed conjunctiva advance so much in front of the globe of the eye, as completely to conceal it. The pain in the orbit and head becomes more and more severe. Unless the progress of the inflammation is arrested, fever, restlessness and delirium, usher in the local symptoms of suppuration ; fluctuation becomes more and more distinct; and at last the matter points and bursts, by one or more openings through the upper eyelid. The skin of the upper lid may slough to a considerable extent before this happens. From the matting together of the parts, the eyeball is apt to be left in a distorted state, being turned towards the temple. Sometimes before exit is afforded to the matter by the spontaneous bursting of the abscess, the periosteum of the fossa lachrymalis takes on inflammation, and the bone becomes affected. The case then turns out a very tedious one, ectropium of the upper eyelid follows (Fig. 3, page *I6), and the fistula, as has already been explained, does not heal till the bone becomes healthy, or till the diseased portion of it is discharged, which may not be accomplished for years. Causes.—Blows on the external angular process of the frontal bone, even slight lacerated wounds of the upper eyelid, and exposure to cold, are, I believe, the common causes of inflammation of the lachrymal gland. I have known the glandula innominata to suppurate and burst, in little more than eight days after an injury of the upper lid. Mr. Todd states, that the greater number of cases which had fallen under his observation, were not idiopathic, but succeeded to inflammation of the conjunctiva, or some other form of ophthalmia. He had known inflammation of the lachrymal gland to accom- pany what he terms the psorophthalmia of children, when that disease was severe, or aggravated by neglect, exposure to cold, or by the incautious use of stimulating or astringent applications. He is also of opinion that, iu some cases, inflammation of the gland ushers in the ordinary forms of ophthalmia, and gives rise to symptoms generally attributed to inflammation of the eye alone.1 Besides the acute form, there is a chronic inflammation of the lachrymal gland, almost entirely confined to the early periods of life, and, in all proba- bility, depending on a scrofulous predisposition. In this affection, there is obvious enlargement of the gland, with occasional cedematous tumefaction of the upper eyelid; the patient seldom complains of much pain, but generally of a sensation of fulness above the globe, and an inability to move the eye of that side as freely as the other. On making pressure between the globe of the eye and the temporal extremity of the upper edge of the orbit, an im- mediate and copious discharge of tears is produced. Mr. Todd inclines to attribute scrofulous ophthalmia to the morbid secretion of the lachrymal gland, during the course of chronic inflammation; and mentions the case of a young lady, who, on one side had chronic inflammation of the gland, with frequent attacks of pustular conjunctivitis, while on the other side, the gland was healthy, and no ophthalmia ever occurred. Besides chronic inflammation, Mr. Todd represents the lachrymal gland as subject to an affection still more decidedly scrofulous, characterized by the age and constitution of the patient; by slowness of progress, although the gland in this disease sometimes acquires considerable magnitude; absence of pain ; and the tumor presenting a surface more or less lobulated. He states that in some instances this affection, after a certain period, will continue 12G ENLARGEMENTS OF THE LACHRYMAL GLAND. stationary for many months, or even for years, while in others it will undergo that form of suppurative inflammation peculiar to scrofulous glands, and will thus prove a tedious and troublesome disease. It is probable that this scrofulous enlargement of the lachrymal gland, especially when the affection has existed on each side, has sometimes been confounded with the diseases to be described in the next Section.3 Treatment.__In acute inflammation of the lachrymal gland, leeches are to be applied liberally to the upper eyelid, forehead, and temple; blood may also be taken from the temple by cupping; purgatives, rest, cooling lotions, and the whole antiphlogistic plan of treatment are to be adopted; venesec- tion is to be employed, if the fever runs high. Calomel, with opium, is to be given, in frequent small doses. In cases of chronic inflammation of the lachrymal gland, or of slow scrofu- lous enlargement, the anti-scrofulous regimen is to be prescribed ; nourishing food, sea-air, tonics, Szc. The constant application of cold cloths; a few leeches to the neighborhood of the gland; a succession of small blisters to the forehead, temple, and back of the ear; small doses of calomel, or blue pill, at night, with a saline, or other laxative, next morning, will also prove beneficial. Iodide of potassium, I have found a slow, but effectual, remedy. If scrofulous inflammation of the gland ends in suppuration, we must not allow the skin to become extensively diseased, but employ the lancet as soon as fluctuation is distinct. If protrusion and disorganization of the eye be threatened, the gland ought to be extirpated. ' Dublin Hospital Reports; Vol. iii. p. 408 ; tion of the Lachrymal Gland, in the Medical Dublin, 1822. Gazette; Vol. iii. pp. 523, 524; London, 182'J. 2 See Duviel's 2d and 3d Cases of Extirpa- SECTION V.—CHRONIC AND SPECIFIC ENLARGEMENTS OF THE LACHRYMAL GLAND. Chronic enlargement, as well as inflammation, affects either the glandulse congregatse, or the glandula innominata separately ; but it is rarely the case that both portions of the secreting lachrymal apparatus are involved in dis- ease at the same time. § 1. Hypertrophy of the Glandules Congregates. I have seen the glandula? congregatae on both sides affected with chronic enlargement. The upper eyelids drooped at the temporal extremity, while the glands presented granulated tumors, of the size and nearly of the shape of an orange seed. Similar cases are noticed by MM. Laugier and Riche- lot, by whom they were treated antiphlogistically at first, and afterwards by the exhibition of sulphate of quina.1 Dr. A. Anderson reports a case in which, in addition to repeated leeching, the inunction of mercurial ointment was useful.3 § 2. Hypertrophy, Chloroma, Scirrhus, and Medullary Fungus of the Lach- rymal Gland. The lachrymal, like other glands of similar structure, suffers several kinds of slow enlargement, one of which has generally been regarded as scirrhous. Besides scirrhus, however, cases on record show the gland to be subject to simple hypertrophy, to medullary fungus, and to a peculiar affection different from all of these. Symptoms.—Whatever be the nature of the chronic enlargement of the ENLARGEMENTS OF THE LACHRYMAL GLAND. 127 lachrymal gland, the progress of the disease may be divided into four stages. In theirs*, the eyeball is protruded directly forwards, and cannot be turned readily towards the temple; the patient complains of epiphora, with burning heat and lancinating pain in the upper and external part of the orbit; but presents no perceptible swelling in that region. In this stage, which may last for years, it may be difficult to diagnosticate an affection of the lachry- mal gland. In the second stage, there is more protrusion of the eyeball from the orbit, bleedings sometimes occur from the nostril, the upper lid is ex- panded and puffy, and the gland is so much enlarged as to form a projecting tumor, which through the skin of the upper lid, or by the finger carried into the upper sinus of the conjunctiva, can be felt to be hard and lobulated. In the third stage, the gland increases so much, that it pushes the eyeball downwards, inwards, and forwards, but chiefly forwards, till it seems actually to hang upon the cheek. If the disease be neglected, or the patient refuses to submit to treatment, the fourth stage ensues, in the course of which the temporal side of the orbit in some cases begins to be dilated, the eyeball actually resisting the pressure better than the bones; but more commonly the protruded eye inflames, swells, suppurates, and bursts; its contents are partly evacuated, partly absorbed ; the gland goes on to enlarge till it com- pletely fills and dilates the orbit, the bones of which are sometimes partially removed by progressive absorption, or destroyed by ulcerative inflammation; the lids are greatly expanded, and the lower one everted; the remains of the eyeball are seen lying on the front of the tumor, which being covered by the distended and inflamed conjunctiva, is apt to be taken for fungus haematodes, or some other enlargement of the eye itself; still continuing to grow, the gland presses itself downwards through the spheno-maxillary fissure, oblite- rates the corresponding nostril, and even deforms the brain ; the patient is at length seized with apoplectic symptoms, or dies worn out by pain and fever. The course of the symptoms varies in different cases. In some the eyeball is slowly pressed aside, and the orbit dilated, without much inflammatory action. In other cases, violent exophthalmia occurs early, with inflammation of the whole contents of the orbit. Double vision is experienced sometimes in the second stage; in other cases, not till the third. Dimness of sight, and at length blindness occur, more or less early; but it is surprising to what extent sight is sometimes retained with a great degree of protrusion of the eyeball and stretching of the optic nerve. Although it is generally the case that the eyeball is pushed from the orbit by the tumor, it sometimes happens that the tumor advances in front of the eyeball, and covers it com- pletely. Thus, in a case operated on by Sir P. Crampton, on removing the tumor, which was at first supposed to be an ocular fungus, the collapsed eyeball was found beneath and behind it.3 As the enlarged gland lies between the orbit and the levator palpebrae superioris, the latter is pressed upon, and loses its power of contraction; the upper eyelid hangs, therefore, almost motionless, over the protruded eye- ball, and is flaccid, swollen, and strewed with varicose vessels. The lower eyelid is always more or less everted. Diagnosis.—As several other kinds of tumor within the orbit, cause pro- trusion and disorganization of the eyeball, we must carefully examine whether the gland is actually felt hard, lobulated, and enlarged. Cases occur in which the lachrymal gland and the eyeball are pushed forward together, by a tumor deep in the orbit, and we may fall into the error of supposing the lachrymal gland to be the cause of the exophthalmos, while the gland is really not enlarged, but merely displaced. In such cases the gland, though it feels lobulated, is soft, not hard and resisting. After the eyeball bursts, the 128 ENLARGEMENTS OF THE LACHRYMAL GLAND. appearances in cases of chronic enlargement of the lachrymal gland might easily impose on a careless observer for those of fungus nematodes of the eve, as may readily be concluded from examining the two figures in Mr. Travers's 5th plate; figure 1, representing fungus haematodes of the eye, and figure 2, an enlargement of the lachrymal gland.4 Considerable difficulty is likely to occur, in forming a diagnosis between enlarged lachrymal gland and the disease described by Schmidt under the name of hydatid, but which, I am convinced, is nothing more than an en- cysted tumor closely connected with the gland. An exploratory puncture would decide the question. Diversities.—It is extremely probable, that different kinds of chronic enlargement of the lachrymal gland have been confounded with each other. That the enlargements which produce the symptoms now described, are in all or many cases malignant, may fairly be doubted on the following grounds: 1st. Their occurring in children as well as adults; 2d. The extreme slowness with which their course generally proceeds; 3d. Their seldom, if ever, affect- ing the lymphatic system ; 4th. Their seldom, if ever, undergoing anything like cancerous ulceration ; and 5th. The extreme rarity with Which anything like malignant disease has been known to return in the neighboring parts, after extirpation of the gland. Independently of scrofulous affections, such as have been referred to in last section, there seem sufficient grounds to admit the following kinds of chronic enlargement of the lachrymal gland: 1. Simple hypertrophy; 2. Chloroma, or fibro-plastic tumor; 3. Scirrhus; 4. Medullary fungus. Of some recorded cases, the nature is doubtful. 1. Simple hypertrophy.—The following congenital case of this sort is recorded by Gluge :— Case 103.—A tumor had been observed from birth in the region of the left lachrymal gland. It slowly extended itself, pushing the eyeball downwards and inwards. Dr. Cunier extirpated it, when the patient was 5£ years old. The operation was tedious and difficult. The extirpated mass, handed to Dr. Gluge in morsels, was at least equal in size to a hen's egg. It consisted of the glandular substance and of the ducts, both in a hypertrophied condition. The internal surface of the glandular vesicles was lined by epithelial cells; and the whole structure normal, only increased in volume.5 2. Chloroma, or fibro-plastic tumor.—The greater number of cases of en- larged lachrymal gland come under this head, the term fibro-plastic tumor being nearly synonymous with the simple sarcoma of former surgical authors.8 Case 104.—I have now before me two greatly enlarged lachrymal glands, which proved the cause of death in a girl of eight years of age, who, from a distance, was brought for advice to the Glasgow Eye Infirmary, on the 17th of December, 1830. It was stated by the parents of the child, that for about five weeks they had observed the left eye protruding from its socket, and for four weeks the right eye also. The dis- ease on both sides had rapidly increased. The cornea of the left eye had already sloughed. The right eye was cedematous, but its power of vision was still considerable. The child complained of sudden attacks of pain in the eyes, but nowhere else. Some dis- charge of blood had taken place from the right nostril, the day before she was brought to the Infirmary. The patient's appetite was impaired, her bowels costive, her urine scanty, and she slept little. From the Journals of the Infirmary it appears that iodine, an opiate, laxatives, and blisters behind the ears, were ordered. On the 24th, the report states the pain to be on the whole diminished. The protrusion of the left eye, however, was increasing. The right cornea was partly ulcerated, the iris inflamed, and the humors muddy. The bowels were more regular, and the urine natural in quantity. On the 22d of January, 1831, the swelling of the left eye is said to have increased; the disease of the right to be stationary, the patient still discerning light and shadow with it, the pain gone, no discharge from the nostril, the appetite good, and the sleep natural. On the 31st, both eyes, it is stated, protruded enormously, the posterior por- tion of the globe projecting between the lids, and covered by the palpebral conjunctiva in a state of eversion. For two days, the patient had had more pain in the right eye. ENLARGEMENTS OF THE LACHRYMAL GLAND. 129 After this date, the child was not again brought to the Infirmary. We afterwards learned, however, that she had continued to experience relief from the opiate at night, so that, although often restless and lying mostly on her face, she never complained of paki. For some weeks before death she was deaf. About 48 hours before that event, which happened on the 9th of March, there was a good deal of hemorrhage from the right nostril. She was convulsed about an hour before she expired. She was never comatose nor delirious. To Mr. John Watt, then practising as a surgeon in Glasgow, I am indebted for the following account of the appearances on dissection :— On withdrawing the integuments in the usual way, the bones of the cranium were observed to be here and there of a light green color. During the process of sawing the cranium, there flowed from the vein which communicates between the integuments and the longitudinal sinus, through the right parietal bone, about four ounces of bloody serum. A number of small tumors were found growing from the dura mater, corre- sponding to.the spots of bone which showed the green appearance above mentioned. Four small tumors, also growing from the dura mater, each about the size of a shilling, were observed, one over the cribriform plate and crista galli of the ethmoid, one on the petrous portion of each temporal bone, and one at the junction of the lambdoid with the sagittal suture. In all these places, the bones were carious, and the tumors dipped into the carious spots. A large quantity of serous fluid was effused under the tunica arachnoidea, particularly towards the occiput. The brain was otherwise healthy. There was no appearance of disease about the optic nerves. On reflecting the integuments over the face, each orbit was found to be occupied by an oval lobulated tumor, nearly 2\ inches in length, and If inch in thickness. These tumors, which were regarded as the lachrymal glands greatly enlarged, adhered firmly to the periosteum, where it is reflected from the os frontis to give support to the upper eye- lids and contents of the orbits. This membrane being cut through, the enlarged glands were easily turned out with the fingers, and dissected from the conjunctiva and integu- ments. The tumors, externally smooth, but lobulated, exactly resembled each other in size, texture, and every other particular. They were of a light greenish or whey color, the exact color of the tumors of the dura mater already mentioned. They also resembled those tumors in consistence, being of a firm uniform texture, perfectly homogeneous in their interior, and without the least appearance of the whitish bands, seen in scirrhus. They not merely completely filled the orbits, but projected about three-quarters of an inch beyond the os frontis, pressing forwards the eyeballs, the humors of which had either been absorbed, or evacuated, while their coats were shrivelled, dry, and pressed down upon the cheeks. A small tumor of the same greenish color, and firm texture, was found on the pars plana of the ethmoid, in the right orbit, which was also carious, with the tumor dipping into the nose. The hemorrhage might have been from this, or from the tumor on the cribriform plate. This case bears considerable resemblance to one related by Mr. Allan Burns, in which the lachrymal gland on each side, the lining membrane of the nasal sinuses, and the dura mater, were all affected with the same sort of degeneration. Mr. Burns7 supposes the disease to have been of a specific nature, and one sui generis. The fact that the lachrymal gland is occasionally converted into a morbid structure, of firm consistence and greenish color, while, at the same time, the dura mater, periosteum, and Schneiderian membrane give origin to tumors of a similar description, is particularly worthy of attention. Besides the case above related, and Mr. Burns's case, other instances of this disease are recorded. In a case published by Dr. J. H. Balfour,8 the eyeballs were protruded and destroyed, and numerous green tumors of the same sort as those into which the lachrymal glands were converted, were attached both to the outside and inside of the skull, and grew from both surfaces of the dura mater. In a case recorded by M. Durand Fardel,9 the lachrymal glands were not affected, but green tumors were found between the dura mater and the arachnoid, between the bone forming the external meatus of each ear and its lining membrane, in each tympanum, in the spleen, and in the cellular mem- brane surrounding the rectum.10 Case 105.—A case of chloroma occurred to Dr. King, of Glasgow, in July, 1849, in a 9 130 ENLARGEMENTS OF THE LACHRYMAL GLAND. girl, aged 6 years and 7 months. The tumors occupied both temples, the roof and super- ciliary region of each orbit, the upper part of the forehead, and the vertex. A remark- able circumstance about the tumors was, that by times they increased and again subsided. Thus the one occupying the roof of the right orbit increased to such a degree as to prevent the eye from being exposed, and again decreased so as to allow the action of the lid. A tumor formed on the mastoid process of the temporal bone, fully larger than a pigeon's egg, but had nearly disappeared before death. The patient gradually sunk, and died on the 5th October. On withdrawing the scalp, the crown of the head presented an extraordinary appear- ance, being nodulated all over with flattened swellings of a yellowish-green color. On dividing the temporal aponeuroses, the situation of the temporal muscles was found com- pletely occupied by the peculiar green substance. The two swellings over the eyes were growths of the same nature, covering the superciliary ridge and the outer portion of each orbital plate of the frontal bone, pressing the left eyeball downwards and outwards, and the right more directly downwards. The whole contents of the orbits were converted into the same green substance, with the exception of the eye, its muscles, and the optic nerve. The various bones entering into the composition of the orbits were partially dis- eased, spiculae of bone projecting from them into the tumors. No trace of orbicularis palpebrarum on either side could be detected. A tumor occupied the external surface of the inferior maxillary bone. The inside of the dura mater presented two flattened masses, one on each side of the falx, pressing into the substance of the brain. In all these situations, the diseased masses presented exactly the same character, except in so far as it varied from being intermixed with the surrounding fibrous, osseous, or mus- cular tissue. The fibrous tissue appeared the matrix from which the morbid formation arose. The masses were perfectly homogeneous, without trace of bloodvessels. Both alcohol and water speedily diminished the intensity of the green color. No bile could be detected in the alcohol in which the tumors were preserved. The substance of the tumors contained no appreciable sulphur, leading to the supposition that it was neither albu- minous nor fibrinous. Some parts of the external table of the skull and its periosteum were perfectly natural; but, in all the places occupied by the tumors, the periosteum was either closely adherent to the diseased structure, or apparently lost by being converted into its substance. In all these places, the surface of the skull was covered by a layer of additional or new bone, presenting a honeycomb structure, or consisting of irregular spiculae and thin plates of bone, growing from the outer table of the skull, and leaving irregular depressions between them, which seemed to reach to the surface of the natural bone. Into these depressions the substance of the tumor, or the periosteum altered in the manner before mentioned, extended by a corresponding set of irregular processes. The same arrangement, though to a less extent, existed in some limited portions of the internal table, corresponding with the diseased external table. On examining the preparations, illustrative of this case, preserved in the Anatomical Museum of Glasgow College, the periosteum of the lachrymal fossae appears to be the origin of the tumors which projected from the orbits, while the lachrymal glands seemed transformed into the same substance as the tumors. The fibro-plastic matter has infil- trated and changed, rather than displaced, all the parts with which it had come into contact, except the nerves, the muscles in the orbits, and the eyeballs.11 Chloroma, or green tumor, unless it belongs to the class of amorphous fibrous tumors of Vogel, or fibro-plastic tumors of Lebert,12 is probably dif- ferent from any of the morbid formations generally recognized by patholo- gists. The green color has attracted the notice both of Yogel and Lebert; and, as it does not depend on bile, they attribute it to a peculiar proximate principle. The following case I regard as one of the fibro-plastic description:— Case 106.—Some years ago, I inspected the body of Mrs. F., aged GO years, a patient of the late Dr. G. C. Monteath. She had long been affected with protrusion of the right eye downwards, inwards, and forwards; and, some years before her death, the eye had burst. We found the empty sclerotica lying on the front of a tumor, which was white and granular, the grains being evidently the enlarged acini of the lachrymal gland. It was as large as a man's fist, occupying a much-expanded orbit, and pressing itself down into the spheno-maxillary fissure. It had been the means of destroying, by absorption, the roof of the orbit, which was still covered by dura mater, except in some few points, where the tumor and the brain were in contact. It had deformed the brain in a remark- able degree, having pressed the lower surface of the anterior lobe of the right hemisphere ENLARGEMENTS OF THE LACHRYMAL GLAND. 131 upwards, and the anterior surface of the middle lobe backwards. The right motor oculi nerve was absorbed. Within the cranium, the right optic nerve was smaller than the left; within the orbit, merely its neurilemma remained. The right nostril was obliterated by the presence of the tumor. The frontal and maxillary sinuses on the right side were full of puriform mucus. This patient had all along refused to submit to any operation. The case of Andrew Smith, related by Dr. Halphin ;13 that of Mary Gib- bons, by Mr. Pemberton ;w and that of David Gibson, by Dr. A. Anderson ;1S coincide in many particulars with M. Lebert's description of fibro-plastic tumor. 3. Scirrhus.—The evidence that the lachrymal gland is subject to scirrhus, is by no means ample. Himly extirpated the gland, for what he believed to be scirrhus. He seems to have been so disappointed by the result that he never again had recourse to the operation. The eyeball did not retreat into the orbit, vision was not improved, and the patient returned with the eyeball affected, he says, with the disease. The proof, however, that the eyeball was affected with scirrhus, is quite unsatisfactory. The patient was a young woman, evidently suffering from scrofula, and the disease of the eyeball appears to have been rather a staphylomatous degeneration of the choroid and sclerotica, than anything malignant.16 Mr. Travers tells us that he "removed the lachrymal gland greatly enlarged, and in a state of true scirrhus, from the orbit of a middle-aged man ;"17 but Mr. Lawrence hints that the circumstance of a lachrymal gland being greatly enlarged rather militates against the opinion that in that state it is afflicted with scirrhus. "The female breast," says he, "when affected with scirrhus, is not usually augmented in bulk; sometimes, on the contrary, it is dimi- nished."18 In Mr. Lawrence's case of John Clifton, the extirpated gland was of " the size of a large walnut, and of compact homogeneous texture. It had a light yellow texture, with an appearance of radiated fibres at one point; it approached in firmness to cartilage, and altogether bore a near resemblance to the firmest part of a scirrhous mammary gland." The operation was performed in 1826. The wound healed completely by adhesion, and the globe of the eye, which had been protruded, regained its natural position. In 1839, however, when Mr. L. saw the patient again, a hard swelling had formed about the middle of the cicatrice, under the superciliary ridge, a circumstance which is certainly suspicious.19 Gluge mentions the case of a man, 40 years old, in whom hypertrophy of the lachrymal gland passed into a state of cancer." The tumor arose without any known cause, and being partially extirpated, it speedily grew again.2*1 4. Medullary fungus.—The only case I have found recorded of medullary fungus of the lachrymal gland, is one in which the gland, along with the eye- ball, was extirpated by Dr. Tourtual, jun. The eyeball was pushed nearly an inch beyond the margin of the orbit, the cornea became opaque, the tem- poral side of the orbit protruded, and the patient suffered from hectic fever. The tumor was covered with a brownish envelope, being within of brain-like appearance. Three years after the operation, a soft, painful swelling rose in the temporal fossa, the hectic fever returned, and in half a year the patient died.21 Doubtful.—Three cases by Daviel,22 one by Todd,23 one by O'Beirne,24 Lawrence's second case,25 one by Schott,25 and Bridget Judge's case by Roe,27 must be placed under this head, their nature not being sufficiently evident. Causes.—In a majority of the cases on record, chronic enlargement of the lachrymal gland is ascribed to blows and other injuries, as exciting causes. Treatment.—In the early stage of enlargement of the lachrymal gland, 132 ENLARGEMENTS OF THE LACHRYMAL GLAND. leeching and cupping may be tried, on the same principle which is followed when we endeavor to reduce a suspected scirrhus of the mamma. A succes- sion of blisters may be applied to the forehead and temple. Iodine, and other solvents and sorbefacients ought to be used. If such means are ineffectual in reducing the swelling, extirpation of the gland is the only other resource, and ought to be employed, especially if we have reason to regard the case as one of simple enlargement, or of chloroma. In cases of scirrhus or medullary fungus, the operation can be regarded only as a palliative. Chloroma or fibro-plastic tumor is a non-malignant disease ; the circumstance, however, of its so frequently implicating other organs along with the lachrymal gland, and especially the dura mater, materially affects the prognosis. The mode of operating is to cut down directly over the tumor, through the integuments and fibrous layer of the upper eyelid, parallel to the edge of the orbit. As the gland lies over the levator palpebrae, this muscle is avoided in this method of operating, which it could scarcely be were the operation attempted through the conjunctiva. The gland being exposed, projecting from the lachrymal fossa, it is to be insulated as much as possible with the scalpel. If it is considerably enlarged, this is not accomplished without some difficulty, owing to the impacted state of the gland between the bone above and the eyeball beneath. Sometimes a blunt-pointed instru- ment is useful in tearing through the cellular tissue; or we feel all around the gland with the finger, and cautiously cut through the connections. When it is pretty well insulated, we seize it with the double volsella, and drawing it out of its place as much as possible, divide its remaining adhe- sions. This is accomplished with more or less difficulty, according to the degree of matting together of the parts, produced by previous inflammation. The eyeball is to be removed, if already destroyed. If entire, it is to be left untouched, whether vision be preserved or not. The bleeding in general is inconsiderable. After it has ceased, the edges of the wound are to be brought together with stitches and stripes of adhesive plaster. The eyeball in some degree goes back immediately into the orbit, and the patient opens and shuts the eye, if the levator be safe. The parts swell a good deal, so that in a few days the eye is again pushed out, and a consider- able quantity of pus may escape from the wound. Gradually the swollen state of the lids subsides. Neither is vision nor the position of the eye restored immediately. Weeks, or even months, may be requisite before these objects are accomplished; and although the malposition of the eye is always lessened in time, if not entirely removed, vision may never return. The moisture and lubricity of the conjunctiva remaining unaffected after extirpa- tion of the lachrymal gland, has partly given rise to the statement, that the patient continues capable of weeping. Tears are undoubtedly discharged, however, from an eye from which the glandula innominata has been removed, owing, no doubt, to the glandulas congregatae being left untouched. Cases of extirpation.—The details which had previously been given on the subject having been but comparatively few,28 a great degree of interest has attached itself to the two following cases by Mr. Todd and Dr. O'Beirne, to which I have already referred:— Case 107.—Mr. Todd's patient was a woman of 70 years of age. The lachrymal gland formed a large irregular tumor, occupying the upper part of the orbit, projecting more than half an inch beyond the supercilinry ridge, and covered by the upper eyelid, which was so stretched upon it as to render the knotty eminences on its surface very conspicu- ous. The tumor was extremely hard. It was movable to a slight extent, in a transverse direction only. The globe of the eye was not enlarged ; but it had been protruded by the tumor, and was so low upon the cheek that the cornea was nearly on a line with the edge of the ala nasi. The lower eyelid was everted, and appeared dragged down with ENLARGEMENTS OF THE LACHRYMAL GLAND. 133 the globe; the conjunctiva much thickened, and chemosed; the transparency of the cornea slightly obscured. There was no apparent disease of the interior of the eye. Vision was destroyed by the pressure of the tumor. The pains were severe and lanci- nating, extending from the tumor to the globe of the eye, and were accompanied with a sensation of heat and a frequent discharge of scalding tears. The sufferings of the patient were most severe at night, and she was almost entirely deprived of sleep ; not- withstanding which, her general health was not much impaired, and her appetite was good. She attributed the disease to a blow received on the eye about seven years before, from which period she had been subject to frequent discharges of tears from that eye, but had suffered no other inconvenience until a year before coming under Mr. Todd's care, when the tumor began to project under the temporal extremity of the eyebrow. At first, she had no pain or headache; but as the tumor increased, these symptoms set in, and ultimately became so severe that she was anxious to undergo any operation which held out a prospect of relief. In consultation with Mr. Carmichael, Mr. Todd determined that an attempt should be made to extirpate the diseased gland alone, and in the event of that being found im- practicable, either from extent of attachments or deep-seated disease, the expediency of removing all the contents of the orbit was fully acceded to; the intense sufferings of the patient, the probable nature of the disease, and the useless state of the eye, appearing to render this an indispensable alternative. The patient having been placed on her back on a table, with her head a little elevated and secured by the assistants, a transverse incision was made through the integuments, nearly parallel to the superior margin of the orbit, from one extremity of the tumor to the other. Having cut through the orbicularis palpebrarum and the ligamentum tarsi, Mr. Todd exposed, by a careful dissection, the entire anterior surface of the gland. Being firmly wedged into the orbit, it was not without difficulty that the handle of the scalpel was introduced between the gland and the> superciliary ridge, in order to detach it from the orbitary process of the frontal bone. The surface of the gland next the eye was irregularly lobulated, and the lobes had insinuated themselves among the muscles and other contents of the orbit, so as to render their disentanglement extremely difficult and hazardous. By cautiously tearing their cellular attachments with the end of the finger, the handle of the knife, and the blunt extremity of a director, and by cutting on the finger with a probe-pointed bistoury some firm membranous bands, which could not be easily broken, Mr. Todd succeeded in extracting the entire tumor. On a careful ex- amination, no farther disease could be detected in the orbit, and as no bleeding occurred, the globe of the eye was gently pressed towards its natural situation, the wound dressed, the parts supported with a compress and bandage, and the patient laid in bed, with strong injunctions to observe the strictest quiet. The extirpated gland was much larger than a walnut. On the surface which had been towards the eye, it presented three considerable eminences or lobes, with deep fissures between them. It was almost as firm as cartilage, and more elastic. A section exposed several small cartilaginous cysts, which contained a glairy fluid, the interspaces consist- ing of a firm fatty substance, traversed by a few membranous bands. Two hours after the operation, an alarming hemorrhage took place, which, from the great depth at which the wounded vessel was situated, and the extensive extravasation of blood into the loose cellular tissue of the orbit, was with difficulty suppressed by pres- sure with the finger. Dossils of lint were then introduced into the wound, and the bleed- ing did not recur. The patient passed a tranquil night, and for the first time during many weeks enjoyed refreshing sleep. On the following day, the appearance of the eye and surrounding parts was by no means encouraging. The globe was protruded from the orbit as much as before the operation, by large coagula, which occupied the situation of the tumor; the lids were affected with extensive ecchymosis; they were livid and cold, as if in the state of gangrene; and the cellular tissue of the conjunctiva was distended with effused blood. Notwithstanding these unfavorable appearances, the patient had ex- perienced much relief from the operation; she was free from acute pain, and the consti- tutional excitement was inconsiderable. In the course of a few days, the coagulated blood contained in the orbit began to dissolve, and suppuration was soon established. The globe of the eye began slowly to return into its natural situation, and the conjunctiva and skin of the eyelids to assume their healthy appearance. On the 12th day after the operation, the improvement in the position of the eye was quite evident; but it was found impossible to prevent the eversion of the lower eyelid, in consequence of a thickened fold of the conjunctiva, which extended between it and the globe. To this fold, the nitrate of silver had been frequently applied without any benefit; Mr. Todd therefore removed it by excision, and was immediately enabled to replace the lid, which showed no farther tendency to become everted. From this period, the patient's recovery was un- 134 ENLARGEMENTS OF THE LACHRYMAL GLAND. interrupted, and she was discharged without any return of disease. Vision remained totally lost, the pupil greatly contracted, the position of the eyeball almost natural. Case 108.—A man, aged 22 years, strong and athletic, came under the care of Dr. O'Beirne, with considerable deformity and imperfect vision of the right eye. The globe projected more by its semidiameter than the sound eye, yet it was covered almost entirely by the upper eyelid, which hung loosely over it, as if palsied; the pupil was dilated and insensible to light, the cornea was turned towards the nose, and the puncta lachrymalia were patulous. The upper and outer part of the orbit was occupied by a tumor, the outline of which could not be distinctly traced, but to its growth were attributed the protrusion of the eye and impaired vision. The patient suffered considerable pain of the right side of the head and face, and much irritation and watering of the eye were pro- duced by cold air, or particles of dust. All objects appeared to him double; and in endeavoring to reach any object, his hand or foot generally fell short of it, so much so as to prevent him from working even as a laborer. About two years before coming under Dr. O'Beirne's care, he perceived first of all sparks, and occasionally mists, before his eyes, with sharp intermitting pains in the right side of his head and face; in about a year, a slight prominence and inversion of the globe were observed ; and from that period, the symptoms gradually proceeded to the state already described. It was decided in consultation, that the tumor should be removed, but it was not even suspected that the lachrymal gland was the part affected. The operation was begun by an incision through the integuments of the upper eyelid, extending from the inner to the outer angle. The orbicularis palpebrarum being next divided, some portions of adipose substance which presented were removed. Dr. O'Beirne then introduced his finger, and at once discovered that the disease was an enlarged and indurated lachrymal gland. The anterior surface of the tumor was exposed by dissection, and it was finally removed by cautiously working with the nail of the little finger, for it was not considered safe to introduce a knife into the back of the orbit. The surface of the extirpated gland was granular, and of a pink color. It was en- larged to at least six times its natural size. When cut into, it presented a hard, mem- branous, or rather cartilaginous centre, from which septa passed to the circumference. No sanies could be perceived. On the tumor being removed, the pupil instantly recovered its contractile power, and the globe retired nearly to its natural situation. Vision, too, was improved, but not perfectly restored. Scarcely any hemorrhage ensued, and the wound was dressed simply. With the exception of a slight erysipelas of the scalp, which yielded to the usual remedies, the patient's recovery was uninterrupted, and the wound was completely healed on the 14th day after the operation. At that time, vision was perfect, all uneasiness had subsided, and the eye occupied its proper place. The upper eyelid, however, having continued so much relaxed as to obscure a great part of the cornea, a camel's hair pencil, dipped in sulphuric acid diluted with three parts of water, was applied in the line of the cicatrice. In a few days a slough separated, and the sub- sequent cicatrization contracted the lid to its natural state. The patient continued per- fectly well, and suffered no inconvenience from the loss of the gland. 1 Translation of this work into French, p. vi.; Paris, 1844. 1 Monthly Journal of Medical Science, Vol. viii. p. 465; Edinburgh, 1848. 3 Dublin Quarterly Journal of Medical Science, Vol. i. p. 80; Dublin, 1846. 4 Travers' Synopsis of the Diseases of the Eye; London, 1820. 5 Annales d'Oculistique ; Tome xxiii. p. 145; Bruxelles, 1850. 6 See Paget's Lectures on Tumors; Lect. V. Part ii.; Medical Gazette; Vol. xlviii. p. 177; London, 1851. 1 Surgical anatomy of the Head and Neck, p. 385 ; Glasgow, 1824. 8 Edinburgh Medical and Surgical Journal; Vol. xliii. p. 319 ; Edinburgh, 1835. 9 Journal Hebdomadaire des Prngrfes des Sciences Medicales; Tome iii. p. 207; Paris, 1836. 10 In addition to the cases mentioned in the text, see one by Williams, in which the peri- cranium, dura mater, and various other organs were affected; Medical Gazette; Vol. xliv. p. 854; London, 1849. 11 Monthly Journal of Medical Science for August, 1853, p. 98. 19 Vogel, AnatomiePathologique Gcne>ale,p. 199; Paris, 1847 : Lebert, Physiologic Patholo- gique, Tome ii. p. 120 ; Paris, 1845; Ib. Lancet, February 26, 1853 ; p. 203. 13 Dublin Quarterly Journal of Medical Science; Vol. i. p. 88; Dublin, 1846. 14 Ibid. Vol. iv. p. 246; Dublin, 1847. 1 • Monthly Journal of Medical Science ; Vol. viii. p. 464; Edinburgh, 1848. 16 Ophthalmologische Bibliothek, von Himly und Schmidt; Vol. iii. Stuck iii. p. 159; Jena, 1807 : Himly, Krankheiten und Missbildungen des menschlichen Auges; Vol. i. p. 291; Berlin, 1843. " Op. cit. p. 228. 18 Treatise on the Diseases of the Eye, p. 798; London, 1841. 19 Ibid. p. 802. 90 Atlas der pathologischen Anatomie, Zwei- ter Theil. 17te Lieferung.; Tab. 3 ; Jena, 1850. 91 Himly. Op. cit: Vol. i. p. 292: Ammnn, Klinische Darstellungen; Vol. ii. p. 27 ; Berliu, 1838. ENCYSTED TUMOR IN THE LACHRYMAL GLAND. 135 99 Quoted in Medical Gazette; Vol. iii. p. strangs; advertisement at the end: Frankfurt 523; London, 1829 ; from a medical journal am Main, 1836. published at Bordeaux in 1829. ^ Dublin Quarterly Journal of Medical Sci- 93 Dublin Hospital Reports ; Vol. iii. p. 419 ; ence ; Vol. i. p. 92 ; Dublin, 1846. Dublin, 1822. 9S Richerand, Nosographie Chirurgicale; 94 Ibid. p. 426. Tome ii. p. 31; Paris, 1808 : Warner's Cases of 95 Op. cit. p. 802. Surgery, p. 108; London, 1784 : Travers, Op. 96 Controverse iiber die Nerven des Nabel- cit. SECTION VI.—ENCYSTED TUMOR IN THE LACHRYMAL GLAND. This disease appears to have been for the first time accurately described by Schmidt, under the appellation of glandida lachrymalis hydatoidea} It certainly consists of a collection of thin fluid in the situation of the supe- rior portion of the lachrymal gland. This fluid Schmidt supposed to be tears; and the cysts in which it collects, to be originally nothing more than one of the cells of the cellular membrane, serving to hold together the acini or grains of which the gland is composed. Whether this is really a lachrymal tumor, or merely a cyst situated in the lachrymal gland, or at least closely connected with it, is, in a practical point of view, a matter, perhaps, of little conse- quence. Schmidt's hypothesis of the origin of the cyst is quite inconsistent with the assumption, that this disease is at all analogous to the entozoa, known under the name of hydatids. That it is a rare disease may be concluded from the fact, that Schmidt relates only two cases of it; and that even Beer's vast experience had brought only three under his observation.2 In one of Beer's cases, the diagnosis became completely evident only after death. In the tumor, he found a small quantity of fluid, which he does not hesitate to call tears; and which was thin, clear, and sharp and saltish to the taste. In his second case, he opened the tumor during life ; the fluid discharged was yellowish like serum, but so acrid, that it immediately caused a small blister when applied to the tongue. In Beer's third case, he was merely consulted in the commencement of the disease. Symptoms.—The development of an encysted tumor in the lachrymal gland is, in some cases at least, very rapid; and its consequences not merely dis- tressing, but dangerous. One of the most striking symptoms attending this tumor, is protrusion of the eye. It is pushed forward from the orbit, and inward, towards the nose; and ultimately may become disorganized by inflam- mation. When the disease produces exophthalmos merely, the patient, perhaps per- fectly well in every other respect, complains of obtuse deep-seated pain in the orbit. The pain is as if something behind the eyeball were pushing it out of its socket. It is felt most when the patient moves his eye in different directions, and especially when he turns it towards the temple. It daily increases. Nothing unnatural in the form or in the texture of the eye or eyelids is as yet discernible. By and by, there is added to the pain behind the eye, a feeling of tension in the orbit and over the side of the head; and the eyeball is now observed to be somewhat protruded from the orbit and towards the nose. Some few individual bloodvessels excepted, it is not red. The patient has a feeling of dryness in the eye. He cannot move it without great aggravation of the pain, and a sensation of sudden flashes of light. At last, he is totally deprived of the power of moving it. When he regards objects with the protruded eye, he sees them disfigured. If he looks with both eyes, he sees objects double, as the protruded eye stands no longer in the natural axis of vision. The more that the tumor pushes the eyeball out 136 ENCYSTED TUMOR IN THE LACHRYMAL GLAND. of the orbit, vision becomes the weaker and the more disturbed. In propor- tion as the disease advances, the patient loses his appetite, and is deprived of sleep. The hemicrania becomes uninterrupted, by day and night. Vision is entirely lost. The eye is so much protruded, that it rests in some measure upon the cheek. The eyelids lose all power of motion, the upper one being firmly extended over the protruded eye. The patient betrays a constant inclination to cover the eye with the eyelids, and at every attempt to do so the eyeball is rolled towards the nose. A resisting hardness is felt with the finger at the temporal angle of the eye, between the protruded eyeball and the external edge of the orbit. The eye becomes sullied and dusky. If nothing is done to relieve the symptoms, coma and death are the consequences. Should the disease produce exophthalmia, besides obtuse, deep-seated, and constantly increasing pain in the orbit, there is pain in the eyeball itself; and whereas, in the former case, the eye, though protruded by the growing tumor, preserves its ordinary appearance, in the present case it is rapidly destroyed by inflammation. It suppurates; and unless opened by the knife, bursts, discharging blood and ichorous matter. The membranes do not col- lapse after this evacuation, but the eyeball, as a fleshy shapeless mass, con- tinues to protrude from the orbit, proving how much its organization had suffered. The pain in the burst eye, and in one side of the head, continues, the patient is deprived of sleep and appetite, and the lymphatic glands about the face become enlarged. Should a patient present himself with such symp- toms, we shall naturally be led to suspect the existence either of this disease, or of some other affection of the lachrymal gland ; and our suspicions will be confirmed if we find a resisting hardness between the destroyed eyeball and the temporal edge of the orbit. It is likely, however, that this may be detected at a much earlier period of the disease. Could we dare to draw conclusions from the few cases of this disease on record, we should say that it is more apt to terminate fatally when attended by exophthalmos, than when accompanied by exophthalmia. In neglected cases, however, of encysted tumor in the lachrymal gland, attended by exoph- thalmia, the disorganization is apt to spread to the bones of the orbit, and at last the brain itself becomes fatally affected. This was the termination of one of the three cases observed by Beer. Treatment.—The radical cure of encysted tumor in the lachrymal gland, would consist, no doubt, in extirpating the tumor, before the eye became protruded, at least to any considerable extent; but at this period, we cannot distinguish the disease with sufficient certainty. Even had we the means of determining that the commencing exophthalmos arose from the cause in question, it might be difficult to extirpate this vesicular swelling without re- moving also the gland in which it is situated, or with which it is intimately connected. A palliative treatment, it is probable, will generally be adopted, by the employment of which we may save both the life, and the eye of the patient. It may even happen that by the early employment of this palliative cure, we may be fortunate enough to cure the disease completely. The palliative cure consists in puncturing the tumor. This should be done, if possible, from under the upper eyelid, with a lancet or small con- cealed bistoury, directed towards the seat of the lachrymal gland. Should the tumor return after the healing of the wound, the operation must be re- peated. I should think any attempt to keep the wound open, and the tumor constantly empty, by the introduction of a bougie or other foreign body, out of the question, if the incision were made from under the upper eyelid. But if the protrusion of the eye were such that the upper eyelid was firmly stretched over the eyeball, and that no instrument could be passed between ENCYSTED TUMOR IN THE LACHRYMAL GLAND. 137 them, the tumor would require to be opened through the upper eyelid, and the wound might be afterwards kept open by a bit of catgut, so as to give exit to any reaccumulated fluid, and perhaps lead to a radical cure. That through the opening, wherever it be made, the cyst of the tumor shall be extracted, cannot be regarded as very likely; although this took place in one of Schmidt's cases. As the present is a rare disease, I am induced to lay before the reader the particulars of the following cases :— Case 109.—A private soldier, aged 2b" years, of a firm and corpulent make, became ill with fever, from fatigue and exposure to cold, in the end of November, 1800. According to the history of the case, he had a slight typhus, which yielded to the use of the proper means, so that he left the hospital in the beginning of January, 1801, and set off for his regiment. Some days before he left the hospital, he had an obtuse deep-seated feeling of pressure in his eye; but he set himself out against it, and said nothing of it to his medical attendant. He was about eight days with his regiment, when he observed that this obtuse deep-seated pain grew more constant and more troublesome. But as he could discover nothing wrong about his eye and saw perfectly well, he let matters rest as they were. In the beginning of the third week, the feeling of pressure became violent, he felt pain with tension in the eye itself, and in the corresponding half of the head; the eye became red and dry, and began to project; he frequently had the sensation of fiery spectra, and at times his sight failed him. About this time, his sleep became interrupted. With these symptoms, he was unable to perform his duty as a soldier. His medical officer ordered the application of a warm poultice. The case grew worse from day to. day. With the beginning of the fourth week, the hemicrania and pain in the eye became furious, day and night, so that he could not get a moment's sleep; the eye protruded completely from its socket, so that it was seen from the other side over the root of the nose; it was slightly red, but not swollen, moist and slippery, but deprived of sight. The appetite for food, which had continued till now, was lost. The patient's restlessness rose to the extreme. In this state he was brought to the Military Hospital of Vienna, on the 4th February. Early on the 5th, Schmidt saw him for the first time. Besides the above-mentioned symptoms, he found the patient affected with spasm of the superior oblique muscle, whereby the eye was every instant drawn more out of the orbit, and towards the nose. The eyelids were not in the least swollen, but quite pushed aside from the eye. Schmidt felt distinctly a resisting hardness in the temporal angle of the orbit. He declared before those who attended the visit, that the disease was seated in the orbit, and that it was probably a steatomatous tumor. Opium internally and externally, warm poultices over the eye and head, nothing checked the fury of the pain. Early on the 6th, Schmidt found the patient in the same state, only that the eye was no longer lively, but dusky and somewhat like the eye of a dying person, while the appearance of the sound eye was still very lively. The pulse, the respiration, and all the other functions, were not in the least altered. Schmidt determined to evacuate the eye, next day, by an incision. Towards evening, the patient fell into a state of sopor, became insensible, discharged his urine and feces involuntarily, and died toward midnight. On dissection, the veins and sinuses of the brain were found distended with blood. There was no accumulation of fluid In the ventricles. On removing the orbitary process of the frontal bone without injuring the periosteum, a fluctuating tumor pressed itself upwards from the temporal angle of the orbit. On continuing the dissection, the muscles of the eye, the optic nerve, and the other nerves of the orbit, were observed to be stretched and elongated, and the ophthalmic vein appeared varicose. The lachrymal gland was Bmaller than usual, and in connection with it lay the fluctuating tumor. The individual acini which were more remote from the tumor, and were directed towards the upper eye- lid, were larger and more coherent; whilst those acini, which lay upon the tumor, were small, and both appeared and felt more loosely scattered than natural. The tumor was in diameter, from behind forwards, the length of an inch; in transverse and perpendicular diameters somewhat less than an inch. It pressed itself close upon the external segment of the eyeball, and even after death, held the eyeball out of the orbit and towards the nose. It had an external and an internal covering. The external consisted of thick, cellular membrane. Between this and the internal covering was a quantity of interstitial fluid. The internal covering was very fine, semitransparent, and contained a limpid fluid. The external membrane could not be easily separated from the scattered acini of the lachrymal gland. The internal, could be freely extracted from the external, covering.3 Case 110.—A young country-woman came to Vienna in May, 1802, and sought Schmidt's assistance. She had weaned her child two months before ; and immediately after that, 138 ENCYSTED TUMOR IN THE LACHRYMAL GLAND. upon being exposed to cold, felt violent hemicrania and pain in the eye. After some days, the eyeball inflamed severely, became swollen, and pressed itself forwards from the orbit. When the woman came to Schmidt, the inflamed eye had the size of a man's fist, the cornea was completely destroyed from suppuration, and the iris was covered by a new and wartlike production, so that it was with difficulty that an eye could be recog- nized in this shapeless mass-of flesh. Together with a constant pressing pain in the orbit, and continual hemicrania, Schmidt found all the symptoms detailed in the former case, with the exception of the spasmodic motions of the eyeball. He mentions that the parotid gland upon the same side, was swollen towards the branch of the lower jaw, but more probably the swelling affected one of the lymphatic glands lying over the parotid. The patient was admitted into the hospital, under the care of Mr. Ruttorffcr, who passed a small flat trocar under the upper eyelid, directing its point towards the fossa lachrymalis, where the resistance and hardness were felt. More than an ounce of ex- tremely clear fluid was immediately discharged through the canula. The canula was removed, and for several days this clear fluid issued from the wound. Some hours after the operation, the hemicrania suddenly and considerably diminished, and from day to day, the exophthalmia became less. On the 14th day after the operation, a whitish streak was observed in the wound, re- sembling pus, but which could not be removed with a little lint. Mr. Ruttorffer laid hold of this with a pair of forceps, and drew forth the cyst, or, as Schmidt chooses to call it, the hydatid, which, as represented in his work, must have measured more than an inch in diameter. After other 14 days, the woman left the hospital, the eye having diminished to a small stump.4 From the state to which the eyeball is reduced in exophthalmia proceeding from this disease, it is not unlikely that cases of this sort have sometimes been taken for cancerous affections, and the eyeball extirpated with the cyst. An instance of this kind we find in the Philosophical Transactions for 1*755, related by Mr. Spry.5 Case 111.