82
NOYES: Laceratiouz of the Eyelids.
DR. HOWE renmarked that he had observed a case of injl1ry in which there was proven to be an efftusion in the tupper part of the orbit of the eye, and from which the patient recovered without any interference whatever. He thought, in the case reported by the Doctor, that there miiight have been an affection of the nerve first, and afterward of the muiiiscle. DR. LITTLE rem)arked that in his case the improvemeent took
place iimmediately after the application of electricity. I)R. NOYEs reported that three cases in his practice had becn relieved at once by operation.
CASES OF LACERATION OF THE EYELIDS. By DR. HENRY D. NOYES,. NEW YORK.
A NOT infrequent accident is laceration of the eyelids. Within two years three such cases liave come under inv notice, and I report tliemii because I have fouind that a certain miethod must be adopted to get the best results in healing. The points to be observed will be alluded to in narratinig the cases.
CASE I.-February, I877. A boy I9 mollnths old, while playing about the floor, got possession of a hook used to button slhoes, pushed it uinder the upper lid of his left eye, and tore away the lid from its attachm]ent at the inner canthuis. I was called to the case within an hotur, and found a laceration beginning on the nasal side of the l)unctuni and rlunning upward and outward along the supra-tarsal fold for three-fiftlhs the length of the tipper lid. The bleeding had stopped anid the flap hunga down over the cornea. I put the child under chloroform, and brought the parts together in the following way: inasmuch as the tarsus had been detaclhed, I saw the necessity of bringing it into proper apposition. To this enid I carrie(l a silk suture through its uipper ed,-,e, at about the miiiddle of the laceratio'n, 'in the form of a loop, througll the entire thickness of the lid at the fornix, and brouiglht both its ends out on the skin at adjacent points, and tied themii over a little roll of muislin. The suture had a needle at eaclh end, which was held by needle-forceps. The performiiance of this step was the critical point in the whole pro-
NOYES: Lacerationt of the Eyelids.
83
cee(ling. It (lrew up the tarsus as by a sling to its proper relations at the fornix. Afterward the external woutd wvas united by several fine interrupted silk sutures and the skin put into perfect coaptation. Slips of isinglass-plaster were laid over the lid, a pad of cotton and a bandage applied. The needles were small and those used at tlle iinner canthus were semnicircular. On the sixth day all the sutures had been taken out, and by the tenitlh day the eye needed no fturther attention. The line of cicatrix is now almost invisible, the appearance is perfectly natural, and the commiand of the lid is comiiplete. The suggestion to be mnade in this case is the importance of uniting the mnucouis membrane and tarsus before the wound of the skin is closed, and in this very young subject the sling-suture was the m11ost suitable, both for its effectiveness and because it could be easily withdrawn. CASE II.-Man aged forty, living in New Jersey. In attemlpting to move a horse-rake whiclh was placed with the shafts turned up against a barn, a hook caught his left upper lid and tore it from its orbital attachmiient for about lhalf its length from the inner canthus to the middle of the brow. The globe was not hurt. A physician of the neighborhood put sUtLtires into the skin, and made a rough coa)tation. External uinion took place, but the inner canthus was not restored and the tarsuis had not been united. In course of time cicatrization of the under surface was accomplished, and ectropiuml-l began. Gradually this deformity increased, and the exposed conjtunctiva underwent the usuial florid papillary hypertrophy; the cornea became. inflamzed, ha;zy, and vascular. About five mionths elapsed before I saw hilm, when he not only presented a disagreeable deformity, btut suffered fromi lachryiimationi, photophobia, pain, and dimness of sight. By passing my finger beneath the lid, ul) toward the fornix, I recognized a dense cicatricial ridge which corresponded to the outer wound. Evidently this har(d tissue was the cause of the ectropium, both by its contraction anid by the barrier whlich it formled to thie return circulation of the veins and lynmphatics. Thlie miian was put under ether, and the cicatrix was cut out along its entire lengtlh, thereby reproduicing almllost perfectly the condition at the first injury-giving a loose flap, which was to be re-established in correct relations. Anticipating considerable retraction, I aimiied to carry the inner enld of the flap, beyond the ininer canthus.
84
NOYES: Laceration of the Eyelids.
