G 000 005 672 i '^ffrt'iiltftmii '^h; \ THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT Dr. and Mrs. v.'. Libby / C>flr. \ ^^ 1 V..c DISEASES OP THE EYE; LECTURER ON SURGERY IN THE PHILADELPHIA ASSOCIATION FOR MEDICAL INSTRUCTION, ETC. ETC. PHILADELPHIA: BLANCHAED AND LEA, 1855. 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. nilLADELPHIA: T. K. AND P. G. COLLINS, PRINTERS. U \o w\ CO 100 EDITOR'S PEErACE. Notwithstanding the very recent appearance of a new American edition of Mr. Lawrence's Treatise on Diseases of tlie Eye, 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 encyclopasdia unequalled in extent by any other work of the kind, either English or foreign."^ 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. ' Dixou on Diseases of the Eye, London, 1855. ADYEETISEMENT 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 takeu 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 : — Amhon, Friedrich August von, Klinische Darstelluugen der Krankheiten und Bildungs- fehler des menschliclien Auges. 3 Theile. Eerlin, 1838, 1841. Beck, Karl Joseph, Abbildungen von Ivi-ankheitsform aua dem Gebiete der Augenheil- kunde. Heidelberg und Leipzig, 1835. Beek, G. Joseph, Lehre von den Augenkrankheiten. 2 Biinde. Wien, 1813, 1817. BoYER, Lucien-A.-H., Recherches sur I'Op^ration du Strabisme. Paris, 1842, 1844. Dalkymple, John, Pathology of the Human Eye. London, 1852. Demours, a. p., Trait*^ des Maladies des Yeux. 4 Tomes. Paris, 1818. Devergie, M. N., Clinlque de la Maladie Syphilitique. 2 Tomes et Atlas. Paris, 1826, 1833. DiEFFENBACH, J, F., Ucber das Schielen und die Hielung desselben durch die Opera- tion. Berlin, 1842. Eble, Burkard, Ueber den Bau und die Krankheiten der Bindehaut des Auges. AVieu, 1828. Geafe, Carl Ferdinand, Die epidemisch-contagiose Augenblennorrhcie Aegyptens in den Europaischen Befreiungsheeren. Berlin, 1823. Hooper, Ptobert, 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. MiJLLER, J. B., Die neuesten Resultate iiber das Vorkommen, die Form und Behand- lung einer ansteckeuden Augenliederkrankheit unter den Bewohnern des Niederrheins. Leipzig, 1823. Panizza, Bartolomeo, Annotazioni Anatomico-Chirurgiche sul Fungo MidoUare dell' Occhio. Pavia, 1821, Sul Fungo Midollare dell' Occhio, Appendice. Pavia, 182G. vi ADVERTISEMENT. RiTTEEiCH, Friedrich Philipp, Jllhrliclie Beitrage zur Vervollkommnung der Augen- heilkunst. Erster Band. Leipzig, 1827. Saundees, John Cunningham, Treatise on some Practical Points relating to the Dis- eases of the Eye. London, 1811. ScAEPA, Antonio, Trattato delle principal! Malattie degli Occhi. 2 Tomi. Pavia, 1816. SiCHEL, J., Iconographie Ophthalmologique. Paris, 1852. SoEMMEREiNG, Wilhclm, Bcobachtungen, iiber die organischen Verlinderungen im Auge nach Staaroperationen. Frankfurt am Main, 1828. Travees, Benjamin, Synopsis of the Diseases of the Eye. London, 1820. Vetch, John, Practical Treatise on Diseases of the Eye. London, 1820. Walton, H. Ilaynes, Treatise on Operative Ophthalmic Surgery. London, 1853. Waedrop, James, Essays on the Morbid Anatomy of the Human Eye. 2 vols. Lon- don, 1819, 1818. Wellee, Carolus Henricus, Icones Ophthalmologicse. Fasciculus I. Lipsire, 1824. AYiLLis, 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 Eichelot, 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 E-ichelot 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, 1854. CONTEjN^TS. Anatomical Inteoduction, Explanatory of a Horizontal Section of th 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 N^erve 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 .... XXlll lb. ib. xxiv xxvi sxvii ib. xxix ib. ib. ib. xxxi ib. xxxii xxxiii xxxiv ib. DISEASES OF THE EYE. Chapter I. Diseases of the Orbit ..... I. Injuries of the Orbit . . . . I 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 49 ib. ib. 50 51 52 ib. ib. 53 61 63 CONTENTS. Osteo-Sarcoma of the II. Periostitis, Ostitis, Caries, and Necrosis of the Orbit § 1. Acute Periorbitis g 2. Chronic Periorbitis ^ 3. Caries and Necrosis of the Orbit III. Periostosis, Hyperostosis, Exostosis, and Orbit, and Cysts in its Parietes § 1. Periostosis § 2. Hyperostosis § 3. Exostosis . ^ 4. Ostco-Sarcoma § 5. Cysts in the Parietes of the Orbit IV. Dilatation, Deformation, and Absorption of the Orbit, from Pressur I 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 Chaptek 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. Inflammation and Suppuration of the Glandulse Congregate § 2. Inflammation and Suppuration of the Proper Lachrymal Gland V. Chronic and Specific Enlargements of the Lachrymal Gland § 1. Uypertrophy of the Glandulse Congrcgatx . § 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 Glandulse Congregatoj and Lachrymal Ducts . VIII. True Lachrymal Fistula . IX. Morbid Tears X. Sanguineous Lachrymation. Hemorrhage from the Lachrymal Gland XL Dacryoliths or Lachrymal Calculi in the Lachrymal Ducts Chapter HI. Diseases of the Etebrow and Eyelids I. Injuries of the Eyebrow and Eyelids § 1. Contusion andEcchymosis § 2. Poisoned Wounds . § 3. Burns and Scalds . § 4. Incised and Lacerated Wounds II. 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 aS'ecting the Eyelids of Infants IX. Cancer of the Eyelids .... 73 74 82 ib. 83 84 90 92 93 94 ib. 96 100 115 116 121 ib. ib. 123 124 ib. ib. 126 ib. ib. 135 139 140 ib. 141 ib. 142 ib. ib. 144 145 147 153 154 157 158 159 160 165 ib. / CONTENTS. IX of the Eyebrow 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 Fibririoiis Tianor § 2. Molluscum, or Albuminous Tumor . § 3. Encysted Tumor § 4. Fibro-plastic, or Sarcomatous Tumor XXIII. Tylosis, or Callosity of the Eyelids XXIV. Ntevus Maternus, and Aneurism by Anastomosis and Eyelids .... XXV. CEdema of the Eyelids . XXVI. Emphysema of the Eyelids XXVII. Twitching, or Quivering of the Eyelids . XXVIII. Morbid Nictitation XXIX. Blepharospasm .... XXX. Palsy of the Orbicularis Palpebrarum and Muscles XXXI. Ptosis, or falling down of the Upper Eyelid ^ 1. Ptosis from Hypertrophy § 2. Congenital Ptosis g 3. Traumatic Ptosis ^ 4. Atonic Ptosis ^ 5. Paralytic Ptosis XXXII. Lagophthalmos . XXXIII. Ectropium, or Eversion of the Eyelids § 1. Eversion from Inflammation and Strangulate § 2. Eversion from Excoriation I 3. Eversion from a Cicatrice . § 4. Eversion from Caries of the Orbit . Trichiasis and Distichiasis Entropium, or Inversion of the Ej^elids . XXXVI. Anchyloblepharon XXXVII. Madarosis .... XXXVIII. Phtheiriasis of the Eyebrow and Eyelashes Chapter IV. Diseases of the Tunica Conjunctiva I. Foreign Substances adhering to the Conjunctiva Dacryoliths, or Lachrymal Calculi, in the Sinuses of the Conjunctiva Injuries of the Conjunctiva ^1. Mechanical Injuries § 2. Burns and other Chemical Injuries Subconjunctival Ecchymosis Subconjunctival Emphysema XXXIV. XXXV. of the II. III. IV. V. Eyebrow CONTENTS. VI. Subconjunctival Plilegmon VII. Subconjunctival (Edema . VIII. Pterygium .... IX. Pinguecula .... X. Warts of the Conjunctiva XI. Polypus of the Conjunctiva *XII. Na3vus Maternus of the Conjunctiva XIII. Fungus of the Conjunctiva XIV. Conjunctival and Subconjunctival Tumors Chapter V. Diseases of the Semilunar Membrane, and Caeunccla Lachry- MALIS ........ I. Inflammation of the Semilunar Membrane and Caruncula Lachry- malis ..... II. Polypus of the Caruncula Lachrymalis . III. Nievus 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 runcta and Lachrymal Canals § 2. Injuries of the Lachrymal Sac I 3. Injuries of the Hasal 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 . XI. 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 an Adipose Tissues of the Orbit I. Injuries of the Orbital Areolar Tissue II. Eff'usion 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. Solid and Encysted Tumors in the orbit . II. Osseous Tumors in the Orbit page 262 263 ib. 267 ib. 268 ib. 269 270 273 ib. 274 ib. 275 ib. 276 ib. ib. 277 ib. 278 282 294 295 296 298 299 300 801 303 309 310 312 ib. 319 320 ib. 323 325 326 ib. 339 II. III. IV. CONTENTS. Chaptek IX. Malignant Diseases of the Areolar and Fibrous Tissues of THE Orbit I. Scirrhus in the Orbit II. Fungus Hojmatodes in the Orbit . III. Melanosis in the Orbit Chapter X. Intraorbital Aneurisms . I. Aneurism of the Ophthalmic Artery II. Aneurism by Anastomosis in the Orbit Chapter XI. Diseases of the Muscles of the Eyeball I. Injuries of the Muscles of the Eyeball . AVant of Correspondence in the Action of the Muscles of the Eyeballs ^ 1. Diplopia § 2. Monoblepsis Palsy of the Muscles of the Eyeball Strabismus, or Movable Distortion of the Eyeball V. Luscitas, or Immovable Distortion of the Eyeball VI. Tetanus Oculi . . . VII. Oscillation of the Eyeball VIII. Nystagmus Chapter XII. Injuries of the Eyeball I. Injuries of the Cornea I 1. Contusion of the Cornea § 2, Foreign Substances imbedded in the Cornea , § 3. Punctured Wounds of the Cornea ^ 4. Licised Wounds of the Cornea § 5. Penetrating Wounds of the Cornea — Loss of the Aqueous Humor — Prolapsus of the Iris — Fistula of the Cornea — Opihthalinitis and other Effects of Wounds of the Cornea II. Foreign Bodies in the Aqueous Chambers III. Injuries of the Iris IV. Injuries of the Crystalline Lens and Capsule § 1. Traumatic Cataract 1 2. Dislocation of the Lens V. V/ounds of the Sclerotica and Choroidea VI. Foreign Bodies in the Vitreous Humor . VII. Pressure and Blows on the Eye . § 1. Amaurosis from Pressure . § 2. Amaurosis from Plows § 3. Effusion of Blood into the Eye from Blows 2 4. Bursting of the Eye from Blows VIII. Gunshot Wounds of the Eye IX. Dislocation of the Eyeball X. Evulsion of the Eyeball . Chapter XIII. The Opiithalmi^e, or Inflammatory Diseases of the Eyeball AND Conjunctiva ...... I. The OphthalmifB in general ..... II. Eemedies for the Ophthalmias ..... XI page 340 ib. 342 343 344 ib. 346 352 ib. 353 ib. 354 ib. 357 387 388 ib. 390 ib. 391 394 ib. ib. 397 399 401 ib. 402 408 409 410 ib'. ib. 411 ib. 412 416 417 418 ib. 428 Xll CONTENTS. III. Objective and Subjective Symptoms of the Ophtlialmite § 1. Arrangements of the Bloodvessels § 2. Kinds of Pain IV. Simple or Phlegmonous Conjunctivitis V. Puro-mucous Conjunctivitis in general VI. Catarrhal Ophthalmia VII. Contagious Ophthalmia . VIII. Ophthalmia of New-bom Children IX. Gonorrhoeal Ophthalmia . I 1. Gonorrhoeal Ophthahnia from Inoculation ^ 2. Gonorrhoeal Ophthalmia from Metastasis § 3. Gonorrhoeal Ophthalmia ivithout Inoculation or Metastasis X. Aphthous Ophthalmia XI. Phlyctenular Ophthalmia XII. Morbillous and Scarlatinous Ophthalmia XIII. Variolous Ophthalmia § 1. Conjunctivitis Variolosa § 2. Corneitis Postvariolosa XIV. Erysipelatous Ophthalmia XV. Rheumatic Ophthalmia XVI. Catarrho-rheumatic Ophthalmia XVII. Scrofulous Sclerotitis XVIII. Corneitis . ^ 1. Scrofulous Corneitis § 2. Arthritic Corneitis .XIX. Iritis in general . XX. Idiopathic or Rheumatic Iritis XXI. Syphilitic Iritis . XXII. Pseudo-syphilitic Iritis XXIII. Gonorrhoeal Iritis XXIV. Scrofulous Iritis . XXV. Arthritic Iritis XXVI. Aquo-capsulitis . XXVII. Choroiditis ^ 1. Acute Choroiditis . § 2. Chronic Choroiditis XXVIII. Idiopathic Retinitis § 1. Acute Idiopathic Retinitis ^ 2. Chronic Idiopathic Retinitis XXIX. Retinitis from undue Lactation XXX. Inflammation of the Crystalline Capsule and Lens XXXI. Inflammation of the Hyaloid Membrane XXXII. Idiopathic Ophthalmitis . XXXIII. Phlebitic Ophthalmitis . XXXIV. Postfebrile Ophthalmitis . XXXV. Compound Ophthalmias XXXVI. Traumatic Ophthalmite . XXXVII. Artificial Ophthalmiie XXXVIII. Reflex or Sympathetic Ophthalmitis XXXIX. Intermittent Ophthalmiaj PAGE 433 ib. 434 435 ib. 438 443 461 467 468 471 472 475 476 490 491 492 493 495 496 500 504 511 512 510 517 523 527 533 5.34 538 541 546 549 550 553 555 556 557 559 560 563 565 571 579 585 586 588 590 599 CONTENTS. Xlll Chapter XIV. I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. Diseases consequent to the Ophthalmia Onyx, or Abscess of the Cornea . Hyp opium .... Ulcers, Fossula, Hernia, and Fistula of the Cornea ; and Hernia of the Iris ...... Opacities or Specks of the Cornea — Nebula, Albugo, Leucoma Pannus, or Vasculo-nebulous Cornea Granular Conjunctiva ..... Conjunctival Xeroma or Xerophthalmia . Anchyloblepharon and Symblepharon Synechia ....... Obliteration of the Pupil .... Cataracts, or Specks of the Crystalline Capsule and Lens Opacities of the Hyaloid Membrane Synchysis, or Dissolution of the Vitreous Humor Atrophy of the Eye ..... Staphyloma ...... § 1. Staphyloma Uvex, or Iridoncosis . § 2. Staphyloma of the Iris, or Staphyloma racemosum § 3. Staphyloma of the Cornea and Iris § 4. Staphyloma of the Choroid and Sclerotica . XVI. Varicosity of the External and Internal Vessels of the Eye XVII. Asthenopia and Amaurosis .... XVIII. Ossification in different parts of the Eye ^ 1. Ossification of the Cornea .... § 2. Osseous Deposit in the Sclerotica § 3. Osseous Deposit in the Anterior Chamber . § 4. Ossification of the Iris .... 2 5. Ossification of the Corpus Ciliare . § 6. Ossification of the Choroid § 7. Ossification between the Choroid and the Retina § 8. Ossification of the Hyaloid Membrane, Crystalline Capsule, and Crystalline Lens Chapter XV. Adaptation of an Artificial Eye Chapter XVI. Partial and General Enlargements of the Eyeball; Effu- sions AND Tumors within its Coats I. Conical Cornea II. Hydrophthalmia, or Dropsy of the Eye I 1. Dropsy of the Cornea I 2. Dropsy of the Aqueous Chambers § 3. Sub- Sclerotic Dropsy I 4. Sub-Choroid Dropsy § 5. Dropsy of the Vitreous Body § 6. General Hydrophthalmia . III. Sanguineous Effusion into the Eye IV. Non-malignant tumors of the Eyeball § 1. Non-malignant Tumors of the Cornea and Sclerotica § 2. Non-malignant Tumors of the Iris § 3. Non-malignant Tumors of the Choroid and Corpus Ciliare § 4. Non-malignant Depositions or Tumors occupying the place of the Vitreous Humor ..... page 601 602 604 606 611 616 617 623 625 630 631 632 ih. lb. 633 634 ib. 635 636 644 645 ib. ib. 647 ib. ib. ib. 648 ib. ib. 649 652 656 ib. 660 ib. 661 662 ib. 665 666 667 671 672 ib. 674 675 CONTENTS. Chapter XVII. Malignant Affections of the Eyeball I. Scirrhus of the Eyeball ..... II. Fungus Hsematodes, or Encephaloid Tumor of the Eyeball III. Melanosis of the Eyeball .... Chapter XVIII. Extirpation of the Eyeball Chapter XIX. Arcus Senilis ...... Chapter XX. Cataract ...... I. Definition and Diagnosis of Cataract; Method of Examining Cases of this Disease ; Causes and Prognosis . II. Genera and Species of Cataract .... Class I. True Cataracts .... Genus I. Lenticular Cataract Genus II. Capsular Cataract Species 1. Anterior Capsular Cataract Species 2. Posterior Capsular Cataract Genus III. Morgagnian Catai-act . Genus IV. Capsulo-Lenticular Cataract . Species 1. Central Capsulo-Lenticular Cataract Species 2. Common Capsulo-Lenticular Cataract Species 3. Siliculose Capsulo-Lenticular Cataract Species 4. Cystic Capsulo-Lenticular Cataract Species 5. Bursal Capsulo-Lenticular Cataract Class II. Spurious Cataracts .... Genus I. Fibrinous Cjitaract Species 1. Flocculent Fibrinous Cataract Species 2. Clotted Fibrinous Cataract . Species 3. Trabecular Fibrinous Cataract Genus II. Purulent Cataract Genus III. Sanguineous Cataract Genus IV. Pigmentous Cataract . III. Various additional Classifications and Distinctions of Cataract § 1. Consistence ..... i 2. Size ...... § 3. Color ...... § 4. Duration and Development . . . - § 5. Curability ...... IV. Complications of Cataract .... V. Palliative Treatment of Cataract VI. Medical Treatment of Cataract .... VII. Preliminary Questions regarding the Kemoval of Cataract by Operation ...... VIII. Position of the Patient during Operations for Cataract — Mode of fixing the Eye — Use of Chloroform IX. General Account of the Operations for Cataract X. Depression and Pveclination .... ^ 1. Depression or Reclination through the Cornea § 2. Depression or Reclination through the Sclerotica § 3. Displacement by Lateral Traction through the Sclerotica CONTENTS. XV XL Extraction ...... ^ 1. Extraction through a Semicircular Incision of the Cornea § 2. Extraction through a Small Section of the Cornea ^ 3. Extraction through the Sclerotica XII. Division ...... § 1. Division through the Sclerotica ^ 2. Division through the Cornea XIII. Choice of an Operation for Cataract; Indications and Contra indications for the different Modes of Operating XIV. Congenital Cataract XV. Secondary Cataract § 1, Lenticular Secondary Cataract § 2. Capsular Secondary Cataract ^ 3. Spurious Secondary Cataract ^ 4. Mixed Secondary Cataract . XVI. Cataract-Glasses . Chapter XXI. Artificial Pupil I. Introductory View of the Methods of forming an Artificial Pupil II. Diseased States of the Eye requiring the Foi'mation of an Artifi- cial Pupil ....... § 1. Partial Opacity of the Cornea .... § 2. Partial Opacity of the Cornea, with partial Adhesion of the Iris to the Cornea ..... § 3. Closure of the Pupil, the Lens and Capsule being presumed transparent ...... ^ 4. Closure of the Pupil, with firm and extensive Adhesion of the Iris to the Capsule, or the Capsule or the Lens known to be Opaque ...... § 5. Closure of the Pupil after an Operation for Cataract § 6. Closure of the Pupil from Protrusion of the Iris after Ex- traction ....... I 7. Partial Opacity of the Cornea, Closure of the Pupil, Adhe- sion of the Iris to the Cornea or to the Capsule, and Opacity of the Capsule or Lens .... III. General Rules regarding Artificial Pupil IV. Incision, Excision, and Separation compared. Conditions neces sary for these Operations V. Artificial Pupil by Incision § 1. Incision through the Sclerotica § 2. Incision through the Cornea VI. Extension of the Pupil by Prolapsus VII. Artificial Pupil by Excision § 1. Lateral Excision § 2. Central Excision VIII. Artificial Pupil by Separation §1. Separation througH the Sclerotica § 2. Separation through the Cornea IX. Compound Operations for the Formation of an Artificial Pupil X. Accidents occasionally attending the Formation of an Artificial Pupil ; After- treatment XI. Sclerectomia PAGE 746 ib. 764 767 770 ib. 778 785 789 ib. ib. 790 793 ib. 794 797 ib. 800 ib. 801 ib. 803 ib. ib. 810 811 812 817 818 ib. 821 ib. ib. ib. 826 827 829 XVI CONTENTS. Chapter XXII. Abnormal States of the Iris, independext of Inflammation I. Myosis II. Mydriasis HI. Tremulous Iris Chapter XXIII. Glaucoma and Cat's Eye I. Glaucoma II. Cat's Eye . Chapter XXIV. Various States of Abnormal Vision I. Myopia, or Near-Sightedness II. Presbyopia, or Far-Sightedness III. Irregular Refraction ^ 1. Uniocular Diplopia § 2. Astigmatism IV. Pliotopsia V. Chrupsia, or Colored Vision VI. Ocular Hypercesthesia VII. Ocular Spectra VIII. Insensibility to certain Colors IX. Myodesopia X. Spectral Illusions XI. Asthenopia XII. Niglit-Blindness . XIII. Day-Blindness XIV. Hemiopia . Chapter XXV. Diseases of the Fifth Nerve, affecting the Organ of Vision I. Painful Affections of the Fifth Nerve . § 1. Neuralgia of the Ocular and Orbital Branches of the Fifth Nerve § 2. Ilemicrania II. Ancesthesia, and Impeded Nutrition of the Optic Apparatus, from Diseases of the Fifth Nerve Chapter XXVI. Amaurosis I. General Account of Amaurosis § 1. Definition . \ 2. Seats § 3. Causes § 4. Symptoms . § 5. Forms, Stages, and Degrees ^ 6. Diagnosis . § 7. Prognosis . § 8. Treatment . II. Classification of the Amauroses , III. Illustration of some of the Species of Amaurosis § 1. Amaurosis from Apoplexy of the Retina ^ 2. Amaurosis from Aneurism of the Arteria Centralis Retime g 3. Amaurosis from Tumors attached to, or contained within, the Envelops of the Op>tic Nerve .... § 4. Amaurosis from Structural Changes in the Optic Nerves 967 ib. CONTENTS. § 5. Amaurosis from Fractured Cranium with Depression, or from Sanguineous Extravasation in consequence of Injury . 968 § 6. Amaurosis from Morbid Changes in the Membranes, or in the Bones of the Cranium .... 969 § 7. Amaurosis from Cerebral Congestion . . . 972 ^ 8. Amaurosis, with Apoplexy, from Encephalic Hemorrhagy, ^c. 975 § 9. Amaurosis from Aneurism of the Encephalic Arteries , 977 I 10. Amaurosis from Enlargememt of the Pituitary Gland . 978 § 11. Amaurosis from Concussion, or other Injury of the Head 980 § 12. Amaurosis from Congestion or Inflammation of the Nervous Optic Apparatus, brought on by Exposure of the Eyes to Intense Light, or by Over-exercise of the Sight . . 981 § 13. Amaurosis from Congestion or Inflammation of the Nervous Optic Apparatus, excited by the presence of Worms in the Intestines ...... 982 § 14. Amaurosis from Congestion or Inflammation of the Nervous Optic Apparatus, consequent to Suppression of the Menses 983 § 15. Amaurosis from Congestion or Inflammation of the Nervous Optic Apparatus, consequent to Suppressed Purulent Dis- charge ....... 984 § 16. Amaurosis from Congestion or Inflammation of the Nervous Optic Apparatus, consequent to Suppressed Perspiration . ib. I 17. Amaurosis from Congestion of the Nervous Optic Apparatus, produced by Poisons . . . . . 986 § 18. Amaurosis from Congestion or Inflammation of the Nervous Optic Apparatus, depending on Acute or Chronic Disorders of the Digestive Organs ..... 989 ^ 19. Amaurosis from Congestion or Inflammation of the Nervous Optic Apparatus, arising from Continued Loss of the Fluids of the Body ...... 993 § 20. Amaurosis from Albuminuria .... 997 § 21. Amaurosis from Irritation of the Branches of the Fifth Nerv § 22. Hydrocephalic Amaurosis .... 998 § 23. Amaurosis from Inflammation and Dropsy of the Brain, consequent to Scarlatina ..... 999 ^ 24. Amaurosis from Morbid Formations in the Brain . 1000 I 25. Congenital Amaurosis ..... 1003 Chapter XXVII. Entozoa in the Organ of Vision ^ 1. Echinocnccus hominis ^ 2. Cysticercus telae cellulosse ^ 3. Filaria Medinensis § 4. Filaria oculi humani ^ 5, 6. Monostoma and Disioma ocxdi humani Formulae ..... 1006 ib. 1007 1012 1013 ib. 1014 LIST OP ILLUSTRATIONS. i. Diagram showing the relative diameter and curvatures of the eye ii*. Structure of cornea. (From Bowman.) .... iii*. Structure of conjunctiva corner. (From Bowman.) . iv*. Vertical section of cornea, structure of membrane of Descemet. (From Todd and Bowman.) ...... V*. View of choroid and iris, showing vasa verticosa, ciliary nerves, &c (FromZinn, copied in Todd and Bowman.) ... vi*. Vessels of the choroid, ciliary processes, and iris ; inner surface after Arnold. (From Todd and Bowman.) .... vii. Pigment membrane of choroid ..... viii*. Foramen retinae centrali of Soemmerring. (From Todd and Bowman.) ix*. The stratum bacillosum ...... X. Diagram of convexities of the lens .... Cells and fibres of the lens. (From Todd and Bowman.) . Lamellated structure of lens. After Arnold. (From Todd and Bowman Diagram of Helmholtz's ophthalmoscope .... Diagram of concave mirror ophthalmoscope Caries of lower margin of orbit, producing ectropion of lower lid . Caries just within cavity of orbit, followed by ectropion and lagophthalmos of upper lid . . . .... Caries of fossa lachrymalis, attended with ectropion and lagophthalmos of upper lid ....... Lagophthalmos from caries of orbit .... Elevation of lower lid, produced by winking in such cases . Exostosis of orbit. (From Baillie.) .... Expansion of all the bones of face, and obliteration of orbits from growth of tumor in maxillary sinus (side view) .... Same (front view) ....... Epithelial cancer of eyelids ..... Chalazion, external appearance of lid affected with Chalazion, internal surface of lids affected with Desmarres's ringed forceps ; Wilde's modification . Diagram of method of strangulating ntevus, by double ligature at right angles ........ 14. Diagrams of Mr. Luke's method of applying ligature to nsevus by means of three needles ....... xii*. xiii*. xiv*. 1. 2. 9. 10. 11. 12. 13. PAGE xxiii xxiv XXV ib. xxix XXX ib. xxxii ib. xxxiii xl xli 76 ib. ib. 81 ib. 109 ib. 167 183 ib. 186 195 ib. * The additional wood-cuts of the American edition. XX LIST OF ILLUSTRATIONS. 15. Diagram of ligature passed subcutaneously around the base of a ntevus of the lid ........ 16. Diagram of ligature passed beneath, and subcutaneously around, a noBTUS 17. Himly's entropi'on or ptosis forceps .... 18. Wharton Jones's operation for ectropion of upper lid 19. Result of AVharton Jones's operation for ectropion of upper lid 20. Sir AVm. Adams's operation for ectropion in lower lid 21*. Dieffenbach's operation for ectropion. (From Lawrence.) 22*. " " " " 23*. 24*. 25*. 26. 27. 28. 29. 30. Dieffenbach's operation of transplanting for same. (From Lawrence.) , Ammon's operation for new lid. (From Lawrence.) . Result of same. (From Lawrence.) Jiingken's operation of transplantation from temple or cheek for ectropion Result of same Brainard's operation on lower lid Distichiasis Cilia forceps . 31. Horn spatula . 32. Toothed forceps 33. Entropion, acute 34. Chronic entropion 35. Silver spatula for the removal of foreign substances adhering to conjunctiv 36. Pterygium tcnue ..... 37. Trichosis bulbi ..... 38*. Encanthis. (From Miller.) 39*. Operation of opening lachrymal sac. (Wharton Jones.) 40*. Fistula lachrymalis. (From ^Miller.) 41. Nail-head style ..... 42. Same, slightly raised after introduction for the purpose of cleansing it. 43. Dupuytren's tube for nasal duct 44*. Wathen's tube for same .... 45. Stylet for introduction of tube 40. Bifurcated stylet (closed) for introduction of tube . 47. Bifurcated stylet (blades separated) for extraction of tube 48. Encysted tumor in the orbit .... 49*. Aneurism by anastomosis in the orbit. (From AValton.) 50*. Illustrating Macdonald's experiment for detection of strabismus. (From Med. Times) 51*. 52*. " 53. 54. 55. 56. 57. 58. 59. 60. 61. 62, 63. 64, Wire speculum ....... Operation for strabismus ...... False pupil (traumatic), by separation of iris from choroid . Detachment of greater part of iris from injury Laceration of iris from its ciliary to its pupillary edge from a blow Detachment of iris with cataract from a penetrating wound Separation of iris, with subconjunctival dislocation of lens . Fistulous opening through the sclerotic, from gunshot wound Reticular arrangement of bloodvessels in the ophthalmiae Zonular arrangement in the ophthalmia .... Fascicular arrangement in ophthalmiae .... Varicose arrangement in ophthalmiae .... LIST or ILLUSTRATIONS. FIG. 65. Synechia anterior, ■with central leucoma 66. Sclerotico-choroid staphyloma . . . . . 67. Staphyloma of cornea, sclerotic, and choroid 68. Double tagging of iris to capsule, the result of rheumatic iritis 69. Single tag of iris, from rheumatic iritis 70. Arthritic iritis. (From W. Jones.) .... 71. Anterior crystalline capsulitis. (From Walther) 72. Inflammation of posterior layer of capsule. (From Walther.) 73. Myocephalon, hernia of iris . 74. Granular conjunctiva 75. Symblepharon . . 76. Staphyloma uveas. (From Klemmer.) 77. Staphyloma racemosum. (From Beer.) 78. Partial staphyloma of cornea and iris 79. Hemispherical total staphyloma of cornea and iris 80. Staphyloma of larger size, showing the iris broken, reticulated, and adher ent to the pseudo-cornea ..... 81. Specimen of staphyloma of less size, exhibiting the iris entire 82. A general choroid staphyloma, from traumatic inflammation 83. Ossific shell between choroid and retina 84. Conical cornea .... 85. Cyst of iris in anterior chamber 86. Fungus haematodes of eyeball. (From Ammon.) 87. Melanosis of eyeball 88*. Nelaton's ophthalmostat 89. Diagram illustrating depression of cataract 90. Diagram illustrating reclination of cataract 91. Bent needle for displacement (front view) 92. " " " (side view) 93. Condition of capsule and iris after reclination 94. Position of lens in a case where it was depressed with its capsule. (From Soemmerring ..... 95. Diagram showing the incision of the cornea; too small 96. " " " " of proper size and position 97. Beer's cornea knife . 98. Section of the cornea for extraction 99. Needle and curette for division of capsule and removal of lens in extraction 100. Blunt-pointed knife for enlarging the section of the cornea 101. Daviel's scissors for the same 102. Sharp hook for taking out the lens . 103. Operation of division through the sclerotica 104. Straight needle for discission 105. Hays's needle for same 106. Same magnified 107. Dr. Jacob's curved needle for division through cornea 108. Same magnified 109. Same, with sharp point 110. Mode of using it . 111. Canula scissors for secondary cataract 112. Same closed .... 113. Blades of canula forceps removed from the canula 114. Forceps closed .... XXll LIST or ILLUSTRATIONS. FIG. 115. Spurious secondary cataract. (From Beer.) 116. Cheseldea's operation for artificial pupil 117. Pupil thus formed ..... 118. Wenzel's operation for artificial pupil by excision . 119. Scarpa's operation by separation 120. Appearance of eye after an operation for artificial pupil 121. Pupil in Sauvages' eye, made by Demours . 122. Rhomboidal pupil the result of the operation by incision 123. Adams's iris knife ..... 124. Operation for artificial pupil by incision through cornea. (From Walton.) 125. Maunoir's scissors for artificial pupil (blades closed) 126. Same opened ..... 127. Diagram of the incisions in Maunoir's operation 128. A quadrilateral opening made by this operation 129. Maunoir's operation by double radiating incision from closed pupil to ciliary margin .... 