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Chapter X11 Eyelids, Lachrymal Passages And Orbit

Anatomy And Physiology.

I. The orbit may be compared, as regards its form, to a four sided pyramid. The base of this pyramid is the anterior opening of the orbit, at which the superior, inferior, internal and external walls terminate. Three of these walls have a sharp margin, making an acute angle with the bones of the forehead and cheek, but the internal wall imperceptibly becomes continuous with the bone of the nose.

The walls of the orbit are composed of very thin osseous plates, the superior wall being formed by the orbital plate of the frontal bone; the inferior wall by the orbital process of the superior maxillary ; the external wall by the anterior surface of the great wing of the sphenoid and the posterior surface of the malar bone; the internal wall by the os planum of the ethmoid, the os unguis, and the nasal process of the superior maxilla.

At the junction of the internal and middle thirds of the superior margin, we find the supraorbital foramen, which gives passage to the nerve and artery of the same name. The infraorbital foramen runs obliquely from before backwards through the inferior wall, and contains the infraorbital vessels and nerve. The optic foramen is situated at the posterior extremity of the superior and internal walls ; the optic nerve and ophthalmic artery pass through it from the cranial cavity into the orbit. To the outside of and below this opening, between the superior and external walls, is the opening of the sphenoidal fissure ; it contains the third, fourth and sixth pairs of cranial nerves, the first branch of the fifth, and the ophthalmic vein. Between the external and internal walls, we find the spheno maxillary fissure, which is crossed by the infraorbital nerve, as also by the cutaneous branch to the cheek.

The walls of the orbit are covered by a periosteum, which is closely adherent only at the foramina, the margins of the fissures, and the anterior opening of the orbit. This periosteum is in direct communication with the periosteum of the cranium and face, and also with the cranial dura mater.

2. The eyelids, as they lie in contact with the anterior convexity of the eyeball, which contact is maintained by the action of tile muscles mid by the atmospheric pressure, close the orbital opening. Their free margins form the palpebral fissure, and are united at the two angles, called respectively the external and internal commissures ; the internal commissure is sometimes called the great angle of the lids. This commissure is occupied by a small raphe, the internal palpebral ligament. The margin of the lid presents an anterior and posterior lip ; between the two lips is situated the intramargindl space, which is from 2 to 3 millimetres broad. The anterior lip is rounded off, and is pierced by the eyelashes; on the posterior we have the openings of the Meibomian glands arranged in a row, and near the internal angle the openings of the lachrymal canals.

The lids are composed of different layers which are superimposed from the conjunctiva to the external integument.

(a) The skin which covers the lids presents a delicacy of texture which is not found in almost any other part of the body. It is connected with the subjacent structures by a very loose cellular tissue, in which are found a great number of sudoriferous glands and the bulbs of the very fine hairs with which the skin of the lid is furnished.

(b) The orbicularis muscle is arranged in concentric fasciculi round the palpebral fissure. Its palpebral portion covers the fibrocartilages and the palpebral fascia to the orbital margins, and extends beyond the external commissure of the lids for more than a centimetre and a half. It is composed of muscular fibres, which arise from the crest of the lachrymal bone, and from the internal palpebral ligament and the neighborhood of the lachrymal sac.

The fibres of the first portion, also called the posterior lachrymal muscle or muscle of Horner, at first cover the lachrymal sac, and are directed towards the great angle of the eye. At this point the muscle divides into two portions one part entering the superior eyelid, the other the inferior, where they form expansions of the tarsal cartilages.

The second part, which forms the anterior lachrymal muscle, surrounds the fibro cartilage, and extends to that portion of the lid where it is absent.

(C) Beneath the muscle there is a layer of cellular tissue, which contains the follicles of the cilia and the small sebaceous glands which open into these follicles. The cilia, whose roots are situated near the margin of the tarsal cartilage, are renewed, like all other hairs, in about a hundred and fifty days.

(d) The tarsal or fibro cartilages form the solid groundwork of the lids. At their palpebral margin they are somewhat thick, but become thinner at their periphery, and are finally lost in the orbital fascia. At this point the levator muscle is inserted in the superior lid. This muscle arises at the bottom of the orbit, and its fibres run forwards beneath the orbital arch. The tendon thus turns downwards over an aponeurosis, which extends from the trochlea of the superior oblique to the external extremity of the superior orbital margin. Thence it expands as a thin membrane beneath the orbital fascia, and is inserted as we have said at the thin margin of the fibro cartilage of he superior lid. In each fibroma cartilage we find a series of sebaceous glands (the Meibomian glands), which are arranged vertically. Their excretory ducts are situated near the posterior lip of the thick margin of the cartilages, and supply a fatty secretion, which lubricates the free margin of the lids.

(e) The conjunctiva is in close union with the posterior surface of the cartilages and of the tarso orbital fascia. The palpebral arteries are branches of the ophthalmic artery, and are situated near the free margin of the lid; they anastomose with the angular, lachrymal, and superficial temporal arteries, thus forming arterial circles, which surround the palpebral fissure. The veins unite in forming the superior and inferior palpebral veins, which join the veins of the temple and face. The nerves of the lid come from the fifth pair ; the elevator of the superior eyelid receives a branch from the third pair ; the orbicularis muscle a branch of the facial nerve.

3. The lachrymal apparatus consists (a) of organs which are connected with the secretion of the lachrymal fluid these organs are the lachrymal gland and the conjunctiva; (b) of the passages which convey the secretion into the nose the passages are the lachrymal canals, the lachrymal sac, and the nasal duct.

(a) The lachrymal gland is divided into two portions, one of which is much larger than the other. The larger of the two occupies a depression situated at the superior and external lateral part of the orbital vault, to which it is attached by an aponeurosis which comes from the tarso orbital fascia. The smaller portion lies beneath this aponeurosis. The gland is composed of a collection of racemose glands, which in structure resemble the salivary and mammary glands. It communicates by a number of small ducts, six to a dozen, with the external extremity of the superior conjunctival cul de sac.

(b) The lachrymal canals are from 8 to, 10 millimetres long. They begin with two small openings, the puncta lachrymalia, situated on the prominent angles of the free margin of the lids, near to the caruncle. Starting at the lachrymal openings, the superior canal rises, while the inferior descends, perpendicularly into the thickness of the tissue of the lids. They then turn abruptly into the horizontal direction and run along the internal margin of the lids. They thus converge at the angle of the eye to open into the Lachrymal sac, which they do nearly at the level of the palpebral ligament. Before entering they may unite, or they may enter separately.

(c) The lachrymal sac is situated between the lachrymal bone and the nasal process of the superior maxilla, so that its inferior half is found beneath the level of the internal and inferior ingle of tile margin of the orbit. The superior extremity of the sac is formed by a sort of dome extending to about 4 millimetres above the palpebral ligament which is stretched horizontally in front of the sac. It is, therefore, everywhere surrounded by soft structures, except on the internal side, where it is in close proximity to the bone. This side descends perpendicularly towards the nasal canal, there being frequently no line of demarcation between the two, although sometimes they are separated by a fold of mucous membrane.

(a) The nasal duct is enclosed in a bony canal in the partition which separates the maxillary sinus from the. nasal fosse It does not run directly from above downwards, but somewhat obliquely from within outwards, and slightly from before backwards. Moreover there are considerable variations in the convexity of this curve depending on the individual conformation of the nose. At the inferior extremity of the bony canal, the nasal mucous canal is often continued between the external wall of the nasal cavity and the pituitary membrane which covers it. The inferior orifice of the canal is occasionally very small ; it is sometimes round or oval; sometimes like a slit, the external lip of which, or, in its place, a prominent fold of the mucous membrane, forms a valve which opens towards the nose and closes the canal from below upwards.

The mucous membrane is covered with a simple layer of pavemented epithelium in the lachrymal canals ; in the sac and nasal duct the epithelium is ciliated like that of the nose ; the membrane also contains small racemose glands. The lachrymal sac being generally very narrow, the membrane of the internal and external walls is usually in close apposition. The membrane of the duct is intimately connected with the bone, and its walls do not come into contact, so that the duct is constantly filled with liquid. The innervation of the lachrymal gland is derived from the lachrymal branch of the first division of the fifth pair. To its influence is due the copious secretion of tears which follows certain emotions or the irritation of the eye. In ordinary circumstances, the secretion of the gland is inconsiderable, the liquid which constantly lubricates the eyeball being in great part a product of the conjunctiva.

The mechanism by which the tears pass from the conjunctival sac into the lachrymal passages is not perfectly understood. Yet it seems to be beyond doubt that the contractions of the orbicular muscle and the consequent movements of the lids propel the liquid contained in the conjunctival sac into the puncta, when the palpebral fissure is closed by the shutting of the lids.

ART. I. Erythema of the Lids.

Diagnosis. The skin of the lids is of a bright scarlet, which disappears on pressure ; the lids are slightly swollen. The superficial veins seem more dilated, and are more easily seen than in the normal condition. The patients do not complain of pain, or at most of a slight sensation of heat.

Et olo gy. This disease, although somewhat rare, frequently accompanies affections of the general circulation. Treatment. The best results are obtained from the application of compresses steeped in a solution of lead acetate (i to ioo), or of nitrate of silver (I to 300)

There is frequently observed in persons who have undergone a physical or mental strain a grayish blue coloration of the lid, especially of the inferior lid and of the integument beneath it. This leaden tint, which is often only transitory, sometimes extends round the orbit, and is accompanied with slight edema of the subcutaneous tissue.

Persons who are subject to these symptoms have frequently a delicate skin, and their general health is, as a rule, not robust. To relieve them of the symptoms in question, we must advise them to avoid any deviation from a strictly regular life, e. g., excessive work, and we may prescribe, as a topical application, a solution of tannin (I to ioo), as also eau de Cologne lotions.

ART. II. Erysipelas of the Lids.

Diagnosis. The lids are very much swollen, and are of a rosecolored and shining appearance. The epidermis is sometimes raised in patches under the form of vesicles filled with serum. The swelling of the eyelids, which is most frequently accompanied with swelling of the face, prevents the patient from opening them ; the conjunctiva is injected and chemotic. All the parts affected are hot to the touch. The disease is not painful, but it is often accompanied by disturbance of the digestion, shiverings, and fever.

Progress and Termination. Erysipelas may end in resolution or in suppuration. In the latter case it sets up diffuse phlegnion, giving to the lid an edematous and. somewhat fluctuating sensation. The skin then takes on a deep red color, and becomes the seat of a very painful distention. The abscess, it' left to itself, may produce very extensive destruction of the cellular tissue. The inflammation may also extend to the cellular tissue of the orbit, placing the eye in extreme danger, and may even prove fatal to the patient, by extending to the membranes of the brain.

Etiology. Erysipelas of the lids, although sometimes due to a chill, is most frequently set up by some traumatic lesion, by a purulent focus in the neighborhood of the lid, or by an affection of the lachrymal sac.

Treatment. An emetic or a purgative is generally administered. The lids are covered with a layer of collodion and wadding. Every abscess should be freely opened, and hot and emollient cataplasms must then be ordered.

ART. III. Phlegmon of the Lids, Abscess.

Diagnosis. The eyelid is red and swollen, and its temperature is considerably increased; the conjunctiva is generally injected, and there is frequently considerable chemosis. On palpation, we find a hard point in the lid, which gradually increases in size, becomes soft, and then gives the sensation of fluctuation, whilst at the same time its summit becomes yellowish. The pain is, as a rule, very severe, preventing sleep, and, in delicate persons, is accompanied with headache and fever. At last the abscess opens, the pus escapes, and the swelling of the lid subsides.

When the abscess is situated near the internal angle (anchilops), it is not always easily distinguished from acute inflammation of the lachrymal sac.

Etiology. The most frequent causes of phlegmon are contusions or similar injuries. It may also accompany phlegnion of the orbital tissues. Sometimes it appears to be produced as a result of cold, and sometimes without any apparent cause.

Treatment. In the early stages we may attempt to arrest the inflammation by the application of cold. As soon as the induratior is recognized, it is better to use hot cataplasms, and the abscess should be opened as soon as possible by a large incision parallel with the free margin of the lid. The hot compresses should then be continued, and may be advantageously made with a half per cent. solution of boracid acid. A compress and bandage may also be applied to prevent excessive separation of the skin.

Furuncle and Anthrax of the lids present the same symptom as phlegnion, and tire distinguished froin it by the gangrene of the subcutaneous tissue and of the skin. The skin is livid, and its epidermis is elevated in vesicles, the parts affected form a pultaceous mass, and this gangrenous destruction causes considerable loss of substance. Anthrax chiefly occurs in aged and worn out persons. The treatment consists in freeing the affected parts by a cruciform incision, and in the application of hot poultices to promote the separation of the gangrenous material. Nourishing food and tonics are necessary to support the strength of the patient.

Malignant pustule is due to the contact of the lids with decomposing animal matter, the virus of farcy or of glanders. It occurs in curriers, tanners, butchers, etc. On the swollen and slightly inflamed lid a serous pustule is formed, which speedily bursts and becomes the seat of a gangrenous ulceration which tends to spread to the neighboring structures. The pain is very acute, and the patient suffers from fever, nausea and shiverings. Before long there supervenes a great prostration of the patient's strength, and he succumbs to the disease. In the cases which recover, the gangrene may be arrested, and the disease terminate in the destruction of the eyelid. Frequently the eye and part of the face are also involved.

Deep incisions, followed by the application of the actual cautery, have been recommended in conjunction with a general treatment suited to sustain the patient's strength.

The pustules of small pox which appear on the eyelid, either isolated or arranged in rows, or along the ciliary margin, may cause a destruction of the skin, the Meibomian glands and the hair follicles in this region. Hence will follow the loss of the eyelashes (madarosis), accompanied with persistent redness of the lids, and, in the later stages, cicatricial contraction, leading to ectropion and displacement of the inferior lachrymal openings, impeding the passage of the tears into the lachrymal sac. Cold compresses (Hebra) or a weak solution of bichloride of mercury (i in iooo) constantly applied, have been recommended as a means of keeping the small pox eruption away from the lids. The imbrication of the lids with small bands of Vigo's plaster is objectionable, for it occasions considerable local heat (Skoda). Puncture of the pustules, followed by the application of collodion and caustic, is of no avail (Hebra). We must, however, carefully attend to the position of the lids, especially of the lachrymal opening, in order to avoid lachrymation (see Diseases of the Lachrymal Apparatus).

ART. IV. Eczema of the Lids. Herpes Zoster Frontalis. Syphilitic Affections of the Lids.

1. Eczema may extend to the lids in cases of general eczema of the face, or it may be set up by the contact of the morbid secretions of the conjunctiva, which irritate the fine skin of the inferior eyelid. If this affection lasts for some time, the skin becomes contracted, and there follows eversion of the palpebral margin. The lachrymal opening not occupying its normal position, the overflowing tears add to the irritation which already exists.

The treatment of eczema in the early stages consists in the application of powdered starch, which may be mixed with a small quantity of zinc oxide. When using this powder as a dust for the lids, we must warn the patient to be careful not to allow any crusts to form on the palpebral margin. Once daily a weak astringent solution (sulphate of copper or acetate of lead 1 300) is applied to skin of the lids. The eversion of the lachrymal opening, if it persist, must be met by a small incision of the lachrymal canal.

2. Herpes Zoster Frontalis or Ophthalmic Zona generally begins with violent neuralgic pains in the course of the frontal and naso ciliary nerves. After a few days the skin becomes red and swollen, and we find an eruption of herpetic vesicles in groups, which unite, become covered with adherent crusts, and often give rise to deep cicatrices, traces of which remain during life. The affected region, although insensible to the touch, may be for a long time the seat of very intense neuralgia. The disease in question never extends beyond the median line of the face. It is often complicated with corneal ulceration (Hutchinson, Bowman) and with iritis (Horner).

The treatment of the ocular affection is the same as in corneitis and iritis. To check the violent neuralgia which persists after the zona is cured, we may employ the ointment of morphine, the constant current, or, finally, subcutaneous neurotomy as proposed by Bowman.

3 Syphilitic ulcerations of the lids are sometimes met with as a primary, and sometimes as a secondary, symptom. These ulcers have a tendency to increase in size, but more especially in depth ; so that their situation on the margin of the lid threatens it with deformity or even more or less complete destruction. Syphilitic ulcerations may also affect the conjunctiva, but they rarely begin in this situation as a primary affection.

The treatment of these ulcers at first requires an active and prolong( ([ use of antisyphilitic remedies locally, applications of nitrate of, silver, and it dressing made with fine calomel powder or ointment of iodoform, or will) a weak Solution of corrosive sublimate ( I-60000).

When the ulcers begin to cicatrize, we may advantageously employ an ointment of the red precipitate (I to 16o of lard).

ART. V. Seborrhea of the Lids. Ephidrosis and Chromidrosis.

(a) The term seborrhea is applied to an increase in the sebaceous secretion which covers the skin of the lids, as also the naso labial folds and the commissures of the lips, with an oily layer or with small yellow pellicles. This affection is apt to become the starting point of an inflammation of the margins of the lids. It is, therefore, a matter of importance carefully to remove all sebaceous masses with hot soap and water lotions, having previously a little glycerine and oil.

After these attentions to cleanliness, we should order the use of coldwater douches or lotions, to which a few drops of eau de Cologne have been added.

