Complete Text (Part 3)

the eye forcibly inward, a body usually as large as a small bean is made to push forward from the external portion of the upper cul-de-sac of the con- junctiva. What is the treatment? _ This consists in hot fomentations at the beginning to encourage forma- tion of pus. When pus is present the tumor may be lanced from the conjunctival surface, or, better still, the fomentations may be continued for a few hours and the pus be permitted to evacuate itself. Is hypertrophy of the lachrymal gland of frequent occurrence ? Hypertrophy of the lachrymal gland is very infrequent, and is prob- ably always due to sarcomatous degeneration. What are its causes and treatment ? The causes are unknown. The treatment consists in extirpation of the gland. What are the causes of cystic degeneration, and its treatment ? Cystic degeneration occurs very infrequently. It may be caused by traumatism, but is sometimes due to the presence of echinococci. Cystic degeneration of the gland is not infrequently associated _ with sarcomatous degeneration. When echinococci are the cause, simple puncture with evacuation of the cyst and destruction of its wall suffices to effect a cure. In other cases, particularly if sarcoma is suspected, the gland should be extirpated. What are the symptoms and treatment for canceroas degenera- tion of the lachrymal gland ? The lachrymal gland may be the seat of sarcoma or of carcinoma. The symptoms in these two forms of malignant growth are very similar. The gland becomes enlarged, and is felt under the upper outer angle of the orbit as a firm mass which protrudes into the orbit, and, when it has attained a sufficient size, compresses the tissues in its immediate vicinity. The globe is not infrequently pushed downward and inward by the in- crease in size of the growth. The treatment consists in total extirpation at the earliest possible moment. What is fistula of the lachrymal gland ? A condition usually due to traumatism, by which the tears find exit on the surface of the brow or cheek. The treatment of this condition consists in an endeavor to stop up the artificial opening on the skin and direct the secretion to the conjunctival 30 THE EYE. sac. The passage of a seton from the gland to the conjunctival surface and the use of the cautery to close the external opening may effect the object desired. What is epiphora? This term is applied to the escape of tears from the conjunctival sac on to the cheek, without inflammatory occlusion of the conducting appa- ratus : it is more properly applied to the escape of tears in excessive lachry mation, which is termed stillicidium lachrymairum. What pathological conditions is the conducting apparatus sub- ject to? The escape of tears from the conjunctival sac into the nasal cavity may be prevented by misplacement of the puncta lachrymalis. Traumatism or inflammatory processes may occlude the canals and the nasal duct. What are the causes of displacement of the punctum ? and how may this condition be remedied? An atonic condition of the lids, such as sometimes occurs in old people, may permit the lachrymal puncta to fall away from the eyeball and make it impossible for the tears to escape. Facial paralysis affecting the orbic- ularis palpebrarum muscle may also bring about this result. The treatment consists in so treating the lids that the lachrymal puncta will be reapplied. Failing in this, the canals may be split up and an opening made which will permit the tears more easily to enter the lach- rymal sac. What diseases of the lachrymal canals come under considera- tion? The canals may be stopped by inflammatory processes, usually ca- tarrhal in nature ; by extension from the lachrymal sac or from the con- junctiva ; they may be the seat of calcareous deposits, or they may be occupied by fungous growths, of which leptothrix buccalis is of most frequent occurrence. The treatment in these cases consists in opening the canals to the sac. What diseases do we meet with affecting the lachrymal sac? Inflammation of the lining membrane of the lachrymal sac, usually purulent in nature, is by far the most common disease the lachrymal apparatus is subject to. The canaes which bring about this condition are included under the term catarrhal, except in those relatively rare cases where necrosis of the lachrymal bone is the originating cause. The entrance and the retention in the lachrymal sac of pus-forming germs and of germs which have a pathological influence on the mucous membrane of the lachrymal sac produce an inflammation which becomes purulent. These deleterious THE LACHRYMAL APPARATUS. 31 influences are communicated usually through the medium of the nasal duct to the lachrymal sac, and originate in a catarrhal affection of the nasal mucous membrane. Stricture of the nasal duct may ensue, caus- ing retention of tears in the lachrymal sac, and preventing the escape of secretions the presence of which tends to perpetuate the inflammatory conditions of the mucous membrane. As the disease progresses an hypertrophied condition of the sac is brought about, and polypi not infrequently form. What are the symptoms and treatment of this condition ? In the early stage of stricture of the nasal duct and of catarrhal in- flammation of the mucous membrane of the sac but little may be no- ticed by the patient other than an escape of tears from the eyelids on to the cheek. This may go on for a number of months or even years. At the onset of acute inflammatory symptoms the patient usually experi- ences pain in the region of the sac, and a swelling of the tissues ensues. Palpation discloses the presence of a round, hard tumor at the inner canthus, which on pressure will evacuate mucus or pus into the conjunc- tival sac or into the nasal cavity. Frequently the pain, swelling, and redness become excessive, the patient suffering very severely. The pus which has accumulated in the lachrymal