I not only excised the old cicatricial tissue at this point, but cut out an open angle of hiealthy skin, into which the point of the flap was to be thrust and held by sutures. The mllanceuvre was difficult because the sm-iall curved needles had to be directed up the acclivity of the nasal bones, and to bring out their points without breaking themii was troublesome. This was not, however, the first step. A careful coaptation of the tarsal edges and imiucous membrane was mnade by three stitches, which were applied to the everted flap and left in situ in the fornix, when the flap should be ready for adjustmenit to its proper place, and for the application of stitches to its cLItaneous surface. Then the preparation of the inner angle, as above mentioned, was imiade, and the necessary interrupted stitches introduced. These were suipported by a fine insect-pin (harelip sutuire) at the inner angle. Before replacing the everted lid some of the hypertrophied conjunctiva was excised. A bandage was applied and retained for twenty-four houirs. Cold.water dressings were used, and about the tenth day the patient went home. Duiring the year I have seen him several times, and at the last visit the eye was entirely comfortable, the cornea clear, the conjunctiva healthy, the lid in position, and its movemiienits normal. It could be lifted to the proper degree, and the line of cicatriix was inconspicuous. The inner canthus had by retraction comiie to be of correct shape. CASE III.-An injury of far greater extent and severity is nlow to be related, in which the probable total severance of the levator palpebrie and of much of the skin, coupled with fractture of the orbital bones, made it imiipossible to effect conmplete restoration of the parts. The case has interesting features aside fromii the damiiage to the lids. For the notes I amii indebted to Dr. Oppenheimer, house surgeon of the New York Eye and Ear Infirmiiary. Charles Ai., aged seven-teen, about a year and a half ago was trying to force his way through a crowd in Washington market, and, to slip between persons who were carrying bLurdens on their shoulders and baskets on their armis, dodged his head down an(d struck against a stationary hook used for lhanging aieat. It penetrated the innier and upper corner of the orbit, lacerated the soft parts, and fractuired the roof of the orbit. He was thrown down insensible, and taken to the New York Hospital, where he remained six weeks. After this time he camiie to me as an out-patient at the New York Eye and Ear Infirmary. There was total eversion of the upper lid, the conjunctiva enormiiouisly thickened, the eyeball deviated to the inner
NOYES: Laceration of the Eyelids.
885
canthus strongly, with no power to turn it out. A deep notch could be felt with the finger about the middle of the superior orbital iiargin, indicating where the bone had been fractured, and the history of his residence in the hospital imiiplied that he had had meningitis. The pupil was normlal, the eyeball seemingly uninjured, but by the ophthalm-ioscope tlie optic nerve was found in a state of miarked atroplhy, presumaably the stage succeeding severe neuritis. The very oblique pdsition of the eye made exatmination of siglht almiiost imi,vracticable, but a low degree could be ascertained. The cornea was covered, notwithstanding the eversion of the upper lid, because all its tissues were so oedemiiatous and thick. 'rhe everted lid border could be tturned down, but would slowly return to its unnatural situation. It was evident that a long time miiust be allowed for reduction of the swollen lid to a normal state. I simiiply directed the continuous use of a pressure-bandage, applied as tightly as could be borne, and removed onily so. often as cleanliness requiired. After about a year the upper lid was thin enough to hang without eversion, but it could not be lifted, and there was a deep notch at its inner and outer angles, and from the inner angle a cicatrix ran along beneath the brow, almiiost to the external orbital border. An improven1eIlt in sight lhad occurred, so that upon the outer part of the field he could see movemiients of the hand. February i, 1879, patient was etherized, and I attemiipted to bring the eyeball to the middle of the palpebral slit, and hoped solmiething might be done to help the upper lid. I proposed to release the adhesions of the eye at the inner canthus, and to attemipt to find the distal end of the torn-off rectus externus, and give it a new attachmiient to the globe. Extensive dissection was made at the inner canthus, by which not only was the insertion of the rectus loosened, but the surrounding connective tissue freely cut. There was abundant cicatricial substance here, and parts were firnmly condensed together. Hiaving done all that seemed appropriate onl this side, I next began upon the outer part of the globe to search for the rectus externus. Its stumiip was founid, but when an effort was made to tuirn the globe outward to meet it, no rotation could be effected. Ptuzzled bv this unlooked-for state of affairs, I could not find any explanation at the inner canthus, and gradually worked miy way at the otuter canthlus backward to the deep part of the orbit. I soon found that there had been fracture of the external wall, and pushing in witlh finger and scissors I at length camie upon a spot where the posterior part of the globe lhad become united to the
NovE:s: Laceration of the Eyelids.