(b) Ephidrosis consists in a hypersecretion of the sudorific glands. The lids are covered with a layer of perspiration, which, as soon as removed, again gathers on their surface. Hence there is excoriation of the angles and margins of the palpebral fissure, accompanied with catarrhal conjunctivitis. This disease is not of common occurrence, and is found most frequently in persons who are subject to perspirations. As to local remedies, we must treat the excoriations with a half per cent. solution of nitrate of silver, and check the general predisposition to perspiration by hydro therapeutics and a strengthening regimen.

(c) In chromidrosis, the lid are of a dark blue or brownish color, which is easily removed with oil or glycerine, but resists pure water. The pigment, when removed, sooner or later reappears. This curious affection almost always occurs in women, and the large majority of persons affected with it are hysterical. Often we are able to convince ourselves that we are dealing with an artificial coloration ; still, in other cases, the reality of the disease is beyond doubt. The disease disappears of itself, and no treatment seems to be of any efficacy,

(d) The presence of lice in the eyelashes and eyebrows has been observed to cause irritation and prurigo. They can sometimes be detected by the naked eye or by means of a magnifying lens, and are easily destroyed by the careful use of mercurial ointment.

ART. VI. Edema and Emphysema of the Lids Palpebral Ecchymoses.

1. Edema of tile eyelids often accompanies affections of the conjunctiva, as also inflammations of the eyeball and of the orbital tissues. This disease is also found as a consequence of contusion of the lids, or affections of the health in general (diseases of the heart and kidneys, tricbinosis), in persons of weak constitution. It is, however, sometimes seen when it cannot be attributed to any direct cause. Sometimes this edema is localized to the inferior lid, which then forms a kind of pendant pouch, more prominent in the morning and diminishing in size during the day; sometimes both lids are so swollen that the palpebral fissure cannot be opened.

The edema symptomatic of an ocular affection disappears with the disease to which it is due: idiopathic edema often resists every treatment.

Having in our treatment complied with the indications furnished by the patient's general condition, we try to overcome the edema with a compress and bandage, or hot chamomile applied in small bags; we should also have recourse to the repeated application of tincture of 'iodine, or iodine ointment. If the edema persist and cause annoyance to the patient, the swelling of the lids may be reduced by the excision of a horizontal fold, or of several vertical folds, of the skin of the eyelid.

2. Emphysema of the lids, that is to say, the penetration of air into the cellular tissue, is easily diagnosed by the crepitation which the swollen lid gives to palpation. The swelling is often considerable and extensive. The skin is not changed, or presents only a few ecchymotic spots. This affection is generally of traumatic origin ; it is often due to fracture of the bony walls of the nose or frontal sinuses. Fracture of the latter allows air to penetrate also into the cellular tissue of the orbit. Again, it may be caused by rupture of the lachrymal canals. Emphysema disappears spontaneously in the course of a few days, especially if the patient avoid every great effort of expiration, such as blowing the nose violently, etc. The swelling of the lid may be made to disappear at once, by making a few small openings with the point of a needle.

3. Palpebral Ecchymosis comes on after contusions of the eye, after operations performed on the conjunctiva and in tile subconjunctival tissue, after lesions of the orbital walls, after intracranial fractures, and sometimes, although rarely, it occurs as oil( of tile prodromata of cerebral apoplexy (Desmarres). These ecchymotic spots are easily absorbed, but are more quickly so when treated with tincture of arnica fomentations, and the regular application of a tightlyfitting compress and bandage.

ART. VII. Inflarnmation of the Margin of the Lid Marginal Blepharitis.

Inflammation of the palpebral margin is characterized in its early stages, and more benign form by a redness of the margin, more especially at the palpebral angles, accompanied by a feeling of heat, burning or itching. These symptoms are increased when the eyes are exposed to dust or smoke, and when the patient engages in any minute work. The affection may retain this form, or it may become aggravated by the hypersecretion of the sebaceous glands, and the formation of small acne pustules.

The part of the skin which supports the cilia is then slightly swollen and covered with crusts, beneath which are excoriations ; and at the side of these crusts we can still distinguish the small acne pustules filled with matter. The crusts are formed by the desiccation of these pustules. The acne spots are found between the cilia, or at their base. In these situations we find numerous fine, soft pellicles, which cover the cilia and unite them into smaller or larger bundles. In the morning, before rising, the margins of the lids are glued together, so that the patient cannot open his eyes. When the crusts are torn off without due precautions, or the patient clears his eyes hastily, the margins of the lids bleed, the hairs fall out, and in a short time the lids are again covered with fresh crusts.

When the iDflammation increases still further, the entire palpebral margin is swollen and becomes ulcerated, the hairs fall out, and are replaced by others which are both weaker and finer ; these latter do not grow in the normal direction, and the processes end in the margin being altogether deprived of cilia (madarosis) ; or we may find only a few very long, pale, isolated cilia bent either inwards or outwards. In such conditions, the hair follicles are atrophied, the cellular tissue which surrounds them is hypertrophied, and the entire margin is thickened and indurated with the cicatricial tissue which is left by the ulceration (tylosis).

The thickening of the lid increases the distance between the palpebral margin and the eyeball ; thus the puncta lachrymalia do not occupy their normal position, and therefore cease to perform their usual functions. Tile tears remain in contact with tile conjunctiva, which moreover is apt to participate ill the ill I ion of tile palpe¬ bear margin ; the Meibomian glands are also obliterated, and, in extreme cases of blepharitis, the entire lid is seen to become gradually inverted.

Progress. Blepharitis is essentially a chronic disease. It begins with symptoms which, although at first slight, before a longer or shorter time become more severe, according to the surroundings of the person affected. There are also periods of remission and exacerbation. judicious treatment may arrest the progress of the disease and bring about a favorable termination, as long as the glands of Meibomius perform their functions and their orifices are not obliterated. If, however, this period be passed, we may still relieve the patient, and improve the condition of the lids; but a complete restitution of the normal condition is no longer to be expected.

Etiology. Blepharitis is especially apt to occur in lymphatic persons, in those whose skin is very irritable and delicate, and in persons who are not of cleanly habits. Again, this disease is often a consequence of chronic conjunctivitis, and especially of anomalies of the lachrymal passages. It has also been frequently found to coincide with anomalies of refraction.

Treatment. The first condition in treating blepharitis is to observe the most scrupulous cleanliness. The lids must be frequently washed with hot water, and if this does not suffice to remove the fine pellicles and adherent crusts, we must cause to be applied, especially in the morning, compresses dipped in a hot solution of lead acetate (i to ioo). If there are neither excoriations nor crusts, but only persistent redness of the palpebral margin, a camel hair pencil dipped in cade oil should be applied daily or every second day. Benefit may also be derived by removing such hairs as are liable to fall out. This may best be done by making them lightly slide between the index finger and thumb, or by means of small cilia forceps. In order to prevent the formation of crusts on the margins of the lids during the night, the patient should, on going to bed, cover his lids with a thin layer of the following ointment:

White precipitate . . . . . 3 parts.
Subacetate of lead . . . 10 parts.
Oil of sweet almonds . . . 50 parts
Vaseline . . . . . . . . . . . . . .500 parts.
Tile white precipitate may be replaced by oxide of zinc or red precipitate.

When the margins of the lids are already excoriated or are the seat of small ulcers, fatty matters are, as it rule, not well supported by tile patient We must then employ it solution of silver nitrate ( i (o too) ; the acne pustules should be opened, and their bases, (It. the bottom of the ulcers which they leave, touched with a very finely pointed mitigated nitrate of silver pencil. As soon as a layer of epidermis is re established, we may again attempt to use the ointments which have just been mentioned. In such conditions, the cade oil and the tincture of iodine are of great service.

If the crusts be numerous and the thickening of the lid considerable, we must order hot cataplasms to be applied for an hour morning and evening. The closed eyelids should also be covered during the night with a lint compress, on which a little of the following ointment has been spread:

Acetate of lead ointment . . . . . . . . . . . . 200 parts.
Linseed oil . . . . . . . . . . . . . . . . . . 200 parts.
Balsam of Peru . . . . . . . . . . . . . . . . I part.
We should also direct our attention to the complications of blepharitis, and bestow such care on the patient as his general health may require. Any form of conjunctivitis which may be present must be treated according to the principles laid down in our chapter on this affection, and diseases of the lachrymal passages according to the directions which we shall give in another chapter. Any anomaly of refraction must be counteracted by the proper glass. Patients affected with blepharitis should be as much as possible in a pure and fresh atmosphere ; they should wear blue spectacles, and avoid any excessive work, as also any excess in their general regimen. A scrofulous or lymphatic diathesis should be held in check by suitable remedies.

ART. VIII. Hordeolum, Stye.

The stye, which is an inflammation of the cellular tissue of the lid, appears near the cilia as a hard button, very painful to the touch, and accompanied with inflammation and swelling of the part of the lid in which it is situated, or of the entire lid. Sometimes patients suffer considerably and may even be feverish. The stye is developed in the course of a few days, its summit becomes yellowish, opens, and gives issue to a little necrosed cellular tissue.

This disease is very subject to relapse, so that a patient may have one stye after another during several weeks or even months. In the very early stages we may try to stop the irflammation by cold compresses; still, should the inflammation have been present for any time, it is much better to use hot poultices and emollients to promote suppuration, and hot lotions of boracic acid. We may leave the bursting of the small tumor to nature, or make a small incision at its apex. If the suppuration is prolonged we may apply the mitigated nitrate of silver pencil to its cavity.

The tendency to relapse is combated by the use of the white precipitate ointment we have just mentioned.

ART. IX. Tumors of the Lids.

I. The chalazion is a small, firm and immobile tumor which develops in the tarsal cartilage, and arises from alteration in the Meibomian gland. In fact, its envelope is formed by the walls of the gland, and its contents are the product of its secretion. Sometimes the contents are changed into a liquid or purulent material; sometimes into a gelatinous, fatty, and sebaceous mass mixed with newly formed cellular tissue.

This small cyst, which may vary from the size of a large pin's head or a lentil to that of a bean, or even of a nut, sometimes protrudes towards the conjunctiva, so that its contents may be seen through the membrane, sometimes towards the external skin of the lid. Frequently several of these tumors are found in the same lid, or in both lids of the same side, and occasionally in the lids of both eyes. The consistency of the tumor depends as a matter of course on the nature of its contents.

The chalazion is almost always of slow growth and may stop at any stage of its development. Rarely does the gradual distention of the cyst lead to the spontaneous perforation of its internal wall. Should this perforation take place, it may be followed by perfect recovery, or the contents of the chalazion may reaccumulate ; and should the opening in the chalazion remain patent, it will be surrounded with fleshy granulations, which sometimes increase to such an extent as to become a source of irritation to the eye.

The treatment of chalazion almost always involves surgical interference, the application of iodine preparations being, as a rule, of little use. The operation required is either excision or incision with evacuation of the contents of the tumor, for which purpose a small steel curette with sharp edges may be used. The latter operation is to be preferred when the contents of the chalazion can be removed without much trouble, and when its walls are very thin. The lid is everted, and the small tumor which projects on tile mucous surface is incised in its entire extent. To remove the contents of the tumor com slight pressure must be made oil tile everted lid from behind the tumor; any matter remaining may be lifted out Will the curette.

Excision is generally made through the conjunctival surface; rarely through a cutaneous incision, which, however, is preferable when the small tumor is situated immediately below the skin. The tissues which cover the tumor are there incised transversely, to an extent sufficient to allow of the easy extraction of the cyst ; care being taken to expose the cyst in the wound. Then the adhesions of the tumor with the surrounding tissues are carefully broken down, and the excision effected ; the mucous membrane or the skin, if the operation be by a cutaneous incision, being left intact. In the latter case, we may unite the edges of the wound with a suture. No benefit is to be derived from the application of caustic to the sac. Desmarres' forceps, applied as in Fig. 207, will be found of use during this operation.

2, Millium or millet is a small pearly white tumor, about the size of a pin's head, situated on the skin in the neighborhood of the cheek, where we frequently find a considerable number of such tumors togetber. If the patient wish the tumor removed, the epidermis which covers it is incised with a needle, or a small, finely pointed bistoury, and the small cyst is removed in its entirety. If the envelope has been previously opened, a small portion of it must be excised.

3. The molluscum is, like the millet, a cystic tumor, but is of much greater dimensions, for it sometimes attains the size of a pea, or may be even larger. Its apex is often more deeply pigmented, and we always see in it the dilated orifice of a hair follicle, which, by its distention and secondary alteration, has produced tile inolluscum. This orifice is occasionally hidden from sight by some brownish sebaceous matter, which seems to be sufficiently irritating to set up, when brought in contact with adjacent follicles, alterations in these follicles which end in the formation of similar tumors (molluscurn contagiosum).

The molluscum may occur on any part of the skin of the lids, but is most frequently found near the periphery. It may become pediculated so as to form a kind of small horn, on the apex of which we can still see the orifice of the follicle. In children, we sometimes see a number of these small horns on the lids and in their neighborbood. To remove them we may evacuate their contents with a pair of large forceps, at the same time taking away their envelope, which yields easily, or the entire tumor may be removed with scissors. If the molluscurn is of somewhat greater dimensions, it is better to extract the entire tumor through a sufficiently large cutaneous incision.

4. Small transparent vesicles, known as transparent cysts, are met with on the margins of the lids. Their origin is not understood, but they may easily be removed by puncturing them with the point of a needle.

5. Dacryops. This is an exceedingly rare tumor; it is situated near the external angle of the superior eyelid, and is due to the dilatation of one of the excretory ducts of the lachrymal gland. Thus, if its orifice be not occluded, on pressing the tumor a few drops of liquid escape. It rapidly disappears on incising the walls of the cyst, but immediate cicatrization should be prevented by opening the lips of the wound with a probe from time to time. With the same object in view, von Graefe operated as follows : Having dilated the small opening of the cyst with a conical stylet, he introduced into it a curved needle furnished with a silk thread, and made a ligature which included about 4 millimetres of the cyst wall. After ten days, he removed the ligature, and cut, with a pair of scissors, the portion of the wall which had not been completely divided. Lastly, he kept the lips of the wound open, by means of a small sound, till lie was assured by the cicatrization of the margins that the cyst was finally destroyed. 6. Erectile tumors or Nevi sometimes appear as bright red warts, which, on palpation, give arterial pulsations; sometimes they occupy large patches of skin. They are almost always congenital, and occur most frequently at the periphery of the eyelid. They may remain stationary, or may gradually increase in size, invading the entire lid, and passing into the orbit, or extending to the forehead and cheek. Nevi may be dealt with in various ways.

When they are of small size, they sometimes disappear after the application of nitrate of silver, or nitric or hydrochloric acid. These acids may be conveniently applied to the tumor by means of a glass rod.

Good results have also been got by inoculating the small maternal nevi of young children with vaccine virus.
After the cases which have been published of a fatal termination following the injection of the perchloride of iron this method is, we think, no longer admissible for the treatment of erectile tumors of the lids. Setons and ligatures are only suited to tumors of medium size. The ligature may be circular, in which case it strangles the tumor below two needles which have been previously inserted at its base. We may at first only include a portion of the tumor in the ligature, the entire structure being removed by several operations. Excellent results are often derived from electrolysis and the galvano cautery, which may be applied either by means of a platinum thread or by needles inserted at various points in the tumor. The great advantages of electrolysis are the absence of pain, danger and cicatricial deformity.

When the erectile tumor is too large to admit of direct interference compression or even ligature of the carotid artery on the diseased side may be attempted.

7. Xanthelasma is the name given to a slightly raised yellow patch which is found on the skin of the lids and in their neighborhood. These patches vary much in size, and are often found in persons who are the subjects of some affection of the liver or who suffer from migraine. To remove a xanthelasma we must excise it, and unite the edges of the wound with one or more points of suture.

8. Fibromata and Sarcomata are sometimes, although rarely, found on the lids. These tumors so resemble each other that they can only be distinguished by microscopical examination. The only differential sign is the rapidity of development and extension peculiar to sarcomatous growths (Virchow).

Sometimes these tumors extend towards the skin; at other times they form circumscribed and resistant tumors in the depth of the lids. Occasionally fibromata appear as cartilaginous, or even osseous, plates.

Fibromata should be made the object of treatment only when they become an intolerable annoyance to the patient. Sarcomata, on the other hand, demand immediate operation.

A few rare cases of lipomata of the eyelids have also been recorded. These are slightly mobile circumscribed tumors, which to palpation give a soft and elastic sensation, and present slight swellings oil their surface. When tile tumor, by its size, becomes a source of inconvenience to tile patient, it is easily enucleated through a clitancons incision.

9. Lupus may occur primarily on the lids, or it may extend to them from the cheek or conjunctiva. It is characterized by semitransparent brownish nodosities, about the size of a pin's head, which surround the ulcerations. The part affected should be scraped clean with the sharp edged steel curette; for if this be not done, the disease will cause extensive destruction of the lids, ending in entropion or ectropion or symblepharon and ankyloblepharon, and bringing about ulceration of the cornea and loss of the eyeball (see article on Lupus of the Conjunctiva). As to operations adapted to restore eyelids which have been destroyed by lupus, it is better to defer operating till the disease is cured, because transplanted flaps may also become affected by lupus.

10. Epithelioma as a rule begins on the ciliary margins of the lids, commonly on the internal half of the inferior lid. In this situation we first observe a small tubercle, resembling a small wart; it is almost transparent and is of a grayish color. To the touch it appears nodulated and composed of several granulations: it increases rapidly in dimensions, and soon enters the period of ulceration. The ulcer is smooth, its base is indurated and its margins are irregular. It is covered with a sanious secretion, which becomes dry at the periphery and forms crusts. The ulcer increases in the surrounding tissue both in extent and dep!h. It may cease to extend for a certain time, after which it again begins to increase; or it may cease to extend in one direction but begin to grow in another.

