No. 942. [1840-41. COURSE OF LECTURES ON THE DISEASES OF THE EYE, Delivered in 1840, AT THE ROYAL SCHOOL OF ANATOMY AND MEDICINE, MANCHESTER, By JOHN WALKER, Esq., Surgeon. (Second Division.) LECTURE XIII. Diseases of the Eyelids. AN individual but little accustomed to wit- ness ophthalmic affections might be inclined to suppose that there is not much either of interest or importance to be said respecting the diseases of the eyelids; I trust, how- ever, that I shall be able to make it appear that this portion of our subject has strong claims on your attention. Affections of the eyelids, as well as being sometimes productive of considerable de- formity, occasionally interfere with the inte- grity of vision, inasmuch as they are very apt to extend, through the medium of their conjunctival surface, to the textures of the globe. Thus, as I have on a former occasion more particularly pointed out, it is very com- mon to find that inflammation and opacity of the cornea have their origin in a morbidly vascular condition of the lining membrane of the lids, and that if the latter be remedied, the healthy condition of the former will often be restored. In some instances, likewise, morbid conditions of the lids act mechani- cally so as to injure the eye itself, as in the case of entropion; in which disease, the margin of the lid becoming inverted, the cilia are directed against the conjunctival cover- ing of the globe, and thus inflammation and opacity of the most inveterate character are often established. So that you will perceive, from these illustrations alone, that your knowledge of ophthalmic surgery will be very imperfect, if the morbid conditions of the palpebrae were to be passed over without an ’ especial notice. The first of the diseases of the eyelids which I shall describe is blepharitis idiopa- thica, or phlegmonous inflammation of the palpebrae. Inflammation of the eyelids is very commonly observed to attend some of the more violent forms of ophthalmia, and more particularly the purulent variety; but the disease of which we are now speaking is an idiopathic affection, and confined, or nearly so, to the palpebrse. It is most frequently witnessed in children, commonly attacking the palpebrae of only one eye, and the upper eyelid is more considerably affected than the lower one. There is much redness and tume- faction of the lid, the swelling being so great as to render it difficult to uncover the eye ; ; but when this is effected, we then perceive that the conjunctiva is but slightly inflamed, and that the substance of the lid is the part chiefly affected. There is usually some ten- derness to the touch and a feeling of increased heat. In some instances, after a certain period of time, and particularly if the case have been unattended to, the suppurative process commences, a throbbing sensation is complained of, and fluctuation becomes evi- dent to the touch. Sometimes the matter is evacuated from the inner surface, but, more commonly, it is discharged externally. This affection is generally supposed to be pro- duced by exposure to cold, and sometimes appears to be the result of injury. The treatment of this disease is the same as that of phlegmonous inflammation in gene- ral. In slight cases, probably, an evaporat- ing lotion may be alone requisite as a local application : if the morbid action be of a more intense character, then leeches may be applied to the cutaneous surface. The gene- ral treatment should consist of mild purga- tives, with an abstemious regimen. Should suppuration seem inevitable, then warm fomentations and poultices should be resorted to. If the matter be not early evacuated by the natural efforts, a free incision must be made so as to occasion its discharge, and the case treated as one of ordinary suppuration. Erysipelatous Inflammation of the Lids. The palpebrae are also frequently the seat of erysipelatous inflammation. More com- monly, erysipelas of the eyelids is witnessed 3 L
Text of COURSE OF LECTURES ON THE DISEASES OF THE EYE,
COURSE OF LECTURES
DISEASES OF THE EYE,Delivered in 1840,
ROYAL SCHOOL OF ANATOMY AND MEDICINE,
MANCHESTER,By JOHN WALKER, Esq., Surgeon.
Diseases of the Eyelids.AN individual but little accustomed to wit-
ness ophthalmic affections might be inclinedto suppose that there is not much either ofinterest or importance to be said respectingthe diseases of the eyelids; I trust, how-ever, that I shall be able to make it appearthat this portion of our subject has strongclaims on your attention.
