Elements of Surgery

by Robert Liston

state of part of the conjunctiva. The diseased portion is generally of a triangular form, commencing at the inner corner of the eye, extending towards the cornea, gradually diminishing in breadth, and terminating in a sharp apex, either at the margin of the cornea, or somewhere between its margin and centre. The thickening is seldom great, but the vessels which traverse the thickened part are numerous, enlarged, and tortuous—are, in fact, varicose. The base of the pterygium is always on the circumference of the eye, generally at the inner corner, and its apex is seldom, if ever, situated beyond the centre of the cornea: frequently the sclerotic conjunctiva alone is affected. The motions of the eye are little disturbed by the disease, but vision is materially impaired when a considerable part of the cornea is covered. Pterygium is in general single, but sometimes, though very rarely, there are two or more pterygia in one eye; and, in such cases, the patient’s vision is seriously affected, in consequence of the apices of the different pterygia uniting and coalescing on the cornea, and investing the greater part of that organ with a thick and dark shade. When several occur, they sometimes unite throughout their whole extent, and cover the half or more of the eye. This disease is very common amongst negroes and persons residing in equatorial climates.

When the pterygium is of considerable size, extending over the cornea, the only remedy is excision. The apex of the web is laid hold of and pulled outwards by forceps or a hook, and the whole diseased part is then carefully dissected off with scissors, the incisions commencing at the apex, and being carried on to the base. The wound gradually contracts; and though an opaque cicatrix must form on the corneal surface, the speck is of much less dimensions than the space formerly occupied by the pterygium. If the web be thin and not exceedingly vascular, it may be sufficient to make a semicircular section of it transversely, by means of a hook and scissors, between its base and the margin of the cornea; its growth is thereby arrested, and there is a probable chance of its beginning to diminish, and ultimately disappearing. When it is small, and so situated as to cause no impairment of vision, it is prudent and good practice not to interfere with it at all.

DISEASES OF THE EYEBALL

Diseases of the eyeball are numerous, and various in their nature. Some are acute, others chronic; and their attack is either sudden, or slow and insidious. Most of them are attended with pain and other annoying symptoms, and some cause loss of vision. Some are cured by internal means; others require surgical operations; and the cure is either complete and permanent, or palliative and temporary. Some destroy the organ, and others, still more malignant, cause extinction of life. All require much attention and care.

Of Ophthalmia, or Inflammation of the Eye.—The symptoms and appearances of ophthalmia vary much according to the particular texture or textures affected. They require to be minutely attended to, that the treatment may be varied in such a way as to obviate any bad consequences which may be threatened. The great importance of the organ, and the danger to its structure and functions which is likely to occur from any other termination of the affection than resolution, must never be lost sight of.

We shall first treat of inflammation of the more external parts of the ball, an affection generally less dangerous than inflammation of the interior, but at the same time of more frequent occurrence, and produced by slighter causes.

Inflammation of the conjunctiva occurs in many individuals during very warm and sunny weather. At such a period, the eye is often excited by reflection of intense light from the surface of the earth; and is irritated by sudden exposure to a degree of light to which it has not been previously accustomed. Different directions of the sun’s rays, and different kinds of light, seem to exert different influences on the organ. The rays are most hurtful when they do not fall in a perpendicular direction on the eye, but slopingly or horizontally. Strong light from the moon, and light reflected from scarlet, are also particularly injurious. Undue exertion of the eye weakens it, and renders it prone to become inflamed. The eyes of infants are often violently inflamed, in consequence of imprudent exposure to light before they have been gradually accustomed to its stimulus. Again, inflammation is caused by imprudent exposure of the eye directly to cold, or by exposure of other parts causing suppression of their discharges, whether natural or not. Inflammation of the conjunctiva often follows suppression, however occasioned, of the menstrual or hemorrhoidal discharges, as also suppression of discharges from the urethra, from the Schneiderian membrane, or from behind the ears. Irritations in the neighbouring parts, as in the mouth during dentition, may also excite the disease. Immediate irritations, however, are the most frequent cause, as the lodgement of extraneous bodies on the surface of the organ—particles of sand, dust, snuff, pepper, or gunpowder, minute insects, loose or inverted eyelashes. By the presence of such substances, the eye is often kept in a very irritated state for a long period. The most violent conjunctival inflammation is sometimes produced by contact of gonorrhœal matter through carelessness. Occasionally metastasis of inflammation takes place from one eye to another; so that a person may be seen one day with severe inflammation of the right, and on the following day with a similar affection of the left, and the right entirely free from disease. Another cause, sometimes met with, of inflammatory action in the conjunctiva, is the lodgement of large foreign bodies in the orbit, with or without destruction of the eye; as splinters of wood, straws, rusty iron nails, sharp portions of stone, &c., penetrating the globe of the eye, or parts in the immediate neighbourhood. Upon removal of the cause, the redness, discharge of tears, pain, &c., sometimes subside without inflammation having been established, the vessels of the part regaining their contractility; but if the cause is continued for any considerable time the effects do not rapidly abate. Wounds and other injuries of the organ are generally followed by inflammation. But a simple clean wound or puncture made with a fine instrument, as in many operations, and in a favourable constitution, frequently produces little or no excitement of the part. The degree of excitement must of course depend upon the nature of the wound, the structure of the parts involved, the lodgement or not of the body by which the wound is inflicted, and many accidental circumstances. The eye may be injured by acids or by lime, and the textures acted upon chemically; again, the membrane may be wounded by pieces of hot metal, and then the destructive action is both chemical and mechanical: in both cases active inflammation of the injured conjunctiva is kindled. The state of the patient’s constitution modifies very much inflammatory action of the eye, however induced; and it has been observed, that dark eyes bear injury or incited action better than those of a light hue. Not unfrequently conjunctivitis is a secondary affection, accompanying eruptile diseases, as measles or small-pox.

In considering the disease, it is necessary to keep in mind the loose connection of the membrane with the subjacent parts, as well as its own texture and functions.

In conjunctival inflammation, the patient first feels a degree of pain and stiffness in moving the organ; and has always a feeling as if a foreign body were present, whether such is the case or not. There is also a degree of itching with a sensation of fulness in the part, and this is followed by redness of the membrane, becoming more and more intense. If the disease gain ground, the colour changes to a darkish red or purple hue. To the redness succeeds heat, with profuse and hot lachrymation. Then swelling supervenes, often to a great extent: the vessels, both veins and arteries, are much gorged, and effusion of serum or blood takes place into the loose cellular tissue which connects the conjunctiva to the sclerotic.