—A mariner's wife complained of violent pain in her left eye, and sometimes of very acute pain in the temple of the same side, with some defect in her sight. She also imagined that her eye was bigger than ordinary; but, upon inspection, it appeared no bigger than the other. The cornea, however, became less transparent, and the pupil greatly dilated. The vessels of the conjunctiva and sclerotica were no way enlarged. Bleeding, blistering, and purging, proved of no effect. On the contrary, the cornea became more opaque, great inflammation of the conjunctiva and sclerotica ensued, and an apparent prominence of the whole eye. She was again purged, and a seton put in the neck; but the symptoms increased. She became still more miserable. The conjunctiva became greatly inflamed, with eversion of the upper lid, attended with great pain. Mr. Spry often scarified the conjunctiva, which bled plentifully, and gave her ease for a day or two. He also took blood from the temporal artery. But the eye being greatly enlarged, and of so terrible an appearance, after all his endeavors for eight or ten months, he judged the disease to be carcinoma, and therefore proposed cutting out the eye as the only remedy. The ope- ration, however, was deferred, till at length the eye becoming much larger, and the pain increasing, extirpation was had recourse to, lest the bones of the orbit might become carious. Mr. Spry having begun his incision round the upper part of the tumor, had not cut deep when a great quantity of fluid, like lymph, poured out upon him with great force, like a fountain. The tumor subsided a good deal; but pursuing the operation, he found a large cyst, which filled the whole orbit behind the eye. A part of this cyst was left to slough off with the dressings. The whole eye being cut out, he filled the wound with lint. The cure went on with success, and was complete in a month. On examining the tumor which had been removed, the eye appeared a little bigger than natural, the aqueous humor not so clear as usual, the crystalline less solid and transpa- rent, the vitreous almost reduced to a liquid state, the cyst very strong and elastic, with a cavity sufficient to contain a large hen-egg. There can be little doubt that this was a misunderstood case of encysted tumor in the lachrymal gland, or, at any rate, of encysted orbital tumor, and not at all a carcinoma. 1 Ueber die Krankheiten des ThrUnenor- ' Op. cit. p. 90. gans. p. 73; Wien, 1803. 4 Ibid. p. 94. 9 Lehre von den Augenkrankheiten; Vol. ii. s Philosophical Transactions; Vol. xlix. Part p. 597; Wien, 1817. i. p. 18; London, 1756. ENCYSTED TUMOR NEAR LACHRYMAL DUCTS. 139 SECTION VII.—ENCYSTED TUMOR IN THE VICINITY OF THE GLANDULE CONGRE- GATE AND LACHRYMAL DUCTS. The subject of this section seems similar in nature to the disease last con- sidered. Its seat appears the principal difference; for the tumor described in the last section is seated in the substance of the superior portion of the lachrymal gland, and is supposed to derive the fluid which it contains from the gland immediately; while the present disease lies almost immediately behind the conjunctiva, in the vicinity of the glandulae congregatae, and derives its fluid according to Schmidt,1 from one or more of the lachrymal ducts. Benedict2 describes it as a mere dilatation of one of these ducts. Encysted tumor in the lachrymal gland produces a series of dangerous symp- toms, long before it comes into view itself, if ever it comes into view; whereas, a similar tumor in the vicinity of the glandulae congregatae and lachrymal ducts, from its superficial situation, is neither productive of so destructive effects, nor can it remain so long concealed. Symptoms.—As soon as it has reached any considerable extent, the pre- sent disease manifests itself by the following symptoms : A circumscribed very elastic swelling, void of pain, is felt immediately behind the upper eye- lid, towards the temporal side of the orbit. If the tumor has already reached such a degree as to present through the eyelid the size of a hazel-nut, and if we press upon it pretty forcibly, the patient feels the pressure in the eyeball, and observes fiery spectra before the eye. If, at the same time that we press the tumor from without, we raise the upper eyelid, and, in some measure, evert it, we see the conjunctiva project in the form of a distended sac, in which we discover fluctuation. When the tumor has reached the size of a pigeon's egg, the motions of the eyeball upwards and outwards are impeded; yet, when we raise the upper eyelid in the manner just now mentioned, the patient is immediately able to move his eye, without difficulty, towards the temple, the eyeball retiring behind the tumor. From extreme distention, the conjunctiva, and the cyst in which the fluid is contained, are so thin, that the pressure we employ in examining the disease, seems almost sufficient to rup- ture the tumor. One of the characteristic marks of this disease, we are told, is the momentary increase of the tumor when the patient weeps. Causes.—It is supposed that the proximate cause is one or more of the excreting ducts of the lachrymal gland terminating in the loose cellular sub- stance under the conjunctiva; that one of the cells is gradually distended by the accumulating tears, and at last forms the thin sac, the projection of which gives rise to the symptoms described. That this is the real nature of the case, is concluded from the alleged fact, that if the tumor be opened through the eyelid, a considerable quantity of pure tears flows through the incision, every time the patient weeps. I must confess that I have no faith in this etiology. Beer3 met with this disease six times, in individuals who were between four and fourteen years of age. In two of these cases, an apparent exciting cause had preceded the disease. In the one, the cause was a bruise on the upper edge of the orbit, from the springing of a billiard ball. In the other, it arose after the incomplete extirpation of an encysted tumor, which had its seat at the same place. Treatment.—Beer's plan of radically curing this disease, by passing a seton through the nostril, is not to be recommended. It is not only apt to fail, but may leave a troublesome fistulous opening through the lid. Either the simple palliative cure should be had recourse to, of puncturing the tumor through the conjunctiva, or the cyst should be extirpated. If the 140 TRUE LACHRYMAL FISTULA.—MORBID TEARS. eyelid cannot be sufficiently everted, to allow the cyst to be exposed and insu- lated through an incision of the conjunctiva, the extirpation should be per- formed through an incision of the skin, parallel to the fibres of the orbicularis palpebrarum. It is remarkable, that the two diseases described in this and the preceding section, have not been met with, as far as I know, by any practitioner in this country. 1 Ueber die Krankheiten des Thranenor- 3 Lehre von den Augenkrankheiten ; Vol. ii. gans, p. 63; Wien, 1803. p. 593; Wien, 1817. 9 Handbuch der praktischen Augenheil- kunde ; Vol. iii. p. 163; Leipzig, 1824. SECTION VIII.—TRUE LACHRYMAL FISTULA. A callous opening, so small as almost to elude the naked eye, situated in the upper eyelid, towards its temporal extremity, and from which there trickles from time to time a quantity of tears, is styled a true lachrymal fis- tula. If we pass an Anel's probe into the orifice, we find that it is led di- rectly towards the lachrymal gland; but we neither perceive any hardness of the gland, feel any portion of bone bare, nor give the patient pain. True lachrymal fistula may arise from a wound of the lachrymal gland, the glandulae congregatae, or the lachrymal ducts. More frequently it is the effect of abscess of the upper eyelid, or of suppuration of the lachrymal gland. It may also be the result of attempts to extirpate an encysted tumor in the vicinity of the lachrymal ducts, or to cure that disease by means of a seton. This almost capillary fistula will require the Anelian syringe, armed with its finest point, to inject any fluid into it. Having widened the fistula, by repeated introductions of the Anelian probe, or the use of a piece of fine catgut, by passing the Anelian probe, coated with nitrate of silver, several times with a rotatory motion, through the fistula, we may expect to excite such a degree of inflammation as shall end in its closure.1 A stout country lad had a fistula of this kind, 3^ lines deep, and com- pletely callous. Beer passed quickly into the opening, and to the bottom of the fistula, a red hot knitting-needle, turning it round several times upon its axis. Five days afterwards, the fistula was completely closed.3 1 To coat a probe with lunar caustic, place a flame of a candle, and roll the probe in the bit on a piece of silver money, such as a six- melted salt, till it is sufficiently covered. pence; hold this with a pair of pliers over the 9 Lehre von den Augenkrankheiten; Vol. ii. p. 186; Wien, 1817. SECTION IX.—MORBID TEARS. The tears are at all times an irritating secretion. The conjunctiva is in- stantly reddened when they flow; and although we were to grant that this was consentaneous with determination of blood to the lachrymal gland, pre- ceding the discharge, yet we observe that if the tears are so profuse as to run over on the cheek, the skin with which they come into frequent contact be- comes inflamed and excoriated. In some cases, the extraordinary degree of inflammation which the tears have excited, has led to the supposition, that SANGUINEOUS LACHRYMATION.—DACRYOLITHS. 141 their chemical properties were changed by disease, so that they had acquired an unusual degree of acridness. In a supposed case of this kind, which some years ago attracted a considerable share of attention in Glasgow, it was dis- covered, that the deep lines of excoriation which ran down the cheeks of the patient, who was a child, were not the work of the tears, but the effects of a deliberate application of sulphuric acid. The woman who kept the child, tempted by some sinister motive, was the author of this extraordinary piece of cruelty. SECTION X.—SANGUINEOUS LACHRYMATION. HEMORRHAGY FROM THE LACH- RYMAL GLAND. Forestus,1 Havers,9 and others have recorded cases in which blood flowed from the eyes like tears, or was discharged from the lachrymal gland, even in such quantity as proved dangerous to life. Professor Rosas witnessed a disease of this sort in a child of nine years of age, of scorbutic diathesis, and in whom it yielded to anti-scorbutic treat- ment.3 In all these cases, however, it is doubtful how far the discharge of blood was really from the lachrymal gland, and not from the conjunctiva. 1 Observationes et Curationes Medicinales, thorp's Abridgment; Vol. iii. part i. p. 252; Lib. xi. Obs. 13; Francofurti, 1634. London, 1716. 9 Philosophical Transactions, No. 208. Low- 3 Handbucb der Augenheilkunde; Vol. ii. p. 347; Wien, 1830. SECTION XI.--DACRYOLITHS* OR LACHRYMAL CALCULI IN THE LACHRYMAL DUCTS. * From $cm(v tear, xido; stone. The tears, like the saliva and all other fluids transmitted along mucous surfaces, are occasionally the source of calcareous depositions. In all such cases, the concretions which are met with, consist of all the chemical consti- tuents of the fluids by which they are surrounded ; but they also occasionally contain principles derived from the mucous membrane. Their forms they borrow from the cavity in which they are contained, or from the surrounding structures with which they are brought in contact, as is observed in the gall- stones, urinary calculi, intestinal calculi, salivary calculi, &c. Case 112.—MM. Laugier and Richelot mention that an old soldier awoke with the sen- sation of a foreign body in his left eye, which was affected with pain, redness, and lachrymation. On reversing the upper eyelid, a small whitish point, like chalk, was observed on the surface of the conjunctiva, about three lines above the edge, and at a little distance from the temporal angle. With the point of a probe, it was felt immovable and hard. Some attempts were made to disengage it from the opening of one of the lachrymal ducts, where it seemed fixed, but in vain. The irritation was speedily subdued by soothing lotions. Two months afterwards the patient left the hospital, with the cal- culus still in its place, without any change in its bulk, or any renewal of uneasiness from its presence.1 Case 113.—Ann Clarke, aged 19, had been in a bad state of health for some months, and frequently complained of a severe pain in the head, particularly across the forehead, and over the left eye, for which she had been bled in the arm and had leeches applied to the temples, but without permanent relief. On the 22d December, 1834, inflammation came on suddenly in the left eye, attended with a good deal of pain ; this increased on the following day, and towards the afternoon Bhe felt a severe lancinating pain in the upper and outer part of the orbit, accompanied 142 INJURIES OF THE EYEBROW AND EYELIDS. with a sudden and profuse discharge of tears; immediately after which she perceived something in her eye, which, on removing, she found to be a small hard body, resembling a fragment of mortar. At first she supposed it to be some extraneous substance which had accidentally fallen into her eye; but in the course of an hour, the pain, which had remitted on the removal of this mass, returned, and another exactly similar came away. During the three or four following days, as many as 28 were discharged with the same symptoms; after which the pain and inflammation gradually abated. During the time that these bodies were escaping, there was no bleeding or purulent discharge. On the day following the removal of the last of them, there were slight appearances of conjunc- tival inflammation; but on everting the upper eyelid, no ulceration or other lesion of the mucous membrane could be perceived there, or on the other parts of the eye. She com- plained of slight tenderness on pressure in the situation of the lachrymal gland. Some of the calculi, which had been preserved, were small, rough, very hard, and of a dirty white color; the largest about a line in diameter. On being viewed with a micro- scope, they looked like rough pieces of chalk, with small portions of silcx imbedded in them. On analysis, they were found to consist principally of phosphate of lime, with a small quantity of carbonate of lime, and traces of animal matter. The narrator of the case thinks it probable that the calculi were lodged, in the first instance, in the lachrymal ducts, and that producing much irritation there, they were discharged with a gush of tears.2 Concretions, deposited from the tears, occur in the sinuses of the conjunc- tiva, in the caruncula lachrymalis, and in the excreting lachrymal passages, as I shall explain more fully in Chapters IV., V., and VI. Similar concre- tions are also met with in the Meibomian follicles. 1 Translation of this work into French; p. - Medical Gazette, Vol. xv. p. 628; London, vi.; Paris, 1S44. 1835. CHAPTER III. DISEASES OF THE EYEBROW AND EYELIDS. SECTION I.—INJURIES OF THE EYEBROW AND EYELIDS. Contusions, wounds, and burns of the eyebrow and eyelids, even in cases where they at first appear trifling, are often productive of serious effects. Lagophthalmos and ectropium are apt to be the consequences of neglected burns and abscesses of the eyelids; while incised and lacerated wounds of the eyebrow and of the neighboring integuments, even of small extent, are often followed by asthenopia, and occasionally by complete, and too often incurable, amaurosis. § 1. Contusion and Ecchymosis. Blows or falls upon the edge of the orbit, even when slight, are apt to pro- duce extravasation of blood into the loose areolar tissue of the eyelids. The extravasation or ecchymosis seldom makes its appearance immediately after the blow. Five or six hours sometimes elapse before the swollen eyelid assumes the livid color denoting the rupture of bloodvessels and subcutaneous effusion of blood. In other instances, however, the ecchymosis is sudden; and the quantity of blood being considerable, a degree of fluctuation is felt in the swollen lid. In pugilistic contests, the eyes are completely closed from the swollen and ecchymosed state of the lids; but the seconds make an open- ing in the skin with a lancet, and squeeze out the blood, so as to enable the CONTUSION AND ECCHYMOSIS OF THE EYELIDS. 143 combatant to see his way a little longer.1 It sometimes happens, that also the subconjunctival areolar tissue is ecchymosed, and occasionally the effused blood stretches back into the orbit, and even protrudes the eyeball. It very rarely happens that the blood effused into the eyelids, operates as a foreign substance, or excites inflammation. In some cases, it is collected, as it were, in a cyst, and imitates the form and feeling of a tumor. I have seen such a spurious cyst extirpated. On laying it open, it contained nothing but water and blood. Had it been left, it might perhaps have degenerated into some sort of tumor. Ecchymosis sometimes presents itself, not merely immediately around the part struck, but in other places more or less remote. Thus, Ammon2 relates a case of contusion with a foil in the vicinity of the right caruncula lachry- malis, with profuse ecchymosis, protrusion of the eyeball, and concussion of the brain. On the third day after the accident, an ecchymosis appeared on the left side, in the very situation, and to the same extent, as that on the right. He calls this a sympathetic ecchymosis ; and could trace no communi- cation from the right side to the left, over the nose or forehead. Some months after the injury, the right eye became amaurotic. Ecchymosis (as mentioned p. 52) is sometimes symptomatic of counter- fracture of the walls of the orbit. In this case, the ecchymosis increases slowly for days, and is not attended by any considerable swelling. Sympto- matic ecchymosis gradually reaches the eyelids, which become more and more discolored; ecchymosis from direct injury extends, on the contrary, from the eyelids to the neighboring parts. Under ordinary circumstances, the blood in ecchymosis of the eyelids is absorbed in the course of two or three weeks, the swelling subsiding, and the skin gradually losing its livid color as the absorption goes on, becoming first brownish, and then yellow. In cases of bruise and ecchymosis of the eyelids, we must endeavor to pre- vent or abate inflammation, and promote absorption of the effused blood. The first of these objects is to be obtained by the application of leeches, followed by the continual use of evaporating and slightly astringent lotions. More "powerful astringents, and gentle pressure, are employed to accomplish the second. To remove a black eye, as it is termed, quickly, is the great desideratum with the patient, who often visits us late in the evening, with a woful dread of what his appearance must be next morning, unless we have some appli- cation which can prevent or remove the discoloration. If the blow has been severe, there can be no question that leeching is the proper mode of treatment. When the patient is a scrofulous child, the appli- cation of leeches is called for, not indeed so much for the removal of the ecchymosis, as for preventing inflammation of the periosteum and bones. If the blow has been slight, and the patient is a robust adult, compresses wet with an evaporating lotion, may be applied, and kept in close contact with the skin, by means of a roller going round the head. Fomentations with warm water, or with hot spirits, are sometimes used, and appear to do good. A popular remedy is a cataplasm of the bruised roots of the con- vallaria multiflora or Solomon's seal. The roots are beat into a pultaceous mass in a mortar, and are reapplied every half hour for three or four hours, or longer if necessary. They cause a degree of redness and swelling, and have been supposed to act by means of the oedema which they excite, diluting the effused blood, and thus promoting its absorption. If long continued, they produce too much inflammation ; and if the skin be abraded, they are too irritating to be applied at all. [A popular remedy much in vogue in the Lrnited States, and one, of which 144 POISONED WOUNDS OF THE EYELIDS. the reminiscence of any one's school-boy days would furnish many a proof of the efficacy in the prevention of the "dreaded black eye," is the red oil, as it is commonly called—which always in former times held its position in the nursery closet, by the side of the sulphur and molasses, as a panacea. It consists of the flowers of the Hypericum perforatum (St. John's wort), treated with sweet oil. It does undoubtedly prevent the occurrence of ecchy- mosis and discoloration of the skin, when applied immediately after the re- ceipt of a severe bruise. As to its modus operandi, we do not feel ourselves qualified to pronounce an opinion. Its application is not attended with the redness and swelling consequent on the use of the cataplasm of Solomon's seal, and it, therefore, probably does not act in the same manner. Its use is not followed by the inflammatory symptoms which ensue after the long-continued use of the latter remedy. It is simply rubbed over the part, and one or two applications are sufficient, and generally even one is all that is required to produce the desired effect.—H.] Whatever application we make choice of, whether a solution of muriate of ammonia, a spirituous fomentation, or a cataplasm of convallaria roots, the patient ought to be directed to keep the eyelids at rest, and to maintain a certain degree of pressure on them by means of wet folds of linen, or the cataplasm. Motion of the lids appears to throw the effused blood more into their loose cellular substance, while rest, and gentle pressure tend both to prevent this, and to promote absorption. By lancing an ecchymosis, more harm is done than would arise from allow- ing the blood to remain. After the swelling has subsided, those who are obliged to appear iu public, sometimes contrive to paint the skin from day to day, till the natural color is restored. § 2. Poisoned Wounds. The eyelids are apt to suffer from the stings of bees, wasps, gnats, &c. From the poisonous principle infused into the wound, the stings of those insects sometimes produce severe irritation and inflammation ; and the effects are generally aggravated if the sting is left in the wound. If we allow our- selves without resistance to be stung by a wasp or a bee, the insect gradually disengages the sting, without breaking it. The sting is flexible, and the wound is curved or in a zigzag direction. If we drive the insect away, the sting is caught in the wound, breaks off, and is left behind.3 The result, if there is only one wound, is a circumscribed inflammatory, or erysipelatous swelling of the eyelid and eyebrow, sometimes ending in a small slough, sometimes in a considerable abscess, which points and breaks at the place of the sting. If there are many punctures, the reaction may extend be- yond the seat of the injury. Rognetta refers1, as to a well-known fact, to the case of an unfortunate postilion, who having overturned a beehive by an accidental stroke of his whip, was so stung about the eyelids and rest of his face, that his head swelled prodigiously, fever with delirium ensued, and he died in a few days. The treatment in ordinary cases consists in extracting the sting, and ap- plying some refrigerant and astringent lotion, as vinegar and water, or a solution of muriate of ammonia. Gillman has recorded5 a case of bite of the eyebrow by a dog, followed by hydrophobia; and Lecheverel, one of bite of the upper eyelid, near the outer canthus, by a dog not mad, which also produced fatal hydrophobia." A case of this sort is related by Mr. Haynes Walton7, who does not hesitate to recommend the wounded part to be excised under such circumstances, not BURNS AND SCALDS OF THE EYELIDS. 145 conceiving the alleged power of neutralizing the poison by escharotics worthy of confidence. Case 114.—The whole integuments of the upper eyelid in a little boy who was brought to me, were destroyed by inflammation and sloughing, consequent to a scratch with the claw of a cat. I feared lest complete ectropium should be the result; but the wound healed very slowly, and the margin of the lid, having luckily escaped, seemed to prevent any eversion. § 3. Burns and Scalds. Burns and scalds of the eyelids present many shades of severity, depending on the nature of the medium by which the heat is applied, the length of time during which the parts are exposed to its influence, and the extent and situa- tion of the surface affected. For example, in cases of exposure to common flame, the eyelids have time forcibly to close, so that only a very small portion of the eyelashes is left unprotected. Common flame, then, singes in general merely the ends of the eyelashes, and scarcely ever touches the eyeball. When gunpowder takes fire, and burns the eyelids, the flame being so sudden and expansive, the lids do not close in time, and the eyelashes, along with the eyebrows, are generally completely burnt off, and often the con- junctiva, or the cornea, is also injured. When unconfined gunpowder takes fire, there is generally no propulsion of its particles, but grain after grain ignites and is consumed, burning of course the lids or any other part which is exposed. For the same reason, a rocket taking fire in the hand, burns the face and destroys the eyelashes and eyebrows, but leaves no grains imbedded in the skin, the conjunctiva, or the cornea; for the powder is previously ground and mixed with an additional quantity of charcoal. When confined, as in a flask, the grains of gunpowder, on the contrary, are driven about unexploded, and fix in the skin of the lids, in the conjunctiva, or in the cornea.s Case 115.—A bit of a lighted cigar, falling on the inner extremity of the left lower lid, gave rise to a blister and ulcer, with much thickening of the lid and general chemosis of the conjunctiva. The swelling subsided and the sore healed slowly, under the appli- cation of cold water. A person falling down in an epileptic fit, perhaps brings the eyelids into merely momentary contact with the ribs of the grate and burns them super- ficially ; or, remaining insensible for a considerable time, and lying in contact with the fire, a large portion of the integuments of the face is disorganized, and that so deeply, that on the eschar separating, the bones are exposed. All cases of burns and scalds of the eyelids should be treated with particu- lar care; for there is, on the one hand, the danger of ankyloblepharon, or union of the edges of the lids, and on the other, of lagophthalmos and ectropium. If hot water, or some caustic fluid, is the offending cause, much will depend on the temperature of the former, and on the degree of concentra- tion of the latter. It is chiefly in cases of scalds from boiling water, and other hot or caustic fluids, as sulphuric acid, in which the cuticle covering the edges of the lids has been detached, and the patient afterwards allowed, from carelessness, to lie for a length of time with the lids shut, that ankyloblepharon follows. To prevent this, if possible, the patient should be obliged frequently to open his eyes, while a little mild salve, melted on the point of the finger, should be introduced along their edges. Symblepharon, or union of the lids to the eyeball, is sometimes produced, when the conjunctiva has been injured by the burn or scald. Its prevention should be attempted in a similar way. Burns and scalds of the external surface of the lids, which have not been 10 146 BURNS AND SCALDS OF THE EYELIDS. sufficiently severe to produce a separation of the cuticle, much less to destroy the texture of the cutis, require merely to be kept constantly wet with water for twenty-four hours, by means of a fold of linen. The same application is also, I conceive, the best in cases in which the skin is blistered ; only, that as soon as the blister has fairly formed, it ought to be punctured with a needle, to let its contents escape. After the first twenty-four hours, a piece of soft linen, spread with simple cerate, is to be applied. Burns so severe as to destroy the texture of the cutis, heal only by a slow process of granulation and cicatrization. The granulations, upon which the new skin is formed, are afterwards absorbed, so that a great degree of con- traction is produced ;* and if the eyelids are involved in the cicatrice, they are liable to be shortened or everted. This happens more frequently to the lower than to the upper lid; while, in some cases of destruction of the skin stretching from the outer angle of the eye towards the temple, we find, after the burn has healed, that both lids are dragged outwards, and their internal surface exposed. One of the worst cases of eversion of the lids from a burn, which I have seen, was consequent to total destruction of a large portion of the skin of the face, occasioned by a child falling against the fire. The lobe of the ear was lost, the cicatrice was very extensive, and both lids were everted, and dragged towards the temple. In such a case, it is impossible to prevent altogether the displacement of the lids, attendant on the contraction of the cicatrice. In cases of burning of the eyelids from the individual falling upon the fire, where the destruction of parts is such that little else is left than cartilage and conjunctiva, the consequent ectropium is necessarily so great, that the eye inflames, suppurates, and perishes, from exposure. But, in ordinary and less severe cases, much may be done by careful dressing and bandaging. The lids must be kept, as much as possible, on the stretch, during the progress of cicatrization ; for if this is not done, little or no new skin will be formed, but the ulcer will be covered at the expense of the loose integuments around, in the same way as an ulcer of the scrotum will some- times heal up without almost any formation of new skin. The patient, then, in whom the cicatrization of a burn in the neighborhood of the eyelids is going on, ought not to be allowed to use his eyes, but should keep the lids, both of the injured and of the sound side, constantly shut, except when the dressings are changed. Let pledgets, spread with simple cerate, be laid upon the parts, and round the head a roller applied so as to press gently on the lids, and keep them on the stretch. This will appear probably a very tedious and annoying mode of treatment. To be allowed to use the eyes, would be much more agreeable to the patient, till he found, as soon as the process of healing was finished, that he could only incompletely close his lids, or that a portion of their inner surface was permanently exposed by eversion. Burns by gunpowder are to be treated in the same way as other burns, * [Such a doctrine as the contraction of a wound healing by granulation and cicatriza- tion, being produced by the absorption of the granulation, is not tenable at the present day, when we have the microscopic researches of Paget and others, proving most con- clusively that it is due to a change iu the form of the lymph corpuscles or nucleated o»lls, composing the granulations. These cells having developed themselves from a round, or oval cell, into a narrow filament of cellular or fibro-cellular tissue, of course occupy much less space than when they composed the granulating surface. " The whole mass of the developing cells becomes more closely packed, and the tissue that they form becomes much drier; with this, also, there is much diminution of vascularity. Thus, there re- sults a considerable decrease of bulk in the new tissue as it develops itself; and this decrease beginning with the development of the granulation cells, continues in the scar, and, I think, sufficiently accounts for the contraction of both, without referring to any vital power." (Paget).—H.] WOUNDS OF THE EYEBROW AND EYELIDS. 147 except when unexploded grains of the powder have been forced into the skin of the eyelids. When this is the case, the particles must be carefully picked out, one by one, with a cataract needle ; an operation which may take hours to accomplish. Under such circumstances, we should not trust much to the application of a poultice, which is recommended with the view of dis- solving and bringing away the grains of powder. If they are left in the skin, indelible spots remain as if the person were tattooed. § 4. Incised and Lacerated Wounds. Punctured wounds of the eyebrow and eyelids are, in general, not attended by any bad consequences. We must be upon our guard, of course, lest a punctured wound of the upper lid has gone deeper than its mere external appearance might denote, and the instrument with which the wound was inflicted penetrated into the orbit, or through the orbitary plate of the frontal bone. (See page 54.) We must also examine carefully whether any portion of the instrument (the broken end of a stick, for example) may not have separated in the wound, and be lodged in the loose areolar tissue around the eyeball. The edges of incised wounds of the eyebrow are to be brought accurately together, and retained by the interrupted suture, with slips of court-plaster between the stitches. Dieffenbach used the twisted suture in such cases, inserting fine insect pins, and twisting a thread around them. The same practice is to be followed in incised wounds of the eyelids. Even when they are parallel to the fibres of the orbicularis palpebrarum, and implicate only the integuments, we shall find the suture the best means of maintaining the edges of the wound in exact apposition, and thereby preventing any un- sightly cicatrice. Stitches are still more necessary where the whole thick- ness of the lid has been divided, either transversely or vertically. When the wound is transverse, we may content ourselves with including only the in- teguments in the suture ; but in vertical wounds, the needle ought to pass through the whole thickness of the divided lid. After the stitches are inserted and the slips of plaster applied, the eyelids are to be closed, and covered with a pledget spread with simple cerate. A folded piece of linen is to be laid over the sound eye, and a roller, going round the head, is to press gently upon both eyes, so as at once to keep the dressings in their place, and to restrain the lids from moving. Generally, by the third day, union is effected, so that the threads may be cut out, or the pins removed ; after which, the slips of plaster are to be replaced, as well as the compresses and roller. If the edges of a wound of the lids do not correspond, they must be made to do so by the application of the scissors. If a large piece of skin be lost, so that the edges of a transverse wound cannot be made to meet, subsequent ectropium may sometimes be prevented, by making an incision parallel to the wound, and about a quarter of an inch from its exterior edge, which will allow the edges of the wound to be drawn together. A vertical wound of either eyelid, passing through its whole thickness so as to divide it into two flaps, somewhat like the two portions of a hare-lip, has received the name of coloboma. If neglected, the edges of such a wound are apt to cicatrize sepa- rately. A similar deformity sometimes occurs congenitally.9 An operation analogous to that for the cure of hare-lip, is to be had recourse to under such circumstances. The edges of the coloboma are to be pared, and then accu- rately brought into contact, and kept so by one or two sutures and slips of court-plaster, till reunion is completed. If a vertical wound of either eyelid is treated merely by the application of plasters, without any suture, the one edge of the wound is apt to slip under the other, union is effected in this position, and the cilia*©f the flap which is 148 WOUNDS OF THE EYEBROW AND EYELIDS. undermost, are turned in on the eye. Should this have happened, the two flaps must be separated with the knife, and their edges being pared with scissors, must be brought accurately together with a suture or two. Case 116.—A little boy had the lower eyelid torn through, near the inner canthus, by the paw of a dog. He was carried into a surgeon's shop, and a piece of adhesive plaster put over the wound. Some days after, being called to see him, I found the flap rolled in, so that the cilia were out of sight. The adhesions were not yet so strong, but I could tear them asunder with a probe; after which I applied stitches, and a compress and roller. It occasionally happens that, through a wound of either eyelid, the eyeball is injured. This does not alter the mode of proceeding with regard to the lid. So instantaneous is the instinctive shutting of the eye when approached by any foreign body, the eyeball rolling upwards and the lid at the same moment descending, that the wound of the lid and that of the ball will pro- bably correspond, when the eye is closed; and the eye being kept in that state after the injury, symblepharon is not unlikely to take place. Mr. Law- rence mentions a case in which a horizontal wound of the upper lid having been neglected, a sort of button-hole was formed, from the edges not having been kept in apposition ; what was worse, accretion of the conjunctival sur- face of the palpebra to the globe had taken place, and the lid hung so much over the globe as to render the eye almost useless.10 On the 1st May, 1836, I saw a boy at the Glasgow Eye Infirmary, who had been wounded in the upper eyelid six weeks before, with a sharp piece of stoneware. The lid could not be raised from the eyeball so as to bring the cornea into view. There was evidently symblepharon, and probably the eyeball had been penetrated, at the time of the wound, as well as the eyelid. Lacerated wounds of the eyebrow and eyelids do not so readily admit of union as incised wounds. The swelling, inflammation, and suppuration which ensue, prevent immediate union. Allowed to heal without particular care, the contraction during the progress of cicatrization is apt to produce ectro- pium, against which we ought to guard by treating lacerated wounds of these parts almost exactly as we would do incised wounds. Having carefully cleaned them, and removed any foreign substances which may have been forced into the cellular membrane, we bring the edges accurately together. If the means employed to produce reunion, do not succeed, or if they seem to produce additional irritation, they must be removed, and the cure must be effected by the second intention. When the contusion and laceration attend- ing a wounded eyelid are very great, of course no attempt at union need be made, till, by leeching, and poulticing with bread and water, the irritation and tumefaction shall have subsided. By guarding against motion, and by the careful use of compresses and adhesive plasters after the parts have become quiet, we shall often be able to accomplish reunion without any con- siderable deformity or displacement. [A dressing for all wounds of the eyelids, which, whilst it would keep the lips of the wound in close apposition—paralyze the orbicularis and levator and yet be devoid of the weight and heat of the compresses and bandages usually employed for the purpose—but which do not fulfil all that they are designed to accomplish—would be a great desideratum to the ophthalmic surgeon. We believe that all the requirements of such a dressing are met in the dressing which we are now in the habit of employing in wounds of the lids, and also in all wounds of the ball, and even after operations for cataract at Wills's Hospital. It consists of a very delicate silk tissue, with large meshes, known as the "Donna Maria gauze," which we secure to the oppo- site sides of a wound by means of the collodion. By securing one end first on one side of the gaping surface, and then, after the collodion has become completely firm, drawing on the other end, we get a firm purchase, and are WOUNDS OF THE EYEBROW AND EYELIDS. 149 enabled to approximate the lips of the wound with a much greater degree of accuracy than by the use of either the ordinary adhesive plaster, or the isin- glass cloth applied in a similar manner. Then binding the free end down on the opposite side, we have the wound completely closed; and yet its whole length in the integument is exposed through the delicate meshes of the tissue, and we can make such topical applications as we may desire directly to it. The introduction of this mode of dressing wounds generally is due to the ingenuity of Dr. Paul B. Goddard, of this city, who has employed it very exten- sively in all his surgical dressings ; and it was from seeing him use it in wounds of the face that its general and peculiar applicability to all wounds about the eye was suggested to us. We now employ it to the exclusion of all other dressing for the eye; and it is also employed by our colleague, Dr. Harts- horne, who was the first to use it (at our suggestion) in the hospital. In a simple transverse wound of the upper lid, after approximating its lips, and securing them by sutures, if necessary, we take a piece of the gauze, about one inch broad, and three or four inches long, and applying one end to the upper lid at the brow, and painting it over with the collodion, it soon becomes securely bound to the integuments. We paint in this way little by little, until we get the whole of it covered down to the upper lip of the wound. We then allow the collodion to become dry and firm. Then drawing on the free end, the lips of the wound are completely approximated; and, if it is near the brow, we secure the gauze to the free margin of the lid, and, after the collo- dion has become dry, then we securely paralyze the muscles of the lid by fastening what remains of the gauze to the cheek, having previously drawn the upper lid down to the lower, and pushed up the integument of the cheek, so that everything may be tight after the collodion last applied has evapo- rated. If the wound is near the ciliary margin of the lid, we do not bind the gauze in a second place to the lid, but, drawing from the first purchase, we close the lids, and secure the dressing to the cheek as above described. In a ver- tical wound, after having closed the cut by a piece of the gauze applied hori- zontally, we secure the quiet of the lid by a piece applied from the brow and upper lid to the cheek, covering all the lid with the collodion, except where the wound is, which we leave covered by the gauze only.—H.] Wounds of the lids from explosions often present a frightful appearance, and are apt to leave the parts in a very altered condition. Case 117.—A gunsmith, employed to repair a musket, which he was told was not charged, put the breech of it in the fire, and looked in at the muzzle. A small charge of powder which was in it exploded, and tore his right upper eyelid through at its inner extremity, forming a deep fissure in the inner canthus, completely charring and blacken- ing all the parts with powder, and, though the eyeball was left entire, burning the cornea and rendering it opaque. Case 118.—Ammon" gives a figure of a boy, who was wounded by a musket-ball, which passing from left to right, struck the face so that it tore away the left lower lid, destroyed the left eyeball, penetrated the arch of the nose, tore away the right lower lid, and burst the right eyeball. The eyes atrophied, and in place of the lower lids there was an ex- posed red mucous surface; the upper lids, being no longer connected at their extremities by any commissure, were slightly everted, and had lost their natural motion. From lacerated wounds, gangrene and sloughing of the injured part may take place, and one or other lid may be destroyed. Case 119.—A man calling to consult me regarding an affection of the lungs, I noticed something remarkable about one of his eyes, and on examination found the lower lid entirely wanting. The skin of the cheek ended abruptly in the conjunctiva oculi. The upper lid was elongated, so as to supply the deficiency. On inquiring into the history of the case, he told me that, several years before, he had received a severe injury of the lid with a reaping-hook, followed by such a degree of inflammation, probably gangrenous, as destroyed the lid entirely. 150 WOUNDS OF THE BRANCHES OF THE FIFTH NERVE. In lacerated wounds, the lids may be so much injured, that, after recovery, one or other of them, or both, shall be found adherent to the eyeball, and the patient scarcely able to expose any part of the eye. If the smallest chink, however, continues open, the eyeball will turn towards that point, and vision be thereby accomplished; as was the fact, no doubt, in the case related by Smetius,12 in which the lids seemed so altered, and so agglutinated to the eyeball, that when the patient began to discern objects, it was absurdly con- cluded that he saw, not from between the lids, but down the nose, which had also been severely injured, and remained more expanded than natural. Incised, and, still more, lacerated wounds of the lids are apt to bring on erysipelas, which, by passing deep into the orbit, may affect the brain or its membranes and cause death, as I shall have occasion to state more fully in the Third Section of this Chapter. Wounds of the upper eyelid are occasionally followed by palsy, in conse- quence of the injury done to the levator palpebral superioris, or to the branch with which it is supplied by the third nerve. This branch, however, cannot be reached, unless the wound penetrates pretty deep into the orbit, and tra- verses the levator muscle. Pare observes13 that the patient, when he wishes to see, is obliged to raise the eyelid with his finger. He attributes this con- sequence of a wound of the upper eyelid, to unskilfulness or inadvertence on the part of the surgeon, inasmuch as he must have omitted sewing the wound properly, and applying the necessary compresses and bandage. M. Ribes mentions the case of a soldier who had received a cut from a sabre in the upper eyelid, towards the superior edge of the tarsus. The wound healed readily: but the patient, even while he retained the faculty of vision, saw none, on account of the impossibility of raising the upper eyelid, which con- tinued constantly depressed.14 Such facts, while they must impress us with the importance of leaving nothing undone which is likely to procure a com- plete reunion of the divided parts, may serve also to warn us against pro- nouncing a prognosis too decidedly favorable, in those cases in which we have reason to suspect that the levator of the upper eyelid, or its nerve, may have been injured. Wounds of the eyebrow and eyelids are sometimes followed by effects still more serious. I have already (page 50) quoted a case from Dease, and re- ferred to another by Petit, in which injuries of this sort were followed by inflammation within the cranium, and death. Weakness of sight, or even loss of vision, is another consequence apparently arising from even trifling injuries of the eyebrows and eyelids, which has attracted much attention. For example, Camerarius relates the case of a young man who received a slight wound at the inner angle of the left eye close to the upper eye- lid. The wound, though small, penetrated to the bone, and the patient immediately felt a severe pain, which was attended by swelling of the part, and by palsy of the right side of his body. The vision of the right eye became dim, and that of the left was totally lost, although nothing appeared diseased about the eye, except a slight dilatation of the pupil. The left upper eyelid was also paralyzed. The use of hot mineral waters seemed to restore the motion of the lid, and also of the right leg and arm. The sight of the right eye was in some degree recovered, but that of the left was irre- mediably lost. Morgagni was consulted by a lady, who had been wounded close to the left eye, in two places, by the fragments of the glass of a carriage window. She had seen none during the four days which followed the acci- dent. One of the wounds was near the outer angle, and the other, which was smaller, was under the commencement of the eyebrow. Sabatier quotes15 these facts, as illustrative of the effects of injuries done to the branches of the fifth pair of nerves. AMAUROSIS CONSEQUENT TO WOUNDS OF THE EYELIDS. 151 Petit having submitted to the French Academy of Surgery the case of an officer, who became completely amaurotic in consequence of a sword-wound in the eyebrow ; some explained the fact by attributing it to the concussion of the brain, produced by the instrument of injury; others thought it probable that the sword had penetrated the orbit, and touched the brain; while a third party denied the fact altogether. In this state of the question, Vicq d'Azyr had recourse to experiment. He laid bare, in a variety of animals, the frontal and superciliary branches of the fifth pair; he bruised and tore the exposed nerves; and convinced himself that this was speedily followed by blindness.18 Sabatier, Beer, and others suppose, that the injury of the supra-orbitary nerve, or of some other of the branches of the fifth pair, operates sympa- thetically on the eye, through the medium of the nasal branch of that nerve, which assists in the formation of the lenticular ganglion. Admitting this supposition to be true, the question naturally arises, how an injury of the fifth pair, operating through the medium of the lenticular ganglion, should produce blindness. This point has been taken up by M. Ribes, who con- tends that the ciliary nerves do not all go to the iris; but that several of them, having reached the anterior part of the eye, penetrate the corpus ciliare, and send filaments back towards the retina.17 Even such a connection, were its truth established, would by no means explain how the irritation arising from an injury of a branch of the fifth nerve, could affect the retina, unless through the medium of the brain. Beer has discussed the subject of amaurosis from wounds of the branches of the fifth nerve, at great length.18 The substance of his observations is, that in severe cases the blindness may be instantaneous ; in less severe cases, slow, sometimes not till after the process of cicatrization has begun, or is com- pleted ; that it may be a consequence of tension of the nerve, or pressure upon it produced by the cicatrice; that the pupil is sometimes expanded, sometimes contracted, in such cases; that we must beware of confounding amaurosis from wounds of the branches of the fifth pair, with amaurosis from concussion of the eyeball, and perhaps laceration of the retina, and bear in mind that, along with a wound of the eyebrow or eyelids, there may have been a severe blow on the eyeball; that in cases in which the amaurosis is really sympathetic, vision may often be completely restored by dividing the lacerated nerve. Chopart,19 Boyer,20 and others have adopted a different view from that of Sabatier and Beer, upon the subject of amaurosis consequent to wounds of the eyebrow and eyelids. They have observed that blindness is not the only attendant on such injuries ; but that convulsions, palsies, delirium, coma, and even death, have not unfrequently been known to result apparently from such wounds, but in fact from disease of the brain, either concomitant with, or pro- duced by, the external injury. They have, therefore, concluded that we ought not to account the amaurosis a mere nervous sympathetic effect, or a mere reaction from the injured nerve of the face upon the nerves of the iris or retina; but that the irritation arising from the wound is propagated to the brain; that the nervous symptoms which follow, are to be ascribed to disease arising in that organ; and that the affection of the brain, or of its membranes, in such cases generally partakes of the nature of inflammation, followed by effusion, or by suppuration. In many cases of this sort, the result has been fatal, and dissection has demonstrated the truth of these views; while in cases of recovery, we should be led to suspect, that the amaurosis, and other nervous symptoms, have disappeared, not in consequence of our dividing the injured nerve, but from the diseased state of the brain having subsided. The instances on record which show that very serious or even fatal disease of the brain, may arise in connection with apparently slight wounds of the 152 AMAUROSIS CONSEQUENT TO WOUNDS OF THE EYELIDS. eyebrow or eyelids are sufficiently numerous. Morgagni has narrated21 several highly interesting cases of this sort. The conclusion to be drawn from such cases is evidently this, that we must watch the effects of such injuries, keep the patient quiet and on low diet, and have recourse freely to the use of blood- letting, if there appear the slightest symptoms of any affection of the brain or its membranes. Similar practice must be followed, if we have reason to conclude that the amaurosis concomitant with a wound of the eyebrow or eyelids is the result, not of the injury done to the branches of the fifth nerve, but of concussion of the eyeball. I have seen numerous examples of a blow on the eye inducing amaurosis, without in the least affecting the vascularity, or the transparency, of its different textures ; and I can easily conceive that, had any wound of the integuments in the neighborhood of the eye accompa- nied such blows, I might have been led into the erroneous supposition that the amaurosis was not direct, but sympathetic. My own experience leads me to state, that a very considerable proportion of the subjects of asthenopia and of amaurosis present cicatrices of the eye- brow or its neighborhood; and a suspicion naturally arises, when no other more likely cause is detected, that these affections of sight have originated in injuries of the branches of the fifth nerve. In some cases I have seen acute inflammation of the retina and iris excited by such injuries ; much more frequently the affection, which has interfered with the nutrition of the eye and the soundness of the retina, has either been slow and insidious in its pro- gress, or has established itself soon after the injury, but without being ob- served. In all such cases I should suspect that injury of the branches of the fifth nerve, having communicated irritation to the nervous centres, a reflex disease, probably inflammatory, was propagated from them to the optic nerve, and to the other nerves concerned in the function of vision. Such consider- ations would lead us, in cases of suspected injury of the branches of the fifth nerve, not only to enjoin rest, to treat the patient antiphlogistically, but to administer calomel, with opium, in doses sufficient to affect the system. It is proper to mention, before quitting this subject, that the section of the injured nerve, proposed by Beer, and which he expressly states to be a means which had never failed him, has been repeated in several instances by others, without producing any effect upon the amaurosis. "I have met," says Dr. Hennen, " with one or two cases of amaurosis from wounds of the supra- orbitary nerve ; the perfect division of the nerve produced no alleviation of the complaint, but after some time the eye partially recovered."22 "When the defective vision follows a wound in the forehead," says Mr. Guthrie, " the only hope of relief that we are at present acquainted with, lies in a free incision made down to the bone, in the direction of the original wound ; and even of the efficacy of this I am sorry I cannot offer testimony from my own practice, having failed in every case in which I tried it."23 Many other remedies deserve a trial, in cases of amaurosis apparently arising from injuries of. the fifth pair, besides the operation here referred to. In a case recorded by Dr. Lichtenstadt, in which the amaurosis seems to have originated in a wound of the infra-orbitary nerve, made in opening a scrofu- lous abscess, electricity appeared singularly useful in restoring vision.24 It is well known, that every wound of the branches of the fifth pair does not produce amaurosis. In a case which fell under my observation, mydriasis rather than amaurosis was the effect of such an injury; for while with the naked eye the patient could not tell that a paper held before him was printed, when he looked through a pin-hole in a card, he could read even a small type. Magendie has even endeavored to show by experiment that pricking the branches in question, especially the supra-orbitary, infra-orbitary, and lachry- mal, has no bad effect on vision. He has been led to propose galvanizing PHLEGMON OF THE EYELIDS. 153 the eye, by touching these nerves directly with the wires communicating with the opposite poles of a galvanic trough.-5 The consideration of these facts naturally leads us to regard with still greater doubt, the alleged occurrence of purely sympathetic amaurosis from slight injuries of the fifth pair, and to suspect that, in supposed cases of this sort there has been, in addition to the external injury, either concussion of the eyeball, or disease excited within the cranium.28 1 Lawrence's Treatise on the Diseases of the Eye, p. 126; London, 1833. 9 Zeitschrift fiir die Ophthalmologic; Vol. i. 125; Dresden, 1830. 3 Reaumur, Histoire des Guepes; Memoires de I'Academie Royale des Sciences, 1719; p. 350; Amsterdam, 1723. 4 Cours public d'Ophthalmologie ; Lancette Francaise, 7 Janvier, 1837. 6 Dissertation on the Bite of a Rabid Animal, p. 170; London, 1812. s Quoted from Bulletin des Sciences Medi- cales; Tome ii.; Paris, 1808: in Langenbeek's Bibliothek; Vol. iii. p. 666: Gottingen, 1810. " Operative Ophthalmic Surgery, p. 93; Lon- don, 1853. " See Lonsdale, Medical Gazette; Vol. xi. p. 696; London,1833. 9 Das Auge, votn Professor Beer, p. 55; Wien, 1813: Heyfelder, Ammon's Zeitschrift fiir die Ophthalmologic; Vol. i. p. 481; Dres- den, 1831. 10 Op. cit. p. 127. " Klinische Darstellungen der Krankheiten des Auges; Zweiter Theil; Taf. vi. fig. 17; Berlin, 1838. 19 Trnka de Krzowitz, Historia Amauroseos, p. 16; Vindobona:, 1781. 13 GSuvres; Liv. x. Chap. 24. 14 Memoires de la Socieie Medicale d'Emu- lation; Vol. vii. p. 92; Paris, 1811. 15 Traite d'Anatomie; Tome iii. p. 228; Paris, 1791. 16 Journal ComplSmentaire des Sciences MSdicales; Vol. xliv. p. 201. Paris, 1832. 11 Memoires de la Societe Medicale d'Emu- lation ; Tome vii. p. 99 ; Paris, 1811. 18 Lehre von den Augenkrankheiten; Vol. i. pp. 176, 185, 189; Wien, 1813. 18 Treatise on Chirurgieal Diseases, trans- lated by Turnbull; Vol. i. p. 267 ; London, 1797. 90 TraitS des Maladies Chirurgicales; Tome v. pp. 245, 248; Paris, 1816. 91 De Sedibus et Causis Morborum, Lib. iv. Epist. 51; Tom. iii. p. 59; Ebrouuni, 1779. See a case in Bright's Reports; Vol. ii. Part i. p. 143; London, 1831. 29 Observations on some Important Points in Military Surgery, p. 366; Edinburgh, 1818. 93 Lectures on the Operative Surgery of the Eye, p. 102; London, 1823. 94 GrSfe und Walther's Journal der Chirurgie und Augenheilkunde ; Vol. vi. p. 569 ; Berlin, 1824. 96 Journal de Physiologic; Tome vi. p. 156 ; Paris, 1826. 96 On amaurosis from wounds of the eyebrow, consult Walther, Grafe und Walther's Journal der Chirurgie und Augenheilkunde; Vol. xxix. p. 505; Berlin, 1840. SECTION II.