Affections of the eyelids, as well as beingsometimes productive of considerable de-
formity, occasionally interfere with the inte-grity of vision, inasmuch as they are veryapt to extend, through the medium of theirconjunctival surface, to the textures of theglobe. Thus, as I have on a former occasionmore particularly pointed out, it is very com-mon to find that inflammation and opacity ofthe cornea have their origin in a morbidlyvascular condition of the lining membrane ofthe lids, and that if the latter be remedied,the healthy condition of the former will oftenbe restored. In some instances, likewise,morbid conditions of the lids act mechani-cally so as to injure the eye itself, as in thecase of entropion; in which disease, the
margin of the lid becoming inverted, the ciliaare directed against the conjunctival cover-ing of the globe, and thus inflammation andopacity of the most inveterate character areoften established. So that you will perceive,from these illustrations alone, that yourknowledge of ophthalmic surgery will be
very imperfect, if the morbid conditions of thepalpebrae were to be passed over without an
The first of the diseases of the eyelidswhich I shall describe is blepharitis idiopa-thica, or phlegmonous inflammation of thepalpebrae. Inflammation of the eyelids isvery commonly observed to attend some ofthe more violent forms of ophthalmia, andmore particularly the purulent variety; butthe disease of which we are now speaking isan idiopathic affection, and confined, or nearlyso, to the palpebrse. It is most frequentlywitnessed in children, commonly attackingthe palpebrae of only one eye, and the uppereyelid is more considerably affected than thelower one. There is much redness and tume-faction of the lid, the swelling being so greatas to render it difficult to uncover the eye ; ;but when this is effected, we then perceivethat the conjunctiva is but slightly inflamed,and that the substance of the lid is the partchiefly affected. There is usually some ten-derness to the touch and a feeling of increasedheat. In some instances, after a certainperiod of time, and particularly if the casehave been unattended to, the suppurativeprocess commences, a throbbing sensation iscomplained of, and fluctuation becomes evi-dent to the touch. Sometimes the matter isevacuated from the inner surface, but, morecommonly, it is discharged externally. Thisaffection is generally supposed to be pro-duced by exposure to cold, and sometimesappears to be the result of injury.
The treatment of this disease is the sameas that of phlegmonous inflammation in gene-ral. In slight cases, probably, an evaporat-ing lotion may be alone requisite as a localapplication : if the morbid action be of amore intense character, then leeches may beapplied to the cutaneous surface. The gene-ral treatment should consist of mild purga-tives, with an abstemious regimen. Shouldsuppuration seem inevitable, then warmfomentations and poultices should be resortedto. If the matter be not early evacuated bythe natural efforts, a free incision must bemade so as to occasion its discharge, and thecase treated as one of ordinary suppuration.
Erysipelatous Inflammation of the Lids.The palpebrae are also frequently the seat
of erysipelatous inflammation. More com-
monly, erysipelas of the eyelids is witnessed3 L
882in conjunction with a similar condition of thehead and face ; but in some cases the palpe-brae alone are thus affected, and often thoseof one eye only are the seat of the disease.There is usually considerable swelling, sothat the lids are not easily separable; theyhave also a rose-coloured tinge, whichvanishes when pressure is made with thefinger, but immediately reappears on its re-moval. There is a feeling of heat, but notmuch pain complained of ; an oedematouscondition of the subcutaneous cellular textureis also frequently noticed, and sometimesvesicles are formed on the surface, whichultimately burst and evacuate the contained Ifluid. In more severe cases, suppurationand sloughing of the cellular texture takeplace, and sometimes large quantities of dis-organised membrane are evacuated with thepus, and much thickening, contraction, andadhesion of the various textures are pro-duced, and considerable deformity is thusoccasioned.
In erysipelatous inflammation of the pal-pebrae, there is generally some extension ofthe disease to the conjunctiva, the Meibomianglands, and the lachrymal sac; and hencethere is usually a certain amount of lachry-mation, agglutination of the margins of thelids, and a mucous secretion from the innercanthus.
Erysipelatous inflammation is usuallythought to be induced by some peculiar at-mospheric condition, or by contagious influ-ence, acting upon persons predisposed fromderangement of the stomach and bowels. Inthe commencement of the disease, there istherefore usually a considerable amount offever present, as indicated by occasionalrigors, headach, furred tongue, and the like,afterwards succeeded by a state of depres-sion and exhaustion. Slight attacks are alsooccasionally induced by the bites of insectsand the application of leeches.As the existence of this disease generally
indicates some vitiated condition of the ali-mentary canal, the treatment should, in thefirst instance, be more especially directed to’that portion of the system. With that view,an emetic should be first ordered, and thisfollowed up by the administration of mildpurgatives. When this has been accom-
plished, then the exhibition of quinine shouldbe enforced. It is rarely necessary to bleed,except in very plethoric persons, or in casesin which we may anticipate cerebral mis-chief ; neither is the employment of leechesgenerally to be commended. Evaporatinglotions are often serviceable, and in slightcases are frequently the only local applica-tions necessary. The use of flour as a localremedy is resorted to by many practitioners.The nitrate of silver in solution is likewisea useful application. Some surgeons scarifythe skin of the lids very freely ; some, again,recommend the inflamed surface to be slightlypunctured all over ; and others, in severe
cases in which suppuration and sloughingare likely to occur, advise deep incisions intothe cellular texture. Mr. Lawrence has re-lated several cases of this last descriptionwhich were beneficially treated by extensivetransverse incisions across the lids.
Ophthalmia Tarsi.Sometimes the tarsus is almost exclusively
the seat of inflammation. The morbid actionis supposed to commence in the Meibomianglands, and extends to the tarsus, conjunctivapalpebralis, and ciliary margins. In thisaffection the patient usually complains of apricking or itching sensation in the marginsof the lids ; and hence the disease has beencalled psorophthalmia. There is also usuallya considerable discharge of the Meibomiansecretion, which causes the tarsal margins tobe adherent, and renders their separation amatter of difficulty after the patient has beenasleep. If the conjunctiva be at the sametime affected, then there will be also someintolerance of light and an increased flow oftears.