86
periosteumn. Keeping close to the bony wall and using a strong l)air of blunt-pointed scissors, curved, on the flat and holdinlg their convex surface against the globe, I succeeded, bit by bit, in clipping away these attachmiients and rendering the eye imiovable. I had by this timiie arrived almiiost at the orbital apex. The eye could lnow be lifted forward about 4 mmll., anid rotated outward a little beyond the nmedian line of the orbit. Examination of the upper lid showed that a dense cicatricial band separated the superior fornix fromii the parts below, like an lhour-glass contractioni, and that a considerable space existed above, which couild be reached with somiie diffictulty by forcing the finger between the cicatiix anld the globe. No effort was iimade to improve the state of the lid, butt the conjunctival wounds were closed after the external rectus had been brotuglht into the best attainable position by sutures. It was not expected that the eye would be imiade miiobile, but a imiore niatural, permianent position was sought for. The ensuing reactioni was rather severe, but the parts healed well. Exophtlhallmius was cauised, but subsided, and the patient went homiie in two weeks. At the last view of his conidition, the upper lid had drawn up sonmewhat, but was helpless in ptosis ; the eyeball was in correct
position. Whether any greater imil)rovemiient is possible is very doubtful. The separation of the levator was comiiplete, and the fracture of the upper plate of the orbit Imlust hiave matted the tissLies together so as to hold the remliainder of the muiiiscle in perfect bondage. Excision of a piece of skin would merely reproduce ectropium, and incision or excision of the scar would catuse uncertain and possibly disadvantageous results. Since the imleeting of the society I have seen the case, and find that retraction has taken lplace in the uipper lid, but not enough to uncover the cornea. The skin hangs perfectly smooth, without wrinkles to indicate action of the orbicularis or of the levator. When lhe forcibly closes the lids the upper does not descend, and corrugates only through the communicated action of the orbicular fibres of the lower lid. Considerable conjunctival thickening exists, and its treatmient is the present indicationi. The globe remliains fixed upon the middle of the orbit, has no imiotion to the riglht or left, and slight movement upj) and down.
Congenital fisstre of
the utp.per
eyelid.-Katie D., aged seven
NOYES: Glioma of both Eyes.
87.
tiionths, was brought to ilme by Dr. Nolden, in May, I879. There was a cleft near the miiiddle of the right upper lid, ruinning tlhrouglh the tarsus, and looking like the accompanying diagram. This was congenital. 1 pared the edges, an d attempted to avoid any notching of the 00 tarsal edge by hollowing out the sides of the fissure and causing the tarsal end of the linle of junction to l)rotriide in a nil)l)le under the pressure of the suLtures. Harelip sutures with fine insect pins were used, and while uinion was obtained, the subsequient retraction of the scar gave rise to a smiall notclh. Before the operation the cornea was to be seen through the fissuire, but afterward the eye was satisfactorily covere(d.
GAIOMA OF BOTH EYES-REMOVAL-RECURRENCEDEATH-AUTOPSY. By DR. HENRY D. NOYES, NEW YORK.
T'HE case to be rel)orted was l)resented to the New York Pathological Society when the specimiiens were freslh. FLurther details of the miiicroscopic examiiination of the brain are now supplied. In Novemiber, 1878, a verv fat boy of Jewislh parents, about one year old, wvas brought to me at the New York Eye and Ear Infirm-iary. 'rhe fatlher stated that when- he was six miionths old a glistening reflex vas tnoticed in the left eye. He did not know at wlhat period something similar apl)eared in the right eye. It was found that the vitreous space of eaclh eye was occul)ied 1)y a yellowish wlhite growth, whiich in the left was distinctly vascular and pressed upon' thic crystalline; in the right eye the growth was not so large, but was distinctly visible. In view of somewhat retarding the deeper developnient of the disease and to anticipate the probable speedy extension ooutside of the eyeball, enucleation of the left was advised. 'T'he case disappeared freiii observationi uniitil January,. i88o, wlhen
NOYES: Laceratiouz of the Eyelids.