130. A pupil resulting from this operation 131. Partial synechia anterior with dense leucoma 132. Artificial pupil resulting from incision with canula scissors in this case 133. Tyrrell's blunt-hook for extraction of a portion of the iris 134. Leucoma with almost complete synechia anterior 135. Pupil, in this case, by prolapsus with Tyrrell's hook 136*. Maunoir's toothed forceps for excision 137*. Fischer's forceps for artificial pupil 138. Reisinger's double hook, closed 139. Same with blades separated . 140. Langenbeck's hook and canula 141. Schlagintweit's guarded book (hook exposed) 142. " " (hook covered) 143. Ordinary blunt-hook for artificial pupil 144. Diagram showing manner of using the hook in the operation of separation 145. The guarded hook in the act of being withdrawn .... 146. Diagram showing the amount of refraction of light in myopia and presbyopia 147. Diagram explaining the positions which muscoo, either anterior or posterior to the focal centre of the eye, appear to assume . 148. Carcinomatous tumor of dura mater producing amaurosis 149. Vertical section of same .... 160. Fungus heematodes of thalami 151. Mr. Logan's case of cysticercus with the head protruding 152. Same, when head was retracted ANATOMICAL INTEODUCTION, EXPLANATORY OF A HORIZONTAL SECTION OF THE HUMAN EYEBALL. BY THOMAS WHARTON JONES, F.R.S. *.;jj* The Numbers (1) (2) (3) &o.. refer to the horizontal section, Plate I. Fig . i. V ^ The human eyeball is nearly spherical in form. The antero-posterior dia- meter or axis (a b, Fig. i.) and the transverse diameter (c d), both measured from the outside, are about equal ; their average length being Hths of an English inch. The strong outer tunic of the eyeball consists of the sclerotica, vi^hich is opaque, and the cornea, which is transparent. Though the surfaces of these two parts are not strictly spherical, it may be allowable to state, in a general way, that the sclerotica is a large segment of a larger sphere, and the cornea a small segment of a smaller sphere. The diameter of the sclerotic sphere, is the same as that above mentioned of the eyeball as a whole. The radius of the convexity of the cornea is about Ifths of an inch. In order to meet each other, the sclerotica, at the line of junction, bends slightly towards the axis of the eyeball; the cornea, in an opposite direction (e/). The eyeball consists of four classes of parts : 1st. The protective parts, or tunics. 2d. Parts subsidiary to the perfection of the eye, as an optical instrument, viz : the iris, which is a diaphragm for correcting the aberration of sphericity, and the dark pigment, which serves to absorb the rays of light, 3d. The especially sensitive parts, viz : the optic nerve and the retina. 4th. The dioptric parts, refractive media, or lenses. I. Protective Parts or Tunics op the Eyeball. In a horizontal section of the eyeball, |ths of the circumference are formed by the sclerotica (1), and the remaining sixth by the cornea (4). Sclerotica. The sclerotica is a strong, dense, white, fibrous membrane. Posteriorly, [and about one-eighth of an inch] to the nasal side of the axis of the eye- ball, it is perforated by the optic nerve (IT), and is there continuous with the sheath (2) which that nerve derives from the dura mater. Near the en- trance of the optic nerve the sclerotica is about ^oth of an inch in thickness ; from this it diminishes to about ^'^th of an inch, but becomes a little thicker again in front, where it is re-enforced by the tendinous insertions of the straight XXIV ANATOMICAL INTRODUCTION. muscles. The texture of the sclerotica consists of an interlacement of lon- gitudinal and transverse fibres of the same nature as those of tendon. [Its fibres, however, are straighter or less wavy than those generally found in common tendon, and the interlacement between the longitudinal and trans- Fig, ii. Vertical section of tbe Sclerotic and Cornea, showing the continuity of their tissue between the dotted lines, a. Cornea, h. Sclerotic. In the cornea the tubular spaces are seen cut through, and in the sclerotic the irrepiular areola-. Cell-nuclei, as at c, are seen scattered throughout, rendered more plain by acetic acid. Magnified 320 diameters.— (From Bowman.) verse portions being at nearly right angles (Fig. ii. h), makes this covering a very strong and unyielding one, well adapted to protect the form of the eyeball from the influence of external pressure, and from the efiects of inter- nal distension.] The sclerotica is penetrated by small orifices, for the passage of bloodvessels into or from the interior of the eye. Like most other fibrous structures, however, it is itself but little vascular. Its scanty capillary net- work is fed principally from the ciliary and muscular arteries. Nerves have not been unequivocally traced into its substance, but many pass through it on their way to the interior parts. Coi-nea. The cornea (4), at once a part of the outer tunic of the eyeball and of the dioptric apparatus, appears to the naked eye as if framed into the sclero- tica, in the manner represented in the section. The diameter of the cornea measures about ^^ih?, of an inch (e/. Fig. i.); but this, the transverse dia- meter, is a little longer than the vertical ; because, in consequence of the encroachment of the sclerotica externally on the upper and lower edges, the circumference of the cornea appears actually oval, its small end being towards the temple. Viewed from the inside, the circumference of the cornea is more nearly circular. The cornea is about ^^ of an inch thick in mature age ; in early life, however, it is somewhat thicker, and in old age thinner. The cornea comprises three principal layers: 1st. The joro/^er corneal sub- stance in the middle (4). 2d. The conjunctiva cornece in front (4'). 3d. The memhrane of Descemet behind (6). The proper substance constitutes the principal thickness of the cornea. Microscopical examination shows it to consist of stratified bundles of fibres. There is, however, no natural separation into distinct layers. [But the whole proper substance consists of a mixture of yellow and white fibrous tissue, freely united so as to form tubes, which are ])laced one on top of the other, and run parallel on the same plane, or across one another, occasionally in an 'oblique manner ; a condition of things very difi"erent from that which we meet with in the structure of the sclerotic, where, as we have seen, the various fibres interlace at right angles, and at much shorter intervals. The lamel- ANATOMICAL INTRODUCTION. XXV lated condition of the cornea explains the greater facility with which an in- strument can be passed horizontally than vertically through its substance. — H.] It is through the medium of the proper substance, that the cornea is joined to the sclerotica. The fibres of the two structures interlace, or are continuous with each other. At its surfaces, which are invested respectively by the conjunctiva cornese and membrane of Descemet, the proper substance of the cornea is smooth, and of a close texture, but can scarcely be said to be formed of distinct membranes. Conjunctiva cornece, the substance which is made to peel off from the ante- rior surface of the cornea, by the action of boiling water, &c., and at the same time rendered opaque, is merely stratified, tessellated epithelium. [This epithelial covering is not, however, entirely composed of tessellated Fis. iii. Vertical section of the Human Cornea near the surface, a. Ante- rior elastic lamina, h. Conjunctival epithelium, c. Lamellated tis- sue, d. Intervals between the lamella?, showing the position of the corneal tubes collapsed, c. One of the nuclei of the lamellated tissue. g. Fibrous cordage sent down from the anterior elastic lamina. — Magnified 300 diameters. (From Bowman.) cells. The superficial ones are essentially such, but those beneath them are rounded (Fig. iii. h.) in their form, and in the most deeply seated layer they are columnar and placed vertically to the surface of the cornea. This epithelial layer has interposed between it and the proper substance of the cornea a thin, structureless lamina (Fig. iii. a), first described by Bowman. It is elastic in its character, and by sending down prolonga- tions (which interlace with each other) in the proper substance of the cornea, serves, as he has indicated, to brace and maintain it in its right configuration. — H.] This is continuous with the epithelium of the sclerotic conjunctiva, and is the sole constituent of most part of the conjunctiva cornece ; the cellulo-vascular basis of the sclerotic conjunctiva extending only a little way over the marii'in of the cornea. Fie;, iv. ^■^'hyWr\rH&rf^. — A man received a wound 18 lines long, above the right eyebrow. On the third or fourtli 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 ; bis abdo- men was painful, e.'^pecially the right hypochondrinm. The symptoms grew speedily worse, locked-jaw supervened, and the man died on the 7th day. A large quantity of pus was found beneath the pericranium, in contact with the fals, and on the tentorinm ; 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. ^ 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.* Contusion of its teui))oral edge has been sometimes followed by the growth of encysted and other tumors within the orbit. These efiFects, ho^NSver, 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 Orhit. 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 ])reviously 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. 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 f;iirly took the piece of bone with it, tearing, of course, the integuments and the eyebrow. The wound healed in such a wny 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 nie, several years after the accile that the whole diseased part has been removed, we lay aside the dossil of lint, and allow the opening to close. I do not imagine that, in cases of caries or necrosis of the bones of the orbit, there ever is any considerable formation of new bone. All that nature eJTects in such cases is, I believe, a heaping up of the diseased part, a bony cicatrice, without any attempt to restore what has been removed by ulcerative absorption, or by exfoliation. Fortunate, indeed, must the case be regarded, when the former process ceases, or the latter is completed, so that the diseased bone may granulate and heal, and the external wound be allowed to close, and this without any greater deformity than a deeply sunk cicatrice. It mav sometimes happen that we are deceived in regard to the state of the bone. The fistula may even close, and yet the bone continue diseased. Gra- nulations may fill up the sinus, without its bottom being sound. Perhaps some trifling exfoliation has taken place, without the whole diseased piece of bone having come away; and the surgeon, misled by appearances and think- ing that all is right, does his best to close up the sinus. Nothing, however, is gained, if the bone is still left in a state of disease. On the contrary, we are only obliged to go over again the same process of dilatation, and to wait for renewed exfoliation. Perhaps, to scrape the diseased surface, or scoop it out with a gouge, may be advisable in such a case. The exfoliation and heaping up of diseased bone is throughout an organic process, and may unquestionably be assisted by whatever remedies tend to support or improve the general health. In syphilitic cases,' mercury, sarsa- parilla, and other anti-venereal remedies, are to be employed. In scrofulous cases, tonics, such as sulphate of quinia, along with a nourishing diet and country air, will be found of use. I have no experience of the power of assafoetida, and a variety of other internal remedies, which have gained a I LAGOPHTHALMOS FROM CARIOUS ORBIT. 81 . reputation for promoting the exfoliation and healing up of bones. If they act at all, they probably do so merely as stimulants or tonics, without any of the specific power over diseased bone which has been ascribed to them. In many cases, iodide of potassium and cod-liver oil will be found advantageous. Unless when the separation of the diseased portion of bone and the healing up of the sinus have been more than commonly prompt, it is rarely the case that recovery takes place without a considerable degree of distortion of the eyelids, constituting i\\% fourth stage. The lagojihthalmos, in such cases, is generally relieved in part by a loosening of the retracted eyelid, effected slowly by the natural action of the orbicularis palpebrarum. Should this prove insufficient to enable the eyelids to close, the operations for ev^'sion to be afterwards described, modified according to the circumstances of the case, might perhaps prove useful. Case 61. — la a patient who was under ray care, at the Glasgow Eye Infirmary, with caries of the roof of each orbit, and lagophthalmos of each upper eyelid, the eyelids came very gradually to close more and more upon the eyeballs. For a time, however, the lagophthalmos was to such a degree, as to leave the conjunctiva constantly exposed to the irritation of the air, and the particles of dust floating through it. The conjunctivitis and corneitis thereby excited, I treated chiefly by the application of lunar caustic solution, till the elongation of the eyelids, produced by the action of the orbicularis palpebrarum in winking, rendered the lagophthalmos gradually less and less, and served at length to permit the eyeballs to be almost completely covered. When this patient was dismissed, the sinuses had long been healed. There still remained a slight speck on one of the cor- neas; and an evident deficiency was felt at the part of each orbit which had been the site of the caries. The solution of four grains of lunar caustic to the ounce of distilled water was of signal service in this case, moderating the external inflammation of the eyeballs, brought on from their state of exposure, and in fiict saving the eyes, till the natural apparatus of protection was in a great measure restored to the exercise of its oflBce. In cases of more considerable lagophthalmos, it is curious to observe the degree of accommodation effected by the lid which is free, for supplying the defective action of the lid which is fixed, so as to lubricate the eyeball in the Fig. 4. Fig. 5. From Am men. From Ammon. act of winking, and protect it from the intrusion of foreign particles. The upper lid, for example, being fixed to the root of the orbit, the appearance, when the eye is open, is such as is represented iu Fig. 4; when the individual winks, the upper lid not being capable of descending over the eye, the vicari- ous lower lid is thrust up, as in Fig. 5, so as to meet the upper lid, and almost to cover the eye. This muscular exertion is, unfortunately, available only while the patient is awake. I need scarcely say that it would be folly to attempt the cure of the eversion consequent to diseased orbit, if the fistula were still open, or the bone unsound. Were we to detach the eyelid from the edge of the orbit to which it is fixed, 6 82 PERIOSTOSIS OF THE ORBIT. replace it in its natural position, and endeavor, by some operative manipula- tion, to make it sit close upon the eyeball, we should merely lose our labor ; for the disease of the bone not being removed, the eyelid would very soon return to its former malposition. The operative means to be adopted after the bone is perfectly healed, we shall consider more fully in the third chapter, under the head of Ectropium. '■ On Diseases of Bone, consult Cumin, Edin- ' Dublin Journal of Medical Science; Vol. ix. burgh Medical and Surgical Journal ; Vol. xxiii. p. 255 ; Dublin, 1836. Ibid. vol. xxvii. p. 385; p. 3 ; Stanley on Diseases of the Bones, Lon- Dublin, 1845. don, 1849: Goodsir, Monthly Journal of Medical ' Zeitschrift fUr die Ophthalmologic ; Vol. i. Science ; Vol. x. p. H9 ; Edinburgh, 1850. p. 41 ; Dresden, 1830. ■^ Demours, Traite des Maladies des Yeux; ' Haynes Walton's Operative Ophthalmic Tome i. p. 91 ; Paris, 1818. Surgery, p. 229; London, 1853. " Pathological and Practical Kesearches on ' Op. cit.; Tome ii. p. 33. See Case by St. Diseases of the Brain and Spinal Cord; p. 29; Yves, Nouveau Traite des Maladies des Yeux, Edinburgh, 1829. p. SO ; Paris, 1722. ■" Quoted by Dr. Abercrombie from new series ' For cases of Syphilitic Caries of the Orbit, of Journal de Medecine ; Tome xi. p. 623. See see Uawkins, Msdical and Physical Journal; Caseof Periostitis of the Face, extending to Dura Vol. Ivii. p. 318; London, 1827 ; Listen, Medical Mater, in a paper on Periostitis, by Sir P. Gazette, Vol. v. p. 843; London, 1830. Crampton ; Dublin Hospital Reports ; Vol. i. p. '° Annales d'Oculistique ; Tome vii. p. 8; 337 ; Dublin, 1818. Bruxelles, 1842. SECTION in. — PERIOSTOSIS, HYPEROSTOSIS, EXOSTOSIS, AND OSTEO-SARCOMA OF THE ORBIT, AND CYSTS IN ITS PARlETES.* Periostosis signifies a thickening of the periosteum ; Hyperostosis, an in- crease of the bulk or thickness of bones ; exostosis, a bony tumor ; osteosarcoma, a degeneration of bone, generally malignant, in which it is converted into a soft mass, with numerous osseous spiculae radiating through it. To all these diseases, the orbit is subject ; as well as to the development of cysts in its parietes. § 1, Periostosis. A node, or periostosis, may form on the surface of any bone ; on the ex- ternal surface of the skull, or within the orbit. I have seen a large venereal node occupying the upper edge of the orbit. Exostosis is often combined with greatly thickened periosteum, A node is not unfrequently affected with secondary inflammation ; it then becomes more swollen, and tender to the touch ; it communicates a feeling of fluctuation, and a flow of matter is looked for on dividing it with the knife. Pus is sometimes discharged under such circumstances, while in other cases only a reddish serum escapes by the incision. Periostosis of the orbit, except when syphilitic, and brought under the in- fluence of mercury, or iodine, is not likely to be either readily recognized or successfully treated.* An incisfon, down to the bone, is certain to relieve the severe pain and tension of a node ; but as the consequences of this practice are generally an unhealthy tedious suppuration, perhaps also an exfoliation of bone, and cer- tainly a very unseemly depressed cicatrice, repeated blisters over the part, and the use of mercury or iodine internally, ought first to be tried. These means are often successful in causing absorption of the eff'used fluid, and procuring adhesion of the periosteum and integuments to the surface of the bone, which may then present a depression in place of an elevation. [The subcutaneous division of the periosteum to relieve the tension, and consequent pain, in a node, or, in periostitis, by means of a fine tenotome, introduced through the HYPEROSTOSIS OF THE ORBIT. 83 skin, at some distance from the seat of the disease, is the method we should always recommend in preference to free incision by the bistoury or scalpel. For, by such a procedure, the strangulation of the tissue is as readily relieved as by the simple incision; and the occurrence of the evil consequences of the latter method, the unhealthy, tedious suppuration, the exfoliation, and the very unseemly depressed cicatrix, are entirely avoided. "We think that this plan should have precedence of counter-irritation ; it failing (which it will be found very rarely to do), then we may, with great propriety, try the discussion of the disease by the means above indicated before laying open the part by a free incision. — H.] Other specific diseases, besides syphilis, may cause thickening of the peri- osteum of the orbit.' § 2. Hyperostosis. . Inflammation of a bone being arrested before the occurrence of disorgani- zation or death of the part, the consequence is sometimes hyperostosis. It is a variety of this process which, in some cases, and these generally complicated with atrophy of the brain, slowly thickens the bones of the cranium, without, perhaps, exciting any suspicion of the existence of such a state, till epilepsy or mania, and ultimately death, are produced. The bones of the orloit are liable to the same process; the cavity will thereby be intruded upon, its contents pressed together, and the eyeball pushed forward from its natural place, and at last destroyed. I have now before me the skull of an Indian child, probably about six years of age, which was picked up as it rolled down the Ganges. There has been ostitis of the roof of each orbit ; but in the left one the affected bone is ele- vated into a hyperostosis, and the surface marked by numerous orifices of the Haversian canals greatly expanded. I have also before me an adult male Indian skull, thickened and altered from ostitis. Although a small skull, it weighs, without the lower jaw, 1 pound 15^ ounces. The bony palate has been in a considerable measure destroyed by caries. The left parietal bone, and the margins of both orbits, are thickened and covered with osseous protuberances, the fibres of which present in several places a stellated arrangement. In some cases, the whole bones of the head are affected with hypertrophy. There may be a combination of hyperostosis with exostosis ; as in the case presently to be quoted from Jourdain. The only treatment likely to be useful in hyperostosis is the employment of alteratives. Case 62. — Hyperostosis of the facial bones shutting up the orbits. Jourdain has related and figured a remarkable case of hyperostosis of the bones of the skull, and especially of those of the face. The patient was the son of a surgeon at Perpignan. At the age of 12 years, he was affected with a lachrymal tumor at the inner ang^le of the right eye, which his father opened, and which suppurated for a pretty long time. When the tumor was opened, an eminence was observed growing from the middle of the nasal process of the upper maxillary bone, about the size of a small almond. It resisted diffei-ent local applications, and grew, so that in a short time it was a considerable tumor. By the time that the patient was 15, his two upper maxillary bones were equal, and presented two eminences so considerable, that they served to bury between them the cartilages of the nose, and so compressed the nostrils that the patient could breathe only by the mouth. His school-fellows could not endure the deformity of his face ; yet they loved him for his wit and talents. Everything was done by his father which was likely to remove the disease, but all was ineffectual. At the age of 20, his appearance was monstrous, so that hia friends dissuaded him from thinking of the priesthood, to which he had intended to attach himself. His lower jaw was also affected with an enlargement, which augmented more and more. Although his appearance was such as to oblige those Avho met him to turn away from looking at him, he was very inquisitive, and would visit everything which ex- cited attention. He ate and drank well, till, having reached his 44th year, he was attacked 84 EXOSTOSIS OF THE ORBIT. ■with fever, during his convalescence from which he became blind. As he recovered strength be began to see with bis left eye, and go about alone ; but inflammation of the chest supervening, with suppuration, and bloody expectoration, he died. On dissection, the left lung was found almost destroyed by suppuration. With the greatest attention, it was impossible to discover any of the muscles of the face. The skin was glued to the periosteum. The cranium and face were entirely exostosed. The malar and superior maxillary bones especially appear, from Jourdain's figure, to have given rise to a large exostosis on each side projecting so as to meet each other, and covering the nose, and in a great measure the orbits. The lower jaw also is exceedingly enlarged. The exostoses were as hard as marble. The cranium and face weighed 5 French pounds; the lower jaw by itself weighed 3 pounds 3 ounces; the whole together, 8 pounds 3 ounces; whereas, an ordinary adult skull, including the lower jaw, weighs generally about 1 pound 9 ounces, or at most 1 pound and 3 quarters; so that taking the pound at 16 ounces, the exostoses had augmented the weight of the head 6 pounds 7 ounces. This patient had never complained of pain in his head or in his lower jaw.* * § 3. Exostosis. This is a circumscribed tumor, consisting of newly formed osseous matter. Tumors, presumed to be exostoses in an incipient state, have been met with within the orbit, wholly in a cartilaginous state ; in other cases, the tumor has been partly cartilaginous, partly osseous. The cartilaginous deposition is supposed gradually to undergo the change which converts it into bone. It is by no means, however, a necessary step in the process by which an exos- tosis is formed, that there shall be a preliminary deposition of cartilage. Three varieties of exostosis have been distinguished ; the cellular, the craggy, and the ivory ; the first presenting an external crust, within which are nume- rous bony partitions, together with a quantity of soft substance, and occa- sionally hydatids ; the second consisting of a mixture of osseous laminae with cartilage, but without any shell ; the third, white and dense throughout, like ivory. In the last, and partly in the first, the deposit consists of pretty perfect bone ; but in the craggy exostosis, the matter deposited is a sort of false bone, not perfectly organized. The cellular exostosis appears to be one of the diseases comprehended under the old name spina ventosa. It proceeds from the periosteum, is not preceded by cartilage, seldom acquires a very large size, and often ceases to grow. Several such exostoses occur not un- frequently in the same individual. The craggy is not so common. It may grow either from the cancelli or from the periosteum. The tumor has a cartilaginous covering, the periosteum being imperfectly traceable over it, and into its substance. The centre of the tumor is generally bone : some- times cartilage. The ivory is exceedingly dense, and of high specific gravity. In composition, it does not differ much from ordinary bone. It originates in the diploe, pressing the compact tissues of the bone before it, and forms a round smooth tumor. It is the most frequent exostosis affecting the orbit, tending at the same time to intrude on the cavity of the cranium. Symptoms. — Exostosis springs in some cases from the edge of the orbit ; its nature is recognized by the touch ; and as it grows, it comes in part to cover and confine the eye. Although, in general, the touch will serve to discriminate between exostosis in this situation, and any other kind of growth, I may mention that I have seen a case of scirrhous tumor attached to the edge of the orbit, and partly within its cavity, so very firm in its consistence, and unyielding in its attachment, as to have been taken for an exostosis, pre- viously to dividing the skin for its extirpation. Exostosis from the edge of the orbit is sometimes combined with encysted tumor, of which I had an instance at the Glasgow Eye Infirmary, in a middle- ,aged female. The encysted tumor had existed from infancy, and was at- tended with exostosis from the edge of the frontal bone, preventing the pa- tient from raising the upper lid. After a gentle mercurial course, the exos- EXOSTOSIS OF THE ORBIT. 85 tosis diminislied so much as to permit the lid freely to exercise its functions. The case was probably in part syphilitic, as the patient afterwards presented herself with a suspicious-looking sore on the arm, which healed under the use of mercury. Exostosis may spring from any side of the orbit. We might perhaps sup- pose it more likely to grow from the floor or from the temporal wall of that cavity, than from the thin bones which form its roof and nasal side ; but this does not appear to be the case. The surface throwing out an exostosis is generally thickened. The most remarkable symptoms produced by an exos- tosis within the orbit are the following : — 1. Exophthalmos. — This is one of the earliest symptoms of any kind of growth within the orbit. Sometimes the eye is projected directly forwards, even when the osseous tumor is afterwards found to arise not from the apex of the orbit, but from one or other of its sides. More frequently the eye- ball is pushed forwards and to one side, towards the nose or temple, upwards or downwards, according to the size of the orbit giving rise to the exostosis. If the case is left to itself, the protruded eye sometimes inflames and bursts. 2. Pain. — This is very variable ; nor is it easy to explain how some suffer so severely, even from a small exostosis within the orbit, while others from large tumors of this sort suffer but little. The pain is communicated through the fifth nerve, and is sometimes felt in the eyeball, sometimes deep in the orbit, sometimes in the temple. 3. Amaurosis. — The protrusion of the eye must be attended with dragging of the optic nerve ; and this, along with the pressure caused by the tumor, generally induces dimness of sight, and at length blindness. Amaurosis is sometimes the earliest symptom. It is wonderful, however, to observe how much an eye is in some cases protruded and displaced by an exostosis, and yet vision retained. 