Psorophthalmia is often a sequel of measles,or some other exanthematous disease. It islikewise frequently produced by changes oftemperature, exposure of the eyes to irrita-ting vapours, working by gas-light, and veryfrequently from a want of cleanliness.
’, The treatment of this affection is very sim-ple. When a case is witnessed in the earlystage, the free use of tepid water, or a colly-rium of the saturnine lotion, with distilledvinegar or liquor ammonias acetatis, is found
to be an agreeable application ; and the zincointment may be smeared upon the edges ofthe lids at bedtime. Care must be taken towash away the morbid secretion whichusually collects about the tarsal margins inthe morning: this is easily accomplishedwith a piece of sponge dipped in warm water.If the secretion be not properly removed, theother remedies will not come into contactwith the diseased surfaces, and consequentlywill be productive of little or no benefit.Moreover, if forcible attempts are made toseparate the adherent tarsal margins, with-out this necessary precaution, the cilia willbe plucked out, and increased irritation anda certain amount of deformity result.
If the disease have reached the chronicstage, then the applications to be employedmust be of a more stimulating character,such as a solution of the sulphate of zinc orof the sulphate of copper for an eye-lotion,and the red precipitate ointment as an unc-tuous application to the margins of the lids.The sulphate of copper in substance may alsobe occasionally applied to the inner surfaceof the lid when the conjunctiva is preter-naturally vascular. In every stage, I needscarcely add, that proper attention should be
directed to the general health of the patient,and occasional purgatives ordered when ne-
When the disease I have just described isof a chronic character, and attended withpustules or small abscesses in the ciliarymargin, it is named tinea tarsi. The affectionthus termed, as I have just said, differs in noother respect but the existence of these pus-tules, and requires precisely similar treat-ment.
Lippitudo.Chronic inflammation of the tarsal margins
having existed for a considerable period, isapt to be succeeded by a degree of thicken-ing and ulceration, and consequent escape ofthe cilia. To this condition the term lippitudois applied, and the eyelids present a veryunsightly appearance when thus affected, forthe margins, instead of being angular arerounded off, have a raw and ulcerated aspect,and the lashes, or many of them, havingfallen out, altogether occasion a considerableamount of deformity. Sometimes the aper-tures which give exit to the Meibomian se-cre-tion are completely obliterated, and veryfrequently there is a degree of eversion of thetarsal margins, which no longer retain butpermit the discharge of the tears over them z,and down the cheek : on other occasions, theopposite state, or that of inversion, succeeds,and produces considerable irritation of theglobe of the eye.
In many cases, when the affection has pro-ceeded very far, but little good can be done.In some, however, a partial improvementmay be effected by the regular application ofthe more powerful stimulants, such as thesulphate of copper and nitrate of silver,either in substance, strong solution, or in theform of ointment. Some advise the extractionof the cilia when there is ulceration com-
mencing, considering that there will thus bea better chance of their reproduction than ifpermitted to fall out spontaneously.
Ectropion.I have just stated that one consequence of I
chronic inflammation and ulceration of the iciliary margin, is that disagreeable conditionnamed ectropion, or eversion of the lid.
Ectropion is often an accompaniment ofpurulent ophthalmia, particularly in infants.But in this case the eversion is produced bya mechanical cause, viz., the pressure of theswollen and infiltrated sub-conjunctival cel-lular tissue, and is therefore more likely tobe successfully treated than when it is theresult of chronic inflammation and ulcerationof the tarsal margins. Indeed, in the formercase, it readily disappears under the treat-ment usually adopted, particularly if it be ofthe stimulant character. Eversion from thiscause is more frequently observed in the
upper lid, because in purulent ophthalmiathat is more extensively affected than thelower one, although both are usually impli-cated.
Ectropion, however, as I have said, iscommonly attributable to chronic inflamma-tion and ulceration of the margin of the lid,and as the lower lid is more frequently theseat of chronic inflammation than the upper,we find the former more commonly affectedwith eversion. Indeed, there is another cir-cumstance which predisposes the lower lidto this affection, from which the upper isexempt, viz., the excoriated condition of theinteguments of the cheek, occasioned by theincessant flow of tears. The skin of thelower lid and cheek is apt to become con-tracted from the irritation thus caused, andthis increases the eversion and exposure ofthe conjunctival surface by dragging the liddownwards. From the constant exposure ofthe conjunctiva to the action of various irri-tants, it frequently becomes thickened anddegenerate, loses its sensibility, and acquiresmore of the character of the common integu-ment.