sac may be unable to escape, and may form an opening on the skin spontaneously. The treatment of this condition, which should be commenced as soon as trouble with the lachrymal sac is noticed, is varied according to the stage of the disease. In its incipiency the correction of a catarrh of the nasal passages may suffice to remove the stricture of the nasal duct and to promote a cure. When pus has begun to be formed the safer method of treatment is to open up the lachrymal canal, pass a probe through the sac and nasal duct into the nose, and. thoroughly cleanse the whole passage by the use of appropriate injections. What is the operation for slitting the lachrymal canals and pass- ing a probe through the nasal duct into the nose ? The lachrymal knife, which is devised for the purpose of opening the canal, consists of a small scalpel which is supplied with a probe point. Various patterns of these knives have been devised by various operators, some of which are known under the names of Bowman^ Wecker, Still- ing, Agnew, Noyes. For the complete operation the knives devised by Stilling and by Agnew are probably the best. Possessing a blade as de- scribed above, with^ slight modifications in regard to form, they are sup- plied with long flexible shanks. The operation is performed by passing the probe point into the canal at the lachrymal punctum (the lower canal is usually the one operated on), then by turning the axis of the knife in the direction of the long axis of the canal the point of the knife is car- ried into the sac and firmly presssd upon the mucous membrane against the lachrymal bone. While this is being done the lid is put on the stretch toward the temple, and, while held firmly in this position, the edge of 32 THE EYE. the blade being directed upward, the handle of the knife is swept up- ward in front of the brow and close to it, and the lachrymal canal is freely opened to the sac. The axis of the blade is then placed in the position corresponding with the axis of the nasal duct, and is pushed down into the nasal duct. The stricture of the duct, if one exists, is divided freely in three or four directions. The knife is then removed and a probe passed into the nose, the same manoeuvre and direction being followed as followed by the knife. After probing, the canals, sac, and duct are thoroughly cleansed by means of a syringe and an anti- septic solution : a 4 per cent, solution of boric acid is employed by many. A solution of bichloride of mercury, 1 : 5000, and a £ per cent, solution of the nitrate of silver, are also popular. The probes employed are of different styles, according to the ideas of the different operators. Those most commonly in use are the probes of Bowman, which are composed, usually, of silver wire tapered at the ends, and of six sizes, the largest size measuring about 1 mm. in diameter and 12 cm. in length. Those of Theobald are much larger. These are twelve in number, and range from 1 to 4 mm. in diameter. Small probes are fancied by some opera- tors, but it appears to be the growing opinion that as large a probe as can be easily accommodated by the canal should be employed. How should the after-treatment be conducted? It is a recognized fact that after opening the canals and nasal duct there is a strong tendency to closure during the process of healing. It is therefore necessary to pass a probe at intervals of from two to eight days during the healing process, and to wash the canals with an anti- septic lotion. What is abscess of the lachrymal sac ? This condition is simply an aggravated stage of the ordinary suppura- tive inflammation of the mucous membrane of the lachrymal sac, during the process of which the nasal duct and lachrymal canals become closed and the exit of pus prevented. What is the treatment of abscess of the lachrymal sac ? The pus should be evacuated either through the lachrymal canals or the nasal duct if possible. When this cannot be done a free incision into the sac through the skin becomes necessary. At the earliest possible moment thereafter the natural canals should be re-established. What is fistula of the lachrymal sac ? Fistula consists in an opening from the lachrymal sac on to the surface of the skin, through which tears and secretion escape. The treatment consists in establishing the natural passages, removing what granulation tissue may have formed along the fistulous track, after which healing, with closure of the fistula, rapidly occurs. THE CONJUNCTIVA. 33 THE CONJUNCTIVA. What is the conjunctiva ? The conjunctiva is a thin, delicate mucous membrane which begins at the free margin of the lids, covers their under surface, and is reflected on to the globe of the eye and continued over the cornea. It is divided into three portions, the palpebral, fornix, and ocular portions. The principal part of the palpebral portion covers and is closely adherent to the tarsi. It then, in loose folds known as the fornices conjunctivae, becomes reflected upon the sclerotic of the globe, to which it is connected by loose areolar connective tissue. Sacs are thus formed, the upper one of which is 1 inch in depth, the lower one i inch in depth. The corneal portion of the conjunctiva is* very thin, and is represented by the epithelium. The epi- thelium of the conjunctiva is of the stratified variety ; over the tarsi, the sclerotic, and cornea the conjunctiva is smooth, but it is thrown into folds, and in some places into papillae, in the fornix. A few tubular glands are found in the fornix folds, and the ducts of the lachrymal glands open into the fornix in the outer third of the upper conjunctival sac. The conjunctiva is richly supplied with lymphatics, which anastomose freely immediately beneath the epithelial layer. At the inner canthus a fold of conjunctiva is formed which corresponds with the membrana nictitans or third eyelid of inferior animals. We also find at the inner canthus