4. Change of form. — Exostosis often increases to such a size as considerably to disfigure and intrude upon the orbit. It advances so as to be felt between the edge of the orbit and the eyeball, or even form a considerable protu- berance beyond the basis of the orbit. It may fill so much of the orbit, that the eyeball is no longer contained in this cavity. It may intrude upon the nostrils, upon the opposite orbit, or even upon the cavity of the cranium, and thus prove fatal. Diagnosis. — In exostosis of the orbit, it is often impossible to decide re- garding the nature of the disease, before proceeding to operate, or before the death of the patient ; for exophthalmos, pain, amaurosis, and deformity of the orbit, are found to arise from several other diseased states of the parts besides an osseous growth ; as encysted and other tumors, fungus of the maxillary sinus, &c. In advanced cases of fungus of the maxillary sinus, other symptoms, no doubt, attend those already enumerated, as softening of the palate, distension of the cheek, and obstruction of the nostril, which may serve to distinguish such cases from any disease confined to the cavity of the orbit. But between an encysted orbital tumor, not yet advanced so as to press upon the eyelids, and a deep-seated exostosis, it is often totally impossible to discriminate. The eyeball is merely extremely prominent, and the patient deprived of the sight of that eye, without any tumor being felt, or any other diagnostic symptom being present. Neither can we pretend to decide in cases of this dubious kind, whether thickening merely of the peri- osteum, thickening of the bones, or such a tumor as we call exostosis, be the cause of the exophthalmos. Prognosis. — Cellular exostoses are said to be occasionally destroyed by suppuration and caries ; any such change can scarcely be expected to take place in the craggy, and much less in the ivory exostoses. Nor will the mere possibility of any exostosis being destroyed by inflammation, ever withhold 86 EXOSTOSIS or THE ORBIT. Fig. 6. US from removing such tumor by operation ; for its spontaneous destruction must be uncertain and tedious. The ivory exostosis is much slower in its progress than the others, and sometimes it entirely ceases enlarging. If the surface of the tumor feels through the integuments nodulated or botryoidal, it may be concluded that it is of ivory consistence, with a broad base, and from its excessive hardness very difficult to extirpate. If the exostosis is small, and does not seem increasing, it should not be interfered with. Several preparations have been described, showing the ultimate result of exostoses of the orbit. Thus, Dr. Baillie, in his Series of Engravings, Illus- trative of Morbid Anatomy, has given a figure of a preparation of exostosis of the orbit, belonging to Mr. Hunter's museum. The figure (Fig. 6) shows an inner view of a section of the fore part of the cranium. The section had been made at such a level, as to include a small part of each orbit. A tumor is represented occupying the left orbit, which it has considerably dilated, and shooting for some way across into the other orbit, and backwards into the cavity of the cranium. Dr. Baillie mentions that the tumor was nodu- lated, and presented a compactness of texture exactly like that of ivory. Unfortunately no history of the case appears to have been preserved.* A frontal bone, picked up in Lower Alsace, is described and figured by Frank, in which an exostosis fills both orbits, projects far upon the face, and occupies a large portion of the cranial cavity.^ These two cases bear a considerable resemblance to the masses of bone, not unfrequently found within the cranium of oxen, and ignorantly taken for ossifications of the brain. Causes. — Besides venereal and scrofulous constitutional disease, contusions and frac- tures of the orbit have been known to give rise to exostosis. Cases of partial hyper- trophy of the osseous system seem some- times to depend on a depraved condition of the digestive organs, combined wnth a de- ficiency of saline matter in the urine. Treatment. — This must consist in atten- tion to the state of the digestive organs and general health, and in the use of anti-venereal and anti-scrofulous reme- dies. In certain cases, an attempt should be made to remove or destroy exostosis of the orbit by operation. Leeches round the orbit ; friction with mercurial ointment, or with a mix- ture of 1 part of iodide of potassium to 8 of mild mercurial ointment, or of 10 parts of muriate of ammonia to 100 of the same ointment ; and mercury and iodine internally are worthy of trial, especially if a syphilitic taint is supposed to be the cause of the disease. Local depletion, change of air, mild alteratives, iodine, and tonics of different kinds, may be tried in scrofu- lous cases. Should these means fail, and the disease be so situated that it can be reached, the attending symptoms may demand, that we should either attempt excision of the morbid growth, or endeavor to produce in it an artificial necrosis. Being well exposed, by an incision, in some cases, through the integu- ments, and between the fibres of the orbicularis palpebrarum ; in other cases, by dissecting back the lids, divided either at the commissure, or vertically, as seems most suitable ; the tumor is to be stripped of its periosteum, and removed with a strong scalpel, a small chisel, or a pair of cutting pliers. A. The inner 8ur£Eu;e of the anterior part of the cranium. B. The rijrlit orbit. C. The exostosis, resembling ivory, filling the left orbit. EXOSTOSIS OF THE OEBIT. 87 If it is connected by a kind of pedicle, it will be more easily removed in this way ; with much more difficulty, if it grows by a broad basis. The gouge and hammer, the saw, the trephine, and various other instruments, may then be required. In some cases, it may be possible to separate the entire exostosis ; in other cases, portions of it merely. It may sometimes happen that it shall be broken into pieces, yet none of these can be got away without severely lacerating, or extensively dividing, the soft parts. If they be left, suppuration will take place round them, and then they will come away. The operation must, of course, be executed very cautiously, lest the thin bones of the orbit be fractured, or any injury done to the eyeball or its nerves, in the attempts to detach the exostosis. The wound made in expos- ing the exostosis is not likely to heal without suppuration. In cases where it is not possible immediately to detach an exostosis from the bone whence it grows, it has been proposed to divest the tumor of its periosteal covering, and then leave the new growth, thus deprived of its nourishment, to perish by exfoliation. After stripping the tumor of its periosteum, it may be rasped with a file, or rubbed with caustic, or with nitric acid, so as to render its destruction still more probable. In conse- quence of this, a scale will drop off, or perhaps the whole exostosis may separate ; for unhealthy structures die more readily than healthy. Cases are recorded in which, after the application of caustic to an exostosis of the orbit, the tumor has in this way mortified, and been thrown off. Yet we must regard this as a practice to be followed only when immediate detach- ment of the diseased growth appears impracticable. It is a mode of cure attended with much more pain, and is much less manageable than the use of the chisel or the cutting pliers ; and, as the tumor is very likely to be nourished by vessels entering its internal, as well as its external surface, it may fail altogether. Ivory exostoses, however, are so hard that even a saw makes little impression on them. Mr. Hawkins thinks it better, therefore, to scrape them, and touch them with nitric acid or pure potass.'' Orbital exostoses have sometimes been removed while in the cartilaginous state, lying under the periosteum. Mr. Travers had seen several cases of this description ; the tumor presenting at the nasal side, and appearing to exteud to the bottom of the orbit, its anterior edge thin and bound down by the orbital circumference. From its compressing the eye to blindness, and pushing it out of the orbit, he inferred that the tumor probably possessed considerable bulk. He once removed, he tells us, a tumor of this kind, on the nasal side of the orbit, scraping it clean away from the bone. It was of the hardness of cartilage, and of great extent. He is unable to say whether the disease returned, having lost sight of the patient soon after the opei-ation. The impression he had of the case was unfavorable, from the character as well as the extent and connections of the tumor.^ Under certain circumstances, it may be advisable to remove the protruded eyeball in cases of exostosis of the orbit ; namely, when vision is destroyed, the pain distressing, and the osseous tumor probably so far back in the orbit that it could not be extirpated. The removal of the protruded eyeball has also sometimes been resorted to, in cases of exostosis of the orbit, when the symptoms were too obscure to lead to any decided diagnosis. Cases. — Although cases of exostosis of the orbit, minutely related, are not very numerous, my limits prevent me from quoting except a few of the most remarkable, each serving to illustrate one or more points of importance. Case 63. — Exostosis of roof of orbit, removed by operation. A female, between 20 and 80 years of age, in good health, applied at the Royal Westminster Ophthalmic Hospital, and stated that, seven months previously, she had noticed her right eye begin to protrude ; the projection was steadily on the increase, and the oi'gan was now directed downwards. 88 EXOSTOSIS OF THE ORBIT. No pain was felt ; vision was perfect ; but the disfigurement was so detrimental to her as a servant, that she was anxious for its removal. On examination, it was found that, besides the symptoms mentioned, the orbital ridge was increased in thickness, and a hard tumor, continuous with it, passed downwards and deeply backwards into the orbit, so as to press upon the upper and back part of the eye, causing its projection. Mr. Canton, having put the patient under the influence of chloroform, made an incision from the external to the internal angular process of the frontal bone, immediately below the eye- brow. The integuments, orbicularis muscle, and palpebral fascia having been cut through, the dissection was continued into the orbit and around the tumor, so as to free the latter from the neighboring and adherent soft parts. A small chisel was then applied to the accessible parts of the base of the tumor, which by degrees became detached from the orbital plate, and was withdrawn from between the latter and the upper and lateral part of the eye. Sutures, plaster and water-dressing were applied, and the patient recovered in a week, not having had a bad symptom. Vision on the affected side con- tinued nearly as perfect as the sound one. The exostosis was about the size of a walnut, very heavy, formed externally of compact bone, while its structure within presented a close reticular character.^ Case 64. — Orbital exostosis removed by operation. A carter, 40 years of age, was admit- ted under Mr. Haynes Walton's care, at St. Mary's Hospital, with an exostosis growing from the upper edge of the orbit ; it had a very broad base, was flattened, and its great- est point of projection measured two inches. The upper edge was covered by the eye- brow, which was considerably elevated ; the lower edge dipped into the orbit, touched the globe of the eye, and, thrusting it downwards and outwards, protruded it about half an inch beyond its fellow, thereby nearly destroying vision. The inner and outer bound- aries were less marked. The surface was tuberculated, and as hard as stone ; the skin was movable, and traversed by a few vessels. When quite a lad, he had fallen down stairs, and pitched on the front of his head; two months afterwards, a little swelling appeared on the orbital ridge, and gradually increased to the extent described. There was no doubt as to its true nature ; hardness, immobility, slow growth, continuity with the bone, and absence of pain and inflammation, suf&ciently marked the case. Chloroform having been administered, Mr. Haynes Walton made an incision in the line of the eyebrow, which had been previou.sly shaved, along the entire superior edge of the tumor ; a second, from the inner extremity of that to the root of the nose ; and a third, from the outer extremity to a little below the level of the outer corner of the lid. The flap thus formed was then dissected down till the lower part of the tumor was reached, when Mr. Haynes Walton passed a narrow saw between it and the eyeball, and sawed from below upwards, endeavoring to follow the natural line of the brow. The texture of the mass was like ivory, and a very long time was occupied in getting through it. The integuments were brought together by suture ; union by the first intention followed, except at a central spot of the transverse cut, through which healthy pus was discharged for eight weeks. Ultimately, the eye was restored to its place, sight returned, and very little indication existed of what had been done. The eyebrow, which concealed much of the scar, descended to its proper level, and the lid could be raised nearly to the extent of its fellow.'" Case 65. — Exostosis of the orbit, consequent to an injury, remolded u-ith difficulty by an operation. A girl, about 17 years of age, received a blow with a rake, the handle of which entered the left orbit. She immediately fell down insensible, but soon recovered her senses ; and, on examination, a deep wound was found between the upper wall of the orbit and the eye, the upper eyelid having been lacerated. There was not much bleed- ing. The eyelid did not become affected, and remained free from inflammation during the healing of the wound, which took place in a short time, and without any particular treatment. About eighteen months after the accident, the girl felt a tumor forming behind the upper eyelid ; but, as it was not accompanied by pain, or any other inconve- nience, she did nothing for it till it had acquired a large size. At the time when Dr. Salzer saw her, four years had elapsed from the occurrence of the accident. The tumor, by this time, was very hard, immovable, and protruding from the orbit, but still com- pletely covered by the eyelid ; the globe of the eye was forcibly pushed aside, and down- wards, so as almost to touch the left nostril ; sight was not completely destroyed. The upper eyelid was divided, and the tumor, having been laid bare in its whole breadth, was found of osseous texture, and attached to the orbit, not (as was anticipated) by a pedicle, but by a broad base. The substance of the morbid growth was so dense, that it was necessary to attack it with the chisel and hammer, and even in this way only portions of it could be removed. Towards the end of the operation, which lasted several hours, it appeared that a large piece of bone was loose ; but this could not be extracted, though several attempts were made to do so. The patient was bled, and had ice applied EXOSTOSIS OF THE ORBIT. 89 over the forehead ; she complained of violent pain, apparently from the pressure ■which the loose pieces of bone exerted on the eye ; for as soon as by a proper apparatus this pressure was lessened, the pain and inflammatory symptoms subsided. The osseous frag- ment, and what remained of the exostosis, having been subsequently removed by the ap- plication of the trephine, the muscles and vessels of the eye were found so much flattened, as almost to resemble ligaments ; however, after some time the globe began gradually to reascend into the orbit, and in six weeks after the operation, recovered its natural posi- tion. The sight had not suffered at all. The quantity of bone removed weighed about 2 ounces, after having been dried." Case ijij. — Exostosis of the orbit destroyed hy inflammation excited by the use of caustic. Brassant's case is often referred to. The patient was a woman, 30 years of age, who had fruitlessly undergone the operation for fistula lachrymalis. Fifteen years afterwards, the OS planum and the internal angular process of the frontal bone presented an exostosis of the size of an egg. The globe of the eye, compressed laterally, was thrust out of the orbit, and hung in some measure on the cheek at the temporal angle Brassant attacked the exostosis with caustic. It suppurated, and within the space of from three to four months, exfoliation of a considerable portion of the bony growth took place. The eye returned to its natural situation, and the cure was ultimately perfect '^ Case 67. — Exostosis exfoliates after repeated operations. Professor Sporing has recorded a case of osseous excrescence, which grew from the bone in the immediate vicinity of the internal canthus. The patient was a man of 35 years of age. The excrescence grew to the size of a very large walnut, pushing the eye nearly out of its socket, and impairing vision. A surgeon tried to remove it by promoting exfoliation ; but the wound bled so freely, that he was happy to close it up again. Some time afterwards, a peasant was al- lowed to try his skill upon it. He began with an incision round the bone, which caused a great effusion of blood. He afterwards applied to it some secret remedy, which pro- duced intolerable pain for 12 days, attended with faintings. Several months afterwards, however, the patient bad the courage to undergo the operation again. In the following spring, the entire exostosis dropped out, the eye returned to its situation in the orbit, and vision was restored."' The difficulty of making any impression on an ivory exostosis, with a saw or trephine, is so great, that in several cases the operation has been aban- doned, without being finished. Into an exostosis of this kind, producing protrusion of the eye, Mr. Keate made a perpendicular cut with iv trephine, but was obliged to desist from its hardness. The patient continued to attend at St. George's Hospital for several years, and had various caustics applied. Ultimately, a large piece exfoliated, in which, owing to its extreme density, so little change had been produced, that the hole made by the trephine was as distinct as when the man left the operating-room. Both in this case, and in another, in which Sir A. Cooper had tried in vain to saw off an ivory exostosis from the frontal bone, just at the edge of the orbit, but which ultimately exfoliated after repeated applications of caus- tic by Sir B. Brodie, Mr. Hawkins remarks that the hollow left by the sepa- ration of the tumors produced so odd an expression of countenance, that he doubts if the patients thought themselves much improved by the cure, though it of course prevented the mischief that would have ensued if the disease had continued to increase.'* Cr/.sc 68. — Operation on an ivory exostosis, abandoned on account of its excessive hardness. In 1843, I had an opportunity of witnessing a case somewhat similar in its result to those of Mr. Keate and Sir A. Cooper. A laborer was admitted into the Royal Infirmary of Glasgow, under the care of Mr. Lyon, presenting an exostosis, about the size of a pigeon's egg, growing from the roof of the right orbit. The supra-orbital ridge appeared as if forced up by it, while the eye was displaced downwards and forwards. The tumor was exposed by an incision parallel to the fibres of the orbicularis, and the finger was passed below and behind the tumor, which felt distinctly defined. Gouge, cutting pliers, rasp, and paring-knife were tried on its surface, without any effect. A chain-saw was passed behind and around the tumor, but would not work. Hey's saw being applied in front, after considerable perseverance, a cut to the depth of three-quarters of an inch was made into the exostosis in the plane of the roof of the orbit. A lever was passed into the track of the saw, but the tumor did not yield to such degree of force as the fear of breaking up the orbital plate, and injuring the brain, permitted to be used. The portion of the exos- tosis projecting anteriorly, between the track of the saw and the eyeball, was after some §0 OSTEO-SARCOMA OF THE ORBIT. diflBculty sawn off, and the wound closed, in the hope that what the operation had com- menced, would be finished by necrosis. Ten years have now elapsed since the operation. The exostosis still remains exposed through the wound, and bears the mark of the saw, as if the operation had been done but yesterday. The portion of the frontal bone to which it is attached feels somewhat loose. The eyeball is entirely extruded from the orbit, and the cornea has become opaque. [Mr. Maisonneuve recently presented to the French Academy of Medicine, a young man from whom he had a short time befi)re removed a large and hard ivory exostosis, involving the whole os planum of the ethmoid bone on the right side ; the whole tumor was as large as an egg. its antero-posterior diameter measuring nearly two inches, its transverse and vertical each one and a half inches. It projected equally into the orbit, and in towards the nose. It filled more than two- thirds of the former, and was continuous with its superior and inferior walls. The eye was completely extruded from tlie orbit and thrust towards the temple, the lids could not close over it, and the conjunctiva was inflamed. The sight, though impaired, was not wholly lost. The tumor was so deeply seated as to preclude the possibility of embracing it, and was so hard as not to be even marked by the blades of a pair of Leston's pliers ; indeed, twice these powerful instruments broke under the united force of the surgeon and his assistants. They even broke a third pair of forceps, furnished by Charriere, who was present, without making any impression on it. Mr. M. at last resorted to the chisel and mallet, and by violent efforts, succeeded in detaching the whole growth, en masse, without doing any injury to the brain, deep seated parts of the face, or even to the eye itself, which was not so much as pressed upon during the whole operation, which lasted one hour and a lialf. The tumor, when extracted, weighed nearly one ounce, avoirdupois. The wound healed up kindly, and the patient got well without one untoward symptom. The function of the eye was entirely restored, and when the patient was pi-esented to the Aca- demy, it was difficult to say on which side the disease had been. For a more detailed ac- count of this interesting case, seeBiille/in Gen. de Therapeutique, vol. xlv. p. 177, 1853.' — H.] The basis of the orbit has been found to be occasionally the seat of exos- toses. Sometimes one portion of it, and sometimes another has been affected ; but the superior maxillary bone most frequent!)''. Cases of this sort have been descril)ed as exostosis of the maxillary sinus. These we shall consider in the next section. In the following case, the whole basis of the orbit seems to have been affected : — Case 69. — Cup-Wee exostosis of the edge of the orbit. Acrel relates a case of this sort under the title of spina ventosa of the right orbit. The bones forming that cavitj', espe- ciall}- the frontal and superior maxillary, were so much protruded, as to present the ap- pearance of a blunt cone, four fingers' breadth high, and about the same in diameter at its basis. He compares it to a small cup inverted, in the Ijottom of which, or end which was turned outwards, was the eye. This was not completely sound and clear, and was smaller than the left eye; it had eyelids, which were movable, and the other parts be- longing to it, and even served to distinguish large objects pretty well. Acrel considered the case incurable. He mentions that he had seen another case of the same sort, for which also he regarded it useless to attempt any operation.'* § 4. Osteosarcoma. Osteo-sarcoma, by some called fibrous exostosis, and by Sir A. Cooper fungous exostosis of the medullary membrane, sometimes attacks the skull, and involves the bones of the orbit. The disease consists in the development of a tumor, involving the sub- stance of a bone ; taking its rise sometimes from the surface, and more fre- quently within the spongy tissue of the bone affected. The tumor gene- rally consists of a substance much softer than ordinary cartilage, containing numerous slender spiculae, or thin osseous plates, radiating through it, being partly the original bone expanded and separated into fibres, and partly new unhealthy bone. This disease depends on a particular state of constitution, and is generally regarded as malignant. Mr. Lawrence, however, distin- guishes'^ indolent from malignant ogteo-sarcoma ; the former occupying years before it attains a very considerable size, attended with little pain, and dangerous only in consequence of interferiog with the functions of parts, from OSTEO-SARCOMA OF THE ORBIT. 91 the magnitude it attains ; the latter attended with pain from the first, and growing very rapidly. A similar distinction is made by other surgical authors, between fibro-cartilaginous and sarcomato-raedullary exostosis. The latter, or malignant osteo-sarcoma, seems to be eneephaloid cancer or fun- gus haematodes occurring in bone; the former is the osteoid tumor of M tiller. In Dr. Hunter's Museum, in the University of Glasgow, two skulls are preserved, which have suffered greatly from osteo-sarcoma. One of them, apparently a male skull, of which no account is preserved, exhibits the whole left side changed by the disease in a most remarkable degree, the spiculiE and laminsB of bone into which it is converted rising at least three-fourths of an inch above the natural level of the bones. The spiculse project also to- wards the interior of the cranium, especially from the temporal bone. A small part of the floor of the orbit only remains unaifected, the three other sides being in a great measure destroyed. The other skull, a female one, is figured by Dr. Baillie, in his Series of Engravings Illustrative of Morbid Anatomy.*'' Nine or ten different parts of the cranium are afi"ected in this instance. The middle of the os frontis, the right temporal bone, both pari- etals, and the frontal behind its right external angular process, are the prin- cipal situations of the disease. At the right temple, the disease penetrates into the orbit, and affects in a slight degree the interior of the cranium. In each parietal region, the inside of the skull is much affected, spiculae of half an inch in length projecting inwards in these situations. In each specimen, the morbid appearances are evidently the effects of a disease springing up in the cancelli, and destroying both tables of the skull. Case (0. — Sir A. Cooper'* has given a sketch of an osteo-sarcomatous tumor on the forehead, extending close to the edge of the orbit. Sir Astley persuaded the subject of this tumor to submit to an operation. On removal, it was found exactly of the character above mentioned, and although partly formed of osseous spiculte, v^as readily broken down with the finger. The patient became feverish and comatose, and died on the 6th day. On dissection, Sir Astley found that the swelling occupied the internal as well as the external table of the skull, that it extended through both, and affected the dura mater, which had several fungous projections proceeding from it, and that the inflammation ex- cited by the operation, had extended to the membranes of the brain. The complaint seemed to have originated in the diploe of the os frontis, and to have produced an effu- sion both between the pericranium and the skull, and between the skull and the dura mater. The swelling, upon the outer part of the head, was, however, much larger than that which had arisen from the inner table. It was evident, too, that this case must have proved fital, although no operation had been performed. Sir Astley concludes this case by observing, that an exostosis on the ex- ternal table of the skull, growing slowly, very little vascular, and unattended with any considerable pain, may safely be made the subject of an operation ; but that a swelling of more rapid growth, red upon its surface, showing signs of considerable vascularity, and attended with great pain shooting through the brain, is one for which he should hesitate again to perform an operation. These latter characters belong not to simple exostosis, but to osteo-sar- coma. Case 71. — Sir Philip Crampton was consulted by a lady of about 55 years of age, on account of dimness of sight affecting the right eye ; the eye felt exceedingly hard to the touch, was affected with strabismus, and projected in some degree from the orbit ; the pupil was immovable, but vision was not altogether destroyed. She complained of severe shooting pains in the head and in the right arm ; her general health was much affected, and her aspect almost cadaverous ; her memory seemed much impaired, and there was a general insensibility to external impressions ; she was depressed in her spirits, yet she made but little complaint. On an attentive examination it was plain that there was some fulness in the situation of the temporal fossa, but the tumor was perfectly indolent and incompressible. 