If the eversion of the lid be not very con-siderable, it will usually be remedied by theapplication of some escharotic or caustiosubstance to the conjunctival surface. ]Vtthere have been cicatrisation of the externalsurface of the lid to such an extent as toproduce a slight eversion of the tarsal mar-gin, then a similar condition of the internalsurface, produced by the caustic application,will tend to correct the deformity, and, ifcarried too far, will bring about the oppositestate, or that of inversion. The nitrate ofsilver will, in slight cases, probably be suffi-
ciently powerful; whilst, in those which aremore aggravated, it will often be necessaryto use sulphuric acid or caustic potass. Thelatter substances require to be used withgreat caution, or otherwise more harm thangood will be likely to result. If the caustic
application do not succeed, it is then neces-i sary to remove a portion of the thickened
conjunctiva, which may be dissected out withthe aid of forceps and curved scissors, carebeing taken not to remove too large a portion,
f so as to occasion inversion.In some cases it becomes necessary to re-
move a triangular portion of the substance ofthe lid. Where the eversion is to such anextent as to be incapable of being remediedby the means previously recommended, thisoperation should be resorted to. The cen-tral portion of the lid should be selected forremoval. After having excised a sufficientportion to produce the desired effect, the
edges of the wound are to be brought toga.ther and retained by sutures.The most unmanageable cases of eversion
are those which succeed to the cicatrisationof burns, wounds, and ulcers. The defor-mity witnessed in some of these cases is verygreat. Thus, Cloquet relates a case in whichthe margin of the inferior lid was drawndown almost to the upper lip. In this statethe lid is usually adherent throughout to theinteguments of the cheek, and the first point
<? L 2
to be aimed at is the liberation of it from its 1unnatural situation, which can only be done Ileby a careful dissection. This being effected,it is necessary further to remove a portion of Ithe conjunctival surface, or in some instancesto extirpate a V-shaped portion from thecentre of the lid, and then to bring the edgesof the wound together by sutures. In somecases, doubtless, these operative proceedingsare serviceable, yet they rarely produce morethan a partial improvement, for the sutures
frequently tear away, and the purposes ofthe operation are to a certain extent frus-trated.
Entropion.The opposite condition of the lid, that of
inversion, is a much more troublesome andmore serious affection than eversion. En-
tropion, or inversion of the lid, is broughtabout in two or three different modes. It isa very common result of long continuedophthalmia affecting elderly persons. Thus,after operations for cataract in old people,who have suffered much from inflammation,and have had a good deal of intolerance oflight, the undue action of the orbicularis,acting more especially upon the edges of thelids, produces inversion of the ciliary mar-gins, and of course of the cilia themselves.This kind of entropion is the most manage-able. It should not be neglected, or other-wise much danger to vision may accrue, asthe inverted cilia are continually rubbingupon the inflamed eyeball, with the effect of
adding to the irritation, and perhaps tendingto produce an irremediable opacity of thecornea.
When entropion arises from this cause, theeyelids exhibit no mark of disease, no thick-ening or contraction of their substance ; butthere is generally a relaxed state of the inte-guments, which appear to be superabundant.If the lower lid be drawn down with thefinger (for the inversion is generally confinedto the lower lid in this case), the ciliary mar-gin resumes its natural position, and the ciliaare directed outwards, and this will continueto be the case for some time; but as soon asthe orbicularis begins to act then the edge ofthe lid is again inverted.
Inversion of the character just describedmay be remedied by the removal of a portionof skin from the affected lid, and which, as Ihave said, is in general superabundant. Thismay be effected either by the excision of aportion of integument, or by the productionof a slough or eschar. Excision is the mostspeedy and perhaps most effective mode ofremedying the defect in question. A portionof integument is to be pinched up betweenthe finger and thumb; when a certain portionis by this means secured, the edge of the lidis brought into its natural position, and wethus ascertain the exact portion necessary tobe removed. If less than this amount of in-tegument be excised, it will be insufficient
for the intended purpose, and there will stillbe a certain degree of inversion; and, on theother hand, if too much is removed, then adegree of eversion will be produced, so thatsome nicety is requisite in determining theprecise quantity to be excised. The portionof integument may be dissected out, eitherwith a scalpel or sharp scissors, and the
edges of the wound brought together bysutures and the usual dressings.
If the escharotic plan be resorted to, eitherthe caustic potass or sulphuric acid may beemployed. The potass is perhaps more ma-nageable, and quite as efficacious as theother: it is to be drawn across the integu-ment of the lid, a little below its margin, in atransverse direction, two or three times, untilit has sufficiently acted upon it, so as slightlyto abrade the cuticle. An eschar is after-wards produced, and when the healing pro-cess is complete, a considerable contractionof the skin will be found to have resulted,which will have effectually remedied the in-version. If the sulphuric acid be chosen, apiece of stick, pointed, is dipped into it, and
then drawn across the skin of the lid in thesame way as the potass. Care must be takento limit its application, or otherwise too greatan extent of ulcerated surface mty be pro-duced.A less manageable form of entropion is
that which is a consequence of chronic in-flammation of the tarsal margins. In thisvariety of the disease, the eyelid is considera-bly altered in character, the tarsal cartilagebeing thickened, contracted, and inverted.Many of the cilia are frequently lost fromulceration of the tarsal margins, whilst thosewhich remain are directed inwards upon theglobe, causing inflammation and opacity ofthe cornea. If this condition continue with-out proper means being adopted to remedy it,the entire cornea frequently becomes vascu-lar and opake, and the conjunctiva thickened,cuticular, and insensible.