—PHLEGMONOUS INFLAMMATION OF THE EYELIDS. Syn.—Blepharitis phlegmonosa. Phlegmonous inflammation of the eyelids occurs more frequently in children than in adults, and oftener in the upper than in the lower lid. Symptoms.—The affected lid is of a deep red color, hot, swollen, and very painful on being touched. The swelling spreads from the edge of the lid, but is generally limited in its progress by the margin of the orbit. It is soon so considerable as to prevent the eye from being opened; the pain is much increased by the least attempt to move the eye. If the inflammation is unchecked, the pain becomes pulsative, the swelling increases, assumes a livid red color, and begins to point, generally about the middle of the lid. The pain is now attended by a pricking sensation. The hardness of the swelling diminishes, and at its most prominent part it becomes less sensitive to the touch. The lid has suppurated, the fluctuation of the matter is now distinct, and by and by the abscess bursts through the integuments. In some cases the abscess gives way on the inside of the lid. Causes.—Abrasion and other injuries of the skin covering the eyelids, appear to bring on phlegmonous inflammation; but not unfrequently the cause is obscure, especially when children are the subjects. Prognosis.—This disease being neglected or mistreated, a portion of the 154 ERYSIPELAS OF THE EYELIDS. integuments of the eyelids may be lost, from ulceration, or from the inflamma- tion going on to gangrene; the consequence will be contraction of the lid, and perhaps ectropium. Treatment.—Leeches to the swollen lid, followed by the constant applica- tion of an evaporating lotion, constitute the local treatment during the first or purely inflammatory stage. The patient is also to be purged, to keep at rest, and live low. If these means are found insufficient to procure the reso- lution of the inflammation, a warm bread and water poultice is to be applied in a linen bag, and as soon as fluctuation is distinct, the abscess is to be opened with the lancet, the incision being made transversely, or parallel to the natural folds of the skin of the eyelids. The matter is generally found immediately under the skin. The poultice is to be continued till the swelling subsides, and the abscess ceases discharging. SECTION III.—ERYSIPELATOUS INFLAMMATION OF THE EYELIDS. Syn.—Blepharitis Erysipelatosa.—Diffuse cellular inflammation of the eyelids. Fig. Dalrymple, PI. XII. fig. 3. In erysipelas of the face, vulgarly styled the rose, the eyelids are much affected, especially the upper. Erysipelas may also arise in the eyelids, and be confined to one or other of them, or affect both. In general, one side of the face only is affected ; but sometimes both at once, or first the one, and then the other. The disease is very variable in severity. Affecting the eyelids, without tumor or vesication, and assuming a chronic course, it is styled erythema. Local Symptoms.—In erysipelas, the lids are much swollen, so that the eye is shut up. The swelling is of a pale red color, but sometimes of a bright scarlet, or even of a deep and livid red. The redness disappears on pressure, but instantly returns when the pressure is removed. The pain is in general not considerable, nor pulsative. The swelling feels hot, and the patient complains of a stinging and burning sensation in the part. A serous effusion frequently takes place under the cuticle, which becomes elevated in vesicles. These bursting, allow the fluid they contain to escape and form crusts. On these falling off, the skin is generally left in a sound state ; and the swelling subsiding, the eyelids recover their power of motion. In more severe cases, the inflammation runs on into suppuration and sloughing of the subcutaneous cellular membrane. In such cases, the redness has more of the livid hue, the swelling is more considerable, and soon becomes tense and firm, the sensation of heat and pain is much aggravated, and is attended by throbbing. At first, the areolar tissue contains a whey-like serum. Mr. Lawrence mentions his having seen this effusion into the eyelids, almost of milky whiteness. It gradually becomes yellow and purulent, and is diffused through the swollen cellular membrane, which becomes so disorgan- ized, that it comes away, after the abscess bursts or is opened, in shreds soaked with matter. An erysipelatous abscess differs from a phlegmonous one in this respect, that it is not bounded by a sphere of adhesive inflamma- tion, but extends irregularly in different directions, producing extensive sloughing of the cellular membrane. An abscess of this sort communicates a peculiar boggy impression to the finger. If neglected, suppuration may take place as well beneath as exterior to the orbicularis palpebrarum, and even destroy the ligamentous layer of the eyelids. At length, the integuments give way in one or more points, a small quantity of matter is discharged, and shreds of disorganized cellular membrane may be extracted. Left, in this ERYSIPELAS OF THE EYELIDS. 155 way, to run its course, severe erysipelas leaves the lids so altered, and their several textures so agglutinated from the loss of the connecting cellular mem- brane, that they are long before they recover, if ever they recover, their natural pliancy and mobility. The conjunctiva, Meibomian follicles, and excreting lachrymal organs, always suffer more or less in erysipelas of the eyelids. A puro-mucous secre- tion accumulates, during the night, along the edges of the lids, and in the nasal angle of the eye. From this symptom, the inexperienced practitioner, called to an advanced case of erysipelas of the lids, is apt to suppose that it is one of contagious ophthalmia. The absorption of the tears is impeded, and there is a slight accumulation of mucus in the lachrymal sac. In some cases, a stillicidium lachrymarum remains after all the other symptoms have disappeared. In severe cases, ending in diffuse suppuration, the matter occasionally penetrates into contact with the lachrymal sac, which is already distended by the presence of an inordinate quantity of mucus. After the integuments in such a case give way, a superficial observer may be deceived by the appearance of the parts. He probably pronounces the case to be a fistula of the lachrymal sac, and forthwith opens the sac. It may happen, however, that the purulent matter of an erysipelatous abscess actually makes its way into the lachrymal sac, which thus comes to be filled with pus received from without, in the production of which its lining membrane has had no share. The latter case, which, for the sake of distinction, may be called spurious fistula of the lachrymal sac, must be carefully distinguished both from the former, in which the sac is entire, though distended with mucus, and from those diseases hereafter to be described, in which the purulent matter which fills the sac, is the result of inflammation of the lining membrane of that cavity itself. The sac, and the lachrymal canals, may suffer so much by being involved in the erysipelatous abscess, as to be rendered ever afterwards unfit to execute their functions. Erysipelatous inflammation, spreading from the eyelids to the cellular mem- brane of the orbit, sometimes terminates in abscess within that cavity, or effusion of matter within the orbital capsule. This appears to be one of the modes, perhaps the most frequent but least suspected mode, in which erysip- elas of the face or scalp proves fatal. The fatal result, under such circum- stances, is generally ascribed to effusion within the head, but may happen without any inflammatory affection of the membranes or substance of the brain being detected after death. In such cases the formation of matter within the orbit sometimes takes place suddenly, at other times slowly and insidiously. The matter is often found deposited in small quantities in dif- ferent parts of the orbit. Numerous cases similar to the following one, are recorded by M. Piorry:— Case 120. — A woman, aged 60, who had been admitted into the Salpetriere, on ac- count of slight bronchitis, was seized with erysipelas, commencing on the right cheek, and affecting chiefly the region of the lachrymal sac. The redness extended to the eye- lids, which became so much swollen as to close the eye. The disease spread to the other parts of the face and to the opposite eye. The part first affected ceased on the fourth day to be elastic, and became doughy. The general health was not at first affected ; but the pulse rose as the disease made progress, and on the third day, stupor, coma, and delirium were added to the other symptoms. The hairy scalp was scarcely affected. The disease was not at first regarded as one of serious import. An abstemious diet, and some simple lotion, made up the treatment. When the symptoms grew more se- vere, and the much swollen eyelids became covered with vesicles, numerous leeches were employed, and derivatives applied to the lower extremities. These means proved fruit- less, and the patient died on the fifth day. On inspection, 24 hours after death, the skin, which had been so very red during life, was everywhere of the same color as that of the other parts of the body. It was scarcely at 156 ERYSIPELAS OF THE EYELIDS. all thickened. Pus was found in two small abscesses, about the size of a pea, in the cel- lular substance of the right cheek, close to the periosteum; and another small abscess, not communicating with the former, was situated over the nasal duct. The eyelids pre- sented pus in their cellular tissue. On removing the roof of the right orbit, small deposi- tions of pus were found in the fatty cellular membrane around the optic nerve, and in that covering the floor of the orbit, chiefly towards its inner wall. There was no large ab- scess, neither did the small depositions of pus communicate with one another. With the exception of the cellular tissue, none of the parts within the orbit appeared inflamed; but the same was the case with the skin, although during life it had presented a crimson color. The left orbit contained no pus; nor was there any abscess in or under the scalp. The brain presented no inflammatory nor other diseased appearance. The lungs had suf- fered from pneumonia. The stomach, otherwise healthy, contained a quantity of green- ish and apparently bilious fluid. The intestines were sound.' It sometimes happens that the cellular membrane of the orbit, although considerably affected by inflammatory oedema, does not suppurate. On the subsiding of the acute symptoms, the eyeball in such cases may be found de- prived of its power of motion, protruded, or even amaurotic from the pres- sure it has undergone. Case 121.—In a case which came under my notice, and which had been attended with Buppuration of both upper and lower lids, the lids having been long kept closed, and the conjunctiva much inflamed, union took place between the upper lid and the lower edge of the cornea, ulceration of the latter having no doubt preceded this symblepharon. The probe was readily passed around the point of union, and the adhesion was divided so as to restore to the lid its natural motion. The centre of the cornea was found to be clear, the pupil natural in size, but motionless, and the retina insensible. Constitutional Symptoms.—Erysipelas of the eyelids is generally preceded by rigors, and attended by a considerable febrile irritation. The tongue is loaded, and the digestive organs much deranged. In fatal cases, death is preceded by delirium, subsultus tendinum, and coma. Causes.—As this disease frequently arises suddenly, without any local injury, it probably owes its origin to some peculiar state of the atmosphere, or to contagion. It is certainly much more apt to attack those whose sto- mach and bowels are in bad order. Local causes, as slight injuries, stings from wasps and other insects, leech-bites, incised or lacerated wounds of the eyelids, cuts and other injuries of the scalp, the application of blisters on the head, exposure of the eyes suddenly to cold after long-continued weeping, and the like, serve to produce it. Treatment.—An emeto-cathartic is the best of all general remedies to begin with, in erysipelas; for example, one or two grains of tartras antimonii, with an ounce or two of sulphas magnesia?, dissolved in two pints of water, and a teacupful given every two hours. In robust subjects, blood-letting may be practised with good effect; but in aged or debilitated patients, this remedy can scarcely be ventured on. Leeches may be applied on the temple or be- hind the ear. After the stomach and bowels have been freely evacuated, gentle diaphoretics are to be employed. The patient must be put on low diet. A prejudice exists among the vulgar, against every sort of wet application in erysipelas; but I have witnessed much advantage from the use of evapo- rating lotions in this complaint, and have never seen them do harm. The part affected may be sponged with spirits of wine, or kept wet with vinegar and water. A solution of nitrate of silver, in the proportions of 4 grains to 1 ounce of distilled water, dropped once or twice a day upon the conjunctiva, re- presses the inordinate secretion of mucus. We seldom require to touch the eyelids, when affected with erysipelas, with the lancet. Cases, however, do occur, in which scarifications, or even pretty deep incisions, ought to be employed. Sir Richard Dobson's mode of scarification consists in making fine punc- PHLEBITIS OF THE EYELIDS. 157 tures, with the point of a lancet, over the whole inflamed part, in number from ten to fifty; then fomenting with warm water in a sponge, to encourage the bleeding and serous discharge ; and repeating this operation two or three times in twenty-four hours, if the parts look red and tense. If done early, it shortens the disease ; at all events, it relieves the vessels in a very remark- able degree, thus producing local benefit, while it also serves to check the severity of the cerebral and general symptoms. It prevents vesication, and what is more important, diminishes the chance of suppuration. Provided the punctures are very minute, and not lengthened into small incisions, they never leave any permanent marks, even on the smooth skin of the forehead, much less on the eyelids.2 Dr. Bright relates3 ten cases of erysipelas, treated by minute punctures. In most of them the lids were affected, and the prac- tice appears to have been highly beneficial. In severe cases threatening to go into suppuration, the treatment by inci- sions ought to be adopted. One or more transverse incisions through the skin and subcutaneous substance of the affected lid, if employed early, may prevent suppuration and sloughing ; if later, it will afford the readiest outlet for the matter and disorganized cellular membrane. The incision is to be made cautiously, through the tissues of the lid, layer by layer, and is immedi- ately to be followed by the application of a warm bread and water poultice. The reader will find cases, serving to* illustrate both the progress of the complaint, and the mode of treatment by incisions, related by Mr. Lawrence, in his valuable paper on the nature and treatment of erysipelas, in the 14th volume of the Medico-Chirurgical Transactions. Should the symptoms in erysipelas of the lids lead us to suspect that the disease is tending inwards to the orbital cellular membrane, calomel, with opium, should be given, and blisters applied behind the ear, and to the temples. If the eyeball has become very prominent, and it seem probable that this is owing to the infiltration of pus into the cellular substance of the orbit, or a collection of fluid in the orbital capsule, the lancet should be em- ployed to give the matter exit. The situation where matter is most frequently deposited, is between the eyeball and the floor of the orbit. Should no matter flow on making a deep incision, still the discharge of blood will pro- bably prove serviceable. The method of opening the orbital capsule is to divide the conjunctiva over the space between the rectus internus, and rectus inferior, as in the operation for strabismus, and then direct the lancet back- wards by the side of the eyeball. If a spurious fistula of the lachrymal sac has formed, it is to be washed out once a day with tepid water, mixed with a little of the vinous tincture of opium. A small quantity of lint dipped in the same tincture is then introduced into the abscess, but not pushed so deep as to enter the sac. After the fistula has healed, should blennorrhcea of the sac continue, it will require to be treated as explained in the Third Section of Chapter VI. 1 Piorry, Clinique Medicale de l'Hopital de 2 Medico-Chirurgical Transactions, Vol. xiv. la Pitie et de l'Hospice de la Salp6tri$re, en p. 206; London, 1828. 1832, p. 381; Paris, 1833. 3 Reports of Medical Cases; Vol. ii. p. 98; London, 1831. SECTION IV.—PHLEBITIS OF THE EYELIDS. Syn.—Blepharitis phlebitica. Case 122.—A man of 78 years of age was admitted into the Hotel-Dieu at Nantz, with erysipelatous swelling of the face and eyelids. He had a quick pulse, pain in his fore- head, and great thirst. General blood-letting, an abstemious diet, and diluents were 153 CARBUNCLE OF THE EYELIDS. employed. The cedematous state of the eyelids increased, and spread to the ocular con- junctiva. A considerable cedematous swelling was also observed in the right parotid region. The tension and redness abated considerably, but the pulse continued quick, the patient talked much, became delirious, and was affected with tremors of the limbs. He died with distinct symptoms of an affection of the brain. On dissection, a circumstance attracted notice, which had not been observed during life; the veins of the forehead and temples felt hard, as if distended by an artificial injection. The scalp was swollen, especially posteriorly; and presented, towards the crown of the head, and on the left side of the sagittal suture, a small superficial ulcer, which the patient had not mentioned, so that, although probably the cause of all the symptoms, it had not been known during the life of the patient. The two frontal veins, and their ramifications, extending to the crown of the head, were full of pus, either concrete or sanious. At several places it was difficult to separate the viscid ropy pus from the lining membrane of the veins. The palpebral branches, which anastomose with those two trunks, were injected with purulent matter more or less solid. This state was more remarkable on the left side. The infra-orbitary branches of the anterior frontal vein of that side were in the same state, and an incision of the eyelid and cheek disclosed a multitude of veins, superficial or deep-seated, filled with purulent clots or with a reddish sanies. The two temporal branches, and their ramifications, even the most deep-seated, the anterior and posterior auriculars, and the ramifications by which they originate in the cranium, were in the same state on the right side only. An incision of the subcutaneous cellular tissue and of the muscles of that region presented the same appearance as the cheek, only still more distinctly. A track of greenish viscid pus marked the course of all those vessels, the coats of which were in some places entire, in others destroyed. The venous anastomoses, external to the parotid, formed a network, which might be compared to a varicose tumor, in a state of suppuration. The external jugular vein contained a black adherent clot, a little softened in its centre. Its internal surface was of a deep red, and evidently injected. It was not permeable to the blood, except towards its lower part. The internal jugular vein was healthy and empty. The right ophthalmic vein was diseased, and a venous abscess existed at the very point where it leaves the orbit to enter the cavernous sinus. The disease terminated suddenly at this place, being bounded towards the cranium by a clot shutting up the vein. The sinuses of the brain did not participate in the disease. The arachnoid was somewhat opaque, especially on the left side and at the anterior part of the brain. There was considerable serous infiltration under the arachnoid ; with a little water in the ventricles. In none of the organs of the body was pus detected, except in the veins already mentioned. The liver was not examined.1 This case demonstrates the necessity, when erysipelatous swelling attacks the eyelids, of examining the scalp and of attending to the state of the veins of the face. It also shows that too much dependence must not be placed upon an apparent diminution of the external symptoms; for in this instance the tension and redness fell, notwithstanding the impeded and disorganized state of a considerable portion of the venous system, and the close approach of death. These cautions are confirmed by a case of phlebitis related by Dr. Silvester2, in which the disease spread from the upper lip, along the sides of the nose, to the eyelids, forehead, and vertex, and proved fatal two months after the first appearance of the symptoms. 1 Archives G6ne>ales de Medecine; Mai, 9 Medico-Chirurgical Transactions; Vol. 1837; p. 63. xxiv. p. 36; London, 1841. SECTION V.—CARBUNCLE OF THE EYELIDS. Syn.—Anthrax Palpebrarum. ^ This circumscribed, gangrenous inflammation of the areolar tissue is occa- sionally met with in the eyelids. The swelling is of a dark red or purple color, extremely hard, and attended by severe burning pain. Vesicles rise on its surface, occasioning intolerable itching. Ichorous matter is discharged, and the affected areolar tissue and skin, becoming black and sloughy, at MALIGNANT PUSTULE OF THE EYELIDS. 159 length fall out. The cavity left by the separation of the slough granulates and heals up. Carbuncle occurs principally in old persons, whose constitutions have suf- fered from irregularities in diet. Opium to relieve the pain, bark and wine to support the strength, laxatives, and gentle diaphoretics, make up the general treatment. An early and free incision into the tumor most effectually relieves the pain, allows the matter to escape, and promotes the separation of the slough. An emollient poultice is to be applied after the incision has been made, and continued till the cavity left by the slough has filled up by granulation. The sore is then to'be dressed with simple cerate. SECTION VI.--MALIGNANT PUSTULE OF THE EYELIDS. Syn.—Die schwarze Pocke, Ger. The disease long known in France by the name of pustule maligne, is a gan- grenous inflammation of the skin, characterized at its commencement by a vesicle filled with bloody serum, under which there forms a small lenticular induration, which, in its turn, soon becomes surrounded by an erysipelato- phlegmonous tumefaction, of a deep red color and glistening surface. Gan- grene seizes the tumor, and extends rapidly from its centre to its circum- ference. This disease would appear in by far the greater number of cases to be produced from contact with one or other of the lower animals, affected in a similar way, or from contact with their carcasses. It is sometimes commu- nicated from one human being to another. It occurs chiefly in farriers, shep- herds, butchers, tanners, and others occupied much with the lower animals or their remains ; attacking those parts of the body which are habitually exposed, as the face, the hands, the arms, or such as have been accidentally exposed; and has been more frequently met with during the existence of epidemic dis- eases of the carbunculous description among cattle than at other times. The bloody serum of the pustule is the means by which the disease is pro- pagated. Its progress in individual cases is rapid, and the result often fatal. Death has been known to occur in 24 hours after the person was attacked. Malignant pustule is said to be rare in Paris ; but common in Burgundy, Franche-Comte, and Lorraine. I am not acquainted with any account of this disease as observed in Great Britain. It cannot be denied that the cases published1 under the name of glanders in the human subject, bear, in some respects, a similarity to those of malignant pustule; but, in glanders, a con- stitutional affection, somewhat like rheumatism, precedes the characteristic local symptoms, while the contrary is the case in malignant pustule. The latter disease displays itself from the commencement, by gangrenous inflam- mation at the point inoculated ; but the former, only after serious derange- ment of the general health, exhibits a pustular and gangrenous affection of the skin, along with an eruption on the Schneiderian membrane, and a dis- charge of purulent matter from the nostrils. These last symptoms do not occur in malignant pustule.2 When malignant pustule attacks the face, the erysipelato-phlegmonous inflammation spreads to the neck, and even to the chest. When the eyelids are the seat of the disease, the face becomes enormously swollen and exces- sively pained. The patient is affected with deep-seated headache, attended by delirium. This is followed by stupor, and great prostration of strength. If he survives the separation of the portion which has become gangrenous the lids are left in such a state of disorganization, that they consist of little 160 SYPHILITIC ULCERATION OF THE EYELIDS. more than conjunctiva. The consequence is, that as the process of recovery takes place, they are so greatly everted, that the eye is lost from want of its natural protection. The local treatment most recommended is a crucial incision of the tumefied part, immediately followed by the application of the actual or potential cautery. Internally, gentle stimulants and tonics appear to be most worthy of con- fidence.3 Brown, Medical Gazette ; Vol. iv. p. 134; des Sciences, pour l7bb ; limaux ei ^naussier, don, 1829 ; Elliotson, Medico-Chirurgical Methode de traiter les Morsures des Animaux isactions ; Vol. xvi. p. 170 ; London, 1830 ; enrages, suivie d'un Precis sur la Pustule Ma- Vol. xviii. p. 201; London, 1833; Wil- ligne ; Dijon, 1785 ; Davy La Chevrie, Disser- 1 Brown, Medical Gazette ; Vol. iv. p. 134; des Sciences, pour 1766 ;^ Enaux et Chnussier, London, Trans and liams' EJements of Medicine; Vol. ii. p. 3S1; tation sur la Pustule Maligne de Bourgogne; London, 1841; Dublin Quarterly Journal of Paris, 1807; Basedow, Grafe und Walther's Medical Science; Vol. viii. p. 442; Dublin, Journal der Chirurgie und Augenheilkunde ; 1849. Vol. vii. p. 184; Berlin, 1825; Rayer, Trait6 9 Rayer, Memoires de I'Academie Royale des Maladies de la Peau ; Vol. ii. p. 71 ; Paris, de Medecine ; Tome vi. p. 733 ; Paris, 1837. 1827. At p. 613 of the same volume, a fatal * Morand, Memoires de l'Acad6mie Royale case is detailed at great length. # SECTION VII.—SYPHILITIC ULCERATION OF THE EYELIDS. Syn.—Blepharitis syphilitica. Fig. Dalrymple. PI. X.figs. 3, 4. PI. XI. fig. 5. That the eyelids are not unfrequently the seat of syphilitic inflammation, is a conclusion to which I have arrived from witnessing numerous cases of this sort. Some of them were suspected to be primary; the greater number were secondary. When we see an adult affected with an ulcer on one eyelid only, which has continued for weeks, or it may be months, and has not yielded to local appli- cations, but has rather grown worse, we should suspect syphilis. I have more than once seen syphilitic inflammation of the edge of an eyelid mistaken for simple ophthalmia tarsi; a mistake which may produce disastrous conse- quences. A similar caution applies to inflammation and ulceration near the inner canthus; for syphilitic ulceration, in this situation, is sometimes taken for dacryocystitis. It is sometimes difficult to distinguish at first sight, a syphilitic from a cancerous ulcer of the eyelid. In syphilis, the skin is more swollen, and of a darker color than in cancer. In cancer, the edges of the ulcer are harder and more elevated than in syphilis. The surrounding integuments are more glued down to the subjacent parts, and the surface of the sore not so foul. The sore is also studded with roundish, whitish tubercles, over which creep varicose vessels, appearances which are not present in syphilis. Case 123.—An old man, a patient at the Glasgow Eye Infirmary, acknowledged having been treated, some time before, for a primary affection; else I should have probably experienced some difficulty in deciding respecting the nature of the case. The lid was much swollen and everted, its conjunctiva greatly inflamed, and on the external surface of the lid there was a deep ulcer, painful, and spreading towards the inner canthus. The skin round the ulcer was of a dark red color. I ordered him two grains of, calomel and one of opium, night and morning. He returned in five days, with another smaller ulcer near the punctum lachrymale of the same lid. The conjunctiva, covering the inner edge of the cornea, was also in a state of ulceration. The first ulcer of the lid was extending upwards and inwards, but at other parts of its edge appeared inclined to cicatrize. The ulcer of the cornea was touched with the lunar caustic solution, and a carrot poultice ordered to the lid. Nine days after this, the eversion and thickening of the lid had become considerably less; the first ulcer had coalesced with that near the punctum, but was granulating and filling up. Soon after this the mouth became sore, and the ulcer SYPHILITIC ULCERATION OF THE EYELIDS. 161 contracted and healed. The mercury was stopped and resumed according to the state of the mouth, and a decoction of elm bark was given. As the lid continued to be everted after the ulcer had cicatrized, the thickened and inflamed conjunctiva was scarified, and the red precipitate salve was applied every evening; after which the lid completely resumed its place, scarcely any deformity being caused by the cicatrice, and no opacity left on the cornea. Case 124.—A boy, of 7 years of age, was brought to me with a foul sore occupying a great part of the right lower lid. He had been under the care of a practitioner, who treated the case as one of fistula of the lachrymal sac, and thrust a probe through the ulcer in the direction of the nasal duct. This made the ulcer much worse. At first I adopted the idea that it was a scrofulous sore ; but in a few days, finding it to increase rather than contract under mild dressings, and the internal use of sulphate of quina, I began to suspect a syphilitic taint; and on examining the throat, a foul ulcer was dis- covered on the velum. I gave the patient calomel and opium, under the influence of which the ulcer speedily contracted, and healed with considerable eversion. How the child had become affected with syphilis, appeared at first quite inexplicable ; but at last it came out that he had been sleeping for some time in the same bed with a person labor- ing under primary symptoms of that disease. Case 125.—J. S. aged 20 years, was admitted under my care, at the Glasgow Eye Infirmary, on the 28th September, 1838. He was born with a congenital deficiency of the upper part of the prepuce, while the opening of the urethra was not through the glans penis, but close behind it. He had a chancre on the glans, a second on the malformed prepuce, two syphilitic sores on the scrotum, and a suspicious looking superficial ulcer on the right leg. He dated these sores from the month of May. Ten weeks before his admission, a small hard swelling formed on the middle of the right upper eyelid, which he supposed to be'a stye. When he applied at the Infirmary, the whole of the eyelid was much inflamed, and rather of a livid color. It felt hard and tuberculated, and was a good deal swollen. Along its margin, to about two-thirds of its extent, it was in a state of ulceration, and presented a considerable notch just about the middle. The internal sur- face was much inflamed, the conjunctiva being thickened, and discharging a considerable quantity of puriform mucus. He constantly held a handkerchief to the eye, to relieve the burning pain of the ulcer. His right cornea was nebulous, which he attributed partly to ophthalmia in childhood. Pulse 108, small. Occasional rigors. He complained of weakness. He had used no mercury. The appearances in this patient were very characteristic. The general swelling of the whole eyelid, the hard nodulated surface of the swelling, the livid color, the spreading of the ulcer along the edge, which at one point it had notched by a complete loss of sub- stance, extending even to the cartilage, and the severe pain felt in the part, were all well marked, so that, before asking any questions about the patient's previous health, the syphilitic nature of the case was forced upon my consideration. The patient gave a very confused account of the rise and progress of his ailment; but there could be little doubt of the secondary nature of the ulcer of the eyelid. All the sores speedily healed under the influence of calomel and opium. Syphilitic ulceration of the eyelids generally occurs either on the edge, going on to destroy at once the skin, cartilage, and conjunctiva; or on the integuments, proceeding rapidly to form a deep and foul excavation. Case 126.—In a girl, aged 11 years, who came under my care at the Glasgow Eye Infirmary, 6th September, 1850, the disease had gone on for 6 months, and been treated as scrofulous. It had commenced over the left lachrymal sac, and at her admission pre- sented a deep foul ulcer in the line of junction of the lower lid with the cheek, while another ulcer, £ inch long, occupied the space between the eyebrow and the upper lid. She was speedily brought under mercury, there being every reason to think that, had this not been done, the left lids would have been completely destroyed. The ulcer soon improved in appearance, and ultimately healed, leaving some degree of lagophthalmos. If near the inner canthus, the ulcer is apt to penetrate into the lachrymal sac. It would appear that sometimes the ulcer commences on the inside of the lid, spreading over a considerable extent of the conjunctiva. Mr. Law- rence mentions his having seen instances, in which foul syphilitic ulcers spread over the whole of the inner surface of the upper lid, without appearing externally. In one case, the sore, he believes, would not have been dis- covered, if he had not been directing his attention some time before to the subject, so that he was led to evert the eyelid, when he discovered a syphilitic ulcer as large as a sixpence.1 11 162 SYPHILITIC ULCERATION OF THE EYELIDS. In one case only, have I seen a syphilitic ulcer occupying the inner surfaco of the eyelid. On placing my finger on the upper lid externally, I felt as if a hard knot was situated internally, and a purulent discharge flowed at the same time from the upper sinus of the conjunctiva. I everted the lid and found a foul deep ulcer on its inner surface. I touched it repeatedly with lunar caustic, and it healed under mercury. I remember M. Cullerier mentioning in his lectures at the Ihipital des Viniriens that chancres of the eyelids were sometimes brought on by a kiss from an infected person, and in other cases, by the virus being conveyed on the finger. In one case which I treated, I was led to suspect that the disease had been directly conveyed in some such way to the eye ; for, besides a deep ulcerated notch in the edge of the lower eyelid, there was a chancre on the conjunctiva oculi, close to the margin of the cornea. The pupil of the affected eye was small, and somewhat dragged towards the ulcer, but there was no iritis. The case did well under the use of mercury. A similar ulcer, however, of the conjunctiva oculi, only smaller, existed in the old man whose case I have related, and in whom the affection was secondary. A case is narrated by Ricord,2 in which the finger of the patient had served to convey the virus from another person to his own eyelid, and in whom the pre-auricular and submaxillary glands seemed to have become infected. Even when secondary, a syphilitic ulcer on the eyelid may be the only symptom of syphilis then manifest; but, in general, secondary sores on the eyelids are attended by other secondary symptoms, particularly by ulcera- tions of the throat, and eruptions on the skin. In one case, I saw a syphilitic ulcer on the edge of the eyelid become covered with an elevated conical scab, such as is presented in rupia promi- nens. Both the primary and the secondary cases are most effectually relieved by the use of mercury. Either to mistake the nature of the ulceration, or to trifle with it in the non-mercurial way, would be to expose the patient to the loss of the affected lid, and even of the eye. Once healed, the ulcer is very apt to return, if the mercurial course is prematurely abandoned. In the case of rupia, the internal use of iodide of potassium proved of great service, along with mercurial external applications. The following case, related by Sir Charles Bell, is interesting on several accounts :— Case 127.—A man presented himself in the hospital, with a squint, the left eye being distorted from the object. On the upper lid of the right eye, there was a deep venereal ulcer. The man was in danger of losing that eye, and required prompt assistance ; but before he could be brought under the influence of mercury, the sore became deeper, and the cornea opaque. The superior rectus muscle being injured by the increasing depth of the sore, the pupil became permanently depressed. The sight of the right eye being now lost, the left eye came into use; it was directed with precision to objects, he had no difficulty in using it, and it daily became stronger. After a few weeks, medicine having had its influence, the sore on the right upper eyelid healed, the inflammation of the eye and opacity of the cornea gradually diminished, and the light again became visible to this eye, first yellow, and then of a deep purple. The muscles now resumed their influence, and the right eye was restored to parallel motion with the left, so as considerably to embarrass vision. But the inflammation of the upper eyelid had been so great as to diminish its mobility; and, what appeared remarkable, the lower eyelid assumed the office of the upper, being depressed when the patient opened the eye, and elevated and drawn towards the nose when he attempted to close it. The upper eyelid was not only stiff, but diminished in breadth ; so that, notwithstanding the remarkable elevation of the lower lid, their margins could not be brought together, and the motion of the eyeball could be seen. On the patient's attempting to close the eye, the pupil was always elevated, and the white of the eye exposed.3 Dr. Campbell has recorded a case, in which the upper and lower eyelids of the right side were wholly destroyed by syphilitic ulceration :__ SYPHILITIC ULCERATION OF THE EYELIDS. 163 Case 128.—Henry Muir, aged 28, was admitted into the Edinburgh Royal Infirmary, on the 17th December, 1831, with his whole forehead covered with incrustations and cica- trices. Commencing at the left superciliary notch, and extending to the external angle of the right orbit, there was a lengthened depression, apparently the result of an exfoliation of the right superciliary ridge, and neighboring portions of the os frontis. Both eyelids of the right side were completely gone, and the conjunctiva was found to be tightly stretched from the upper margin of the orbit, with which it was firmly connected, to the lower, being here continuous with the integuments of the cheek, as it was above with those of the forehead. The whole conjunctiva was thickened, and the portion to the inner side of the cornea was partly in a granulated state. The cornea was opaque, and appeared as if a thickened and somewhat corrugated membrane extended over it. AVithin the external angle of the os frontis, there was a small patch of red membrane, with some ulcerated points, through which a limpid fluid, like tears, sometimes copiously exuded. A con- siderable part of the conjunctiva appeared superficially ulcerated. No trace of the puncta lachrymalia could be discovered. With this eye the patient was sensible only of very strong light, as that produced by placing a lighted candle close to the eyeball. The eye moved in the orbit to a limited extent, its motions being retarded by the tense state of the conjunctiva. The prepuce had been entirely destroyed by ulceration, leaving the glans penis un- covered. There was an ulcer, with undefined edges, encircling the root of the penis, and another on the lower side of the penis near the glans, where a small opening communi- cated with the urethra, and allowed a great part of the urine to escape. An ulcer of a similar character was also observed on the nates. No satisfactory history could be obtained of the case. The ulcers were believed to be syphilitic, and the patient admitted that he had taken mercury to a considerable extent. When the patient was admitted into the hospital, a considerable part of the sclerotic conjunctiva presented a raw surface ; but after the use of an astringent lotion, it came to be covered with a thin film of new cuticle, excepting two very limited portions at the inner and outer angles of the eye. At two places, a little distant from each other, near the outer angle of the eye, and a little below the situation of the lachrymal glaDd, the tears were seen exuding from very minute and nearly invisible orifices, where they col- lected in globules, and whence they trickled down the cheek. At the inner canthus, there was sometimes seen resting upon the surface, a little clear fluid, which, it was conjec- tured, might come from the lachrymal sac, if this cavity was not obliterated. The patient suffered neither pain nor inconvenience from the exposed state of the eye. The ulcers on the genitals, being in a chronic and indolent state, showed little disposi- tion to take on a healthy action ; but by putting the patient on a generous diet, and ad- ministering nitric acid internally, together with the local application of lunar caustic, followed by solutions of sulphate of copper and sulphate of zinc to the sores, these were brought into a healing state.4 In his remarks on the case, Dr. Campbell observes, that in carcinomatous affections of the eyelids, requiring their removal, surgeons have directed the eyeball to be extirpated at the same time, in order to save the patient from the extreme degree of suffering which would otherwise arise from its constant exposure ; but that the case shows a state of irritation not to be an invariable result of such exposure, since the patient experienced neither pain nor uneasiness, nor was likely to do so, the parts being covered and protected by the formation of a new cuticle over the surface left exposed by the loss of the eyelids. This view of the matter is so far confirmed by the case of a pauper patient in this town, whom I had an opportunity of examining on the 13th Septem- ber, 1838, through the kindness of Dr. Jackson, under whose care she then was. I shall here embody the account, published5 by Dr. Jackson, of this patient, with such additional notes as I took of her state. It must not be overlooked, however, that in cases such as those described by Dr. Campbell and Dr. Jackson, the eyeball would gradually accommodate itself to expos- ure, in proportion as the eyelids became destroyed. The irritation would necessarily be much greater, if these parts were removed at once by a surgi- cal operation. Case 129.—The patient is a widow of 60 years of age. The entire nose and nasal bones, a considerable portion of the ethmoid bone, and of the superior maxillary bones, the inferior turbinated bones, the vomer, and the whole hard and soft palate, have been 164 SYPHILITIC ULCERATION OF THE EYELIDS. destroyed by ulceration and exfoliation, so that the nostrils and mouth are converted into one opening, without any sort of division even in front. The opening is bounded above by the ethmoid bone, and below by the tongue; and is capable of admitting the "> fingers. The alveolar processes of the upper and lower jaws have been completely removed. Over the centre of the frontal bone there is a large depression, the conse- quence of repeated exfoliation, and the integuments there are still in a state of ulcera- tion, leaving portions of dead bone exposed. The whole of the upper lip, and the greater part of the lower, have been destroyed by ulceration; but the integuments surrounding the cavern into which the nostrils and mouth are now converted, though puckered and drawn inwards, are perfectly cicatrized. Especially on the left side, the finger is easily passed from the nostril into the antrum Highmorianum. The eyelids on each side, as well as the eyebrows, have been completely removed by ulceration, and the skin has united to the conjunctiva, covering the sclerotica. The integuments proceed, in fact, from the circumference of the orbits into the conjunctiva bulbi, without forming any fold. The conjunctiva of each cornea is semi-opaque, permit- ting the dark appearance of the iris to be seen, but not the pupil. The eyeballs present their usual size, form, and consistence; but are almost destitute of motion. When the patient makes an effort to move the eyes, a slight motion of the skin is observed. Her whole power of vision consists in a perception of light and shade. She cannot distinguish whether one or two fingers be held before her eyes. The want of eyelids does not cause her much uneasiness when the eyes are shaded; but when she turns up her face towards the window, or to a bright light, the eyes are pained. Touching the eyeballs does not seem to excite any pain; they never appear red or inflamed. She does not seem to sleep much, and never soundly. When she goes to sleep, she covers the eyes with a bit of cloth. When she sits up, she keeps her head depressed towards her breast, so as to avoid the light. On each side there is a small fistulous opening, apparently communicating with the lachrymal gland, from which there is a constant exudation of limpid fluid. When she weeps, which she does frequently, there is a copious flow of tears from these openings down the cheeks, and she says that at the same time she feels a burning pain in the eye- balls. The surface of the eyeballs is always dry; never covered with mucosity. No puncta lachrymalia can be discerned on either side; but below the inner canthus on the right side, there are two ulcerated openings which appear to lead into the lachry- mal passage. From the feeling of elasticity which pressure in the neighborhood of the inner canthi, particularly on the right side, yields to the finger, it is probable that the ossa unguis are gone, though in consequence of the firmness of the cicatrice there, and the pain which pressure produces, it is difficult to ascertain this point with anything like certainty. No other part of the orbits, however, appears to be destroyed. She seems to enjoy a considerable degree of smell. She can detect a bad smell; and relishes the odor of snuff. She speaks with great difficulty, but her daughter understands what she says. It is almost impossible for her to swallow fluids. When she swallows spoon meat, she lies on her back, and throwing the morsel down, she gulps it with difficulty, and an expression of pain. The tongue, from its constant exposure, is swollen and inflamed. Her hearing is much impaired. Over the right scapula, there is a large ulcer, through which several pieces of bone have passed. The whole body is much emaciated. The arms and hands are particularly attenuated, and their joints very flaccid. The commencement of her complaint she dates 14 years back. The bones of the head were affected, before any disease appeared in the face. The ulceration, after having destroyed the lower lip, attacked the upper eyelids, then the lower eyelids, whence it spread downwards and removed the nose and upper lip. The eyelids of both sides were removed before the nose was involved. She blames her husband for improper conduct towards her. She never had any eruption. She had not taken mercury antecedently to the disease commencing in the face. After that, she was salivated by mercury, and took large quantities of sarsaparilla, without the progress of the disease being checked. Large portions of bone came away at various intervals. Dr. Jackson, in his notice of the case, remarks, that it shows to what a dreadful extent secondary syphilis will proceed, in spite of mercury, sarsaparilla, &c, in a patient in whom the primary symptoms have not been treated with mercury. He thinks the exten- sive exfoliation of bone could not, in this instance, be attributed to mercury, but to the influence of syphilis. ' Lectures in the Lancet; Vol. x. p. 324; 3 Nervous System of the Human Body; Ap- London, 1826 : Lancet for 1830; 1831; Vol. i. pendix, p. lvi; London, 1830. P- 735. * Edinburgh Medical and Surgical Journal; Lettres sur la Syphilis; p. 47; Paris, 1851. Vol. xxxvii. p. 254; Edinburgh, 1832. ' Lancet, 8th September, 1838, p. 839. SYPHILITIC ERUPTIONS.—CANCER OF THE EYELIDS. 165 SECTION VIII.—SYPHILITIC ERUPTIONS AFFECTING THE EYELIDS OF INFANTS. Fig. Devergie, Clinique de la Maladie Syphilitique, PI. 37; Paris, 1826. Infants have been repeatedly brought to me, as affected with sore eyes, whom I have found to be laboring under the effects of congenital syphilis. This disease generally appears within a few weeks after birth, about the anus and organs of generation, and upon the face and hands. It assumes the form of pretty broad and flat pustules. They break, scab, spread, and run into one another, leaving the skin of a dark red color, excoriated, and chapped, over almost the whole body, and with a peculiar wrinkled withered appearance, especially about the lips. The eyelids of such children inflame and adhere in the morning; the conjunctiva, without being swollen or much inflamed, secretes puriform mucus; the Meibomian and ciliary glands give out matter ; the cilia and the hair of the head fall out; the nostrils become stuffed, so as to prevent the child from sucking; the mouth aphthous; the voice hoarse; there is much restlessness, itching, and fretfulness; and great emaciation ensues. The capsule of the lens is sometimes to be observed quite red, the pupil becomes contracted, the retina is probably insensible, and atrophy of the eyeball ensues. Not unfrequently the cornese become infiltrated with pus, and give way; an event indicative of excessive debility, and generally a precursor of death. Cases of this kind are much more frequent in infants than syphilitic iritis, uncombined with an eruption. They may readily be distinguished from ophthalmia neonatorum, but are sometimes confounded with ophthalmia tarsi. I have known cases treated as itch. Case 130.—A child, 5 months old, was brought to me, with the left eye atrophic and the right cornea burst, the mouth presenting the chapped withered appearance, so cha- racteristic of infantile syphilis. The eruption had disappeared. The mother was not conscious of having had any disease. A practitioner to whom she had applied, had given her cream of tartar and sulphur, telling her that by her taking this medicine, her child would be cured. From half a grain to a grain of calomel, combined with from a twelfth to a sixth of a grain of opium, is to be administered thrice a day. From one to two grains of hydrargyrum cum >:*eta, twice or thrice a day, answer very well. In a few days, evident improvement takes place ; and by perseverance in the remedy, a complete and permanent cure is effected. Tepid ablution of the lids, and mild red precipitate salve to their edges on the child's going to sleep, make up the local treatment. The father will be found to have labored under evident symptoms of syphilis, previously to the conception of the child. The mother may, or may not, have been affected with evident symptoms; and it is remarkable, that she rarely if ever, becomes infected from her child; but if any other woman nurses a child diseased in the manner described, she is almost sure to take syphilis, becoming affected with first ulcers on the nipples, followed by sore throat, sores on the genitals, an eruption on the skin, and iritis. Those who handle the child, also, are apt to become infected. SECTION IX.—CANCER OF THE EYELIDS. Syn. Cancroi'de; Lebert. Epithelial cancer. Epithelioma: Hannover. Fig. Ammon, Zweiter Theil, Tab. III. figs. 1, 2, 3, 6, 7. Dalrymple, PI. V. fig. 6. All parts of the skin are not equally liable to be affected with cancerous ulceration. That of the face, and particularly that of the eyelids, is the most 166 CANCER OF THE EYELIDS. liable ; and next, that of the lower lip. This disease, slowly consuming the skin and the muscles, destroys not merely the eyelids, but perhaps a great part of the cheek, entering also into the orbit, attacking the eyeball, and at length proving fatal. Dr. Jacob, in some excellent observations1 on the dis- ease, points out, as its characteristic features, the extraordinary slowness of its progress, the peculiar condition of the edges and surface of the ulcer, the comparatively inconsiderable suffering produced by it, its being incurable unless by extirpation, and its not affecting the neighboring lymphatic glands. Although not exempt from scirrhus and other malignant diseases, the eye- brow, and especially the eyelids, are particularly apt to suffer from that variety of cancer, which, from its structure being composed in a great measure of epidermic scales, is known by the appellation epithelial This appellation, bestowed on this variety of cancer from the microscopical character of one of its elements, must not, however, deceive us into any less suspicious notion of its malignancy, than what was previously entertained. Symptoms and progress.—This affection of the eyelids rarely occurs until after middle life. It presents two stages ; one of induration, and another of ulceration. At some particular spot, either close to the edge of one or other of the lids, but much more frequently the lower than the upper, at their tem- poral angle, or on the side of the nose, near the lachrymal caruncle, some degree of thickening and elevation may at first be discovered, indicating the existence of a peculiar kind of growth, but which the patient often neglects as a wart or something of no consequence. The indurated spot is at first uninflamed externally, presenting the natural color of the skin, with the excep- tion perhaps of some varicose vessels ramifying over it, and it is not particu- larly sensible. It may remain in this state for a considerable length of time, and attract almost no attention till it begins to ulcerate. That the disease sometimes originates in a mere crust or wart, which being picked off with the finger leaves a raw surface, exposed to the irritation of the tears, and apt to spread by ulceration; or in some common sort of tumor, which, allowed to burst on the inside, or, it may be, on the outside of the eyelid, becomes fretted, and is thus induced to assume the ulcerous or can- cerous action, is a doctrine2 which must be received with some hesitation. It has been asserted, indeed, that a mere scratch or excoriation of the edge of the eyelid, or the irritation of an old cicatrice, such as that which results from smallpox, may give rise to cancer of the eyelids; but it is probable, that the ulcerative stage of the disease is always preceded by a deposition or hyper- trophy of a specific kind. As exciting causes, I may mention a blow with a rod of iron on the lower edge of the orbit, as giving origin to the disease in a man whose eyelids and eyeball I removed. In an old gentleman who consulted me, the irritation of the frame of his spectacles brought it on at the temporal angle of the eye, with eversion of the upper lid. A doubtful point is, whether the Meibomian follicles are often, or ever, the original seat of this disease; but it seems generally admitted, that the induration may commence in the conjunctiva, and may be limited to it for a long time; the whole structures of the eyelid becoming at length thickened and knobbed, and assuming a dark red color. The conjunctiva may then become ulcerated, and the ulceration gradually involve the other textures. Scirrhus, ending in carcinomatous ulcer, has not been sufficiently distin- guished from epithelial cancer. I was disposed to consider scirrhous a case which came under my observation, in which the first symptoms were hardening of the lower lid, fixedness as if it had been glued to the eyeball so that it could not be moved, and a remarkable degree of retraction, as if the disease, originating in the cellular membrane of the orbit, had dragged the eyelid CANCER OF THE EYELIDS. 