92 CYSTS IN THE PARIETES OF THE ORBIT. Sir P. did not see the lady again for four or five weeks, ■when he found her nearly co- matose ; the swelling on the temple had increased to a considerable degree, and the eye was still farther protruded from the orbit. She expired in a few days, and on the day following her death, the head was examined. On raising the aponeurosis of the temporal muscle, the temporal fossa was found to be occupied by a grayish-colored substance, of the consistence of brain ; the muscle itself had completely disappeared; numerous osseous spiculte proceeding from the frontal and temporal bones, passed into the tumor, of which they constituted a considerable part. On opening the head, a tumor of precisely the same description, beset in the same man- ner by bony spiculaj, was found lodged between the dura mater and the internal orbital process of the frontal bone. On macerating the bone, it exhibited the most perfect specimen Sir Philip had seen of fibrous exostosis. The spiculsB proceeding both from the outer and from the inner table of the cranium were each about as thick as a hog's bristle, and three-fourths of an inch in length; they were set as closely together as the hairs of a brush, and extended in an undulating line over a space of about two square inches in extent. The tables of the skull were slightly separated from each other in the part corresponding to the exostosis, and the diploe seemed to contain some of the same brain-like matter which formed the bulk of the tumor. Sir P. thinks it impossible to decide whether the disease commenced in the soft parts, or in the bone; although it seemed probable that it commenced in the bone, because the spiculae were furnished by the bone itself, and not by the periosteum or dura mater, which were separated by the tumor to the distance of nearly an inch from the outer and inner tables of the skull respectively.'^ Sir P. observes that, in maliprnant osteo-sarcoma, it is more usual to find a deficiency than an excess of bony matter ; for although spiculae of bone are interspersed through the brain-like substance which forms the bulk of the tumor, the bone itself is usually divested of its earthy basis, and is converted into a steatomatous or cartilaginous substance. Sometimes, however, the tendency to secrete phosphate of lime is surprisingly increased, and then large and singularly shaped masses of bony matter are thrown out from the surface of the diseased bone. The presence or absence of bony matter in an osteo-sarcomatous tumor will probably depend, Sir Philip thinks, on the relative activity of the secreting and absorbing systems in the diseased bone. He is also of opinion, that the varieties which are met with in the character and nature of osseous tumors, depend greatly on the kind of constitution of the patient, whether that be healthy, cachectic, or scrofulous. Case 72. — Dr. Schott operated in a case, in which the eye was pushed out of the orbit by a fungous growth, arising from the diploe of the great wing of the sphenoid, the outer half of the pars orbitalis, planum semicirculare and z_ygomatic process of the frontal, as well as the angulus sphenoidalis of the parietal and anterior half of the squamous portion of the temporal. The growth had pushed itself not merely into the orbit and temporal fossa, but into the cavity of the cranium. The operation removed the diseased mass from the orbit and temporal fossa. The patient died in 12 hours. ^^ It is scarcely necessary to add, that in cases of osteo-sarcom^ of the orbit, the less that is done the better. ^^ § 5. Cysts in the Parietes of the Orbit. The bones are subject to two kinds of encysted tumors, viz : the hydatid- encysted, containing echinococci similar to those met with in the liver, and the serous-encysted. These tumors are developed in the cancellated structure, and expand the affected bones often to a great size. The frontal and the upper maxillary bones have not unfrequently been found the seat of such dis- eases; in the latter situation, connected sometimes with the fangs of the teeth. A remarkable example of hydatid-encysted tumor of the frontal bone is related by Mr. Keate. The tumor projected from the forehead, chiefly over the left orbit, and presented the shape and size of three-fourths of a large DILATATION, DEFORMATION, AND ABSORPTION OF THE ORBIT. 93 orange. The tumor was laid open, and, ultimately, about 28 hydatids came away. Twenty years after the last operation, the patient continued well.-=^ In both kinds of encysted tumor, the bone covering the cyst must be freely laid open, and the cyst thoroughly extirpated. ' On tumors of the bones, consult Hawkins' Clinical Lectures, Medical Gazette, Vol. xxiii. ; London, 1838, 1839. * Dublin Journal of Medical Science; Vol. ix. p. 255 ; Dublin, 1836. ^ Medical Gazette ; Vol. xv. p. 265 ; London, 1835. ■* Jourdain, Traite des Maladies de la Bouche; Tome i. p. 289; Paris, 1778. ' Baillie's Series of Engravings, Fasciculus X. Plate i. ; also his Morbid Anatomy, p. 446; London, 1812. * J. P. Frank, Opuscula Posthuma, p. 77, Tab. iv. V. vi. Pavia, 1825. ■" Op. cit. p. 500. ' Travers' Synopsis of the Diseases of the Eye, p. 227: London, 1820. 'Medical Times; Vol. xxiii. p. 494; Lon- don, 1851. " Ilaynes Walton's Operative Ophthalmic Surgery; p. 345; London, 1853. " Quoted from the Neue Zeitschrift fiir Na- tur- und Heilkunde, in the Lancet for 1831 ; Vol. i. p. 671. '^ Memoires de TAcademie P>,oyale de Chi- rurgie ; Tome xiii. p. 277, 12ino. ; Paris, 1774. ''^ Quoted from Haller by Mr. B. Bell, in his Treatise on the Diseases of the Bones, p. 121 ; Edin. 1828. Referred to also by Acrel. I have not been able to find the original account of the case. '* Op. cit. p. 500. " Acrel. Chirurgische Vorfalle, ubersetzt von Murray ; Vol. i. p. 102 ; Gottingen, 1777. '* Lectures on Surgery, Medical Gazette; Vol. vi. p. 454; London. 1830. " Fasciculus X. Plate i. ; London, 1799. '* Surgical Essays, by Cooper and Travers; vol i. p. 212; London, 1818. " Dublin Hospital Reports ; Vol. iv. p. 554. Dublin, 1827. *" Controverse liber die Nerven des Nabel- strangs; advertisement at the end; Frankfurt am Main, 1836. ^' The reader will find a remarkable case of degeneration of the bones of the cranium and face, involving the orbit, related and figured by Cruveilhier, Anatomie Pathologique ; Tome i. Livraison 21. He considered the affection as cancerous. ^^ Medico-Chirurgical Transactions; Vol. x. p. 278; London, 1819: Hawkins, Op. cit. p. 471. SECTION IV. — DILATATION, DEFORMATION, AND ABSORPTION OF THE ORBIT, FROM PRESSURE. When an abscess or a tumor forms within any of the osseous cavities of the body, pressure slowly dilates even the bones, thins them, softens them, and forces them to give way. The bones of the cranium are not exempt from these changes, and have been known to allow a tumor of the bi'ain to protrude externally. Dr. Donald Munro has related a case of this kind, in which a tumor of the brain protruded through the os frontis ;* and Mr. Hunter has noticed a case in terms so exactly similar, that it is likely it was the very same which was seen by Dr. Munro. Mr. Hnnter thinks that the tumor had prob- ably formed in the pia mater. It was oblong, above an inch thick, and two or more inches long. It was sunk nearly its whole length into the brain, seemingly by the simple effects of pressure; but the outer end of it, by press- ing against the dura mater, had produced the entire absorption of this mem- brane at the part pressed upon. The same irritation had been communicated to the skull, which was also absorbed; after which, the same disposition was continued on to the scalp. As these respective parts gave way, the tumor was pushed farther and farther out, so that its outer end came to be in the passage which the absorbents were making for it in the scalp, by which it probably would have been discharged in time, if the man had lived; btit it was so connected with the vital parts, that the man died before the parts could relieve themselves. While all these exterior parts were undergoing absorption, the internal parts which pressed upon the inner end of the tumor, and which pressure was sufficient to push it out, did not in the least ulcerate, nor did the tumor itself, which was pressed upon on all sides, in the least give 94 PRESSURE ON THE ORBIT. way in its substance. No matter had been formed, neither by the dura mater, the edge of the bones of the skull, nor that part of the scalp which had given way. The general effect, however, was similar to the progress of an abscess, insomuch that it was on the side nearest to the external surface of the body that the irritation for absorption had taken place. ^ The process by which an abscess or a tumor is thus brought to the surface of the body, Mr. Hunter regarded as a combination of interstitial and pro- gressive absorption — interstitial, because particles from the interstices only of the part are for a time removed, the part still remaining — progressive, on account of the tending to the surface, till at length the surface gives way, and the abscess or the tumor finishes its progress by being exposed or evacuated. By the process in question the internal parts of the body are, to a certain extent, protected from the intrusion of such diseases, and in many cases a cure is effected by the discharge of the morbid accumulation or growth. Hence, Mr. Hunter called interstitial and progressive absorption the natural surgeon,^ If, then, the thick bones of the cranium are forced to yield, how much more readily will the bones of the orbit suffer from the same process, excited either from within that cavity, or without, from the surrounding cavities, the nostril, the frontal, maxillary, and sphenoid sinuses, or the cranium I § 1. Pressure on the Orhit from within the Orbit. Various causes within the orbit may, by pressure, produce dilatation and absorption of its walls. I have seen the orbit slowly enlarged by the growth and pressure of a diseased lachrymal gland, till it was of size sufficient to con- tain the fist, and at several points had given way. Effused blood, collections of matter, aneurisms, enlargements of the eyeball, encysted and other tumors, are all capable of producing such effects. If pressure from within the orbit is sudden, it will in some cases produce inflammation of the bones, and caries; but if carried on slowly, perhaps during the course of many years, dilatation and absorption, without any form- ation of matter, and even without inflammation, will be the effect. It some- times happens, however, that after the orbit has been slowly dilated, and perhaps partly absorbed, in consequence of the pressure of a morbid growth within it, the tumor begins to inflame and form matter, and this action, spreading to the surrounding parts, brings on caries. If it is the roof of the orbit which becomes affected in this way, the dura mater inflames and se- cretes pus ; the brain participates in the disease ; to fever, there are added delirium and coma ; and death follo\\s more or less speedily. § 2. Pressure on the Orhit from the Nostril. 1. Nasal polypus. — The nostril communicates with the orbit by the lachry- mal passage. The os unguis and os planum of the ethmoid form a thin par- tition between these cavities ; a partition which, but for the tendency already referred to, which morbid growths have towards the external surface, would often be broken through by nasal polypus. This tumor, after filling the nostril in which it has originated, dilates it at its anterior opening, pushes itself backwards, so as to appear behind the veil of the palate, and presses the septum narium aside, so as to amplify the cavity of the one nostril at the expense of the other. It is not, in general, till the nostril is in this way greatly dilated, and of course the face much disfigured, that the polypus pushes itself through the os unguis, and projects, covered by the inflamed in- teguments, in the situation of the lachrymal sac Previously to this, however, the passage for the tears is obstructed, and a painful feeling of i)ressure ex- EXOSTOSIS BETWEEN NOSTRIL AND ORBIT. 95 perienced in the orbit and through the head. If the polypus continues to advance, the nasal bones will be separated from the superior maxillary, the orbit will be still more intruded upon, the eyeball displaced, vision lost, and at last even the cavity of the cranium giving way, the morbid growth may come into contact with the brain. Nasal, much more rarely than antral, polypus is the cause of deformation of the orbit, and of such destructive effects as I have just now enumerated. Antral is apt to be taken for nasal polypus ; and I strongly suspect that, in several recorded cases, this mistake has been committed. In all cases of ex- ophthalmos, or protrusion of the eye, it is necessary carefully to examine the nostril with the finger and the probe, lest polypus of the nose or of the an- trum be the cause. Antral polypus, having by pressure destroyed the bones and mucous membrane which separate the antrum from the nose, sometimes pushes its way into the nostril, and imitates a nasal polypus ; nay, I have known a polypus of the antrum to traverse both nostrils, and project at the inner angle of each orbit. I do not conceive it necessary to enlarge on the treatment of nasal polypus. Early extirpation ought to be practised. 2. Exostosis between nostril and orbit. — In the following case, the orbit was displaced by an osseous tumor, which was i:|||timately removed by spon- taneous separation. This case, and one of osseous tumor in the orbit, to be noticed, along with other orbital tumors, in a following chapter, appear to have been exostoses, growing by narrow necks, which at length giving way, left the tumors free. It is a fact of much practical importance, that the surface of the attachment of an exostosis scarcely ever extends, but that the increase of the tumor takes place chiefly or only upon its periphery.* Case 73. — When Thomas Moore was about 13 years of age, a little pimple, like a wart, appeared under his left eye, close to his nose. He scratched off the head of this pimple, which formed a scab. This was followed by a tumor, which grew for 23 years. The tumor, although slow in its progress and free from pain, gradually became more conspicu- ous, and at last produced great disfigurement of the face. The septum nasi was pushed towards the right side, so as nearly to obliterate the right nostril ; the turbinated and cellular apparatus on the left side of the nose was destroyed ; and the left orbit was thrust outwards. After a time, the tumor displaced the inner wall of the orbit ; and the globe of the eye, being thus subjected to pressure, became the seat of most excruciating pain, though vision was very little impaired. When the patient was about the age of 19, the eye, yielding to the pressure, burst, and discharged its fluid contents. In less than an hour after this took place, the patient, who had been deprived of rest during several weeks, was buried in profound sleep. He awoke nearly free from pain; and this comparative ease continued. When he had reached the age of 30, the tumor was observed to be somewhat loosened, and to be becoming detached by ulceration of the surrounding soft parts. The process of detachment was alleviated by copious suppuration, and occasionally by profuse hemor- rhagy from the vessels of the adjacent structures. For a time, the tumor was retained merely by bands of integument, which it would have been easy to divide. At length, several small irregular portions of bone came away ; but the large mass continued to be maintained in its situation until the transverse bands were divided by ulceration, when to the patient's astonishment, the whole tumor fell from his face. Neither pain nor bleeding attended this separation ; but a large chasm was left between the nose and the orbit, bounded below by the nasal surface of the hard palate, and the floor of the left antrum, above by the left frontal sinus and left half of the cribriform plate of the ethmoid bone, internally by the septum nasi, which presented a concave surface, with a small opening through its lower part, communicating with the right nostril, and externally by the left orbit. Posteriorly, the chasm opened into the pharynx. When Mr. Hilton drew up his account of the case, the roof, the outer wall, and part of the inner wall, were covered with granulations. On comparing the distances from the median line of the face to the malar edge of each orbit, that on the leftside was found to be nearly an inch greater than that on the right. The left eyebrow was elongated in the same direction for about half an inch ; and the cerebral cavity appeared to be encroached upon by the pressure of the tumor upwiirds. 96 PRESSURE ON THE ORBIT FROM THE FRONTAL SINUS. The tumor weighed 14| oz. Its specific gravity was 1.80. Its greatest circumference measured rather more than 1 1 inches, and its least 9 inches. Externally it was undulated, and its postei-ior surface concave. A section of it presented a very hard surface resem- bling that of ivory, with lines, to the number of fifty, arranged in concentric curves, en- larging as they proceeded from the posterior part of the tumor.* I 3. Pressure on the Orhit from the Frontal Sinus. If we consider that when the frontal sinus is large, independently of dis- ease, it separates the orbitary plate of the frontal bone into two laminte, as may not unfrequently be observed in the skulls of old persons, and some- times in the young, it will not appear strange, that the pressure of a diseased and dilated frontal sinus should deform the orbit, displace the eyeball, destroy vision, and ultimately disorganize the bones upon which the pressure is ex- ercised. The frontal sinus, like the maxillary, is liable to several different kinds of disease ; namely, 1st. Inflammation of its lining membrane, ending in a col- lection of matter, which may be either thin, or thick and curdy ; 2d. En- cysted tumors, or what some have chosen to call hydatids ; 3d. Tumors, more or less solid, which are considered to be of the nature of fungus or polypus ; 4th. Exostosis. 1. Injiammation of the ffontal sinus , ending in a collection of matter. — The frontal sinus, on each side, is lined by a thin fibro-mucous membrane, a con- tinuation of that which lines the nostrils. The two sinuses are separated by a bony partition, which rarely runs in the course of the middle line ; so that, in general, the one sinus is larger, and, in many instances, much larger, than the other. Each sinus communicates with the middle meatus of the nostril, through the medium of the anterior ethmoid cells. The communication is narrow and indirect. Whether the diseases of the frontal sinuses are mainly, or frequently, or at all, to be attributed to accidental closure of this commu- nication, I shall not pretend to say. Beer has mentioned sudden suppression of severe catarrh, as a cause of matter collecting within the sinuses. It is known, that in cases of wounds penetrating into these cavities, their lining membrane inflames, and secretes a white puriform mucus, which has some- times been mistaken for the substance of the brain. Cold, and the other causes which give rise to the inflammation of mucous surfaces, may also affect the lining membrane of these cavities ; and in scrofulous constitutions, curdy pus will be apt to collect there, as it often does in the maxillary sinuses. Suppression of the natural discharge of the Schueiderian membrane, or of that discharge when increased by disease, seems occasionally to be the cause of amaurosis;" probably through the medium of cerebral congestion. It is scarcely necessary for me to quote examples of simple suppuration of the frontal sinuses ; I shall refer the reader to the cases related by Runge'' and Ilichter.* One of these recovered after the diseased cavity was opened externally ; another, after bursting of the matter into the nostril ; while a third proved fatal after spontaneous discharge of the matter through the ex- ternal table of the frontal bone, and through the middle of the upper eyelid. In the early stage of inflammation of the frontal sinuses, the obscurity of the symptoms will rarely permit any decided judgment to be formed of the case, or any active treatment to be adopted. In all the three cases to which I have referred, the disease had advanced, either to a considerable protrusion of the outer wall of the affected sinus, or even to the giving way of the cavity, and the evacuation of the contained matter, before any suspicion seems to have been excited. Leeches to the inside of the nostrils, and other anti- })hlogistic means would, of course, be adopted, were we called in early enough, and did the pain, and other symptoms, appear to indicate inflammation of the lining membrane of the sinus. Emollient, and afterwards, stimulating PRESSURE ON THE ORBIT FROM THE FRONTAL SINUS. 91 vapors drawn up into the nostrils, might be tried. If they succeeded in ex- citing a considerable discharge from the Schneiderian membrane, this might tend to relieve the inflamed state of the sinuses.^ In the suppurative stage, perhaps counter-irritation, and a variety of other measures, might prove useful. The last stage, in which the frontal bone becomes deformed, thinned, softened, so that it yields to external pressure, like a piece of elastic cartilage, or is even perforated by absorption or by caries, can scarcely be mistaken. The opening, however, which is formed in the bone, and ultimately in the integuments, is not above, or on a level with, the eyebrow, where a careless examination of the anatomy of the frontal sinuses might lead us to expect it, but close to the inner canthus, or beneath the middle of the superciliary arch ; so that, sometimes, the case might be mistaken for a disease of the lachrymal sac, till the probe, taking a direction upwards and backwards, showed the true nature of the case. In a patient of the Glasgow Eye In- firmary, the first symptom which attracted notice was the abscess pointing under the skin, immediately above the tendon of the orbicularis palpebrarum. No pain had attended the first stage of the disease. A large quantity of thick pus was discharged for a length of time. The eye was not aff'ected. In this stage there cannot exist any doubt about the propriety of exten- sively laying open the sinus, either with a strong curved knife, or a small trephine, evacuating its contents, endeavoring to improve the state of its lining membrane, by lunar caustic injections and the like, and then allowing the parts to granulate and heal. In one instance in which Beer trepanned the sinus, not merely was that cavity restored completely to its natural state, but the eyeball returned to its proper place in the orbit, and vision was recovered. In a second case, in which the external appearances were not nearly so alarming as in the former, after opening the outer table, he found, on examining cautiously with the probe, that the inner was softened, and even drilled through; in this case the eye was totally blind, and Beer endeavored merely to check the progress of the disease, by making a counter-opening through the conjunctiva, above the eyeball. In a third case, the symptoms were decidedly those of a collection of puriform mucus in the sinus, but the patient would hear of no operation. Five weeks after Beer's first visit, the outer wall of the sinus gave way of itself; and in the course of two weeks more the eye was lost, and a great portion of the orbit and of the nose destroyed by caries. The other eye remained completely amaurotic.'" 2. Encysted tumors, or hydatids, of the frontal sinus. — Professor Langen- beck has published two cases of pressure on the orbit from disease in the frontal sinus. He speaks of them as cases of hydatid ; a term much mis- applied by some of the German pathologists. Runge would have probaljly regarded them as cystic or encysted tumors ; perhaps the one was nothing more than a collection of mucus, and the other of thick matter. The situa- tions of the protrusion of the outer table of the bone, are amongst the most remarkable circumstances of these cases. Case 74. — F. Eeingarten, aged 17, enjoyed perfect health till she was 8 years of age, ■when Iiaviiig fallen into the water one hot day in 1802. she was seized next day with couvulsionti, followed some da^-s after by an eruption. This was probably niea.sle.-, l)nt they ran an irregular course. In the autumn of the same year, she fell, so that her right temple struck against tlie sharp corner of a table, soon after which a hard swelling ap- peared in the region of the right frontal sinus. Devoid of pain, it gradually extended towards the right temple, and involved the whole right side of the frontal bone. The right eye speedily became displaced by the swelling, in a direction outwards and down- wards, and tlie power of vision gradually decreased. In November, 1818, when the patient applied at the Surgical Hospital of Gottingen, 7 98 PRESSURE ON THE ORBIT FROM THE FRONTAL SINUS. the swelling extended upwards as far as the coronal suture. The orbital edge of the frontal bone, the eyeball, and the orbit were pressed downwards. The eye was covered by the eyelids, and not pressed out of the orbit, so that properly no exophthalmos ex- isted ; but the orbit rather, along with the eye, was pressed forwards, outwards, and downwards, so that the eye was in a line with the point of the nose, The fissura palpe- brarum had a crescentic form. The eyeball could with difficulty be moved a little towards the nose ; it preserved its natural form, and was not atrophic, but completely amaurotic. Although the swelling was on the whole hard, yet in the temporal region, and above the eye, it yielded to the pressure of the fingers, and immediately rose again, when the pres- sure was relaxed, as if one were pressing the lid of a tin box. The swelling was entireW free of pain, except when one pressed hard on it, above the nose. That the swelling did not extend in the direction of the brain was evident from there being no sign of any dis- turbance in the cerebral functions. There was no headache, vomiting, vertigo, insensi- bility, or coma, and the general health was good. From its situation, its hardness, and the circumstance that at certain points a thin lamina of bone could be depressed with the finger, and from the brain being free from suffering, it was concluded that the swelling depended on the frontal sinus being dilated, and filled with some morbid product. Langenbeck proceeded to open the swelling on the 2d December, 1818. At the place where the tumor yielded to pressure, he divided the integuments by a crucial incision. The outer table of the frontal bone was next penetrated by a perforator ; and through the aperture thus made, a pair of forceps was applied so as to break away some pieces of the outer table. Through the opening there was discharged a clear ropy lymphatic fluid, es- caping from a white shining cyst, which filled the whole frontal sinus, and which had been penetrated by the perforator. The cyst, or hydatid as the narrator of the case styles it, was laid hold of with the forceps and partially extracted. In order to ascertain the dimensions of the cavity, a measure was introduced. From the opening to the orbitary process of the frontal bone, it measured three inches ; to the frontal sinus of the opposite side, and to the posterior wall of the cavity, three inches and a half. With the finger the posterior wall of the sinus was distinctly felt. The an- terior wall was thin and spongy. The cyst was thick, and where it had been attached, almost cartilaginous. Internally it formed several lobes, containing a yellowish fluid. The sinus was filled with lint, and after some days discharged a quantity of thin ichor- ous matter, for which injections of willow-bark decoction, with myrrh, were employed. After a time injections containing corrosive sublimate were used; but, bringing on sali- vation, they were omitted. The internal treatment was at first antiphlogistic ; but when the ichorous discharge came on, bark was given. The swelling subsided only in an incon- siderable degree when the patient left the hospital. In winter 1819-1820, she returned, with the swelling in the same state, and the discharge of matter still as abundant. Lan- genbeck now passed two setons through the sinus, by which means the discharge and the swelling diminished." Case 75. — A ploughboy, 20 years of age, 11 years before his admission into the hos- pital, had, while playing at tennis, received a stroke with a racket on the left side of the nose, and on the left eye, the consequence of which was a great degree of swelling, which, after a time, completely disappeared. Two years afterwards, he began to feel pain in the part, and observed a protuberance at the inner angle of the eye. When the patient came to the hospital, Langenbeck found the eyeball natural in form, the power of vision not affected, and the pupil lively. The eyeball, however, was pressed outwards and downwards, by a considerable swelling at the inner angle of the eye. The swelling had exactly the appearance and the situation of a greatly distended lachrymal sac, but was considerably bigger than we almost ever find the sac, even in its state of greatest enlargement. That this swelling did not consist in an enlarged lachrymal sac, Langenbeck concluded from his not being able to empty it, no mucus or tears being evac- uated from the puncta on pressure, and the tears being duly conveyed into the nostril, without dropping upon the cheek. The patient's voice was similarly affected as that of one with polypus in the nose. The swelling communicated an obscure impression of fluctuation. At the inner side of the swelling, or towards the nose, it was bounded by a sharp edge of bone, which was felt exactly where the nasal process of the upper maxil- lary bone rises by the inner side of the orbit. As the surface of the swelling was not covered by any layer of bone, but felt soft and fluctuating, it was not easy to form a proper judgment regarding its seat, and one might have readily fallen into the error of supposing it to be an enlarged lachrymal sac. Against such a supposition, no doubt, there was the remarkable displacement of the eye outwards and downwards. As the swelling also extended from the inner angle upwards and towards the frontal sinus, Langenbeck concluded that that cavity was the seat of the disease. An incision being made from above downwards, close to the sharp edge of bone which was felt at the inner side of the swelling, and in such a way as to avoid both the PRESSURE ON THE ORBIT FROM THE FRONTAL SINUS. 