This form of ulceration is distinguished from the syphilitic ulceration already mentioned by the slowness of its progress, by the condition of the adjacent integuments, but especially by the study of the patient's antecedents.

Epithelioma is rarely found before middle life: its progress is at first slow, but it becomes more rapid when the disease reaches the conjunctiva.

The prognosis of this disease is serious. In cases of operation, a return is more likely to occur if the diseased tissues have been imperfectly removed.

The treatment consists either in the extirpation of the diseased part by the knife, or in its destruction by caustics. When the tumor is of moderate extent and well defined, so that we may hope to remove it in its entirety, extirpation is indicated. We make our incisions in the healthy portions of the skin, and we should remove the tumor in such a way as to leave tile parts suitable for the transplantation of a flap of skin (consult article oil Blepharoplasty).

As a caustic, we often employ caustic potash, or a paste made of chloride of zinc and nitric acid.

Bergeron has used chloride of potassium, both locally and internally, with great success (see Bulletin de Therapeutic, t. xlvi, p. 12). He applies to the tumor pledgets of lint impregnated with the following solution : Distilled water, 5 41 ; chlorate of potash, 3 5. Internally he administers 30 grains of the chlorate per diem.

Dr. Broadbent has recommended acetic acid, which he uses, in the strength of i part of the acid to 4 of water, as an injection, or by painting on the tumor. Similar treatment has been tried with nitrate of silver, chloride of zinc, etc.

ART. X. Blepharospasm.

Spasmodic contractions of the orbicular muscle of the eyelids assume very various forms.

Thus, we may have short contractions of a few fibres of the muscle, which cannot be attributed to any cause, and which as unaccountably disappear. In such cases the patients usually say that they feel something jerking in their eyelids, and they also notice that these jerking sensations supervene or increase as a consequence of emotion, or after anything which causes the eyes to be fatigued.

In other cases we find a constant winking of the lids, often more disagreeable to those who see it than to the patients themselves. These winking movements are sometimes due primarily to an irritation of the conjunctiva, or to an excitation of the sensory nerve fibres supplying the integuments of the eye.

Such movements are also common after efforts of accommodation greater than the person is accustomed to, and thus they not infrequently affect children who have just begun their education. The regimen when the patient is weak or nervous, are sufficient to overcome this form of blepharospasm.

By the term blepharospasm. is generally meant the spasmodic occlusion of the palpebral fissure, whether it take place only intermittently or last for some length of time.

This form of blepharospasm may be due to various causes. Sometimes it is due to the presence of a foreign body in the conjunctival sac ; at other times it is a concomitant of certain inflammations of the cornea and conjunctiva (scrofulous blepharospasm) ; again, it may be only a reflex symptom of a neurosis of the fifth pair.

In some cases it should be attributed to the presence of intestinal worms, whilst in others it is a hysterical manisfestation. Whatever be its cause, the forced contractions of' the lids often remain after the patient has recovered from the disease which has given rise to them.

Often the blepharospasm is at first only intermittent, but becomes continuous, and extends to the neighboring muscles, and even to those at some distance. This chiefly occurs in cases of general neurosis. In these cases also it has been observed that in the region supplied by the fifth pair there is a point where, if the nerve be compressed against the bone, the blepharospasm. is made to cease.

Prognosis. Except in cases where the blepharospasin is the result of hysteria, injury, conjunctivitis, or a corneitis, recovery is uncertain, and the prolonged contraction of the lids may involve serious consequences to the eye; and, moreover, as the patient is not able to use his eyes, his spirits and general health are sure to suffer.

Treatment. In treating this disease, it is of primary importance to ascertain its true cause. Formerly, the examination of the conjunctival sac of the diseased eye necessitated the use of chloroform to overcome the muscular spasm. At present we often obtain the same result by instilling a few drops of cocaine. The duration of the effect of cocaine varies from a few minutes to many days (in hysterical subjects), and hence it is in many cases a useful adjunct in the discovery of the cause.

Should we find that the blepharospasm. may be explained by the presence of a foreign body in the conjunctival sac, or by some disease of the cornea, we must adapt our treatment to the removal of such a cause, if necessary enlarging the palpebral fissure by section of the external palpebral ligament. (Consult article on the Operation of Cantoplasty.)

If the blepharospasm. remain even after the inflammatory concomitants have disappeared, or if it be determined by a neurosis of the fifth pair, we must ascertain whether compression on the course of one or other of the branches of that nerve does not modify the spasmodic contractions or cause them to cease altogether. The nerve which chiefly supplies the orbicularis with sensory fibres is the supraorbital, and we, therefore, should begin our attempts at compression with it; but experience has shown that we should not stop with it, but also try the effect of compression of the infraorbital, the temporal branch of the major, and the inferior dental.

When we have thus determined the point at which compression seems to act favorably on the contractions, we generally try the effect of subcutaneous injections of morphia at that situation.

Nor should it be forgotten that the result often depends on the solution being injected exactly at that spot and in the centrifugal direction of the nerve. Several striking examples have convinced us that want of success is often the result of errors committed in these respects.

Sometimes morphia injections, if repeated often enough, succeed in curing the disease ; in other cases, however, they only procure a 'transitory amelioration; and, again, in some cases they are only palliative; and then our treatment should be directed to the point at which the compression of the nerve and the injection of the narcotic have either modified the spasmodic contractions or caused them to cease. It is in such cases that we are authorized to have recourse to a neurotomv or neurectomy.

In choosing which nerve is to be divided, we must, as may naturally ,be supposed, take into account the results of our examination as to the effect of compression of the fifth pair in arresting the blepharospasm. Amongst these branches may be mentioned, beginning with the less common, the inferior dental, which is best divided, in the mouth, the neurotome cutting the branch which comes from the inferior maxilla; the temporal branch of the malar division, which may be divided in the temporal fossa itself; the infraorbital and the supraorbital nerves, which have often been divided, with results varying with the exciting cause of the blepharospasm.

To perform this operation on the supraorbital branch with the required degree of exactness, the patient, especially if a child, should be put under chloroform. The surgeon, standing either in front of or behind the patient, puts his hand on the eyebrow, and draws it firmly upwards and outwards; he then inserts his tenotomy knife from without inwards under the skin and makes it glide along the orbital arch. When the knife is inserted to within 25 millimetres of the root of the nose, that is to say, about the union of the internal and middle thirds of the superior orbital margin, the edge is turned towards the bone, and an incision is made, extending down to the periosteum. If the cutaneous sensibility be examined immediately after the operation, we sometimes find only a very imperfect and restricted anoesthesia, even when the nerve has been completely divided ; this anesthesia, however, greatly increases in the course of the first two days succeeding the operation.

To prevent subcutaneous ecchymosis, it is well to put on a firm compress and bandage. As a rule, the patient may leave his room a few days after the operation. The cutaneous sensibility which has been destroyed by the section of the supraorbital nerve, is not restored till after a lengthened period, but this partial anesthesia does not annoy the patient to any considerable extent. If we have not been able to find a point at which compression of the nerve causes the blepharospasm to cease, or if our neurotomy has not been followed with success, we must try the constant current, using a current of medium strength for a few minutes at a time, or else keeping on one or two elements for several hours during sleep. The negative pole is applied to the lids, and the positive over the fifth cervical vertebra. When there is a hysterical temperament we may also try the effect of metallo therapeutics.

ART. XI. Symblepharon and Ankyloblepharon. Blepharophimosis.

1. Ankyloblepharon is the union of the free margins of the lids, closing to a greater or less extent the palpebral fissure. It is sometimes found as a congenital deformity, sometimes as a consequence of traumatic lesions, especially burns, or again, it may be the result of an ulceration of the mucous membrane and of the ciliary margin.

Treatment. The operation consists in dividing the adhesion with a bistoury, or, better, with one stroke of a pair of scissors. It is prudent to pass a grooved sound behind the part where the margins are adherent.

When the adhesions have been divided, the surgeon has to prevent a reunion of the palpebral margins. For this purpose, many plans have been adopted with the view of overcoming the difficulty which is experienced in preventing the reproduction of these adhesions. Thus, attempts have been made to keep the lids separate by fixing them, either with strips of adhesive plaster, or by a thread passed through the skin of each lid and attached to the forehead or cheek. It has also been proposed to place foreign bodies between the palpebral margins, to cover the lips of the wound at short intervals with a layer of collodion, or, again, to cauterize one of the lids only with nitrate of silver. The very best remedy and the only reliable one, is to stitch the palpebral conjunctiva, previously dissected off and drawn out, to the skin of the inferior lid (Ammon). After twenty four or forty eight hours, the sutures are no longer required, and may therefore be withdrawn.

This reunion of the mucous membrane and the lips of the cutaneous wound is absolutely indispensable if we have to deal with cicatricial bands situated near the angles of the eye ; for without it the angles of the wound always become united, and thus the palpebral fissure is made narrower. It is therefore necessary, after having incised the cicatricial band, or excised it, if it be of large dimensions, to perform the second part of the operation for blepharophimosis, or to make a true cantoplasty (consult description of these operations further on).

Ankyloblepbaron is often complicated with adhesions of the lid to the globe, and it then becomes a matter of importance to ascertain the extent of the adhesion before undertaking any operation, which would be a fruitless task were the palpebral conjunctiva adherent to the entire surface of the cornea. Of the extent of the adhesion, we judge by the mobility of the eye behind the lids, and for this purpose we cause the patient to move the ball as far as possible, and make him attempt to open and shut the eye. We may also pass a probe into an opening at the internal and external angle, and find whether or not the instrument can be moved freely from above downwards in the oculo palpebral space.

2. Symblepharon is the adhesion of the palpebral conjunctiva to that of the eyeball, and may be either partial or entire. In the first case,.we have to deal with a larger or smaller band uniting the palpebral conjunctiva to the ball, but leaving the cul de sac free ; in the other form, the cul de sac also participates in the abnormal condition.

When the symblepharon forms a thick layer, it is called sarcomatous symblepharon ; but if the conjunctiva is atrophied or destroyed, it is said to be a membranous or fibrous symblepharon. This condition supervenes after burns or ulcerations of the ocular and palpebral conjunctiva ; it also accompanies xerophthalmia.

The prognosis of symblepharon is the more serious the greater its extent, the more the conjunctival cul de sac participates in the condition, and the greater the extent of surface transformed into cicatricial tissue.

Treatment. Symblepharon becomes the object of treatment when its extent and position prevent the movements of the eye or of the lids, or when it covers a portion of the cornea so as to interfere with vision. The method of operation in symblepharon and the success of the operation depend, to a great degree, on the position and size of the band which connects the eyeball with the lid. Thus, when a simple band is stretched from the lid to the ocular conjunctiva, it can easil y be separated by means of a ligature tied tightly round the cicatricial, tissue. In the same way when the bridge is larger, we may succeed by using two ligatures, each of which encloses one half of the tissue which extends from the lid to the eyeball. As soon as the separation is complete, that part of the band which adheres to the cornea is removed, and the edges of the wound are united with a few points of suture. It is only when the wound is perfectly cicatrized that the portion adhering to the palpebral conjunctiva is taken away.

A similar method is employed in complete symblepharon The base of the symblepharon is pierced with a triangular needle, parallel with the palpebral fold, and inserted as deeply as possible. Then a leaden thread is inserted in the wound made by the needle, and its two ends are moulded so as to fit the angles from which they emerge. Some surgeons unite the ends of the thread, and, from time to time, tighten the knot (Fig. 2o8). The thread is left in situ till the wound is cicatrized, when the adhesion is cut in the same way as for incomplete symblepharon.

A more rapid, but perhaps less certain, method of operating on a complete symblepharon is the following, recommended by Arlt: Whilst an assistant separates the lid from the eyeball, so as to make the intermediate tissue operation tense, the surgeon passes a strong silken thread beneath the portion of the symblepharon which is next to the cornea ; then, drawing on the thread he cuts the tissue a; near to the cornea as possible, and frees it with a bistoury or pair of scissors from the eyeball right down to the bottom of the conjunctival sac. This being accomplished, and any bleeding thoroughly arrested, a needle is put on each end of the thread, and both ends are passed through the lid, from within outwards, near to the orbital margin. The two extremities of the thread are then drawn tight, so that the detached adhesion is brought in contact with the internal surface of the 'lid, and thus the membranous surface of the flap is next to the conjunctival wound. The edges of the conjunctival wound are brought together by a few points of suture (Fig. 209), and as soon as it is cicatrized, .the flap left on the lid may be excised.

Another very ingenious operation for symblepharon consists in transplantation . The following is a description of the operation as performed by its inventor, Teale : Having made an incision through the adherent lid, in a line corresponding with the margin of the cornea (A, Fig. 210), the lid is dissected from the eyeball till the latter is as free as possible. Thus the apex of the symblepharon, formed by the palpebral skin, remains attached to the cornea.

This being accomplished, two flaps, in size and form resembling B and C in Fig. 211, are dissected from the ocular conjunctiva. In making these flaps we must take care to cut them in the conjunctiva only, leaving the subconjunctival tissue untouched ; we must also see to it that they are sufficiently detached to be stretched over the place formerly occupied by the symblepharon, without difficulty and without tension.

The two flaps thus prepared are placed in their new situation in the following manner (Fig. 2 12): The internal flap, B, is stretched over the bare surface of the lid, and its apex is united to the healthy conjunctiva near the external angle of the wound. The external flap, C, should be placed over the denuded eyeball, and its apex should be attached to the conjunctiva near the base of the internal flap. If, when both flaps are in position, they seem to be under too great a strain, the defect may be remedied by several small incisions in the conjunctiva near their base.

In the last place, the conjunctiva is stitched together over the parts from which the flaps have been taken (D, E, Fig. 212), and the margin of the transplanted conjunctiva may also with advantage be sutured to each other, so as to prevent their rolling upon themselves. The portion of the symblepharon (A) which has been left on the cornea becomes atrophied, and finally disappears. In other cases, Teale* proposes to take the conjunctival flap from above the cornea; he makes the flap slide over the cornea downwards, like a bridge, to the position in which he wishes to attach it. It is advantageous to insert the threads before dissecting the flap.

Wolfe has attempted to cure symblepharon by transplanting a piece of conjunctiva taken from a rabbit. has, for the same purpose, taken the buccal or vaginal mucous membrane.

Knappl cuts for the same purpose two large flaps in the conjunctiva near the internal and external margin of the cornea, without detaching their superior bases, draws them firmly downwards and sutures them, so as to fill up the loss of substance produced by the ablation of the symblepharon.

Taylor§ has proposed the following operation : Having dissected the symblepharon, a horizontal flap is cut from the skin of the adherent lid, allowing the flap to remain attached to the surrounding tissue on the nasal side. Near the nasal extremity a vertical opening is made through the orbicularis, the tarsal cartilage, and the conjunctiva; the cutaneous flap is then introduced through this opening into the conjunctival opening, and fixed there by a few sutures, with its raw surface towards the palpebral wound of the symblepharon. The cutaneous flap which is placed in the conjunctival sac gradually becomes somewhat like the mucous membrane. Nicati has made a similar proposal.

When a large symblepharon involves a considerable portion of the conjunctiva, and almost entirely covers the cornea, it would be wrong, no matter what method we adopt, to hope for complete and ultimate success. Neither must we indulge too soon in vain expectations, for the result is often less satisfactory some time after the operation. Consequently symblepharon should be considered as one of the lesions most difficult to remedy.

3. Blepharophimosis is a contraction of the palpebral fissure, which is diminished in length, the angles of the eye being brought closer together. It is remedied by an operation generally known as cantoplasty.

This operation is also available in certain cases of ankyloblepharon, or of cicatricial contraction of the palpebral fissure, in a few cases of ectropion with shortening of the free margin of the lid, in blepharospasm, and again, when we wish to diminish the pressure of the lids on the eyeball, as in granular conjunctivitis.

The operation is performed as follows: The external commissure is divided in its entire thickness in a line with the direction of the palpebral fissure. This section may be made with a bistoury, the point being gently inserted between the eyeball and the external commissure.

The entire thickness of the integuments is then transfixed with the point of the knife from within outwards, and the whole commissure is easily divided by pushing the bistoury outwards.

The operation is still more easily performed with straight scissors, one blade being introduced behind the commissure; the wound in the skin should always be a few millimetres longer than that in the conjunctiva.

The section of the commissure being thus completed, an assistant draws the margins of the wound upwards and downwards, so as to change a horizontal into a vertical section. The surgeon takes hold of the conjunctiva near the centre of the section, and passes through it a very fine needle furnished with a silken thread; he then lets go the conjunctiva, And takes hold of the external skin also at the centre of the section; the needle is carried through the skin, and on tying the suture the corresponding margins of the skin and mucous membrane are brought together. In like manner two sutures are also inserted near the angles of the wound (Fig. 213).

When the operation is only intended to relieve the pressure of the lids on the eyeball, the last two sutures are not required. In such cases it is also beneficial, after dividing the external commissure, to divide the tarso orbital fascia.

Cusco performs cantoplasty in the following manner: He cuts out, by two incisions which diverge from the external palpebral commissure, a small, cutaneous, triangular flap, the base of which is turned outwards and the apex inwards. The two incisions should be from iYZ to 2 centimetres long. The flap is dissected up to its base, and the external conjunctival cul de sac is divided with a probe pointed bistoury from within outwards. Lastly, the apex of the flap is fixed by a single point of suture to the bottom of the wound, taking along with it the conjunctival cul de sac.