Entropion of this latter character cannotusually be remedied by caustic applications,or by the removal of a portion of integument.It is the tarsal cartilage which is in this casethe seat of the disease ; it is thickened, con-stricted, and bent inwards upon the eyeball;and the object which the surgeon has in viewis to remove this constriction, and thus re-medy the unnatural direction of the lid,which cannot be done by any operationmerely on the integument. Various pro-ceedings have been adopted for the purposeof remedying this morbid condition of the
tarsus, some advising the removal of the tar-sal cartilage by excision, whilst others re-commend the excision of the margins of thelids, so as to destroy the roots of the cilia ;but these operations are not always success-ful. The operation found to answer best isthat performed by Mr. Crampton, of Dublin.It consists in making a perpendicular incisionat both angles, to the extent of about one-
fourth of an inch, by means of a sharp-pointed bistoury, which is pushed throughthe substance of the lid from within outwards.In making the incision at the internal angle,it is desirable to avoid the lachrymal puncta.The effect of this operation is to take off thepressure produced by the constriction of thelid ; but this would be but a temporary reliefif the incisions were allowed to heal toosoon. To prevent this it is found that, inaddition to the operation already mentioned,the best plan is to excise a portion of theskin of the lid in the manner described forthe treatment of entropion from relaxation ofthe integuments, to bring the edges of thewound together by sutures, and by the aid ofthe sutures attached to the brow by strips ofadhesive plaster, to cause the everted lid tobe suspended for a period of eight or tendays, so that granulations may arise in theedges of the perpendicular incisions, and thehealing process be prevented from takingplace too rapidly. When at length the di-vided portions of the lid are reunited, the Iconstriction of the tarsus is found to be muchdiminished, and the direction of the ciliarymargins nearly natural.Sometimes entropion is produced by means
of a burn or scald of the conjunctival cover-ing of the lid, or by lime or mortar coming incontact with it. In some cases, too, as I for-merly stated, it is produced by the use of thenitrate of silver as a remedial agent. In suchcases excision of a portion of the skin of thelid, or its destruction by the caustic potass,will usually remedy the inversion.
In some instances the cilia alone are thesubject of inversion, whilst the margin of thelid maintains its natural position. Occasion-
ally the cilia exist in a double row, one beingdirected naturally and the other turned in-wards, so as to irritate the eye. When thereis a double row the affection is termed dis-tichiasis. Inversion of the cilia is sometimeswitnessed without there being any visible
change in the structure of the lid, althoughit is often connected with chronic inflamma-tion or ulceration of the tarsal margins. i
There are two kinds of treatment to be ad-vised, according to the peculiarity of the in-dividual case. The most simple proceedingconsists in plucking out the inverted lasheswith a suitable pair of forceps. This, how-ever, is but a palliative, as the cilia shortlybecome reproduced. Some individuals aresatisfied with this, and prefer having themextracted occasionally, to submitting to anyoperation on the lid itself. In some instances,after repeatedly removing them in this man-ner, they resume the natural direction. Ifthis should not be so, and the patient is de-sirous of some further treatment, then the
production of a small eschar on the skin ofthe lid, very near to the ciliary margin, so asto produce slight eversion, may be service-
able. In very unmanageable cases, theexcision of the ciliary margin has beendeemed advisable, so as to remove theirroots, and thus prevent the reproduction ofthe lashes.There are other affections of the eyelids
which appear to arise, independently of in-flammation ; and there are two very oppositeconditions which occasionally come undernotice in which the upper lid is exclusivelyaffected, and to which I shall next draw yourattention,-I mean labophthulrnos, or shorten-ing of the lid, and ptosis, or drooping of it.
Lagophthalmos.This, as I have just said, is a shortening
or retraction of the upper lid, and is com-monly the result of cicatrisation after a woundor burn,or sometimes of suppuration within theorbit. In this condition the upper lid is more orless everted, tucked up to the edge of the orbit,and cannot be drawn down so as to meet thelower one; and the consequence is that, underall circumstances, the eye is left unprotectedand exposed to various sources of irritation.Unfortunately, we know as yet of no meansof remedying this disagreeable condition.
Sometimes inability to close the lids arisesfrom paralysis of the orbicularis muscle. Inthis case, although the effect is nearly thesame, there is no shortening or other diseaseof the substance of the lid. The mischiefarises solely from some morbid condition ofthe nervous branches which supply thesphincter muscle of the eyelids. When the
inability to close the lids arises from thiscause, there is a better chance of remedyingit ; such cases are often successfully treatedby a combined antiphlogistic and mercurialtreatment.