99 Inchrymal sac and lachrymal canals, after the soft parts were sufBciently divided, a -white glistening sac came into view. On touching this with the finger, it was evident that it contained a soft mass. Langenbeck separated the swelling as much as possible ; but as he found that it extended deep in the nostril, he opened it, whereupon there issued from it a grayish-white tenacious substance. He cut away with the scissors as much as he could of the sac, and introduced his finger into its cavity. Its depth extended to 3 inches. With the point of his finger he reached as far as the floor of the nostril. He could not reach the orbit, nor touch the eyeball. He felt from the diseased cavity the inner wall of the orbit, formed by the os planum of the ethmoid, a part of the orbitury plate of the frontal, and the os unguis. This wall of the orbit, along with the lachrymal sac and nasal duct, was pressed outwards; hence arose the displacement of the eyeball, while the pas- sage of the tears into the nose continued uninterrupted. Langenbeck introduced his forefinger up into the frontal sinus. He decided, therefore, that the disease had origin- ated there, and had descended by the side of the nostril. He could now see into a large cavity filled with a grayish-white tenacious mass, which he removed with his finger and a pair of forceps. This substance was contained in a shut sac, distinct from the mucous membrane of the sinus ; and had it not been so, bethinks the substance in question would have made its way into the nostril. As has already been mentioned, the swelling was not covered by bone at the inner angle of the eye. It must, therefore, he thinks, have made its way, either between the os unguis and nasal process of the superior maxillary bone, or it must have prodviced the absorption of the latter. This is the more probable con- jecture, as the edge of the nasal process felt so sharp. The tenacious substance, which was extracted, was enough to fill a tea-cup. '^ 3. Polypus of the frontal sinus. — Polypus has been found in the frontal sinuses, the same disease existing in the neighboring cavities at the same time. It is quite conceivable, however, that a polypus might occupy one or other of the frontal sinuses, without any tumor of the same sort existing in the nostrils or maxillary sinuses ; and that slowly dilating the cavity in which it took its origin, it might displace the eyeball, and attenuate and soften the external table of the frontal bone. Under such circumstances, the sinus should be opened ; and as polypus is often attached by a narrow neck to the mucous membrane which gives it birth, the tumor might probably be extir- pated with success. Case 76. — A boy, aged 10, was put under Dr. Wuth's care, on account of a disease of the left eye, under which he had labored 9 years. The eye was so entirely pushed out of the orbit, that it lay on a level with the back of the nose. Its lateral displacement projected it so much over the cheek-bone that, viewed in front, it hid the neighboring side of the face. Its displacement downwards brought it into a line with the point of tlie nose. For the last three years, it had closed less and less completely, and the lids now covered it so imperfectly that the cornea, with a circumference of sclerotica four lines broad, remained constantly exposed. A large, deep ulcer of the cornea threatened a speedy disorganization of the eyeball. The regions of the frontal and nasal bones were greatly protruded. The eyeball had gradually quitted its natural place, in proportion as the orbit had become contracted hy tlie pressure exercised upon its constituent bones. The left side of the nose formed one flat surface with the back of it, and a firm obstacle presented itself to the finger passed into the left nostril. From the stretching of the skin, the left eyebrow was separated widely from the right, and dragged downwards. The skin itself was thickened and doughy to the touch, while at the outer under part of the eyebrow was a small opening, from which, on pressing the surrounding region, a whitish mucus welled out. Dr. Wuth, being of opinion that a large polypus occupied the frontal ^nus, proceeded to remove it by making first a vertical incision, 2 inches long, from the root of the nose upwards through the soft parts ; and then a horizontal one, also 2 inches long, close above the eyebrow. He next dissected back the triangular flap thus formed, so far as to permit the frontal sinus to be trepanned. In the middle of the superciliary arch was a small hole in the bone, opening into the sinus, and explaining the source of the fluid already mentioned. In consequence of the great dilatation of the sinus, it was necessary to make two openings into it with a small trephine, whereupon an immense quantity of polypi protruded, and were removed. The cavity in which they were contained would have held three hen-eggs. The healing of the parts occupied twelve months, the frontal sinus being by that time considerably lessened in all directions, and the eye having partially retreated into the orbit. The ulcer of the coi-nea soon cicatrized. From the first night after the operation, 100 PRESSURE ON THE ORBIT FROM THE MAXILLARY SINUS. the patient enjoyed sleep, such as he had not had for years, and he speedily improved in health. '» 4. Exostosis of the fro7ital sinus. — I know of no recorded case of this sort. By chance, I possess two preparations, each showing a small exostosis in the frontal sinus. § 4. Pressure on the Orhit from the 3f axillary Sinus. The diseases of the maxillary are upon the whole analogous to those of the frontal sinus. They are more frequent, more variable, and generally more easily recognized. They dilate the cavity of the sinus, thin by pressui-e the bones which form its walls, and force them at last to give way. They disfigure the face, displace the eyeball, and, if neglected, prove fatal.** 1. OoUections of tmictis or of pus within the maxillary sinus. — A thin con- tinuation of the Schueiderian meralirane passes from the upper part of the middle meatus of the nostril, through a narrow aperture, into the maxillary sinus, and forms its lining membrane. The fluid secreted by this membrane is in health discharged into the nostril, as one lies on the opposite side ; but is apt to accumulate, constituting what some have called dropsy of the sinus; in other cases, this cavity is filled with thin puriform mucus, or with thick curdy pus. Obstruction of the communication between the sinus and the nostril, cold, blows, aflections of the teeth, smallpox, and various other causes, have been mentioned as giving rise to these diseased accumulations, which have often been known to increase so much as greatly to dilate the sinus, elevate the floor of the orl)it, and foi'ce the eyeball forwards from its place. The matter may be discharged by the alveoli, or into the orbit, or by an opening which it makes for itself through the fossa canina. As an important diagnostic sign it may be mentioned, that in cases of mucous or purulent collection within the sinus, or of accumulation of fluid in a cyst de- veloped in the substance of the bone, the external bony shell generally becomes so thin as to yield and crackle under pressure, like the lid of a tin box. This symptom is wanting in exostosis, and also generally in fungus or polypus of the maxilhiry sinus. It is right, however, never to depend en- tirely on external diagnostic signs in diseases of the antrum; but always, before proceeding to any further operation, to perforate, or attempt to per- forate, the tumor, so as to ascertain its nature. In a case related by M. Gensoul, the incompressibility of the tumor led him to suppose it to be bony, and he was proceeding to the excision of the upper maxillary bone, when, on plunging a pair of scissors into the swelling, it proved to be a collection of mucus, within the antrum.'* When, in consequence of obstruction of the nasal aperture of the antrum, a simple accumulation of mucus takes place within the cavity, a swelling is apt to form behind the ala nasi and into the nostril, on puncturing which within the nostril, a large quantity of glairy fluid is discharged. If the natural aperture is now restored, well and good; but if this does not happen, the aperture which has been made with the lancet, or with a sharp point of pure potash, continues patent, and the discharge, becoming purulent, may continue for years. Not being entirely evacuated, however, by such an aper- ture, the walls of the antrum may become thiuued and elevated about half an inch below the edge of the orbit, the molares and dens sapientise get loose, aud pus ooze through the alveoli ; the roof and the floor of the cavity may soften, the bones become bare internally, and caries ensue. For an example of apparently simple accumulation of mucus within the maxillary sinus, I may refer to a case which occurred to M. Dubois : — C'a.ie 77. — The patient, when a boy of 7 years of age, was observed to have a hard round tumor, about the size of a filbert, near the root of the nasal process of the left PRESSURE ON THE ORBIT FROM THE MAXILLARY SINUS. 101 upper maxillary bone. It gave no pain, and did not appear to be increasing. A blow, however, which he received about a year after by a fall, excited this tumor to grow, which it did by almost insensible degrees till he was 15. It then began to enlarge more evidently and to cause slight pain. By the time he was 18, it was so considerable in size as to raise the floor of the orbit, so that the eye was pressed upwards, and appeared less than the other, on account of the limited motion of the lids. The palate was depressed, so that it formed a swelling of about the size of an egg divided longitudinally; the nos- tril was almost completely' closed, and the nose was twisted to the right. The cheek was prominent; and the skin below the lower eyelid, and covering the upper part of the tumor, Avas of a livid color, and seemed ready to give way. The upper lip was pushed upwards, and the whole length of the gums on the left side had advanced beyond the level of those on the right. Breathing, speech, mastication, and sleep, were impeded. Sabatier, Pelletan, and Boycr being called into consultation, the unanimous opinion appears to have been that this was a case of fungus of the maxillary sinus, requiring an operation. So much thinned was the bone behind the upper lip, that Dubois felt there a degree of fluctuation, and proceeded to open the sinus at that place, expecting merely to give issue to a small quantity of ichorous fluid, and then to encounter the fungous tumor. The opening, however, allowed a very considerable quantity of ropy substance to escape, similar to what is found in ranula. The probe being passed into the opening, entered evidently a large cavity, quite free of any kind of fungous or polypous growth. It is probable that the opening made at this first operation, if kept from closing, would have served for the complete cure of the disease; but Dubois appears to have thought differ- ently, and proceeded, five days afterwards, to extract three teeth, and to remove the cor- responding portion of the alveolar process. This enabled him, on placing the patient in a favorable light, to see the whole interior of the dilated sinus, at the upper part of which, and near to the edge of the orbit, he discovered a canine tooth, which he extracted. After this, the cavity gradually shrunk ; the tumor of the cheek, that of the palate, and the displacement of the nose, continued for some time ; but after 17 months no deformity existed. '^ A collection of pus within the maxillary sinus, whether produced in conse- quence of primary inflammation of its lining membrane, or of inflammation excited by diseased teeth, which is more generally the case, is not unfre- quently evacuated in part through the opening of the sinus into the nostril ; much oftener, however, that opening appears to be obstructed, so tliat the pus oozes through the alveoli, or collects and distends the sinus, producing a series of symptoms similar to those which occur in cases of simple mucocele of the antrum. Case 78. — Some years ago, I had under my care a gentleman, in whom the left maxil- lary sinus was distended to such a degree that the face was strikingly deformed, the bone absorbed at the most prominent part of the cheek, and the eye partially displaced. I directed the second molaris, which was in a decayed state, to be removed ; and through the alveolus, I perforated the sinus so as to give exit to a considerable quantity of puru- lent fluid. I then pushed up a lachrymal style into the opening, removing it every day and injecting the sinus with tepid water. Under this treatment, the secretion of matter ceased, and the sinus shrunk to its natural size. In neglected cases of suppuration within the maxillary sinus, various parts of its walls are apt to be absorbed, in consequence of the pressure of the accumulated pus, or rendered carious from inflammation. The floor of the orbit sometimes suffers these changes. The matter, issuing from the sinus, infiltrates behind the lower eyelid, which swells and inflames, sometimes in the neighborhood of the lachrymal sac, and at length there is formed a fistulous opening through the eyelid, by which matter is from day to day discharged. Perhaps the patient is brought to us in this state, when on passing a probe along the fistula, we readily ascertain that it enters a diseased maxillary sinus. Case 79. — In a case of this sort, in which the eye was already lost and the floor of the orbit fistulous, Bertrandi, having introduced a probe, or slender perforator, along the fistula into the maxillary sinus, directed it as perpendicularly as he could against the in- ferior wall of that cavity, and while with two fingers of his left hand he pressed against the roof of the mouth, he pushed the instrument through the alveolar process from above, 102 PRESSURE ON THE ORBIT FROM THE MAXILLARY SINUS. between the last two molares. After this opef ation, the pus ceased to flow by the fistula of the orbit, and the patient recovered." The mode of operating followed in this case may be adopted when the jaws, as is sometimes the case, cannot be suflSciently separated to permit a similar openina; into the sinus to be made from below. Wherever the open- ing is made, whether at the fossa canina, or through one of the alveoli, it ought to be kept patent, either by a dossil of lint, a lachrymal style, or a silver canula, which is to be withdrawn daily, and the sinus injected either with water or a weak solution of nitrate of silver. The patient may also use a gargle frequently, and press it up into the antrum. Cases of suppurating maxillary sinus have sometimes been successfully treated by the introduction of a seton through the dilated cavity, although this is not a practice to be much recommended. The seton is passed either through openings in the bone already formed in the course of the disease,*^ or by new perforations. Weinhold penetrates from the outside of the cheek into the diseased antrum, and brings out the perforating instrument on the palate ;'^ Hedenus separates the cheek from its connection with the superior maxillary bone, and then pushes a strong needle, armed with woollen threads, through the diseased cavity.'" In some instances, where the cavity was much dilated, a cure has been effected by practising an extensive opening into the side of the antrum above the alveoli f^ and in others, only after considerable exfoliations of its walls.*' 2. Poll/pus or fungus of the maxillary sinus. — It may not be possible to recognize this very serious disease in its incipient stage ; but as it advances, it always affects the neighboring parts in such a way as to render evident the nature of the case, and vindicate the employment of an effective surgical treatment. The dilated sinus is changed in form ; the teeth belonging to the affected bone become loose, or fall out spontaneously ; the alveolar pro- cess becomes spongy, and from its cavities there sprout out fungous granu- lations ; there is frequent bleeding from the corresponding nostril ; respiration through that nostril becomes impeded ; and on inspection, a polypous mass is found stretching into it from the antrum ; often the same growth raises and destroys the skin in the situation of the lachrymal sac ; sometimes it extends across the nostrils, producing by its pressure the absorption of the septum narium, and projects at the inner angle of the opposite eye also ; the cheek is greatly dilated and deformed, and at length the prominent point of the bony shell gives way ; the floor of the orbit is destroyed, and the eyeball is pushed upwards and forwards from its place ; the palate is softened and de- pressed; if nothing is done to remove the polypus, frequent hemorrhages weaken the system, hectic fever comes on, and death closes the scene. The order in which the symptoms occur varies in different cases. Some- times a violent feeling of toothache is the first symptom ; sometimes a swel- ling in the seat of the lachrymal sac ; sometimes a bleeding from the nose. Frequently, the patient has been conscious of a stuffing of the corresponding nostril for years. Then, there follows violent itching of the lower eyelid near the margin of the orbit ; to which are added fulness and hardness there, protrusion of the eyeball, oedema of the conjunctiva, and the appearance of a polypus in the nostril. Attempts are made, perhaps, to tie, or to twist off the polypus ; and it is then discovered to sprout from the interior of the antrum. The patient may present himself with a fungous growth in the seat of the lachrymal sac, the nostril being filled with the polypous growth from the antrum, but the antrum itself not dilated. I have known such a case taken for an exostosis of the ethmoid bone, and operated on as such. For years, the patient has sometimes noticed that one side of his face felt dif- ferently from the other, especially in shaving. PRESSURE ON THE ORBIT FROM THE MAXILLARY SINUS. 103 In general, no exciting causes can be fixed on by the patient. In one case, a blow on the face with a rope seven years before, was mentioned as likely to have been the cause. It scarcely admits of doubt that there are essential differences in the nature of the polypous or fungous growths, which are met with in the upper maxilla or within the antrum. The success which has attended the treatment in some cases, in which the tumor has been slowly destroyed, and the fatal result in other cases where extirpation of the tumor, or even excision of the upper maxillary bone, has been accomplished, would lead us to this conclusion. There is reason to believe that the most frequent, as well as the most dan- gerous diseases of the antrum, partake of the nature of encephaloid cancer or fungus haematodes, which in some cases seems to be formed entirely within the cavity, proceeding from the mucous membrane, and in its progress de- stroying the bones ; while, in other cases, the bones appear to be first affected, so that the disease is a malignant growth developed within the sub- stance of the bone, and, in fact, osteo-sarcoma. I have also known the dis- ease to be developed at the same time within the antrum, and in the perios- teum at the lower edge of the orbit. The bones which are implicated vary also in different cases ; for sometimes the disease is confined to the upper maxillary bone, while in others the sphe- noid gives rise to the tumor, which pushes itself forwards into the antrum and the orbit. That the direction of the pressure of a fungus within the antrum, is differ- ent in different cases, is a fact of which I am convinced from cases which have come within my own observation. In some, chiefly children or adoles- cents, the principal protrusion is forwards and outwards, so that the floor of the orbit is less disturbed ; in others, the pressure is chiefly inwards, so that the tumor speedily makes its appearance in the nostril, destroys the septum narium, and rises into view at the inner canthus of each eye, covered only by the integuments; while in a third set, and these chiefly old people, the fungus makes little or no pressure outwards, but proceeds inwards and up- wards, causing absorption of the floor of the orbit, destroying the soft parts within that cavity by exciting inflammation and suppuration, and lastly affecting the orbitary plate of the frontal bone. Treatment. — Though polypus of the antrum shows itself in the nose and in the orbit, it is not to be attacked in either of these directions. It is through the facial wall of the cavity that the tumor is to be reached. This is illustrated by the following case, which also serves to show the effects of the disease on the orbit : — Case 80. — James Macculloch, aged 53, •who became a patient under my care, at the Glasgow Eye Infirmary, in February, 1828, stated that he had been sensible of a stuffing of the right nostril for some years ; that six months before his admission he had been attacked with supra-orbital pain, darting towards the right side of his head ; and in a ehort time after this, with pain in the region of the right maxillary sinus, stretching towards the floor of the orbit, and increased when he opened his mouth. This was soon followed by stillicidium lachrymarum ; a soft elastic swelling, in the situation of the right lachrymal sac; and protrusion of the eyeball forwards, outwards, and upwards, from the orbit. He complained of a want of the sense of taste in the right side of his mouth. He slept little on account of the pain above the eye. On examining the palate, it was found to be yielding and elastic under the right maxillary sinus. For several weeks, the vision had been double, in consequence of the displacement of the right eye. The conjunctiva was inflamed, the eyelids adhered in the morning, and in consequence of the exposed state of the protruded eye, a small ulcer existed at the lower edge of the cornea. The right nosti'il was found to be filled by a polypous excrescence, of a white color and me- dullary texture, which bled profusely on being touched. After clearing away this substance with the polypus-forceps, a carious opening, sufficient to admit the end of the little finger, was found to exist between the nostril and the maxil- lary sinus. With the finger introduced through this opening, it was ascertained that the 104 PRESSURE ON THE ORBIT FROM THE MAXILLARY SINUS, sinus was completely filled with the same kind of polypous excrescence which had occu- pied the nostril. The clearing of the nostril was performed on the 19th ; and it is re- markable, that this had so much relieved the pressure on the orbit, that five days after, when I proceeded to open the maxillary sinus, the ulcer of the cornea was already cica- trized, evidently in consequence of the eyeball having retreated somewhat into the orbit, so as to allow it to be better defended by the lids. On the 24th, I made an incision, oblique in its direction, from above downwards, and from without inwards, through the cheek, down to the bone, with the intention of open- ing the sinus and removing its contents. I found, however, that the polypus had already produced absorption of the outer wall of the sinus, to the extent of half an inch in diameter. Through this opening the polypus was broken down and extracted. It re- sembled brain in color and consistence. The bony parietes of the sinus were felt through- out to be diseased ; its nasal side much disorganized; the os unguis gone; the orbital side, and indeed the whole interior of the sinus, denuded of its lining membrane. A long dossil of lint was introduced into the sinus. In a few days, a profuse secretion of white fetid matter flowed from the whole of the internal surface of the sinus, on remov- ing the dossil of lint. By the 4th March, the nose and lachrymal region were much more natural in their appearance, and the eye more in its place. A solution of chloride of lime (^i- to Ibij. of water) was daily injected into the sinus, with the view of correcting the fetor of the dis- charge. The long dossil of the lint was carefully introduced, so as to fill the cavity com- pletely. By the 9tli, all pain had ceased, the eye was still more in its place, the vision improved, and the shape of the face much more natural. The discharge had lost its fetor, and was less in quantity. By the 18th, the double vision was gone. By the 27th April, there was very little discharge, and the vision was much improved. On the 5th August, the report runs thus : General health and local symptoms go on improving. — On pressing the site of the lachrymal sac, thick white matter issues from the lower punc- tum, but is diminishing under the use of an injection of the nitras argenti solution. Antrum seems contracting, and discharges very little. Water injected by the opening, flows out by the nostril. On the whole, this case proved much more satisfactory than, from the very disorganized state of the sinus, I had expected. Vision and life were saved bj' the operation. More than six years after, the patient was in good health, the wound much contracted, the sinus still kept open with a bent wooden style, and no appearance of any reproduction of the polypus. In April, 1835, however, MaccuUoch presented himself at the Eye In- firmary, with similar symptoms on the left side, as had formerly attended the commence- ment of the disease of the right antrum. He was ordered to be received as an in-patient, but appears to have declined admission. In the case which I have just now related, the bleeding was easily re- strained ; but in other instances profuse hemorrhage has followed the cutting or tearing away of the tumor, so as to demand the application of the actual cautery. This means had also been employed for destroying the remains of the fungus, when it could not be completely extirpated. The sinus might have been cleared, in Maccullocb's case, without making any incision through the integuments, namely, by detaching the cheek from the upper maxillary bone ; but in this way the discharge would of course have flowed into the mouth, which would have been very disagreeable to the patient, and he would have been exposed to foreign substances entering the sinus. When we are anxious about the personal appearance of the patient, we will perhaps prefer this mode of operating ; but when that is less our object than a ready and effectual method of getting rid of the disease, the in- cision through the cheek will be adopted. The method of operating followed by Desault, in fungus of the maxillary sinus, consisted, not merely in opening that cavity, after detaching the cheek from the bone, but in removing with the gouge and mallet, a considerable portion of the alveolar process.** I should regard this as in general unne- cessary, and to be had recourse to only when this portion of the wall of the antrum is unsound, or gives origin to the morbid growth. Through the mouth, it may be somewhat difficult sufficiently to lay open the sinus ; but by cutting through the cheek, the bone may be so completely exposed, and an opening made of such a size into the sinus, as shall readily permit the PRESSURE ON THE ORBIT FROM THE MAXILLARY SINUS. 105 diseased mass to be removed. Since I first published these remarks in 1830, a still more formidable operation has been frequently performed for the cure of fungus of the maxillary sinus, as well as for other diseases of the upper maxilla, namely, total excision of the upper maxillary bone. An operation of such severity should be had recourse to, only where there is reason to conclude, first, that the disease is so confined to the maxillary and neighbor- ing bones, that it can be completely removed ; and, secondly, that it cannot be destroyed by any other method. A fungus completely confined within the antrum may always, I apprehend, be extirpated, without sacrificing more than a portion of its parietes ; it is not probable that a malignant tumor, originating within the antrum, but which has already thrown its ramifications into the nostril and the orbit, could be removed, even by the sacrifice of several of the other bones of the face besides the upper maxillary. Still more hopeless are fungous tumors originating in the ethmoid or sphenoid.