167 inwards. In another case, which I saw at the Glasgow Eye Infirmary, 19th May, 1842, a tumor nearly an inch long, and half an inch broad, rose from the lower lid, covered at its middle with a scab. The patient was a woman of 18. On extirpation, the tumor was found made up of a mixed soft and gristly substance, apparently scirrhous. In former editions of this work I spoke of a variety of callosity of the eye- lids, under the name of tylosis scirrhoeides, which I am now disposed to con- Fig. 9. sider of the nature of epithelial cancer. I described it as attacking the lower lid more frequently than the upper; affecting more the inner, than the outer, surface of the lid; being of a white, or slightly yellow color, more or less tuberculated, and apt to end in ulceration. From its appearance (Fig. 9), its occurring generally in old people, its intractable nature, and its ending in ulceration. I said it was liable to be confounded with scirrhus, with which, however, I considered it by no means identical. I mentioned that I had watched some cases of this kind for a number of years; and although the induration and swelling did not subside, yet, by care to avoid injuring the part, using the red precipitate salve to the edges of the lids, and applying lunar caustic solution to the ulcerated points, the complaint had been kept at bay, and the operation of removing the affected part avoided. I said that, although sometimes successful in warding off the progress of the disease, in other cases it had caused such irritation of the eye, increased so much in size, and produced so much deformity, as to warrant extirpation. This I had recourse to in the instance figured above. In none of the cases in which I operated before ulceration took place, has there been any relapse. The anatomical structure of epithelioma, as the disease now under our consideration has been termed, is different from that of any other variety of cancer. It consists not so much in the substitution of a new tissue, as in the alteration of a normal one; it is a hypertrophy of the superficial epidermic layer, complicated by inflammation and ultimately by ulceration. The cir- cumstance, however, of a tumor consisting chiefly of epithelic corpuscles is not to be deemed sufficient evidence of its being an epithelial cancer. I have no doubt this would be the case nearly equally with the elevated edges of Jacob's " ulcer of peculiar character," and of Cock's "peculiar follicular disease,"3 as well as of several other varieties of growth and ulcer of the skin, in malignancy and other particulars widely different from each other. Some epithelial growths are perfectly innocent. The progress of the ulceration is generally very slow. I have known it for years confined to the lower eyelid, without making almost any advance; nay, occasionally contracting, and partially, or even totally, cicatrizing; again to 168 CANCER OF THE EYELIDS. commence, and spread for a certain space, and again to heal. It has been known to remain for ten, nay, for twenty years, without making much pro- gress. In other cases, however, we see the eyelids entirely destroyed, the eyeball exposed, so as to become inflamed and at last to burst, the lachrymal passage laid open, the bones of the orbit deprived of their periosteum and rendered carious, while the ulcer, spreading down the face, eats away the cheek, lays bare the teeth, and at last forms a hideous opening communicating with the mouth. Yet, even after it has produced the most shocking deformity, its progress is sometimes stayed for months or for years, so that the indi- vidual lives with his eyelids entirely gone, the eyeball dissected from almost all its connections, and perhaps half of the %ce destroyed. The appearances of the diseased surface are different at different times. Sometimes it presents a scab, which, on being removed, is succeeded by an- other; but generally the sore exposed on removing these successive scabs, is found to be slowly enlarging, growing deeper, and becoming more painful. When the sore becomes an open ulcer, too large, irregular, and active to be covered by a scab, we observe that it eats away all parts indiscriminately which may be in the direction in which it is spreading. In one of the cases which have fallen under my care, the ulceration of the skin appeared, after a time, entirely to cease, while the disease proceeded deep into the orbit by the inner side of the eyeball. Not unfrequently, we find that the progress of the ulceration is checked at one part of the circumference of the sore, while it is advancing at another; or that the whole sore assumes, for a time, a healing action. When this is the case, the pain grows less, the edges become smooth and glossy, and even the part within the edges becomes smooth, or is gradually covered with florid healthy-looking granulations. These are occasionally firm in texture, and remain unchanged in size and form for a length of time. Veins of considerable size are seen ramifying over the surface of the sore. If it heals up, it does so in patches, which are hard and smooth, and marked with the same venous ramifications. When it again begins to ulcerate, it loses its florid hue and glistening and granulating appearance. There is often a tendency to actual reparation, as well as to cicatrization; there is a deposition of new material, and a filling up in certain places, which gives an uniformity to the surface, which otherwise would be very irregular. The healing which occurs may take place on any part of the surface, whatever be the original structure. In a case which Dr. Jacob had under his care, the eyeball itself, denuded as it was by ulceration, became partially cicatrized. The skin in the vicinity of the sore is not, in general, much thickened or discolored, differing in these respects from the disease called lupus, or noli me tangere, in which a diffused swelling and a deep blush surround the ulcer. In cancer of the eyelids, the edges of the ulcer are occasionally formed into a range of elevations or tubercles, of a pale red color, which, if removed with the knife, are speedily reproduced. But there is, in general, little or no fun- gous growth in this disease, or indeed any elevation, except at the edges of the sore. The veins which ramify over the surface of the sore are apt to give way, and considerable bleeding to take place. From the surface itself of the ulcer, there is no considerable bleeding. When hemorrhage does occur, it arises from the superficial veins giving way, and not from sloughing or ulceration opening the vessels. Sometimes the surface of the sore assumes a dark gan- grenous appearance, arising from effusion of blood beneath. The discharge from the surface of the sore is not, in general, of the de- scription called unhealthy, nor sanious, but yellow, and of proper consistence; neither is there more fetor than from the healthiest sore, if the parts be kept perfectly clean, and dressed frequently. Mr. Travers, however, whose short CANCER OF THE EYELIDS. 169 notice4 of this disease differs in several particulars from the more elaborate description of Dr. Jacob, mentions that it is attended by an unhealthy dis- charge. Dr. Jacob has represented the sufferings of persons laboring under this disease as not very acute. He says there is no lancinating pain, and that the principal distress appears to arise from the exposure, by ulceration, of nerves and other highly sensible parts. In the cases he had met with, the disease, at the worst period, did not incapacitate the patients from following their usual occupations. He states that one gentleman, who labored under this disease for nine years, and who died from a different cause, was cheerful, and enjoyed the comforts of social life after the ulceration had made the most deplorable ravages. These statements of Dr. Jacob may be received with implicit confidence. Yet it must be noticed that, when the ulceration affects the infra-orbitary and supra-orbitary nerves, very severe suffering is experi- enced. I have also witnessed the most excruciating pain when the eyeball was attacked. It ulcerates and bursts, the lens and vitreous humor are evacuated, and sometimes, till this emptying of the eye is effected, the pain is agonizing. I have known the lens protrude through the cornea for several days, producing great^ irritation. When the disease extends to the periosteum, the bones of the orbit are laid bare, and become carious. They sometimes exfoliate in small scales, but more generally they are destroyed, as the soft parts are, by an ulcerative pro- cess. This may proceed to such a length as to expose the nostril or the antrum, through the destroyed orbit, or even to lay open the cavity of the cranium through the orbitary plate of the frontal bone. Inflammation of the dura mater and of the brain will, in this case, soon put an end to the patient's sufferings ; although more commonly he dies worn out by fever, and sometimes diarrhoea. Diagnosis.—The researches of Burns, Hey, Abernethy, Wardrop, Breschet, Fawdington, and others, into the nature of malignant tumors and ulcers, have established at least this fact, that there are essential differences between a number of diseases formerly confounded under the appellation of cancer. We are now at no loss in distinguishing scirrhus from spongoid tumor, and spongoid tumor from melanosis ; but with regard to the malignant ulcerations which attack different parts of the skin, and especially the skin of the face, there existed, till very lately, a considerable degree of confusion. To the microscopical examinations of malignant growths, we owe the important establishment of epithelial cancer as a distinct species of disease. Dr. Bateman, Mr. S. Cooper, and others, seem to consider the disease of the eyelids which we have been considering, as noli me tangere, which, accord- ing to Sir A. Cooper, is an ulceration of the cutaneous follicles. Dr. Jacob, however, observes, that the disease commonly called cancer of the eyelids, is evidently peculiar in its nature, and is to be confounded neither with genuine carcinoma, nor with the. disease called lupus, or noli me tangere. From the former he thinks it may be distinguished by the absence of lancinating pain, fungous growth, fetor, slough, hemorrhage, and contamination of the lym- phatics ; from the latter, by the absence of the furfuraceous scabs, and in- flamed margins, as well as by the general appearance of the ulcer, its history, and progress. Mr. Lawrence has contrasted5 cancer of the skin with lupus ; the latter is a disease which also sometimes involves the eyelids ;6 but in fact it is not easy to describe in words the differences between such diseases. From syphilitic chancre, cancer of the eyelids may generally be distin- guished by its slow progress, by its not causing so much swelling of the integuments around the ulcer, and by its history. Occurring in the skin over the lachrymal sac, I have known this disease no CANCER OF THE EYELIDS. mistaken for dacryocystitis. One patient called on me expressly to have a style introduced. Another had actually worn a style, which he fancied had t dropped down into the nasal duct, and which he wished extracted. There " was no style ; it had probably dropped out by the opening through the skin. Prognosis.—Left to itself, epithelial cancer of the eyelids compromises the life of the patient. While other varieties of cancer are of constitutional origin, and involve the economy generally, this seems entirely a local disease; and hence, no doubt, the slowness of its progress. The fact of there being in epithelial cancer no tendency to lymphatic propagation, so that the gene- * ral health may remain long intact, renders the prognosis somewhat less un- favorable, and seems to afford grounds for the hope that extirpation may prove a complete cure. The disease, however, often returns. Treatment.—1. Alterative and other medicines.—It is a question of great importance, whether this disease can be removed by any other means than the knife, or powerful escharotics. Dr. Jacob's opinion is, that it bids defi- ance to all remedies short of extirpation. " I have tried," says he, "inter- nally, alterative mercurials, antimony, sarsaparilla, acids, cicuta, arsenic, iron, and other remedies ; and locally, simple and compound poultices, oint- ments, and washes, containing mercury, lead, zinc, copper, arsenic, sulphur, tar, cicuta, opium, belladonna, nitrate of silver, and acids, without arresting for a moment the progress of the disease. I have indeed observed," adds he, "that one of those cases which is completely neglected, and left without any other dressing than a piece of rag, is slower in its progress than another which has had all the resources of surgery exhausted upon it." Although these remarks of Dr. Jacob are perhaps rather too sweeping, yet it cannot be denied, that both internal and external remedies have extremely little control over this disease, and that though it may for a time seem to mend under their influence, it has rarely, if ever, been known to be thoroughly cured, except by destroying the part with escharotics, or removing it by the knife. The precipitated carbonate of iron sprinkled on the sore, and arsenic in- ternally, are the means which, I believe do most good. I have known them to operate as palliatives, but never to produce a radical cure; and therefore I should never trust to them. Whatever treatment improves the general health, has a favorable influence on the local disease. I have known the ulcer from this cause improve considerably under the employment of two grains of calo- mel, with half a grain of opium, continued each night for several months. 2. Diet.—Mild nutriment, without wine, is the diet which should be adopted. Case 131.—Dr. Twitchell, an American surgeon of note, aged 68, cured himself of a cancer of the eyelid, by abandoning the use of flesh, and living entirely, for two years, on bread, milk, and cream. The disease had been slowly increasing for about ten years, and had been twice ineffectually removed by the knife.7 3. Caustics.—These means are certainly not much to be commended; being more painful and not so sure as the knife. They do occasionally succeed, when the disease is limited to the outer surface of the eyelid, or to the skin of the nose ; never, when the whole thickness of the eyelid is affected. Often they do harm instead of good.8 As caustics which act not on the surface alone, but deeply, if allowed to remain in contact with the diseased part, may be mentioned, hydrate of potassa and quicklime, made into a p'aste with a few drops of alcohol, and chloride of zinc, made into a paste, with flour or cal- cined sulphate of lime. The danger of using such substances, on the eyelids, arises from their aptitude to spread to the eyeball. The best, perhaps, and most manageable, is the pencil of potassa fusa. The great advantage derived from arsenical applications to lupus, has led CANCER OF THE EYELIDS. in to their use in cancerous ulcerations of the face; but in these cases they are neither so efficacious, nor so safe as in the former. Sometimes the irritation produced by them occasions the sore to spread more rapidly than it would otherwise do. Dr. Jacob mentions, that a woman in the Incurable Hospital at Dublin, had had a burning cancer plaster applied several times, and seventeen years after, the arsenical composition called Plunket's powder, without any good effect. A gentleman, to whose case he repeatedly refers, had the sore healed, when it was very small, by the free application of lunar caustic, under the care of Mr. Travers. It broke out again, however, and spread, without in- terruption, until it destroyed the lids and globe of the eye. Under these circumstances, he, in despair, submitted himself to a quack, who, bold from ignorance, gave a full trial to escharotics. He repeatedly applied what was understood to be a solution of muriate of mercury in strong nitric acid, which, in a short time, produced a hideous cavern, extending from the orbitary plate of the frontal bone above to the floor of the maxillary sinus below, and from the ear on the outside, to the septum narium within. The unfortunate gen- tleman survived, the disease continuing to preserve, in every respect, its original character. Case 132.—Dufresne, a bleacher, aged 30, was admitted into the Hotel Dieu on the 23d February, 1831, having been affected for seven or eight months with a carcinomatous ulcer at the inner angle of the right eye. The ulcer had continued to extend itself from the very commencement. M. Dupuytren, having satisfied himself of the cancerous nature of the disease, endea- vored to effect its destruction by cauterization with the nitrate of mercury dissolved in nitric acid, a remedy he had found to succeed in similar cases. Three or four cauteriza- tions were practised at intervals of eight or ten days ; the fourth induced an erysipelas of the face, which had not been cured when M. Breschet took charge of the patient. He deferred attacking the cancer again, till the erysipelas had entirely disappeared. On the 10th April, the ulcer was of an oblong form, occupying the inner angle of the right eye, and the corresponding ala of the nose ; its base had a fungous nipple-like ap- pearance, of a livid color, and it discharged a trifling quantity of fetid sanies. Its edges were unequal, notched, and a little inverted. An ointment, composed of seven parts of lard and one of iodide of mercury, was now applied daily ; but, after three weeks, the ulcer was scarcely in the least improved. The application was therefore changed for another, composed of seven parts of lard and one of" biniodide of mercury. In a few days, the appearance of the sore was completely changed, its base became of a vermilion tint, the nipple-like excrescences and fetid dis- charge disappeared, and the swollen edges gradually shrunk. After 12 days' employment of the ointment, the sore was treated with simple dressing, and healed rapidly. On the 3d May, the patient was dismissed entirely cured, without deformity, the scar being white, flexible, and free from pain or tumefaction.9 4. Extirpation by ihe knife.—When the disease exists in a situation which admits of extirpation by the knife, the sooner it is done the better. The effects of removing one or both lids, have already been explained. The upper lid will, much more than we could expect, supply the loss of the lower lid; and the lower that of the upper. If, however, the whole of the upper lid, or of both lids be removed, the cornea will become gradually opaque from exposure, and the conjunctiva cuticular and insensible. Even when the disease is confined to the movable part of the lids, I con- sider it better to remove it by a semilunar incision, than by one of the form of the letter V, and to allow the wound to heal by granulation, than by bringing its edges together with stitches. A hook or ligature being passed under the parts to be removed, so as to enable us to hold them and elevate them from the subjacent textures, the incisions ought to be made into the sound parts. "If the disease adheres to the perichondrium, the whole thickness of the lid must be sacrificed; if to the periosteum, it must carefully be removed. If the disease has spread in H2 CANCER OF THE EYELIDS. any considerable degree to the conjunctiva of the eyeball, the eye can scarcely be saved, although this appears to have been effected in one instance, by Grafe. Case 133.—Davielwas called to an Ursuline nun at Bordeaux, 45 years old, on account of a tumor which she had for 20 years upon her right upper eyelid. It began by a small wen, and increased by degrees so as very much to incommode the patient. She applied to a surgeon, who began with some drops of a liquid caustic, which enraged the tumor still more; he appeased it again by anodyne medicines; and, although the patient felt a continual sharp pain in the part, the tumor remained a long time without any sensible increase. She consulted another surgeon, however, who cut off the tumor. The ulcer, which was the result of this operation, did not heal, but, on the contrary, made great progress, and became callous. The surgeon touched it with lapis infernalis, and sometimes with a liquid caustic, which much increased the evil. Daviel was of opinion, that there remained no other method of treatment, but a farther extirpation, which might not only save the eye, but prevent an incurable and fatal cancer. The disease had already made great progress under the eyelid, and it was much to be feared that it would spread into the eye, and over the face. He passed a crooked needle, with a waxed thread, under the lid, by which he suspended and drew up the lid and the tumor, which he cut off with a pair of curved scissors, as far as he could under the orbit. Slight hemorrhage ensued, but was soon stopped with dry lint, and a compress and bandage. In 14 days she was perfectly cured ; and although the lid was cut away very high, the eye remained very neat and well, performing its several functions properly when Daviel left Bordeaux. Six years afterwards, he found the patient extremely well, seeing per- fectly with the eye. What he considered very singular was, that the skin of the lid descended pretty low to the cornea, which it almost covered; so that the whole globe was in a manner hid. The descending skin looked like a lid without eyelashes.10 Case 134.—A woman, 60 years old, had a cancerous tumor, for 16 years, in the inner angle of the right eye. It began by a little wart, which itched violently, and made her scratch it very often, which so irritated the tumor, that in a little time it became as large as a dried fig flattened, with its edges turned outward and callous. It reached from the commissure of the lids to the ala nasi, and adhered to the bone. Daviel dissected off the tumor down to the periosteum, but did not lay the bone bare; for he thought it sufficient for a complete cure to take away all the callosities. But he was mistaken; for the swelling increased, and the wound seemed larger than before. He used, in vain, all the remedies commonly thought of in such cases ; he scarified the edges of the ulcer, to bring it to suppuration; but it became more hard and callous than before the operation, and much more painful. He now resolved to cut away all that remained of the tumor, with the periosteum, which appeared very much swelled. This second operation was so successful, that the swelling, and every other bad symptom, disappeared almost suddenly. In three days the wound looked red and very well, without any pain, and the cicatrice was perfectly formed on the 15th day from the operation, without any sensible exfoliation of the bone, or the least deformity of the eye. Five years after Da- viel saw the patient in perfect health, and the cicatrice of the part very even.11 Case 135.—A country woman, 42 years of age, sought assistance on account of a can- cerous tumor, which occupied the inner third of the upper and under eyelids, the carun- cula lachrymalis, and the inner commissure, as far as the back of the nose, and was connected with the conjunctiva of the eyeball. Although, under these circumstances, there appeared little hope of saving the eyeball, yet this was attempted by the extirpa- tion of all the diseased parts. For this purpose Grafe passed, from the side of the eye towards the nose, a bodkin-shaped instrument through the middle of the basis of the swelling, and carefully separated the diseased part of the conjunctiva from the eyeball. Then with a pair of blunt-pointed scissors he divided the upper eyelid as far as the arch of the orbit, in such a way that the whole inner third of the eyelid was separated from the middle third ; a similar incision was then made through the lower eyelid, and the two extremities of these incisions joined by another in a curved direction over the back of the nose. The carcinomatous tumor was then separated from the bones. After this, in con- sequence of the retraction of the remaining parts of the eyelids, nearly the whole of the inner half of the anterior hemisphere of the eye was exposed. The wound was dressed simply with warm water, and the same dressing continued daily. To the joy of all concerned, the eyelids elongated, whilst the granulations ex- tended more and more inwards, and within three weeks were united in such a way by a cicatrice, that not the slightest deformity or exposure of the eye remained. The repro- duced commissure was found, on close inspection, to want the puncta lachrymalia, the caruncula, and semilunar fold. The loss of all these parts, and the complete removal of OPHTHALMIA TARSI. 113 both canaliculi lachrymales, produced no stillicidium lachrymarum, which, on physiolo- gical grounds, was to have been expected. Rudolphi was requested to examine the patient; but he was as unsuccessful as Grafe, in discovering the manner in which the tears were removed after the destruction of the parts above mentioned.I2 In several cases, I have removed a large portion of both lids, along with their nasal commissure, and have been surprised at the rapidity with which the wound healed, and the little deformity which ensued. In one instance, however, the cicatrice drew the lids so much towards the nose, that the patient could open the eye but very incompletely. In the case already referred to, in which I removed both lids, along with the eyeball, the skin contracted in the course of healing so as to cover the whole front of the orbit, leaving an aperture sufficient only to allow a quill to enter. When one or other lid has been removed by the disease or by the knife, it has been proposed to replace it by a new lid formed out of the neighboring integuments.13 So far as the loss of the lower lid is concerned, such a pro- cedure is unnecessary. The deformity and inconvenience arising from the want of the lower lid is trifling. The mere contraction of the cicatrice suf- fices to bring up the cheek to the level of the lower edge of the orbit. The skin unites to the conjunctiva, and at first sight, it is not observed that the eyelid has been removed. The palpebral opening is a little smaller than natural, both from above downwards, on account of the upper lid descending more than usual, and transversely, from the external angle of the lids having assumed a rounded form. Autoplasty, under such circumstances, would do little good. It is different with the upper eyelid. As its loss is likely to lead to a cal- lous state of the investing membrane of the eyeball, opacity of the cornea, and loss of vision, the proposal of forming a supplementary upper lid has something to be said in its favor. ' Dublin Hospital Reports; Vol. iv. p. 232; * This case is minutely recorded in the Dublin, 1827. Charleston Medical Journal, for Nov. 1849; 2 Daviel, Philosophical Transactions; Vol. and quoted in the American Journal of the xlix. Part i. p. 186; London, 1756; Warren's Medical Sciences, for July, 1850, p. 269. Surgical Observations on Tumors, p. 27 ; Bos- a See Daviel's 1st and 10th cases, Op. cit. p. ton, 1837. 186. 3 Guy's Hospital Reports, Second Series; 9 Quoted from the Lancette Francaise, in the Vol. viii. pp. 168, 170. Lancet, for 1830, 1831; Vol. ii. p. 607. 4 Synopsis of the Diseases of the Eye; p. I0 Op. cit. p. 189. 100; London, 1820. " Ibid. p. 191. s Lectures on Surgery; London Medical Ga- 12 1822. Jahres-Bericht iiber das clinische zette ; Vol. vi. p. 194; London, 1830. chirurgisch-augenarztliche Institut der Uni- 6 Basedow, Grafe und Walther's Journal der versitSt zu Berlin, p. 3 ; Berlin, 1823. Chirurgie und Augenheilkunde; Vol. xv. p. 13 Auvert, Selecta Praxis, Fasciculus II.: 497; Berlin, 1831: Dalrymple's Pathology of Ammon's Darstellungen, Zweiter Theil, Tab. the Human Eye, PI. V. fig. 5; London, 1849. vi. figs. 3, 4. SECTION X.—INFLAMMATION OF THE EDGES OF THE EYELIDS, OR OPHTHALMIA TARSI. Syn.—Blepharitis scrofulosa. Fig. Dalrymple, PI. I. figs. 3, 4. PI. II. figs. 1, 2. The edges of the eyelids are subject to an inflammation of a very tedious character. It is this disease which, closing the Meibomian follicles, and destroying the bulbs of the eyelashes, produces the state termed blear eyes. If long neglected, it becomes obstinate, and, in some respects, incurable. We usually term this disease ophthalmia tarsi; but it has received various names, and different views have been entertained of its nature. Any one 174 OPHTHALMIA TARSI. affected with this complaint, was called by the Romans lippus. Hence lippi- tudo, which we sometimes use to signify the effects of this disease. Celsus's lippitudo was what we now designate by the name of catarrhal or purulent ophthalmia. Ophthalmia tarsi he describes under the name of xerophthalmia or lippitudo arida. Comparing ophthalmia tarsi to eruptions of the hairy scalp, it has been called by some, tinea palpebrarum; while others have regarded it as herpetic or porriginous. As itchiness is one of the symptoms of the disease, it has been called scabies palpebrarum, and psorophthalmia; but that this complaint ever partakes of the nature of psora, is a notion which, in this country, is entirely laid aside. Ophthalmia tarsi affects the Meibomian follicles, their apertures running along the edge of the lid near its inner margin, the neighboring portion of the conjunctiva, the glands at the roots of the eyelashes, and the surrounding skin. Even the cartilage is sometimes implicated. Local symptoms.—One of the most striking symptoms of the disease is the adhesion of the edges of the eyelids in the morning, by means of a glu- tinous and superabundant secretion from the conjunctiva, Meibomian follicles, and ciliary glands. Incrusting, during sleep, into a gummy consistence, this matter binds the eyelashes together, so that the patient is obliged either to soften them before opening his eyes in the morning, or to use considerable, and even painful, effort for their separation. This is accomplished not with- out tearing out some of the eyelashes, which no doubt aggravates the inflam- mation of the sebaceous follicles at their roots, and produces a succession of little abscesses and ulcers. Frequently torn out in this way, and their bulbs injured or destroyed, the eyelashes are apt to become feeble, dwarfish, and irregular, or their reproduction to cease. The Meibomian secretion, naturally bland, and small in quantity, serving merely to smear the edges of the eyelids, so as to prevent them from adhering, and to conduct the mucus of the conjunctiva and the tears towards the puncta lachrymalia, becomes, in this disease, augmented in quantity, and changed into a puriform matter. This matter of itself, as well as the inflammation in which it originates, causes constant irritation, and frequent itchiness of the eye and eyelids, and adhering to the eyelashes, prevents the little ulcers from healing which arise at their roots. The tears, excited by the irritation, are discharged more frequently than natural, and being no longer conducted along the edges of the lids towards the puncta lachrymalia, as they are in health, they drop over upon the cheek, chafing and excoriating the integu- ments. The consequence is, that we frequently find this disease attended with much swelling and redness of the eyelids, and the skin of the cheeks inflamed, ulcerated, or covered with scabs. Not unfrequently, the conjunc- tiva, lining the lids, is considerably inflamed, and gives out a disordered secretion. One or more of the Meibomian follices are often greatly distended with purulent matter, which oozes out from their apertures on pressure. In other cases, the edges of the eyelids are occupied by a thick crust of matter, under which ulceration is proceeding slowly to destroy the secretory appa- ratus of the eyelashes. Sometimes the whole substance of the eyelids, near their edges, is thickened, indurated, and distorted; a state which is termed tylosis. The local symptoms of ophthalmia tarsi vary considerably in severity, in obstinacy, in the appearances of the matter discharged, and even in the seat of the principal morbid changes; for, in some, the Meibomian follicles, in others, the ciliary glands, or bulbs of the eyelashes, are the parts chiefly affected. The inflamed state of the conjunctiva in this disease, as well as that of the Meibomian follicles themselves, produces a feeling of sand, or a sensation of OPHTHALMIA TARSI. 175 roughness in the eyes, which causes the patient to open the lids partially, and frequently to keep them close altogether. He complains also of feelings of stiffness, dryness alternating with agglutination, heat, soreness, and in- tolerance of light, increased in the evenings, or when he exerts his eyes on minute objects. Two events are apt to follow, when ophthalmia tarsi has continued long, and been neglected. The one is a partial or total obliteration of the Mei- bomian apertures, along the margin of one or both eyelids. These orifices are in fact skinned over. In this case, which may be regarded as incurable, the inner margin of the affected lid becomes rounded off, instead of being angular ; it is smooth, red, and glistening; no Meibomian secretion is seen oozing out upon pressure, and, generally, the eyelashes are in a great measure wanting. The other event is lagophthalmos and eversion of the lower lid, originating in the contracted state of the skin, consequent to the healing up of the excoriated eyelid and cheek. Not unfrequently, these two sequelas go together. Trichiasis or inversion of the eyelashes, distichiasis or misplaced eyelashes, and even inversion of the lids, must also be enumerated among the effects of long-continued ophthalmia tarsi. Those in whom the palpebral conjunctiva is much affected, or suffers from repeated ulcerations, and who acquire a habit of opening their eyes very partially, are most subject to inversion. Constitutional symptoms.—Inflammation of the edges of the eyelids is much more frequent in children than in adults. In almost every case, the patient presents undoubted marks of a scrofulous constitution ; the functions of the skin, and of the digestive organs, are disordered; and the general health impaired. Occasionally, we find the disease associated with scrofulous conjunctivitis, enlarged lymphatic glands, swollen upper-lip, sore ears, scald head, tumid abdomen, paleness and looseness of the skin, restlessness during the night, and morning perspirations. In general, however, ophthalmia tarsi does not affect the general health in so great a degree as the disease called scrofulous ophthalmia or phlyctenular inflammation of the conjunctiva. Causes.—Ophthalmia tarsi is by no means always a primary disease ; but frequently takes its origin from catarrhal ophthalmia, ophthalmia neonatorum, or scrofulous conjunctivitis, or from the affections of the eyes attendant on measles, scarlatina, or smallpox. In all these diseases there is more or less inflammation of the Meibomian follicles, and when the other symptoms sub- side or totally disappear, the ophthalmia tarsi is apt to remain. When this disease appears to be primary, cold, impure air, smoke, and filthiness, ope- rating directly on the eyelids, are among the most common exciting causes; while the scrofulous constitution, aggravated by indigestible or unwholesome food, and other causes, affords its aid in perpetuating the complaint, or at least in favoring relapses. In adults, we often find the habitual use of wine and spirits keeping up this affection of the eyelids. Linnaeus1 tells us that the Laplanders are generally blear eyed. He ascribes this to their exposure to the sharp winds, the reflection from the snow, the fogs, the smoke, which escapes only by a hole in the roof of their huts, and the severity of the cold. The Finlanders are afflicted in the same way, and many of them thereby deprived of sight. Treatment.—The treatment of this disease comprehends, 1st, Remedies likely to abate the inflammation, upon which the whole train of symptoms originally depends, to soothe the pain and itching, and prevent the bad effects of gluing together of the lids ; 2dly, Such applications, whether astringent, stimulant, escharotic, or epulotic, as may deaden the excoriated and ulcerated parts, promote their healing, or strengthen the debilitated eye- lids ; and 3dly, Constitutional remedies. 176 OPHTHALMIA TARSI. 1. The first direction to be given to the patient, or to his attendant, is never to attempt to open the eyes in the morning, till the concreted purulent matter is completely softened, so that the eyelids may separate without pain, and without injuring the eyelashes. For this purpose, a teaspoonful of milk, with a bit of fresh butter melted in it, may be employed for smearing the lids, rubbing it with the finger gently along the agglutinated eyelashes. A piece of soft sponge, wrung out of hot water, is then to be held upon the eyelids for some minutes; after which the patient will find the eyelids yield, without pain, to the least effort he makes to open them. With the finger nail, the whole of the matter is immediately to be removed; and should it happen, that during the day, or towards evening, there is any reappearance of it, the same plan must again be adopted. This is absolutely necessary, because so long as the matter is allowed to remain, no application of lotion or salve can be of any use, as it never gets into contact with the seat of the disease. 2. Occasional scarification of the palpebral conjunctiva, and the applica- tion of leeches to the external surface of the lids, and to the neighboring skin, are to be employed for the purpose of subduing the inflammation. 3. Advantage is derived from emollient, refrigerant, and sometimes astrin- gent applications, in the form of fomentations, cataplasms, pledgets, and collyria. For example, after the lids have been completely freed from their morbid secretion in the morning, they may be fomented with warm water, or a warm decoction of poppy heads, chamomile flowers, the leaves of water germander, or the like; and this may be repeated once or twice in the course of the day, till the pain and principal inflammatory symptoms subside. Cataplasms of bread and water, with a little fresh butter or olive oil, inclosed in a small linen bag, and laid over the eyelids through the night, are useful in aggravated cases. A cataplasm, made of crumb of bread and weak vinegar, is often of service. A piece of caddis, spread with some soft cerate, and kept upon the eyes during the night, is useful. When the disease is slight or incipient, an evaporating lotion proves grateful to the patient, and promotes a cure. One or two drachms of the spirit of nitrous ether, with as much vinegar, in 8 ounces of water, frequently applied to the lids by means of a bit of sponge, will answer this purpose. In cases of longer standing, and especially after the inflammatory symp- toms are somewhat subdued, it is advantageous, repeatedly during the day, to bathe the eyelids carefully with a solution of from one to two grains of corrosive sublimate in eight ounces of water. This solution may be used cold or tepid, as the patient inclines; and after the outside and edges of the lids are well soaked with it, it may be allowed to run in upon the eye, so as to come into contact with the inner surface of the lids. Other collyria may also be employed; as a weak solution of sulphate of zinc, or a mixture of brandy and water. One of the chief uses of the col- lyria is to keep the eyelids perfectly clean, without which no cure can be effected. 4. Counter-irritation, by means of blisters behind the ears or to the nape of the neck, a warm plaster between the shoulders, or a caustic issue in the neck, is often attended with benefit. Indeed, it rarely happens that much good can be done without a continued discharge, in those cases in which the lids, from long neglect, have become greatly thickened and callous. 5. The application of a salve to the edges of the eyelids at bedtime, is an essential part of the treatment. The salves which have been found most useful, are those possessed of a stimulating or slightly escharotic power, such as the red precipitate, or the subnitrate of mercury salve. The latter, com- OPHTHALMIA TARSI. 177 monly known by the name of citrine ointment, is prepared according to the formula in the Pharmacopoeia, but is usually much reduced in strength, before being employed as an eye-salve. The former consists of from 12 to 20 grains of red precipitate, carefully levigated into an impalpable orange powder, and mixed with one ounce of butter, or lard, free from salt. About the bulk of a split pea of the salve selected, is to be melted on the end of the finger, and rubbed into the roots of the eyelashes, and along the Meibomian apertures, every night, or every second night, according to the severity of the symptoms and the effects produced. If much irritation follows the ap- plication of the salve, once every second night will be sufficiently often, a little simple cerate, softened by an addition of axunge, being used on the alternate nights. Some surgeons trust their patients with a very weak salve only, which is to be applied freely, by rubbing it along the edges of the lids; while, with a camel-hair pencil, they themselves apply occasionally some stronger salve, such as one composed of 10 grains of nitras argenti to the ounce of soft cerate, taking care to confine the application to the diseased parts. Salves are often employed for the cure of ophthalmia tarsi, without almost any effect, from these two necessary particulars not being known or not attended to ; namely, that the salve is not to be smeared over the purulent crust formed, by the disease, but applied only after the lids are freed from every particle of the morbid secretion; and that it is not to be pencilled softly on, but pressed, by repeated friction, into the diseased roots of the eyelashes, and into the mouths of the Meibomian follicles. Unless it smarts considerably, it, in general, does little good. Other salves besides those above mentioned, are sometimes employed in this disease; especially Janin's, which consists of 2 drachms of prepared tutty, the same quantity of Armenian bole, and 1 drachm of the white pre- cipitate of mercury, with half an ounce of lard. In old people, and in those incurable cases in which the Meibomian apertures are obliterated, this salve answers better, perhaps, than any other. The ointment of oxide of zinc, one composed of 2 drachms of burnt alum to 1 ounce of lard, and various others, have also been used. In cases supposed to be porriginous, a mixture of precipitated sulphur with diluted subnitrate of mercury ointment, has been found very effectual. Not unfrequently we meet with slight, but very irritable cases of ophthal- mia tarsi, in which not even the mildest salve can be borne. Fomentations, with poppy decoction, or simply with warm water, afford most relief in such cases. 6. If small ulcers are present along the edges of the lids, they are to be touched with the lunar caustic solution, or with the solid nitras argenti. It is useful, also, to touch the inflamed conjunctiva, from time to time, with the same solution. When the lids are greatly thickened and indurated, their edges much in- crusted, and the roots of the eyelashes ulcerated, it has been recommended to extract all the eyelashes, and then touch the whole diseased surface lightly with a pencil of lunar caustic. This has a great effect in healing the ulcers and diminishing the swelling. In a few days, the caustic may be repeated. Three or four repetitions are generally sufficient. This is the practice of Quadri of Naples, who, in the interval between one application of caustic and another, bathes the parts with brandy.3 Mr. Lawrence, who also recom- mends the practice, states as an additional inducement .to extract the cilia, that those which fall out by ulceration are never replaced, because the bulb which secretes the hair is destroyed; but when they are plucked out, they are afterwards restored. It is not, however, absolutely necessary to extract 12 178 OPHTHALMIA TARSI. the cilia, in order to derive advantage from the application of the lunar caustic. I have frequently employed it, after having merely cleared the cilia of the morbid crust which adheres to them, and found the practice highly useful. 7. As the obstinacy of ophthalmia tarsi almost invariably depends on a faulty constitution, tonics and alteratives are always necessary. The tonics chiefly to be depended on are the sulphate of quinia, and other preparations of bark, the mineral acids, the precipitated carbonate of iron, and chalybeates in general. These are to be given in appropriate doses, and continued for a length of time. A solution of 15 grains of muriate of barytes in half an ounce of diluted tincture of bark, of which from 8 to 20 drops are given thrice a-day, in a wineglass of water, is much recommended by Dr. Zimmer of Prague, and I have witnessed good effects from it.* The alteratives chiefly employed in the cure of this disease, are iodine and mercury, the former as iodide of potassium, the latter in the form of Plum- mer's pill. Purgatives are useful from the first; and whether alteratives or tonics are afterwards employed, a dose of laxative medicine, as sulphate of magnesia, infusion of senna, or powdered rhubarb and jalap, ought to be occasionally interposed. 8. The regulation of the patient's diet is essential for the cure of this dis- ease. Care is to be taken that the stomach be not overloaded at bedtime, or disturbed by indigestible or improper food during the day; for, if this be permitted, the morbid secretion from the lids becomes more copious, and a greater degree of irritation and inflammation is induced. 9. The warm bath, with sea-water, if it can 'be had, is an excellent remedy. The vapor-bath is also useful. If neither of them can be procured, let the tepid pediluvium be employed every night at bedtime. 10. Pure air, and regular exercise, are to be recommended. Violent ex- ercise is to be avoided, as Horace knew, himself afflicted with this disease:— Namque pila, lippis inimicum et ludere crudis.3 11. The clothing of those affected with ophthalmia tarsi ought to be par- ticularly attended to. A delicate child is easily chilled. The skin, stomach, liver, and bowels are thereby disordered; and an attack of this disease, or of scrofulous conjunctivitis, is a frequent concomitant. The difficulty of curing these diseases is always increased, when the weather is damp and cold. 12. Sleep at early hours is of great consequence. Hardly anything tends more to confirm this affection of the lids, than sitting up late at night, espe- cially if the eyes are at the same time employed on minute objects. Prognosis.—So obstinate is ophthalmia tarsi in many instances, that we are not unfrequently asked, if it will ever be cured. The answer depends on the state of the Meibomian apertures, and on the perseverance of the patient, or his friends, in the means of cure. If, from neglect, the mouths of the Meibomian follicles, in number about 30 on the edge of each eyelid, are par- tially, or totally obliterated, so that the skin covering them is smooth and shining, and nothing can be pressed out of them, the case is so far incurable; and the patient must, for life, pay attention that the lids do not get worse. He must use Janin's or some other salve, every night; and follow the gene- ral directions regarding diet, clothing, and exposure, already laid down. If, on the other hand, the Meibomian apertures are patent, however much inflamed and disfigured the eyelids are by the disease, the case is perfectly curable by perseverance; but even after the symptoms appear completely gone, the remedies will require to be continued, for months at least, The establishment of puberty exercises its influence over this, as over other scro- fulous diseases. PORRIGO LARVALIS AFFECTING THE EYELIDS. 179 Sequelce.—As important consequences of ophthalmia tarsi, may be men- tioned, tylosis, or chronic thickening of the whole substance of the lid; lip- pitudo, excoriation of the edges of the lids, or blear eyes; obliteration of the Meibomian follicles, the cause of incurable lippitudo ; madarosis, or loss of the eyelashes; lagophthalmos and ectropium, from the contracted state of the skin, consequent to the healing up of the excoriated lids ; trichiasis, or inversion of the eyelashes; distichiasis, or misplaced eyelashes; entropium, from repeated ulcerations of the edges of the lids, and contraction of the car- tilages. Several of these sequelas I shall take up separately. 1 Lachesis Lapponica, by Smith; Vol. ii. pp. 4 Grafe und Walther's Journal der Chirurgie 5, 132; London, 1811. und Augenheilkunde; Vol. xxiv. p. 156; Ber- 2 Treatise on the Diseases of the Eye, p. 339; lin, 1836. London, 1833. ' Horatii Sat. i. v. 49. 3 Annotazioni Pratiche sulle Malattie degli Occhi; Lib. i. p. 145 ; Napoli, 1818. SECTION XI.---HERPES AFFECTING THE EYELIDS. There is scarcely any cutaneous disease which may not be seen occasion- ally on the eyelids. Herpes I have often met with, both in children and adults. It runs its usual course of about a fortnight, leaving pits, like those of smallpox. Not unfrequently it attacks the cornea, a vesicle having its seat there, ending in an ulcer. Gentle laxatives and diaphoretics, a light diet, and fomenting the eyelids with warm water, make up the general treatment. Should ulceration take place on the cornea, it ought to be touched with lunar caustic solution, and the eyelids painted over with the extract of belladonna. SECTION XII.—PORRIGO LARVALIS AFFECTING THE EYELIDS. Porrigo larvalis, or crusta lactea, not unfrequently spreads to the skin of the eyelids. Infants are almost exclusively the subjects of this disease. It is characterized by an eruption of pustules, followed by thin yellowish or greenish scabs, which often intrude upon the edges of the lids, sealing them up, and preventing the child from opening its eyes. Falling off, these scabs leave the cuticle red and tender, marked with deep lines, and apt repeatedly to exfoliate. The conjunctiva sometimes takes on puro-mucous inflammation during an attack of porrigo larvalis, and occasionally the cornea gives way, and the eye is destroyed.1 The lymphatic glandular system, in neglected cases, becomes affected, both externally, as under the jaw, and internally, as in the mesentery; diarrhoea and hectic fever follow, and the patient perishes in a state of great emaciation.3 Careful ablution of the lids, with some mild and tepid fluid, as milk and water; the solution of nitrate of silver (4 grains to %i of distilled water) dropped on the conjunctiva once a day; and the red precipitate salve applied to the edges of the lids at bedtime, will be found useful; with alterative doses of mercurial purgatives, followed by a course of sulphate of quinia. 1 Stenheim, Grafe und Walther's Journal der 2 Bateinan's Practical Synopsis of Cutaneous Chirurgie und Augenheilkunde; Vol. xiv. p. Diseases, p. 162," London, 1849. 75; Berlin, 1830. 180 MEIBOMIAN CALCULI. SECTION XIII.—VITILIGO AFFECTING THE EYELIDS. Fig. Guy's Hospital Reports, Second Series; Vol. vii. p. 274; London, 1850. This disease, when it affects the eyelids, of which I have met with several instances, presents a row of yellowish, or ochre-colorcd, flat patches, of irre- gular shape, slightly elevated, presenting scarcely any induration, and gene- rally appearing on both sides of the face symmetrically. They are seated in the cutis, and the cuticle covering them seems healthy. They avoid the margins, and appear chiefly in the loose skin of the lids, sometimes spreading slowly to the sides of the nose and to the cheeks. Other parts of the body, as the palms, fingers, elbows, &c, are sometimes affected in a similar man- ner. The disease sometimes accompanies jaundice, and has been supposed to depend on a defective action of the liver. This should be corrected. The eyelids should be fomented with vinegar and warm water. Benefit has been derived from the repeated application of the nitrate of silver. SECTION XIV.—ABSCESS OF THE MEIBOMIAN GLANDS. I have already (page 174) mentioned the occasional occurrence of abscess of the Meibomian glands, as an attendant on ophthalmia tarsi. Idiopathic cases of this kind are also met with, one or more of the glands being turgid with puriform fluid, perhaps without any affection of the edge of the lid, but sometimes with a swelling of its edge resembling a hordeolum. On everting the eyelid, we immediately discover the nature of the case, and the difference between it and common hordeolum. The pus sometimes oozes out, under pressure, at the aperture of the inflamed gland; in other cases, the abscess requires to be opened with the lancet, on the edge or the inside of the lid. In other respects the treatment for ophthalmia tarsi is to be followed. SECTION XV.--OBSTRUCTION OF THE MEIBOMIAN APERTURES. Occasionally the external orifice of one or more of the Meibomian ducts becomes covered by a thin film, apparently of epidermis. This prevents the escape of the secretion, which, accumulating, raises up the film into a small elevation, like a phlyctenula. This does not actually cause pain, but gives rise to slight uneasiness when the eyelids are moved. The film is easily broken, and the accumulated secretion removed on the point of a pin. SECTION XVI.—MEIBOMIAN CALCULI. Two sorts of concretions are met with in the Meibomian glands. They differ in appearance, and in the direction by which they seek to escape. The one is semi-transparent, like a particle of rice, and soft in consistence. It projects by the orifice of the follicle it occupies, and on pressure starts out. The other is white, opaque, and calcareous; it does not project on the edge, but on the inner surface of the lid, sometimes penetrating through the con- junctiva, and causing great irritation of the eye. For its removal, the con- junctiva covering the calculus requires to be divided with a lancet, or cata- ract needle, and the concretion lifted out with the pointed end of a probe, or edge of a small spatula. Numerous concretions of this sort are often met with in the same eyelid. PHLYCTENULA AND MILIUM OF THE EYELIDS. 181 SECTION XVII.—HORDEOLUM. Fig. Dalrymple, PI. IV. Fig. 1. A hordeolum, or stye, is a furunculus, or small boil, projecting from the edge of the eyelid. According to some, it implicates merely the cellular tissue ; but Zeis suspects1 that it has its seat in the capsule and glands of the roots of the cilia. Certainly it is not an abscess of the Meibomian glands. Symptoms.—The swelling is of a dark red color, very hard, attended at first by stiffness and itching, and afterwards by a great degree of pain in proportion to its size. The tension and exquisite sensibility of the skin which covers the edge of the eyelids, serve to explain the vehemence of the pain. The inflammation spreads, in some degree, to the conjunctiva, and the motions of the lids are impeded. In delicate irritable subjects, fever and restlessness are excited. The swelling suppurates slowly, and at last points and bursts. After discharging a small quantity of thick pus, and sometimes a little disorganized cellular membrane, it subsides and disappears. If Zeis be correct, the disorganized substance which is discharged, must be the cap- sules of the cilia. The cilia fall out from the part affected, to be generally, but not always, reproduced. Causes.—Hordeolum is most frequent in scrofulous subjects. It frequently depends on late hours, the use of spirituous liquors, or on disordered bowels. Pickles and peppers produce it. Treatment..—In the incipient stage, cold applications are to be used, as water acidulated with vinegar, or an iced poultice. If suppuration appears to be advancing, a warm bread and water poultice, inclosed in a little bag of linen, or a roasted apple poultice is to be applied. If slow of bursting, the abscess may be opened with the point of a lancet. The pus and destroyed areolar tissue are to be pressed out, and the poultice continued. It some- times happens, that the sloughy matter is slow of coming away, in which case the cavity may be touched with a pointed piece of lunar caustic, after which it soon closes. In the commencement of hordeolum, an emetic, followed next day by a purge, will be found useful. 1 Ammon's Zeitschrift fiir die Ophthalmologic ; Vol. v. p. 220 ; Heidelberg, 1836. SECTION XVni.—PHLYCTENULA AND MILIUM OF THE EYELIDS. Fig. Wralton, Figs. 88, 89. Semitransparent vesicles, or phlyctenular, filled with watery fluid, fre- quently occur on the edges of the eyelids, especially at the inner canthus, sometimes single, often in groups, varying in size from that of a mustard- seed to that of a pea. Having been punctured with the lancet, their walls are to be laid hold of with a pair of toothed forceps, and snipped off with the scissors. Small white tumors, like millet seeds, containing a suet-like substance, are often observed on the edges of the eyelids. They are to be opened with the point of the lancet, and their contents pressed out. 182 TUMORS IN THE EYELIDS. SECTION XIX.—WARTS ON THE EYELIDS. Fig. Dalrymple, PI. V. Fig. 1. Warts are not uncommon on the external surface of the eyelids, and some- times grow from their edges. Keeping the excrescence constantly covered with a piece of lint, saturated with a decoction of tormentil root, or a solu- tion of carbonate of soda, will sometimes serve for its removal. [Even cold water continually applied will serve the same purpose.—H.] But if this does not succeed, the wart may be tied with a waxed silk thread, close to its root; or, if it has a broad attachment, destroyed by the application of lunar caustic. The shortest way is to snip off the excrescence with scissors. SECTION XX.—SYCOSIS AFFECTING THE EDGE OF THE EYELID. Fig. Dalrymple, PI. IV. Fig. 5. To others this may seem a very trifling disease; but to the patient ex- tremely desirous to get quit of it, and to the surgeon who finds it exceedingly difficult to disperse it, its apparent insignificance affords little consolation. Other hard tubercles of the same kind are generally present on the face ; but the one which is situated on the edge of the lid, or so close to either punctum as almost to surround it, shows a still greater tendency to persist than any of the rest. On the edge of the lid, the tubercle sometimes shoots out with a sharp edge, which may be snipped off with the scissors. A regulated diet, the use of laxatives and antacids, daily touching with sulphate of copper, and warm fomentations, make up the treatment. SECTION XXI.—HORNY EXCRESCENCES ON THE EYELIDS. Fig. Dalrymple, PI. V. Fig. 2. The exudation from a sebaceous follicle becoming indurated, and gradually covered by layers of desquamating epithelium, has sometimes pushed itself into the form of a little horn, projecting in a curved form from the skin of the eyelids. Seized with the fingers, the horn is to be drawn forwards, and snipped out by the root. SECTION XXII.—TUMORS IN THE EYEBROW AND EYELIDS. The eyebrow and eyelids are the occasional seats of various kinds of tumors. We shall turn our attention first to those which are common in their occurrence, then to those which are rare. § 1. Chalazion, or Fibrinous Tumor. From xaXafa a hailstone. Syn.—Tarsal Tumor. Fig. Dalrymple, PI. IV. Fig. 2. Walton, Figs. 90, 91. This extremely common disease bears some resemblance to a hordeolum, but it is not situated on the edge of the lid, nor does it point towards the edge. It is generally placed at some distance from it, and when it comes to point, it does so generally towards the internal, rarely towards the external, TUMORS IN THE EYELIDS. 