ART. XII. Abnormally Wide Palpebral Fissure. Tarsoraphia.

The palpebral fissure may be enlarged, if either of the angles be torn, by paralysis of the orbicular muscle (lagophtbalmos), by exophthalmos in Basedow's disease, or by anything which causes real or apparent protrusion of the eyeball.

When there is paralysis of the orbicular muscle (as in facial paralysis) our treatment must primarily be directed to the cause. If we are dealing with a rheumatic paralysis, we should order diaphoretics, either in the form of a vapor bath, or of pilocarpine injections repeated twice or thrice every week. In addition, we may administer iodide of potassium, which will also be found a useful remedy, in conjunction with mercurial inunctions, when we suspect a syphilitic taint. Locally, we may order veratria ointment, strychnia injections in the temple, and the application of the faradic current.

If the paralysis is already of long standing, and if medication has failed, we must, by an operation, diminish the palpebral opening so as to protect the cornea.

The palpebral fissure may be reduced to its normal size by the operation known as tarsoraphia.

This operation, proposed in the first place by Walther and modified by von Graefe,* should be performed in the following manner (Fig. 214): Having made the patient close his eyes, the external commissure is taken between the blades of a pair of forceps, or, better still, between the index finger and thumb of the left hand, so as to straighten the palpebral fissure to the required amount, and, for greater security, this point is marked in ink on both lids.

Having introduced an ivory shield between the lids, a flap, i millimetre broad and from 3 to 6 millimetres long according to circumstances, is removed from the free margin of each lid near the external commissure. The two wounds should meet behind the commissure at the point, a, and should terminate in front perpendicularly to the free margin of the lid at the point, b. The flap must include all the hair bulbs.

To ensure a closer union, the ciliary margin, for an extent Of 2 or 3 millimetres, is denuded, care being taken to avoid the cilia. The edges of the wound are then brought together by one or two suture" and a compress and bandage are applied. The sutures may be taken out on the second or third day, but the lids should be kept shut till cicatrization is complete. The effect produced may in the first instance be too great, but it will soon decrease to. the required dimensions.

To avoid any unsightly dragging on the new commissure when the eye is directed upwards, von Graefe has proposed to prolong the superior incision for about 3 or 6 millimetres towards the temple, inclining it slightly downwards ; he then excises a triangular cutaneous flap from the superior lid, the base of this flap being formed by the prolongation of the superior incision.

When a protrusion of the eyeball has enlarged the palpebral fissure, and in certain cases of ectropion, it may become necessary to protect the cornea by bringing the margins of the lids together in their entire extent or nearly so (blepharoraphy of Mirault). With this object in view,we denude the whole of the superior and inferior intra marginal spaces, carefully avoiding the cilia and the lachrymal points; and we then unite the lids by six or eight sutures, which should embrace the entire thickness of the lid, in order to prevent their separating too soon.

The ingenious operations devised by Adolph Weber for relaxation of the palpebral border will be described in our chapter on diseases of the lachrymal passages.

ART. XIII. Distichiasis and Trichiasis.

These affections are characterized by an irregularity in the insertion and direction of the cilia. In tricbiasis, the cilia are inverted towards the eyeball, whilst the free margin of the lid preserves its normal situation. In distichiasis there are two rows of cilia, the external in the usual position, the other nearer the eyeball. Sometimes these anomalies are restricted to a portion of one lid, but the entire lid may be affected. In other cases both lids are found to suffer, and in some cases all the four lids. The deviating cilia are sometimes few in number, and they are so pale and so minute that they readily escape detection. Such anomalies keep up a constant irritation of the ocular conjunctiva, and may be the source of severe corneitis, and of complete loss of vision.

The most frequent cause of these affections is to be found in a deformity of the tarsal cartilage, which, by cicatricial contraction after granular ophthalmia, becomes more concave, and thus its free margin is drawn inwards towards the eyeball.

The object of our treatment should be: (i) Either to tear out the deviating hairs ; or (2) to take away the portion of the margin of the lid in which the hairs or their roots are inserted ; or (3) to displace the palpebral margin, so as to give to the hairs a better and more natural direction.

2. In tearing out cilia, we use a special kind of forceps (without teeth and with very broad extremities), with which, after the lid has been slightly everted with the left hand, each cilium is taken at its root and drawn out by gentle and steady traction. When we require to operate on both lids, it is better to begin with the superior. In our own practice, we always apply nitrate of silver after this epilation, as it seems to retard the growth of the cilia.

An attempt has been made to replace epilation by anointing the margin of the lid with the hydrated sulphide of calcium (d'Argentan, Duval),* the eyeball being previously protected from contact with the remedy by an ivory shield. The lids must be thoroughly cleansed a few minutes after the application of the remedy. Dr. Williamst has proposed to destroy the hair follicles by introducing a needle dipped in liquor potasse at the point where the cilia are inserted. The same object may be accomplished by galvano cautery.

2. Operations for the removal of the portion of the lid in which the hairs are implanted consist in its ablation, which is so accomplished as to preserve the entire length of the lid.

In Flarer's* method the margin of the lid is split into two portions by an incision in the intra marginal space (Fig. 215) ; the anterior division should contain all the hair bulbs. A second incision, extending from the external surface of the lid to the tarsal cartilage, serves to circumscribe the external portion of the palpebral margin with the cilia and their follicles. When there are no deviating hairs at the external commissure, this incision should be made as indicated by the dotted line, a, in Fig. 216.

When, on the other hand, the misplaced cilia extend to the external commissure, it should be first of all divided by a horizontal incision, and the longitudinal band should be cut as indicated by the dotted line, b, Fi . 217, for the upper lid, and by the line, a, for the lower lid. The longitudinal band, which is thus marked off by the two incisions, is raised with a pair of toothed forceps and completely dissected off, the adhesions which keep it in position being divided with a bistoury or pair of scissors. This method, although possessing the advantage of removing the deviating hairs without the shortening of the lid which takes place when the entire palpebral margin is cut off, has still its inconveniences. In the first place, it deprives the eye forever of the natural protection afforded by the cilia; and, moreover, it may give rise to a cicatricial eversion of the lid. For these reasons, it should only be employed when the method of displacement, about to be described, cannot be used.

3. To modify the faulty direction of the cilia, various methods have been recommended, with the common object of changing the position of the palpebral margin into which the hairs are inserted, either by eversion or by transplantation.

Even in slight cases, eversion, in our opinion, can only be obtained after an intra marginal incision, 3 or 4 millimetres in depth, dividing the palpebral margin into two portions. Only the outer lip of the wound into which the cilia are inserted is to be everted by the following means : According to the effect required, we use either cauterization of the skin beneath the cilia with the ga Ivan o caut ery, or excision of parts of the skin near the cilia and suturing the wound, or the insertion of ligatures, according to Gaillard's* method, or according to his method modified by Rau.t If we deem it expedient to use several ligatures, we proceed astures should be made of strong, well waxed silk thread, and they should be inserted along the surface of the tarsal cartilage, and, according to the effect desired, should include a larger or smaller portion of the orbicularis and skin.

Tamamcbeff performs the divi¬sion of the ciliary margin as in Flarer's operation, and cauterizes the whole wound with a finely¬ pointed pencil Of nitrate of silver.This very simple proceeding has an excellent immediate effect upon the direction of the cilia, but this effect does not seem to be always permanent. Direct transplantation of the external lip of the lid is effected by the operation devised by Jaesche T and modified by Arlt.§ It is performed in the following manner:
We begin by dividing the lid into two portions, according to Flarer's method (see p. 567, Fig. 215), and then we excise a cutaneous flap by means of two incisions oil tile external surface of tile lid (Fig.219, dotted lines ; both of these incisions should extend down to the tarsal cartilage. This flap, the vertical diameter of which should be in proportion to the amount of inward deviation of the cilia and to the looseness of the external skin, is dissected up so as to spare the orbicular muscle as much as possible. The lips of the wound are then brought together by sutures which unite the superior margin of the strip containing the cilia to the superior lip of the cutaneous section, thus drawing the band upwards over the fibro cartilage (Fig. 220).

Unfortunately, it occasionally happens that union does not take place by the first intention, and that the strip of skin becomes gangrenous and is destroyed by suppuration. It is also found that this transplantation has little effect on the cilia situated near the angles of the lids.

To obviate these drawbacks, von Graefe * has introduced important modifications in this operation, which he per¬ forms as follows (see Fig. 221):

He makes two vertical incisions, 9 millimetres long, extending up kards from the free margin of the lid, through the skin and orbicular muscle, and thus marks off laterally the part which is to be transplanted. He next proceeds to make the intra marginal section, dividing the lid into two sections, according to Flarer's method (Fig. 215).

Having done this, it becomes easy to evert the cilia and to attach the cutaneous layer, so that the ciliary margin be drawn up about four lines. To increase the effect, and to make sure of the direction of the cilia ' an oval piece of skin may be excised, the extremities of which do not require to extend to the vertical sections (see Fig. 221) ; or we may content ourselves with including a similar fold of skin between two or three ligatures without previous excision. In von Graefe's as in ArIt's operation, we may recover the denuded intra marginal portion with the cutaneous flap taken from the skin of the lid. A combination of the special advantages found in the methods which we have just described gives the following method: The operation is begun by a cantoplasty (see P. 564, Fig. 213), then the palpebral margin is divided into two by an incision in the intra marginal space (see P 567, Fig. 215), and ligatures are inserted as suggested by Gaillard, so that they include a bridge of skin and muscular tissue about 8 or io millimetres broad (Bauchon, de Wecker t). Still, ligaturing the skin should be avoided on account of the unsightly cicatrices which it leaves, and may be replaced by the use of subcutaneous ligatures inserted as follows :

Having applied a blepharostat which holds the lid firm and prevents any hemorrhage, which is often such a source of annoyance to the surgeon (Snellen, Knapp, Warlomont), a cutaneous incision is made throughout the entire length of the lid, at 2 or 3 millimetres from and parallel to the ciliary margin. The skin is dissected up to the height of the tarsal cartilage or even beyond it (Anagnostakis). Four or five ligatures are then inserted through the ciliary margin, and carried on beneath the orbicularis, the thread running as close as possible to the anterior surface of the cartilage, until the needle comes out at its superior margin, or even a little higher, without touching the palpebral skin (Lebrun). The threads are then tied tightly, and the cutaneous flap is allowed to fall forwards. A portion of this flap may be excised if it be too long. If necessary, we may combine this method with cantoplasty, and, if we wish to obtain a very great displacement of the ciliary margin, we may perform at the same time the intra marginal incision dividing the lid in two (Warlomont).

Panas makes a horizontal incision through the skin and muscle as in the operation just described; he then dissects the marginal flap from above downwards, laying the tarsal cartilage bare, and inserts the ligatures, passing the needles from above through the suspensory ligament of the lid, and through the marginal flap behind the row of cilia.

The operation of Hotz is analogous to that just described, except that he begins by the intra marginal incision.

The method first proposed by Watson and modified by Junge consists in a double transplantation, in which the ciliary margin with the hairs is displaced, and a cutaneous flap brought into the situation which it formerly occupied. This operation (on the superior lid) iE performed in the following way (Fig. 222): The margin of the eyelid has at first to be divided by an intra marginal incision, as in Jaesche. Arlt's method; then we make a horizontal incision, parallel to the margin, at a distance Of 3 to 4 millimetres, extending from one angle to the other (a b). From the two extremities of this incision, twc small incisions are then made (from a to c and from b to d) traversing the entire thickness of the margin. We have thus described a quadri. lateral, which in retracting removes the lines a e to a' c' and b d to b' d (see Fig. 222).

Now we make, through the skin at 3 to 4 millimetres above the line a b, mother horizontal incision parallel to the last, thus obtaining a bridge, al e,f, b, which we detach entirely from the subjacent tissue, leaving it only attached at its two extremities. This bridge is then drawn downwards and replaced by the quadrilateral containing the cilia. The edge, a b, is united to it by four catgut sutures, and the bridge, a, b, e,f, fixed in the intra marginal incision also by means of sutures. Before performing this double transplantation, hemorrhage must be completely arrested.

The operations of Gayet and Dianoux are based on the same principles. After the intra marginal section, a horizontal incision extending down to the tarsus is made from one angle to the other at a distance Of 4 millimetres from the ciliary margin. A third incision 3 millimetres above and parallel to the last, but 2 millimetres longer at each extremity, is then made, and the bridge thus formed, detached from its base and drawn under the ciliary border by means of forceps, is then fixed by means Of 3 sutures in the intra marginal space. The ciliary flap is drawn upwards and held in place by 3 sutures passed through the tarsus. Antiseptic dressing is applied. Similar operations have been proposed by Nicati,* Schoeler,t and Burchard.1 The chief danger to be apprehended in these very rational and well conceived operations is partial or total sloughing of the transplanted flaps.

Nevertheless, in our hands this operation has been attended with good results.

In partial trichiasis or disticbiasis, a good result may be obtained by excising the corresponding parts of the lid. For this purpose we may, as in Fig. 223, insert a triangular knife in the intra marginal space, behind the deviating cilia along the tarsal cartilage, to the depth of 5 millimetres. Having done so, we excise, by means of two incisions extending down to the cartilage, a V shaped flap (Fig. 223, A) from the external surface of the lid. This flap should include the follicles of the deviating hairs; and the margins of the wound may be brought together by one or two sutures. When the misplaced hairs are situated at the external or internal commissure, the incisions are made as figured at B (Fig. 223)

Another method of curing partial trichiasis or distichiasis is that proposed by Herzenstein ; it consists in the introduction of a seton, which sets up an inflammatory suppuration leading to the destruction of the follicles. His plan is as follows: A needle, N (Fig. 224), furnished with a silk thread, is introduced at the point, a, in the intramarginal space, pushed on beneath the skin parallel to the cartilage, and brought out at the point, b, at 4 or 5 millimetres above the palpebral margin. It is again inserted at the point, b, and made to slide under the skin, parallel to the ciliary margin of the lid, till it is brought out at the point, c, the distance, b c, being equal to the length of the portion of the ciliary margin which has misplaced hairs. The needle is again inserted at the point, c, and made to descend to the point, d, in the intra marginal space, at which it is finally brought out. The extremities of the thread are fastened to the cheek, and the eye is covered with a compress and bandage. This method does not always give a certain result.

In cases where a single cilium or several isolated cilia are misplaced, which we would like to preserve but in a better direction, we can try the ancient method of illequation which has been revived by Snellen. lie runs a thread through the tissues at the side of the cilium, and carries it round the cilium so as to enclose it in a noose. As the noose is withdrawn it takes with it the included hair.

ART. XIV. Entropion.

By entropion is meant the inversion of the palpebral margin. A part of the eyelid only may be thus turned towards the eyeball (partial entropion); but, most frequently, the entropion is total ; it may affect one or both eyelids. Considered as to its setiology we can distinguish two varieties of entropion i, entropion due to spasm of the orbicularis muscle; 2, entropion due to retraction of the conjunctiva and deformity of the tarsal cartilage.

1. The first variety is most commonly found to affect the inferior eyelid, which is rolled on itself, sometimes to such a degree that the ciliary margin is brought into the conjunctival cul de sac. If the finger be applied to the external part of the lid and the skin drawn slightly downwards, the margin of the lid with the cilia returns to its normal position, and is only again displaced when the eyelids are closed. The slackening of the integuments of the eyelid which takes place in advanced life (senile entropion) promotes the development of this anomaly and renders it permanent.

Its real cause is a contraction of the circular portion of the orbicularis muscle, such as takes place in those attacks of ophthalmia which are accompanied with edema of the lids, or when a compress and bandage have been kept on for a length of time.

2. The second form is often the result of granular conjunctivitis or of chronic blepharitis, producing atrophy of the conjunctiva with thickening and incurvation of the cartilage. This condition may also be due to cicatrices of the conjunctiva, the result of injuries or burns. The superior eyelid is as liable to this alteration as the inferior, whilst not uncommonly both eyes are affected at the same time.

Entropion gives rise to considerable irritation of the eyeball, with photophobia, lachrymation and blepharospasm. As a consequence, the cornea becomes inflamed, and a pannus is formed which seriously compromises the vision.

The treatment of entropion necessarily varies with the nature and the degree of this deformity.

When we have to deal with a simple inversion of the margin of the lid, due to some passing cause, such as the prolonged application of a bandage on the firmly contracted lids or some analogous circumstance, it suffices to draw the lid outwards with a strip of adhesive plaster. In such cases, benefit is to be derived by placing a small ball of lint between the orbital margin and the lid, keeping it in position with strips of plaster.

Arlt* recommends the following dressing : He takes a narrow band of linen, an inch and a half long and half an inch broad, and fixes one extremity with a layer of collodion beneath the internal angle, between the orbital margin and the adherent margin of the tarsal cartilage. Having done so, he stretches the band tightly, drawing horizontally from within outwards towards the skin of the external angle, which is pushed as much as possible beneath the linen before its external extremity is also fastened down with collodion. When the band is firmly attached by both its extremities, we may insure and increase its effect by covering it with a layer of collodion, for it then contracts on itself and the lid is readjusted.

The same result may be obtained by enclosing a fold of skin near the free margin of the lid in a ligature or in a pair of catch ptosis forceps (see Fig. 225). But the pressure exercised by such instruments on the skin is very ill supported by the patient, at least if it is of long duration; so that the surgeon is sometimes obliged to divide the external palpebral ligament, as Wardrop advises, especially when the spasm of the orbicularis is kept up by the irritation of the conjunctiva or of the cornea. Stellwag performs in these cases an oblique section through the entire thickness of the lid near the external angle.