DR. HOWE renmarked that he had observed a case of injl1ry in which there was proven to be an efftusion in the tupper part of the orbit of the eye, and from which the patient recovered without any interference whatever. He thought, in the case reported by the Doctor, that there miiight have been an affection of the nerve first, and afterward of the muiiiscle. DR. LITTLE rem)arked that in his case the improvemeent took
place iimmediately after the application of electricity. I)R. NOYEs reported that three cases in his practice had becn relieved at once by operation.
CASES OF LACERATION OF THE EYELIDS. By DR. HENRY D. NOYES,. NEW YORK.
A NOT infrequent accident is laceration of the eyelids. Within two years three such cases liave come under inv notice, and I report tliemii because I have fouind that a certain miethod must be adopted to get the best results in healing. The points to be observed will be alluded to in narratinig the cases.
CASE I.-February, I877. A boy I9 mollnths old, while playing about the floor, got possession of a hook used to button slhoes, pushed it uinder the upper lid of his left eye, and tore away the lid from its attachm]ent at the inner canthuis. I was called to the case within an hotur, and found a laceration beginning on the nasal side of the l)unctuni and rlunning upward and outward along the supra-tarsal fold for three-fiftlhs the length of the tipper lid. The bleeding had stopped anid the flap hunga down over the cornea. I put the child under chloroform, and brought the parts together in the following way: inasmuch as the tarsus had been detaclhed, I saw the necessity of bringing it into proper apposition. To this enid I carrie(l a silk suture through its uipper ed,-,e, at about the miiiddle of the laceratio'n, 'in the form of a loop, througll the entire thickness of the lid at the fornix, and brouiglht both its ends out on the skin at adjacent points, and tied themii over a little roll of muislin. The suture had a needle at eaclh end, which was held by needle-forceps. The performiiance of this step was the critical point in the whole pro-
NOYES: Lacerationt of the Eyelids.
83
cee(ling. It (lrew up the tarsus as by a sling to its proper relations at the fornix. Afterward the external woutd wvas united by several fine interrupted silk sutures and the skin put into perfect coaptation. Slips of isinglass-plaster were laid over the lid, a pad of cotton and a bandage applied. The needles were small and those used at tlle iinner canthus were semnicircular. On the sixth day all the sutures had been taken out, and by the tenitlh day the eye needed no fturther attention. The line of cicatrix is now almost invisible, the appearance is perfectly natural, and the commiand of the lid is comiiplete. The suggestion to be mnade in this case is the importance of uniting the mnucouis membrane and tarsus before the wound of the skin is closed, and in this very young subject the sling-suture was the m11ost suitable, both for its effectiveness and because it could be easily withdrawn. CASE II.-Man aged forty, living in New Jersey. In attemlpting to move a horse-rake whiclh was placed with the shafts turned up against a barn, a hook caught his left upper lid and tore it from its orbital attachmiient for about lhalf its length from the inner canthus to the middle of the brow. The globe was not hurt. A physician of the neighborhood put sUtLtires into the skin, and made a rough coa)tation. External uinion took place, but the inner canthus was not restored and the tarsuis had not been united. In course of time cicatrization of the under surface was accomplished, and ectropiuml-l began. Gradually this deformity increased, and the exposed conjtunctiva underwent the usuial florid papillary hypertrophy; the cornea became. inflamzed, ha;zy, and vascular. About five mionths elapsed before I saw hilm, when he not only presented a disagreeable deformity, btut suffered fromi lachryiimationi, photophobia, pain, and dimness of sight. By passing my finger beneath the lid, ul) toward the fornix, I recognized a dense cicatricial ridge which corresponded to the outer wound. Evidently this har(d tissue was the cause of the ectropium, both by its contraction anid by the barrier whlich it formled to thie return circulation of the veins and lynmphatics. Thlie miian was put under ether, and the cicatrix was cut out along its entire lengtlh, thereby reproduicing almllost perfectly the condition at the first injury-giving a loose flap, which was to be re-established in correct relations. Anticipating considerable retraction, I aimiied to carry the inner enld of the flap, beyond the ininer canthus.
84
NOYES: Laceration of the Eyelids.