183 surface of the eyelid. It is situated either between the orbicularis palpebra- rum and the tarsus, or in the substance of the cartilage itself. The tumor is at first movable ; but, as it enlarges, it becomes fixed, and the skin covering it grows red. By everting the lid, we cause the tumor to project on its inner surface, which appears inflamed, and often presents a depression over the centre of the tumor. Fig. 10 shows the external appearance of the lower lid affected with chalazion ; and Fig. 11 its inner surface. After the disease Fig. 10. Fig. 11. has continued for a considerable time, that portion of the cartilage which lies behind the chalazion becomes thinned by absorption, and we find a small fungus-like substance projecting through the cartilage and palpebral con- junctiva. In one case, I found the fungous growth making its way through the upper punctum. A chalazion often goes on to suppurate, or rather sup- puration takes place round the tumor, and at length the tumor is destroyed by this process, the abscess evacuating itself, in some cases on the outside, and in others on the inside of the lid. Chalazion is met with more frequently in the upper than in the lower eyelid. Sometimes it occurs in both at the same time. In some cases, there are more than one in the same lid. It is very rarely seen in children. The digestive organs of those who are troubled with chalazia, are generally in bad order; the stomach acid and flatulent; the bowels slow, and the evacuations morbid. In incipient cases, the further progress of the tumor may often be checked by alterative doses of the blue pill, and by the use of laxatives and tonics, especially bark and steel. Under this treatment, I have seen many such tumors disperse entirely. A vinegar poultice, in a small linen bag, continued every night, sometimes proves useful; as well as friction over the tumor, with camphorated mercurial ointment, for ten minutes twice a-day. Small hard chalazia should not be touched, especially if situated at the extremity of either lid. When it has attained a certain size and become somewhat softened, this sort of tumor requires to be removed by operation. As it is unencysted, it is needless to think of a regular extirpation. If this be attempted, the operator is very likely to be foiled, as the tumor eludes dissection; or if he still persists, he may extirpate perhaps a piece of the cartilage, and leave the lid with an opening through it, like a button-hole. I have seen cases in which the structure of the lid was materially damaged by attempted extirpations of chalazia; a portion of the cartilage having been 184 TUMORS IN THE EYELIDS. removed, leaving the lid inverted, or bound to the eyeball by frauia. All that is necessary, in general, is to evert the affected lid, divide the tumor through its whole length with the lancet pushed through the cartilage, and then press out the gelatinous-like contents. Pretty firm pressure is necessary to effect this. If the tumor, fairly divided, does not start out, the pointed end of a probe may be passed through the incision, the structure broken up, and then pressure applied. The cavity where the chalazion was lodged, immediately fills with blood, keeping up an appearance as if the tumor was still there, although lessened in size; but gradually the swelling, redness, and other signs of the disease, go off entirely. In some few cases, it may be proper to perform this operation through the integuments; but, in general, the tumor lies nearer the inner surface of the lid. If the chalazion threatens to burst through the cartilage, or if there is already a little opening with a small fungous protrusion, the incision ought to be made in the line of this protrusion, and not to one side of it, even though the tumor is more promi- nent where the cartilage is still entire. It is much easier to press out the chalazion through the thinned part of the tarsus, than elsewhere. If the fungus which protrudes is considerable, it is to be snipped off. Sometimes two chalazia, sitting close together, appear as one; but require two separate incisions for their removal. Attempts to destroy chalazia by caustic are always ineffectual, and often hurtful, producing induration of the lid, and sometimes trichiasis. A mere division of the tumor through the conjunctiva and tarsus, is also insufficient, even with the application of caustic introduced through the wound; the tumor must be evacuated in the manner described. By this means, the cha- lazion, if not in a state of suppuration, is generally removed entire. It is of a light reddish color, and gelatinous consistence, with spots of blood through it. Becoming white and opaque on being immersed in diluted alcohol, dis- solving with great ease in acetic acid, and being thrown down by prussiate of potash, it seems to consist of an imperfect fibrinous matter. § 2. Molluscum, or Albuminous Tumor. Syn.—Glandiform tumor. Tumeur folliculeuse, Fr. Fig. Dalrymple, PI. IV. Fig. 3. Walton, Fig. 87. Willis, PI. 63. Molluscum or albuminous tumor occurs much more frequently in children than in adults. It is seated in the skin ; sometimes close to the edge of the eyelid, but generally at some distance from it. When close to the edge, the eye is apt to be irritated and inflamed by its presence. The integuments covering the tumor are so thinned as to allow its white color to shine through. It presents a granulated appearance even before extirpation ; and on being removed, is still more distinctly seen to be formed of numerous grains, the acini of hypertrophied sebaceous glands. The tumors vary in size from that of a pin's head to that of a horse-bean, or even larger, are firm, free from pain, unencysted, and not apt to go into suppuration. They are sessile on a contracted base, but not pedunculated. In their centre they present a small orifice, whence a whitish fluid exudes. After a time, the integuments become ulcerated, and the mass is discharged entire, or in portions. The eyelids often present numerous albuminous tumors, and sometimes they are scattered over the other parts of the face. It is well ascertained, that this disease, when recent, proves contagious, the whitish fluid which exudes by the orifice of the tumor being the apparent medium by which the disease is communicated. In one case, I saw the hands of a gentleman inoculated from the face of his child. The recent dis- TUMORS IN THE EYELIDS. 185 ease is styled molluscum eontagiosum ; the chronic, which seems to have lost the contagious property, and has often been known to last for many years, is called molluscum pendulum, from the elongation which its attachment to the skin gradually acquires. Chemical examination of the tumor shows it to possess the characters of coagulated albumen. If albuminous tumor be dependent on any constitutional cause, it seems of scrofulous origin. I have seen a crop disappear from the eyelids of a scro- fulous child, during the use of the sulphate of quina. Albuminous tumors may be destroyed by being touched with potassa fusa, nitrate of silver, or sulphate of copper; but the readiest way of extirpating them is by a transverse incision through the integuments, and through the diseased mass. By firm pressure with the thumb-nails, placed on the sound skin, we are then able to bring away the tumor entire, without any farther dissection. Sometimes, on making pressure after dividing the tumor, the central parts only of it escape, leaving the exterior layer adhering to the skin, almost like a cyst. By repeating the pressure, this portion is also brought away.1 In chronic cases, affecting the upper eyelid, the tumor sometimes attains an enormous size, so as to hang down and completely cover the opening of the lids. In cases of this sort, examples of which are related and figured by Liston'2 and Craigie,3 the rest of the body is generally covered with mollus- cous tumors. To remove the deformity of the eyelid under such circum- stances, an elliptical portion of skin, embracing the diseased structure, requires to be removed, and the edges brought together by stitches. § 3. Encysted Tumor. Encysted tumors, filled with serous fluid, or with suety or still more solid substance, rarely occur in the eyelids. Congenital tumors of this kind, how- ever, are not unfrequently met with, close to their outer angle, or above the eyebrow. Their pappy contents are sometimes mixed with short hairs, like cilia, having bulbs, and growing from the inside of the cyst. They often lie under the orbicularis palpebrarum, and adhere to the bone, so that, when we proceed to their extirpation, it is necessary to make a larger incision than the size of the tumor might seem to require, and to dissect carefully round and under the cyst, laying back the orbicularis palpebrarum as well as the integuments; for unless this is done, the extirpation will be effected with difficulty. When seated in the eyelids, the cyst is often very delicate, so that it is difficult to remove it entire. If the cyst bursts, we may introduce one blade of the hooked forceps within it, while the other seizes it exter- nally, and go on to dissect out the cyst. In some instances, I have found the cyst seated between the conjunctiva and the orbicularis palpebrarum, so as to be beyond the tarsus; and in this case, the extirpation is best accom- plished through the inner surface of the lid. Instead of attempting a regular extirpation, it may sometimes be advisable merely to lay open the cyst with the lancet, and then squeeze out its con- tents, along with the cyst, which I have sometimes accomplished. If the cyst cannot be thus brought away, we may introduce into its cavity for a few seconds a pencil of lunar caustic, or pure potash. After a few days, the cyst comes away, and the wound heals up. Or the tumor may be divided at once into two halves, the contents removed, and the cyst allowed to collapse; then, with a pair of forceps, the one half of the cyst is to be laid hold of, drawn out through the wound, and snipped off with scissors, and the same with the other half. If any part of the cyst is left, the wound will perhaps 186 TUMORS IN THE EYELIDS. not close, or is apt to open again, after being healed, and continue for a length of time to discharge matter. Should this take place, it may be pro- per to make an incision, and remove the bit of the cyst which had been left at the former operation. [Both encysted and fibrous tumors differ very much as to their original seat of development on the lids. They may begin on either side of the cartilage, and by pressure produce absorption and perforation of the part of that struc- ture with which they come in contact, and then manifest themselves more or less equally on both sides; or no alteration in the condition of the cartilage may ensue, and the tumor remain entirely isolated on the one side, or become adherent to the cartilage. When developed external to the cartilage, they may be either simply sub- cutaneous, or lie between it and the orbicularis. AVhen subcutaneous only, they are more defined in their form, and more movable than when they are covered by the muscle. The tumors developed beneath the orbicularis, if movable at first, very soon lose that character, and, becoming adherent to the cartilage, perforate that tissue, being kept in close contact with it by the action of the orbicularis ; and hence, it generally follows that the tumors which perforate the cartilage have had origin beneath the muscle. The tumors which originate on the inner side of the lid are developed in the tissue connecting the conjunctiva with the cartilage, and are at first quite movable. When small, they give an undefined fulness to the part of the lid beneath which they lie; but when, however, they attain a large size, and are firm, they present very much the same appearance as those beneath the muscle ; but their true seat will be readily shown on simply everting the lid. Now a careful examination of the original seat of these tumors is of some moment in determining on which side of the lid the incision is to be made for their removal, as we shall see presently. A source of great annoyance, and a not unfrequent cause of failure in the complete extirpation of these little growths, is in the profuse hemorrhage which follows the slightest incision of the lids. To avoid this, M. Desmarres designed his ring-forceps, which consist of a pair of ordinary dressing forceps, with their ends armed—the one with an oval plate about one inch by half an inch, and the other with a ring of the same dimensions. They are to be applied—the one blade on either surface of the lid, and firmly pressed together by means of a screw and button; this will completely interrupt the circulation in the part embraced by the ring through which the tumor is to be removed, the plate beneath serving as a firm basis on which the incisions are to be made. The accompanying wood-cut represents the instrument as modified by Mr. Wilde, of Dublin. His modifications consist in diminishing the size of the Fig. 12. plate and ring, which, in the original instrument, are unnecessarily large; and in placing the button and screw on the opposite side, so that the ring can be placed over the tumor on the conjunctival surface, and the two blades TUMORS IN THE EYELIDS. 187 screwed together, which could not be done so readily under such circum- stances in the original instrument. Mr. Kolbe, an ingenious instrument maker, formerly of Mr. Luer's establish- ment in Paris, but now resident in Philadelphia, has substituted the wedge- shaped slide, similar to that on the dog-toothed forceps, for the screw and button. This enables the instrument to be applied with equal facility for the removal of the tumor on either side. Mr. Wilde,4 of Dublin, prefers removing tarsal tumors by incision through the conjunctiva, whereas Mr. Desmarres5 evidently employs the external in- cision, to the exclusion of any other for the purpose. Neither, however, in our opinion, should be used exclusively. In cases of simple subcutaneous tumors, it would be entirely unnecessary to evert the lid, make an incision down to the tumor, and remove it in that way; the division of the integument is all that would be required in such cases. But the simple subcutaneous tumor is the rarest form of tarsal growths we meet with, the majority of cases about which we are consulted being either of the subconjunctival or submuscular form, and the latter where the cartilage has been perforated and the tumor is pointing at the conjunctival surface, for these are the forms of tumor which give rise to the greatest irri- tation and annoyance, compelling the patient to seek for relief at the hands of the surgeon. In such cases, the operation is more readily and perfectly performed by the incision through the conjunctiva.—H.] Simple puncturing of encysted tumors does not answer well, as it is apt to excite inflammation in the neighboring cellular membrane, and lead to fun- gous growths from the cyst. § 4. Fibro-plastic or Sarcomatous Tumor. Case 136.—A Moor, 24 years of age, applied at the French Hospital at Algiers on account of an enormous nodulated tumor in the right upper eyelid, of several years' standing, the origin of which he attributed to a blow with a stick. The tumor hung down so far, that the cilia were nearly on a level with the chin; it rose in relief above the prominence of the nose, and measured 6 inches in its vertical diameter, and 5 in its transverse. The upper part of the tumor passed into the orbit, and adhered to the globe of the eye, which was partially atrophied, with its cornea opaque. When the tumor was raised, however, the patient appeared to discern the light. The patient was much harassed by this morbid growth; it deranged his whole system, disturbed his nutrition, and had reduced him to a state of great emaciation. M. Baudens, the surgeon of the hospital, explained to his colleagues how he should dissect out the tumor from below upwards, leaving a sufficient portion of integuments to supply the loss which the conjunctiva would suffer, and avoiding in his operation the orbicularis palpe- brarum, the levator palpebras superioris, and the cartilage of the lid. His opinion was adopted, but the operation was more troublesome than he had calculated, chiefly from the unmanageableness of the patient. The nodules of the tumor were interspersed among the fibres of the orbicularis palpe- brarum; and the operator felt his difficulties augmented when he came to separate the diseased structure from the eyeball, which he was most desirous not to injure. He con- trived to manage it, by using his forefinger as a guard between the eye and the tumor; and syncope having come on, he availed himself of the moment to dissect the integument, which he wanted for the new eyelid. To this he attached the edge of the old eyelid, by a few stitches, thus preserving the cilia. Simple dressings were then applied. In twenty- four hours, the sutures were removed, the cicatrice being consolidated. In eight days, the patient was almost quite well. In the course of two months, the cornea recovered a great part of its transparency. The lid could be raised and depressed, and its dimensions nearly corresponded with those of the opposite side. As to the tumor, it was found strongly imbedded in a fibrous envelop, several lines in thickness. It weighed fifteen ounces, and resembled, in every respect, a mass of pale fibrin, such as is obtained from abstracted blood. A number of little serous cysts were seated in its centre.6 Other tumors, still, might be described ; for example, neuroma or painful subcutaneous tubercle, scirrhus, fungus haematodes, melanosis,7 &c. But I 188 TYLOSIS.—NJEVUS MATERNUS OF THE EYELIDS. think it unnecessary to enter on the particular consideration of these diseases as affecting the eyebrow or eyelids. 1 On Molluscum, consult Peterson, Edinburgh mio Surgery. Dublin Quarterly Journal of Medical and Surgical Journal, Vol. lvi. p. 279 ; Medicine ; vol. v. p. 475 ; 1848.] Turnbull, ib. p. 463; Cotton, ib. Vol. lxix. p. 6 [Traite des Maladies des Yeux, par L. A. 82 : Caillault, Archives Generates de Medecine, Desmarres. P. 144. Paris, 1847. H.] 4e Serie; tome xxvi. pp.46, 316. Paris, 1851. "Baudens, Clinique des Plaies d'Arraes » 3 Lancet, July 13, 1844, p. 4S9. Feu; p. 168; Paris, 1826. 3 Edinburgh Medical and Surgical Journal. ' Edinburgh Medical and Surgical Journal; Vol. lxxv. p. 108 : Edinburgh, 1851. Vol. xxxviii. p. 324 ; Edinburgh, 1832. * [Wilde's Report on the Progress of Ophthal- SECTION XXIII.—TYLOSIS, OR CALLOSITY OF THE EYELIDS. There are several varieties of thickening and induration of the eyelids, which merit attention. What I said in former editions of this work, of the scirrhoid, I have transferred to the head of epithelial cancer. (See p. 165.) There remain the scrofulous, and the arthritic varieties. 1. The former arises, as has been already (page 174) explained, from ne- glected ophthalmia tarsi. Iodide of potassium or Plummer's pill failing to remove it, a caustic issue in the nape of the neck is perhaps the best remedy for this, the scrofulous tylosis, added to the ordinary treatment of inflamma- tion of the edges of the eyelids. 2. Tylosis arthritica rarely occurs, except in those whose digestive organs are deranged by the habitual use of ardent spirits. It is attended with red- ness, attacks generally the upper eyelid, and seems to have its chief seat external to the cartilage. The whole length of the eyelid is commonly affected; but in some cases merely a part, and that not unfrequently the neigh- borhood of the papilla lachrymalis. Occasionally, the Meibomian glands are evidently enlarged; and sometimes the disease is combined with chalazion. I have never seen this variety of callosity end in suppuration or ulceration. It slowly increases, and then becomes stationary. The patient generally complains of thirst, acidity, and want of appetite. The application of leeches, friction with camphorated mercurial ointment, the use of laxatives, and the exhibition of alteratives internally, I have sometimes found successful, but often fruitless, in this complaint. SECTION XXIV.—N^VUS MATERNUS, AND ANEURISM BY ANASTOMOSIS,1 OF THE EYEBROW AND EYELIDS. Syn.—Mother's mark, Vulg. Loupe variqueuse, Petit. Tumeur erectile, Fr. Incorrectly called by some French authors, Fongus hematode. Der Blutschwamm, Ger. Telangi- ectasia, from t^oj end, ayyuov vessel, and Ijcrao-j? extension. Fig. Bell's Principles of Surgery, vol. i. p. 461; vol. iii. N03. 56, 57, pp.261, 222. Burns' Surgical Anatomy of the Head and Neck, PI. VIII. Fig. 1. Walton, Fig. 73. Although it strictly comprehends every sort of congenital mark, such, for example, as that called mole, the term ncevus maternus is generally used to signify only a particular kind of anastomotic or erectile tumor. It seems to be the common opinion, that anastomotic tumors, whether con- genital or acquired, consist, in a great measure, of dilated bloodvessels; and that, in some cases, these are chiefly venous, and in others chiefly arterial. Tumors of the latter sort are, in fact, aneurisms by anastomosis, and are cha- racterized by their rapid and dangerous course, continual and distinct pulsa- NSEVUS MATERNUS OF THE EYELIDS. 189 tion, and the great dilatation, tortuosity, and throbbing of the arteries which supply them; while the former, usually called ncevi, are without pulsation, and are generally slow in their progress. Both sorts give out arterial blood on being punctured. If they are situated on the head, both sorts become suddenly tense, as if ready to burst, when the patient stoops, or if he is ex- posed to much heat, indulges in violent exercise, or is under the influence of mental excitement. If the patient be a child, a nsevus assumes this state of distention when it cries. The terms venous and arterial, applied to these two varieties of tumor, may be incorrect; for we are, as yet, in a considerable measure, ignorant of the real structure of anastomotic growths, and cannot, therefore, pretend perfectly to explain their nature. The appellations passive and active seem less objectionable. When laid hold of, the passive have a pecu- liar dough-like feeling, yielding slowly to pressure, till they seem empty and flaccid, then filling up almost immediately to their former size; the active, on being touched, give the impression of a violent pulsatory movement, and can scarcely be emptied by the fingers, unless the large vessels whence they derive their blood be at the same time firmly compressed. On dissection, a nsevus is found to consist of lobes, and these internally to be formed of irregular cells, or loculi, communicating together. The walls of these cavities, as well as the exterior covering of the lobes, are fibrous. The relation of these cavities to the arteries has not been satisfactorily made out; but with the veins, the reticular texture of the lobes freely communi- cates ; and a general resemblance to the structure of erectile tissue is mani- fest. If the resemblance is real, the nsevus must be destitute of capillaries, and therefore the blood must pass through it with increased rapidity.3 The distinction of cutaneous, subcutaneous, and mixed nsevi, is of con- siderable importance. In the first, the disease appears to be seated entirely in the skin, which is sometimes of a scarlet color ; in the second, the integu- ments covering the tumor not being at all implicated in the disease, can be pinched up from off the diseased mass, and the nature of the case may be obscure ; in the third, both the skin and the subjacent areolar tissue are in- volved, and the surface presents a purple or livid color. Owing to the re- sisting texture of the skin, the progress of the cutaneous is slower than that of the other varieties. The limits of the subcutaneous and mixed are much less defined than those of the cutaneous. In the eyelids, there occur both venous or passive, and arterial or active nsevi, both cutaneous, subcutaneous, and mixed. In one case which I saw, the tumor was most prominent on the conjunctival surface of the lid ; and it sometimes happens that the disease does not affect the lids or brow merely, but stretches deep into the orbit. Not uncommonly, we meet with a small nsevus on the lids, and one or more larger ones, on the scalp, trunk, or ex- tremities. The branches, however, of the external and internal carotids, are much oftener concerned in anastomotic tumors than any other arteries. In some instances in which the disease occurs on the lids or their neigh- borhood, the place affected is from the first of a bright scarlet color, and whether flat or slightly prominent, whether smooth like a cherry, or granu- lated like a raspberry, is probably cutaneous merely. In other instances, the integuments, in the seat of the disease, appear at birth merely a little puffy, but, after a time, they become doughy, livid, and swollen, while through them, there shines a collection of dilated bloodvessels. In this case, the disease is subcutaneous. Prognosis.—Some nasvi, though vivid at birth, spontaneously disappear. Those of the venous sort especially, after having increased to a certain degree, sometimes cease to enlarge, or gradually wither and contract, till scarcely a vestige remains. Any means applied immediately before the commencement 190 CURE OF N.EVUS BY PRESSURE AND A KTR1 N(l ENTS. of such spontaneous atrophy, is apt to get the credit of having effected a cure. Any severe illness, reducing the general powers of nutrition, as measles, hooping-cough, or bronchitis in infants, promotes the natural cure. Some nsevi, having attained a certain size, remain stationary through the rest of life, although varying in intensity of color at different seasons, and according to different conditions of the circulation. Although abundantly supplied with blood, nan i often appear to be endowed with a low degree of vitality, so that some slight injury will cause them to ulcerate and slough; and being in this way partly destroyed, the remainder becomes consolidated, and the disease is thus prevented from increasing. Another set commence to spread, either immediately after birth, or from incidental causes, at some subsequent period; advancing slowly but steadily, they form complicated and dangerous connections with neighboring parts, not at first involved, and from small beginnings,, become vascular tumors of great extent, and not unfrequently formidable from partaking of the nature of the cases so well described by Mr. John Bell, under the name of aneurism by anastomosis, apt to burst, and to give rise to impetuous hemorrhages, which, if they do not prove suddenly fatal, materially injure the health.3 A nsevus on one or other eyelid may be, at birth, no bigger than a pin's head ; but in a month's time, may spread to the third of an inch in diameter. Some very slight cause of irri- tation, as a trifling bruise, will sometimes excite a mere stain-like speck, or minute livid tubercle, into an uncontrollable state of diseased action. The passive nsevus has been known to assume the character of the active, aud vice versa. Case 137.—In a case recorded by Pauli, a naevus occupied the upper eyelid close to the external angle of the eye, and at birth, was of the size of a lentil. The lid, a little red- der than the rest of the skin, hung over the eye ; but after some days, it assumed its proper situation. In nine months, the tumor was as big as a duck-egg. Towards the third year, it covered the eye almost completely, and went on extending itself under the skin in every direction. At nine years, it occupied completely one half of the face and head, and displaced the ear upwards. Two years after, it hung so much upon the face, that the little patient was obliged to have it supported in a bag. The cartilage of the nose was twisted to the other side, and the tumor was gaining upon the cavity of the mouth. When Pauli saw the case, the patient being 15 years of age, the tumor was elastic, soft, bossulated, and apparently fluctuating ; it could easily be compressed, and frequently, on placing the hand upon it, it communicated a pulsation, which diminished a little on com- pressing the corresponding arteries, but did not disappear completely. Every change of weather affected the tumor with pain; abrasion of it caused it to bleed.4 Treatment.—Yarious methods of treating nsevus or aneurism by anasto- mosis have been adopted. The principle of some of them is the obliteration of the abnormal structure by inflammation; that of others is the total destruc- tion or removal of the tumor. Our choice must be regulated by the situation of the growth, its size, and its degree of activity. Other things being equal, the methods which leave the skin entire, so that no ectropium is likely to ensue, claim a preference when the disease is seated in the eyelids. If a nasvus is small, superficial, and not increasing, we may be tempted to let it alone, or to cover its surface every second or third day with collodion, which, as it dries, causes a certain degree of contraction, or to pencil it daily with tincture of iodine, or a solution of lunar caustic. If it fades away under such applications, the probability is, that we are merely aiding in a spontane- ous cure, which would have occurred, even had nothing been done.5 If the tumor, on the other hand, is evidently increasing, there should be no delay in having recourse to some efficient mode of treatment. 1. Abstraction of heat, pressure, and astringents.—A moderately sized nsevus above the eyebrow, or in any other situation permitting it to be emp- tied by pressure against a subjacent bone, may, in general, be cured by con- CURE OF NSEVUS BY VACCINATION. 191 tinuing the pressure methodically. This is best effected by a pad, connected with a steel spring passing round the head. This plan I adopted success- fully, in a case of nsevus situated between the nose and the inner canthus. Boyer relates the case of a child, of two years of age, with this disease in the upper lip, the cure of which was effected by perseverance in the plan of pressure. The nsevus extended from the adherent edge of the lip, under the nostrils, and into the septum narium ; so that a complete extirpation being, in Boyer's opinion, impossible, he advised the mother to bathe the tumor with alum water, and with her forefinger placed transversely under the nose, to compress the part as often as she could. This advice was followed with a degree of constancy which maternal tenderness only could have accomplished. The mother sometimes passed seven hours continuously, in pressing the tumor with her finger ; and this assiduity was attended with such complete success, that ultimately no trace of the disease remained.8 Mr. Abernethy, after mentioning the particulars of an aneurism by anas- tomosis on the forearm, cured by permanent and equal pressure, and by keeping low the temperature of the limb, relates the following case:— Case 138.—A child had this unnatural state of the vessels in the orbit. They gradually increased in magnitude, and extended themselves into the upper eyelid, so as to keep it permanently closed. The clustered vessels also projected out of the orbit, at the upper part, and made the integuments protrude, forming a tumor as large as a walnut. The removal of this disease did not appear practicable, and pressure to any extent was evi- dently impossible; but the abstraction of heat, and consequent diminution of inflamma- tory action, might be attempted. Mr. Abernethy recommended that folded linen, wet with rose-water saturated with alum, should be bound on the projected part, and kept constantly damp. Under this treatment, the disorder as regularly receded as it had before increased. After about three months, the tumor had gradually sunk within the orbit, and the child could open its eye. Shortly afterwards all medical treatment was discontinued, and no appear- ance of the unnatural structure remained.7 In flat naavi, up to the size of a crown piece, Dieffenbach tells us that much may be done by a careful employment of astringents, such as pure liquor plumbi, or a solution of alum, even without pressure. Lint, steeped in the fluid, is fastened over the part with a bandage, and frequently wetted, without lifting it. After days, or weeks, the swelling becomes whiter, flatter, and firmer; soon after, little firm white spots form on the surface, and the cure is certain. By means of solution of alum and compression, Dieffenbach has cured nsevi so large, that extirpation would have been impossible. It may be necessary to keep the solution constantly applied for six months.5 From the nature of the situation, the plan of treating nsevus on the eyelids, by pressure and astringents rarely succeeds; and the delay occasioned by giving it a trial, may prove highly detrimental. When a cure does follow this sort of treatment, it is probably accomplished more by nature than by the artificial means employed. In one case, in which I used a saturated solu- tion of alum, the fluid, by getting into the eye, occasioned a pretty severe puro-mucous ophthalmia. The application was discontinued, and after some months a natural cure took place. Brandy is said to have been tried with good effect as an astringent application. 2. Vaccination.—Small, and sometimes even extensive, cutaneous ncevi have, in their early stage, been cured by the application of vaccine lymph. The principle upon which this method of cure depends, is the destruction, by suppuration, of the abnormal tissue. With a lancet already charged with the recent lymph, slight scratches are made upon the surface, and round the circumference of the nsevus, at regular distances from each other. As soon as the bleeding has ceased, additional lymph is to be introduced ; and then over the whole surface of the tumor, a bit of linen, saturated with the same 192 CURE OF N^VUS BY INJECTIONS. fluid, is to be applied, and retained for several hours. In the usual time, vesicles appear. Each produces a degree of inflammation, which induces an occlusion of the nseval cells and vessels only to a certain distance around it; and therefore it is necessary to inoculate the surface of the tumor at such close distances, that the whole lobes of which it consists may be involved in the inflammation. In favorable cases, the tumor gradually subsides, leaving scarcely any mark behind. Not unfrequently the cure is effected, however, only after a very tedious festering and ulceration. If the child has been vac- cinated in the common way, previously to the nsevus attracting much notice, this plan of cure will rarely succeed ; and even in children not previously vaccinated, it often fails to accomplish the object intended.9 3. Stimulants.—When vaccination has failed, or vaccine lymph cannot be procured, some other stimulating fluid may be tried, inserting it into the nsevus in the same way as we do the lymph. A strong solution of tartrate of antimony may be used for this purpose ; or a pustular eruption, affecting the nsevus to a sufficient depth, may be excited by rubbing it with tartrate of antimony ointment, or covering it with an antimonial plaster. It is likely that vaccine lymph produces no specific effect upon this sort of tumor, but operates merely by inflaming the part; and that any other stimulant of pro- portionate energy, and applied with equal care, would be followed by the same result, especially if the disease were merely cutaneous. Croton oil appears to have answered.10 4. Escharotics.—Both fluid and solid escharotics have been used, to de- stroy the organization of nsevi. Some employ lunar caustic. For a small cutaneous nsevus, painting the surface of it with a bit of wood, dipped in strong nitric acid, answers well. Dr. Ammon touches the tumor from time to time with a solution of the nitrate of mercury in nitric acid.11 Mr. Ward- rop has repeatedly employed pure potash, applying it to the nsevus so as to produce an eschar. In some instances, the eschar, on falling out, has been found to comprehend the whole diseased mass ; while, at other times, the separation of the eschar has been followed by ulceration, which destroyed the remainder of the tumor.12 These were cases, we may presume, of the sub- cutaneous or mixed kind. The potash is to be rubbed only on the centre of the tumor. Ulceration follows, and spreads, destroying the nsevus. A poul- tice is applied, the parts fall out, and cicatrization takes place. The potash may require to be applied, however, four or five times before the object is obtained. "I have seen cases," says Liston, "in which most profuse and alarming hemorrhage had followed boring into erectile tumors, with strong potential cauteries, and in which, after all the pain, danger, and delay, no benefit accrued from the practice."13 It is for cutaneous cases chiefly, that escha- rotics are adapted. When the eyelids are concerned, the contracted cica- trice, which is apt to be left after the destruction of the tumor is accomplished, renders this method of cure objectionable. 5. Injections.—Mr. Lloyd14 proposes to inject into the substance of the nsevus some stimulating, or even escharotic, fluid. He tried a mixture of the spirit of nitrous ether with nitric acid. By repeated injections, one portion of a large nsevus on the face and eyelids was destroyed ; but the child took measles before the cure was completed, and died. The injection did not enter very readily; therefore, much could not be accomplished at once. In another case, it passed freely into the substance of the nsevus, and five injec- tions accomplished a cure. The effect of the injection was the hardening of the part into which it entered; and as the hardness subsided, the disease disappeared. A solution of perchloride of iron has been recommended as a fit injection, CURE OF NSEVUS BY INCISION. 193 from its power of coagulating the blood in the vessels; and a particular sort of syringe has been invented for injecting it. The point of the syringe should be introduced through an aperture in the skin, at some little distance from the disease, as it is then easier to stop the bleeding by compression. Before injecting, the nsevus should be compressed, so as to empty it of its blood, and the pressure continued till the instant when the fluid is projected by the syringe. The fluid should be retained in the nsevus from five to ten minutes, by making pressure along the track which had been occupied by the tube of the syringe. Mr. Lloyd warns us to make pressure around the nsevus during the act of injection, lest the fluid be forced into the contiguous cellular tissue, where it might excite inflammation. For making the pressure, he recommends the cover of a pill-box, with a notch in it for .the passage of the point of the syringe. A much more serious accident, however, than the injection of the cellular tissue is apt to attend this method of treating naavus; namely, the passage of some of the fluid into the veins, and thence into the heart. There is strong reason to suspect that this was the cause of instant death in a child nearly two years old, in whom a nsevus, situated over the angle of the jaw, was injected with diluted aqua ammonise.15 6. Actual cautery.—Another mode of producing inflammation, and thereby obliterating the tumor, is by the actual cautery. The centre of the tumor is touched with the red-hot iron; or a number of long sewing needles, heated to a white heat, are pushed across the tumor in different directions, so as to cauterize every part of it.16 Platinum wires are put through the nsevus in different directions, and heated to a red heat, by being connected with the poles of a galvanic battery. Small sloughs form at the points where the wires penetrate the skin. The operation may require to be repeated.17 7. Subcutaneous incision of the vessels within the tumor.—The danger of hsemorrhagy from excision, the pain of the ligature, and the extensive scar left by vaccination, induced Dr. Marshall Hall to consider whether some less objectionable operation might not be devised for the cure of nsevus. Accord- ingly, he proposed to introduce a couching-needle with cutting edges, at one point of the circumference of the nsevus, close by the adjoining healthy skin, and from this point to pass the instrument through the tumor in 8 or 10 dif- ferent directions. The first puncture, the only one through the skin, is to be made in the centre of the several rays of incisions, which are effected by merely withdrawing, and again pushing forward the instrument. This ope- ration was tried, under Dr. Hall's direction, in a case of oval nsevus, rather larger than a shilling, the situation of which, however, he does not mention. After the incisions were made in the manner described, a little pressure was applied on the tumor, by means of strips of adhesive plaster. There was no pain, nor hsemorrhagy. Dr. Hall expected that inflammation would take place, and that a cicatrice would be formed, which, from its solid texture and progressive contraction, would obliterate the tumor. For several weeks there was little or no change. Indeed, it was almost concluded that the plan had failed. What a short time, however, did not effect, a longer period accomplished completely. Half a year after the operation, the tumor was found to have disappeared, and the color of the skin to be nearly natural. Dr. Hall observes, that this operation may be repeated at longer or shorter intervals, and with more or fewer punctures, according to the degree of inflammatory action necessary for the obliteration of the nsevus. He adds that pressure forms no necessary part of the treatment; and that the cure in the case detailed was gradually effected, long after pressure had ceased to be employed.18 13 194 CURE OF N.EVUS BY THE LIGATURE. 8. Subcutaneous incision combined with cauterization.—With a knife about \ inch broad, Sir B. C. Brodie cuts up the interior of the nsevus, in the mode recommended by Dr. Hall, and then introduces a silver probe, coated with nitrate of silver, into the cuts. This causes sloughing of the interior of the nsevus, but does not destroy the skin. If the tumor is large, the operation will require to be done more than once.19 This is one of the methods of cure best adapted for nsevus of the eyelids. 9. Seton.—The cure of nsevus by the passage of a seton through the tumor, as proposed by Mr. Fawdington of Manchester, is tedious. The saving of deformity is its great recommendation, little more remaining than the scars produced by the needle. In employing the seton, it is necessary to secure two material objects: namely, the suppression of hsemorrhagy from the vessels divided by the needle in the first instance, and subsequently a degree of irritation sufficient to excite inflammation and suppuration throughout the diseased mass. The first of these objects is accomplished by using a skein of spongy cotton- thread, large enough fully to occupy the aperture made by the needle; and the second, by a needle that will admit, relatively to the dimensions of the tumor, a seton of considerable proportions. The seton is commonly directed to be passed through the tumor; but Mr. Lizars directs the tumor to be raised with the fingers, so that the needle may pass completely under and free of it. In this way, the seton is more likely to cause obliteration of the vessels leading to the tumor; for, when passed through the diseased mass, the vessels leading to it rapidly reproduce that which has been destroyed.20 In treating nsevus in the eyelids or their neighborhood, with the seton, several threads ought to be passed through or beneath the tumor, parallel one to another, and their ends tied together, so as to prevent them from slip- ping out. If the irritation which follows, seems insufficient, thicker threads should be passed, and additional ones may be introduced in a transverse direction to the first. When the suppuration becomes abundant, the threads should be reduced in thickness, to allow the pus freer exit. The threads must be persevered in till the tumor shrinks, and seems to be becoming consoli- dated. The object in view may be promoted by occasionally passing a probe, coated with nitrate of silver, through the channels formed by the threads.21 10. Ligature.—The ligature is employed in the treatment of nsevus, either, 1. To excite inflammation, and consolidate the parts only; or, 2. To destroy them and make them slough. It is used, also, either to grasp and cut through the skin as well as the tumor ; or to strangulate and destroy the tumor, but leave the integuments nearly entire. It might be supposed, perhaps, that only the latter mode of using the ligature would be answerable when the lids are the seat of the disease, owing to the contraction which must result when the skin covering the nsevus is destroyed. I have found, however, that nsevi on the lids, especially on the upper lid, unless very extensive, may be treated with the ligature in the common way, without much risk of producing ectropium. One mode of using the ligature is the following: The tumor being laid hold of with the finger and thumb, so as to raise it as much as possible from the proper substance of the lid, two or more slender pins are passed under it, so as to intersect each other; the ligature is then placed around the base of the tumor, under the pins, and being drawn tight, is tied. Another method is to pass a common curved needle, or a curved needle fixed in a handle, and having an eye near its point, which is called a nsevus needle, armed with a strong waxed linen thread, through the base of the tumor, so as to divide into two portions. The thread being cut, and the needle removed, each portion of the tumor is to be grasped by its own liga- CURE OF N.EVUS BY THE LIGATURE. 195 ture. If the tumor is very large, it may be divided into four portions, by passing the needle, armed as before, a second time, but at right angles to its first direction. The ligatures are to be drawn tight, and secured by a double knot. In the following method, the common needle may be used, and there is no liability to mistake the threads to be tied : Blacken half the length of a long white thread with ink, and thread a wide-eyed needle with it. Trans- fix the tumor in the common way, and cut the bow so as to keep the black thread in the needle. Then thread the needle also with the white end, which has not passed through the tumor, and transfix the tumor at right angles to the former direction. Draw the white ends tight and tie them; then, the black. Each thread includes a figure of 8 portion of the tumor, as is shown in Fig. 13. The dotted lines show the course of the threads under the tumor. Fig. 13. If any part of the tumor slips from the grasp of the ligature intended to embrace it, a needle must be thrust under that part, and held there till the knot is tied, or left till the tumor separates. After the ligatures are drawn tight, but before they are tied, it may be advisable to divide the skin round the base of the tumor, so as to allow the ligatures to sink into contact with the tumor. After the ligatures are tied, the tumor may be punc- tured so as to diminish its bulk. Care must be taken, in whatever way the ligature is applied, that no part of the tumor is excluded from its embrace, as any small portion that is left may give rise to a reproduction of the disease. In the course of 48 hours, the tumor will have entirely lost its vitality, so that it may be sliced off, and the ligatures removed ; or it may be left till it turns black, shrivels, and falls off, which, in nsevi of the eyelids, generally happens in five or six days. A poultice is then to be applied, and continued till the exposed surface granulates and heals. Occasionally, it requires to be touched with lunar caustic. Some very extensive and irregular nsevi, stretching over the neighboring parts as well as the eyelids, may require more than two ligatures. For such cases, Mr. Luke's method of applying the ligature will sometimes be found answerable. He threads several straight or curved needles, at distances from each other of about 12 inches, with one long thread, the number of needles corresponding to the size of the tumor. The needles are passed in a row, under the nasvus, as is represented in the diagram, Fig. 14 ; they are then FiS-14. removed by cutting the ligature near to the eye of each ; and the succession of loops is tightened by tying a with a, b with b, c with c, and so on, till the whole tumor is strangulated.22 The same thing may be done, as Mr. Curling has shown, with the nsevus needle.23 Besides the perfect strangu- lation which this plan affords, it lessens the puckering and drawing in of the surrounding integuments which must always, in some degree, follow the use of the ligature, but which it is material to avoid when the eyelids are the seat of the disease. 196 CURE OF N.EVUS BY THE LIGATURE. Fig. 15. If the nsevus is entirely subcutaneous, the skin, as Mr. Liston24 advises, may be divided and turned aside, so as to expose the tumor, to which the ligatures are then to be applied. I may here notice M. Lallemand's mode of treating nsevus. Sometimes he inserts a number of pins into the tumor, without transfixing it, and twists a waxed thread around the pins. In other cases, he transfixes the tumor with a great number of pins, in every direction, and then applies the ligature, so as to strangulate the tumor. In whichever way they are applied, he re- moves the pins and ligature in seven or eight days, or when they are thought likely to have excited sufficient inflammation to consolidate the morbid struc- ture. In this way, there is no loss of integuments. Occasionally, he makes an incision through the whole substance of the nasvus, and immediately unites the two lips of the wound by needles and the twisted suture. The in- flammation and the cicatrice which follow, obliterate the tumor.25 When we are anxious to save the skin, the ligature may be applied sub- cutaneously. This is done in one or other of two ways. In the one method, the ligature is passed, by means of the common curved needle, or the nsevus needle, round as much of the basis of the tumor as can be conveniently accomplished by a sweep of the instrument, as from a to b in the diagram, Fig. 15, and brought out through the skin at b. Again armed with the same ligature, the needle is reintroduced at b, and carried round either the whole remainder of the tumor, or round a portion of it only, according to its size. Suppose it is carried round to c, and there brought out, the needle, again armed with the ligature, is reintroduced at c, and carried round to a, where the two ends of the ligature will emerge, after it has encircled the whole basis of the tumor. The dotted line in the diagram shows the course of the subcutaneous ligature, which is now to be drawn tight, and secured by a double knot. In the other method, the needle, armed with a ligature, is passed trans- versely under the tumor, from the one side of its base to the other, as from A to b, in the diagram, Fig. 16. The loop is then cut, and the needle re- lieved. Armed as usual [with the ends of the divided loop alternately], the needle is now swept round, first, the one-half of the basis of the tumor, as in the course of the dotted line b c a; and then round the other half, as in the course of the dotted line bda. Each half being now surrounded by its own ligature, first the one, and then the other ligature is to be drawn tight, and tied at a. The subcutaneous ligature, applied in either of these two methods, if it is to be left till it comes away of itself, requires to be tightened from day to day. The orifice by which it emerges, Fig. 16. CURE OF ANASTOMOTIC ANEURISM BY EXCISION. 197/ allows a discharge of matter for some time, and a slough is occasionally with- drawn from the cavity formerly occupied by the morbid growth. Mr. Startin connects the ligature to a band of vulcanized caoutchouc ; and through its means exercises an elastic tension, which gradually brings the ligature away.26 Some practitioners allow the ligature, whether it is applied over or under the skin, to strangulate the tumor only for a day or two ; they then withdraw it. This temporary application suffices, perhaps, to produce a certain de- gree of inflammation, but no slough. This plan is apt to fail, the disease again increasing after the irritation has subsided. To insure a cure, astrin- gents and pressure should be employed, after the ligature is removed. The subcutaneous ligature has been found to cure, not only the subcuta- neous variety of the disease, but also the mixed. Sometimes it fails, from not sufficiently interrupting the flow of blood into the tumor, through the vessels of the skin.27 11. Tying the vessels of supply.—In cases of aneurism by anastomosis, large arteries are felt throbbing strongly round the tumor. These vessels of supply have often been tied, in the hope of causing the tumor to shrink; but the practice is not to be recommended, as it has generally proved totally ineffectual. As soon as one vessel is obliterated, another anastomosing branch becomes enlarged, and an equally copious supply of blood is sent to the tumor. Cases 139 and 142 will illustrate the inefficacy of this plan of treatment. 12. Excision.—Nsevi and anastomotic aneurisms have been removed by excision. This is an effectual, but by no means a very safe mode of cure.25 When the morbid growth itself is cut, a powerful gush of arterial blood takes place, which can hardly be restrained ; and although the knife keeps clear of the tumor, there is, in general, very serious hsemorrhagy, so that in removing even small nasvi in this way, alarm has justly been excited for the life of the patient, and the recovery of strength and color has been very tedious. Yet, according to Dieffenbach,29 extirpation of nsevi, and union of the edges of the wound by pins and the twisted suture, is the best method of all, when astringents fail. He extirpates the tumor totally or partially, ac- cording to its size. If partial extirpation is employed, an oval slip of the tumor is excised from the middle; and when the wound so produced has healed, another piece is excised ; and so on, till the whole has been removed. Piecemeal extirpation, in this way, may, perhaps, answer in cases of passive nsevi; but would be quite inapplicable in such an active tumor as was present in the following case :— Case 139.—A gentleman of about 25 years of age, had an aneurism by anastomosis upon his forehead. It began with a small spot like a pimple, of the size of a pea; and was, when he consulted Mr. John Bell, of the size of an egg. It was seated close upon the eyebrow, and at its commencement was so small, and so little troublesome, that it was believed to be a pimple, brought on by a tight hat. When it had attained the size of a sparrow's egg, the patient thought he felt occasional pulsation in it. He consulted a surgeon, who found the pulsation distinct, pronounced it to be an aneurism, and advised that it should be cut out. The patient delayed, and was recommended by some one to try pressure. This producing pain but no good effect, he let the aneurism grow for five years. An operation was now decided on. The tumor appeared to derive its blood from two arteries; one, a branch of the temporal, enlarged and tortuous, which passed into the upper end of the tumor, while the other, coming from within the orbit, entered the lower end. The two arteries and the intermediate tumor beat in concert, and very strongly. Under the apprehension that the disease was merely an enlarged artery, the surgeon first passed a ligature round the arterial branch coming from the orbit, and tied it; but this did not abate the pulsation of the aneurism. He next tied the temporal branch, but the pulsation remained unaffected. The tumor was then laid open in its whole length. It bled very profusely. A needle, armed with a ligature, was stuck into its centre, where 198 CURE OF N./EVUS BY EXCISION. there was one artery larger than the others; but from all the rest of the surface there was one continual gush of blood. The hoemorrhagy was repressed, and the wound bound up with a compress and bandage. It healed slowly, the ligature came away with diffi- culty, the pulsation began again, and by the time the wound was healed, the tumor was as large as before the operation. For nine months the patient allowed the disease to go on unmolested, and then con- sulted Mr. Dell. The tumor was of a regular oval form, and across the middle of it ran the scar of the operation. The spot was not purple on its surface, but was covered by a firm sound skin. The two arteries were felt pulsating with great force ; and when' the patient was heated, stooped, or breathed hard, the pulsations became very strong. By this time it was also affected with pain. Mr. Bell knew, that if he cut within the active circle of the tumor, he should have innumerable bloodvessels to contend with. He there- fore resolved to cut out this aneurism, not to cut into it. He made an oval incision, which comprehended about a fourth part of the surface of the tumor, dissected the skin of each side down from it rapidly, went down to the root of the tumor, and turned it out from the bone. It bled furiously during the operation, but the moment it was turned out, the bleeding ceased. The two arteries were tied, the eyebrow was brought nicely together, and the incision healed in 10 days. The tumor appeared a perfect cellular mass, like a piece of sponge soaked in blood.30 This, then, is an example of the subcutaneous arterial aneurism by anasto- mosis, and of the mode of cure by excision. The following case, related by Mr. Allan Burns, furnishes an instance of the venous variety of nsevus, affect- ing both the skin and the subcutaneous tissues :— Case 140.—A middle-aged stout man presented a large, livid, compressible tumor, in the vicinity of the right orbit. The swelling had existed from birth, was sometimes more distended than at others; but was seldom productive of pain, except when injured, on which occasion it poured out a considerable quantity of fluid blood. It never pulsated ; but during exertion, or walking in a very hot or very cold day, it became exceedingly tense. Externally it covered about one-third of the temporal extremity of the upper eye- lid, and occupied the whole extent of the lower one, the folds of which were separated to such an extent, as to produce an unseemly irregular, and pendulous swelling, which hung down over the cheek. Towards the outer canthus of the eye, the morbid texture was interposed between the conjunctiva and sclerotica, to within the eighth of an inch from the cornea. It was chiefly in this direction that the disease was spreading. From the external angle of the eye the tumor was prolonged both outwards, and downwards. In the first direction, it extended to the point of junction of the temporal and malar bones; in the latter, it descended nearly half an inch below the line of the parotid duct. Through its whole extent, the tumor was free from pulsation; no large artery could be traced into it; by pressure it was readily emptied of its contents ; but, on the removal of the pres- sure, it was again slowly filled. When emptied, by rubbing the collapsed sac between the fingers, a doughy impression was communicated to them. On the surface it was of a dark purple color, with a tint of blue on those parts covered by the skin; but where in- vested by the conjunctiva, it had a shade of red. It was cold and flabby, communicating to the fingers the same sensation which is received on grasping the wattles of a turkey- cock. As the tumor was increasing and threatened to extend over the eye, the patient was anxious for its removal. Mr. Burns began the operation by detaching the lower eyelid along its whole extent; he then dissected away that part of the tumor adhering to the sclerotica, and next removed that which adhered to the upper eyelid. This being done, he Ued a pretty large artery which passed into the tumor from the outer and lower part of the orbit, by the temporal side of the inferior oblique muscle. The next stage of the operation consisted in dissecting off the tumor from the aponeurosis of the temporal muscle, the zygomatic process, the malar bone, and from over the branches of the portio dura, and the parotid duct. After the great body of the tumor was in this way removed, Mr. Burns found that a part of the spongy morbid mass still remained attached to the parts behind the parotid duct and portio dura. He also discovered that some of the tumor dipt beneath the fascia of the temporal muscle, which was reticulated. From these parts there was a general oozing of blood; and from the divided transverse facial artery, as well as from the arteries which perforated the malar bone and the masseter muscle, there was a pretty profuse bleeding. The vessels were secured, and then, with the for- ceps and scissors, Mr. Burns cleared away the diseased matter from behind the parotid duct and portio dura, both of which were thus detached from all connection with the neighboring parts. In the same way, he was obliged to cut away a quantity of diseased substance from behind the zygoma. As the morbid parts were here ill defined, and much intermixed with the fibres of the temporal muscle, a considerable part of it required to be CURE OF NSEVUS BY TYING THE CAROTID. 