In slight and recent cases of spasmodic or senile entropion (especially of the inferior lid), we may attempt to evert the eyelid by the cicatricial contraction which follows cauterization, ligature or excision of the skin, near the margin of the lid (Fig. 226). If, as frequently happens in cases of chronic entropion, the palpebral fissure be contracted and the external commissure displaced, we must, to remedy the entropion, begin by enlarging the palpebral fissure by a cantoplastic operation (P. 564). Often this operation by itself suffices to replace the palpebral border in its normal position ; if not, it may be beneficially combined with Gaillard's ligatures, as has been recommended by Pagenstecher, or with excision of portions of the cuta surface of the inverted lid.

Von Graefe has indicated for the various forms of spasmodic stricture a method of operation which we have often employed with good results (Fig. 227). At 3 millimetres from the palpebral margin and parallel with it, a cutaneous section is made which extends on both sides to within 3 or 4 millimetres of the commissure; a triangular flap is then excised, and the margins of the wound are slightly freed and brought together by two or three sutures. The horizontal wound is left to itself.

As to the size and height of the flap which should be excised, they vary with the relaxation of the cutaneous structures. Its height is, however, of little importance ; its base should be from 6 to 10 millimetres.

If, in elderly persons, the relaxation of the orbital portions of the orbicular muscle be greatly at fault, von Graefe makes his flap in the shape of a cupola. When the palpebral fissure is contracted, this method may be combined with the operation for (P¬563)

In cases of spasmodic entropion of the upper lid, in which the corresponding tarsal cartilage is perceptibly altered, von Graefe, in addition to his ordinary operation, partially excises the tarsal cartilage in the following manner (see Fig. 228): The cutaneous flap having been excised in the way described, the lips of the wound are separated by retractors ; the orbicular muscle is incised horizontally, close to the free margin of the lid, and the fibres are pushed upwards so as to lay bare the tarsal cartilage. A triangular portion, B, is excised from the tarsal cartilage in the opposite direction to the cutaneous flap ; its base should measure 5 or 6 millimetres, and should coincide with the orbital margin of the cartilage, whilst its summit should extend to the palpebral margin. The cartilage should be excised in its entire thickness, leaving only the conjunctiva. The sutures should be so arranged that the middle one (b in Fig. 228) includes both the skin and the superficial layers of the cartilage. As a rule, this operation should be combined with that of blepbaropbimosis.

Frequently entropion is accompanied with incurvation of the tarsal cartilage, and can then only be cured by one of the following operations directed towards this complication :

Streatfield's Method.* The lid being held in Suellen's clamp, so that the flat blade is in contact with the mucous membrane, and the ring with the skin, a cutaneous incision is, made with a scalpel, at 2 millimetres from the palpebral margin and parallel to it, laying bare the roots of the hairs, without incising them.

Then, freeing the skin, this incision is carried down to the cartilage, and the extremities of the section are made to incline towards the palpebral margin. This having been done, a second incision is made at 3 or 4 millimetres above the first and parallel to it, at once dividing the integuments down to the cartilage; this second incision should be continued till it meets the extremities of the first. We then excise an oval portion of the fibrocartilage, taking hold of it with a pair of forceps and liberating it from all adhesions with a scalpel or pair of scissors (grooving the cartilage). At the same time we remove the corresponding portion of the integument, and allow the wound to cicatrize without using sutures.

The cicatricial process causes a contraction in the portion of the cartilage which is contiguous to the free margin.

SoelbergWells has succeeded in curing difficult cases of entropion with contraction and incurvation of the cartilage, by the following very ingenious combination of the methods of Arlt and Streatfield. He begins his operation in the same way as Arlt (see P. 569), and, having excised the cutaneous flap, makes a longitudinal incision through the fibres of the orbicular muscle down to the cartilage. This latter being laid bare, he marks out a triangular portion, the base of the triangle being towards the external integuments and the apex towards the conjunctiva. He then excises the cartilaginous flap by means of a bistoury. The size of the portion removed must depend on the incurvation. and contraction of the cartilage. The lips of the cutaneous incision are united by sutures, which should be passed sufficiently deep to take hold of the fibres of the orbicular muscles, but need not be passed through the cartilage itself.

Snellen has proposed the following excellent method, which has been generally adopted : Having put on a lid clamp, be makes an incision at 3 millimetres from the free margin of the lid and parallel with it; the incision is made only through the skin, and extends right across the lid. The skin is then dissected so as to uncover the orbicularis, from which a band 2 millimetres broad is excised. The tarsal cartilage being thus uncovered, a wedge shaped portion is removed from its entire length, the apex of the wedge being directed towards the conjunctiva. The removal of this piece being effected, three sutures are applied in the following manner: The thread, provided with a needle at each extremity, is passed through the tarsal cartilage above the excised portion ; both of the needles are then passed through the skin near the palpebral margin, so as to bring them out a little above the line of the cilia at about 8 millimetres from each other. Two other sutures are inserted in a like manner, so that all the points of exit are about 8 millimetres apart. A small guard is then put on each thread so as to prevent the skin being cut, and they are then drawn tight and tied in a firm knot. Lastly, the two threads are turned up over the brow where they are held in position by strips of plaster.

Berlin's method is much more simple: He makes an incision at 3 millimetres from the palpebral margin of the lid through its entire thickness skin, muscle, cartilage and conjunctiva. Having freed the muscular tissue and uncovered the cartilage, he removes 2 or 3 millimetres of it at the place of its greatest incurvation. The wound is left without sutures and dressed with cold compresses. Burow makes a transverse incision through the conjunctiva and tarsis in the entire breadth of the lid. He excises a cutaneous flap as in Solberg Wells' method, and unites the external wound with sutures.

The methods described in the chapter on trichiasis are also of great service in dealing with entropion, and may be combined with excision of a piece of the cartilage.

ART. XV. Ectropion.

Ectropion is characterized by the more or less pronounced eversion of the palpebral margins towards the cheek, or towards the superciliary ridge. This eversion of the lids removes the ciliary margin from contact with the eyeball, and at the same time the conjunctiva] surface of the eyelid is turned outwards. Ectropion may be variable in amount, and depends upon very different causes.

It occurs as a consequence of excoriat ion and cicatricial contraction of the skin of the lid, followed by thickening of the conjunctiva. This condition, which is most frequently found in the inferior eyelid, is due to chronic inflammations of the conjunctiva, or of the palpebral margin. When we observe it in elderly persons, in whom the orbicular muscle has already lost a portion of its normal power, we find that the lid is at a slightly greater distance from the eye, so that the lachrymal punctu m. has lost its normal position, and has ceased to perform its functions.' The tears then accumulate in the retro tarsal fold, and escape over the cheek, still further increasing the irritation of the integument.

Ectropion also occurs in the more serious forms of conjunctivitis, which are accompanied with considerable chemosis, directly everting the lid, by increasing the volume of the conjunctiva. This eversion produces spasmodic contractions in the ciliary part of the orbicular muscle, which, so to speak, strangles the subjacent structures and prevents the palpebral margin from returning to its proper situation. In children this condition is still further aggravated by their struggles and cries.

In the chronic forms of ophthalmia, the cartilage sometimes participates in the inflammation. It becomes soft and loses its consistence, thus contributing, by its lack of resistance, to the formation of ectropion; at the same time the palpebral margin is separated from the eyeball.

Ectropion may also be due to tumors of the orbit, protrusion of the eyeball, and paralysis of the orbicularis; and, therefore, may depend on the various causes of these affections.

Again, one of the chief causes of ectropion is cicatricial contraction in the neighborhood of the lid, as happens after wounds and burns, and it is especially a feature of the adherent cicatrices which are formed in caries of the orbital margin.

The first effect of ectropion, especially when it attacks the inferior lid, is lachrymation. Following this, there are alterations of the conjunctiva, which are due to the continued exposure of that membrane to the air; its epithelium becomes thickened and encrusted. As to the cornea, it especially suffers from the want of protection when the superior eyelid participates in the ectropion ; for, if the lower lid alone be affected, the eyeball is carried upwards, and is thus protected front the irritation which would otherwise endanger it. When this is not the case, the cornea becomes the seat of deep ulceration, which may bring about its destruction.

The treatment to which recourse is had in dealing with cetropion is as varied as the causes which may occasion this deformity. In acute cases of sarcomatous ectropion, it sometimes suffices to replace the lid in its normal position, and to retain it there by a compress and bandage. When we find some difficulty in replacing the lid, either from the congested state of the mucous membrane, or from spasmodic contractions of the orbital portion of the orbicular muscle, it is well, before applying the bandage, either to make numerous scarifications of the conjunctiva, or, if necessary, to divide the external commissure. If there be considerable hypertrophy of the conjunctiva, we may cauterize the mucous membrane with solid sulphate of copper, and then repeat the scarifications.

These manipulations generally diminish the extent and thickness of the conjunctival swelling. If, notwithstanding this treatment, the conjunctival exuberance is still such as to prevent the reduction of the deviated lid, it is then beneficial to excise a band of the thickened conjunctiva, parallel to the free margin of the lid.

We can also treat ectropion with Suellen's sutures, which are applied in the following manner : A silk thread is provided with two strong needles, one at each of its extremities. One of these needles is made to enter the conjunctiva at its most prominent part, and is carried as near the skin as possible, being brought out on the face 2 centimetres below the lid. A similar manceuvre is made with the other needle, the point at which it enters the conjunctiva being I centimetre from that where the first needle entered, go that the noose formed by the thread is perpendicular to the palpebral margin. The point of exit of the second needle should be on the cheek at 3 centimetres below the lid. This being done, the extremity of the inferior thread is drawn so as to bring the loop into close and firm contact with the conjunctiva, the lid being thus caused to rotate from below upwards, and from before backwards. The threads are then tied over a piece of glove leather to prevent their cutting the skin of the lid. It is often necessary to make a second suture of the same kind.

Still, in a certain number of these cases, such attempts have only a transitory effect, the lid (we are dealing here, especially with the inferior lid) soon falling again into its abnormal position. This is especially to be feared when the margin of the lid seems to be consid rably elongated. It then becomes necessary to reduce its volume by surgical interference.

The method which is most efficient, and which is applicable to almost any case, is tarsoraphia combined with excision of a triangular cutaneous flap. This method, first suggested by Dieffenbach and modified by von Graefe, is the following (see Fig. 229): An incision is made as in ordinary tarsoraphia in the external commissure, and the palpebral margins are made raw; but, in this case, we must make raw a larger portion of the everted lid than of' the other (4 to 6 millimetres). This being done, we next excise a triangular flap (A, Be D), having for its base the extremity of the commissure, and being about 4 or 6 millimetres broad. Before uniting the lips of the wound we must free the skin surrounding the triangular wound from the subjacent tissue. The sutures are first applied to the lips of thetriangular wound, then to the lips of the external commissure as in ordinary tarsoraphia.

When the ectropion affects the external portions of both lids, so that the entire external commissure is everted, we shall find most applicable the method of tarsoraphia proposed by Walther,* combined with Adams't operation. The free margins of both lids are excised to the extent of the eversion, as are also the commissure and a triangular flap of the surrounding skin. The base of the triangle thus marked off is turned towards the eye, the summit towards the temple. The inventor of this method immediately unites the lips of the incision by two twisted sutures.

Walther's method, which we have just described, is, as it were, only an application to both lids of the older method of Adams, modified by Ammon, such as was proposed by these authors for evertion of a single lid.

Adams,* to bring the lid into its normal position, excised a triangular portion from its entire thickness, as shown in Fig. 231 After the flap has been excised, the lid is held in its normal position, and the edges of the wound are brought together by a twisted suture. In this method there is danger of a coloboma of the lid, if the union of the wound does not take place in the manner hoped for, or there is at least the inconvenience of the deformity caused by the cicatrix. To obviate this as much as possible, von Ammon t placed the triangular flap so that its external side is the prolongation of the external commissure (see Fig. 231).

All these methods of operation are wholly insufficient for those varieties of ectropion in which the everted lid is retained in that position by a retraction of the integuments, or by a cicatricial band. The operations which we are about to describe are applicable to this form of ectropion, and may be regarded as types which can be modified to suit the necessities of the case. Wharton Jones' Method.* When a cicatrix has shortened the palpebral skin and has everted the lid, Wharton Jones sets it free, as shown in Fig. 233, by two convergent incisions, which begin near the angles of the eye, and meet on the cheek or forehead beyond the cicatrix; the section is thus V shaped. The cutaneous flap circumscribed is carefully dissected off, from the summit towards the base, all adhesions which would prevent the free movement of the flap being divided. Lastly, the palpebral margin is restored to its normal position, and the skin near the margin of the incision is freed to a certain extent, in order to promote coaptation. When the parts are sutured, the edges of the wound are in the form of the letter Y.

This operation is specially applicable to the inferior lid; it is less so to the superior, as the apex of the flap may involve the hairs of the eyebrow. It may also be advantageously employed in cicatricial displacements of the external commissure. Still it does not remedy any abnormal elongation of the palpebral margin, and cannot he used either to raise or to lower the level of the external commissure; hence, it becomes necessary to combine it with tarsoraphia (Stellwag).

Von Graefe's Method.* Von Graefe, in cases of pronounced ectropion of the inferior eyelid, accompanied by alteration of the palpebral margin, recommends the following method:

Having carefully cleansed the everted lid, we endeavor to find the point at which the cilia are implanted, an(l make a horizontal incision behind them that is to say, in the intra marginal space. This incision should extend from the lachrymal puncturn to the external commissure (see Fig. 235, d and e). From the extremities of this incision two vertical incisions (d, b, and e,f) are made, about I% or 2 centimetres long.

The quadrilateral flap thus marked off is freed in its entire extent, and, if necessary, when the cutaneous contraction is great, beyond the inferior extremities of the vertical sections.

We then draw the flap firmly upwards, holding it by its superior border with a pair of forceps, and stitch it into its new position, introducing the first sutures at its inferior aspect. The extremities of the flap now extend considerably beyond the angles of the lid, and should be shortened as much as may be necessary.

Von Graefe advises that the shortening should be effected by two incisions, b, b, which meet at the angle, e; he also fixes the angle, c, to the point previously occupied by the internal angle of the flap. The nearer the point, c, is to the palpebral margin, the more does the section shorten the margin and the less does it elevate the flap.

When the ectropion is due to a cicatrix adherent to the bone, there are different methods of operating. It sometimes suffices to detach the cicatrix from the bone by the subcutaneous method, and thus to render the entire lid mobile ; when the latter is restored to its normal situation, it may easily be maintained in it by occlusion (,see Mirault's Method).

When the cicatrix is extensive, von Ammon's Method may be employed with advantage. It is performed in the following manner: He makes an incision in the skin round the cicatrix and leaves the skin adherent to the bone (see Fig. 236) ; then he frees the adjacent integuments round the incision, so as to liberate the eyelid and allow the patient to shut the eye. He then makes raw the old cicatrix, and draws the lips of the wound together over it.

Dieffenbach * makes a triangular section round cicatrices of this kind, the base of the triangle being directed towards the palpebral margin ; he then entirely removes the cicatrix (see Fig. 237), and prolongs the horizontal section in both directions. He next frees the skin all round the incision so as to allow of the lid sliding, and having placed the lid in its normal position; lie fixes it with sutures as iudicated in Fig. 238.


Guerin's Method. A V shaped incision is made, with the opening turned away from the everted margin, and two incisions, starting from the inferior extremities of the first, are made towards the edge of the lid. The two triangular flaps which result from the incisions are dissected off, which may be done in such a way as to make their margins fit into the primary incisions of the inverted V. The flaps are then united to each other by interrupted sutures, so that their lowest point is below the summit of the triangle, which occupies the same position as it did before the operation.

When the external integuments of the everted eyelid are changed in their entire thickness into cicatricial tissue, the retraction is very great, and it is difficult to get the surrounding skin to move with sufficient freedom. In such cases the foregoing methods are insufficient, and we must, therefore, have recourse to one of the following:

Fricke's Method.* The cicatrix is surrounded by two semielliptical incisions and excised (see Fig. 239) If the cicatrix is narrow, a simple incision is made parallel with the free margin of the lid: after which all cicatricial bands are cut and the skin very carefully dissected up to the ciliary margin of the lid, thereby being rendered perfectly mobile. The lid is then put in its normal position, by continuous traction being made in the direction of the palpebral fissure, and by the careful division of all adhesions which seem to prevent the complete reduction of the lid.

There is thus established a considerable opening in the external integuments, of a variable size, which we try to cover by a cutaneous flap taken from the neighborhood. For the superior lid, we generally try to take it from the temple and from the cheek for the inferior lid.

As shown in Fig. 239, we mark off a flap having the same form as the opening which it is intended to fill up, only we make it 2 Millimetres longer and broader, in order to allow for the ultimate retraction. This flap, previously measured and marked off, is dissected from the subjacent structures with as Die by J. C. G. Fricke. I lam.

much cellular tissue as possible, and in such a way as to leave it attached to its original position by a very large It is then adapted to the palpebral wound, and fixed in position by ordinary sutures. To avoid repetition we will here state that, in our experience, trans,plantation of non pediculated skin flaps from the arm replaces in a most satisfactory manner those flaps taken from the adjacent parts. Details will be given in the chapter on Blepharoplasty.