^ The following case is worthy of consideration, not less on account of the great degree of disorganization produced by the disease, than for the sim- plicity of the method of cure : — Case 81. — A man, aged 36, applied to Dr. Eble, on account of an ulcerated state of the left cheek, with protrusion and amaurosis of tlie eye of that side. The cheek was not merely inflamed, painful, and partly ulcerated ; but the subjacent bone was exposed, softened, and perforated in five different points. The probe, introduced through these openings, was met by an elastic fleshy substance, which completely filled the antrum, and by pushing up the roof of this cavity had driven the eyeball forwards and outwards. The floor of the antrum Avas yet entire ; but the alveolar process at one place, where formerly there had been a carious tooth, gave issue to a considerable quantity of fetid ichor. The eye was so much protruded, that it could not be covered by the lids ; the amaurosis so far advanced that the patient could at a footstep's distance perceive very large objects but obscurely; the motions of the eye extremely difficult; severe nocturnal pain in the bottom of the orbit prevented sleep. The patient had always been healthy, except that for the last two years he had suffered from severe toothache, for which he had had three carious teeth extracted ; and from ulcers of the gums. He had, moreover, experienced an in- creasing weakness of sight. At this period, the surgeons who attended him opened twice a swelling over the second and third molare.s, and at each time a quantity of yellowish and slightly fetid pus was evacuated. To limit the spread of the ulcerative inflammation of the cheek, Dr. Eble ordered leeches to the sound parts, and the diseased parts to be bathed with a lukewarm lotion, and carefully cleaned. The swelling and pains diminished, and the ulcerated places became cleaner. The matter not escaping easily from the antrum in consequence of the smallness of the openings, he dilated these with sponge-tent, and then endeavored to destroy the polypous mass, by means of nitrate of silver, which he applied daily through one or other opening, for the space of 10 minutes. In four weeks, there was a free space of 4 lines betwixt the edges of the openings and the polypus, so that he could now inject into the interval, twice daily, a saturated solution of nitrate of silver. This hastened very much the destruction of the polypus; for in 14 days the eyeball was perceptibly retracted, and its motions had become freer. The violent pains at the bottom of the orbit were at the same time mitigated ; but vision was not improved, although the pupil was not so much dilated. In the 8th week of the treatment. Dr. Eble removed with the scissors the portion of bone between two of the openings, and in consequence of this was enabled to apply the caustic more freely, by which the complete destruction of the polypus was effected in the 12th week. It now appeared that the osseous walls of the antrum were nowhere carious, but only spongy, and that the floor of the orbit had suffered very little. As the polypus shrunk, all the symptoms of amaurosis were removed, and the eye returned into its natural situation; a good-conditioned suppuration took place in the whole parts affected; the ob- stinate growth of the mucous membrane stopped, and the spongy bone became firmer in its texture ; healthy granvilations sprung from all the openings ; and these gradually contracted until one after the other closed. In four months, the patient was ijerfectly cured. 25 A remarkable instance of successful extirpation of a maxillary fungus occurred in the practice of Dr. Thomas White of Manchester. Indeed, the bones of the orbit appear to have suffered more in this case than in any other on record. 106 PRESSURE ON THE ORBIT FROM THE MAXILLARY SINUS, Case 82. — The patient was a female. In two years' time, the tumor, situated betwixt tlie left zj'gomatic process and the nose, put on a frightful appearance ; having grown to such a bulk that it pressed the nostrils to one side, so as to stop the passage of air through them, and thrust the eye out of its orbit, so that it lay on the left temple. Though thus distorted, the eye still performed its office. The swelling occupied the greater part of the left side of the face, extending from the lower part of the upper jaw to the top of the forehead, and from the farthest part of the left temple to the external canthus of the eye. Upon handling the tumor. Dr. White found an unusual and unequal bony hardness. It was of a dusky livid color, with varicose veins on the surface, and there was a soft tubercle projecting near the nose, where nature had endeavored in vain to relieve herself. Dr. White began the operation with a semicircular incision below the dislocated eye, in order to preserve that organ and as much as possible of the orbicular muscle ; then carrying the incision round the external and inferior part of the tumor, he ascended to the place where he began, taking care not to injure the left wing of the nose. After taking away the external part of the tumor which was separated in the middle by an im- perfect suppuration, there appeared a large quantity of a matter like rotten cheese, in part covered by a bony substance, so carious as to be easily broken through. Abundance of this matter was scooped away, with a great many fragments of rotten bones. Upon cleansing the wound with a sponge. Dr. White found the left bone of the nose, and the zygomatic process, carious, and removed them. He says there were no remains of the bones composing the orbit. The optic nerve was denuded as far as the dura mater ; this membrane and the pulsation of the vessels of the brain were apparent to the eye and touch. The superior maxillary bone, in the sinus of which the disease had had its origin, was surprisingly distended, and in some places carious. The alveolar process was pro- bably in this state, as Dr. White mentions that he removed it. He then applied the actual cautery to the rest of the bones, taking care not to injure the eye and neighboring parts, which were sound. The patient drew her breath through the wound, and was so incommoded by the fetid matter flowing into her throat, that she was obliged for several weeks to lie on her face, to prevent suffocation. Notwithstanding her miserable condition, nature at length assisted, laudable pus appeared, sound flesh was generated, and the patient recovered. The eye returned to its place, and she enjoyed the perfect sight of it. The only inconve- nience that remained, was a constant discharge of mucus from the inner canthus of the eye. 26 Mr. Plowship has illustrated, by an engraving, the great extent to which the bones, forming the parietes of the antrum may be dilated by this disease. Case 83. — The patient, whose skull he has represented, a woman about 30 years of age, was received into the Westminster Hospital, with an extraordinary swelling upon the right side of the face, producing great distortion of countenance, but not attended with any discoloration of the skin. The basis of the tumor extended upwards to the eye, which was almost closed, and reached below to the chin ; the adjacent angle of the mouth being much depressed, and thrown out of its line, and the nose pressed aside towards the left cheek. In the most prominent part, the tumor projected about four inches beyond the general line of the bones of the face. On the inside of the mouth, the tumor was very large, having extended itself across the palate, nearly to the opposite teeth. The tumor was confined entirely to the bones about the upper jaw ; it was apparently fleshy, and where it extended across the roof of the mouth, it was of a florid red color. The teeth of the upper jaw, thrown out of their natural situation, formed an angle with the re- maining part of the alveolar circle. All those teeth involved in the extent of the tumor, were thus forced into the middle of the mouth, greatly impeding deglutition. The disease was of five years' standing, and had begun with a small soft swelling in the right nostril. In this state, it had produced no uneasiness. On the presumption of its being a polypus, the tumor had been partially extracted at difl'erent times. These operations seemed only to accelerate the progress of the disease, aggravating the degree of uneasiness and pain the patient now suffered, and hastening the increase of the swell- ing. W' hen the complaint had become more completely formed, there were two or three teeth which from their horizontal position were very much in the way, and troublesome from their being loose. Although the operation of removing them required no great eff"ort, it was attended with such a hemorrhage as brought the patient very low, before it could be effectually checked. A second violent bleeding took place about three weeks afterwards, from a spontaneous breach in the softer part of the tumor. This reduced her so much that she languished only a week longer. On dissecting the tumor, it proved to be a fleshy mass, or excrescence, not contained merely within the antrum, but surrounding and enclosing all the bones of the upper jaw. These bones had, from pressure, suffered a separation at their respective points of union, PRESSURE ON THE ORBIT FROM THE MAXILLARY SINUS. lOT with such a degree of extension and attenuation of their substance, that in many places they were reduced to the thinness of paper. The os malse was detached from the rest of the bones, and (though in its natural state a very solid bone) exhibited a cribriform appearance. The origin and nature of the disease cannot be a matter of any doubt. The bones had most likely remained uninjured till the soft fungous yascular mass from within the cavity of the antrum began to operate, first by producing, absorption of the membrane lining that cavity, and then by the pressure of its peculiar and partially organized texture, not exciting regular absorption of the bone, but sufficiently loosening its structure to admit of considerable distention. In the progress of the disease, as might naturally be ex- pected, the circulation in the periosteum made some effort towards repairing the mischief, by the secretion of new bone, as happens in cases of necrosis, although this effort, owing to the almost disorganized condition of that membrane, had proved irregular and abortive.^ The following case illustrates the cure by excision of the upper maxillary bone : — Case 84. — Janet Steel, aged 42, admitted into the Eoyal Infirmary of Edinburgh, on the 20th November, 1834, stated that, about ten years before, she had received a kick on the face from a cow, which was followed by swelling that never entirely disappeared. In the beginning of 1834, she began to suffer pain in the seat of enlargement, and at the same time remarked a great increase in the rapidity of the growth. The superior molar and bicuspid teeth of the affected side, soon afterwards loosened and came away. Within a few months of her admission, the progress of the disease had not been so rapid, but it had advanced so far as to be very distressing, and threatened to prove still more serious. The cheek was considerably distended by a tumor springing from the superior maxilla, which, though firm, did not possess the hai-dness of bone. When the finger was drawn across the lower margin of the orbit, an inequality in its surface was detected, and the floor of the cavity could be felt distinctly elevated. The palate, throughout the whole of its extent on the left side, and also for some distance beyond the mesial plane, was greatly thickened, and extremely irregular on its surface, which exhibited the characters of a malignant ulcer. The patient in all other respects enjoyed good health, and it was, there- fore, thought proper to attempt eradication of her formidable and extensive disease, which was evidently confined to the superior maxillary bone. On the 28th, the patient being seated in a chair, a perpendicular incision was made, by Professor Syme, from the inner angle of the eye down through the lip, and another from the convexity of the malar bone to the angle of the mouth. The flap thus formed was dissected up, and the integuments on each side turned back so as to expose the whole surface of the maxillary bone. One blade of a pair of cutting pliers was then introduced into the nostril, and the other into the orbit, so as to divide the ascending nasal process. A notch was next made with a saw in the malar protuberance, which then readily yielded to the pliers. After this, only the palate and septum of the nose remained to be divided, which was done by first circumscribing the morbid surface in the roof of the mouth with a sharp-pointed straight bistoury, and then cutting through the bone with the pliers. The diseased mass was now easily turned out to the side, and de- tached from its connections, when it appeared that the tumor had been removed quite entire. It was of moderately firm consistence, and of a yellowish color, springing from tlie maxillary bone and filling the antrum. By its pressure it had caused absorption, as well as displacement, of the floor of the orbit. The arteries requiring ligature having been tied, the patient was conveyed to bed. An hour after the operation, the cut edges of the integuments were brought into accurate contact by the interrupted suture, except at the two points where the lip was divided, each of which was secured by the twisted suture, a sewing-needle being used for tte pur- pose. Cloths moistened with cold water were diligently applied. The wounds healed by the first intention, and the patient was dismissed on the 20th December, with wonderfully little deformity. ^^ Fungus of the maxillary sinus occasionally proves fatal, not so much by the hemorrhage which attends it, or the hectic fever it induces, as by the pi-essure it causes on the brain. " I have seen," says Bertrandi, " a polypous excrescence, so situated, that, inferiorly it destroyed the bones of the palate ; it filled the mouth, and anteriorly consumed the maxillary bone ; superiorly, it pushed the eye almost out of its socket ; at length it destroyed the roof of the orbit, pressed upon the brain, and the patient died apoplectic. "-^ Case 85. — .Janet Anderson, aged 44, applied at the Glasgow Eye Infirmary, on the 2-5th March, 1838. She stated that nine weeks before that date, her left lower eyelid had 108 PRESSURE ON THE ORBIT FROM THE MAXILLARY SINUS, assumed a dark red color, as if affected with ecchymosis from a blow. For twelve months she had beeu much troubled with pain in the left side of her head, attended by a feeling of pressure and stoppage in the left nostril, which was deficient in moisture and sense of smell. She complaiued of numbness over the left side of her face, and the hearing of the left ear was impaired. Both left eyelids, as well as the conjunctiva, were cedematous at her admission ; a symptom which generally attends cases of pressure on the orbit, from whatever quarter or cause the pressure arises. She stated that, since the swelling of the eyelids commenced, her head had been relieved. There were no symptoms of dacryocystitis. The vision and the power of moving the eye were natural. Tongue cleau. Pulse ninety-six. She was ordered to be bled at the arm, and to take two grains of calomel with half a grain of opium at bedtime. Juue 13th, Has not attended since 25th Mai'ch, and went away without being bled or getting the pills. Pain gone. Still considerable swelling between the upper eyelid and eyebrow, with fluctuation towards the inner angle of the eye. Skin of a d.ark red color. Conjunctiva of lower eyelid red and swollen. The eyeball is somewhat displaced towards tlie side of the orbit. An incision being made through the upper eyelid into the swelling, some matter was discharged, and a considerable cavity was felt with the probe, extend- ing to the periosteum of the orbit. A poultice was applied, and two aloes and blue pills ordered to be taken at bedtime. 15th, Complains of chilliness about 6 o'clock P. M., followed by a hot fit. A grain and a half of sulphate of 9aX^of eye. The ancient xerophthalmia, or dry lippitudo, was what is now called ophthalmia tarsi. There are two kinds of xeroma, or dryness of the eye, the one lachrymal and the other conjunctival ; the former, depending on a suppressed or im- perfect secretion of tears ; the latter, on a deficiency of the mucous secretion, which, in the natural state, lubricate the surface of the eye.^ Lachrymal xeroma may be owing to a diseased condition of the substance of the gland, to a want of the proper nervous energy upon which its secre- 122 LACPIRYMAL XEROMA OR XEROPHTHALMIA. tive power depends, or to an injured state of its ducts, such as may arise from an abscess behind the upper eyelid. I am not certain that xeroraa is a common, though it maybe an occasional symptom, in inflammation of the gland. The assertion that it accompanies scirrhus or enlargement of that body, is contradicted by the cases related by Mr. Todd and Dr. O'Beirne.^ Yet we can scarcely suppose that the function of the lachrymal gland will go on without impediment, when its substance is either much inflamed, or greatly indurated. We are not surprised to meet with xeroma in old people, either by itself, or attendant on amaurosis ; for in them the gland is shrunk, and the nervous energy of the fifth, like that of all the nerves, diminished. We meet, how- ever, with this symptom as a frequent attendant on the incipient stage of amaurosis, even in those not far advanced in life : and we hail, as a favorable omen in such cases, the return of the lachrymal secretion ; for, we almost invariably find that, after this change, vision begins to improve. Chronic pains of the head are sometimes greatly relieved by a renewed activity of the lachrymal gland. ^ We may regard the xeroma which occasionally attends deep grief, as a purely nervous or sympathetic phenomenon. In all those cases, when we look at the eye, no appearance of dryness is to be observed ; for the mucous secretion of the conjunctiva is not aficcted. The eye looks as moist and slippery as ever, but the patient complains that it is never wet ; or, if it be at times bedewed with tears, great relief is ex- perienced, evidently showing that the dryness depends on want of the lachry- mal, not of the conjunctival, secretion. If xeroraa seems to depend on inflammation of the lachrymal gland, or if we suspect any incipient affection likely to lead to enlargement or change of structure of that body, local bleeding, and other antiphlogistic remedies, will be proper. Sternutatories are found useful, when want of nervous energy seems to be the cause. If the affection appears to be sympathetic, purga- tives, tonics, and antispasmodics may be had recourse to. The influence of music has sometimes been very remarkable in removing the xeroma attendant on grief.* As a substitute for the tears in xeroma, Wathen recommends^ the use of a saponaceous lotion. Three or four drops of a({ua potasses are to be added to two ounces of tepid water, filling about two-thirds of an eye-cup. This is to be applied to the open eye, for a minute or more. It gives little or no pain, brings away all the morbid excretions from off the eye and its lids, and as instantly removes what the patient calls the cloud from his sight. But as this will quickly return, its frequent application will be requisite. In order to excite, if possible, the natural secretion of tears, it ought to be made fresh every time it is used, and its strength gradually increased, till it becomes, not only a wash, but a stimulus. Keeping the eye at intervals in tepid water alone, for some minutes at a time, the same author remarks, is not only a substitute for the tears, but along with the means already mentioned, serves also to relax the parts, and dispose them to resume their natural functions. ' Mr. Wardrop has recorded (Lancet, 29 Nov. ■* Dictionnaire des Sciences Medicales ,• Tome 1834, p. 3i4) a coiigeiiital case of lachrymal and xxxv. p. 71 ; Paris, 1819. conjunctival xeinina. ' Method of eurinle 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 othervvi.se 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 notice* 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 ])one. 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 lupxis, 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 contrasted' cancer of the skin with lupus ; the latter is a disease which also sometimes involves the eyelids f 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 170 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 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 ineflfectually removed by the knife.' 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.^ 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 paste 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, Itl 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. jNI. Duijuytren, 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 niti'ic 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.^ 4. Extirpation hy the hiife. — 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 K the perichondrium, the whole thickness of the lid must be sacrificed ; if to B the periosteum, it must carefully be removed. If the disease has spread in I 112 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. — Daviel was 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 bandagCi 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.'" 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 loth 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 verj- even." Case 135. — A country woman, 42 j-ears of ago, sought assistance on account of a can- cerous tumor, which occupied the inner third of the upper and under eyelids, the carun- cula lachrym.alis, 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 Grilfe 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 Avere 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. ITS both canaliculi laclirymales, produced no stillicidium lachrymarum, -which, on physiolo- gical grounds, was to have been expected. Kudolphi 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.'^ 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.*^ 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 somethino; 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; - 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- * See Daviel's 1st and 10th cases, Op. cit. p. ton, 1837. 186. "Guy's Hospital Reports, Second Series; ' Quoted from the Lancette Fran^ai.se, in the Vol. viii. pp. 168, 170. Lancet, for 1830, 1831 ; Vol. ii. p. 607. ' Synopsis of the Diseases of the Eye; p. '° Op. cit. p. 189. 100; London, 1820. " Ibid. p. 191. ' Lectures on Surgery; London Medical Ga- '^ 1822. Jahres-Berieht iiber das clinische zette ; A^'ol. vi. p. 194; London, 1830. chirurgiseh-augenarztliche Institut der Uni- •^ Basedow, Grafe uud Walther's Journal der versitat zu Berlin, p. 3 ; Berlin, 1823. Chirurgie und Augenheilkunde; Vol. xv. p. ''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. L 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 hlear 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 xeroplithalmia 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 jjalpebrarum, and 2}SorophthaI>m'a; 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 seci'etion 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 api)a- 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. 115 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 sequela? 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 filthincss, 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. Linnteus' 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. It6 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 Avhich 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. ITT 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 sevei'ity 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 eff"ect, 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 eifectual. Not uiifrequently 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 arc 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.^ 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. t. 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 eflFects 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 Ijcdtime, 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.^ 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 difliculty 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 Jauin'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 Sequelcs. — 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 sequelae I shall take up separately. ' Lachcsis Lapponica, by Smith; Vol. ii. pp. ^ Griife und AValther's Journal der Chirurgie 5, 132 ; Loudon, 1811. und Augenheilkunde ; Vol. xxiv. p. 156; Ber- ^ Treatise on the Diseases of the Eye, p. 339; lin, 1836. London, 1833. ' Horatii Sat. i. v. 49. ^ Annotazioni Pratiche sullo 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.^ 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. '^ 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. ' Stenheim, Grafe und Walther's Journal der ° Bateman'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, 1S50. This disease, when it affects the eyelids, of which I have met with several instances, presents a row of yellowish, or ochre-colored, flat patches, of irre- gnlar 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 checks. 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 l)een derived from the repeated application of the nitrate of silver. SECTION XIV. — ABSCESS OF THE MEIBOMIAN GLANDS. I have already (page 114) 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. Tlie 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 «.scape 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 XVn. — 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 suspects' 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. Ammon's Zeitschrift fiir die Ophthalmologie ; Vol. v. p. 220 ; Heidelberg, 1836. SECTION XVIII. — PHLYCTENULA AND MILIUM OP THE EYELIDS. Fig. Walton, Figs. 88, 89. Semitransparent vesicles, or phlyctenulae, 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 x^aXal^a. a hailstone. Syn. — Tarsal Tumor. Fig. Dalrymple, PI. TV. 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 Fio;. 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 l3y 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 weU 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 frfena. 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. Si/n. — 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 contagiosum ; 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.* 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^ and Craigie,^' 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 continne 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. When 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 He ; 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 nnfrequent 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. Ltier'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,* of Dublin, prefers removing tarsal tumors by incision through the conjunctiva, whereas Mr. Desmarres' 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. Fihro-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 palpebrte superioris, and the cartilage of the lid. His opinion was adopted, but the opei'ation was more troublesome than he had calculated, chiefly from the immanageableness 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 depi'essed, 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.^ Other tumors, still, might be described ; for example, neuroma or painful subcutaneous tubercle, scirrhus, fungus hcematodes, melanosis,^ &c. But I 188 TYLOSIS. NiEVUS MATERNUS OP THE EYELIDS. think it unnecessary to enter on the particular consideration of these diseases as affecting the eyebrow or eyelids. ' On Molluscuui, consult Peterson, Edinburgh mic Surgery. Dublin Quarterly Journal of Medical and Surgical Journal, Vol. Ivi. p. 279 ; Medicine ; vol. v. p. 475 ; 1848.] Turnbull, ib. p. 463 ; Cotton, ib. Vol. Ixix. p. ' [Traite des Maladies des Yeux, par L. A. 82 ; Caillault, Archives Generales de Medecine, Desmarres. P. 144. Paris, 1847. H.] 4« Serie ; tome xxvi. pp. 46, 316. Paris, 1851. " Baudens, Clinique des Plaies J'Arraes a ^ Lancet, July 13, 1844, p. 489. Feu; p. 168; Paris, 1826. ^Edinburgh Medical and Surgical Journal. '' Edinburgh Medical and Surgical Journal; Vol. Ixxv. 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,* OF THE EYEBROW AND EYELIDS. Syn. — Mother's mai-k, Vulg. Loupe variqueuse. Petit. Tumeur erectile, Fr. Incorrectly called by some French authors, Fongus hematode. Der Blutschwamm, Ger. Telangi- ectasia, from rlXof end, ayyiiov vessel, and Exras-jj extension. Fig. Bell's Principles of Surgery, vol. i. p. 461 ; vol. iii. Nos. 