Complete Text (Part 2)

or years, but sooner or later the ulcer extends. When in active growth the patient experiences frequent lanci- nating pains, which, however, are seldom severe. As the deeper struc- tures are involved pain increases. What is the treatment of epithelioma ? Various methods of treatment of epithelioma have been employed. The use of escharotics in the form of chloricle-of-zinc paste or the actual cautery have been employed with more or less success. The application of acetic acid in the form of glacial acetic acid has met with some favor. It is conceded, however, by many authorities that excision as complete as possible, supplemented by the use of the cautery in cases where the knife or curette do not succeed in removing all of the tissue involved, is the most successful. 22 THE EYE. What are papillomata ? These growths are hypertrophied papillae of the skin. They should be removed whenever found, as there is a possibility of their degener- ating into epithelioma. Lipoma is a tumor of the lid that is met with but very infrequently. It is harmless in nature. What is molluscum contagiosum ? This term is applied to an affection of the sebaceous glands whereby the gland and duct become greatly hypertrophied and form rounded ele- vations on the lids, appearing usually on the lower lid near the nose. There are usually a number of these elevations present at the same time, varying in size. They may reach the height of \ inch, but usually are only a few millimetres in height. Their diameter, as a rule, corresponds to their height. In the centre of the top of each elevation a whitish point may be seen, which marks the opening to the duct of the gland involved, and from this duct a whitish cheesy material may be made to exude on pressure. These growths are undoubtedly mildly contagious. They are unaccompanied by pain unless acutely inflamed. What is the treatment of molluscum contagiosum ? The elevation may be split from base to apex and the contents thor- oughly scraped out, or, what is better still, the entire growth may be excised. Relapses are uncommon. What are the manifestations of syphilis found in the lids ? Indurated chancre, gumma, and tertiary sores. Indurated chancre is of rare occurrence on the external surface of the lid, but is not so infre- quent an occurrence on the conjunctival surface. It manifests itself in the form of a dark-red papilla with indurated base and a scaly or ulcer- ated surface, exactly as the indurated chancre appearing in other parts. The history of chancre of the lid as to cause is frequently obscure, and the appearances only, taken in connection with the effects of antisyphi- litic treatment, must serve to make the diagnosis. What are the appearances and symptoms of gumma and tertiary sores ? Gumma of the lid has no peculiar characteristics to distinguish it from gumma of other parts of the body. Its appearance is accompanied with little pain. The history in the case and the conduct of the elevation under general antisyphilitic treatment will serve to make the diagnosis. Tertiary sores are not of common occurrence. They, however, occur, usually forming near the free margin of the lid and extending rapidly. Like tertiary sores in other parts of the body, they present an ulcerated surface with indurated bases, and pass quite rapidly to destruction of the tissue in- volved. A lid may disappear very rapidly under the influence of the tertiary sore. The diagnosis must depend largely on the history of the case and the effect produced by antisyphilitic treatment. DISEASES OF THE EYELIDS. 23 What is meant by the term blepharospasm ? This terra is applied to involuntary closures of the lids, which may be of a clonic nature, occurring frequently in rapid succession, or they may be of a tonic nature. What are the causes of blepharospasm ? It is due in all cases to irritation of filaments of the facial nerve. The causes of this excitation in clonic spasm are errors of refraction, diseases of the nervous system, as chorea, epilepsy, etc. ; in tonic spasm, to for- eign bodies in the eye, ulcerative conditions of the cornea or conjunctiva, and injuries to the eye, producing photophobia. What is the treatment of blepharospasm ? Removal of the cause where this is practicable, and improvement of the general condition where the cause is obscure. What is ptosis? Ptosis is the term applied to a drooping of the upper lid in such a manner that it cannot be raised sufficiently to open the palpebral fissure to the desired extent. What are the causes of ptosis ? The causes of ptosis are congenital malformation or non-development of the nucleus of the third nerve, diseases affecting the function of the third nerve, or traumatism. In congenital ptosis other parts of the third than those concerned in elevating the lid are usually involved. In ac- quired ptosis syphilis is frequently the cause. What is the treatment of ptosis. The treatment is medicinal and surgical. The history of the case must be carefully ascertained, and if syphilis or other disease-processes are instrumental in its production, appropriate medication must be em- ployed to correct the condition if possible. Congenital ptosis must usually be corrected by operative procedure. The simplest form of operative procedure consists in the removal of an elliptical piece of skin, with the underlying muscle, from the upper lid, and stitching the edges of the wound together. The operation devised by Pagenstecher is ap- plicable to nearly all forms of ptosis, and is frequently efficient. It con- sists in forming subcutaneous cicatricial bands from the margin of the lid to the anterior portion of the occipito-frontalis muscle. Pagenstecher passes a suture through the integument at about 2 cm. from the ciliaiy margin, at the centre of the lid, and continues it subcutaneously to the ciliary margin. He then forms a loop, passes the suture upward again, and brings it out on the skin of the lid near the point at which the suture entered. The ends of the suture are then tied, and tightened every day until the suture has cut through the tissues. A cicatricial band is thus formed, which, according to Pagenstecher, is usually suf- ficient. Two or more bands may be formed as desired. 