Dieffenbach's Method. For the inferior lid Dieffenbach, in dissecting off a cutaneous contraction ora cicatrix, made a triangular incision, the base of the triangle being turned upwards (see Fig. 240, a, b, c). This triangular space he then filled by a flap formed by two incisions, one being the direct prolongation of the horizontal base of the triangle, and the other parallel with its external border (see Fig. 240, b (1, d e). The length of the line, b d, should be a few millimetres greater than that of the base of the triangle. Any hemorrhage being arrested, the detached flap is made to slide into the opening which it is intended to fill, and carefully adapted to its new situation by simple sutures (see Fig. 240. where the flap has been taken, may, as far as possible, be brought together by suture , and the remainder should be allowed to cicatrize. For the after treatment the student is referred to the chapter on Blepharoplasty.

An excellent means of preventing contraction of the cicatricial tissue, which may often spoil the best deviscd operations for blepharoplasty, consists in the temporary occlusion Of the lids according to Mirault's plan. For this purpose the internal margin of each lid is removed, care being taken not to injure the cilia and lachrymal punctum. Then the raw surfaces are united by four or five suture points, which should pierce the entire thickness of the lid. This blepharoraphia is necessary after nearly all operations for ectropion.

Before the operation. This figure represents ectropion of the inferior lid with granulations sprouting from the bone of the orbital margin.

a, The everted inferior lid, kept everted by cicatricial contraction ; 6, the external commissure drawn outwards and downwards so that it is % centimetre below the level of the internal ; c, everted conjunctival cul de sac ; d, granulations arising from the bone. There exists a deep depression, at the bottom of which we find bare bone ; all round it the integuments are thinned and excoriated by ulceration.

a a", Double incision freeing the interior lid, the external commissure, an 1, consequently, the superior lid from all adhesions with the bone ; b b", the two lids are sutured together, their free margins having been made raw; cc", the space left bare after dissection of the commissure ,?d1l, the superior flap marked off but not yet dissected ; e ell, the inferior flap.

Denonvillier's Method.* It is begun by a dissection of all cicatrices and adhesions, so as to allow of the palpebral margin being restored to its normal position. Then the palpebral margins are made raw and sutured. The exact amount of tissue which has to be made up being thus ascertained, the surgeon marks off a flap from the malar region and dissects it from the point to the base. When the base is reached, the incisions are separated, so that, if possible, the border of the wound is brought in contact with the adjacent border of the flap. The first suture is inserted at the summit of the flap next, the most distant point is sutured, and finally the nearest (method by pivoting).

Richet's Method. Richet begins by freeing the lid so as to restore it to its normal position, after which he performs occlusion. Lastly, be marks off flaps ; the one he uses to fix and maintain the lid, the other he shapes inversely to the former so that its contraction may neutralize that of the other.

ART. XVI. Blepharoplasty.

The destruction of the lid, either by gangrene, as after malignant pustule or burns, or from lupus or epithelioma, or, lastly, from extirpation of tumors of this region, requires a plastic operation to fill up the loss of substance or, sometimes, to completely replace the destroyed tissue.

As we have previously stated, we are always in tile habit of performance trans Ilan ta ion of it non pediculated flap taken from (lie arm, and have succeeded in that way with flaps of more than 10 centimetres in extent.* This method has the advantage of being applicable in those cases where the skin surrounding the lids is so much damaged that no flap can be taken from it. Again, we avoid those cicatrices which are produced by the removal of flaps from the face. Finally, should the graft be unsuccessful, we may repeat the operation ; whilst unsuccessful transplantation of a flap from the adjacent skin aggravates the condition of the patient, and seldom admits of a second attempt.

In order to obtain a good result, it is of the first importance to preserve as much of the lid as possible, especially of its free border, and to save the mucous membrane as completely as may be. Secondly, the preserved skin of the eyelid should be liberated from the subjacent tissue, so as to allow the easy coaptation of the two borders which are to be united by blepharoraphia. We take the flap from the fine skin on the internal aspect of the forearm of the patient, or of another person, which is preferable in operating upon infants. The extent of the flap should exceed by one half that of the defect in the lid. When detached, the flap is laid on a warm plate, and every particle of fat and cellular tissue carefully removed. Then we apply it to the defect, and retain it in its position by a sufficient number of sutures. It is much better that the flap should be too loose or even in folds than have any tension. The dressing consists of lint covered on the side of the flap with a thick layer of boracic acid, vaseline ointment and phenicated cotton, kept in place by a flannel band which should exercise a moderate compression. The first dressing is left unchanged for four or five days. In removing it, we insert a large spatula between the lint and the flap, in order to retain the latter in its place. Half of the sutures are then cut, and the other half upon the removal of the second dressing at the end of about three days. The epidermis of the flap is generally puffed up and has to be cut. The entire flap shrinks considerably in the course of time, hence, as we have already stated, the necessity for making it much larger in the first place than the loss of substance seems to require.

In view of the results we have thus obtained, it seems to us likely that this so called Indian method, which was first applied to the eyelids by Lefort (187o and 1872), and afterwards by Wolfe'(1874), will become extensively appreciated, and entirely replace the blepbaroplasty hitherto employed.

Blepharoplasty consists in the transplantation of a flap taken from some adjacent part, to which it remains attached by its base. Here also the size of the flap to be transplanted should always exceed that of the opening into which it is to be placed : for cicatricial contraction is prevented from disturbing the result, and the part transplanted can be more easily adapted to the margins of the wound, without giving rise to tension.

We must also take care that the neighboring skin, after the coaptation, be not too tense; if necessary, we must relieve the tension by superficial incisions near the base of the flap, removing early any sutures which seem to cause the tension. The base of the flap should always be large enough to assure the vitality of the transplanted skin. The vitality is moreover influenced by the good adaptation of the raw surface of the flap to the subjacent structures. In this respect the dressing of the parts after the operation is of the greatest importance. The bandage should be so applied as to ensure the close contact of all the structures, but, at the same time, the flap should not be pressed too tightly against the subjacent bone. The chances of success are all the greater the nearer the transplanted flap is to a cutaneous surface in all respects healthy and free from any inflammatory or cicatricial alteration.

Amongst the operations which may be employed, we have already, in speaking of ectropion, mentioned those of Fricke and Dieffenbach (PP. 5 75, 5 76). The method of the latter, which consists of the immediate transplantation of a triangular flap taken from the neighborhood of the part to be covered, is inconvenient, in so far as it leaves near the lid a wound which must be left to cicatrize by granulation. This cicatrization almost invariably drags on the surrounding structures, and we can easily understand that the new lid will be readily disturbed by such traction.

This inconvenience may be in great part avoided by the. Ingenious method devised by Burow, which is performed in the following manner:

We begin, as in Dieffenbach's operation, by giving the palpebral wound a triangular form (Fig. 245, a b a). Then the horizontal incision.

The temporal flap, Be being excised, we take hold of the skin near the point, a, and dissect it sufficiently to make the cutaneous flap, a a d, completely mobile. Then we draw it inwards, so that its angle, a, is placed at b, and the border, a d, forms the free margin of the is prolonged in a straight line towards the temple, and is made to form the base of another triangle (a d e), the apex of which is directed upwards. The length of the incision which serves as a base to the triangle marked out in the temporal region should be equal to the and by sutures unite e a with c b, and d e with a e, so as to skilfully mask the two losses of substance base of the triangular flap of the lid ; the vertical incisions may be shorter. In dealing with the superior lid, the apex of the lateral triangle should be made downwards.

The methods of Fricke, Dieffenbach, and Burow may be used to make good a loss of substance in the middle of the lid, and even to replace in r ntire lid. For this latter purpose, Blasius* mill hasner d'Artha* have also devised methods which restore the lid by flaps taken from the skin of the forehead or nose. Figures 247, 248, 249, 250, 251, and 252 sufficiently indicate the nature of these operations, and render further detail unnecessary.

Knappt uses a very ingenious method which was suggested to him by one of his pupils, Dr. F. Pagenstecher of Heidelberg, for the restoration of a lid which had been partially removed for cancer (see Fig. 253). Having given to the margins of the wound the rectangular form depicted in the figure, he prolonged the horizontal incisions towards the nose, and in this region dissected out a quadrangular flap. He then made two incisions, one starting from the external commissure, and dividing the skin on the temple ; the other a continuation of the primary inferior horizontal incision on the cheek; the extremities of these two incisions slightly diverging from each other.

He thus formed an elongated flap, which widened considerably towards its base; this flap was detached from the subjacent tissue and united by its vertical border to the vertical border of the internal flap. The two flaps when made tense perfectly covered the loss of substance. They were carefully united by several sutures, as indicated in Fig. 254.

When we require to restore a loss of substance, involving the commissures of the palpebral fissure, we may use the following methods of operation suggested by Hasner d'Artba: In the usual manner we make two elliptical incisions round the diseased part, as indicated in Fig. 255, a. We then take from the integument of the nose a flap whose base should be about 6 millimetres from the internal extremity of the wound. This flap ends in a bifurcation similar to the angle itself.

Having cut the bridge of the flap, b, and detached it down to its base from the subjacent tissue, we fix it in its new position by means of sutures (Fig. 256). In order to cover as completely as possible the wound left by the dissection of the flap, we draw downwards and inwards the flap formed by the divided bridge.

In dealing with the external commissure, we proceed in a perfectly similar manner, only we take the flap from the temporal region (see Figs. 257 and 558)

ART. XVII. Drooping of the Superior Eyelid, Ptosis.

Inability to raise the upper eyelid is called ptosis, and this want of power is more or less complete according to the degree of the affection.

This condition may be a consequence of paralysis of the levator palpebrm superioris muscle (paralysis of the third pair; 1). 482) ; in which case it should be treated by the remedies generally used in paralysis, especially by electricity. Paralytic ptosis becomes the sub ject of surgical interferance only when there is no longer room to hope for the re establisliment of the innervation, and when the disease is in a state of stability perfectly characteristic.

Again, ptosis results when the eyelid becomes too heavy, from superabundance of skin, chronic inflammation or granulations, or when the levator palpebre have been implicated by wounds and suppuration. Finally, it exists congenitally when the levator muscle is defective or absent; this condition is often accompanied by defect of the superior rectus and other muscles of one or both eyes.
When there exists simply an excess of the integument forming a fold, we may remedy it by excision. The same operation may be applied to cases of relaxation of 'the skin with hypertrophy of the cellular tissue, as occurs in old people, or after chronic palpebral affections with congestion of the tissues.

With von Graefe's forceps we then take hold of a horizontal fold of the integuments sufficiently great to make the droop of the lid disappear when the patient looks straight before him, taking care, however, not to make it of such a size as will interfere with the shutting of the eyelids. This fold is excised and the wound is united by a few points of suture.

The existence of deficiency of the levator muscle is best recognized' when the patient looks downwards, the separation between the lids being then equal on both sides. In those cases excision of a cutaneous fold would be injurious; for them von Graefe has recommended an operation which tends to diminish as much as possible the resistance which the levator meets in the contractions of its antagonist, the orbicularis, and at the same time to increase the action of the levator by bringing its insertion nearer to the free margin of the lid.

This operation is performed in the following manner: We make a horizontal incision in the skin of the superior eyelid, at 5 millimetres from its free margin, from one commissure to the other. We then separate the edges of the wound by drawing the one firmly upwards, the other downwards, and lightly dissect the adjacent subcutaneous tissue.

The orbicular muscle is thus laid bare, and of it we lift up with toothed forceps a piece 8 or 10 millimetres broad, which we excise with curved scissors, taking care not to injure the subjacent aponeurosis. Immediately after the excision of the orbicularis, we unite the edges of the wound by two or three sutures, which should include the margins of the muscular wound as well as those of the cutaneous.

These sutures may be inserted as follows : The needle is first introduced into the lower lip of the cutaneous wound, and then the inferior lip of the muscular wound is lifted with a pair of forceps, and the needle is run deeply into it.

Next, the superior lip of the muscular wound is taken with the forceps, and the needle is run through it from within outwards, and then through the superior lip of the cutaneous wound. Finally, the suture is made fast. Three such sutures are generally found to be sufficient, but, if necessary, the cutaneous wound may be closed by a few additional ones.

When the action of the levator muscle is entirely wanting, it may be replaced by that of the frontal muscle, by a cicatricial union between it and the eyelid a procedure originated by Dransart * and Pagenstechent To do this by means of a simple ligature, including also the palpebral skin, should be avoided, on account of the deformity caused by the scar. It is better to make subcutaneous ligature by means of a silk thread furnished with needles at each extremity. One of them is introduced near the ciliary margin, following the tarsus, and emerging 1. centimetre above the eyebrow; the other is inserted in the same way, parallel to the first, and at a distance of about 5 millimetres. By making traction upon the two extremities of the thread, the eyelid may be raised as required somewhat higher than the lid of the opposite eye, and the ligature closed over a roll of kid. Two or three of these ligatures may be inserted according to the size of the lid. Before inserting the ligatures, de Wecker makes a horizontal incision, or even an oval excision of the skin, and removes part of the orbicularis muscle, as in the operation of von Graefe, which we have just described.

In some very severe cases, we have obtained excellent results by dissecting the palpebral skin up to the superciliary muscle, after having made a horizontal incision across the lid at a distance of 1 centimetre from its margin, and two vertical ones extending from the extremities of the first upwards to the extremities of the eyebrow. This cutaneous flap being turned up to the forehead, three cat gut ligatures are successively introduced from above downwards, at a distance of I centimetre apart, under the superciliary and orbicular muscles, the needle being guided over the cartilage, and brought out near the ciliary margin. In closing these ligatures, they may be tightened so as to raise the lid as required, and the ends cut off close to the knots. The cutaneous flap is then put in place, and United to the ciliary margin by several points of suture. The dressing is the same as for plastic operation.

Should no operation be admissible, the lid may be lifted and maintained in place by small ptosis forceps (Fig. 259).
ART. XVI I I. Traumatic Lesions of the Lids.

Incised and lacerated wounds of the eyebrows and lids vary in their gravity according to their situation and extent. A horizontal incised wound, which does not extend down to the conjunctiva, usually heals very rapidly without disfiguring the patient, unless, indeed, the levator muscle has been divided, in which case there will be extreme ptosis.

Superficial wounds in the vertical direction, when they do not involve the palpebral margin, are free from danger. When the injury extends through the entire thickness of the lid, there is reason to fear simultaneous injury of the eyeball, or the ulterior formation of a symblepharon.

Ruptures of the lid may, moreover, end in suppuration, and thereby cause deformity from the irregular cicatrization. When the lesion has involved the supraorbital nerve, blindness of the corresponding eye has been known to occur.

The treatment of all such injuries requires often the greatest care. A simple wound produced by a sharp instrument may be united by a suture. In dealing with a torn lid ' the wound must be carefully cleansed, all lacerated tissue removed, and the edges drawn as carefully together as possible by one or seve ' ral sutures. In all these cases the best dressing is a compress and bandage. In stings inflicted by wasps, bees, and other insects, we sometimes have considerable swelling and irritation. If the sting of the insect remain in the wound, we must try to extract it, after which the lid may be anointed with olive oil, and protected with a compress steeped in a solution of chloride of ammonium.

We have already spoken of the malignant pustule (P. 544).

Deep burns of the lids are often dangerous from the cicatricial contraction, which may become the origin of severe ectropion. The best method of preventing such a result is to close the eyelids at once by suture, and to use a skin graft, in order to obtain a favorable cicatrization.

ART. XIX. Congenital Anomalies of the Lids. Coloboma and Epicanthus.

1. By coloboma is meant a fissure of the lids, which is sometimes found to be confined to one lid, but sometimes involves both. This fissure is often combined with other anomalies of a similar nature, such as harelip and cleft palate, etc. In treating coloboma of the lids, we make raw the margins and very carefully draw them together by sutures, one of which at least should pierce the cartilage.

2. Epicanthus, a congenital anomaly caused by the presence of a fold of skin covering the internal angles of the palpebral fissures, is often complicated with a flattening of the bones of the nose, and an enlargement of the space which separates the internal angles of the eyes. Along with epicanthus we often have microphthalmos (sometimes only apparent and caused by the contraction of the palpebral fissure), drooping of the superior lid, strabismus, and affections of the lachrymal passages.

The operation for epicanthus has for its object the contraction of the skin which separates the two internal angles. It is not necessary to perform this operation in the first years of life, for the contraction often takes place spontaneously, and the fold of skin disappears as the nose becomes more prominent. Still, if this does not take place, and the deformity is so very obvious as to be a source of annoyance to the patient, we must operate, removing an oval and vertical piece of skin from the back of the nose. This operation is applicable when the epicanthus affects both eyes, and is performed as follows:

To determine the amount of skin which must be removed, we pinch up, either with the fingers or with a pair of ectropion forceps, a fold of skin sufficiently great to make the epicanthus disappear, and then draw an ink mark round the base of the fold. Having done so, we may immediately insert the sutures which will be required to unite the lips of the wound after the excision of the cutaneous flap. In this excision, which is best made with a sharp bistoury, we must carefully dissect the angles of the wound, so that its margins may be brought together without difficulty.

When epicanthus is present only on one side, we make the incision on the corresponding side of the nose.

ART. I. Anomalies of the Puncta Lachrymalia and Canaliculi.

The anomalies of the puncta and canaliculi are chiefly displacement, contraction, and obliteration. Such anomalies prevent these organs from performing their proper functions, and occasion a more or less pronounced degree of lachrymation, or irritation and even inflammation of the conjunctiva, produced by the contact of the tears.

The lachrymal punctura may be displaced in a twofold direction. We may find it displaced outwards, as in cases of eversion of the palpebral margin, or we may find it separated to a greater or less distance from the eyeball. The causes of eversion are the same as those of ectropion ; the causes of separation are swelling Of the caruncle or thickening of the lid and the palpebral conjunctiva.