199 taken away, and in doing this, the deep-seated anterior temporal artery was divided. What of the tumor remained on the cheek, adhered so firmly to the zygomatic muscle, and was so closely incorporated with its substance, that the one could not be separated from the other. The insulated part of the portio dura and the parotid duct were now laid back on the masseter muscle, and the edges of the integuments brought into contact over them, and supported by means of a single suture. Over the malar bone the lips of the wound could not be made to approach, nor did the oozing from the bone cease. A fold of linen and a layer of sponge were therefore laid into this part of the wound, and retained there by a compress and. bandage, applied so tightly as to restrain the bleeding. The sponge was removed two days afterwards, and an attempt made to bring the lips of the wound nearer to each other. The sore began to granulate, and threw out a flabby red fungus, the growth of which could not be checked by the application of sulphate of copper. By bringing the edges of the sore together, it was at length reduced to the size of a shilling, and was soon afterwards completely cicatrized. Three years after the operation, the patient continued free from any return of the dis- ease, and the cicatrice was becoming smaller. The only inconvenience which he expe- rienced, arose from the motion of the upper lid being impaired, by its adhesion to that part of the sclerotica from which the tumor had been dissected. From the same cause, the eye did not possess the same latitude of motion as formerly. It required a consider- able effort to turn the pupil towards the nose.31 It will be evident upon the slightest consideration, how very different in activity, if not in nature, this case of Mr. Burns is from that of Mr. Bell; and how much less the danger attending the extirpation of such a passive or venous aneurism by anastomosis, compared to that which is inseparable from every attempt to touch with the knife, the active or arterial tumor of the same sort. 13. Obliteration of ihe carotid artery.—The bold and successful practice of Mr. Travers, who, for an aneurism by anastomosis within the orbit, tied the common carotid artery, has been followed by Mr. Wardrop in several cases of this disease situated externally. In these cases, Mr. Wardrop went upon the probability, that if the current through a nsevus were arrested by tying the arterial trunk supplying it, the blood contained in the cells or parenchyma of the tumor, would undergo a process of coagulation, as the blood does in a common aneurismal sac after the artery has been tied, that the coagulated blood would be afterwards absorbed, and the tumor gradually shrink. Mr. Wardrop has published the particulars of three cases of nsevus of the face, in which he tied the common carotid. All the three patients were young chil- dren. Two of them died, the circumstances preceding the operation being very unfavorable. Case 141.—A female child, five months old, had a large subcutaneous nsevus on the left side of the face, covering one-half of the root of the nose, the eyebrow, and the upper eyelid. The eyelid could not be sufficiently raised to expose the eyeball, nor could the precise limits of the disease be traced in the orbit, within which it seemed to penetrate deeply. The tumor was of a pale blue color, and there were numerous tortuous veins in the integuments covering it. It had no pulsation, felt doughy and inelastic, and when squeezed became greatly diminished; on removal of the pressure, its original size was rapidly restored. As it would have been extremely dangerous, and probably even impracticable, to remove the tumor with the knife, and as it had been rapidly increasing since a few days after the birth of the child, Mr. Wardrop concluded that the only chance of arresting the progress of the disease, was by tying the common carotid of that side on which the tumor was situated. The incision of the integuments was made about the middle of the neck, along the tracheal edge of the mastoid muscle, and the rest of the dissection was accom- plished chiefly with a sharp-pointed double-edged silver knife. The operation was more difficult than might have been expected in a simple dissection amongst healthy parts, from the unceasing cry of the infant, which kept the larynx and trachea in constant motion upwards and downwards. This not only prevented the pulsation of the carotid from being,distinguished, but when the sheath of the vessel was distinctly penetrated by the point of the knife, rendered it difficult to get the point of *Bremner's aneurismal needle conducted by the finger, fairly within the sheath. When, however, the latter step of the operation was accomplished, the needle passed around the artery with great facility. Some divided vessels bled a good deal during the operation, so that the wound was kept 200 CURE OF ANASTOMOTIC ANEURISM BY TYIN(i THE CAROTID. filled with blood, and the dissection was necessarily conducted with the finger as the only guide. The ligature being tied, the edges of the wound were brought together by a single stitch, and no adhesive plaster or bandage employed. The infant appeared pale and much exhausted after the operation, and had a teaspoon- ful of the syrup of white poppies. A remarkable change was immediately observed in the tumor. No sooner had the carotid been tied, than the child was observed to raise the upper eyelid sufficiently to expose the eyeball, which, until that period, had never been in view, on account of the swollen state of the lid. The color of the tumor also changed, losing its scarlet hue, and appearing of a much darker blue shade ; a change, observes Mr. Wardrop, which evidently had arisen from the collapse of the arteries, whilst the veins and cells of the tumor remained filled with venous blood. Soon after the operation, the child became tranquil, and in a few hours was permitted to suck, care having been taken to keep the mother's mind easy by her absence during the operation, and by con- cealing from her the extent of the wound. The child passed a very quiet night, the operation seeming to produce very slight excitement in the general system. She con- tinued to suck as if nothing had happened, and the wound inflamed so little as to require no dressing. The ligature came away upon the eleventh day. On the day following the operation, the tumor continued of the same diminished bulk, and of the same dark purple color, which it had assumed immediately after the artery was tied. On feeling the tumor, it seemed either as if the blood which it contained had coagulated, or that it was emptied of its blood; for pressure, instead of emptying its contents, now produced no sensible alteration. A gradual, though not always regularly progressive diminution followed; by degrees, more and more of the eyeball became exposed; and ten months after the opera- tion, nothing of the tumor remained, more than the membranous bag originally distended with blood.32 Case 142.—A fat comely girl, 18 years old, was admitted as a patient into the Massa- chusetts General Hospital, 4th May, 1829. Little more than a year before that time, she began to experience a strange feeling in the inner angle of the right eye, at the anasto- mosis of the facial, ophthalmic, and frontal arteries. This sensation she described as a crowding feeling in the eye. It soon extended to the head, and was accompanied with a pain so severe, that though otherwise in perfect health, she was obliged to give up her work as a house-servant, and had remained idle for some months before entering the hospital. At this time, there was a tumor at the inner angle of the eye, just above the lachrymal sac, as large as a hazel-nut. It had an active pulsation, which extended into the neigh- boring arteries. The pulsations of the facial were very strong ; and by compressing that artery, the vibrations of the tumor were much lessened. Compression of the temporal artery produced bo change. The skin over the tumor was slightly reddened, and there was an increase of heat. The carotid artery had an augmented pulsation. Pressure on this artery suspended the pulse of the tumor. The stethoscope, applied over the carotid and facial arteries, gave the saw-mill sound. After observing the case for a few days, Dr. Warren performed the following operation: He made a small incision, between the tumor and the cavity of the orbit. The pulsation of the anastomosing branch of the ophthalmic was discovered, and a ligature passed round this branch. Next, an incision was made across the facial artery, below the tumor; and after allowing about 18 ounces of blood to flow, a compress was applied, including the artery and the tumor. On the division of the facial, the pulsation ceased, and the patient was relieved from her distressing feelings. On removing the compress, three days after, a slight pulsation was perceived. The wounds healed immediately; and the patient finding herself very comfortable, was discharged on the first June, although the pulsation had not wholly ceased. Dr. Warren was disposed to believe, that the cutting off the supply from the ophthal- mic and facial arteries would be followed by the disappearance of the tumor. His expectations were disappointed. In the latter part of October, the patient returned to the hospital. A very slight pulsation was discernible in the tumor, and the inner angle of the left eye had a pulsation somewhat stronger than that on the right side. The arte- ries leading into it, had strong pulsations. The carotid on each side, especially on the right, throbbed violently; so that she sometimes said she felt as if the top of her head were flying off. The upper part of the face and the forehead were red and swollen; and, on the whole, there was a great aggravation of the disease. Dr. Wrarren was at a loss how to proceed, as the disease now appeared equally on the left and on the right side, and extended apparently to the whole arterial system of each. He began by trying the effect of general remedies. The patient was ordered to be kept perfectly quiet; to live as low as possible ; to have blood taken from the arm, and leeches applied frequently to the head; and to take the tincture of digitalis. These measures were followed by no favorable effect.' Dr. W. therefore laid bare and penetrated the METHODS OF TREATING NSEVUS. 201 temporal artery of the right side, allowed it to bleed freely, and then divided it; but the pulsations remained unmitigated. There seemed but one*course left, that of tying both carotids, or rather, of tying one, and, if this did not answer, the other. _ On the 2d January, 1830, Dr. W. tied the right carotid. The pulsations on the right side were immediately relieved. Those on the left continued for a time, then slowly sub- sided, and on the 3d March, the patient was discharged perfectly well. Dr. W. thinks that the complete success, from tying the right carotid, showed that the affection of the left side was altogether sympathetic.33 _ As the interruption of the current through the facial and ophthalmic arte- ries was not successful in checking the disease in the case just quoted, while it was ultimately cured by tying the carotid, it might perhaps seem advisable in similar cases to begin by securing the carotid, and not the immediate arte- ries of the tumor. Dr. Warren states, however, that, this is not the inference he should draw. He would not recommend the ligature of the carotid in such a case, in the first instance ; because he should expect that vessels so small as those passing into the tumor, and communicating so freely with those of the other side, would be immediately supplied with blood from anas- tomosing arteries, to a sufficient degree to keep up the circulation, and maintain the morbid action in the tumor. He feels satisfied that tying the carotid at first, would not have accomplished the cure in the above instance. The facial, temporal, and ophthalmic arteries had been previously divided, and the disease had felt the impression of this measure ; the suspension of the current from the carotid, coming in aid of the means already employed, was sufficient to effect a cure. In support of these views, Dr. W. refers to the case of a woman, who having fallen down stairs, and struck the inner angle of the right eye, a pulsating tumor arose there, which affected the vision of the eye. It extended into the orbit, so that he could not reach the ophthal- mic branch within the tumor. He therefore tied the carotid, but without any alleviation of the disease. He would then have attempted the angular arteries ; but the patient refused, and left the hospital. These views of Dr. Warren are confirmed by a case of nsevus situated on the vertex, in which both carotids were tied by Dr. Mussey, with little permanent advantage, the disease afterwards requiring to be extirpated. This was done six weeks after tying the second artery, at the expense of a considerable share of hse- morrhagy ; from the consequence of which, however, the patient eventually recovered.34 Mr. Morgan tied the carotid in a case of nsevus occupying the entire side of the face, and which had previously been treated by ligature and the actual cautery. The patient recovered from the operation, but the expected benefit did not ensue.35 With regard to the various methods of treating nsevus, it has been well observed by Mr. Philips, that each has succeeded, and all have failed. It may also be observed, that it is often the case that a cure, partially effected by one method, requires to be completed by another. One method having proved a total failure, a cure is sometimes readily effected by a different method. The danger of exciting erysipelas and phlebitis by some of the methods, must not be overlooked, fatal results having followed from these accidents. Hemorrhage also must be guarded against, as exceedingly likely to follow some of the plans of cure above described. The disease here under consideration a.f- burgh, 1829. There is also a varix racemosus fects the small vessels, but there is an analo- for cases of which see Warren's Surgical Ob- gous state of the arterial trunks, sometimes servations on Tumors, p. 427 ; Boston, 1837. called aueurisma racemosum. See Maclachlan, a On the structure of naevus, consult Miil- Glasgow Medical Journal; Vol. i. p. 81; ler on the Nature of Cancer, translated by Glasgow, 1828; Syme, Edinburgh Medical and West; PI. V. and VI. figs. 16, 17; London, Surgical Journal; Vol. xxxi. p. 66; Edin- 1840: Paget, Lectures on Tumors; London 202 OEDEMA OF THE EYELIDS. Medical Gazette; Vol. xlviii. Lect. 8 : Birkett, Medico-Chirurgical Transactions ; Vol. xxx. p. 193; London, 1S47: Coote, Medical Gazette; Vol. xiv. p. 412 ; London, 1850. * Bell's Principles of Surgery ; Vol. i. p. 456 ; Edinburgh, 1801: Batemaa's Synopsis of Cu- taneous Diseases, p. 239 ; London, 1819 : Faw- dington, North of England Medical and Surgi- cal Journal; Vol. i. p. 56; Manchester, 1830 ; Philips, Medical Gazette; Vol. xii. p. 7; Lon- don, 1833. 4 Annales d'Oculistique ; ler. Vol. Supplem. p. 26; Bruxelles. 1812. 5 See Brainard's cases, cured by collodion, Monthly Journal of Medical Sicence; Vol. x. p. 72 ; Edinburgh, 1850. s Trait6 des Maladies Chirurgicales; Tome ii. p. 269; Paris, 1814. 1 Surgical Observations on Injuries of the Head, and on Miscellaneous Subjects, p. 228; London,1810. 8 Dieffenbach, Operative Chirurgie; Vol. i. p. 236 ; Leipzig, 1845. 9 Medico-Chirurgical Review; Vol. vii. p. 280 ; London, 1827 : Lancet; Vol. xii. p. 750; London, 182" : Glasgow Medical Journal; Vol. i. p. 93; Glasgow, 1S2S. See Case of large subcutaneous Na)vus, cured by Vaccination, by Woolcott, Lancet, Mnrch 13, 1852, p. 261. 10 Medical Gazette; Vol. xxxv. p. 786; Lon- don, 1845. 1' Zeitschrift fur die Ophthalmologic; Vol. i. p. 485 ; Dresden, 1831. 12 Lancet; Vol. xi. p. 652 ; London, 1827. 13 Liston's Practical Surgery, p. 333; Lon- don, 1846. 14 London Medical Gazette; Vol. xix. p. 13; London, 1836. 1S Ibid. Vol. xxi. p. 529; London, 1837. 16 Warren, Op. cit. p. 418: Lallemand, Archives Generates de Medecine, 4*. S6rie, Tome i. p. 416 ; Paris, 1843. 11 See Case by Bernard, Medical Times nnd Gazette, March 27, 1852, p. 3IS. 18 Medical Gazette; Vol. vii. p. 677; Lon- don, 1831: Lancet, Nov. 1837, p. 353. 19 Medical Gazette; Vol. xxvii. p. 005; London, 1841. 20 System of Practical Surgery; Part i. p. 118; Edinburgh, 1838. 21 Fawdington, Op. cit. p. 66; Macilwnin, Medico-Chirurgical Transactions; Vol. xviii. p. 189; London, 1833: Bellingham, Dublin Medical Press, August 16, 1848, p. 97. 22 Medical Gazette; Vol. xii. p. 581; Lon- don, 1848. 23 Ib. Vol. xiv. p. 138; London, 1850. 24 Op. cit. p. 335. 25 Archives Generates de Medecine; 2e Se- rie, Tome viii. p. 5; Paris, 1835; 4e SGne; Tome i. p. 459 ; Paris, 1843. 26 Medical Times and Gazette; July3,1852, p. 22, and December 11, 1852, p. 594. 21 On the subcutaneous ligature, the sug- gestion of which is ascribed to M. Iliconl, see Curling, Op. cit.: Birkett, Guy's Hospital Re- ports, Second Series; Vol. vii. p.294; London, 1851: Broadhurst, Medical Times and Gazette, May 8, 1852, p. 474. 28 Petit, Traite des Maladies Chirurgicales; Tome i. p. 266 ; Paris, 1790. 29 Op. cit.; Vol. i. p. 241. 30 Bell, Op. cit; Vol. i. p. 461. 31 Observations on the Surgical Anatomy of the Head and Neck, p. 331; Glasgow, 1824. 32 Lancet; A'ol. xii. p. 267; London, 1827. Mr. Wardrop's unsuccessful cases are contained in the Medico-Chirurgical Transactions, Vol. ix.; and in the volume of the Lancet now quoted. 33 Op. cit. p. 400. 34 Medical Gazette; Vol. vi. p.76; London, 1830. 35 France's Edition of Morgan's Lectures on the Diseases of the Eye, p. xiv.; London, 1848. SECTION XXV.--C3DEMA OF THE EYELIDS. The looseness of the cellular membrane of the eyelids, and the absence of adipose tissue, permit them readily, and to a great extent, to become cede- matous. This affection may depend either on local or on general causes. There is generally some oedema attending the acute stages of the ophthal- mise. We see the lids become cedematous from wounds and bruises ; from erysipelas ; from diseases of the orbit, as necrosis; or diseases within that cavity, as^ orbital tumors; from diseases of the nasal sinuses, as polypus; from the irritation of abscesses of the face or scalp ; from the application of pressure to the lower parts of the face, as after the operation for harelip ; and even from the pressure of crutches. When disease of the orbit, or within it, or disease of the nostril, is the cause, the oedema often affects the opposite lids, as well as those of the same side ; and the like is observed when abscesses about the head are the cause. After scarlatinous ophthalmia, and after the too frequent use of emollient fomentations and poultices, during inflammatory affections of the eyes, particularly where the poultices are allowed to become cold, and to lie long without being changed or removed, we not unfrequently find the lids puffy and cedematous. In other cases, oedema of the lids is part of a general dropsy, as in the EMPHYSEMA OF THE EYELIDS. 203 anasarca consequent to scarlet fever; or it exists without any other part of the body being dropsical, in adults of leucophlegmatic constitution, or in scrofulous children. In some cases it appears to be a sympathetic affection, connected with disease in some remote organ. Dr. Parry observed it in several instances, in connection with violent pain of head, depending proba- bly on costiveness.1 Albuminuria may be suspected, and the urine should be examined, when the lids long remain puffy. It rarely happens that this affection occurs spontaneously, or without some evident cause, in an indi- vidual otherwise perfectly healthy. The eyelids affected with oedema are swollen, smooth, sometimes pale, sometimes red, semi-transparent, and soft; yielding easily to the pressure of the finger, and in some cases retaining the mark of pressure for a time. Their motions are impeded, and the eyes cannot be completely opened. (Edema of the eyelids succeeding to a wound or bruise, to an attack of erysipelas, or to the pressure of a bandage on the lower parts of the face, is gradually and completely removed, when the cause which had produced it ceases to operate. That which appears in the morning in persons of a leuco- phlegmatic habit, diminishes during the course of the day, and is not danger- ous. That which arises in scrofulous children, or in adults without any evident cause, continues long, or comes and goes at uncertain intervals of time. Bloodletting and diuretics, in scarlatinous dropsy, and in the inflammatory variety of Bright's disease, prove effectual in removing the attending oedema of the lids, in proportion as the urine becomes natural and copious. In albuminuria depending on fatty degeneration of the kidney, a mild diet, without alcohol, ought to be prescribed, and purging or mercury should be avoided. In other cases, gentle stimulants externally, and tonics internally, may be used with advantage. Bathing the lids with rose-water, or with limewater sharpened with a little brandy, will be found useful. Bags of dried aromatic herbs, as chamomile flowers, sage, or rosemary, with a little powdered cam- phor, suspended from the brow, so as to cover the lids, are highly recom- mended. The bags should be made of old linen, quilted, so as to keep the herbs equally spread out. When the cedema is periodic, and without any evident cause, a blister to the nape of the neck will be found advantageous. In scrofulous and debilitated subjects, chalybeates, and the preparations of cinchona, are indicated. 1 Collections from the unpublished Medical Writings of C H. Parry, M. D.; Vol. i. p. 581; London, 1S25. SECTION XXVI.—EMPHYSEMA OF THE EYELIDS. A swelling of the eyelids, produced by the presence of air in their cellular membrane, may either be part of a general emphysema, arising from an in- jury of the organs of respiration, in which case the air, escaping from the lungs, spreads through the whole body, and accumulates chiefly where the cellular substance is loose; or it may be the consequence of such an injury or diseased state of the nasal parietes, as shall permit the air to pass from the cavity of the nose directly into the cellular membrane of the eyelids. The following cases illustrate the second variety of emphysema of the eye- lids .-1— Case 143.—A young man received a violent blow on the nose in consequence of which he experienced rather severe pain. Some hours after, while forcibly blowing his nose, 204 EMPHYSEMA OF THE EYELIDS. he felt a peculiar sensation ascending along the side of it, to the internal angle of the left eye, and spreading to the two eyelids. These immediately became so much swollen, that the eye was entirely covered. When the patient was received at the IIotel-Dieu, the lids were very tense and shining, but indolent and without any change of color in the skin. An emphysematous crepitation was distinctly perceived. He was bled from the arm, and compresses, dipped in a discutient lotion, were applied over the swelling. In four or five days, the cure was complete. M. Dupuytren supposed that the blow received by the patient had occasioned laceration of the pituitary membrane, opposite the union of the lateral cartilage of the nose, which had been detached from the lower edge of the nasal bone.2 Case 144.—A lad of 16 years of age, as he was going along the street, with a load, ran inadvertently against a person passing in the opposite direction; a scuffle ensued, in which he received a severe blow immediately over the right frontal sinus. About an hour after, having occasion to blow his nose, the eyelids and parts adjacent became immediately inflated, so as completely to close the eye, and he felt the air rush, he said, into those parts. On being admitted into Guy's Hospital, under the care of Mr. Morgan, the eye- lids were much distended, and so closely approximated, that they could not be separated by any voluntary effort of the patient; the eyebrow was also puffed up, and the cellular membrane between the ear and the orbit was in the same state of emphysema. The parts were not at all painful on pressure ; they yielded a crackling sensation to the touch, and were free from discoloration. The supposed seat of the fracture was at a small dis- tance above the superciliary ridge, where a slight depression, but no crepitus, could be felt. The globe of the eye was perfectly natural. Two small incisions were made through the integuments, about the eighth of an inch behind the external angle of the frontal bone, which allowed the air to escape. The swelling subsided in twenty-four hours, leaving the eye and surrounding soft parts in a perfectly healthy condition.3 Case 145:—A robust man, 46 years of age, was brought senseless into the Hotel-Dieu, and placed in one of the surgical wards ; but as there was profound stupor, with stcrtor and complete relaxation of all the limbs, without any external lesion, he was removed into one of the medical wards. On examining him with care, the jaws were found strongly convulsed, and the muscles of the neck stiff. When the nose was pinched, so as to inter- rupt the passage of the air, respiration was suspended during at least half a minute, when a violent expiration being made, the left upper eyelid was perceived to swell a little, and the experiment being repeated, the same effect was again produced, and the eyelid assumed a considerable size, with emphysematous crepitation. On examining the eyelid, there appeared a slight abrasion, and yellowish tint of the skin, from which it seemed probable there was a fracture of the roof of the orbit, or of the base of the cranium, per- mitting the air from the ethmoid or sphenoid sinuses, to pass into the substance of the eyelid, when an obstacle was presented to its exit by the nose. Information was obtained, that he had been assaulted, about twelve days before, by several men, who hit him on the face with an umbrella and left him lying senseless on the street. He died the second day after his admission. On dissection, a fracture of the roof of the orbit, with laceration of the anterior lobe of the brain, extending to the depth of eight lines, was discovered. The dura mater was separated from the bone to a great extent around the fracture, but was not torn. One of the osseous fragments extended to the great notch of the frontal bone, and communi- cated with the middle ethmoid cells, which contained a small quantity of liquid blood.* I have seen several cases of emphysema of the lids from blows. In some crepitation vftis distinct, in others not. In one case, the upper lid hung over the eye, as if palsied. In another, the eyeball was considerably forced for- wards by the presence of air in the areolar tissue of the orbit. This affection may arise altogether independently of a blow. Case 146.—A scrofulous girl, blowing her nose violently, felt her right eyelids drawn together. Next day, I found the lids puffy, but without any crackling. She had no per- ceptible disease in her nose, but had suffered much from scrofulous ophthalmia. On the second day after the accident, the swelling was less, but the emphysematous crackling, when I pressed the lids, distinct. Case 147. _A man whose right nostril was nearly closed by a twist of the septum, tried to clear it by blowing. Suddenly the right lids swelled with air, and the eyeball became somewhat protruded. The application of cold water, and a dose of laxative medicine, formed the whole treatment in these two cases, both of which probably depended on a rupture of some part of the Schneiderian membrane. TWITCHING, OR QUIVERING OF THE EYELIDS. 205 The plan of incision through the-integuments, followed in Case 142, is also adopted when the eyelids are greatly distended, in cases of universal emphy- sema. It is merely, of course, a palliative remedy ; the complete removal of the disease depending on the healing up of the injured part of the lungs, or windpipe. Even in cases of rupture of some portion of the nasal parietes, the evacuation of the diffused air is merely palliative, and scarcely worth the while to practice. Till consolidation is effected, the emphysema will be liable to return when the patient blows his nose, against which he is therefore to be put on his guard. 1 A case of emphysema of the eyelid, from a par Dupuytren; Tome i. p. 128; Paris, 1832. gunshot wound of the frontal sinus, is related 3 Lancet; Vol. x. p. 31; London, 1826. by Baudens, in his Clinique des Plaies d'Armes 4 Meniere, Archives Generates de Medecine; a Feu, p. 162; Paris, 1836. Tome xix. p. 344; Paris, 1849. 2 Lecons Orales de Clinique Chirurgicale, SECTION XXVII.—TWITCHING, OR QUIVERING OF THE EYELIDS. Syn.—kwixoj o-Traa-y.0;, Aretazus. Tic non-douloureux, Fr. Spasmodic or muscular tic. Life-blood, Vulg. I have often been consulted by patients who complained of a tremulous, quivering, or twitching motion of one or other eyelid, or of both, which they were unable to control or to prevent, and which, from the frequency of its repetition, had become very annoying, although not attended with pain. In many cases, the quivering of the ciliaris is so slight as not to produce any visible motion of the affected lid; the patient merely feels the part moving; but in other cases, the motion is very evident, and is not confined to the orbicularis palpebrarum, but extends to other muscles of the face, and especially to the zygomatici, so that while the eyelids are convulsed, the angle of the mouth is drawn upwards. In some cases, as in those related by M. Francois,1 the whole of the muscles of the face animated by the portio dura, are convulsed. In one instance, even the muscles of the velum, the stylo-hyoid, and the pos- terior belly of the digastric, seem to have been affected.3 In some cases, I have seen the spasm spread to the neck and to the arm, so that these parts were strangely agitated along with one side of the face, whenever the patient began to speak. Morbid nictitation, and blepharospasm, to be considered in the following Sections, are akin to twitching of the lids; as is also that spasmodic affection of the frontalis, in which the eyebrows are every other minute drawn violently upwards. These are in general reflex diseases of the portio dura; they are spasms, clonic or tonic, of muscles under its control. Agitation of mind generally aggravates twitching of the lids, so that in speaking to a stranger, it becomes much increased. The patient is conscious of this; his feelings are hurt by the knowledge of his being subject to the complaint, and he often becomes anxious to undergo any sort of treatment likely to relieve him, not even excepting an operation. Although, in by far the greater number of cases, no pain attends the disease, it is occasionally accompanied by pain so severe as to resemble tic douloureux. Causes.—I have generally found the patient's digestive organs deranged, and most frequently, from the use of alcoholic fluids. In one case which I saw, the disease was brought on in a female servant, from her sitting up in the night, and over-fatiguing her eyes in stitching fine linen. The discovery of Sir C. Bell, that the fifth nerve is the nerve of sensibility, and the portio dura of the seventh the nerve of motion of the face, leads us to refer the cause of such abnormal motions to a disordered influence of the 206 TWITCHING, OR QUIVERING OF THE EYELIDS. portio dura. In certain cases, the disease may perhaps depend on some limited affection of one or other of the fasciculi of the facial nerve, altogether exterior to the cranium; but, in general, the nerve seems to be excited to irregular action in consequence of some remote disorder, sufficient to disturb the natural control of the brain over the motions of the face. The original irritation seems to be most frequently propagated from the stomach to the nervous centre, probably by the nervus vagus, whence it is reflected to one or more twigs of the facial, and shows itself in clonic spasms of the lids and face. The state of spasm or convulsion on one side of the face, sometimes pro- duces an appearance as if the other side were affected with palsy. " A lady complained of pain in the head," says Sir B. C. Brodie, "and her mouthwas drawn to one side; and hence she was supposed to suffer from paralysis of the muscles of one side of her face. However, when I was consulted respect- ing her, I observed that there were nearly constant twitches of the cheek and eyelids on that side to which the mouth was drawn; and on more minute examination, I was satisfied that the distortion of the mouth arose, not from the muscles on one side of the face being paralytic, but from those on the opposite side being in a state of spasm. The case precisely resembled that of a patient with spasmodic wry-neck, except the disease influenced a different set of muscles, namely, those supplied by the facial nerve."3 Prognosis.—When the affection is recent, and limited to the lids, and the patient has resolution enough to submit to a proper regimen, the prognosis is not unfavorable. Otherwise, the disease persists for life. Treatment.—1. The patient must give up entirely the use of wine, ale, spirits, and the like. 2. Essential benefit results from the use of laxative, alterative, and tonic medicines. A blue pill every night, or every second night, and one or two compound rhubarb pills every morning, for a fortnight, will generally be attended with good effects; after which, a course of bitter infusion, precipi- tated carbonate of iron, or some of the preparations of cinchona, ought to be prescribed, along with country air and exercise. 3. Anodyne liniments, rubbed in along the course of the portio dura, have been recommended. 4. Continued pressure, so as to limit the motion of the parts spasmodically affected, has been found advantageous, tending to break the habit on which, in a great measure, the complaint depends, by what means soever it may have been originally produced. 5. The abstraction of blood from behind the ear, by cupping or by leeches, is advisable. The lower lid being affected, I have known much relief ob- tained from a leech at the inner angle of the eye. Turberville had a patient long troubled with pain and convulsions in his cheek ; the place where the pain was, could be covered with a penny ; the convulsions pulled his mouth, face, and eye aside. Turberville applied a cupping-glass to the place, then scarified, and cupped again; after which he put on a plaster, and the patient was perfectly cured.4 6. An issue between the angle of the jaw and the mastoid process has proved decidedly useful. 7. Division of the nervous filaments of the facial nerve would remove the disease, but would substitute a paralysis. In order to avoid this evil, and yet attain the same object, Dieffenbach, in one case, performed a subcuta- neous division of the offending muscular fibres.5 This is done by introducing a narrow knife under the skin, turning its edge towards the muscle, and dividing it as the knife is withdrawn. MORBID NICTITATION.—BLEPHAROSPASM. 201 1 Edinburgh Medical and Surgical Journal, thorp's Abridgment, Vol. iii. part i. p. 34; Vol. lxxv. pp. 86, 381; Edinburgh, 1851. London, 1716. 2 Ibid. p. 104. B Romberg's Manual of the Nervous Diseases 3 Medical Gazette; Vol. v. p. 559; London, of Man, translated by Sieveking; Vol. i. p. 297 • 1830. London, 1853. 4 Philosophical Transactions; No. 164; Low- SECTION XXVIII.—MORBID NICTITATION. While natural nictitation is accomplished so instantaneously and easily as scarcely to attract the notice of ourselves or others, there is a morbid nictita- tion, which appears to be not so much the effect of relaxation of the levator palpebrse superioris, as a convulsive action of the orbicularis palpebrarum, too remarkable not to be observed by others, and of which, at last, the patient himself becomes painfully conscious. In the cases referred to, the shutting of the eye, instead of being performed only once, is repeated several times in imme- diate succession. In some instances, the upper eyelid is principally affected ; in others, the lower. Sometimes one eye only; generally, both eyes are affected. Analogous to the subject of last section, although readily distin- guishable from it, the present disease is aggravated by the same causes, especially agitation of mind, and disordered digestion. Sometimes a single eyelash, growing inwards so as to touch the eyeball, is the cause of morbid nictitation. In other instances, slight conjunctival oph- thalmia produces it. These causes being removed, the complaint will cease. In many instances, morbid nictitation seems merely a bad habit, or what the French term a tic. We often see it in children, whose eyes are overworked. Sometimes it is a sign of indigestion. In such cases, a treatment similar to what has been recommended for quivering of the eyelids, should be adopted. Advantage is obtained from wearing a green bonnet-shade, and using a col- lyrium, containing from 1 to 2 drachms of the tincture of belladonna, in 8 ounces of water. From 6 to 12 grains of rhubarb powder, with from the twelfth to the sixth of a grain of tartar emetic, each night, prove serviceable. SECTION XXIX.—BLEPHAROSPASM. The reflex action by which the eyelids are closed, often assumes the form of tonic spasm, and is then termed blepharospasm. It is generally, but not always, accompanied by intolerance of light, or photophobia, and often by epiphora. It generally affects both eyes pretty equally; sometimes, only one. The stimulus on which the spasmodic contraction of the orbicularis palpe- brarum depends, is of course communicated through the facial nerve. The exciting cause of the irritation resides sometimes in the organ of vision; sometimes, in remote organs. In different cases, it operates on the nervous centre whence the facial nerve arises, through the fifth nerve, through the optic nerve, through the nervus vagus, or through the great sympathetic; or is derived immediately from some cerebral disturbance. 1. A particle of dust adhering to the inner surface of the upper eyelid, an inverted eyelash, or some minute deposition in the site of the Meibomian fol- licles, is a common cause of blepharospasm; the irritation being communi- cated to the nervous centre through the fifth nerve. The photophobia and spasm of the eyelids generally subside very soon after the cause of irritation is removed. 2. In scrofulous conjunctivitis, the spasm is often continued, with slight 208 BLEPHAROSPASM. evening remissions, for months together. The patient, generally a child, is all that time unable to bear the least accession of light, or to open the eyes in the smallest degree, during the day. The inflammation during this state may be very inconsiderable, so that on forcing open the lids, scarcely a red vessel is discovered. Such, however, is the sympathy between the conjunctiva, which is the primary seat of irritation, and the neighboring parts, the retina, cerebral optic apparatus, lachrymal gland, and orbicularis palpebrarum, that the admitted light seems to the patient to blaze like the rays of the sun reflected from a mirror; the lachrymal gland instantly pours out a tide of tears, and the spasm of the orbicularis forces the lids together with new vio- lence. The removal of the ophthalmia, by the treatment hereafter to be explained, is the only means of obviating these, its reflex effects. 3. In some cases of severe blepharospasm and intolerance of light, the symptoms have been completely relieved only by the extraction of carious teeth, or teeth at the roots of which abscesses existed. Several remarkable instances of this sort are recorded by Dr. Hays of Philadelphia,1 showing the propriety of examining with care if such cause of irritation may not be in existence. 4. In a fourth set of cases, the original irritation appears to be in the retina, the disease being the result of over-use of the eyes. Case 148.—Sir C. Bell has recorded2 a. case of photophobia and blepharospasm, brought on by over-exertion of the eyes upon minute objects, in which the attacks came on peri- odically, the patient losing all control over the muscles of the eyelids and eyeballs. The complaint was attended with oceasional pain extending round the head, as if it were bound with a hoop, and a whizzing noise in the ears. Suddenly the spasm would go off, the eyes becoming open, and capable of being fixed on the surrounding objects, for per- haps the space of an hour. Excitement of the mind in conversation would produce this temporary improvement; and what was very remarkable, the patient, an intelligent young lady, discovered that on pressing with the point of her finger on the little pit before her ear and above the jugum, the eyes instantly opened, and remained so long as the pressure was continued. Sir C. found, that when he put the point of his thumb under the angle of the jaw, and pressed the carotid against the vertebrae, the same effect was produced, proving, he thinks, that the cessation of the spasm was caused by some influence of the circulation over the nervous system of the head. On pressing down the cartilages over the left hypochondriac region, so as to affect the cardiac portion of the stomach, the eyes opened and remained open while the pressure continued. Iii cases of this kind, the intolerance of light is often excessive; we find the patient in a room totally dark, with his eyes tied up ; he cannot allow them to be examined; and compares the sensation he experiences from attempting to open his eyes, to what might be felt on looking at a sea of molten gold. In one young gentleman in this state, by whom I was con- sulted, the attempt to open his eyes often seemed ready to throw him into a state of general convulsion. He was cured completely by leeches, blistering, and a long-continued course of calomel and quinine. I have seen numerous cases of this sort, which have resisted for years every kind of treatment, and have at length undergone a spontaneous cure. 5. Sometimes, spasm of the orbicularis palpebrarum of one side is brought on in consequence of a blow on the head, or other injury, the effects of which have been communicated to the brain or its membranes. The spasm con- tinues long; for weeks, perhaps, or months; and is apt to be mistaken for palsy of the levator of the upper lid. A restless state of the edge of the upper lid, and the difficulty experienced in raising it even with the finger, will serve to distinguish this state from palsy. Cerebral congestion, from fever and other causes, apoplexy, and various other disorders of the brain, are productive of blepharospasm. In such cases, both sides are generally affected, the intolerance of light is excessive, BLEPHAROSPASM. 209 exposure to strong sunlight is apt to produce violent and universal muscular spasms, and the recovery is exceedingly slow. 6. The organic nerves of the digestive system are sometimes the medium by which an irritation is transmitted to the nervous centre, whence it is reflected to the facial nerve, and the muscles, which it serves to excite, as it often is to other nerves and other organs. The cure, when this is the case, will depend on a judicious regulation, of the diet, along with the administra- tion of purgatives, alteratives, and tonics. In some cases, anthelmintics will prove serviceable, by means of their specific effect. 7. Many cases of blepharospasm are of hysteric origin. They are often mistaken for palsy of the levator palpebral superioris, and erroneously desig- nated by the name of hysteric ptosis. Case 149.—Dr. Schb'n relates3 the case of a scrofulous girl, of 15 years of age, who labored under blepharospasm of the right eye for 15 months, not being once able during the whole of that time to separate the lids from one another. He employed all the reme- dies usually recommended, both internal and external, without the least effect. The left eye continued well, and the right never showed even a trace of inflammation. During the night of the 24th April, 1831, the catamenia appeared for the first time, and the very next morning, the patient could open her eye with perfect freedom, and no longer saw double, as was previously the case when her lids were separated by another person. In the case of a lady by whom I was consulted, the inability to open the affected eye sometimes continued constantly for two or three days, while at other times she had complete command over the eye. In another lady, not merely the sphincters of both eyes were affected, but also the muscles of the nose and lips, producing closure of the eyes, along with a peculiar and painful screwing together of the mouth. Much benefit was derived, in this last case, from the continued use of aloes and assafoetida. A combination of such remedies with tonics often proves useful in hysteric cases. General treatment.—I have already hinted at most of the remedies to be used for the relief of blepharospasm. The cause of the original irritation must first be sought for, and against it the treatment must be directed. In cases of an inflammatory cast, or where the disease is traced to an in- jury of the head, bloodletting from the arm, leeches to the temples, and a course of mercury are indicated. In gastric and hysteric cases, purgatives, antispasmodics, and tonics, such as quinine and iron, are the most available remedies. Belladonna, internally, is often of great service ; as is the inhala- tion of ether or chloroform, every second or third day, to the extent of pro- ducing slight insensibility. Externally, counter-irritation is to be employed by means of friction with volatile liniment, tincture of cantharides, and the like, on the forehead and temple, and behind and before the ear. The appli- cation of blisters and the insertion of issues, are requisite, when milder means are ineffectual. Exposing the eyes to the vapor of opium or of belladonna, by mixing their tinctures with hot water in a teacup, to be held under the eyes, and fomenting them with poppy decoction, or a warm infusion of ex- tract of belladonna, are useful. Poultices, containing opium, hyoscyamus, or conium, are also recommended to be applied over the eye. A small con- tinued stream of cold water, or of water impregnated with carbonic acid gas, directed against the eye by means of a syringe or a syphon, is highly recom- mended by Dr. Jiingken.4 The vapor bath, in some cases, has proved effi- cacious; the cold shower bath, in others. The patient wearing*?? double green shade, should gradually accustom his eyes to the light, and not indulge, as is often done, in an increasing degree of obscurity. 1 Medical Gazette; Vol. xxviii. p. 617; Lon- 3 Ammon's Zeitschrift fiir die Ophthalmolo- don, 1841. gie; Vol. ii. p. 153; Dresden, 1832. ' Nervous System of the Human Body; Ap- ' Lehre von der Augenkrankheiten, p. 778 ; pendix, p. xlvi.; London, 1830. Berlin, 1832. 14 210 PALSY OF THE ORBICULARIS PALPEBRARUM. SECTION XXX__PALSY OF THE ORBICULARIS PALPEBRARUM AND MUSCLES OF THE EYEBROW. Syn.—Blight, Vulg. Palsy of the portio dura. Hemiplegia facialis. Fig. Dalrymple, PI. XXX. In most cases of palsy of the face, there is a degree of lagophthalmos; or in other words, the eyelids cannot be completely closed, on account of the paralytic state of the orbicularis palpebrarum. The patient cannot wink hard, nor press the eyelids against the eyeball; neither can he, from the dis- ease extending to the epicranius and corrugator supercilii, elevate his eye- brow, or frown, upon the palsied side. All this is most evident when the patient keeps the sound eye open, and tries to close the lids of the palsied side. He then finds that he cannot do so, at least not completely; but he closes the palsied lids much better, when he at the same time closes those of the sound side. The levator palpebral superioris, retaining its power, raises the upper lid to the natural degree, and again, on its becoming relaxed, the lids fall to a certain extent, but the two lids cannot be brought together. They remain in some cases four-tenths of an inch apart. When the patient looks down, the levator is relaxed, and the lid falls considerably more than when he looks forwards. The tears run over on the cheek, from want of the action of the lower lid, which hangs depressed and everted ; exposed to dust flying about, the patient is distressed by its getting into his eye ; and thus inflammation of the conjunctiva and opacity of the cornea may be excited.1 The loss of power, however, in the orbicularis varies in degree. It but rarely happens that it exists to such an extent as to cause any material injury to the eye, except in infants, in whom the cornea sometimes becomes wholly opaque or even destroyed by ulceration. In general, the lids merely do not close accurately, and we see the exposed eyeball turn up, when the ineffectual effort is made to bring the lids together. But in other cases, the lids gape widely, and the patient can neither raise the lower, nor bring down the upper, by any voluntary effort. If we push down the upper lid with the finger, it is thrown into loose folds, and is immediately drawn up when we cease to press upon it; if we draw down the lower lid, and then let it go, it does not spring to the eye as in health. On the patient's falling asleep, the upper lid covers the pupil, the eyeball turning up, and the levator palpebral relaxing, but the lower lid remains depressed and everted. The retracted lids are generally puffy, and the eyeball seems protruded. The other muscles of the face are generally paralyzed at the same time, and the natural motion of the lips is lost, so that the mouth opens most on the unaffected side, and the actions of whistling, laughing, &c. are impeded. While the sound side of the face is rotund and full, or marked by a dimple, the palsied is soft and sunk. If the disease has continued long, there is a marked diminution in the thickness of the muscles. The cheek becomes so thin that, when the patient speaks, it flaps about as if it were only skin, and the corrugator supercilii and occipito-frontalis are so wasted, that the bones seem covered only by integuments; the mouth is dragged from the palsied towards the sound side, and even the nose is twisted. Sensation over the face is natural, unless some cause be present which affects the fifth pair, as well as the portio dura of the seventh. From the exposed state of the eye, and the evaporation which goes on from its surface, the patient has a feeling of coW in it, which he remedies by covering it, perhaps, with his hand. At first he is apt to sleep with the eye uncovered, when the air drying it, will cause pain ; but by and by he contrives to fall asleep with his fingers on his lids, or turns half over on his face, so that the pillow presses the lids toge- PALSY OF THE ORBICULARIS PALPEBRARUM. 211 ther. Occasionally he complains of pain at the root of the ear, or in the neighborhood of the stylo-mastoid foramen, from which the portio dura escapes, to send its branches over the face. It is stated by Landouzy, that when the cause is non-cerebral, although above the geniculate ganglion, ex- altation of hearing is present.3 Dulness of hearing is certainly not an un- frequent symptom, even in non-cerebral cases; and is probably owing, not to any affection of the portio mollis, but to derangement in the movements of the bones of the tympanum. Absolute deafness would indicate that the portio mollis was implicated. At the commencement of the disease, pain is sometimes felt, radiating along the branches of the nerve. On looking into the throat, the uvula is sometimes found to be bent into an arc^ind its point turned towards the palsied side. In some cases, both sides of the face are palsied.3 A case of this kind, which I saw, arose from a poor man being maltreated on the road, and kicked on the occiput. In such cases, the patient experiences a degree of dysphagia, speaks through his nose, and pre- sents other symptoms indicating palsy of the velum.4 Causes.—Palsy of the face always depends on some affection of the portio dura; but it is of great importance to distinguish those cases in which the cause exists within the cavity of the cranium, from those in which the nerve suffers in its passage through the aqueduct of Fallopius, or after it has emerged from that canal, and is spreading itself to the facial muscles. Pre- viously to the discoveries of Sir C. Bell, palsy of the face was generally regarded as cerebral in its origin, and even when the seat of the disease was altogether exterior to the cavity of the cranium, the patient was treated with the severity which a serious disorder of the brain might properly demand. If the uvula is drawn to the unaffected side, and there are signs of a paralytic state of the velum, it is presumed that the cause is above the geniculate ganglion, which is situated on the first bend of the facial nerve, in the Fallo- * pian aqueduct, and where the facial communicates with Meckel's ganglion i by the greater superficial petrosal nerve.5 If this deviation is absent, the cause is presumed to be below the ganglion. Exposure to a current of cold air is the most frequent cause of palsy of the face. This cause probably operates by producing inflammation of the portio dura, and, perhaps, in some cases inflammatory swelling of the peri- osteum lining the aqueduct of Fallopius, and diminution of its calibre, so that the trunk of the nerve suffers pressure. According to Dr. Marshall Hall, as the inflammatory affection of the portio dura subsides, the paralytic symptoms are transmuted into a spasmodic state.6 The disease has been known to arise from the pressure of a lymphatic gland lying between the mastoid process and the angle of the jaw, and enlarged in consequence of inflammation of the mouth from the action of mercury. Dr. Bennett relates a case,7 in which a cancroid tumor of the parotid was the cause. I have seen repeated instances in which palsy of the face attended carious abscess of the tympanum, affecting, no doubt, the aqueduct of Fallopius. In a case which came under my observation, the disease followed a severe fall on the side of the head, which produced a discharge of blood from the auditory canal, and, it is probable, an extravasation of blood within the cavities of the temporal bone. Division of the portio dura, in any accidental wound or surgical operation, about the angle of the jaw, will produce it. Mr. Shaw mentions a case,8 in which, during the removal of a tumor from before the ear, the moment the branches of the portio dura were cut, the patient cried out, "Oh! I cannot shut my eye." One or other of the temporo-facial branches of the nerve may in this way be divided, and consequently one or other lid only may be palsied. Experience proves that facial hemiplegia may be produced by a vivid moral 212 PALSY OF THE ORBICULARIS PALPEBRARUM. affection. Andral has seen it after a violent fit of anger; Bellingeri, from a fright; Frank, from the announcement of bad news; Bottu-Desniortiers, in a young girl, from repeated crosses during profuse menstruation.9 Facial palsy may depend altogether on cerebral disease; on pressure of the nerve, for example, by congested vessels or by some morbid effusion or formation within the cavity of the cranium, between the origin of the portio dura and its exit by the meatus auditorius interims. In such a case, which I have known to arise from fatigue and too much stooping, other cerebral symptoms will be present, as feelings of fulness and pain in the head, giddi- ness, sleepiness, &c If other nerves are implicated, as the sixth, pressure on the pons Varolii is likely to be the cause. Occasionallv it happens that palsy of the face, depending on an affection of the aqueduct of Fallopius, is present along with serious disease within the cranium ; the latter, however, in nowise operating on the portio dura. In other cases, the disease of the temporal bone, which originally produced the palsy of the face, goes on to affect the dura mater and the brain, suppura- tion of these parts takes place, and death speedily follows. This is especially apt to happen in scrofulous children.10 Treatment.—In ordinary cases, the treatment must be directed against neither the brain nor the eyelids, but against the portio dura and the Fallo- pian aqueduct. Antiphlogistic means of cure are to be adopted in the first instance, as leeches behind the ear, and near the angle of the jaw, cupping on the back of the neck, and free purging. Calomel and opium, and the use of diaphoretics, may next be had recourse to. A continued action on the digestive system by Plummer's pill, does good. A caustic issue, or a semi- lunar blister below the ear, and stimulating liniments over the course of the nerves going to the paralyzed parts, will be found of advantage. A succes- sion of small blisters, dusted over with strychnia, is likely to be useful. Should these means not prove effectual, a trial may be given to electricity, galvanism, or electro-magnetism. Each cheek may be touched with a plate of metal, and a shock thus passed, on which the sound lids close, but the paralytic remain unaffected. Electro-puncture appears sometimes to have been successful." When caries of the tympanum, by affecting the portio dura, produces palsy of the face, a perpetual discharge should be kept up behind the ear. The diseased ear may be cautiously injected every second or third day, with a weak solution of nitrate of silver. The membrana tympani is always partially, and often totally, destroyed in such cases; and the indiscriminate use of in- jections might excite inflammation, extending to the brain and its membranes. If the patient be a scrofulous child, residence at the sea-side, and a course of sulphate of quina, ought to be prescribed. Cerebral disease, producing palsy of the face, must be combated chiefly by means of depletion, abstinence, and counter-irritation. To prevent the bad effects of exposure of the eye to the atmosphere, and to the particles of dust collecting on the conjunctiva, the patient should be directed to foment the eye frequently with warm water, and to move the eye- lid over his eye. He should keep the eyelid down during the night by means of a compress and roller. In cases not likely otherwise to recover, the eversion of the lower lid may be remedied by tarsoraphia.13 If the upper lid is permanently elevated, Dieffenbach divides the levator subcutaneously.13 1 See Shaw, Medico-Chirurgicsl Transac- tions: Vol. xii. p. 117; London, 1823. 2 Medical Gazette; Vol. xlvi. p. 909 ; Lon- don, 1850. 3 See case by Magnus, Miiller's Archiv fiir Anatomie, 1837, p. 258. 4 On Palsy of both facial nerves, consult PTOSIS. 213 Davaine, Gazette Medicale de Paris, 13 Nov. 1852. and following Numbers. * Cyclopaedia of Anatomy and Physiology; Vol. iv. p. 553 ; London, 1849. 8 Dublin Medical Press; Vol. xxiv. p. 185; Dublin, 1850. 1 On Cancerous and Cancroid Growths, p. 83 ; Edinburgh, 1849. ' Op. cit. p. 138. • Translation of this work into French; p. viii.; Paris, 1844. 