I not only excised the old cicatricial tissue at this point, but cut out an open angle of hiealthy skin, into which the point of the flap was to be thrust and held by sutures. The mllanceuvre was difficult because the sm-iall curved needles had to be directed up the acclivity of the nasal bones, and to bring out their points without breaking themii was troublesome. This was not, however, the first step. A careful coaptation of the tarsal edges and imiucous membrane was mnade by three stitches, which were applied to the everted flap and left in situ in the fornix, when the flap should be ready for adjustmenit to its proper place, and for the application of stitches to its cLItaneous surface. Then the preparation of the inner angle, as above mentioned, was imiade, and the necessary interrupted stitches introduced. These were suipported by a fine insect-pin (harelip sutuire) at the inner angle. Before replacing the everted lid some of the hypertrophied conjunctiva was excised. A bandage was applied and retained for twenty-four houirs. Cold.water dressings were used, and about the tenth day the patient went home. Duiring the year I have seen him several times, and at the last visit the eye was entirely comfortable, the cornea clear, the conjunctiva healthy, the lid in position, and its movemiienits normal. It could be lifted to the proper degree, and the line of cicatriix was inconspicuous. The inner canthus had by retraction comiie to be of correct shape. CASE III.-An injury of far greater extent and severity is nlow to be related, in which the probable total severance of the levator palpebrie and of much of the skin, coupled with fractture of the orbital bones, made it imiipossible to effect conmplete restoration of the parts. The case has interesting features aside fromii the damiiage to the lids. For the notes I amii indebted to Dr. Oppenheimer, house surgeon of the New York Eye and Ear Infirmiiary. Charles Ai., aged seven-teen, about a year and a half ago was trying to force his way through a crowd in Washington market, and, to slip between persons who were carrying bLurdens on their shoulders and baskets on their armis, dodged his head down an(d struck against a stationary hook used for lhanging aieat. It penetrated the innier and upper corner of the orbit, lacerated the soft parts, and fractuired the roof of the orbit. He was thrown down insensible, and taken to the New York Hospital, where he remained six weeks. After this time he camiie to me as an out-patient at the New York Eye and Ear Infirmary. There was total eversion of the upper lid, the conjunctiva enormiiouisly thickened, the eyeball deviated to the inner
NOYES: Laceration of the Eyelids.
885
canthus strongly, with no power to turn it out. A deep notch could be felt with the finger about the middle of the superior orbital iiargin, indicating where the bone had been fractured, and the history of his residence in the hospital imiiplied that he had had meningitis. The pupil was normlal, the eyeball seemingly uninjured, but by the ophthalm-ioscope tlie optic nerve was found in a state of miarked atroplhy, presumaably the stage succeeding severe neuritis. The very oblique pdsition of the eye made exatmination of siglht almiiost imi,vracticable, but a low degree could be ascertained. The cornea was covered, notwithstanding the eversion of the upper lid, because all its tissues were so oedemiiatous and thick. 'rhe everted lid border could be tturned down, but would slowly return to its unnatural situation. It was evident that a long time miiust be allowed for reduction of the swollen lid to a normal state. I simiiply directed the continuous use of a pressure-bandage, applied as tightly as could be borne, and removed onily so. often as cleanliness requiired. After about a year the upper lid was thin enough to hang without eversion, but it could not be lifted, and there was a deep notch at its inner and outer angles, and from the inner angle a cicatrix ran along beneath the brow, almiiost to the external orbital border. An improven1eIlt in sight lhad occurred, so that upon the outer part of the field he could see movemiients of the hand. February i, 1879, patient was etherized, and I attemiipted to bring the eyeball to the middle of the palpebral slit, and hoped solmiething might be done to help the upper lid. I proposed to release the adhesions of the eye at the inner canthus, and to attemipt to find the distal end of the torn-off rectus externus, and give it a new attachmiient to the globe. Extensive dissection was made at the inner canthus, by which not only was the insertion of the rectus loosened, but the surrounding connective tissue freely cut. There was abundant cicatricial substance here, and parts were firnmly condensed together. Hiaving done all that seemed appropriate onl this side, I next began upon the outer part of the globe to search for the rectus externus. Its stumiip was founid, but when an effort was made to tuirn the globe outward to meet it, no rotation could be effected. Ptuzzled bv this unlooked-for state of affairs, I could not find any explanation at the inner canthus, and gradually worked miy way at the otuter canthlus backward to the deep part of the orbit. I soon found that there had been fracture of the external wall, and pushing in witlh finger and scissors I at length camie upon a spot where the posterior part of the globe lhad become united to the
NovE:s: Laceration of the Eyelids.