24 THE EYE. What are trichiasis, distichiasis, and entropion ? They are various forms of one and the same affection, and consist in a displacement of the cilia toward, and usually against, the cornea. What is the cause of these affections ? An abnormal development of the cilia may produce the condition known as trichiasis, but in almost every case these three affections owe their existence to the cicatrization of the conjunctiva produced by gran- ulated lids. What is the treatment of these conditions ? Trichiasis, if not extensive, may be corrected by the frequent removal of the cilia. Electrolysis may be employed here with beneficial effect. Distichiasis and entropion usually require operative procedure of a more pronounced nature. All operations employed for this purpose have for their object the correction of the direction of the cilia. The Streatfeild- Snellen operation is one of the most popular, and is performed as fol- lows: The globe is protected by the introduction of a horn spoon or of a plate clamp into the conjunctival sac. An incision is then made through the skin and muscle of the lid to the tarsus, extending from the inner to the outer canthus, and placed about 2 lines from the margin of Fig. Upper Flap Groove in Carti- Lower Flap, The Streatfeild-Snellen Operation for Entropion. the lid. An elliptical piece of the skin from 1 to 2 lines in width, in- cluding the underlying tissues to the tarsus, is then removed with a sharp scalpel or scissors. A wedge-shaped piece of the tarsus, having its base outward and extending the length of the incision, is then removed. The wound is then closed by three sutures, which are passed in the following manner : At the margin of the lid the needle is passed through the skin DISEASES OF THE EYELIDS. 25 and underlying loose tissues, carried to the upper margin of the wedge- shaped depression in the tarsus, where it includes the superficial layers of the tarsus, and is brought out without piercing the integument of the upper margin of the wound. These sutures are then firmly tied. This manoeuvre suffices to draw the lower margin of the skin of the lid upward and to attach it to the tarsus, producing eversion of the cilia. Numerous other operations are devised and employed by various operators. What is spasmodic or spastic entropion? A form of entropion not infrequently met with in old people, always affecting the lower lid, is known as spasmodic or spastic entropion. It is usually corrected by removal of an elliptical piece of integument and underlying connective tissue and muscle, the long axis of which is placed at right angles to the margin of the lid. The opening is closed with three or four sutures. What is ectropion? This term is used to designate a condition of the lid in which the mar- gin of the lid is everted and the conjunctival surface is exposed. What are the causes of ectropion ? Injuries of various kinds, of which burns are the most frequent, that destroy the skin of the lids, and produce ectropion by the cicatricial con- traction which follows. Ectropion may also result from the paralysis of the facial nerve. Certain hypertrophic conditions of the conjunctiva also produce ectropion. What is the treatment of ectropion? In the mildly-marked cases due to the hypertrophy of the conjunctiva the condition may be corrected b}^ painting the surface with a solution of nitrate of silver, 10 or 20 grains to the ounce, the application being repeated every twenty-four or forty-eight hours. In pronounced cases operative procedure must be resorted to. In ectropion of the lower lid, in which there is an evident elongation of the margin of the lid and atony, of the adjacent skin, a wedge-shaped piece of tissue, having its base at the margin of the lid and its apex at the bottom of the conjunc- tival sac and the integument below, may be removed, and the oppos- ing margins of the wound brought together with strong sutures. This operation, which is known as Adam's operation, is usually successful in this class of cases. In extensive ectropion skin-grafting must be re- sorted to. The lid is dissected free and fixed in position by attaching it to the margin of the fellow-lid, and the wound thus resulting is covered with flaps of skin, either taken from adjacent parts, to which they are attached by a pedicle, or from remote parts after the manner of Wolfe. What is epicanthus? This is a condition of the skin at the base of the nose in which the 26 THE EYE. inner canthus is partly hidden from view. It gives the peculiar almond- eyed appearance characteristic of the Chinese. What is the treatment of epicanthus? Epicanthus usually appears in young children, and by the development of the bridge of the nose will disappear. When present in older indi- viduals an elliptical piece of skin may be removed from the bridge of the nose, its long axis extending from above downward, and the margins of the wound brought together with fine sutures. "What is ecchymosis of the lids? This is a condition of the lids brought about by contusion, which pro- duces the escape of blood and of serum from the vessels of the lid, causing a bluish discoloration and swelling commonly known as "black eye." What is the treatment? The most efficient treatment in the early stage is by cold applications, cold acting as a haemostatic preventing further escape of fluids into the tissues. After twenty-four or thirty-six hours have elapsed the exuda- tion will have ceased, and hot applications to promote