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 viaterniis 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 hy anastomosis, and are cha- racterized by their rapid and dangerous course, continual and distinct pulsa- N^VUS 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 joasstwe 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 naevus must be destitute of capillaries, and therefore the blood must pass through it with increased rapidity."^ The distinction of cutaneous, subcutaneous, and mixed luevi, 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 pi'ominent, 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 neevi, 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^VUS BY PRESSURE AND ASTRINGENTS. 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 stationai:y 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, nsevi 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 6rst 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 hy anastomosis, apt to burst, and to give rise to impetuous hemorrhages, which, if they do not prove suddenly fatal, materially injure the health.^ A nosvus 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 uebvus has been known to assume the character of the active, and vice versa. Case 137. — In a case recorded by Pauli, a ncevus occupied the upper ej'elid 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 bng. 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. "^ Treatment. — Various methods of treating ntevus 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 nisvus 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.* If the tumor, on the other hand, is evidently increasing, there should be no delay in having recourse to some ef&cient mode of treatment. 1. Abstraction of heat, pressure, and astringents. — A moderately sized naevus 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 N^VUS BY VACCINATION. 191 tiiiuing 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 n^vus 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 usevus 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 matei'ual 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." 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 diminvition 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.'' In flat neevi, 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 5 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 Avould have been impossible. It may be necessary to keep the solution constantly applied for six months.^ From the nature of the situation, the plan of treating neevus 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 na;vi 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 mevus, 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 nteval 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 Avay, previously to the neevus 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. ^ 3. Stimulants. — When vaccination has failed, or vaccine lymph cannot be procured, some other stimulating fluid may be tried, inserting it into the niBvus 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 nJBVus 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.'" 4. Escharotics. — Both fluid and solid escharotics have been used, to de- stroy the organization of noevi. Some employ lunar caustic. For a small cutaneous ncevus, 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." Mr. Ward- rop has repeatedly employed pure potash, applying it to the ngevus 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.'^ 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."'^ 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. Lloyd'* proposes to inject into the substance of the noBvus 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 nosvus, and five injec- tions accomplished a cure. The eff"ect 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 N^VUS 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 naevus 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 nsBvus 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 nasvus 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 ncevus ; 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 ncevus, situated over the angle of the jaw, was injected with diluted aqua ammonia. ^^ 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.^^ Platinum wires are put through the naevus 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. ^^ 7. Subcutaneous incision of the vessels tvithin the tumor. — The danger of ha3morrhagy 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 naevus. Accord- ingly, he proposed to introduce a couching-needle with cutting edges, at one point of the circumference of the nasvus, 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 naevus, 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 hcemorrhagy. 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 nasvus. 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. ^^ 13 194 CURE OF N^VUS 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 nsvus, 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.^^ This is one of the methods of cure best adapted for n^vus 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.^ In treating ntevus 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.^' 10. Ligature. — The ligature is employed in the treatment of naevus, 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 nasvus 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^VUS BY THE LIGATURE. 195 FiK. 13. 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. 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 nssvi 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 nsevus, as is represented in the diagram, Fig. 14 ; they are then ^ig- ^^^ removed by cutting the ligature near to the eye of each ; and the succession of loops is tightened by tying a with a, h with h, c with c, and so on, till the whole tumor is strangulated."^ The same thing may be done, as Mr. Curling has shown, with the nsevus needle.^" 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 OP NiEVUS BY THE LIGATURE. Fiff. 15. If the n^evus is entirely subcutaneous, the skin, as Mr. Listen^ 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 nogvus, 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.^ When we are anxious to save the skin, the ligature may be applied sub- cuitaneously. 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 nasvus 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, fii'st, the one-half of the basis of the tumor, as in the course of the dotted line boa; and then round the other half, as in the course of the dotted line b d a. 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. 19t 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 A'ulcanized caoutchouc ; and through its means exercises an elastic tension, which gradually brings the ligature away."^ 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.^^ 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. — Naevi and anastomotic aneurisms have been removed by excision. This is an effectual, but by no means a very safe mode of cure.'^ 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 ntevi 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,^'' extirpation of noevi, 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 usevi ; 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 arter}^ 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 OP N^VUS 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 htemorrhagy 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. Bell. 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.^ 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 na^vus, 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 sclei'otica, 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 doAvnwards. 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 conjanctiva, 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 tied 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 N^VUS BY TYING THE CAROTID. 199 taken away, and in doing this, the deep-seated anterior temporal artery was diyided. 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 efl"ort to turn the pupil towards the nose.*' It will be evident upon the slightest consideration, how very diiferent 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 the 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 naevus 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 na3Yus on the left side of the face, covei-ing 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 coloi', 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 difi&cult 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 TYING THE CAROTID. filled -with blood, and the dissection was necessarily conducted with the finger as the only giiide. 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 remai-kable 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 ej-eball, 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. 2^ 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 tlie 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 no change. The skin over the tumor was slightlj^ 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 tliecomj^ress, three days after, a slight pulsation was perceived. The wounds healed immediatel^y ; 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 ofl^ 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 verj^ slight pulsation was discernible in the tumor, and the inner angle of the left eye had a pulsation somewhat stronger than tliat 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. Wai'ren 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 efi'ect. Dr. W. therefore laid bare and penetrated the METHODS OF TREATING N^VTJS. 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, 18-30, 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. '^'^ As the interruption of the current through the facial and ophthahnic 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 sfruck 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.** 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. ^^ With regard to the various methods of treating ntevus, 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 af- burgh, 1829. There is also a varix racemostts, 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 aneurisma racemosum. See Maclachlan, ^ On the structure of nasvus, 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 YI. figs. 16, 17; London, Surgical Journal; Vol. xxxi. p. 66; Edin- 1840: Paget, Lectures on Tumors; London 202 (EDEMA OF THE EYELIDS. Medical Gazette; Vol. xlviii. Lect. 8 : Birkett, Medico-Cbirurgical Transactions ; Vol. xxx. p. 193; London. 1847: Coote, Medical Gazette; Vol. xlv. p. 412 ; London, 1850. = Bell's Principles of Surgery ; Vol. i. p. 456 ; Edinburtrh, 1801 : Bateman's Synopsis of Cu- taneous Diseases, p. 2.39 ; 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. ' Annales d'Oculistique ; 1<=''. Vol. Supplem. p. 26 ; Bruxelles. 1842. ' See Brainard's cases, cured by collodion, Monthly Journal of Medical Sicence; Vol. x. p. 72 ; Edinburgh, 1850. ^ Traite des Maladies Chirurgicales ; Tomo ii. p. 269; Paris, 1814. ■" Surgical Observations on Injuries of the Head, and on Miscellaneous Subjects, p. 228; London, 1810. ^ Dieffenbach, Operative Chirurgie; Vol. i. p. 236 ; Leipzig, 1845. " ]\Iedico-Chirurgieal Review ; Vol. vii. p. 280 ; London, 1827 : Lancet; Vol. xii. p. 750; London, 1827: Glasgow Medical Journal ; Vol. i. p. 93; Glasgow, 1828. See Case of large subcutaneous Nievus, cured by Vaccination, by Woolcott, Lancet, March 13, 1852, p. 201. '° Medical Gazette ; Vol. xxxv. p. 786 ; Lon- don, 1845. » ' ' Zeitschrift f iir die Opnthalmologio ; Vol. i. p. 485 ; Dresden, 1831. '- Lancet; Vol. xi. p. 652; London, 1827. '^ Liston's Practical Surgery, p. 333; Lon- don, 1846. " London Medical Gazette; Vol. xix. p. 13; London, 1836. " Ibid. Vol. xxi. p. 529; London. 1837. '" AVarren, Op. cit. p. 418: Lalleiuand, Archives Generates de Medecine, 4«. Serie, Tome i. p. 416; Paris, 1843. '■^ See Case by Bernard, Medical Times and Gazette, March 27, 1852, p. 318. '* Medical Gazette; Vol. vii. p. 677; Lon- don, 1831 : Lancet, Nov. 1837, p. 353. '' Medical Gazette; Vol. xxvii. p. 605; London, 1841. ^° Svstem of Practical Surgery; Part i. p. 118 ; Edinburgh, 1838. ^' Fawdington, Op. cit. p. 66; Macilwain, Medico-Chirurgieal Transactions; Vol. xviii. p. 189; London, 1833: Bellingham, Dublin Medical Press, August 16, 1848, p. 97. ^- Medical Gazette ; Vol. xii. p. 581 ; Lon- don, 184S. " lb. Vol. xlv. p. 138; London, 1850. ^* Op. cit. p. 335. *' Archives Generales de Medecine; 2* S6- rie. Tome viii. p. 5; Paris, 1835; 4^ Serie; Tome i. p. 459 ; Paris, 1843. ^^ Medical Times and Gazette; July 3, 1852, p. 22, and December 11, 1852, p. 594. ^^ On the subcutaneous ligature, the sug- gestion of which is ascribed to M. Ricord, 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. '* Petit, Traite des Maladies Chirurgicales; Tome i. p. 266 ; Paris, 1 790. " Op. cit.; Vol. i. p. 241. " Bell, Op. cit.; Vol. i. p. 461. ^' Observations on the Surgical Anatomy of the Head and Neck, p. 331 ; Glasgow, 1824. '- Lancet; Vol. xii. p. 267; London, 1827. Mr. Wardrop's unsuccessful eases are contained in the Medico-Chirurgical Transactions, Vol. ix.; and in the volume of the Lancet now quoted. " Op. cit. p. 400. ^* Medical Gazette; Vol. vi. p.76; London, 1830. ^' France's Edition of Morgan's Lectures on the Diseases of the Eye, p. xiv. ; London, 1848. SECTION XXV. (EDEMA OP 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 (Ede- matous. This affection may depend either on local or on general causes. There is generally some oedema attending the acute stages of the ophthal- miaj. 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 ccdema 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 fre(iuent 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 Ijeing changed or removed, we not unfrequently find the lids puffy and ffidematous. In other cases, oedema of the lids is part of a general dropsy, as in the EMPHYSEMA OP 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 costiveuess.* 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 oedema 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. ' Collections from the unpublished Medical Writings of C. II. Parry, M. D.; Vol. i. p. 581 ; London, 1S25. SECTION XXVI. — EMPHYSEMA OP 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 :^— 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 OP THE EYELIDS. he felt a peculiar sensation ascending along tlie 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. AVhen the patient was received at the Hotel-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.^ Case 144. — A lad of IG years of age, as he was going along the street, with a load, ran inadvertently against a person passing in the opposite direction; a scuflSe 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 eliort 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.^ 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 stertor and complete relaxation of all the limbs, without any external lesion, he was removed into one of tiae medical wards. On examining him Avith 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 was 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. Ca.se 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 OP THE EYELIDS. 205 The plan of incision throngh 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 com-se, 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. ' 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 ^ Lancet; Vol. x. p. 31; London, 1826. by Baudens, in his Clinique des Plaies d'Armes * Meniere, Archives Generales da Medeeine; k Feu, p. 162; Paris, 1836. Tome xix. p. 344; Paris, 1849. ° Le§ons Orales de Clinique Chirurgicale, SECTION XX Vn. — TWITCHING, OR QUIVERING OF THE EYELIDS. Syn. — Kuvixof a-TTas-fAOi, AretcBus. Tic non-douloureux, Fr. Spasmodic or muscular tic. Life-blood, Vulff. 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 orioicularis 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,^ 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.^ 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 sti*anger, 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 douloui'eux. 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 mouth was 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 distoi'tion 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. "^ 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 hal)it 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.* 6. An issue between the angle of the jaw and the mastoid process has proved decidedly useful. ^ 1. 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.^ 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. 20T ' Edinburgh Medical and Surgical Journal, thorp's Abridgment, Vol. iii. part i. p. 34; Vol. Ixxv. pp. 86, 381; Edinburgh, 1851. London, 1716. * Ibid. p. 104. * Romberg's Manual of the Nervous Diseases ^ Medical Gazette ; Vol. v. p. 559 ; London, of Man, translated by Sieveking; Vol. i. p. 297 ; 1830. London, 1853. * Philosophical Transactions ; No. 164; Low- SECTION XXVni. — MORBID NICTITATION. While natural nictitation is accomplislied 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 eflfect of relaxation of the levator palpebrse superioris, as a convulsive action of the orbicularis palpebrai'um, 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 eS"ects. 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,* 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 recorded^ a case of photophobia and blepharospasm, brought on by over-exertiou of the eyes upon minute objects, in which the attacks came ou peri- odically, the patient losing all control over the muscles of the eyelids and eyeballs. The complaint was attended with occasional 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 vertebra3, the same eflfect 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. In 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 difiiculty 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. T. Many cases of blepharospasm are of hysteric origin. They are often mistaken for palsy of the levator palpebrte superioris, and erroneously desig- nated by the name of hysteric ptosis. Case 149. — Dr. Schon relates* 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 nble 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 cat^imenia 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 coniuni, 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.* The vapor bath, in some cases, has proved effi- cacious ; the cold shower bath, in others. The patient wearing a double green shade, should gradually accustom his eyes to the light, and not indulge, as is often done, in an increasing degree of obscurity. ' Medical Gazette; Vol. xsviii. p. 617; Lon- ^ Ammon's Zeitschrift fiif die Ophthalmolo- don, 1841. gie; Vol. ii. p. 153; Dresden, 1832. " Nervous System of the Iluman Body; Ap- * Lehre von der Augeukrankheiten, p. 778 ; pendix, p. xlvi. ; London, 1830. Berlin, 1832. 14 210 PALSY OF THE ORBICULARIS PALPEBRARUM. SECTION XXX. — PALSY OP THE ORBICULARIS PALPEBRARUM AND MUSCLES OP THE EYEBROW. SyA. — Blight, Vulff. Palsy of the portio dura. Hemiplegia facialis. Fi(/. Dalrymple, PI. XXX. In most cases of palsy of the face, there is a degree of lagophthahnos ; or in other ^yords, 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 palpebrse 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.'^ 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 inefi'ectual 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 palpebrse 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 cold 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 tlier. Occasionally he complains of pain at the root of the ear, or in the neighborhood of the stylo-mastoicl 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.^ 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, and its point turned towards the palsied side. In some cases, both sides of the face are palsied.^ 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.* 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 by the greater superficial petrosal nerve. ^ 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. ^ 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,'' 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,* 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 ORBICTJLARIS PALPEBRARUM. affection. Andral has seen it after a violent fit of anger ; Bellingeri, from a fright ; Frank, from the announcement of bad news ; Bottu-Desmortiers, in a young girl, from repeated crosses during profuse menstruation. ^ 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 internus. 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. Occasionally 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. la 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.'" 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 mean's 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 Pluramer'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.'^ If the upper lid is permanently elevated, Dieffenbach divides the levator subcutaneously." ' See Sbaw, Medicn-Chirurgienl Transac- ^ See case by Magnus, Muller's Archiv fiir tions; Vol. xii. p. 117; London, 182^1. Anatnmie, 1837, p. 258. '^ Medical Gazette; Vol. xlvi. p. 909; Lon- * On Palsy of both facial nerves, consult don, 1850. PTOSIS. 213 Davnine, Oazette Medicale de Paris, 13 Nov. 1852. and following Numbers. ' CyclopaBdia of Anatomy and Physiology ; Vol. iv. p. 553 ; London, 1849. * Dublin Medical Press; Vol. xxiv. p. 185 ; Dublin, 1850. ' On Cancerous and Cancroid Growths, p. 83 ; Edinburgh, 1849. " Op. cit. p. 138. ' Translation of this work into French ; p. viii. ; Paris, 1844. '" 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 leftside 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 ; A^ol. Ixiii. p. 4C3; London, 1830. '^ France, Lancet, January 5, 1850, p. 14. '^ Die Operative Chirurgie ; Vol. i. p. 743; Leipzig, 1845. SECTION XXXI. — PTOSIS, OR FALLING DOWN OF THE UPPER EYELID. nrSo-tf, from mTrrt), I fall. Syn. — Blepharoplegia, a terin applicable oidy to the bth 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 (Edematous or san- guineous effusion into its substance, or treated by the long-continued use of cataplasms, we tjometimes 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 palpebrag 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 I'emains 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. 11), and then de-sire the patient repeatedly to open and shut 214 PTOSIS. the eye. If he be able to do this, it is a proof that the forceps 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.* 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-froutalis \ 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 palpebraj 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 sufBciently 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 Van 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 ammonise.^ 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 face, 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. When 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 allowed 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.* 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 evening, 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. lu 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 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 completeiy 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. ^ 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, an(| then perform Mr. Hunt's operation.^ ' Alessi, Annales d'Oculistique, 1" Vol. nal of Medical Science, September, 1850, p. 823. Suppl. p. 3S ; Bruxelles, 1842. Case of Palsy of left side of face, ptosis, luscitas, ' 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, Dietionnaire Ophthalmologique, Edinburgh Medical and Surgical Journal, Vol. Tome ii. p. 6 ; Paris, ISOS. Iviii. p. 377 ; Edinburgh, 1842. * See Case of Amaurosis and Paralytic ' Medical Gazette ; Vol. xxviii. p. 617 ; Lon- Ptoeis, with seizures of a mingled epileptic and don, 1841. paralytic character, in Bright's Reports of Medi- " Curling, Medical Gazette; Vol. sxviii. p, cal Cases; Vol. ii. p. 533; London, 1831. Case 16 ; London, 1841. Hunt, ibid. p. 11!. Holt- and Dissection, by Hare, from Aneurism of left bouse, ibid. p. 152. Hall, ibid. p. 306. posterior communicating artery, London Jour- 218 LAGOPHTHALMOS. SECTION XXXn. — ^LAGOPHTHALMOS. From Kayk, hare, and ofSaX^woj, eye ; because it was believed hares slept with their eyes open. The terra 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.* This plan was found to be ineffectual, as the cicatrice resulting from the very operation, necessarily gave rise to a new degree of contraction. Diefifenbach, 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.^ 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 eases 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. ' Aetil Cotitraetae ex Veteribus Medieinoe ''Die Operative Chirurgie; Vol. i. p. 472} Tetrabiblos ; Tretrabib. 11. Sermo iii. cap. 73 ; Leipsig, 1844. p. 360; Basilese, 1549. SECTION XXXm. — ECTROPIUM, OR EVERSION OF THE EYELIDS. 'extp'jttiov, Actuarius ; from lx, out, and rfiTrtu, 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, Tig. I. This variety 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 ophthalmige. 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.' 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 inefiectual efforts of the orbicularis to bring tho 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. Wiien 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 aversion, 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 vie\.', but perhaps find the eye staphylomatous, and, of course, vision lost. § 2. Eversion from Excoriation. Syn. — ChroBic eversion. Ectropium senile. Fig. Ammon, Zweiter Theil, Tab. V.; Dalrjmple, 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. — 1. 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 surgeons^ 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 ))ecomes 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. Dieflfenbach 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 into 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. Eversion from a Cicatrice. Fig. AmmoD, 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 biit imperfectly the pro- l^erties 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 ectropiura. 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 notices* the case of a patient in the Hopital 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 talies 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 gives* 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 tlie 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. Tills 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 emersion 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 look at, 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.^ 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 extii'pation 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.'' 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.^ 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 quadrangidar flap. — In cases of adhesion of the eyelid to the upper or lower edge of the orbit. Dr. Amnion 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.^ The objection to this mode of operating is, that a large wound will be left to fill up by granulation. 4. Perpendicular transpositioii 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. Unlike 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 ej'elids. 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 fiice 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 flap, 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, Avhere 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. 221 surface of this wound there sprung out a small soft fungus, which was cut o£F with the scissors, and the root touched with the lunar caustic pencil. '" Fig. 18. Fig. 19. F)ff. IS. a a ConTerging incisions. 6 Cross-cut unitinp; them. These three incisions enclose the flap, which is slid clown by the yielding of the cel- lular tissue. Fig. 19. shows the parts when healed, a The cicatrice where the gap was. b b bb The marks of the sutures. Fig. 20. 5. Separation of imnatural 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," may be adopted with advantage :• — In ihQ 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 danger 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 Grlife 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 1] 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.'^ 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 Jliger, 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 palpebralis from the artificial opening formed by the incision just described, is the part in which the reduc- tion of the ti-ansverse 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. Coaptatioa 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 Jiiger'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 sui)ra-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." 