Clinical Lecture on Certain Operations on the Eye
BMJ (Clinical Research Edition)
FROM a record of cases, carefully tabulated and extending over many years, I find that strabismus in young children is more frequently due to the irritation of intestinal worms than is geinerally stated in manuals of eye (liseases. It is, however, quite an uncommon thing to find reflex amautrosis and strabismus associated in one and the same person, and arising from the same cause-tlue presence of worms. In the case 1 am about to narrate there is one other feature which renders it of more than
... rs it of more than ordinary interest. ,My little patient, barely tlhree years old, was, wlhen she came under my care, the intermediary lhostess of three kinds of entozoa -namely: oxyurides (tlhe little thread-worm), trenia (tape-worm), and ascaris lumbricoides (rotund worm). On searching tlrough the medical journials, 1 liav,e not met witlh a parallel case, and I have (liscovered only a very few cases of reflex amaurosis from worms, one of whicl, narratedl by Dr. Burgers, was puiblished in the BRITISH MEDICAL JO.ItNAL Of 18t62. A still smaller number of cases hav-e also been reportedl in which, it is said, deathi lhas resulted from the perforation of the intestine by ascaris lumbricoides. Rt is said that the tlhree kin(ds of worms named by me will not exist together. It is diflfcult enough to account for theirpresence in the intestine of so yountg a chlild, and belonging as she di(d to the middle class of society. Polluted (Irinking-water is the carrier of filarike, and this might have been unwittingly used by the nurse to mix witlh the milk which formed the staple food of the child. It is known, too, that the ova and embryos of parasitic worms will occasionally undergo a passive migration; that is, direct from intestine to intestine, and witlhout passing through an intermediary host. It is quite possible, therefore, for embryos to be conveyed in the blood of the motlher to the fcetus in utero, and not reaclh their final stage until some months after the birth of tlhe child. In my case, there was no history of the kind; the mother is quite certain she never was afflicted with worms, but, curiously enough, on going back another generation, the grndmother had passed several tape-worms after slhe was married. When Mrs. D. consulted me about her clhild's sight, the ordinary symptoms of worms were mostly absent. Ier sleep was not disturbed ; she had no nasal irritation; no craving for food of any kind; disliked meat, and had a small and capricious appetite; her daily food consisted for the most part of milk and bread and light sweet puddings. She was spare in boly, weak in 1her legs, and her movements were consequently slow, passing from one clhair to another by touch. This the motlher attributed to the loss of sight, whiclh had iiow persiste(l for more than a year. Ier speechi was v-ery defectiv-e; lher vocabuilary consisting of a few iinintelligible sounds, just sufficient to make her wanitsliiown to her niurse, and no more. When placed in front of a strong light, the eyeballs rapidly moved upwards, the irides being concetled by the upper lid. From this cause, and that of the persisteint squinit, I was quite unable to inake any ophthalmoscopic examination. 1, inevertheless, came to I he conclusion, not shared in by anyone who lhad previously seen the child, that the strabismus at all events was symptomatic of wvorms. I accordingly prescribed anthelmintics, commencing, w;ith scammony and jalap, whiclh, after the administration of a second powder, gave tlhe first intimation of the correctness of my diagnosis, as it brouiglht away a large number of ascarides. My next remiiedy, filix raas, dislodged a portion only of a tapeworm, eighiteen inches long: otlier portions came away some days :;fterwards; and I next prescribed three-grain doses of santonin mit bedtime, to be followed by a ftill dose} of castor-oil the following morning. This treatment proved very effectual; the first powder brought away five or six large lumbrici. In the course of hIie following fortiliglit, five or six and tweenty rouind worms, olneasuring from four to eight inches in lenngtll, were expelled ; the relier obtained by the little patient was most gratifying to be-Aold. Two months have elapsed. She is recovering her sight, aIn1d the strabismus has entirely disappeared. Her bodily health is quite chlangred for the better; she is strong on herfeet, can walk a considerable distance, and has gained inintelligence and in speech -is, in fact, an altered child. From the large size and strength of the female lumbrici, I should not have been surprised if perforation of the intestine, in one so young and delicate, had taen place before I succeeded in dislodging all the worms. Surgeoii to the Nottinighlam anid Midla,tiii Eye I'iliriniary. GENTLEMrEN,-Of the operations you lhav-e seen, there are tlhree only to whicll I wish to call your attention. The first of these was the case of steniosis of the laclhrymal duct, which was dilated without slitting the punctum. This is easily accomplished with the probe which I have had modelled by MIessrs. Weiss, on the pattern of Weber's canaliculuis knife (Fig. 1) , and the results, as you may imagine, are much more satisfactory than when the sucker-like function of the punctum is permanently destroyed, as in the usual operation, by conversion into aII (Ipen clhannel. Fig. 1. The second was an exceedingly obstinate case of triclhiasis and entropion specially affecting the upper lid. The patient, aged 4.), who lhad travelled a considerable distance in the hope of relief, has been twice operated on elsewhere without lasting benefit, and was so blind on admission that slhe could not get abouit alone. In these cases I make a perpendicular incision at eaclh extremity of the lid, evert it, and connect the two incisions by a deep cut on the inside riglht down to the cuticle, Just within the roots of the lashes, as in Burow's operation. (Fig. 2. ) I then take a piece of skin from the upper lid, and, retaining a broad pedicle, transplant it into the wound tlhus made. The approximation of the edges of the gap in the upper lid by sutures everts the lashes, and the transplanted skin effectually prevents any return to their abnormal situation. Fig. 2.