The drooping of the upper lid, which isknown under this designation, arises eitherfrom relaxation or superabundance of the
integuments, or from a loss of power of thelevator palpebrae muscle. In this state,the front of the eye is more or less coveredby the drooping lid ; and if this take place tosuch an extent as to obscure the pupil, thepatient is to all intents and purposes tempo-rarily deprived of sight. True, it is restoredsimply by raising the drooping lid, but thisdoes not prevent its being regarded as a
source of anxiety and an annoyance. Whenptosis arises from mere relaxation of the in.teguments, if a portion of skin be pinched upbetween the thumb and forefinger, and thepatient told to elevate the lid, the eyeballwill be properly exposed by the action of thelevator muscle. So that the remedy for thisspecies of ptosis is excision of so much of thesuperabundant integument as will permit ofthe due elevation of the lid. Ko precise di-rection can be given as to the quantity of in-tegument to be excised, as all dependsupon the relaxation of the individual case.
A transverse fold of the skin is to be laid holdof either with the finger or suitable forceps,which may then be dissected off with a scal-pel or curved scissors; the edges of thewound being afterwards brought together bysutures, and proper applications employed topromote their union.When ptosis arises from paralysis, of
course it is then properly an affection eitherof the motor oculi nerve, or of the branch ofthat nerve which is distributed to the levatorpalpebrae muscle, or it may arise from anaffection of the brain itself. The treatmentof this case, in the first instance, as I beforeexplained in speaking of paralysis of theorbital nerves, is by general and local bleed-ing, counter-irritation, purgatives, and moreespecially by the liberal exhibition of mer-cury, so as to produce its specific effect on thesystem. If the affection have been of longstanding, local stimulants may then be tried,such as the aromatic spirit of ammoniarubbed upon the eyebrow or lid, or we maytry the application of strychnine to a blisteredsurface either on the temple or forehead. Inthe event of these remedies failing to producea beneficial change, we may then have re-course to the operation of removing a portionof integument ; and in such a case it wouldbe proper to adopt the plan recommended bymy colleague, Mr. Hunt. That gentleman,after removing a tumour from the orbit, foundthat the levator palpebrae had been so muchinjured as to leave it perfectly powerless.With a view of remedying this defect, he firstof all excised a portion of skin in the mannerusually recommended without benefit ; hethen proceeded to remove another portion ofintegument, and that so high towards thebrow as to bring the lid under the influenceof the occipito-frontalis muscle, and it wasafterwards found that the patient could
really elevate the lid very considerably bythe agency of that muscle. The idea appearsto be very ingenious, and if subsequent expe-rience should demonstrate the general suc-cess of this modification of the usual opera-tion, it must be admitted to be an importantimprovement.
Turnouts of the Lids.I must now direct your attention to the va-
rious tumours which are occasionally foundaffecting the eyelids. Some of these affect
only the margins of the lids, whilst others aresituated within their substance. I shall firstnotice those which are observed in the ciliarymargins.
Hordeolum, or stye, is a small inflamma-
tory tumour situated on the edge of the lid,which generally suppurates and looks verymuch like a little boil. There is often consi-derable pain and irritation experienced,owing to the high degree of sensibility withwhich the margin of the lid is endowed. Anevaporating lotion may be prescribed in the1i.r&bgr;t stage : so soon as suppuration has com-
menced, then the use of warm fomentationsand poultices is indicated, and an early eva-cuation of the matter should not be omitted.
, Sometimes a chronic tumour is found to
affect the margin of the lid, without any ac-companying inflammation or suppuration.This is named grando. It may be puncturedwith a lancet, its contents squeezed out, anda pencil of nitrate of silver applied freelywithin the cavity. Another species of chronictumour is named chalazion, from its resem-blance to a hailstone; and there are some
very small watery tumours sometimes ob-served about the size of a millet-seed, whichare therefore termed milia or phlyctenulce.A simple puncture, or a slight application ofthe nitrate of silver, is usually effectual indispersing them.
Encysted tumours are generally found oc-cupying the substance of the lid, usually be.tween the tarsal cartilage and the fibres ofthe orbicularis muscle. They are found ineither eyelid, and very often in both. Some-times these tumours are filled with a wateryfluid, at others with a puriform matter, andsometimes they consist of fleshy or vasculargrowths. Occasionally, these tumours dis-appear by absorption, and this process may,in some instances, be accelerated by frictionon the external surface of the lid. To aid
this, we may prescribe some stimulating ap-plication, such as the soap or mercurial lini-ment. Instances of spontaneous absorptionare not, indeed, uncommon.Sometimes these tumours disappear and re-
cur at irregular intervals ; and I have knownthem to occur in females during pregnancy, anddisappear after parturition. In like manner,any considerable change in the system, suchas fever, favours their absorption: thus, achild who was brought to me with an en-
cysted tumour of the lid, had, a few daysafterwards, an attack of measles, on recover-ing from which the tumour had disappearedwithout any means having been employed. Ingeneral, however, this process cannot be re-
lied upon, and the patient will prefer theremoval of such a tumour at once. For thispurpose, we must use a scalpel or a pair ofcurved scissors, with which it must be cau-tiously dissected out. The first step is toevert the lid (for the operation should alwaysbe performed from the inner surface), thenthe tumour is to be transfixed with a slenderhook or a tenaculum, and an incision is made
through the cartilage so as to expose it, whenit will be readily excised either with the scal-pel or scissors : care must be taken not to cutthrough the entire substance of the lid, asinstances have been known in which a button-hole perforation has remained permanentlyfrom this cause.