Obliteration of the lachrymal puncta may be due to their deviation, to burns, ulcers, or injuries involving the puncta or the surrounding tissue. It may also be due to various forms of conjunctivitis or blepbaritis.

Contraction or obliteration of the canaliculi may also be attributed to the extension of some inflammatory condition of the conjunctiva, to burns or wounds in their neighborhood, or again to the presence of foreign bodies (cilia, calcareous concretions, filiform fungi).

Treatment. When the anomalies just described are the source of inconvenience to the patient, it becomes necessary above all to establish the natural drainage of the tears. A simple stricture of the canaliculi can always be overcome by the use of a fine conical style. But the greatest precaution should be taken to avoid any rupture of the mucous lining, which, in cicatrizing, would add to the contraction of the passage. Further dilatation may be attained by means of probes successively increasing in diameter, or by a small instrument with movable branches (dilator of Bowman or Desmarres, Fig. 26o) constructed for this purpose. Should complete and lasting permeability not be obtained by these means, the puncta and duct must be divided as first taught by Bowman.* This operation is very simple. Bowman performed it with a narrowpointed bistoury and a small grooved director. The following is the manner in which he used these instruments: Applying one finger of the left hand to the external angle of the eye, the inferior lid is drawn towards the temple ; the palpebral margin is thus made to assume a perfectly horizontal position. Another finger of the same hand is placed in the internal angle beneath the canaliculus so as slightly to evert it. The grooved director can then be easily introduced with the right hand into the passage and pushed forwards till it reaches the sac. This having been done, the sound is kept by the thumb and index of the left hand in the horizontal position, so that the canal may be straightened and made tense. The bistoury is then pushed along the groove and the canal is divided.

The operation thus performed is, however, much too long, and presents some difficulties, especially if we have to deal with a timid patient who contracts the orbicularis muscle, or if we are short of assistance. It may happen that, just at the moment at which we pass the sound from one hand into the other, some movement on the part of the patient may cause the sound to slip out of the canal, and the whole operation has to be begun again. On this account it is better to use a small dacryotome (Fig. 261), in which both sound and bistoury are combined. It is introduced into the inferior canal in the same manner as the sound just mentioned; then, by pressing the extremity of the instrument, the small knife which it contains (b) glides forwards. This little instrument, so easily managed, is still used by us in operations on such patients as are frightened by the appearance of any cutting instrument.

We may also perform this small operation with a pair of very sharp scissors, the points of which have been rounded off to prevent their piercing the mucous membrane while being used. One of the branches, purposely made thinner than the other, should be introduced into the canal in the same way as the probe, and then, whilst the lid is stretch by the fingers of the left band, the two branches are brought rapidly together and the canal is incised with a single stroke. The best way is to use the small probe pointed knife devised by Weber (Fig. 262). The rounded extremity is made to slide into the canal, which is divided by raising the handle of the knife. To obtain a satisfactory result, slight downward traction should be made on the canal that is to say, it should be drawn in the direction opposite to the movement of the knife.

In cases where the eversion of' the punctum is considerable, the canal need not be divided in its entire length ; a small incision about 2 millimetres often suffices to cure the lachrymation.

If some difficulty be experienced in introducing the blunt point of the scissors, of the knife, or of the director, into the opening of the duct, which is sometimes very much contracted, the orifice should be previously dilated by the introduction of a small conical style, which should be pushed into the canal for a certain length and then rotated several times between the thumb and index finger.

Whatever be the method which we employ to divide the lachrymal passage, we must be careful to divide the mucous membrane only to the same extent as we divide the entire thickness of the canaliculus.

If this precaution be not observed, we may produce a cicatricial contraction which will forever obliterate the passage. We must also divide the canal so as to leave the artificial opening as far as possible turned inwards that is to say, towards the eyeball. This is easily accomplished by everting the eyelid in the manner we have just described, and by turning the edge of the knife towards the eye.

If, notwithstanding this precaution, the thickening of the lid and the swelling of the mucous membrane are so great as to keep the parts at such a distance from the eye, that, even after careful probing, the canal remains everted, and the tears which cannot flow through it still escape over the cheek, we must adopt Critchett's method.* This surgeon recommended that, in these cases, a piece of the posterior wall be taken hold of and cut off with a pair of scissors. By so doing we obtain a triple benefit: the canal is drawn more towards the caruncle, the passage of the tears into the sac is rendered easier and the reunion of the various structures is prevented.

When the lachrymal punctum is closed the treatment is more complicated. In such circumstances it is sometimes a matter of difficulty to discover the orifice, which, however, should be carefully looked for, if necessary with the aid of a magnifying lens. If it be found, we can, as a rule, introduce a very fine probe. If we do not succeed, we should, following Juengken, remove with scissors the portion of the conjunctiva which covers the canaliculus, and search in the wound for the opening by which to introduce the probe. According to Bowman, there is less risk of the opening again closing if the incision be made obliquely. When the canaliculus has been converted into a permanent groove, if the tears still escape over the cheek, we must look for some obstruction'at a more remote point of the lachrymal passage. This obstruction is sometimes situated near the internal extremity of the canaliculus at the point where it opens into the sac. In that case, as soon as the probe arrives at the contraction, there is the sensation of an elastic resistance, and, on pushing it still farther, we see the external integuments in the neighborhood moving with the probe. Then we introduce~ a small hollow probe, enclosing a trochar (Fig. 263) into the lachrymal canal. As soon as the constriction is reached, we push forward the point of the trochar, at the same time making the skin tense with the fingers of the left hand, and thus enter the sac. Having removed the obstacle, we withdraw the trochar, and prevent the occlusion of the opening by introducing a fine probe.

If the careful and persistent introduction of the probe is a matter of too great difficulty, or does not have the desired effect, we divide the canaliculus and enlarge its opening into the sac, thus securing a permanent communication between the conjunctiva and the lachrymal sac.

After each exploration or operation of the lachrymal passage, we make a careful injection of tepid water, or a weak solution of borax, by means of a very small syringe (modification of Anel's). It is necessary to insert the nozzle as far as the lachrymal sac, and to make very slight pressure while injecting the liquid, which, if the head of the patient be depressed forward, flows out through the corresponding nostril, thus proving the permeability of the entire lachrymal apparatus.

For ourselves, we desire to see the indiscriminate habit of dividing the canaliculus in all cases of epiphora abandoned, inasmuch as we consider it useless and injurious. Whenever we can introduce a fine probe into the lachrymal sac, and an injected liquid flows freely through the nostril, it is sufficient to renew these proceedings several times to obtain a cure. Even when the exploration of the nasal canal (vide infra) requires the introduction of a probe, the division of the canaliculus may be avoided ; and in those cases where the division of the canaliculus seems indispensable, the probes and the syringe ought to be introduced near the sac, in order to allow the punctum and the adjacent part of the canaliculus to cicatrize, and so recover their normal functions.

ART. II. Catarrh of the Lachrymal Sac and of the Nasal Canal. Blennorrhea.

In the large majority of cases this disease develops very slowly and in a very insidious manner. The patients at first notice a more or less pronounced degree of lachrymation, which increases when they are exposed to cold or moisture, or to the action of any irritant. Soon the region of the lachrymal sac becomes slightly swollen, and if it be gently pressed a mucous or serous liquid resembling the white of an egg emerges from the puncta. In other cases, the liquid on pressure passes down into the nose. In the first case, the liquid lodging in the culde sac of the conjunctiva is a frequent cause of conjunctivitis or blepharitis.

The quantity of the abnormal secretion due to the catarrhal swelling of the inflamed mucous membrane of the lachrymal sac is proportionate to the amount and extent of the irritation.

The products of secretion lead by slow degrees to a distention of the sac, which may be sufficiently great to form a tumor large enough to be a great source of annoyance to the patient (hernia of the lachrymal sac). As long as the distention of the sac is not considerable, the disease may pass off spontaneously. Should this distention have supervened, spontaneous cure is still possible after acute phlegnion (vide infra) Etiology. Catarrh of the lachrymal sac is often caused by an inflammation, either of the mucous membrane of the nose, or of the palpebral conjunctiva ; sometimes it is due to constriction of the nasal duct or canaliculus. Lastly, in many cases in which it seems to be idiopathic, it may be attributed to a natural narrowness of the lachrymal passages, which sometimes coincides with pronounced flattening of the back of the nose, sometimes with an abrupt projection of the nasal bones.

Treatment. The first indication for treatment is to overcome the catarrhal state of the mucous membrane of the nose, or of the lids, when it is the cause of the disease.

In many cases, it is sufficient to inject water into the nostrils, or' for a certain length of time, to use nasal douches of salted or chlorated water, at the same time adopting such general treatment as will overcome any tendency of the patient to catarrh of the mucous membranes.

Still, it must not be forgotten that the lachrymation may have caused some irritation of the conjunctiva, which irritation in turn will hinder tile cure of the lachryination. I Hence our next indication, not less important than the first, is to re establish tile permeability of' the lachrymal passages, and thereby prevent the stagnation of the liquids.

For this purpose, after dilating the lachrymal duct, we make use of injections as described in the preceding article. If the injected liquid flows freely through the nostril, the treatment should be continued with weak solutions of sulphate of zinc or copper, or nitrate of silver, and the patient advised to press upon the sac with his finger from time to time. If the liquid does not pass, or passes with difficulty drop by drop, we introduce an olivary sound, not too fine (Bowman's No. 2), into the duct, without previously dividing it, and thence through the sac and into the nasal canal. This, with the addition of injections, will succeed when there is only a moderate degree of general swelling, or slight isolated strictures. But should the first introduction of the probe demonstrate the presence of a considerable contraction, which is likely to require its prolonged use or other treatment, we pass immediately to a method which Bowman has described in the Ophthalmic Hospital Reports for October, 185 7 The method is as follows: We begin by opening the inferior lachrymal passage, as has been described in p. 6oo. The communication once established, we can easily empty the sac by external pressure, and thus prevent the accumulation of matter.

To penetrate the nasal canal, we select one of the finer numbers of Bowman's series of probes. There are six. sizes in the series. These probes, made of malleable silver, are of different diameters, No. 1 being about the thickness of a strong horse hair, whilst No. 6 is nearly a millimetre in diameter. We prefer to use probes with an olivary point, for they seem to enter more easily, and are less liable to tear the mucous membrace or to make a false passage. The probe which we are about to use may be bent into a curve, as it then follows the course of the passages more easily. The introduction of the probe by the inferior canaliculus may be effected in the following manner:

With the left hand the inferior palpebral margin is drawn outwards, then the probe is introduced into the opened canaliculus, along which it is made to glide gently towards the lachrymal sac, its extremity being directed inwards and slightly upwards. In this way the probe is advanced, without interruption, till its progress is arrested by a firm structure. Having arrived at this point., the direction must be completely changed. Keeping the extremity in the sac, we give to the probe a circular movement, only stopping when it is in a straight line with the nasal canal. At the same time, we always keel) close to the posterior wall of the sac, along which it should be made to glide into the canal.

In the majority of cases, if the rules just described have been carefully observed, there is no difficulty in entering it. Still, if the membrane be greatly swollen, the probe may be caught in the orifice. The exercise of any force should be carefully avoided in these manipulations. Whenever the probe meets an obstacle, it must be slightly withdrawn, and again pushed gently forwards in a fresh direction, until we feel it sliding gently into the opening.

If these precautions are not attended to, we run the risk of irritating the mucous membrane, or even of perforating it and of making a false passage. If, notwithstanding all our care and patience in these delicate manipulations, we do not succeed in finding the opening of the canal, it is better to give up all attempts for the time being, and to repeat them next day.

When we have once entered the duct, we require only to push the instrument from above downwards, gradually increasing the pressure if we experience any resistance, but avoiding any deviation t o one side or the other. Most frequently the obstacle is overcome without difficulty when it consists only of a moderate swelling of the mucous membrane, or even of a slight cicatricial contraction.

When we are stopped by a constriction, it is well to withdraw the probe for a short distance and to push it in again, endeavoring to remove the obstacle by continuous and steady pressure. The probe first introduced is of moderate size (No. 2 or 3 of Bowman); but when the contraction is great we are obliged to have recourse to No. 1.

When we wish to catheterize the nasal canal by Weber's* method, that is, by introducing the probe by the superior canaliculus, we use Weber's knife (Fig. 262) to open it. The small rounded point of the knife is introduced into the superior lachrymal punctum, whilst we draw the internal angle with the left hand upwards, and turn the palpebral margin slightly outwards. The small knife is then made to enter the sac, and the canaliculus is divided by lowering the handle.

If we wish at the same time to divide the internal palpebral ligament, a proceeding which will greatly facilitate the introduction of probes, we make the blunt point of Weber's knife slide along the posterior wall of the sac behind the ligament, then, turning the edge of the knife forwards and pressing it against the ligament, we divide it by a single sweep of the knife from behind forwards.

Weber also uses special probes; these are elastic bougies, and the smallest corresponds with Bowman's No 5 If he does not succeed in introducing the finest at the first attempt, he uses a narrower conical probe to break up the constriction (Fig. 265). Otto Becker has shown that we can introduce probes without previous division, even using those of considerable size with conical extremities. procedure be employed, it is well to inject afterwards cold water into the sac and canal. In case the injected fluid does not pass through the nose it is necessary to use hollow sounds, to which we can adapt a caoutchouc bag or a small syringe filled with water. Having introduced the sound into the canal, we apply the small bap , and make the water pass through the sound, which is gradually withdrawn from the canal and sac. We may also use injections of tepid water or antiseptic solution to cleanse the nasal canal and diminish the congestion of the mucous membrane. In the same way we may also inject astringent lotions, such as solutions of the sulphate of zinc or of copper. During the injection the patient should be directed to bend the head a little forwards, so that the liquid which comes into the nasal cavity may escape by the nostrils.

The sounding of the nasal duct should be continued till its perme¬ability is re established. Although the is arrested, and the tears resume their regular course, and the patient experiences greatrelief, we should not all at once discontinue the treatment, but increase the length of time between the successive introductions of the probes, and thus overcome any tendency to relapse, which is only too frequent in such cases. Usually we do not employ any larger probes than Bowman's No. 3 or 4.

For patients who cannot come sufficiently often to consultation, and with whom the insertion of a probe for a few minutes does not seem to be sufficient, we, as a rule, leave the probes in position for several days. In such cases we use small probes with olivary ends, with the other extremity curved at a right angle and made very thin,'so that it can rest in the inferior canaliculus. If its contact irritates the conjunctiva, we bend its extremity at an acute angle over the skin of the commissure. Bowman, Critchett and Schweigger have used similar sounds, and have been satisfied with this permanent dilatation. Still, if we seem to be long in accomplishing our purpose, we try for a few days the introduction of Bowman's or Weber's largest sounds, and continue their use according to the effect produced.

Sometimes a continuation of the lachrymation is due to an increase in the size of the caruncle, which may easily be reduced by a partial excision. At other times we treat the condition of the mucous membrane by injecting astringents into the nasal duct, and by injecting nitrate of silver into the lachrymalsac. In a certain number of cases, it is true, we can easily pass sounds into the canal, but neither the tears nor any liquids injected by the hollow sound escape into the nasal cavities. We must then look for an obstruction at the inferior opening of the duct. To remove it we introduce a grooved sound as deeply into the canal as possible, and by means of this sound we guide a very narrow pointed knife down to the obstacle, which we divide. We then at regular intervals during the first few days wash out the duct by injections.

Special attention must also be given to any change in the dimensions of the sac.

When, for example, the sac has been much dilated and the walls thinned and distended by the long retention of accumulated fluids, it often happens that, after the obstruction of the canal has been overcome, the sac, from the relaxed and dilated condition of the walls, does not regain its normal dimensions ; such dilatation may seriously impede the recovery of the patient.

In such cases, the patient should be directed to empty the sac frequently by pressing on it with the finger, compressing it as often and as long as possible so as to prevent its filling again To prevent its repletion during the night, we may have recourse to pressure kept up by means of compresses kept in position either by adhesive plaster or a bandage. We never follow Bowman's advice, viz., to remove by dissection a portion of the anterior wall of the sac, nor Critchett's, who makes a large opening into the sac, and applies potash to its interior, thereby destroying it considerably, without damaging the skin.

Weber, with the intention of preventing the tears from entering the sac for some time, causes a temporary eversion of the inferior lachrymal canal by means of a small ligature, in which he encloses the lachrymal punctum and a small fold of the external skin. The faradic current applied to the orbicular muscle also hastens the return of the sac to its former dimensions.

In the large majority of cases, a combination of these different expedients overcomes the disease. Still it must be admitted that we find cases in which, although the lachrymal passages have returned to their normal condition, there remains a certain amount of lachrymation. It must also be remarked that, in a certain number of cases, the probing of the nasal duct should be continued for a length of time, and that a course of treatment of several weeks' or even months' duration is not possible in all cases, and is not always followed out by the patients.

In these cases benefit is derived from the use of Stilling's procedure, Which consists of the internal division of the constrictions of the nasal canal, and is performed in the following manner : The canaliculus is first incised, and an exploratory sound introduced to ascertain the exact seat of the stricture. Having withdrawn the sound ' we introduce Stilling's small knife (Fig. 266), with its edge forwards, and push it on till it encounters the obstruction. If the obstruction is distinctly felt, we plunge the instrument in up to the handle; then we withdraw it a little, and make incisions in three or four different directions, so that, the instrument, which was at first tightly grasped, can be turned on itself in every direction. This finishes the operation, and the knife is withdrawn. According to Stilling we should beware of introducing sounds after the operation.