10 See case in an adult, in Pilcher's Treatise on the Structure, Economy, and Diseases of the Ear, p. 165; London, 1838. Palsy of portio dura from fatal fracture of base of skull, see Lancet, January 8, 1853, p. 24. Destruction of temporal bone, and of 7th and 8th pairs, see Medical Gazette; Vol. xlviii. p. 927; London, 1851. Palsy of right side of face, and left side of body, from disease of right side of pons Varolii, see Medical Times, Nov. 22,1851, p. 535. " See case by Montault, Medical and Physi- cal Journal; Vol. lxiii. p. 463; London, 1830. 12 France, Lancet, January 5, 1850, p. 14. 13 Die Operative Chirurgie; Vol. i. p. 743; Leipzig, 1845. SECTION XXXI.—PTOSIS, OR FALLING DOWN OF THE UPPER EYELID. TlrSne, from trlirru, I fall. Syn.—Blepharoplegia, a term applicable only to the 6th variety. Inability to raise the upper eyelid may depend on a variety of causes; as, a re- dundant state of the integuments, or an injury, weakness, or palsy of the levator. Fig. 17. § 1. Ptosis from Hypertrophy. After inflammation of the upper eyelid, at- tended with considerable cedematous or san- guineous effusion into its substance, or treated by the long-continued use of cataplasms, we sometimes find the lid so much thickened, and its integuments so much relaxed, that they form a fold, hanging down over the opening of the lids, while the levator palpebrse superioris is unable, from the weight and bulk of the lid, to raise it so as to uncover the eye. We perceive distinctly the endeavors of the muscle, as soon as the patient is earnestly desirous of opening his eye; but the eyelid is either raised only to a very inconsiderable degree, or remains complete- ly depressed. If we take hold, between the fin- ger and thumb, of a transverse fold of the skin, so as to relieve the levator muscle of the addi- tional weight of integuments, the patient can, .without difficulty, open his eye, showing that the case is not one of paralytic ptosis ; but as soon as we quit our hold, the eyelid sinks to its former position. Sometimes the relaxation does not occupy so much the middle of the eyelid as its temporal portion. It is also occasionally the case, that when the fold of integuments is very considerable, it presses, by its weight, the edge of the lid, along with the cilia, inwards, so as to produce a degree of entropium. For the cure of this variety of ptosis, the common practice is to remove a transverse fold of the integuments. In order to perform this with the necessary exactness, we take hold of the skin, where it appears most relaxed, with a broad convex-edged pair of forceps, commonly called entropium forceps (Fig. 17), and then desire the patient repeatedly to open and shut O o 214 PTOSIS. the eye. If he be able to do this, it is a proof that the forcgps includes neither too much nor too little of the skin. If he cannot lift the lid, we have taken hold of too little, and must apply the forceps again, so as to include a greater portion of the skin. If he can, indeed, lift the lid, but not completely shut it again, we must let go a little of the skin from the grasp of the instrument. It is important also to take care that we do not apply the blade of the forceps too close to the edge of the lid; for if this be done, too little space will be left for the application of stitches. As soon, then, as the forceps is properly applied, we squeeze its blades together with moderate firmness, that the in- teguments may not escape, and then remove the portion laid hold of, by a stroke or two of the scissors. The bleeding is inconsiderable, and ceases in a few minutes by the use of cold water. Seldom more than two stitches are necessary ; one is frequently sufficient. Union is generally effected very quickly, without any suppuration, and scarcely leaves any perceptible scar. As soon as the union is complete, the prolapsus is cured. § 2. Congenital Ptosis. I have repeatedly met with a degree of depression of the upper lid, so considerable as materially to impede the function of vision, and which had existed from birth. In some of these cases, the lid was the reverse of being swollen ; it rather appeared atrophic, as if the levator muscle had either been originally deficient, or had wasted from disease. This sort of incomplete ptosis is sometimes hereditary, and is occasionally complicated with flatness of part of the superciliary arch.1 Removing a transverse fold of the integuments was tried in several of the cases to which I refer, but generally with little or no advantage. Perhaps better success might attend the operation recommended by Mr. Hunt, which I shall immediately have occasion to explain. § 3. Traumatic Ptosis. In penetrating wounds of the upper lid (see p. 150), the levator may be cut or torn across, or the branch which it derives from the third nerve may be divided. The consequence will be inability to uncover the eye. In such a case, I have known the power of raising the lid to be restored, probably from the reunion of the muscular fibres which had been divided. The snipping out of a small fold of the skin of the lid can be of no use in such cases. A close attention, however, to the structure and healthy func- tions of the parts concerned, has led Mr. Hunt, of Manchester, to a more rational mode of operation for traumatic ptosis. His method may also be" useful when this disease arises from congenital deficiency, or from palsy of the levator. The operation recommended by Mr. Hunt, is performed by dissecting off a fold of integument from the eyelid, and the difference between his operation and the usual way of proceeding, consists in the greater extent of the portion removed. The upper incision is made immediately below the eyebrow, and stretches, each way, to a point opposite the commissures of the eyelids. In making the lower incision, no precise direction can be given. It should approach within a short distance of the tarsal margin, and should meet the upper incision at both its extremities, so that a portion of the integuments is removed, of the shape of an olive leaf, the extent of which must vary accord- ing to the greater or less degree of the relaxation of the skin, which is the same in no two individuals. The divided edges should be accurately united by at least three stitches, and the wound dressed in the usual manner. The effect produced, when adhesion is completed, is the attachment of the eyelid to that portion of the skin of the eyebrow upon which the occipito-frontalia PTOSIS. 215 acts. By means of that attachment we substitute the action of this muscle, in raising the eyelid, for that of the levator. The deformity likely to be produced by the removal of so large a portion of skin, in such a conspicuous situation, or the likelihood of substituting a lagophthalmos, or eversion, for the ptosis, may perhaps be urged as reasons against this mode of operating. The following case by Mr. Hunt, affords an answer to both these objections:— Case 150.—In removing a large and deeply seated tumor from the left orbit of a patient of the Manchester Eye Institution, owing to the connection of the levator palpebrae with the diseased mass, the muscle was so much injured, that, after the patient had perfectly recovered in every other respect, what then appeared an incurable ptosis remained. When the lid was raised with the finger, the eye was found to possess perfect vision. Anxious to remedy the evil, Mr. Hunt, when all tumefaction of the integuments had dis- appeared, removed an elliptical fold of skin in the usual way. The wound healed well; but although a considerable portion had been included between the incisions, the effect upon the lid was hardly perceptible. The poor man, after waiting for some weeks, was very solicitous to have another por- tion removed; and it was more in compliance with his desire than from any expectation of further benefit, that Mr. Hunt at length consented to repeat the operation. Whilst deliberating on the portion to be removed, it struck him that, if it were sufficiently near the eyebrow, the action of the occipito-frontalis, which affects this portion of the skin, might also be available for raising the eyelid, and fortunately the result fully justified the conjecture. The operation was performed as is described above, the wound united by the first intention, and the patient could raise his eyelid to the same extent as that of the other side. No deformity was produced, and the eye could be as perfectly closed as before the occurrence of the disease. § 4. Atonic Ptosis. In some instances, we meet with a depressed state of one or both upper eyelids, dependent apparently on mere weakness of the levator muscle. In this case, mechanical support, by means of a strip of adhesive plaster, assists in restoring to the muscle its wonted power. Applications of a strengthening kind are to be made to the lids ; sponging them, from time to time, with rose-water, a solution of alum, brandy, or the spirit of nitrous ether; rubbing them gently with tinctura saponis, and the like. It is in atonic cases, that such applications as that with which Wenzel cured Maria Theresa, Empress of Germany, after Yan Swieten and De Haen had failed, are likely to do good. He applied pledgets over the eyes, wrung out of a mixture of lime-water and aqua ammonias.3 Electricity may be tried, and general tonics. § 5. Paralytic Ptosis. Palsy of the levator of the upper eyelid is an affection by no means uncom- mon. In one set of cases it bears an analogy, in point of cause, to the most frequent instances of palsy of the faoe, or, in other words, it arises from cold. In another set, the cause is cerebral; it is, perhaps, arterial or venous con- gestion, sanguineous or serous effusion, or some tumor, formed within the cranium, and pressing on the third pair of nerves. It is often difficult, espe- cially in the incipient stage, to distinguish these two sets of cases. Paralytic ptosis, without any participation of the muscles of the eyeball, is rare. We find that, along with the depression of the upper eyelid, either all the muscles of the eyeball are paralyzed, so that the eye stands stock-still in the orbit, or much more frequently, that, from the abductor retaining its power, the eye is immovably distorted towards the temple (luscitas), while from the palsied state of the other recti, the patient is unable to move his eye upwards, downwards, or inwards. In the cases which are regarded as rheumatic, but which are probably as often apoplectic, one eye only is gene- rally affected, and the abductor retains its power. In cases more decidedly cerebral, both eyes are apt to be affected from the beginning, although some- times one side is first paralyzed, and then the other. 216 PTOSIS. In paralytic ptosis, the orbicularis palpebrarum, preserving its power, keeps the eyelids constantly closed, so that the patient sees none, unless he raises the lid with his finger. AVhen he does so, he sees double ; and if he tries to walk across the room, is affected with a great degree of vertigo. The double vision and vertigo are owing to the axis of the palsied eye no longer corre- sponding to that of the sound one, and cease as soon as the eyelid is allowed1 to drop. In long-continued cases, the attempts of the patient to raise the lid by calling the epicranius into action, causes the eyebrow to become elevated and arched, and the skin of the forehead marked with transverse furrows. The rheumatic variety of this palsy is brought on by exposure to currents of cold air, and the like. I saw it induced, on both sides, in a man who walked about all day, with his hat wet from having dropped it into a river. The cerebral variety is either sudden, or slow; the sudden, arising after fatiguing exertion, violent mental excitement, exposure to the direct rays of the sun, intoxication, blows on the head, concussion of the body, and the like; the slow, keeping pace with the growth of scrofulous tumors, fungous excres- cences from the dura mater, and other organic changes about the basis of the brain.4 The disease often wears an apoplectic aspect. An old gentleman walks quickly on a hot summer's day, along the banks of a river, in order to reach a small boat, in which he means to cross to the other side. He reaches the small boat, sits down in it, perspiring much about the head, and is in- stantly seized with a chill, and palsy of all the muscles of one eye under con- trol of the motor oculi. I was called to see a military gentleman, who having spent the previous evening in celebrating the king's birthday, amused him- self next day in rowing a boat on the Clyde, overheated himself, threw off his cap, but returned home in perfect health, and went to bed, in the evenings as usual. Next morning, on awaking, he was greatly alarmed by finding that he could not see. He had been seized with complete double ptosis; both eyeballs were twisted to the temples, and the pupils dilated. Both these patients recovered perfectly, under anti-congestive treatment. In an old man whom I saw, double ptosis, with loss of speech, and weakness of the limbs, occurred suddenly, and did not yield to remedies. The third nerve is more obnoxious to palsy than any other of the cerebal nerves. This is perhaps owing to its position, as it emerges from the brain, between the posterior artery of the cerebrum and the superior artery of the cerebellum. Sometimes the former vessel traverses the trunk of the nerve. Congestion, then, of these vessels, may readily cause palsy of the nerve. The vision of the eye, which lies behind the palsied lid, may, or may not, be affected. We find, from the commencement of the rheumatic variety, the pupil dilated, the iris partaking in the paralysis of the other muscles supplied by the third nerve; and this dilatation of the pupil is accompanied with the usual obscurity of vision met with in mydriasis. Generally it happens in the cerebral cases, that vision becomes gradually affected, but sometimes it is suddenly so from the first. Treatment.—When palsy of the upper eyelid appears to arise either from cold, or from some sudden cerebral affection, we employ general and local blood- letting, rest, the antiphlogistic regimen, and blistering of the head. After the use of these means, we generally find that the vertigo and other symptoms begin to yield. In both cases, we employ mercury till the mouth is affected, combining it in rheumatic palsy with opium, that it may act as a sudorific; in cerebral cases expecting it to prove useful as a sorbefacient. Warm fomentations of the eye are useful. Sudorifices, as guaiac, and stimulants, as camphor, have been highly recommended in the rheumatic cases. In the cerebral cases, low diet and the use of iodine are indicated. PTOSIS. 21T Rubbing the forehead, the temple, and the palsied lid with the aromatic spirit of ammonia, issues in the neck, blisters to the brow, the raw surface being afterward dusted with strychnia, and the use of electricity or galvanism, are attended with advantage. Exercise of the eye does good. A shade being placed over the sound eye, the diseased one should be forced into use. In slow cerebral cases, I have seen almost every sort of practice tried with- out effect. -^ In an Infirmary patient, in whom the disease attacked first one upper eye- lid, and then affected both, with a paralytic debility present also in one side of the body, the internal use of arsenic appeared beneficial. To enable this patient to attend a little to her household affairs, we were obliged to keep j the eyes alternately open by a bit of adhesive plaster, attached to the lid and/ fixed by its other extremity to the brow. A poor old Highlander, who applied at the Glasgow Eye Infirmary with double ptosis, had contrived, by tying a pretty thick twisted band round his head, to keep up both upper eyelids very well. Although both his eyes were turned towards the temples, he did not complain of diplopia. The neatest contrivance for elevating the upper eyelid, in single or double ptosis, is that of Dr. Mackness. A very thin and narrow piece of ivory, forming the seg- ment of a circle, is riveted upon a piece of the mainspring of a watch, about eight inches long. The loose end of the spring being carried through the hair over the crown of the head to the occiput, the piece of ivory is placed upon the eyelid so as to keep it open. The piece of ivory, being very narrow, is completely hid in a fold of the eyelid, while the spring, being accurately painted to imitate the color of the skin, is scarcely observable. As the eye- lids occasionally require closing, in order to keep the eye moist, the patient soon acquires a knack of raising the spring to allow the eye to wink, and then replacing it again.5 Even in favorable cases, the power of the levator returns, in general, very slowly. We perceive, first of all, that the lid does not hang so flaccid, or so totally motionless as it did ; but that, as the patient exercises his volition in respect to it, it is affected with a tremulous oscillation, and at length is raised a little from contact with the lower lid. Day after day, the degree of eleva- tion is augmented, the iris comes into view, and by and by a part of the pupil, so that the sound eye being closed, the patient begins to discern the objects placed before him. Half the pupil is at length uncovered, and slowly more and more of the eyeball can be exposed, till the motion becomes as extensive and as rapid as in health. Mr. Hunt's operation may be had recourse to in cases of double paralytic ptosis, when no signs of improvement appear ; and even in single ptosis, if there be no luscitas. The epicranius is active, depending on the stimulus of the facial nerve, and the plan of bringing the lid under its influence deserves a trial. It has been proposed, also, to divide the abductor in such cases, if luscitas be present, and then perform Mr. Hunt's operation.6 1 Alessi, Annates d'Oculistique, 1" Vol. nal of Medical Science, September, 1850, p. 823. Suppl. p. 39 ; Bruxelles, 1842. Case of Palsy of left side of face, ptosis, luscitas, 2 North of England Medical and Surgical deafness, and amaurosis, from tumor in pons, Journal; Vol. i. p. 166 ; Manchester, 1830. with hardness and tumidness of 3d nerve; " Wenzel, Dictionnaire Ophthalmologique, Edinburgh Medical and Surgical Journal, Vol. Tome ii. p. 6 ; Paris, 1808. lviii. p. 377 ; Edinburgh, 1842. 4 See Case of Amaurosis and Paralytio * Medical Gazette; Vol. xxviii. p. 617; Lon- Ptosis, with seizures of a mingled epikptic and don, 1841. paralvtic character, in Bright's Reports of Medi- e Curling, Medical Gazotte; Vol. xxviii. p. cal Cases; Vol. ii. p. 533; London, 1831. Case 16 ; London, 1841. Hunt, ibid. p. 111. Holt- and Dissection, by Hare, from Aneurism of left house, ibid. p. 152. Hall, ibid. p. 306. posterior communicating artery, London Jour- 213 LAGOPHTHALMOS. SECTION XXXII.—LAGOPHTHALMOS. From Xayoj, hare, and J^flaXjUo;, eye; because it was believed hares slept with their eyes open. The term lagophthalmos is employed to denote that state, in which one or other eyelid, or both, are shortened in their perpendicular diameter, so that they cannot be completely closed. (Figs. 4 and 5, p. 81.) The consequence is that even during sleep, a part of the surface of the eyeball remains exposed to the action of the air, and the irritation of foreign particles. In some cases, even more of the eye is exposed during sleep than when the patient is awake. This state is generally the result of the contraction attending the cicatrization of a burn or other injury, or of retraction of one or other eyelid and adhesion to the edge of the orbit, in consequence of caries. In either case, lagophthalmos may or may not be attended with eversion of the affected lid. I was, in one instance, consulted on account of a great degree of depres- sion and retraction of the lower lid, without any eversion. As there was neither destruction of its integuments, nor disease of the bone, I was inclined to suspect that suppuration between the eyeball and the floor of the orbit, had been the cause of the diseased position of the lid, but nothing of this kind appeared from the history of the case to have happened. The substance of the retracted lid was much indurated, and ultimately became affected with cancerous ulceration. I have already (page 210,) spoken of lagophthalmos as the result of palsy of the orbicularis palpebrarum. A slight degree of lagophthalmos, especially if the lower lid only is affected, may not be attended by much inconvenience. When more consi- derable, inflammation of the conjunctiva and cornea, opacity and abscess of the cornea, and even staphyloma, may be the consequences. The exposed eye is incapable of the usual exertion, and is affected with epiphora and in- tolerance of light. Treatment.—Demosthenes and other ancient surgeons attempted to relieve the lagophthalmos which arises from a cicatrice, by making a crescentic inci- sion through the contracted integuments, and endeavoring to keep the edges of the wound separate, as much as possible, by the interposition of dressings, till the cure was complete.1 This plan was found to be ineffectual, as the cicatrice resulting from the very operation, necessarily gave rise to a new degree of contraction. Dieffenbach, however, ascribes the want of suc- cess to the incision being confined to the integuments, and recommends the adoption of the following among other operative means of cure :__ 1. In small irregular cicatrices of the external integuments, excision of the cicatrice, the edges of the wound being brought very nicely together. 2. In transverse cicatrices, repeated subcutaneous division of the whole upper lid, including the cartilage; the lid to be then strongly drawn down, and fixed by plasters, till the parts are healed. 3. In long, hard, elevated, vertical cicatrices, by which the middle of the lid is particularly shortened, excision of the cicatrice by means of two long elliptical incisions. The edge of the shortened lid is laid hold of with a pair of toothed forceps, and drawn well downwards, one blade of a pair of small sharp scissors is passed between the eyelid and the eyeball, as high as the extremity of the cicatrice, and a long stripe of the lid inclosing the cicatrice is cut out. With insect pins, the edges of the incision are brought exactly together. 4. In cases of actual shortening of a sound eyelid, without any cicatrice, STRANGULATED ECTROPIUM. 219 subcutaneous division of the levator. A small wooden spatula being intro- duced under the upper eyelid, a small concave-edged knife is made to perfo- rate the eyelid at its temporal extremity, and as it is passed on under the skin to its nasal extremity, the muscle is divided.3 The lagophthalmos arising from caries of the orbit, is occasionally attended (Fig. 2, p. 76,) by a considerable transverse elongation of the edge of the eyelid, at the same time that it is drawn into an angle, and immovably fixed in its unnatural position. Under these circumstances, an operation similar to one or other of those practised for ectropium, may sometimes be performed with advantage; such as, after extirpating the cicatrice, to extend from each extremity of the wound, an incision parallel to the edge of the orbit, dissect the integuments, on both sides, pretty extensively, and then transpose them, so that the seat of the cicatrice is covered and the lagophthalmos removed. Of course, nothing of this sort should be attempted till the bone has been long perfectly healed. When, in consequence of the exposed state of the eye, the conjunctiva becomes inflamed in cases of lagophthalmos, advantage will be derived from the use of the lunar caustic solution, and the employment of such mechanical means as may moderate the access of light and air. 1 Aetii Contracts ex Veteribus Medicinae 2 Die Operative Chirurgie; Val. i. p. 472; Tetrabiblos ; Tretrabib. II. Sermo iii. cap. 73 ; Leipsig, 1844. p. 360; Basileae, 1549. SECTION XXXIII.—ECTROPIUM, OR EVERSION OF THE EYELIDS. 'Ex-Tpomov, Actuarius; from In, out, and rptirco, I turn. There is one acute, and there are several chronic varieties of ectropium. The acute depends on swelling and protrusion of the conjunctiva; the chronic arise in consequence of morbid contractions and adhesions, or of par- tial or total destruction, of the skin of the eyelids. § 1. Eversion from Inflammation and Strangulation. Syn.—Acute eversion. Ectropium sarcomatosum. Fig. Vetch, Fig. I. Thisvariety takes place only when the conjunctiva is in a state of acute puro-mucous inflammation, such as in the Egyptian, or any other of the con- tagious ophthalmise. It may affect either eyelid, but the upper is much oftener affected than the lower; rarely both. When sarcomatous ectropium affects the upper lid, the protrusion of the conjunctiva is often enormous, and the surface of the membrane presents in an extraordinary degree, that peculiar degeneration of the papillary structure of the conjunctiva, called granular conjunctiva. The mode in which this protrusion happens, has been well explained by Dr. Yetch.1 The inflamma- tory oedema of the eyelids, which, in the contagious ophthalmise, is for a time excessive, beginning at length to subside, while no proportionate diminution of the swelling of the lining membrane of the lids has as yet taken place, the swollen and granulated conjunctiva loses that counterpoise which the external swelling afforded to it, and is forced outwards by the action of the orbicularis palpebrarum. If the protrusion is not immediately returned, the upper part of the eyelid and the retroverted cartilage act like a ligature on the parts protruded, and as the swelling increases, the stricture becomes still stronger by the natural but ineffectual efforts of the orbicularis to bring the 220 STRANGULATED ECTROPIUM. tarsus into its proper position. The protruding tumor, therefore, is occasioned in a great measure by strangulation, like the swelling in paraphymosis. When this eversion occurs in children affected with ophthalmia neonatorum, or some other severe puro-mucous ophthalmia, its origin is often in a great degree accidental. For example, the attendant, upon attempting to look at the eye, or remove the copious purulent discharge, unfortunately turns the upper eyelid inside out; the child begins to cry violently, this increases the eversion, and all attempts to reduce the lid to its natural position are found ineffectual. It is allowed to remain everted for some hours, or, as I have repeatedly seen it happen, for several days, and then the child is brought for advice. The everted lid is by this time greatly injected with blood ; some- times to such a degree, that pressure fails to overcome the eversion ; or if we succeed in restoring the lid to its natural position, it very probably returns to the state of eversion, the moment that the child begins to cry. When this variety of eversion affects the lower lid, there is nothing acci- dental in its production; it is entirely the result of the swelling and protru- sion of the inflamed conjunctiva. Treatment.—The great object is to abate the inflamed state of the con- junctiva. If this is effected, the eversion will speedily be removed. We have recourse, in the first instance, to the application of leeches to the skin or to the everted conjunctiva, or we scarify the conjunctiva with the lancet. After the tumefaction of the eyelid is somewhat reduced by the discharge of blood, we are in general able to return it to its natural position. For this purpose, we lay hold of it in such a manner, with the thumb and forefinger of each hand, as to express from it as much as possible of the thin fluid effused into its substance, and then suddenly bend its edge towards the eyeball, at the same time that we push back the protruded conjunctiva. If the state of inflammation is not very acute, we ought to maintain the lid in its natural position by means of a compress and roller. If the ophthalmia be still severe, we must content ourselves with recommending great care on the part of the attendants to avoid whatever might cause the child to cry, and instruct them in the manner of reducing the eversion, should it happen to return. From day to day, or more frequently than once a day, if this is thought necessary, the eye is to be examined, and the proper means applied to the conjunctiva for removing the ophthalmia, as lunar caustic in different forms, sulphas cupri, red precipitate salve, and the like. Every other remedy, general or local, likely to promote the cure of the original disease, is at the same time to be persevered in. I have seen repeated instances in which scarification failed, or if we suc- ceeded by its means in lessening the degree of eversion, it speedily returned. In such cases, I have sometimes succeeded in keeping down the lid by means of a piece of strongly adhesive plaster, or by collodion immediately covered with a piece of thick cloth placed across the lids. The plaster or the cloth, which is attached to the upper lid first, should be broad, then become narrow, and be fixed to the lower lid and to the cheek. Being narrow over the fissura palpe- brarum, it allows the discharge to escape. [Here the Donna Maria gauze and collodion will serve an excellent purpose.—H] I have, in other cases, found a circular band of vulcanized caoutchouc answer very well in keeping the upper lid in its proper situation. All other means failing, we must extirpate a portion of the diseased con- junctiva. By means of a ligature, or simply with a hook, or a pair of toothed forceps, we raise up the middle of the exposed and thickened portion of that membrane, and remove, with the scissors, a fold of it of the shape of a myrtle leaf. The wound bleeds profusely, and this assists in reducing the lid to a state favorable for replacement. Strips of plaster, passing from the upper ECTROPIUM FROM EXCORIATION. 221 to the lower lid, and a compress and bandage, are then applied, and are to be renewed from time to time till the cure is complete. Prognosis.—It is important to observe, that although our prognosis in every case of this variety of eversion may be favorable, so far as the eyelid is concerned, we must pronounce nothing regarding the future vision of the patient, unless we are able distinctly to bring the cornea into view. In cases which have been neglected for a number of days, the swelling of the everted conjunctiva may be such, that we shall find it impossible to see the cornea, on our first examination of the eye; and under such circumstances we ought to forewarn the friends of the patient that we can promise nothing regarding sight. After the use of scarification and other means, we reduce the eversion and bring the cornea into view, but perhaps find the eye staphylomatous, and, of course, vision lost. § 2, Eversion from Excoriation. Syn.—Chronic eversion. Ectropium senile. Fig. Ammon, Zweiter Theil, Tab. V.; Dalrymple, PI. II. Fig. 2. The most common cause of eversion is excoriation of the lower eyelid and cheek, in consequence of long-continued catarrhal ophthalmia, or ophthalmia tarsi. In this variety, we find the skin of the affected lid contracted, its tarsal edges rounded off, the Meibomian apertures partially or totally oblite- rated, the cilia destroyed, and a considerable portion of inflamed conjunctiva permanently exposed to view. In children, this eversion is the result of neglected ophthalmia tarsi; in old persons, of chronic catarrhal ophthalmia. In the former, the misplaced state of the lid has generally been preceded by considerable superficial ulceration of the skin, the cicatrization consequent to which has shortened the lid, and dragged it downwards. In old persons, again, there is less appearance of cicatrization, while it would seem that the orbicularis palpebrarum has lost its power of supporting the lid, and that the tensor tarsi, being also weak- ened, allows the punctum lachrymale to fall forwards. In the commencement of the disease, the exposed conjunctiva is swollen, presents a pale red color, and possesses a natural degree of sensibility to the touch. Gradually, from the constant influence of the air upon a part not intended to be exposed to this excitement, and the occasional contact of external bodies, the conjunctiva of the everted lid assumes a redder and firmer appearance than natural, and at last becomes almost insensible to the contact of those substances which formerly excited pain or brought on bleeding. The consequences of this disease are stillicidium lachrymarum, and occa- sional attacks of inflammation of the eyeball. Both these are the unavoid- able effects of the interruption of the natural functions of the lower eyelid. In the state of eversion, it no longer covers completely and accurately the inferior part of the eyeball, which consequently remains exposed to innumer- able causes of irritation, from which it ought to be guarded. In this state, also, the tears are no longer guided onwards to the punctum lachrymale, nor is the punctum kept in contact with the eyeball, as in health, so that the tears are allowed to drop over on the cheek. If nothing is done to remove the eversion, and the cause in which it has originated is allowed to continue, the lid becomes transversely elongated, so that, were it liberated from its unnatural situation and raised into contact with the eye, it would be found not to fit exactly, being longer than sufficient to cover accurately the surface of the eyeball. 222 ECTROPIUM FROM EXCORIATION. Eversion of the upper lid from excoriation rarely occurs, and never to any great extent. Treatment.—I. By the use of the appropriate means, we endeavor to re- move the remaining symptoms of the ophthalmia, which has given rise to the eversion. 2. The contracted state of the skin is to be relieved as much as possible, by frequently fomenting the lids with warm water, then drying them, and anointing them with oxide of zinc ointment. This softens the skin of the everted lid, renders it more pliable, and protects it from farther irritation. 3. Scarification of the exposed conjunctiva is highly useful, as well as the keeping of the lid raised to its natural position by means of a compress and roller, carefully applied. 4. The application of escharotics to the internal surface of the lid is, in general, an effectual means of counteracting the tendency to misplacement in this variety of eversion. The sulphate of copper, or the nitrate of silver, solid, or in solution, will be found to answer well. Some surgeons2 venture on the employment even of sulphuric acid for this purpose. The upper lid is to be raised by the finger of an assistant, and the patient is to look upwards ; then the surgeon, everting the conjunctiva of the lower lid as much as possible, and wiping it dry, passes the nitrate of silver pencil along its surface, which instantly becomes white; after which it is to be touched with a little water, by means of a camel-hair brush. If sulphuric acid is preferred, a bit of wood or the blunt end of a common silver probe, is to be dipped in that fluid, and rubbed upon the conjunctiva of the lid, carefully avoiding the punctum lachrymale, caruncle, semilunar fold, and eyeball. The portion of conjunctiva touched by the acid immedi- ately becomes white ; and, in order to prevent the acid from affecting the eyeball, a stream of water should now be directed over the eyelid, by means of a small syringe. If the acid does not appear to have made the conjunctiva sufficiently white, the application may be repeated with the same precautions. The application of the caustic, or of the sulphuric acid, should be repeated every fourth day. Neither of them causes a slough, but merely a general contraction of the part, and, after two or three applications, an evident diminution of the eversion. The escharotic applications must be continued from time to time, till the lid assumes its natural direction. 5. Should the means already indicated prove ineffectual, a portion of the relaxed and thickened conjunctiva must be extirpated. In order to execute this with exactness, it is necessary to estimate beforehand about what amount of contraction of the conjunctiva would be sufficient to reinstate the eyelid in its natural position. If we remove too little, a degree of eversion will remain. If we remove too much, we produce a new disease, namely, inver- sion, which is at least as bad as that which we have been endeavoring to relieve. The operation and after-treatment are the same as have already been mentioned under the first variety of eversion. If our calculation in the quantity to be removed has been correct, we find the ectropium cured as soon as the conjunctiva has healed. 6. In very bad cases of this sort we may, with advantage, have recourse to the removal of a wedge-shaped portion of the whole thickness of the lid; an operation we are frequently obliged to employ in the third variety of eversion. 7. Dieffenbach has proposed an operation, by which the everted lid is at once brought into its proper position, and the natural antagonism, which ought to exist between the internal and external structures of the affected lid restored. He removes no part of the conjunctiva or of the tarsus. The integuments being pinched up inrt) a fold, they are to be divided by ECTROPIUM FROM A CICATRICE. 223 an incision, parallel to the lower edge of the orbit, and a few lines above it. This incision is to extend to two-thirds of the transverse breadth of the lid. The semilunar flap, formed by the incision, is to be dissected upwards, as far as the adherent edge of the tarsus, which in eversion is nearer the eyeball than the free edge, and there the lid is to be penetrated, and the conjunctiva divided to the extent of the external wound. By means of a hook, the con- junctiva, along with the tarsus, is now to be drawn into the external incision, and fixed there by the twisted suture. A similar operation may be practised on the upper lid.3 § 3. Eversion from a Cicatrice. Fig. Ammon, Zweiter Theil, Tab. V. The cicatrice which operates in the production of this variety of eversion, is generally the consequence of a wound, an abscess, an ulcer, or a burn. In such cases, though nature contrives to produce, in place of the portion of skin which has been destroyed, a supplementary substance, yet matters are not restored exactly to their former state. The ulcer is covered, partly at the expense of the surrounding sound skin, which is drawn together and contracted over the sore, and partly by the formation of a new membrane, which, though we give it the name of skin, possesses but imperfectly the pro- perties of the old integuments. It is neither so large as the piece of skin which has been lost, nor is it so yielding, nor so elastic, nor so movable upon the part which it covers. It is smooth and shining, and scarcely capa- ble of distension ; but above all, so far as the present subject is concerned, the surrounding original cutis is drawn towards this supplementary produc- tion, is puckered and thrown into folds, and, to use the homely comparison of Mr. Hunter, the whole appears as if a piece of skin had been sewed into a hole by much too large for it, and therefore it had been necessary to throw the surrounding old skin into folds, or gather the surrounding skin, in order to bring it into contact with the new. A lacerated wound of either eyelid, allowed to heal without due attention, is very apt to end in eversion. The upper lid particularly we sometimes see completely everted, and peaked up into an angle, in consequence of a neg- lected or mismanaged laceration. From severe burns, the eyelids are generally much puckered, contracted, and indurated ; and, not unfrequently, both the upper and lower are affected with ectropium. The skin having been destroyed from the margin of the eyelid to the eyebrow, or to the cheek, the lid is folded completely back, and adheres throughout its whole length to the edge of the orbit. It often hap- pens that the skin round the everted eyelids having also suffered, it is replaced by a hard unyielding cicatrice, stretching to the forehead, nose, cheek, and temple. The displacement being much greater in cases of this variety of eversion than in that which results from mere excoriation, the effects are still more annoying to the patient. The eye is more exposed to the contact of foreign substances, suffers oftener from inflammation, and is in a greater degree dis- figured. The feeling of cold in the eye, from want of the covering naturally afforded by the lids, is often distressing. The degree in which the everted lid is dragged from the eye is sometimes astonishing, and the consequent deformity actually hideous. For example, Cloquet notices4 the case of a patient in the Hdpital Saint-Louis, who had eversion of each lower lid, in consequence of syphilitic ulcers of the face. The left lower lid was drawn down to the outer part of the upper lip. The tarsus had not been destroyed, but elongated ; and formed, on a level with 224 ECTROPIUM FROM A CICATRICE. the lip, a slight-curved elevation of a whitish color, from which proceeded the cilia. Treatment.—Such being the origin and effects of this variety of eversion, it comes to be a question how far it is curable, or, in other words, whether there be any method of removing or counteracting the contraction arising from cicatrization. This contraction, so far from diminishing of itself, gradually increases for some time after the process of cicatrization appears completed, in consequence of the absorption of the granulations, on which the new skin is formed. Mat- ters then appear for a while to remain stationary; but in the course of years, the everted eyelid will have loosened itself a little from its unnatural situation, and not quite so much of the eyeball will be exposed. In consequence of the mechanical motion to which the parts are subjected, a slight increase takes place in the flexibility of the cicatrized surface, and it becomes some- what less firmly attached to the subjacent textures. The parts, which were at first matted immovably together, yield a little to the motions impressed on them by external causes, and the absorbents appear to contribute to this slight relaxation, by removing some of the adventitious substance which bound down the integuments. This is all the return which is ever made to the natural state by the action of the parts themselves. The hand of art, however, has sought to relieve, not only the present variety of eversion, but similar consequences of cicatrization in various parts of the body, by a more speedy and effectual method. Celsus gives5 us an account of the operation, practised in his time, for the cure of this kind of eversion. It is the same operation as that employed by the ancients for lag- ophthalmos, and to which I have referred in the last section. When the disease was situated in the upper eyelid, an incision down to the cartilage was made, in the form of a crescent, the extremities of which were turned downwards. When the disease affected the lower lid, an incision of the same form was made there, the extremities still pointing downwards. The edges of these incisions were kept open as much as possible by means of lint put into the wound, so that they healed up by a slow process of granulation and cicatrization. It was expected that the space between the edges would be filled up by new substance, that the eyelid would consequently be consider- ably elongated, and would return to its natural position, or, in other words, that the eversion would be cured. This operation has been frequently tried in later times; but, so far from permanently curing eversion, it has often been found in the end to increase the very disease it was intended to relieve. Immediately after the incision, indeed, the eyelid can perhaps be brought nearly, if not altogether, into its natural situation ; and so long as the process of granulation is going on, the case continues at least much better than it had been before. As soon as the wound is healed, however, it is found that the eversion has begun to return, and at the end of some months, matters are probably rather worse than they were before the operation. 1. Extirpation of conjunctiva.—The following case, by Bordenave, suf- ficiently illustrates both the failure of the ancient operation, and the good effects of extirpating a portion of the conjunctiva, in this variety of, ever- sion :— Case 151.—A man, aged 21 years, had eversion of the right lower eyelid, from a cica- trice, the consequence of a burn of the face, which happened in infancy. The eversion was considerable, the protruding part of the eyelid presented a redness disagreeable to lookat, and the eye could not be covered by the lids. Bordenave found the cicatrice considerably flexible, and believed himself justified in hoping for a cure by the ordinary operation, which he performed some days afterwards, according to the prescribed rules. Having made a semilunar incision of moderate depth, below the tarsus, he separated ECTROPIUM FROM A CICATRICE. 225 the lips of the wound with charpie, and kept them in this state by adhesive plasters, com- presses, and a suitable bandage. Some days afterwards, suppuration took place. The eyelid appeared extremely relaxed, it covered almost entirely the eye, and the cure seemed certain. But these appearances of success were not of long duration; the cica- trice being completed, and the eyelid no longer restrained, things returned to their former state. Not convinced, however, of the faultiness of the operation, Bordenave believed that he had not performed it with sufficient exactness; and therefore repeated it, but with no better success. He says that he should now have despaired of curing the case, had not the patient's eagerness to be relieved forced him in some manner to try a different treatment. Seeing that he was unable to elongate the eyelid, in order to conceal the everted con- junctiva, he resolved to remove a portion of this membrane in almost all its length. This he did with a straight bistoury, and found the operation exceedingly beneficial. Some time after, the conjunctiva still protruding a little, he practised a second excision, which had all the success desired. In proportion as the conjunctiva cicatrized, the eyelid re- turned to its proper direction, it applied itself more immediately upon the eye; at last the eye closed much better, and the deformity became scarcely visible.6 In many cases, then, of eversion, arising from a cicatrice, the simple ope- ration of removing the palpebral conjunctiva may be sufficient. 2. Separation of unnatural adhesions, and extirpation of conjunctiva.— We meet with cases of eversion, caused by an external cicatrice, in which the dragging of the lid is too great to permit us to hope that the counteraction of an internal cicatrice will of itself suffice to restore the part to its natural situation.7 Under such circumstances, it may be proper to set free the everted lid from its morbid adhesions, and then to extirpate the conjunctiva. An incision being made through the cicatrice, or beyond it, and parallel to the everted cilia, the external surface of the lid is to be cautiously dissected from the parts to which it is bound down, so that it may be returned to its natural position. More or less of the conjunctiva, according to the degree of the eversion is then to be removed; after which compresses and a roller are to be applied, to keep the eyelid in the position to which it has been reduced, till the conjunctiva heals, and the external wound is cicatrized.8 Professor Chelius, however, does not trust to compresses and a roller, but to keep the edges of the wound apart till it granulates and cicatrizes, he passes two loops of thread through the skin of the eyelid, near its edge, and fastens them by plasters to the cheek, if it is the upper lid; to the brow, if it is the lower lid. Dzondi dressed the wound with resinous ointment mixed with cantharides, to insure a sufficiently copious process of granulation before cicatrization should commence. He then applied lunar caustic, in order to heal the wound quickly, a practice against which Chelius warns us, as exceedingly likely to cause absorption of the granulations, and thus to defeat the object of the treatment. It is rarely the case, that one operation of the sort now under consideration, suffices to cure a bad ectropium. Repeated operations are frequently neces- sary, a farther amendment being accomplished by each, till the lid or lids are restored to their natural position. 3. Separation of unnatural adhesions, and perpendicular transpositions of a quadrangular flap.—In cases of adhesion of the eyelid to the upper or lower edge of the orbit, Dr. Ammon proposes the following operation. The integuments, to the distance of an inch from the place of adhesion, being put on the stretch, so that the morbid connection of the eyelid to the orbit is brought completely into view, let an incision be made parallel to the edge of the orbit, and about half an inch distant from it, somewhat more extensive than the morbid adhesion. From the ends of this incision, carry two other smaller incisions to the edge of the orbit. The flap, thus circumscribed, is now to be dissected from the subjacent parts, taking care not to cut through the thin hard eyelid, where it adheres to the edge of the orbit, and avoiding, 15 226 ECTROPIUM FROM A CICATRICE. in the upper lid, the lachrymal ducts. The dissection being finished, and the wound cleared of blood, the eye is to be shut, and sutures applied, so that the eyelid may remain in the state of replacement and elongation to which it has been restored by the operation.9 The objection to this mode of operating is, that a large wound will be left to fill up by granulation. 4. Perpendicular transposition of a triangular flap.—The following case illustrates a mode of operating, which Mr. Wharton Jones has found success- ful in eversion and shortening of the upper eyelid, from contraction of the skin consequent to burns. The peculiarity of the plan consists in the two following particulars : 1. The eyelid is set free by incisions made in such a way that, when the eyelid is brought back into its natural position, the gap which is left may be filled up by approximating its edges, and thus obtaining immediate union. TJnlike the Celsian operation, the narrower the cicatrice the more secure the result. 2. The flap of skin, embraced by the incisions, is not separated from the adjacent bone, but advantage being taken of the looseness of the cellular tissue between the skin and the bone, the flap is pressed downwards, and thus the eyelid is set free. The success of the ope- ration depends on the looseness of the cellular tissue. For some days before the operation, therefore, the skin should be often moved up and down over the frontal bone, to render the cellular tissue more yielding. Case 152.—A woman, aged 24, had her face much scarred. Both eyeballs were quite exposed, on account of shortening and eversion of the upper eyelids. On the left side, the eversion of the upper eyelid was not so great as on the right. On this side, the ciliary margin of the tarsal cartilage corresponded to the edge of the orbit, and the opposite margin of the cartilage occupied the usual position of the tarsal margin, so that when an attempt was made to close the right eye, it was the orbital margin of the tarsal cartilage which was pressed down. There was some degree of shortening and eversion of the left lower eyelid. The patient saw very well with the right eye, but with the left, on account of some opacity of the cornea, she did not see well enough to recognize a person. At the age of one year and three months, she fell into the fire, and had her face severely burned, which was the cause of the state above mentioned. Two years before coming under the care of Mr. Jones, she had an operation performed on the left eye, and was improved by it. The eversion had probably only been lessened by the operation, for the shortening of the upper eyelid was still very great. On the 22d February, 1836, Mr. J. operated on the left upper eyelid. He made two incisions through the skin, from over the angles of the eye upwards. The incisions con- verged towards each other, and met at a point somewhat more than an inch from the adherent ciliary margin of the eyelid. By pressing down the triangular flap thus made, and cutting all opposing bridles of cellular tissue, but without separating the flap from the subjacent parts, he was able to bring down the eyelid nearly into its natural situation by the mere stretching of the subjacent cellular tissue. A piece of the everted conjunc- tiva was snipped off. The edges of the gap, left by the drawing down of the Cap, were now brought together by suture, and the eyelid was retained in its proper place by plas- ters, compress, and bandage. During the healing of the wound, a small piece of the apex of the flap, which had been too much separated from the subjacent parts, sloughed. By the 1st April, the parts were healed, and the eversion completely cured. The cicatrice, where the part sloughed, was pretty broad. When the bandages were first left off, the eyelid was so much elon- gated, that if the lower lid had not also been shortened, the eye would have been entirely covered. After leaving off the bandages, some shortening took place, not from contrac- tion of the cicatrice, but of the skin. Being no longer on the stretch, the skin assumed, as it contracted, more of its natural appearance. About the middle of March, Mr. J. operated on the right upper eyelid. He made the incisions in a similar way, except that they did not meet in a point, a space being left between their extremities of about one-sixth of an inch in length, which was divided by a transverse cut. By the stretching of the subjacent cellular tissue, Mr. J. succeeded in drawing down the flap, and thus elongated the eyelid so much as to cover the eye entirely; but in con- sequence of the long-continued displacement of the tarsal cartilage, the ciliary margin of it did not come into contact with the eyeball. He did not interfere with this state of parts, by attempting any transverse shortening of the lid. In the operation, he removed a piece of the everted conjunctiva, and with it a bit of the tarsal cartilage. From the ECTROPIUM FROM A CICATRICE. 22? surface of this wound there sprung out a small soft fungus, which was cut off with the Bcissors, and the root touched with the lunar caustic pencil.I0 Fig. 18. Fig. 19. Fig. 18. a a Converging incisions. 6 Cross-cut uniting them. These three incisions enclose the flap, which is slid down by the yielding of the cel- lular tissue. Fig. 19. shows the parts when healed, a The cicatrice where the gap was. bbbb The marks of the sutures. Fig. 20. 5. Separation of unnatural adhesions, extirpation of conjunctiva, and ex- cision of a wedge-shaped portion of the eyelid.—When the edge of the everted eyelid is much elongated from canthus to canthus, the integuments of the lid destroyed, and its remaining substance firmly adherent to the bones forming the edge of the orbit, the following plan, first practised by Sir William Adams,11 may be adopted with advantage :__ In the first place, the everted eyelid is to be separated from its unnatural adhesions. In the second place, the palpebral conjunctiva, especially if it be much thickened, is to be extirpated. In the third place, in order to coun- teract the morbid elongation of the eyelid from the outer to the inner can- thus, a portion of the whole thickness of the eyelid, of the shape of the letter a (Fig. 20), is to be cut out with the scissors, after which, the edges of the last wound are to be brought together with an insect pin or two, and a twisted thread. This makes the eyelid sit close upon the eyeball, as in health, and completely cures the eversion. The wedge-shaped portion has generally been removed from the middle of the lid; but as the scar which results, produces some degree of deformity, it is preferable to cut out the piece near the temporal ex- tremity, as here the scar is less apparent, and produces less interruption of the mo- tions of the part. The size of the piece to be removed, depends on the degree of the 228 ECTROPIUM FROM A CICATRICE. transverse elongation of the everted eyelid, and must therefore be left to the judgment of the operator. He must avoid cutting out too much, as, in this case, the parts will be so shortened, that the edges of the wound will not be brought into contact without stretching them so as to produce ulceration, thereby detaching the parts before union is effected, and leaving them in a worse condition than they were at first. By the speedy union of the edges of the wound left by the excision of the wedge-shaped portion, the eyelid will be retained in its place, and the clanger of the integuments readhering to the orbit be, in a great measure, prevented. To aid, however, in the cure, the eyelid should be covered with a spread pledget, and supported, against the eyeball, by a compress and roller. The opposite eye should be closed and covered, so that it may be kept at rest. The following case shows how the operation may be sometimes modified, and the eyelid supported in a different way, from that just mentioned. Case 153.—In a case of eversion of the lower eyelid, Professor Griife first cut out a wedge-shaped portion of the eyelid, and united the edges of the wound by means of the harelip suture ; but just before twisting the thread round the pins, he divided the skin of the cheek to the extent of I\ inch by an incision concentric with the edge of the orbit. He then twisted the threads, drew the ends of them upwards, and fixed them to the fore- head by sticking-plaster, so that the edge of the lower eyelid might be raised sufficiently. The incision through the skin of the cheek was thus made to gape, and in order to heal it with a broad scar, the edges were kept separate by a crescentic plate of lead, which was pressed in between the lips of the wound, and retained by strips of plaster. The wound of the eyelid was quite united on the third day, and that into which the plate of lead was inserted was cicatrized in the fourth week, the size and situation of the eyelid appearing natural.IZ 6. Separation of unnatural adhesions, excision of a portion of the edge of eyelid, perpendicular and lateral extension of the eyelid and neighboring in- teguments.