absorption should be employed. What treatment is employed when wounds or burns of the lid occur ? Lacerated wounds of the lids should be corrected as quickly as possi- ble after occurrence by stitching and other appropriate surgical methods. Burns and scalds are treated as burns and scalds in other parts of the body. What is meant by the term ankyloblepharon ? This term is applied to a condition where the margins of the lids be- come adherent to each other. Its correction requires division of the bands of adhesion simply. What is meant by the term symblepharon ? This term is used to designate the condition of adhesion between the lids and the eyeball. It is usually the result of a burn of the conjunc- tiva from lime, acid, or any other eseharotic. Its correction requires operative procedure, which' is usually unsatisfactory. THE LACHRYMAL APPARATUS. Of what does the lachrymal apparatus consist ? _ It consists of a secretory and conducting portion. The secretory por- tion is the lachrymal gland, which is composed of acini and resembles the salivary glands in construction. The lachrymal uland is made up of two portions — a large superior portion and a smaller inferior portion. THE LACHRYMAL APPARATUS. 27 The superior portion of the lachrymal gland measures about J inch by i inch, and is ^ inch in thickness. It is located at the outer superior angle of the orbit, immediately beneath its roof, in a depression known as the lachrymal fossa. It is held in position by numerous delicate bands of connective tissue, and communicates with the conjunctival sac by from six to ten ducts. The smaller, inferior portion of the lachrymal gland consists of a number of isolated lobules situated immediately beneath the conjunctiva of the upper lid, near the external canthus. They com- municate by individual ducts with the conjunctival sac at its outer supe- rior portion. The secretion of these glands, which is a watery fluid containing about 1 per cent, of solids and strongly impregnated with chloride of sodium, is thrown out under a stimulus to the sympathetic. It passes into the conjunctival sac, and serves to moisten the anterior portion of the j^lobe, being distributed by the movements of the lid. Fig. 4. Dissection of the Lachrymal Apparatus. In what way do the tears escape from the conjunctival sac? The tears (or lachrymal secretion) pass from the conjunctival sac into the nose by the way of the lachrymal puncta, the lachrymal canals, the lachrymal sac, and the nasal duct. The lachrymal puncta are two small elevations which occur at portions of the lids situated about 2 lines from the inner canthus. They are pierced by openings measuring about 5 mm. in diameter. Commencing immediately beneath the lachrymal puncta 28 THE EYE. are the two lachrymal canals, one beneath the upper and one beneath the lower lid. They first pass upward and downward respectively for a very short distance, then describe a curve about the inner canthus, unite, and pass into the lachrymal sac. Immediately beneath the puncta they measure about 1 mm. in diameter, but in the course of the canal they reach a diameter of 6 mm. , and remain of this size until they enter the sac. The walls of the lachrymal canals are relatively thick. They are lined with stratified epithelium, and contain numerous fibres of muscle- tissue. What are the form, situation, and structure of the lachrymal sac ? The lachrymal sac is situated in a groove formed by the lachrymal bone and the nasal process of the superior maxillary. It measures about J inch in its vertical diameter and about i inch in its horizontal and transverse diameters. It is located immediately to the inner side of the inner canthus, and is pierced by the lachrymal canals at a distance of about 3 inch from its apex. Its lower extremity is a direct continuation of the upper part of the nasal duct. Its walls are relatively thin, com- posed of connective tissue, and its inner surface is lined with ciliated epithelium. The nasal duct, a continuation of the lachrymal sac at its lower extremity, consists of a similar structure, and lies in a canal the bony walls of which are formed by the lachrymal, superior maxillary, and inferior turbinated bones. It measures about f inch in length and is ^ to j inch in diameter. The surface of the mucous membrane lining this canal is paved with ciliated epithelium, and has a free opening into the inferior meatus of the nasal fossa. The tears pass through the puncta, through the lachrymal canals, the lachrymal sac, and nasal duct, and are discharged into the inferior meatus, where they are dispersed by evaporation. What are the diseases that the lachrymal gland is subject to ? Inflammation, known as dacryoadenitis, hypertrophy v cystic and can- cerous degeneration. What are the causes of dacryoadenitis ? The causes of dacryodenitis are probably of an infectious nature. The entrance of dust into the conjunctival sac, carrying with it infectious material, which makes its way into the lachrymal ducts, exposure to cold, and traumatism, may be considered as factors. What are the symptoms and treatment of dacryoadenitis ? Dacryoadenitis manifests itself by a swelling at the outer angle of the lids, with more or less redness of the outer portion of the conjunctiva. It is accompanied with slight pain, referable to the temple. Its onset is sudden, and it usually reaches its height at the end of two or three days. It eventuates usually in suppuration, rapidly subsides on evacuation of the pus, and runs its course in from a week to ten days. The superior THE LACHRYMAL APPARATUS. 29 portion of the lachrymal gland is seldom affected. It is, on the whole, a rare disease, and may be recognized, in addition to the symptoms above described, by the presence of a hard swelling at the margin of the orbit, appreciable on palpation. If the patient is directed to turn