Diseases of the Lachrymal Apparatus.The lachrymal passages are very fre.
quently the seat of disease, this being gene-rally indicated by one very prominent symp-
tom, viz., an obstruction to the flow of tears, ferior aperture. Sometimes the bony canalwhich therefore escape from the inner can- appears to be actually obliterated, and thisthus over the cheek. may be either congenital or the result of dis-
Znflsmmation of the lachrymal sac is one ease.
very frequent source of such obstruction ; it The treatment of obstruction of the lachry-is indicated by the ordinary signs of inflam- mal passages must, in the first place (no ac-mation, viz., redness, tenderness to the touch, tive inflammation being present), be by theand swelling of the integuments at the inner employment of stimulant applications, suchcanthus, over the situation of the lachrymal as a solution of sulphate of copper, or ofsac. When the inflammation is very acute, nitrate of silver, introduced into the innerthe pain is often considerable, and extends to canthus, so as to be absorbed by the punctathe eye and into the nasal duct. The treat- and carried into the sac. This treatmentment of this affection must, in the first in- will in some instances, be serviceable, butstance, be strictly antiphlogistic, such as the more frequently it is of no avail. It thenapplication of leeches to the inflamed surface, becomes necessary to introduce within theevaporating lotions, and the internal admi- nasal duct a silver instrument named a style,nistration of purgatives. With proper atten- the head of which, resembling that of a nail,tion, it occasionally happens that the inflam- lodges externally on the integument over themation totally subsides without being produc- sac, whilst the body passes through the sactive of any serious result. There is, however, into the duct. Before the insertion of thein most instances, a strong tendency to sup- style can be effected, it is necessary to makepuration ; a change which is readily observed, an incision through the integuments and intoand is indicated by the usual phenomena, the lachrymal sac and orifice of the duct; ;When it is established, the cold lotions are to this is best effected with a sharp-pointed bis-be changed for warm fomentations and poul- toury, which should be introduced perpendi-tices : the abscess should be speedily opened, cularly at the point where the lachrymalwhen a considerable quantity of muco-puru- canals enter the sac, and over the tendon oflent fluid is discharged, and the swelling sub- the orbicularis, and pushed into the duct assides. far as it will pass. The style is then, in
In some cases, after the process of suppu- general, readily introduced; but when theration has been gone through, the morbid ac- obstruction is considerable, it is sometimestion altogether disappears, and the patient not easy of accomplishment. But the diffi-
experiences no further inconvenience. But, culty which is commonly experienced arisesvery frequently, the improvement is only tem- from the swelling and induration of the in-porary, since we often find that more or less teguments, which are often so great as toobstruction to the passage of the tears still render it no easy matter to ascertain the pre-exists, the lachrymal sac being distended cise situation of the orifice of the duct. Whenwith mucus, which by pressure may be forced the style has been properly introduced, thereeither downwards along the nasal duct or is not much occasion to disturb it frequently ; ;upwards through the lachrymal puncta. but it may be occasionally removed for theSometimes a fistulous aperture through the purposes of ablution, and to ascertain if theinteguments remains, which communicates passage continue to be much constricted orwith the lachrymal sac, and through which otherwise. It is commonly necessary to wearthe tears and mucus are discharged, consti this instrument within the duct for severaltuting a case of fistula lachrymal is a term months ; and although it is almost always ofwhich is by some indiscriminately and im- considerable benefit to the patient, yet it fre-properly applied to all cases in which there quently fails to effect a cure, as after its with-is an obstruction of the lachrymal passages. drawal the tears are sometimes apt to flowWhen this obstruction is permanent, it is pro- over the cheek, but at the same time therebably owing, in most cases, to a constriction is much less disposition to suppuration thanof the lining membrane of the nasal duct, before.analogous to what takes place in stricture Considerable pain and irritation sometimesof the urethra; whilst, in other instances, follow the operation, so that the palpebraathere is doubtless some diseased condition of are much swollen, and incapable of beingthe bony parietes, narrowing, and sometimes separated for several days ; but all thisobliterating, the duct. In such circumstances, usually subsides in a short time, and it willa renewed attack of inflammation and suppu- be proper to prescribe some evaporatingration of the sac frequently comes on, and lotion, or a bread-and-water poultice, with a.proves a source of considerable anxiety and view of diminishing the irritation. It occa-suffering : I have known instances in which sionally happens, likewise, that the integu-the attack has come on almost regularly at ments over the sac are so much swollen thatthe period of menstruation, and afterwards the style is buried within, and it is very diffl-subsided. In some instances the enlargement cult to withdraw it. This accident may beof the sac is constant, without the existence prevented by tying a piece of thread aroundof acute inflammation or suppuration, the pa- the neck of the instrument at the time of itstient being able with the finger to evacuate introduction.the mucus through either the superior or in- Some surgeons prefer the use of a small
silver tube; the great advantage of this in-strument is, that it may be introduced entirelywithin the sac, the integuments being allowedto heal over it, so that nothing is seen exter-nally ; the contrary of which is a great ohjec-tion in the minds of some persons to the useof the style. The tube was much recom-mended by Dupuytren, and it is frequentlycalled after him, although it was introducedinto practice by Joubert. It is probably notof much importance which instrument is used ;I have frequently tried both with very goodeffect. In the case of the tube, after it hasbeen worn a few months, it becomes consider-ably corroded, and ultimately passes down- Iwards into the nostril. Such at least hasoccurred in some cases which I have wit-nessed.