—When the deformity is considerable, in cases of lagophthalmos or ectropium, produced by cicatrization, both the transverse and perpendicular diameter of the eyelid are faulty in their dimensions. The perpendicular diameter, or breadth of the eyelid, is shortened; the transverse diameter is elongated. An operation has been proposed by Professor Jiiger, of Vienna, the object of which is to increase the perpendicular length of the eyelid, as well as to reduce its transverse elongation. Before proceeding to the operation, the difference in the length of the edge of the everted lid, and of the sound lid on the other side of the face, is to be accurately measured. In the operation, the transverse length of the everted lid is to be reduced to that of the sound one. In operating on the upper lid, the surgeon begins by taking hold of it about the centre of its edge, with a hook or forceps, and drawing it down- wards so as to put on the stretch the cicatrice, by which the lid adheres to the margin of the orbit. A horn spatula may be inserted between the lid and the eyeball, so as to protect the latter. With a small scalpel, a transverse incision is now to be made, about midway between the edge of the everted lid and the superciliary arch. The incision is to be commenced and termi- nated in sound skin, and is to be carried through the whole thickness of the lid, so as to permit its edge to fall down, and the eyeball to appear through the slit which has thus been formed. The length to which the incision is to be carried must depend on the circumstances of the case. The narrow slip separating the natural rima palpebrals from the artificial opening formed by the incision just described, is the part in which the reduc- tion of the transverse diameter of the lid is to be made. The size of the portion which ought to be removed, is already known from the measurements made before the operation was commenced. The portion removed will gene- rally have a quadrilateral form. With forceps and scissors, this part of the operation is easily effected. ECTROPIUM FROM A CICATRICE. 229 A straight double-edged scalpel is now to be used, for separating any unnatural adhesions of the lid, and for detaching the integuments from the os frontis. Taking hold of the upper lid of the wound with the forceps, and separating it a little from the edge of the orbit, the scalpel is to be intro- duced upwards, between the posterior surface of the orbicular muscle and the anterior surface of the frontal bone. The scalpel is now to be carried with a sawing motion towards the temple and external canthus, and then towards the middle line of the forehead, without enlarging the original wound of the lid, transfixing the skin, or injuring the periosteum. By this process, the skin and muscle covering the supra-orbital region and angles of the orbit are loosened from the subjacent parts, and rendered capable of undergoing a change in their position. The height to which the scalpel will require to be carried, and the extent in the transverse direction to which the integuments ought to be detached, must always be proportionate to the loss of the palpe- bral substance, and the different degrees of mobility of the skin of the forehead. The wounds are now to be united by the interrupted suture. In the first place, the bridge or narrow slip of the lid, whence the quadrangular portion was removed, is to be united by two stitches. Then the integuments, which have been loosened from the supra-orbital space and angles of the orbit, are to be pressed downwards by the assistant, over the eyeball, so that the edges of the transverse wound of the lid may be brought together. A stitch is to be inserted near the middle of the transverse wound, so as to act as a central point of traction upon the surrounding integuments. Should the upper lip of the wound not much exceed the lower lip in length, lateral stitches may be immediately inserted; and if, on the other hand, it exceed to the extent of forming a fold, this must be removed by the scalpel or scissors, in order that the edges of the wound may be nicely adjusted. The number of stitches required cannot a priori be determined. Coaptation of the wound having thus been effected, the eyeball is covered by integuments obtained partly from the supra-orbital region, but chiefly from the angles of the orbit; the eyebrow, however, will be somewhat more de- pressed, and describe a smaller and less convex arch than formerly. Professor Jager's operation upon the lower eyelid consists in removing a wedge-shaped piece from its edge, and in detaching the integuments from the margin of the orbit and the cheek, by a similar process to that already described for increasing the perpendicular diameter of the upper lid. The stitches are to be supported by interposing narrow strips of court- plaster. The wounds are then to be covered with small pieces of lint, and graduated compresses are to be placed upon the supra-orbital region, or cheek, according as the operation has been performed for the restoration of the upper or lower lid. Over the graduated compresses long strips of adhesive plaster are to run, being applied in such a manner as to draw the integuments to- wards the lid, and approximate them to the bones. When the upper lid has been operated on, the adhesive plaster may extend from the nape of the neck to the cheek. A roller may be applied to assist the action of the plasters, if it be deemed necessary. In the after-treatment, nothing ought to be omitted likely to effect union by the first intention. Smart inflammation, requiring active treatment for its removal; nausea and vomiting, demanding the use of opium and effervescing draughts; premature removal, from accident, of one or more of the stitches; and ulceration of the edges of the wounds; are among the unfavorable occurrences which occasion- ally supervene to the operation.13 7. Tarsoraphia.—It occasionally happens from an extensive burn, that both eyelids are everted, and dragged towards the temple. In such cases, 230 ECTROPIUM FROM A CICATRICE. besides dividing the cicatrice, removing part of the exposed conjunctiva, and perhaps cutting out a portion of the whole thickness of one or of both lids, it has been found useful to pare away a portion of the edges of the lids at their outer angle, and then to bring the two together by a stitch. This tar- soraphia, as it has been termed, reduces the opening between the lids to its natural length, and removes much of the deformity. A somewhat similar practice was followed by Le Dran, in a case of ever- sion of the lower lid, at the inner angle of the eye. lie removed the thick- ened conjunctiva, extirpated the cicatrice, and brought the edges of the wound together by two stitches.14 Professor Walther has published15 a case of traumatic eversion of the external angle of the lids, cured by the same plan. 8. Extirpation of cicatrice, and bringing together of the integuments from each side.—The lower lid being the seat of the ectropium, Dieffenbach re- moves a triangular flap of skin, including the cicatrice, of nearly three inches in length, the basis corresponding to the edge of the lid. With four or five pins, he brings the edges of the Fig. 21. Fig. 22. lower part of the wound together, in a vertical direction, and then the remaining parts of the wound, diverging from each other, are united in the same way to the edge of the tarsus. Zeis describes this method somewhat differently. The triangular portion of integu- ments, including the cicatrice, being removed, the incisions c a, c a (Fig. 21), are extended freely on each side, to allow of the ready approximation of the two sides, b, b. These being fixed by sutures, the two edges a c, c a, are now con- nected to the corresponding margin of the lower lid, included between c c. The appearance, after the sutures are applied, is such as is represented in Fig. 22.16 A similar operation was practised by Dieffenbach for eversion, involving both eyelids and their external commissure. He extirpated the commissure, along with a triangular piece of the neighboring integument, the basis of which was towards the eye, and the apex towards the ear. One curved in- cision was then carried above the supra-orbitary arch, and another beneath the lower orbitary margin, towards the nose, each incision measuring about 1^- inch in length. The two crescentic flaps thus formed were then raised, and after bringing them over the triangular wound, they were adapted as new lids to the remaining conjunctiva.17 9. Extirpation of cicatrice, and lateral transposition of a triangular flap.— Operations for the relief of ectropium, by transposing a portion of skin, are styled blepharoplastic. With respect to such operations, in general, it may be remarked, that though we cannot pretend to make a perfect eyelid by the transposition of a piece of skin, destitute of mucous lining, as,well as of cilia, lachrymal apparatus, cartilage, and muscles; yet a new eyelid, even of mere skin, covers and protects the eye, lessens deformity, and frees the patient from suffering. In attempting to supply a new eyelid, we should save the con- junctiva as much as possible, cutting none of it away, but separating it, if necessary, from the diseased integuments. We ought to lay the flap of trans- posed skin on the conjunctiva, so that they may adhere together. We should save, with the same care, the border of the old eyelid, with its cilia, and unite ECTROPIUM FROM A CICATRICE. 231 it by sutures, to the edge of the flap. The puncta and lachrymal canals ought also to be spared. As it is not likely that the new eyelid will possess much muscular motion, we must avoid making it either too large or too small. Dieffenbach appears to have tried many ways of forming new eyelids by transposition of skin. The following does not appear to have ultimately retained his good opinion, as he says nothing of it in his latest work, Die Operative Chirurgie. As it was successfully adopted, however, not only by himself, but by Lisfranc, Ammon, Eckstrbm, Blasius, Fricke, and Chelius, I think it proper still to describe it. The cicatrice is first to be extirpated, and a triangular form given to the wound, the basis of the triangle being always turned towards the eye. In this part of the operation, the ciliary edge of the eyelid, if present, is to be preserved; but if the ulceration has destroyed the whole eyelid, except the conjunctiva, this membrane is to be detached from the parts to which it ad- heres, in the course of a line drawn from the inner to the outer angle of the eye, and laid out upon the eyeball. The triangular space being thus pre- pared, into which the flap of skin is to be transplanted, an incision is to be made from the temporal extremity of the basis of the triangle, in the direction of the Fig. 23. meatus auditorius, whether it be the upper or the lower lid which is to be supplied. This incision of the skin should be con- siderably longer than the basis of the triangular wound. From the temporal extremity of this incision, another is now to be carried upwards, if it is the upper lid which is to be supplied, downwards, if it is the lower, and in either case parallel to the temporal edge of the triangular wound. These incisions are the bound- aries of the flap, which, being transposed, is to form the new eyelid. The flap is now to be dissected from the subjacent parts. The bleeding having ceased, and [From Lawrence.] the internal surface of the flap being freed from coagulated blood, the flap is to be drawn from without inwards, so that its inner edge is brought into contact with the inner edge of the triangular wound. These two edges are first of all to be steadied by a stitch at the inner canthus; then the tarsal edge of the flap and the conjunc- tiva are to be brought together by fine silk stitches; and lastly, the inner edge of the flap is to be connected by Dieffenbach's suture to the internal edge of the triangular wound. Except by Chelius, the temporal edge of the flap is not connected by sutures. The triangular space left by the transposition of the flap is generally covered with lint and adhesive plasters, so applied that they serve also to support the new eyelid in its place. Should suppura- tion take place, in the course of the cure, beneath the transposed flap, the matter formed will escape from under its temporal edge. Cold applications are recommended, as most likely to promote speedy adhesion, and prevent suppuration.18 Case 154.—Mrs. S. had the misfortune to have her face sadly disfigured by syphilis. She lost her nose; her upper lip was so much shortened, that she could not cover the teeth of the upper jaw ; the left upper eyelid was destroyed, and the lower in a state of complete ectropium. Several extensive cicatrices on the hairy scalp and forehead showed the previous existence of necrosis, with exfoliations of the outer table of the skull. A considerable portion of the upper, outer, and lower edge of the orbit had been lost in this 232 ECTROPIUM FROM A CICATRICE. way. The greater part of the left upper eyelid was so completely removed by ulceration, that its remains surrounded merely, without covering, the eyeball. The conjunctiva of the small portion which remained was turned outwards, and its tarsal edge very irregular. Fig. 24. Fig. 25. [From Lawrence.] [From Lawrence.] Dr. Ammon began his operation by insulating and separating from the temple the flap of skin, by which the defective upper eyelid was to be supplied; he then divided all the adhesions of the old eyelid, and prepared the place for the reception of the new one. He formed the flap by a horizontal incision two inches and a half in length, to which he joined a perpendicular one, bounding the flap towards the temple, and then dissected it off. He reduced the shrunken remains of the old eyelid with the bistoury ; but unfor- tunately found it impossible to separate enough of conjunctiva from it, to form a lining membrane for the new eyelid. As soon as the bleeding had ceased, the flap forming the new eyelid having been brought into such a position that it covered the eye, it was secured along its inner edge by Dieffen- bach's suture ; and thus ended the formation of the upper eyelid. To remedy the ectropium of the lower eyelid, Dr. Ammon first of all carried an incision through the skin, parallel to the edge of the lid, and then dissected it from its unnatural adhesions; he next extirpated a horizontal fold of the exuberant conjunctiva; and lastly, having made a cut like a button-hole through the lid, about 4 lines from its edge, by means of a ligature, he laid hold of that part of the conjunctiva which still remained attached to the tarsal portion of the lid, drew out the ligature through this wound, and so fixed the lid in its natural position. At the temporal angle, the upper and lower eyelids were now connected by the twisted suture, which, after some hours, was removed, Dr. Ammon fearing that thereby the fissura palpebrarum might be made too small. The wound on the temple, caused by the trans- plantation of the new eyelid, was covered with charpie, and a thick compress wet with water. Next day, the transplanted skin was somewhat swollen, so much so that the fissura palpebrarum was no longer visible, and the eyeball was entirely concealed. By injecting tepid water, Dr. Ammon removed the matter which collected on the eye; but, notwith- standing this precaution, a considerable oedema of the conjunctiva took place. Union of the inner edge of the transplanted flap was not entirely effected by the first intention, so that, as the stitches were gradually withdrawn, strips of sticking plaster were applied. The wound on the temple granulated favorably. The cut through the lower eyelid, into which the conjunctiva had been drawn, closed perfectly; so that the eyelid, after the oedema had subsided, maintained its proper position. The granulation of the wound on the temple proceeded, and along with it the formation of the new outer canthus. Three weeks after the operation, the fissura palpebrarum appearing too small, Dr. Ammon slit up the outer canthus as far as the edge of the orbit, and endeavored to prevent reunion by the introduction of charpie between the lips of the wound. Notwithstanding this, he was obliged, two months afterwards, not only to slit up the outer canthus again, but to extirpate a stripe of skin, so as to give to the fissura palpebrarum the proper degree of length ; in which he completely succeeded. The transposed flap forming the upper eyelid, assumed more and more of a natural appearance. The middle of it, however, continued to be oedematous and of a bluish color, till, on forming a new nose for Mrs. S. out of ber forehead, erysipelas came on and spread to the new eyelid; after which the oedema became greatly less, and at last vanished entirely. ECTROPIUM FROM A CICATRICE. 233 Seven months after its formation, the new eyelid closed over the eyeball, without irri- tating it; it could be lifted from it like a natural eyelid, but generally hung over it in a state of semi-ptosis. The cicatrice on the temple was very small, so that it was difficult to believe that so considerable a portion of the integuments had been taken from that part.19 10. Transplantation of a crescentic flap from the temple or the cheek.—Pro- fessor Jiingken proposed to extirpate the cicatrice, and then dilate the wound, so that by giving the lid sufficient length, it might assume its na- tural position. A piece of pasteboard was then to be taken, of the exact size and shape of the wound, and laid on the cheek, if the lower lid was the seat of the eversion ; on the temple, if it were the upper lid. The piece of skin covered by the pasteboard, except a narrow slip, which was to be left undivided, was now to be insulated by an incision; it was to be dissected from the parts it covered, with as much cellular substance attached to it as possible; and then twisted round into the wound left by the extirpation of the cicatrice. The bleeding was to be stopped by the application of cold water, the clotted blood removed, and the edges of the supplementary piece of skin connected with those of the wound left from the extirpation of the cicatrice, by means of stitches, strips of plaster, and a bandage. When there was reason to think that organic union had taken place be- tween the piece of skin and the subjacent surface, the connecting slip was to be divided, and returned as much as possible to its original place. The stitches were to be removed at the proper time, and the parts secured by sticking plaster alone, till entire union and cicatrization were effected. The wound caused by the abstraction of the piece of skin was to be closed as completely as possible by sticking plaster, that it might heal with a small scar.20 Professor Jiingken twice adopted this method, in cases of ectropium of the lower eyelid; but in both cases it failed entirely.31 Some such method appears, however, to have succeeded in the hands of Dr. Fricke of Ham- burgh.23 In later years, the operation has been frequently performed, both on the upper and on the lower lid. In general, it is performed without twisting the flap, as in the following case :— Case 155.—Maria Connell, aged 14, was admitted under my care at the Glasgow Eye Infirmary, 10th Aug. 1843. When about 16 months old, she received an injury by a gate falling upon her, in consequence of which an abscess formed in the left upper eyelid, and, bursting through the skin, discharged matter for many months. This was followed by ectropium, to such an extent, that, when the eyes are open, a large portion of the con- junctiva is exposed, and the cilia tilted up so as to be in contact with the eyebrow. (Fig. 26.) The ectropium is increased when the patient attempts to close the eye. There is a very great deficiency of skin in the everted eyelid, and it feels as if bound by a band to the inner surface of the orbit. The upper part of the left cornea is hazy, and vision of that eye so imperfect that she with difficulty distinguishes with it one finger from another. She keeps the eye constantly covered, to hide the deformity. The everted eyelid was divided transversely in the seat of the cicatrix, and the edges dissected so as to dilate the wound (Fig. 27, a, b), and allow the lid to resume its natural situation. A piece of pasteboard was laid on the temple, and the flap [b, c) was insulated with the scalpel, of the exact size and shape of the piece of pasteboard. The anterior edge of the flap was continued into the wound. The flap was now dissected off, except at its basis (6), turned round into the wound of the eyelid [b a), and connected with its edges by stitches. The edges of the wound on the temple were brought together by stitches. A considerable degree of ectropium still remained. Both eyes were covered with spread pledgets, and a double-headed roller applied from the hind-head forwards. 13th, The external dressings were removed. There is little or no swelling about the parts that were cut, and she makes no complaint of pain. The lid appears more in its natural place than it did immediately after the operation, owing probably to the support of the dressings and bandage. l^th, Three of the stitches removed. \ 234 ECTROPIUM FROM A CICATRICE. 15th, Six more of the stitches removed, being all those which served to keep the flap in its new situation. Two stitches remain in the wound on the temple, which appears quite united. There is considerable motion in the new eyelid. Stripes of court-plaster were applied in place of the stitches along the lid, and another stripe across both upper and lower lids. Compresses and a roller were applied over both eyes. Fig. 26. Fig. 27. 16th, All the stitches removed, as well as a ligature which was applied on one of the branches of the temporal artery. Two stripes of court-plaster applied across the left eyelids, and both eyes covered with a compress and roller. 21st, All the dressings omitted. 24th, On closing the eyes, without making any particular effort to do so, the left lids do not come together, but leave an interstice between their edges of about ^ inch in breadth; but on making an effort to close the eyes, the edges of the left lids come together perfectly. On looking straight forwards, the left lids are open almost exactly to the same extent as those of the right eye, but the eyeball is a very little directed more downward than the right. This seems the effect of having long retained the eye in that position previously to the operation. The cicatrice by which the upper edge of the flap is united to the eyelid forms a depression exactly in the situation of the natural sulcus, formed by the action of the levator muscle. The lower edge of the flap is united without any evi- dent cicatrice. The line by which the edges of the wound on the temple is united is scarcely distinguishable; and it would be impossible to discover, by mere inspection, that at B any turn or change of place had been given to the flap. Not the slightest eversion remains. From the very great deficiency of integument in the everted eyelid, there could be no hesitation as to the choice of an operation in this case. It was evident that a transplantation of skin only could remedy the deformity. Sup- pose that the tarsus had been drawn down into its natural position by an incision of the cicatrice, and an attempt made according to Chelius' plan, to, keep the edges of the wound apart till it granulated and cicatrized, months would have elapsed ere this could have been accomplished, and even after cicatrization was finished, the granulations would have been apt to be ab- sorbed, and the eversion to return; an event completely prevented by the blepharoplastic plan. It does not do to trust to the eye, in estimating the size of the flap which is to be insulated and detached. An exact measure of the wound, made in ECTROPIUM FROM A CICATRICE. 235 dividing the cicatrice and replacing the lid, must be transferred to the piece of pasteboard. Owing, however, to the contraction which the skin suffers, both in breadth and length, as soon as it is raised from its natural place, the flap requires to be somewhat broader and longer than the wound into which it is to be received. Fricke says it should be one line broader and longer, but this would scarcely be sufficient. At the same time, by applying numer- ous stitches as close as possible to the edges of the wound and of the flap, the latter may be extended considerably after it is adjusted to its new situa- tion, and by employing pretty thick compresses and a double-headed roller, it may be prevented from shrinking so much as it would otherwise do. [It might almost be said to be an axiom in plastic surgery, that the opera- tor never can make his flap too large. If he had dissected up a larger portion than the exact dimensions of the wound to be filled requires, it need cause him no alarm, for the tissue thus transposed will contract and accommo- date itself to the requirements of its new position. This we have seen occur again and again.—H.] Some operators would dissuade us from bringing the edges of the wound left by displacing the flap, together by suture lest the doing so should drag too much on the flap, and cause the stitches by which it is fixed to give way. They would allow it to heal by granulation. When a blepharoplastic operation is to be performed, the thickened conjunc- tiva should be left untouched, and no part of the skin, neither sound, nor hardened and contracted by previous cicatrization, nor any portion of the cellular substance, should in general be removed. The incision of the lids should pass through the middle of the cicatrice. The transplantation should then be accomplished; and when the incisions are healed, it will rarely be found necessary to interfere with the conjunctiva, or to shorten the lid trans- versely by the extirpation of any part of it. When the operation of restoring a lower lid is attempted, the flap has sometimes been taken from the cheek; but it appears to answer fully better to take it from Fig. 28. the temple, as was done by Dr. Brainard, in a case related93 by him, and of which Fig. 28 shows the situation whence the flap was taken, and the adaptation of it by sutures to supply the place of the defective lid. One of the chief dangers attendant on such blepharoplastic operations is gangrene of the transplanted flap. This may arise from the basis by which it retains part of its natural connections being too narrow, from its not being kept closely in contact with the wound to which it is transferred, or, on the other hand, from being too much pressed against the bones by the compress and roller. Another untoward event is the flap not continuing to lie flat and in contact with the wound, but curling gradually up into a globular mass, so that, as Dieffenbach says, it looks more like the point of the nose than an eyelid. The success of a blepharoplastic operation depends much on the state of the integuments, whence the flap is to be taken. The prospect is good, if the skin to be transplanted is healthy. In this state it is very extensible, so that it may be transferred from its natural place to a degree that it is scarcely con- ceivable. But if the skin to be transplanted is changed in structure from inflammation and cicatrization, the chance of success is much reduced. 236 ECTROPIUM FROM CARIES OF THE ORBIT. § 4. Eversion from Caries of the Orbit. Syn.—Ectropium symptomaticum. Fig. Dalrymple, PI. II. Fig. 3. I have already had occasion to refer (pages T6 and 81) to the great degree of shortening of the lid, with which eversion from caries of the orbit is gene- rally attended, and to a circumstance which we may remark more or less in every variety of this disease, but which is often very strikingly displayed in those cases where the upper lid is dragged up under the edge of the orbit, from an affection of the bone, namely, the degree of accommodation of the lower lid to the deficient state of the upper. Cases such as those represented in Figs. 1, 2, and 3 (page ?6), may often be relieved by one or other of the operations recommended for the third variety of eversion, and particularly by those compound ones in which the morbid adhesions are separated, the eyelid and neighboring integuments extended, the thickened conjunctiva removed, and a wedge-shaped portion of the eyelid cut out. If the distortion, however, is slight, it ought not to be meddled with, or merely a fold of conjunctiva ought to be extirpated, without interfering with the skin, or attempting to detach the cicatrice. When the distortion is very great, we may be led to attempt a blepharoplastic operation. Dr. Ammon, in a case of eversion, with adhesion of the cicatrice to the outer surface of the edge of the orbit, surrounded the deeply depressed cicatrice by an incision, left it adherent to the bone, detached the neighboring integu- ments all round to such an extent that the lid was set at liberty, and the patient could shut the eye, and then closed the external wound over the old cicatrice. The lid was in this way elongated, a scarcely observable scar ensued, and the disagreeable depression at the edge of the orbit was no longer in view.24 By a still simpler operation, Mr. Wilde relieved a similar case, of which he gives a figure, not materially different from Fig. 1, p. *76:— Case 156.—The parts above and below the cicatrice being made as tense as possible, Mr. AVilde introduced a small narrow-bladed and double-edged knife, at the distance of nearly an inch on the outer side of the cicatrice, passed it obliquely down to the bone, and under the cicatrice, and moving it in a semicircular manner from above downwards, and at the same time pushing it forwards, he detached the entire adhesion, and nearly an inch' on each side of it, fully from the bone. As'soon as it was found perfectly free, and that the lid could be restored to its normal position, the knife was withdrawn, and the small wound closed with adhesive plaster. The effusion of blood which immediately took place beneath the cicatrice, caused a tumor where the depressions had existed, and care was taken that none of this blood escaped through the external wound. A ligature was then passed through the lower lid, about one-quarter of an inch from the ciliary margin, and the ends of it drawn up and attached to the forehead during the next three days. Cold applications were applied, and Mr. W. had the satisfaction to find that, within a fortnight afterwards, the deformity was completely removed, the depression of the cheek filled up, and the lid restored to its natural position.25 1 Practical Treatise on the Diseases of the ' See case by Reil, in which extirpation of Eye, p. 228; London, 1820. conjunctiva was first tried, and failed; but a 2 See Guthrie's Lectures on the Operative cure afterwards effected by incision of the lid. Surgery of the Eye, p. 61 ; London, 1823. Duncan's Annals of Medicine; Vol. i. p. 159; 3 Staub de Blepharoplastice, p. 79; Berolini, Edinburgh, 1790. 1835. 8 See case by Curling, Medical Gazette; Vol. 4 Pathologie Chirurgicale, p. 136: PI. x. Fig. xxviii. p. 17 ; London, 1814. 17; Paris, 1831. 9 Zeitschrift fur die Ophthalmologic ; Vol. i. s De Re Medica; Lib. vii. Pars ii. Cap. i. p. 47; Dresden, 1830. Sect. 2. 10 Medical Gazette; Vol. xviii. p. 224; Lon- 6 Memoires de I'Academie Royale de Chi- don, 1836. rurgie; Tome xiii. p. 170; 12mo; Paris, 1774. ll Practical Observations on Ectropium, &c; TRICHIASIS AND DISTICHIASIS. 23Y London, 1814. To Sir William Adams belongs the merit of the operation described in the text. The reader, however, who has at all turned his attention to the history of this part of surgery, will at once trace the resemblanco of Sir Wil- liam's operation to that practised by Antyllus, some fourteen or fifteen centuries before. The incision practised by Antyllus, having the form of the Greek letter A, implicated only the structures on the inside of the lid, leaving the skin undivided. The lips of the wound were drawn together by a suture. Aetii Contractae ex Vcteribus Medicinal Tetrabiblos; Tetrabib. Ii. Sermo iii. cap. 72, p. 359; Basileae, 1549. 12 Bericht iiber das clinische chirurgisch- augeniirztliche Institut der Universitat zu Ber- lin, fur 1829 und 1830, p. 9; Berlin, 1831. 13 Dreyer,NovaBlepharoplastices Methodus, p. 40 ; Vindobonse, 1831: Brown, London Me- dical Gazette; Vol. xvii. p. 721; and Vol. xviii. p. 485. 14 M6moires de l'Acad6mie Royale de Chi- rurgie; Tome ii. p. 343 ; 12mo; Paris, 1780. 16 Grafe und AValther's Journal der Chirur- gie und Augenheilkunde; Vol. ix. p. 86; Ber- lin, 1826. 16 Review of Zeis's Handbuch der plastichen Chirurgie, in British and Foreign Medical Re- view, for April, 1839, p. 406. 11 Ibid. 18 Ammon's Zeitschrift fiir die Ophthalmo- logic ; Vol. iv. p. 428 ; Heidelberg, 1835 ; Staub. Op. cit. p. 98 : Chelius, Handbuch der Augen- heilkunde; Vol. ii. p. 166; Stuttgart, 1839. 19 Zeitschrift fiir die Ophthalmologic; Vol. v. p. 313; Heidelberg, 1836. 20 Lehre von den Augenoperationen, p. 267; Berlin, 1829. 31 Ibid. p. 9. 22 Die Bildung neuer Augenlider; Hamburg, 1829. Delpech has published an interesting case of restoration of part of the lower eyelid, and side of the nose, by an autoplastic opera- tion, in his Chirurgie Clinique de Montpellier; Tome ii. pp. 221, 253; Paris, 1828. See case by Horner, American Journal of the Medical Sciences; Vol. xxi. p. 105 ; Philadelphia, 1837. 23 American Journal of the Medical Sciences, for October, 1845, p. 356. 24 Zeitschrift fiir die Ophthalmologic; Vol. i. p. 49 ; Dresden, 1831. 25 Dublin Quarterly Journal of Medical Sci- ence, for May, 1848, p. 473. SECTION XXXIV.—TRICHIASIS AND DISTICHIASIS. Tf>i^i'a?, having two rows. Fig. Ammon, Zweiter Theil. Tab. IV. Figs. 9, 10. Dalrymple, PI. II. Fig. 4. Trichiasis is an inversion of the eyelashes; distichiasis means a double row of eyelashes, the inner row, or pseudo-cilia, as they are termed, being turned in upon the eyeball. The fact is, however, that what are called pseudo-cilia in distichiasis, although they issue from the skin at a wrong place, and grow in a wrong direction, are seldom, if ever, new or supernumerary productions, but merely natural cilia, the bulbs of which have been displaced by pressure or by disease, affecting the border of the eyelid. Symptoms.—We very seldom find all the eyelashes turned towards the eye- ball, except when the trichiasis is merely a symptom of inversion of Fig. 29. the edge of the eyelid, a disease which we leave out of view for the present, and even when it is a symp- tom of inversion of the edge of the eyelid, the trichiasis is often partial. In the same manner, the displaced cilia in distichiasis (Fig. 29) seldom occupy the whole length of the eye- lid ; but in most cases are strewed here and there in parcels, between the natural cilia and the Meibomian apertures, but generally nearer to the latter. In some instances, we find the outer margin of the lid rounded off, and the whole space between it and the Meibomian aper- tures covered with cilia. When only one or two small colorless eyelashes are inverted, they are apt to escape being noticed, and the diseased appearances of the eye, which are 238 TRICHIASIS AND DISTICHIASIS. owing to their irritation, are supposed to be occasioned by some disorder of the eyeball itself. Means are even directed against the effects while the cause is overlooked, and the eye may be seriously injured, and even vision lost, from a derangement so minute that it is apt to pass unobserved. In every case in which recovery from an attack of ophthalmia proceeds with more than ordi- nary slowness, the surface of the cornea continuing dim, and strewed with bloodvessels, the eye discharging tears upon the smallest increase of light, and the patient complaining of the sensation of a foreign body rubbing against the eye, we ought carefully to examine the edges of the eyelids, and discover whether any of the eyelashes be inverted. In distichiasis especially, the dis- placed eyelashes are in general so soft, short, and light-colored, that they can be seen only when the eyelids are opened wide, but at the same time allowed to remain in contact with the eyeball. The moment that the edge of the lid is drawn forwards from touching the eyeball, the displaced cilia are scarcely or not at all visible. On again applying the edge of the lid to the eyeball, so that the iris, or the pupil, forms a contrasting background to them, the cilia return into view. Condensing the light upon them by means of a convex lens, assists in rendering them visible. Trichiasis and distichiasis affect the upper, much oftener than the lower eyelid. This may, perhaps, depend on the natural disposition of the borders of the two eyelids; the border of the upper being directed downwards and inwards, while that of the lower is turned upwards and outwards. Causes.—Trichiasis and distichiasis are in an especial manner the conse- quences of neglected catarrhal ophthalmia, scrofulous ophthalmia, and oph- thalmia tarsi. Smallpox was formerly a very abundant source of these derange- ments of the cilia. Burns of the conjunctiva and edge of the lid, and every affection attended with abscesses and ulcers at the roots of the eyelashes, are apt to give rise to trichiasis and distichiasis, especially if the patient is allowed to lie much on the face, so that the cilia, loaded with mucus, or matted together by the diseased secretion of the Meibomian follicles, are forced in a constant direction towards the eyeball. I have seen a swollen state of the upper lid from syphilitic inflammation, caused by pressure of trichiasis of the lower lid. The exciting causes of trichiasis, such as those now enumerated, produce, as Mr. Wilde has pointed out,1 an unhealthy deposit in the interspaces be- tween the roots of the cilia, along with a contracted state of the conjunctiva, which may be regarded as the proximate cause. Palliative cure. Evulsion.—The palliative cure of trichiasis and distichiasis consists in removing one after the other, all the inverted and misplaced cilia, by means of a proper pair of forceps. (Fig. 30.) The best cilia-forceps are Fig. 30. those without teeth; the surfaces which meet, to lay hold of the hair, being merely roughened. Each eyelash is to be laid hold of as close as possible to the skin, and pulled out in a straight direction, in order that it may not break. Except when the edge of the lid is perfect, and the trichiasis entirely the result of the cilia having been matted together by mucus, this operation must be regarded as calculated to afford merely temporary relief. Carefully and frequently repeated, it occasionally proves, even in cases of distichiasis, espe- cially in young subjects, a radical means of cure ; but on this we cannot de- TRICHIASIS AND DISTICHIASIS. 239 pend, and, therefore, as soon as the inverted or displaced cilia reappear they must again be extracted. We meet with patients who for many years' have been obliged, every eight days or oftener, 4o have this repeated. " Radical cure.—The constant repetition even of the trifling operation of evulsion being found by many extremely annoying, we are often asked whether there is no means by which trichiasis or distichiasis can be permanently removed. With this view, the following plans have been had recourse to :— 1. Restoring to the cilia their natural direction.—The practice of turning the distorted hairs into their proper direction, and cementing them to the other cilia, or to the skin, is not altogether to be despised. When the dis- torted hairs in trichiasis are long, by keeping them for a fortnight or three weeks in their natural direction, a cure may sometimes be effected. For this purpose, collodion may be used, or strong shell-lac varnish. A little of one or other of these fluids, taken up on the point of a bit of wood, is to be applied to the distorted hairs, and those beside them, so as to mat them to- gether, and bind them down to the skin. The parts must be examined daily, and retouched, if the crust formed by the drying of the collodion, or the varnish, has anywhere given way.3 This practice will be of no service in distichiasis. 2. Extirpation of a fold of skin—In cases of trichiasis, in which, for a considerable space along the edge of either lid, the eyelashes, instead of standing out horizontally with their natural curve, are directed perpendicu- larly, so as to cling to the surface of the eyeball, and this without any • irregularity or disorganization of the edge of the lid, we generally find that by laying hold of a transverse fold of the skin of the lid, the eyelashes assume their proper direction. Estimating, then, the quantity of skin necessary to produce this effect, we lay hold of it with the entropium forceps (Fig. 16, p. 213), clip it out with a stroke or two of the scissors, and bring the edges of the wound together with two or three stitches. _ 3. Cauterization of the skin.—The same thing may be effected by cauteriza- tion, actual or potential. A smooth horn spatula (Fig. 31), convex on the Fig. 31. one side, and concave on the other, and grooved transversely on its convex side, a little way from its extremity a, is to be passed between the eyeball and lid, in such a way that the edge of the lid shall rest in the transverse groove, and the lid be put on the stretch by pressing the spatula a little forwards. A small, flat cautery, about the twentieth of an inch in thickness, raised to a white heat, is then to be drawn along the skin of the lid, parallel to the eyelashes, and at the distance of about the twentieth of an inch from them. The same cauterization may be effected by a pencil of pure potash pointed by dipping the end of it in water. When the eschar separates a* slight ectropium will result from the contraction of the cicatrice, and the eyelashes will resume their natural direction.3 The direction of single inverted hairs may be corrected, by running the point of a lancet into the edge of the lid immediately to the outside of the 240 TRICHIASIS AND DISTICHIASIS. root of the hair, and inserting into this little wound a speck of pure potash, thus producing a small ulcer, which, in cicatrizing, alters the direction of the hair. 4. Destruction of the bulbs by inflammation.—The effect of inflammation in destroying the ciliary bulbs, or hair capsules, as exemplified in ophthalmia tarsi, smallpox, &c, which sometimes leave the lids affected with partial madarosis, or baldness, has suggested the plan of exciting artificially such inflammation in these secreting organs of the cilia as shall be sufficient to destroy them, or at least render them incapable of continuing their function. Celsus, and even modern surgeons, have used the actual cautery for this purpose; but, generally, inoculation with some irritant has been preferred, such, for instance, as the tartrate of antimony. The parts being put on the stretch by means of a small hook, or over the horn spatula, the bulb is to be punctured with a lancet, or an iris-knife, which should be entered close to the base of the inverted cilium, in the direction of its growth, to the depth of ^ inch, and moved about a little so as to widen the bottom of the wound, and cut the bulb. The bleeding having wholly ceased, and the lid being wiped quite dry, the inoculation is to be effected with the point of a small probe, or the drilled end of a darning-needle, slightly damped, and dipped in powdered tartrate of antimony, inserted into the punc- ture, and held there for a few seconds ; or the same may he done with a bit of platinum foil, shaped like a lancet, heated, covered with a very thin coating of sealing-wax, and pushed, while hot, into powdered tartar emetic. The eyelash is now to be seized close to its root, and extracted. Bulb after bulb is to be treated in this way. The inflammation which immediately follows, generally subsides in twenty-four hours ; but if the operation has been pro- perly performed, it recurs in a day or two, with the formation of small pus- tules, and though of very limited extent, is sufficient to destroy the functions of the bulbs. Dr. James Hunter, to whom we are indebted for this plan of curing trichiasis and distichiasis, tried alcohol, nitric acid, aqua ammonise, capsicum; euphorbium, and croton oil, for inoculating the bulbs; but these substances were ineffectual.* 5. Excision of the edge of the eyelid.—Some operators have contented themselves, in cases of trichiasis, with the simple plan of paring away the edge of the eyelid, removing in this way that part of the lid whence the cilia grow, as well as the Meibomian apertures.5 I remember seeing a Jew girl in Yienna, who had been operated on in this manner by Dr. C. J'ager. The pain and inflammation of the eye, and the opacity of the cornea, caused by the inverted lashes, were of course removed, and the deformity, produced by this curtailment of the lids, was very trifling. A perpetual tendency to lip- pitudo, however, must follow the obliteration of the Meibomian canals. Dr. Jacob performs essentially the same operation, in the following manner: He passes the point of a fine hook beneath the lid, and draws the hook to- wards him till its point shows through the skin, at a distance of about a line from the external angle of the eye. He, then, with common straight scissors, cuts into the lid between the point hooked and the external angle of the eye, continuing the incision by repeated clips along the lid, and at a distance of something more than a line from the margin, until he comes to the punctum. In fact, he clips away the ciliary margin of the eyelid from the external angle to the punctum, including skin, cartilage, and roots of the cilia, not leaving any notch at either end, but sloping the incision as he cuts in at the external angle and out at the punctum, thus obtaining a regular edge, and leaving a portion of the cartilage sufficient to preserve the form and motions of the lid.0 6. Extirpation of a stripe of the integuments, including the bulbs of the TRICHIASIS AND DISTICHIASIS. 241 cilia___The operation proposed by Professor Jager,7 for the cure of trichiasis, is one of the most efficient. It differs both from Mr. Saunders' extirpation of the cartilage, and from the paring of the edge of the lid just mentioned. It consists in removing that portion of the integuments under which lie the bulbs of the cilia, leaving the cartilage, and as far as possible, the Meibo- mian apertures, entire. The bulbs of the cilia must be removed, the lachry- mal canals and puncta being preserved ; if the trichiasis is only partial, then the operation is to be limited to the part where the eyelashes have a wrong direction. The horn spatula (Fig. 31) being introduced beneath the eyelid, and the skin put on the stretch, the skin, and orbicularis are divided, with a small scalpel, by a transverse incision, parallel to, and fully a line from, the diseased cilia; the spatula is now withdrawn, the ciliary edge of the wound laid hold of, at its temporal extremity, with a pair of toothed forceps8 (Fig. 32), and Fig. 32. by repeated strokes of the knife, the outer margin of the lid, along with some of the fibres of the orbicularis, and the whole bulbs of the cilia, is dissected off in a stripe. Dr. Jiiger leaves the wound to cicatrize ; Mr. Wilde brings its edges together with fine sutures. If any of the bulbs of the cilia have escaped extirpation, they appear like black points in the wound, about the third or fourth day after the operation. Caustic should immediately be applied to them, so that they may be de- stroyed. 7. Excision or destruction of the bulbs of the cilia.—The following opera- tion is recommended9 by Yacca Berlinghieri, of Pisa :— The surgeon having ascertained the number of inverted eyelashes, and the extent which they occupy, with pen and ink traces a line on the skin, parallel to the margin of the eyelid, and at the distance of a quarter of a line from it. The line, drawn with a pen, should show upon the external surface of the eyelid the exact space occupied towards its internal surface by the dis- torted cilia. The horn spatula (Fig. 31) is now to be introduced between the lid and the globe of the eye, so that the edge of the lid is placed on the grooved part of the convex surface of the spatula. With one hand, the assistant holds the spatula, while, with the index and mid finger of the other hand, he keeps the lid fixed and on the stretch. The surgeon now makes two small vertical incisions through the integuments, with the scalpel, com- mencing a line and a half from the edge of the eyelid, and terminating exactly at its edge. These two incisions inclose the space on which the line was marked with ink. A transverse incision, parallel to the line so marked, is now to unite the two vertical incisions. The flap, circumscribed by these three incisions, is to be raised from the subjacent parts, so as to bring the bulbs of the cilia into view. It is not, however, always easy to see and extir- pate them, partly from the blood which conceals them, partly from the dense tissue which surrounds them and renders it difficult to lay hold of them. The surgeon, therefore, must cleanse the wound well from blood, and be provided with a good pair of fine forceps, with which, and a small scalpel, or scissors, he may remove all that lies between the everted flap and the external surface 16 242 TRICHIASIS AND DISTICHIASIS. of the tarsus. That being done, the operation is finished. The flap is re- placed in its natural position, and kept so by a strip of court-plaster. Having repeatedly performed this operation, I conceive a transverso incision, about a line from the margin of the lid, to be sufficient, without the two vertical ones. The incision gapes sufficiently to allow us to go on with the extirpation of the bulbs, without dissecting back any flap. The cellular tissue, surrounding the bulbs, however, is too dense to permit of being seized with forceps. I use, therefore, a small sharp hook, which I pass beneath the spot where I conceive the bulbs to lie, and raising the part seized with the hood, I snip it out with scissors. I then seize another and another bit, till I think I have accomplished the extirpation of all the faulty bulbs. If I have doubts about any of them, I touch the part with a pointed piece of potassa fusa. Next day the wound is healed, without any dressing. If the inverted cilia are placed at a considerable distance from one another, and in the interval between them there are cilia growing naturally, Yacca directs us to attack particularly the bulbs belonging to the distorted cilia, and not to uncover nor destroy the roots of the natural ones. He confesses that the extirpation of the bulbs, in the manner described, might puzzle one not accustomed to perform delicate operations. He tried, therefore, the plan of raising the flap as before, and destroying the bulbs with nitric acid. This may be better applied by means of a bit of wood, than by the contrivance used by Yacca. The cilia, of which the bulbs have been dissected out, or destroyed, would come away, about the sixth day after the operation; but it is better to pull them out immediately. I have repeatedly assisted my colleague Dr. Rainy, while he performed the following operation for trichiasis or distichiasis:— Everting the eyelid, and laying hold of it with a pair of forceps, he made an incision, with an extraction-knife, close and parallel to the inner edge of the border of the lid, and then another between the natural row of cilia and the inverted or displaced ones. He then extirpated the piece of the lid intervening between these two incisions, including the morbid cilia and their bulbs. It is difficult to make the incision deep enough, owing to the firmness of the cartilage and other textures. 8. Excision of a wedge-shaped portion of the lid.—When four or five eye- lashes, in a bundle, turn in upon the eye, we may cut out a triangular or narrow wedge-shaped piece of the whole thickness of the lid, including the faulty eyelashes, and bring the edges of the wound together by stitches, as in the operation recommended by Sir W. Adams for the cure of eversion. False eyelashes are sometimes met with, growing from different parts of the conjunctiva, even from the conjunctiva cornese. Dr. Monteath mentions10 a case, in which one exceedingly strong hair grew from the inner surface of the lower lid. It was directed perpendicularly towards the eyeball, and irri- tated it. The natural cilia were of a light color, the pseudo-cilium jet black, and double the strength of the common cilia. I once met with an eyelash fully an inch in length, soft, and woolly, in a patient who had long suffered from ophthalmia. 1 Dublin Journal of Medical Science for March, 1814, pp. 105, 109. 2 Jacob, in Dublin Hospital Reports; Vol. v. p. 394; Dublin, 1830. 3 Chirurgie Clinique de Montpellier, par Del- pech : Tome ii. p. 295 ; Paris, 1828. 4 Edinburgh Monthly Journal of Medical Science; Vol. i. p. 259; Edinburgh, 1849. * Heisteri Institutiones Chirurgicae; Vol. i. p. 514; Amstelsedami, 1750: Schreger, Chirur- gische Versuche; Vol. ii. p. 253; Niirnberg, 1818. 8 Jacob, Op. Cit. p. 391. 1 Hosp, Dissertatio sistens Diagnosin et Curam Radicalem Trichiasis, Distichiasis, nee non En- tropii; Vienna?; contained in Radius's Scrip- ENTROPIUM. 243 tores Ophthalmologic! Minores; Vol. i p. 199; from Blomer's forceps, which has two teeth pro Lipsiaj, 1826. jecting from the one blade, and one from the 8 The toothed forceps, figured in the text, other. have at the end of the one blade a tooth, which 9 Nuovo Metodo di curare la Trichiasis; Pisa, is received into an interstice at the end of the 1825. opposite blade. When shut, the instrument ap- I0 Translation of Weller's Manual; Vol. i. p. pears like a small probe. It differs, therefore, 115; Glasgow, 1821. SECTION XXXV.—ENTROPIUM, OR INVERSION OF THE EYELIDS. Entropium, from Iv, in, and Tf>s7r/ sion, to render the cornea vascular and nebu- ENTROPIUM. 245 lous. The pain they induce by rubbing against the eye, deprives the patient of the enjoyment of sight; he keeps his eyes constantly shut, and avoids everything which would produce motion of the lids or of the globe of the eye. At length, the cornea becomes quite opaque, and its conjunctival layer ac- quires a degree of morbid thickness and insensibility, which renders the pain attending the disease less distressing. Long previously to this, however, the whole conjunctiva has, in general, lost its secretive power, and become affected with xeroma. Irregular action of the orbicularis palpebrarum may also have to do with the production of this kind of inversion, but it is evident that the structure of the lid is here much more impaired. Inflammation has altered the gland- ular organs, the conjunctiva, the perichondrium, and even the cartilage itself. Repeated ulcerations have destroyed the form of the edge of the lid, notched it with cicatrices, and permanently fixed it in the state of contraction and inversion. 3. Traumatic entropium is generally the result of a scald or burn of the conjunctiva, or of the intrusion of some caustic substance, as quicklime, into the sinuses of the eyelids. It is often conjoined with a degree of symble- pharon, and sometimes the cartilage has been partially destroyed by the injury. Prognosis___This is favorable in the acute variety, as it is always curable by proper applications, or by operation. Sometimes the disease returns; only a temporary cure in either of these ways having been effected. In the chronic variety, the prognosis is much less favorable. Relief to the pain, and other urgent symptoms, may be obtained from operation, but the lids are apt to remain shrunk, the conjunctiva atrophied, and the cornea diseased. The prognosis in traumatic cases is very variable. Treatment.—1. The treatment of the traumatic variety will depend on the degree of the disease ; in slight cases, the operation about to be described as suitable for acute inversion will be sufficient; in worse cases, a similar plan of cure to that pursued in chronic inversion, may be necessary. As the one of these two kinds or degrees of inversion is much less complicated in its symptoms than the other, so is the method of cure for the one simple, for the other complex. Case 157.—In consequence of a wound of the upper lid with some sharp instrument, and the wound neglected, in a man who put himself under my care, the nasal half of the lid was inverted, and the patient sadly tormented by the irritation of the eyelashes. They were so much inverted as to be fairly on the inside of the portion of the lid to which they belonged. I made a vertical incision with a pair of scissors through the lid, where the nasal and temporal halves met, intending to snip out a fold of the skin, and then bring the edges accurately together by the interrupted suture. I found, however, that it would be unnecessary to remove any portion of the skin. As soon as the vertical incision of the lid was made, the nasal portion came itself into its place, so that I had merely to bring the edges of the incision together with two stitches. 2. In every case of inversion, acute or chronic, it is proper to endeavor to remove the conjunctival or the tarsal inflammation, in which the misplacement of the lids has originated. This is greatly promoted, in most cases, by clean- liness, fresh air, and proper attention to diet. The ophthalmia must be treated with the remedies which its peculiar nature demands; and on this point, the reader may consult the sections on ophthalmia tarsi, catarrhal, catarrho-rheu- matic, and scrofulous ophthalmia?. We meet with many cases in which an operation for entropium is the only means which can remove the ophthalmia, and save the eye. 3. Acute entropium sometimes, but, it must be confessed, very rarely, sub- sides under antiphlogistic means, aided by such mechanical contrivances as keep the lid in its natural place. For this purpose, strips of adhesive plaster used to be applied so as to cross each other upon the middle of the lid; or a 246 ENTROPIUM. small pad, sewed upon a piece of tape, was made to press upon the lid, the tape passing over the nose, under the ears, crossing on the occiput, and tying on the forehead. These means are now supplanted by collodion." The lid being held in its natural position, the whole of its external surface is to be painted by means of a smooth piece of stick, or camel-hair pencil, with collo- dion. This, drying instantly, keeps the lid from reassuming the state of inversion. The application must be renewed every two or three days, and sometimes it proves a radical cure. Before I read Mr. Bowman's paper on the subject, I covered the collodion with a bit of cloth, but this I have laid aside. In acute inversion, when we take hold of a transverse fold of the skin of the inverted lid, the displacement is for the time removed, and the patient can open and shut the eye without difficulty, and without any return of the inversion. Having laid hold, then, of the fold of skin with a pair of broad, convex-lipped forceps (Fig. 17, p. 213), remove it with the scissors, bring the edges of the wound together by two stitches, and as soon as union is completed, the inversion will be found to be cured. So much skin as is sufficient to overcome the inversion, and neither more nor less, is to be removed. After laying hold of the fold with the forceps, the surgeon must observe whether the cilia appear in their natural place, and have their proper direction. If they still incline inwards, the fold is too little, and more of the skin must be laid hold of; if the cilia not only incline out- wards, but the conjunctiva is brought into view, the fold is too broad, and less skin must be grasped with the instrument. In old people, it is sometimes necessary to remove a very broad piece of skin. Care must always be taken to leave sufficient integument between the cilia and the edge of the wound, for the insertion of the stitches. [We have seen this operation f6eiplaa-ii, from