7. Tarsorapkia. — 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. He removed the thick- ened conjunctiva, extirpated the cicatrice, and brought the edges of the wound together by two stitches." Professor Walther has published'^ a case of traumatic eversion of the external angle of the lids, cured by the same plan. 8. Extirpation of cicatrice, and hringing together of the integuments from each side.' — The lower lid being the seat of the cctropium, DieiFenbach 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, h, 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.*^ A similar operation was practised by Dieflfenbach 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 \\ 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. ''' 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 hlepharoplastic. 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, Eckstrom, 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." 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 ; tbe 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. 25. [From La-wffence.] 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 foi-m a lining membrane^or 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 Diefi'en- 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 efl'ected by the first intention, so that, as the stitches were gradually withdi-awn, 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 iipper 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 her 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. '9 10. Transplantation of a crescentic flap from the temple or the cheeh. — Pro- fessor Jtingken 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 pastel)oard 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.=° Professor Jiingken twice adopted this method, in cases of ectropium of the lower eyelid ; but in both cases it failed entirely.'^' Some such method appears, however, to have succeeded in the hands of Dr. Fricke of Ham- burgh.** 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 IG 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 eyebi'ow. (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 difQculty 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 (6, 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 [b), 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. 14th, Three of the stitches removed. 2U 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 hare 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 w^ill 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 ablepharoplastic 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 related"^ 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 Diefifenbach 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 Orhit. Syn. — Ectropium symptomaticum. Fig. Dalrymple, PL II. Fig. 3. I have already bad occasion to refer (pages 16 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 16), 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.** 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. Wilde 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 cicati'ice, 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 di'awn up and attached to the forehead during the next three days. Cold applications were applied, and jSIr. 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.*^ ' Practical Treatise on the Diseases of the ' See case by Rail, in which extirpation of Eye, p. 228; London, 1820. conjunctiva was first tried, and failed; but a ^ 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 j Vol. i. p. 159; ' Staub de Blepharoplastice, p. 79; Berolini, Edinburgh, 1796. 1835. » See case by Curling, Medical Gazette; Vol. ^ Pathologic Chirurgicale, p. 136: PI. x. Fig. xxviii. p. 17 ; London, 1814. 17; Paris, 1831. ^ Zeitschrift fiir die Ophthalmologie ; Vol. i. * De Re Medica ; Lib. vii. Pars ii. Cap. i. p. 47; Dresden, 1830. Sect. 2. "> Medical Gazette; Vol. xviii. p. 224; Lon- ^ Meinoires de I'Academie Royale de Chi- don, 1836. rurgie; Tome xiii. p. 170 ; 12mo; Paris, 1774. " Practical Observations on Ectropium, &c. j TRICHIASIS AND DISTICHIASIS. 23t London, 1814. To Sir William Adams belongs the merit of the operation described in the test. The reader, however, who has at all turned his attention to the history of this part of surgery, will at once trace the resemblance 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 Contractse ex Veteribus Medicinte Tetrabiblos ; Tetrabib. II. Sermo iii. cap. 72, p. 359; Basilea;, 1549. '^ Bericht liber das clinische chirurgisch- augenarztliche Institut der Universitat zu Ber- lin, fur 1829 und 1830, p. 9; Berlin, 1831. '^ Dreyer, NovaBlepharoplastices Methodus, p. 40 ; Vindobonje, 1831 : Brown, London Me- dical Gazette; Vol. xvii. p. 721; and Vol. xviii. p. 485, " Memoires de I'Academie Royale de Chi- rurgie; Tome ii. p. 343; 12rao; Paris, 1780. '^ Grafe und Walther's Journal der Chirur- gie und Augenheilkunde ; Vol. ix, p. 86 ; Ber- lin, 1826. " Review of Zeis's Handbuch der plastichen Chirurgie, in British and Foreign Medical Re- view, for April, 1839, p, 406. '^ Ibid. '^ 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, 1S39. '^ Zeitschrift fUr die Ophthalmologic; Vol, V. p. 313 ; Heidelberg, 1836. ^° Lehre von den Augenoperationen, p. 267; Berlin, 1829. "' Ibid. p. 9. °^ 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. ^^ American .Journal of the Medical Sciences, for October, 1845, p. 356. ^■' Zeitschrift fiir die Ophthalmologie ; Vol. i. p. 49 ; Dresden, 1831. *' Dublin Quarterly Journal of Medical Sci- ence, for May, 1848, p. 473, SECTION XXXIV. — TRICHIASIS AND DISTICHIASIS, Tfixja-a-i?, from ^fi^, hair. Distichiasis, from Jts-Ti;:^^?, having tivo rows. Ficj. Ammon, Zweiter Theil. Tab. IV. Figs. 9, 10. Dalrymple, PI. IL Fig. 4. TricMasis 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 ai'e 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,* 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, to 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.^ 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.^ 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 eifect 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 orer the horn spatula, the iDulb 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 be 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.^ I remember seeing a Jew girl in Vienna, who had been operated on in this manner by Dr. C. Jager. 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." 6. Extirpation of a stripe of the integuments, including the bulbs of the TRICHIASIS AND DISTICHIASIS. 24i cilia. — The operation proposed by Professor Jilger/ for the cure of trichiasis, is one of the most efficient. It differs botli 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 forceps*' (Fig. 32), and i 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 destricction of the bulbs of the cilia. — The following opera- tion is recommended^ 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 tl'rough 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 transverse 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 naturgjly, Yacc^ 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 Vacch. 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 tvedge-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 cornea?. Dr. Monteath mentions" 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 sti-ength 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. ' Dublin Journal of Medical Science for ' Heisteri Institutiones Chirurgica; ,• Vol. i. March, 1844, pp. 105, 109. p. 514; Amstela;dami, 1750 : Schreger, Chirur- * Jacob, in Dublin Hospital Reports; Vol. v. gische Versuche; Vol. ii. p. 253; Nurnberg, p. 394; Dublin, 1830. 1818. ^ Chirurgie Clinique de Montpellier, par Del- ^ Jacob, Op. Cit. p. 391. pech : Tome ii. p. 295; Paris, 1828. '' Hosp, DissertatiosistensDiagnosinetCuram " Edinburgh Monthly Journal of Medical Radiealem Trichiasis, Distichiasis, nee non En- Science; Vol. i. p. 259; Edinburgh, 1849. tropii; Viennse; contained in Radius's Scrip- ENTROPIUM. 243 tores Opbthalmologici Minores; Vol. i p. 199; Lipsire, 1826. ' The toothed forceps, figured in the text, have at the end of the one blade a tooth, which is received into an interstice at the end of the opposite blade. When shut, the instrument ap- pears like a small probe. It differs, therefore, from Blomer's forceps, which has two teeth pro jecting from the one blade, and one from the other. ' Nuovo Metodo di curare la Trichiasis,- Pisa, 1825. '° Translation of Weller's Manual; Vol. i. p. 115; Glasgow, 1821. SECTION XXXV. — ENTROPIUM, OR INVERSION OP THE EYELIDS. Entropium, from Iv, in, and rf'eTrai, I turn. Fig. Wardrop, Vol. I. PI. VII. Figs. 2, 1. Dalrymple, PI. II. Fig. 5, PI. III. Fig, 1. Exclusive of trcmmatic entropium, there are two varieties of this disease, which differ materially in their causes, symptoms, and modes of cure. The one is acute or spasmodic, the other chronic or infiamviatory. The first is attended with little organic change of the affected lid, the second with much; the first is most frequently met with in old persons, the second in young ; the first in healthy, the second in scrofulous subjects ; the acute is a disease chiefly of the tegumentary, the chronic chiefly of the conjunctival surface of the lids. 1. The acute variety not unfrequently takes its origin in an attack of ophthalmia, during which the patient kept the eyelids long shut, perhaps covered with a poultice, or pressed inwards by a bandage. I have repeatedly seen it take place during the after-treatment of extraction of the cataract. The lower lid is almost exclusively the seat of this variety of inversion. The skin of the inverted lid is generally swol- len and puffy. Its edge is perfectly regular in form, not thickened nor indurated, but entirely rolled back towards the eyeball, so that the eyelashes are fairly out of sight (Fig. 33), lying between the eyeball and the internal surface of the eyelid. On apply- ing the finger to the outer surface of the lid, and drawing it a little downwards, the eye- lashes start into view, clinging to the sur- face of the eyeball ; a little more traction rolls the edge of the lid completely into its natural place, and there is no appearance of trichiasis. The conjunctiva is nowise contracted, the lid nowise shortened, the cartilage nowise changed in structure. If we cease making pressure on the lid, it remains for a minute or two in its proper position, and then, with a sudden jerk, becomes inverted as before. This kind of inversion appears to be owing partly to the relaxed state of the integuments, partly to an irregular action of the orbicularis palpebrarum. The circumferential part of the muscle seems to have lost its wonted power of supporting the body of the lid, while its ciliary portion, acting inordinately, rolls the edge of the lid into the inverted position. We meet with this variety of entropium almost exclusively in elderly persons in whom the skin has al- ready lost its natural contractility, so that it falls into folds, particularly about the eyelids. A superabundant state of the skin evidently favors the disease. [This form of entropium of the lower lid is also favored in old persons by the sinking of the eye in the socket consequent on the absorption of the adipose matter, which in the earlier periods of life, surrounds the optic nerve in the bottom of the orbital cavity, and which causes the prominence of the eye of a person of robust health. Hence this form of entropium may occur in consequence of great emaciation, after a long spell of illness, and disappear as the health improves and the patient recovers his former rotundity. 244 ENTROPIUM. This cause of entropium can only produce the disease in the lower lid. The reason of this fact can readily be appreciated by a reference, in the difference of the movements of the two lids, produced by the contraction of the orbicularis muscle. The upper lid descends in a vertical manner as low down (according to ScEmraerring) as an eighth of an inch below the inferior margin of the cornea before it meets with the lower lid, which is rather thrust forward in a horizontal direction (as has been shown by Sir C. Bell) by the action of its portion of the orbicularis; and when the eye is closed, its ciliary margin is completely overlapped by that of the upper lid. The ciliary portion, which is the strongest, of the orbicularis, always keeps the ciliary edges of both lids in contact with the ball, whether they be closed or widely opened. Such being the movements of the two lids, and the action of the orbicu- laris, the mechanism of the above-mentioned cause of entropium of the lower lid can readily be understood. The cartilage of this lid, which is very nar- row, is diverted from its more or less horizontal position and becomes some- what vertical. This it is allowed to do by the relaxed condition of the integuments, cellular tissue, and the circumferential fibres of the orbicularis, the latter perhaps favoring it more than any of the others. In this position its ciliary border being considerably below the horizontal axis of the eye can readily be turned in by the slightest rotation of the ball downwards, and having once assumed an inverted position it will be retained there by the ciliary portion of the orbicularis. It can readily be seen that such a state of things could never occur in the upper lid by the action of this cause. — H.J The eyeball is much irritated by the eyelashes rubbing against it in the act of winking, and hence the patient keeps the eye shut, and as much as possible at rest. He even squeezes the lids so much together, as to bring the skin of the upper and lower lids into contact. The eye waters much, and the tears fret and excoriate the skin of both lids. The cornea inflames, and in conse- quence of neglect may become totally opaque. This variety of inversion is an occasional attendant on catarrho-rheumatic or arthritic ophthalmia, along with severe circumorljital pain, and sometimes with ulceration of the cornea. In such cases not only must the entropium be removed, but at the same time venesection, calomel with opium, and other remedies must be used, to cure the ophthalmia. We occasionally meet with this variety in children, along with scrofulous ophthalmia. 2. The chronic variety of inversion is the result of long-continued ophthal- mia tarsi, or neglected catarrhal conjunctivitis. The upper lid is as liable to be affected as the lower, and often both are inverted at the same time. The edge of the affected lid is thickened, irregular and notched, and shortened from canthus to can thus, so that it presses unnaturally on the eyeball.^ The cartilage is indui'ated as well as inverted. The sinuses of the conjunctiva are contracted, and its surface more or less dry and cuticular. No degree of traction which we employ, is sufficient to roll the lid into its natural situation ; we may drag it from the eyeball, and bring the cilia into view, but still the edge of the lid continues inverted. (Fig. 34.) The cilia are generally few in number, dwarfish, and themselves aS'ected with inversion, independ- ently of the state of the lid, so that there is a combination of trichiasis with entropium. Notwithstanding their being few and small, the cilia are sufficient to keep up constant suf- fering, and by the irritation which they occa- sion, to render the cornea vascular and nebu- ENTROPIUM. 245 lous. The pain tliey 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 paiu 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 i)rognosis 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 witli 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 tlie 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 vortical 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-rhcu- matic, and scrofulous ophthalmias. 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 ENTEOPIUM. 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 for entropion with the ordinary form of Himly's forceps, as delineated at p. 213, fail of success more frequently from the character of the instrument used, than from the principle on which it was performed. In cases of slight inversion, where only the central cilia are distorted, the instrument will answer very well ; but when the entropion is more extended, and generally when all the cilia are turned in, the curve of the blades is too great, and their length, from corner to corner, not sufficient for the removal of a fold of the integuments of a proper size and form. For such cases, we have had the instrument made Avith blades of a length sufficient to remove an elliptical piece, one and a half inches long, should it be necessary, instead of nine-tenths of an inch, the greatest length that can be removed by the original form. And in order that the breadth of the piece thus removed, should not be proportionally increased, we had the curve of the blades changed, from that corresponding to a segment of a circle of three-fifths of an inch radius, the original curve, to that of one and a half inch radius. The portion of integument excised by the aid of forceps thus constructed, measures half an inch in its vertical diameter, and corresponds, in this respect, precisely with the portion removed by the original instrument ; it, however, exceeds it in its transverse or long diameter by more than half an inch. To make the instrument hold more firmly, the blades should not be bevelled and roughened on their inner surface, but should be flat and deeply grooved, so as to give to each a well defined, double biting edge — not so sharp, how- ever, as to cut the tissues within their grasp. These forceps should also be provided with a wedge-shaped sliding catch, not placed, however, on the inside of the handle, but on the back of one, so as to enable it to be made lai'ge. The wedge should be triangular from above downwards, flattened from side to side, near half an inch long, one-eighth wide, with a base of one-fifth of ENTROPIUM. 24^ an inch, and from this it should taper down gradually to a sharp edge ; the handle on which this slides, should have a fenestra in it for the transmission of the cross piece from the opposite handle, which should have a square hole in itself, to receive the wedge. By this means the blades can be kept in any degree of proximity with the utmost firmness and precision, and will be effectually prevented from slipping by the starting of the patient at the first stroke of the cutting instrument. — H.] If this variety of inversion has lasted a considerable time, and in addition to the mere displacement of the lid, consequent to the redundant state of the skin, and irregular action of the orbicularis, there appears some unnatural disposition of the cartilage to turn inwards, it may be proper, after removing the cutaneous fold, to snip off" some of the fibres of the muscle, so as to form a firmer cicatrice, actually fixed to the cartilage. Mr. Haynes Walton^ insists particularly on the removal of the ciliary portion of the orbicularis, conceiv- ing the disease to depend on its inordinate action. The portion of the skin to be removed might be destroyed by the actual cautery, or by escharotics ; but the operation just described is much to be preferred. The escharotic employed by Helling* and Quadri'* for this pur- pose is concentrated sulphuric acid, which is applied in the following man- ner ; — The skin of the inverted lid, to the breadth of about three lines, and one line from its tarsal edge, is to be rubbed with the acid, by means of a pencil of wood dipped in it, with the precaution of not taking up more than what merely wets the pencil. After ten seconds, the part is to be dried, and the acid reapplied, and this even a third or a fourth time, until a sufficient eschar has been formed, or a marked contraction has taken place. The part is then to be cai'efidly washed. Of course, great care must be taken that none of the acid gets into the eye. After a time, it may be necessary to repeat the operation. Instead of a horizontal, some surgeons, as Janson, of Lyons, cut out a vertical slip of skin, and bring the edges of the wound together in the usual way.^ [Janson's method will be found particularly applicable to cases of entropion in the old, which owe so much of their intensity to the relaxation of integu- ment and sinking of eyeball. — H.] 4. In chronic entvopium, neither the operation with the scissors, nor the application of escharotics, is, in general, of any use. In slight cases, however, where the tarsus is but little affected, it may be proper to try the effect of removing a fold of skin, especially if it be the lower lid which is affected. Acute inversion is curable by an operation on the skin, by shortening in fact the skin of the affected lid, and binding down the tarsus to the cicatrice; but in chronic inversion, we generally find that nothing done to the skin merely is of much service. Portion after portion of it may be removed in advanced cases of this variety of inversion, but the disease continues as before. The altered condition of the tarsus prevents the lid from resuming its natural position. The lid, then, must be attacked in a different way. Saunders'' • cut out the tarsus of the upper lid altogether, along with the roots of the cilia ; others have amputated the entire edge of the lid, or extirpated the bulbs, as has been explained in the preceding section. As an evident shortening of tlie lid in the transverse direction attends the inveterate cases of this kind of inversion, and produces a degree of constric- tion on the eyeball, an idea suggested itself to Ware, that the lid in such a state might be relieved by a perpendicular incision through its whole thick- ness, either at its temporal extremity, or in its middle. Such an incision would at least release the eyeball from the state of pressure caused by the 248 ENTROPIUM. contracted lid; aud if left to itself, to be filled up by granulation, might allow a permanent elongation of the lid in the transverse direction. It was probably from this hint of Mr. Ware, that Sir P. Crampton was led to devise the following operation for the relief of inveterate cases of chronic inversion. Supposing it to be the upper lid which is affected, it is to be divided perpendicularly, for the length of from a quarter to half an inch, close to its temporal extremity,^ with straight probe-pointed scissors. A similar incision is then to be made at the nasal extremity of the affected lid, taking care to avoid the punctum and lachrymal canal. ^ These incisions being made, the eyelid immediately feels unconfined ; it can be lifted from the eyeball, and the patient is already freed from a great part of his uneasi- ness. "Were we now to leave the lid to itself, it would speedily resume its former place, the incisions by which we had liberated it Avould unite by the first intention, and no permanent relief would be effected. To prevent im- mediate union, Sir P. Crampton employed an instrument similar to Pellier's speculum (Fig. 31, b), by which he kept the eyelid constantly suspended, and permitted only a slow union by granulation. Instead of using the speculum, Mr. Guthrie recommended a fold of the skin of the afi'ected lid to be excised, exactly as in the operation for acute inversion ; the edges of the wound, made by the removal of this fold, to be brought together by two or three stitches ; aud then, by means of three ligatures, inserted through the edge of the lid, and fixed to the forehead by strips of plaster, the lid to be kept ele- vated for eight or ten days. Over the everted lid, a bit of spread lint is to be applied, and a roller round the head. The perpendicular incisions slowly fill up by granulation; the slower the better; we ought daily to separate their edges with the probe, and touch them with sulphate of copper, to hinder them from healing rapidly; the union, when at length completed, does not compre- hend the orbicularis palpebrarum ; the divided fibres of the muscle shrink, like the divided ends of every other muscle ; the diseased cartilage, in the meantime, loses also much of its induration and irregularity, and thus the lid, when reunited, is found improved in structure, and almost natural in position.^" Such, at least, is the hope held out by the favorers of this mode of cure. I am sorry to say, that my experience of this operation has not been satisfac- tory. Temporary relief it certainly affords ; but after the healing process of the vertical incisions is complete, the lid is generally found nearly in as bad a condition as it was before the operation. On this subject the reader may consult with advantage, Mr. Wilde's paper on entropium and trichiasis, in the Dublin Journal of Medical Science for March, 1844. A surer method of relieving chronic entropium will be found in Jager's excision of the bulbs of the cilia, as described in the last Section. Mr. Wharton Jones informs me, that in chronic cases of inversion of the lower eyelid, he has performed the following operation, with perfect success. Having made an incision through the whole thickness of the lid, perpendicular to its edge, near the outer canthus, he cuts out a piece of the skin, and, by means of the thread forming the suture, fixes the lid in the everted position. ' See Ammon on Phpiosis Palpebrarum, in ^ Carron du Villards, Guide Pratique ; Tome Zeitschrift fur die Ophthalmologie; Vol. ii. p. i. p. 320; Paris, 18.38. 140 ;^ Dresden, 1832. " Treatise on some practical points relating to ^ See Bowman, in Braithwaite's Retrospect the Diseases of the Eye, p. 41; London, 1811. of Medieitio and Surgery ; Vol. xxiii. p. 264: * If the incision, as directed in the te.xt, is Lo^ndnn, 1851. made close to the temporal extremity of the ° Operative Ophthalmic Surgery, p. 160; Lon- lid, it will cut through the glandula; congre- don.1853. gata, and some of the lachrymal ducts. Unless * Ilufeland's Journal, 1815 ; St. 4, p. 98. the ins-ersion extends, therefore, to the very ' Aunotazioni Pratiche sulle Malattie dedi angle, it may be proper to avoid these parts, by Occhi; Vol. i. p. 69 ; Napoli, 1818. PHTHIRIASIS. 249 keeping a line or two from the extremity of the of a transverse fold of the integuments. In lid, and towards the nose. Mr. Guthrie's modification of the operation, the ' Sir P. Crampton cut through the lachrymal cartilage is divided transversely, as well as the canal; but ever since I began to give lectures conjunctiva. on the eye, in 1818, I have directed this to be '° Essay on the Entropeon ; by Philip Cramp- avoided. I have always discountenanced also ton, M. D.; London, 1806: Lectures on the the transverse incision of the conjunctiva, re- Operative Surgery of the Eye ; by G. J. Guth- commended by Sir Philip ; and insisted par- rie, p. 31 ; London, 1823 : Jacob, in Dublin ticularly on the propriety of following up the Hospital Reports; Vol. v. p. 389; Dublin, first steps of this operation, by the extirpation 1830. SECTION XXXVI. — ANCHYLOBLEPHARON. This, althongli strictly a disease of the eyelids, I shall consider along with symblepharon, in a following chapter, among the diseases consequent to the ophthalmise. SECTION XXXVII. — MADAROSIS. MaSapaayij, from juajjf, bald. Partial madarosis is common after hordeolum, and after smallpox, the abscesses seated on the edge of the eyelid destroying the bulbs of the cilia. Neglected ophthalmia tarsi is apt to end in a more extensive madarosis of the same kind. The cilia, of which the bulbs have been destroyed, cannot be reproduced. Both the cilia and the hairs of the eyebrow are liable to fall out, from dif- ferent constitutional diseases ; but in this case they generally grow again. The want of the eyelashes and hairs of the eyebrow is productive of frequent nictitation, in order to moderate the glare of day, and prevent the entrance of foreign particles into the eye. Case 158. — I was consulted, some time ago, by a man "who had lost every hair of his body. His head was perfectly bald, he had no eyebrows nor eyelashes, his beard was gone, no hair in the armpits, on the pubes, nor on the limbs. He vras anxious to regain chiefly the eyebrows and eyelashes, as he found his eyes much weakened by the want of them. He was inclined to attribute his disease to some slight venereal complaint, which had been cured by mercury. I was consulted also by a lady, who had sustained a similar loss of the whole hairs of the body. The treatment, both local and general, already recommended for ophthal- mia tarsi, must be carefully adopted in cases of threatened madarosis. In constitutional cases, tonics are to be employed both internally and exter- nally, as it is evident that weakness has much to do in the production of the disease. Cinchona is particularly recommended internally, and an infusion of the petals of the rosa centifolia in wine, as a collyrium. When there is a suspicion of syphilis being the cause, mercury and sarsaparilla should be tried. In such cases as those to which I have referred, artificial eyebrows may be applied with advantage. SECTION XXXVm. — PHTHIRIASIS OP THE EYEBROW AND EYELASHES. cSaiptao-ij, from