Epiphora.There is a minor degree of obstruction of
the lachrymal passages sometimes observed,which is also indicated by a watery state ofthe eye, the tears running over the cheek in-ordinately, from very slight causes, moreparticularly exposure to cold,-a conditionwhich is termed epiphora. In this case, thereis probably some slight constriction of thelachrymal canals, or possibly of the nasalduct. It is distinguished from the precedingaffection by the absence of distention of thelachrymal sac, and of the discharge of mucuson pressure. To remedy this inconvenience,it will be proper, in the first instance, to trythe effect of some mild stimulant dropped intothe inner canthus; and if this be ineffectual,and the constriction should appear to be inthe lachrymal canals, we may then introducea very fine wire probe through the punctainto the sac. If the constriction should ap-pear to be in the nasal duct, then probablythe only remedy will be the style or tube, ifthe case should be deemed of sufficient im-portance to require such treatment. There ais a small instrument, somewhat resemblinga sound, which may also be properly intro-duced from the nostril into the duct, for thepurpose of ascertaining whether there be con-striction or otherwise.
I must now bring my remarks to a close.If there has been one error more than anotherwhich I have wished to avoid, in the lecturesnow terminated, it was that of being unne-cessarily diffuse. I may possibly have falleninto the opposite error of being occasionallyobscure, from not having entered into a fullerdetail of some of the topics which I have hadto discuss. There are some minor points,too, which I may have passed over withoutnotice ; but I think I may say that I havetouched upon all the leading practical sub-jects on which the student of ophthalmic sur-gery has a right to expect information ; andI should be happy if I could think that I haveaccomplished the task in such a manner asto leave a favourable impression on theminds of those whom I have endeavoured toinstruct.
PATHOLOGY, PHYSICAL SIGNS,AND
VALVULAR DISEASES OF THE
By THOMAS MOORE, Esq., M.R.C.S., lateSecretary to the Dublin Medico-Chirurgi-cal Society.
(Continued from p. 748.)PART III.
THE number of interesting circumstancescontained in the case of circumscribed aneu-rismal disease of the left ventricle, the re-flections the writer has been induced to
bestow on them, and the description of anaperture in the third ventricle, and a canal, or,perhaps, in more descriptive language, 11 a
tunnel," leading from it, upwards and back-wards, hitherto, to the best of his know-ledge, undescribed in pathological anatomy,have caused a digression in the essay ; but,before dismissing the subject of permanentpatency of the auriculo-ventricular aper-tures, and this form of insufficiency of thevalvular structures, it is his wish to give anabstract of the most striking facts connectedwith a case of this disease complicated withacute pericarditis.
CASE 5.-Perinanent patency of the auri-culo-ventricular apertures, with pericardi-tis ; action and sounds of the heart obscuredby a peculiar 11 double-dash murmur" notlimited to the cardiac region; action of thearteries distinct, &c. &c.A woman, upwards of forty years of age,
was admitted on September 5, 1839, intohospital, complaining of violent palpitationsof the heart; an oppression and uneasinessabout this part of the chest ; dyspnoea to aconsiderable amount, and the existence of a11 curios see-saw noise" situated beneaththe left mamma, the sensation of which shehad experienced during several weeks past.The colour of her skin was dusky-yellow ;the eye bright and clear ; face bloated,rather oedematous ; neck ptiffed up, but noincreased action of the arteries, or turges-cence of the veins, could be observed. Shehad no affection of the head, no whizzing,no inordinate pulsation of the temporal arte-ries. Percussion over the cardiac region,and at the lower part of sternum, was ob-viously more dull than usual, and the lossof sonoriety more extensive. On applyingthe hand, a distinct twang or thrilling sen.sation was communicated, the vibrationsbeing felt over the sternum and to the rightof this bone. The heart’s action was strongand audible over nearly the entire of the