86
periosteumn. Keeping close to the bony wall and using a strong l)air of blunt-pointed scissors, curved, on the flat and holdinlg their convex surface against the globe, I succeeded, bit by bit, in clipping away these attachmiients and rendering the eye imiovable. I had by this timiie arrived almiiost at the orbital apex. The eye could lnow be lifted forward about 4 mmll., anid rotated outward a little beyond the nmedian line of the orbit. Examination of the upper lid showed that a dense cicatricial band separated the superior fornix fromii the parts below, like an lhour-glass contractioni, and that a considerable space existed above, which couild be reached with somiie diffictulty by forcing the finger between the cicatiix anld the globe. No effort was iimade to improve the state of the lid, butt the conjunctival wounds were closed after the external rectus had been brotuglht into the best attainable position by sutures. It was not expected that the eye would be imiade miiobile, but a imiore niatural, permianent position was sought for. The ensuing reactioni was rather severe, but the parts healed well. Exophtlhallmius was cauised, but subsided, and the patient went homiie in two weeks. At the last view of his conidition, the upper lid had drawn up sonmewhat, but was helpless in ptosis ; the eyeball was in correct
position. Whether any greater imil)rovemiient is possible is very doubtful. The separation of the levator was comiiplete, and the fracture of the upper plate of the orbit Imlust hiave matted the tissLies together so as to hold the remliainder of the muiiiscle in perfect bondage. Excision of a piece of skin would merely reproduce ectropium, and incision or excision of the scar would catuse uncertain and possibly disadvantageous results. Since the imleeting of the society I have seen the case, and find that retraction has taken lplace in the uipper lid, but not enough to uncover the cornea. The skin hangs perfectly smooth, without wrinkles to indicate action of the orbicularis or of the levator. When lhe forcibly closes the lids the upper does not descend, and corrugates only through the communicated action of the orbicular fibres of the lower lid. Considerable conjunctival thickening exists, and its treatmient is the present indicationi. The globe remliains fixed upon the middle of the orbit, has no imiotion to the riglht or left, and slight movement upj) and down.
Congenital fisstre of
the utp.per
eyelid.-Katie D., aged seven
NOYES: Glioma of both Eyes.
87.
tiionths, was brought to ilme by Dr. Nolden, in May, I879. There was a cleft near the miiiddle of the right upper lid, ruinning tlhrouglh the tarsus, and looking like the accompanying diagram. This was congenital. 1 pared the edges, an d attempted to avoid any notching of the 00 tarsal edge by hollowing out the sides of the fissure and causing the tarsal end of the linle of junction to l)rotriide in a nil)l)le under the pressure of the suLtures. Harelip sutures with fine insect pins were used, and while uinion was obtained, the subsequient retraction of the scar gave rise to a smiall notclh. Before the operation the cornea was to be seen through the fissuire, but afterward the eye was satisfactorily covere(d.
GAIOMA OF BOTH EYES-REMOVAL-RECURRENCEDEATH-AUTOPSY. By DR. HENRY D. NOYES, NEW YORK.
T'HE case to be rel)orted was l)resented to the New York Pathological Society when the specimiiens were freslh. FLurther details of the miiicroscopic examiiination of the brain are now supplied. In Novemiber, 1878, a verv fat boy of Jewislh parents, about one year old, wvas brought to me at the New York Eye and Ear Infirm-iary. 'rhe fatlher stated that when- he was six miionths old a glistening reflex vas tnoticed in the left eye. He did not know at wlhat period something similar apl)eared in the right eye. It was found that the vitreous space of eaclh eye was occul)ied 1)y a yellowish wlhite growth, whiich in the left was distinctly vascular and pressed upon' thic crystalline; in the right eye the growth was not so large, but was distinctly visible. In view of somewhat retarding the deeper developnient of the disease and to anticipate the probable speedy extension ooutside of the eyeball, enucleation of the left was advised. 'T'he case disappeared freiii observationi uniitil January,. i88o, wlhen