a reddish elevation which is known as the caruncle. This is covered by mucous membrane, and sometimes presents a few very fine hairs pro- jecting from its surface. What forms of inflammatory disease is the conjunctiva subject to? They may be classified as follows : First, simple conjunctivitis ; second, traumatic ; third, muco-purulent conjunctivitis ; fourth, purulent or gonorrhoeal conjunctivitis; fifth, granulated lids or trachoma; sixth, phlyctenular conjunctivitis; seventh, diphtheritic conjunctivitis. What is simple conjunctivitis ? Simple conjunctivitis is the mildest form of inflammation that the con- junctiva is subject to. The symptoms presented are redness, lachrymation, slight irritation, and more or less photophobia. What are its causes and treatment? It is usually due to exposure to cold and raw wind, the presence of minute foreign bodies, eye-strain, excessive bathingin salt water, etc. The treatment is very simple, consisting in removing any cause that may be instrumental in its production and bathing of the eyes with mild astringents or antiseptic solutions. Ordinary salt and water or a 2 per cent, solution of boric acid will suffice to effect a cure. Simple conjuncti- vitis of a chronic nature is often associated with catarrh of the nasal mucous membrane, and may be cured by correcting the catarrh of this membrane. 3— Eye D 34 THE EYE. What is traumatic conjunctivitis? Any inflammation excited by the entrance of foreign bodies, irritating fluids, or direct injury to the conjunctiva may be termed traumatic con- junctivitis. Since it does not depend on the presence of any infectious principle, recovery usually rapidly occurs on the removal of the obnoxious substance. Cleanliness secured by bathing in salt and wate* or a boric- acid solution will hasten the restoration to the normal condition. What is muco -purulent conjunctivitis? This is a term given to a diseased conjunctiva in which there is redness and swelling of this membrane, accompanied by the production of a secretion which contains numerous pus-corpuscles mixed with mucus. There are more or less lachrymation and puffiness of the lids. This disease has as synonyms the terms catarrhal conjunctivitis and acute epidemic conjunctivitis. It is very contagious in nature, reaches its acute stage in forty-eight to seventy-two hours, has no tendency to affect the cornea, and runs a natural course in from ten days to six weeks ; in exceptional cases the disease may continue for six months. Relapses are of frequent occurrence. This disease becomes endemic in communities and in residential schools, showing its greatest activity usually in the spring and fall months. Its epidemic nature is recognized throughout the civilized world. What are the causes of muco-purulent or epidemic conjunctivitis ? The form most frequently seen is a specific disease and has a specific cause. This is found in the presence of a small bacillus, which has been carefully studied and described by Weeks. The pathogenic micro- organism is a small straight bacillus measuring i micro-millimetre in width by from 1 to 2 mm. in length. It grows on agar at a temperature ranging between 85° and 110° F., and its inoculation into the normal con- junctival sac from a pure cultivation invariably produces the disease. The disease is communicated undoubtedly through secretion from the eyes of patients suffering from the malady. Traumatic conjunctivitis and mild forms of gonorrhoeal conjunctivitis sometimes produce a muco- purulent secretion, and are classed under this head. What are the symptoms of this disease ? The patient first experiences a burning sensation in the lids and the sensation of the presence of a foreign body. This irritation is rapidly followed by lachrymation and the production of a mucoid secretion. In twenty-four hours the secretion becomes muco-purulent. The con- junctiva is swollen and the lids slightly puffed. As the disease pro- gresses the annoyance to the patient becomes marked, and photophobia is experienced. The disease reaches its height in from two to four days, at the end of which time the secretion assumes a more purulent charac- ter. The annoyance to the patient gradually ceases, secretion becoming less marked, and recovery without other treatment than cleanliness often THE CONJUNCTIVA. 35 occurs at the end of the second week. Adults suffer more than children. False membranes are sometimes noticeable on the conjunctival surface, phlyctenule may appear as a complication after the disease has lasted for three or four days, and trachoma, due to a secondary infection, may continue after a subsidence of this form of conjunctivitis. What is the treatment of muco -purulent conjunctivitis? During the first few days much relief can be given to the patient by the application of cold compresses and by frequent cleansing with a sat- urated solution of boric acid. After the third day mild astringents may be applied with benefit. The cleansing should be continued until all secretions have disappeared. The astringents employed are solutions of the nitrate of silver, \ to 1 per cent. , and of the sulphate of zinc or ace- tate of lead, 1 grain to the ounce. If phlyctenulae or trachoma develop, the treatment should conform to that for the disease mentioned. The presence of pseudo-membrane does not call for a change in the plan of treatment. It usually disappears in from three to ten days. It is pres- ent only in the severer cases. Muco-purulent conjunctivitis never degen- erates into true purulent conjunctivitis. What is purulent conjunctivitis? _ This is one of the most severe forms of inflammation of the conjunc- tiva. The term is used to designate the gonorrheal form of conjuncti- vitis, which bears this name in the adult and is known as ophthalmia neonatorum in the infant. The period of incubation is about thirty-six to forty-eight hours ; the disease runs a long and tedious course,