Other surgeons prefer to catheterize the nasal duct with Weber's Sounds immediately after the division of the stricture. We use Stilling's method in cases in which there is a single contraction difficult to dilate; and in these cases it has always given good results. We never use it when the passage is stopped up by a swollen mucous membrane, which yields more easily and with less risk of future complications to astringent injections. To incise a single constriction we introduce a grooved sound, and along the groove run a small narrow convex probe pointed knife. Having withdrawn the sound, we make our incisions, and immediately thereafter pass a thick sound, and finish the operation by injecting cold water.

When there is no contraction we must look for the cause of lachrymation also in a faulty position of the palpebral margins, accompanied with an insufficient occlusion of the lids and a defective action of the orbicular muscle. This source of lachrymation has been specially mentioned by Ad. Weber,* who has also suggested some very ingenious methods of remedying it.

In certain cases we find a shortening of the palpebral fissure due to cicatricial contraction of the free margin of the lids (after blepharitis). The inferior lid is then stretched between the external and internal palpebral ligaments, and does not, when the lids are shut, become displaced inwards so as to compress the lachrymal sac.

The skin seems wrinkled at the internal angle, as in epicanthus. When the patient tries to shut his eye, the lachrymal puncta project forwards. To remedy this state of affairs, we may divide the external palpebral ligament in the following manner: An elongated vertical oval, comprising the skin and the muscular layer, is excised, in a zone intermediate between the external palpebral commissure and the insertion of the external palpebral ligament to the orbital margin. Having freed the margins of the wound above and below, we take hold of the external palpebral ligament on a sharp hook and detach it with a pair of scissors. This being done, if the palpebral occlusion is still imperfect, we incise, on both sides of the external palpebral ligament, the tarso orbital aponeurosis in a direction parallel with the palpebral margin; then we unite the wound horizontally by two or three sutures. If there be at the same time a tendency to ectropion, we make the incision in the skin alone, and separate it, especially towards the inferior lid, as far as the palpebral margin, so as to give it perfect mobility.

In another set of cases, the lids are relaxed ; they seem to be too large and are much wrinkled. If the relaxation is confined to the margin, we excise from the neighborhood of the external commissure a semi lunar piece, the concavity of which faces inwards, and which embraces the skin, the aponeurosis and the tendon. The size and shape of the piece excised should vary with the amount of lid tension which we wish to procure. The margins of the wound are united in the primary direction by sutures which pierce the skin and the muscle. If we wish to increase the tension throughout the entire breadth of the lid, we remove in the same way and from the same situation a flap in the form of an open V directed upwards.

In a third set of cases the lids are so relaxed as to allow the external palpebral commissure to fall downwards, the superior lid covers a large segment of the cornea, and the inferior lid leaves here a greater portion of the sclerotic beneath the cornea, especially towards the external angle. To rectify this condition, we excise, opposite to the external commissure, a rectangle including the skin, the muscle and the aponeurosis. The ligament should be entirely left alone, and the position of the rectangle should be such that its inferior border corresponds with the inferior margin of the palpebral ligament. According to the effect which we desire to obtain we must vary the diagonal length of the rectangle which begins at the commissure and extends upwards and outwards. The union of the margins of the wound is so arranged that the angle of the rectangle nearest to the commissure fits into the angle immediately opposite.

These operations of Weber only indicate general principles, which the physician may modify and combine according to the nature of the case.

ART. III. Phlegmon of the Lachrymal Sac, Acute Dacryocystitis.

This disease manifests itself by redness of the skin near the internal angle of the eye, and by a swelling in the region of the lachrymal sac. The redness and the swelling extend along the lids, and even the bulbar conjunctiva becomes hyperemic and chemosed. This condition is accompanied by intense pain on pressing the lachrymal sac.

At this period, phlegnion of the sac is apt to be confounded with diffuse abscess of the cellular tissue which surrounds it. The diagnosis, however, is cleared up if there be a previous history of lachrymation and catarrh of the sac.

Moreover, after some time, we find in the middle of the general swelling a well defined tumor, of the shape and in the position of the lachrymal sac. The swelling increases, as does also a throbbing pain the skin becomes of a deeper red and softens, and fluctuation sets in before long the tumor bursts, and gives issue to the purulent matter contained in the sac. The evacuation of the abscess greatly relives the patient ; and, in fortunate cases, the inflammation disappears, the opening in the sac contracts and becomes closed, and the tears resume their normal course.

In other cases, the pus passes beyond the wall of the sac, and makes its way to a point at a considerable distance from the morbid focus; hence there is a fistulous opening which allows the morbid products and, at a later stage, the tears to escape (fistula of the sac). This condition, and the persistence of the catarrh of the mucous membrane, predispose to repeated attacks of phlegnion. Etiology. Phlegmon of the lachrymal sac is frequently caused by the constriction of the nasal canal, due to catarrh of the lachrymal passages. Inflammation of the periosteum and caries of the bones of the nose, in syphilitic or scrofulous subjects, also lead to acute dacryocystitis. This disease is sometimes also idiopathic, being occasionally accompanied with erysipelas of the lids and face after a chill.

Treatment. In the very beginning of the disease, we may apply hot fomentations to the diseased part ; we keep the patient at rest and administer a laxative. As soon as we feel fluctuation, it is necessary to empty the sac of its purulent contents in some way. Formerly, for this purpose, an incision was made through the external integuments, the sac was emptied, and advantage was taken of the opening thus made to apply the necessary remedies to the mucous membrane. In actual practice, we now preserve the external integuments of the sac as much as possible, and empty it of its morbid contents by opening one of the canaliculi and dividing the internal ligament, which allows the pus to escape freely by the conjunctival opening. Hot compresses promote the separation of the pus, and, if necessary, we afterwards inject and catheterize the canal (v. the preceding chapter).

Snellen suggests the following treatment: When, in cases of phlegmon of the sac, we are threatened with perforation, or it has already taken place, a large incision should be made through the anterior wall of the sac, into which as large a piece as possible of prepared sponge should be inserted, and allowed to stay for twelve or twenty four hours. The wound is then sufficiently enlarged to admit of the entire surface of the membrane being painted with nitrate of silver after the removal of the sponge.

Recovery takes place rapidly, and we begin, when necessary, the catheterization of the nasal duct in the usual way.

In treating a fistula of the lachrymal sac, we must, in the first place, by catheterizing, ensure the escape of the tears by the usual passages. This of itself, in a number of cases, suffices to close up the fistula.

If, however, it remains open, notwithstanding that the normal conditions as to the excretion of tears have been restored, we must have recourse to some operation adapted to close the fistulous passage and its external opening. Thus, we may incise the fistula, excise the membrane which lines it, and unite the edges of the wound by one or two sutures.

In these cases, we have found the application of the galvano cautery of great benefit. It is applied by means of a loop of platinum thread introduced into the fistula, and heated after introduction ; the external integuments being carefully protected from contact with the thread. We have sometimes been obliged to apply the cautery several times, but even then we prefer it to any other method, for patients do not experience any pain, and can return immediately after this small operation to their ordinary occupations.

Obliteration of the lachrymal sac is only employed in the most serious cases, in which the integrity of the structures is so compromised that we cannot hope to restore, even incompletely, the freedom of the nasal duct. Such cases are those in which the bone and the periosteum are affected, in which the sac has been the seat of repeated inflammations, with prolonged suppuration in the fistula, the skin being discolored and altered, or in which we can no longer find any trace of the nasal duct.

The methods by which the sac may be destroyed are many, but to be of any service they must fulfil the same ends viz., ( 1 ) the obletiration of the canaliculi, in order to prevent the tears reaching the sac ; (2) the destruction of the mucous membrane of the sac, so as to allow of the obliteration of the sac by granulations.

To destroy the passages, we use the galvano cautery with good results. The loop of platinum thread is introduced into the passages and heated to a white heat ; the thread being pressed against the internal wall of the passage until it is destroyed. Occlusion takes place rapidly, but, when necessary, the cautery may be reapplied.

For the obliteration of the sac, we may use the galvano or thermocautery, or solid caustics, such as nitrate of silver. We must first, however, make a large opening in the wall of the sac, that through the opening thus made we may be able to apply the caustic to the entire mucous membrane, and especially near the internal orifices of the lachrymal passages. This cauterization occasions no reaction which cannot easily be held in check by cold compresses and a bandage.

When we wish to destroy the sac by solid caustics, we may advantageously use Delgado's* caustic holder (Fig. 267).

The movable valves of this instrument separate the lips of the wound considerably, and allow the caustic to be directly applied to the openings of the canaliculi. After forty eight hours the thick escbar which covers the mucous membrane should be removed, and a bandage applied sufficiently tight to bring the surfaces of the sac together.

An unsuccessful result is sometimes due to the alterations of the thickened mucous membrane, on which the caustic has hardly any effect. It may then be necessary to excise the membrane lining the sac before applying the caustic.

Berlin, of Stuttgart, has published a certain number of cases in which he has obtained obliteration of the sac by simple excision of the mucous membrane, which he has removed either at once or by small flaps at different times

ART. IV. Inflammation of the Lachrymal Gland (Dacryoadenitis), Hypertrophy and Tumors of the Lachrymal Gland.

1. Inflammation of the lachrymal gland, an exceedingly rare affection, produces a considerable swelling at the superior and external margin at the orbit. The superior lid is swollen and hyperernic, the conjunctiva is injected and chemosed. If the swelling is great, the eyeball may be displaced downwards and inwards, and its movements upwards and outwards restricted. Inflammation of the lachrymal gland is rarely acute. Should it be so, the parts are exceedingly painful to the touch, and the swelling is great ; fluctuation is soon perceptible, and the skin is perforated, giving outlet to a little pus. The perforation may close again in a short time, or may remain open, constituting a fistula of the lachrymal gland, through which the tears escape. Chronic inflammations of the gland may also end in fistula.

Acute inflammation, which has been sometimes observed occurring simultaneously on both sides, is generally due to the effects of cold, or to injuries. In the chronic state, it has been observed in persons who have suffered for a long time from conjunctivitis and corneitis accompanied by considerable lachrymation.

The treatment of acute inflammation demands acute antiphlogistic measures, as the application of leeches, followed by hot cataplasms. When there is suppuration, we must open the abscess freely. In chronic inflammation, mercurial and iodine ointments have been used.

2. Hypertrophy of the lachrymal gland, slowly and without pain, gives rise to a circumscribed lobulated tumor, sometimes tolerably hard, which attains considerable dimensions. It then comes to interfere with the movements of the eyeball and of the superior lid.

This hypertrophy appears without any known cause, and has been observed to occur in children and even newly born infants. We may try to procure its absorption by rubbing with mercurial and iodine ointments; but the excision of the tumor always becomes necessary when, from its bulk, it becomes a source of great annoyance to the patient.

3. Fibroid and sarcomatous tumors of the lachrymal gland have been recorded, as also adenomas, hydatid cysts, and, more rarely, cancers. They require extirpation of the gland (vide infra).

Dacryops has already been described with the tumors of the lids.

ART. V. Operations Performed on the Lachrymal Gland.

The operation for fislula of the lachrymal gland does not present any other difficulty than that of obtaining a permanent obliteration of the fistula. For this purpose, we may introduce into it probes covered with melted nitrate of silver, or needles at a white beat.

There have also been tried galvano cautery, the injection ,f irritants into the fistula, and the union of the fistulous opening after its margins have been made raw or excised. Bowman * has been completely successful by establishing an artificial opening on the conjunctival surface of the superior lid. He operated in the following manner: A silken thread was provided, with a needle at each of its extremities; one of these needles was introduced by the fistulous opening on the external surface of the lid, and directed somewhat upwards; then it was made to pierce the lid and the conjunctiva so as to come out on the internal surface of the lid, drawing the thread with it. The other needle was introduced in a similar way through the conjunctiva, at about half a centimetre from the first, and more towards the superior aspect of the lid. The ends of the threads were brought out at the external commissure and fastened to the temple.

Ten days after, a larger thread was introduced, which caused more irritation than the first. Lastly, the external opening of the fistula was closed by excising the portion of skin which contained it, and bringing the edges of the wound closely together. Four days later, the thread was withdrawn, the wound being perfectly cicatrized.

The extirpation of the lachrymal gland is rendered necessary by the development of tumors in the gland itself, or in its neighborhood, and by its hypertrophy and induration.

It has been recommended and practiced to overcome lachrymation which has not yielded to any form of treatment (Z. Laurence). When there is a hypertrophy or a tumor, the operation is begun by a cutaneous incision above the tumor, 'parallel with the orbital margin, and sufficiently long to lay bare the anterior portion of the tumor which forms the altered gland.

We may also, before the incision, draw the lid firmly downwards, and carry the knife into the skin of the closely shaven eyebrow. If the size of the tumor requires it, we may, following Velpeau's advice, divide the external commissure towards the temple, thus uncovering the external two thirds of the orbital circumference.

The gland thus laid bare should be seized with a hook or toothed forceps, drawn forwards and separated from all adhesions with a knife or scissors. When there is induration of the gland, it is better to free the tumor with the finger nails and the handle of the scalpel. After the removal of the tumor we must carefully examine the cavity with the. finger, in order to make sure that no indurated tissue remains. When the hemorrhage has stopped, we clear the wound from all clots and bring the margins together with sutures. A compress and bandage keep the eyeball in position, and maintain the walls of the cavity which contained the tumor in close apposition.

Laurence's method of removing the healthy lachrymal gland is the .following: After the patient has been completely anesthetized, the skin is divided with a long and narrow scalpel, immediately above the orbital margin, in its external third. The fascia is then incised, and we enter the orbit at the lachrymal gland. This last is easily felt, as a smooth round body, by running the finger along the orbital wall.

If any difficulty is found in getting the gland, Laurence advises that the external commissure be divided by a horizontal incision which is prolonged till it meets the first ; thus a flap is formed with the apex turned outwards, and the gland can be much more easily felt. It is then seized with a double hook, drawn forwards, and detached with the extremity of the scalpel. The hemorrhage which follows this operation should be arrested by cold water irrigation, and, after it has completely , stopped, the lips of the wound may be drawn together by a few sutures.

In one case of congenital epiphora of both eyes where all treatment had been of no avail, the patient being a young girl of sixteen who considered her condition as insupportable, we extirpated both lachrymal glands with complete success.* In order to avoid the cicatricial retraction of the upper eyelid in case of suppuration, the incision was made above the eyebrow after drawing it firmly downwards, following the superior border of the orbit from its external third to its union with the inferior border. The soft parts being detached from the periosteum, and the gland being laid bare, it was drawn out and separated from its adhesions. After the hemorrhage was arrested, the wound was closed with some sutures and a borated dressing rather tightly applied. The wound united by first intention, leaving only a linear scar, scarcely visible. The epiphora completely disappeared, and the eyes did not appear drier than in their normal condition.


ART. I. Inflammation of the Cellular Tissue of the Orbit and of Tenon's Capsule. Periostitis, Caries and Necrosis of the Orbital Walls.

1. Inflammation of the cellular tissue is manifested in its early stages by an erysipelatous swelling of the lids and a serous, chemosis of the conjunctiva. The patient complains of localized pain in the depth of the orbit and of supra and sub orbital neuralgia. Contemporaneously there supervenes a gradual protrusion of the ball and a restriction of its movements in all directions. When the disease attains its height, the eye becomes immobile, and the chemosis is. sometimes so considerable as to prevent the lids being shut. The sensibility is very great, the patient is feverish and sometimes delirious.

The development of this disease is generally very rapid, rarely it is very slow ; in the latter case all the symptoms are less pronounced. Exceptionally, the inflammation of the orbital tissue terminates in resolution ; as a rule it ends in suppuration. The skin! of the lids then becomes of a dusky red, and the swelling becomes localized to one spot, at which we can feel a more or less pronounced fluctuation. Lastly, the abscess bursts on the eyelids or into the conjunctival sinus. The vision may remain intact ; occasionally there supervenes an optic neuritis with secondary atrophy of the nerve. Separation of the retina and suppurative choroiditis have also been observed ; complications which can be explained by the communication of the lymphatic channels, of the sub choroidal space and of Tenon's capsule (Schwalbe).

A more benign form of this disease, in which the inflammation is entirely confined to the fibrous envelope of the eye, has been described under the name of capsulifis, or inflammation of Tenon's capsule. The symptoms, less pronounced than in phlegnion of the orbit, consist of a slight swelling of the lids (this, however, may be entirely absent), and of a subconjunctival injection with chemosis, accompanied by slight exophthalmos and diminished mobility of the eve, which, when the visual acuteness is perfect, may give rise to diplopia. This form of capsulitis has been observed after injuries to the capsule, after strabotomies, in cases of panophthalmitis, in erysipelas of the face, and idiopathically after chills.

2. Periostitis of the orbit in its acute form has many points of resemblance to phlegnion of the orbital tissue. As distinctive symptoms of periostitis we would mention the acute pain which follows pressure on the orbital margin; the lids in the early stages are less swollen, and do not present the intense redness of inflammation of the cellular tissue; lastly, the inflammation is often more circumscribed, so that the eyeball is displaced only to one side, and its mobility is more restricted in one direction than in another. The pain is very great, and is accompanied with great prostration of the physical strength of the patient.

Suppuration sometimes takes place very rapidly, and the pus, escaping along the periosteum, produces necrosis of the osseous walls and perforation into the adjacent cavities.

Chronic periostitis is much slower in its course. The disease is accompanied with periorbital pain and slight swelling of the superior lid. It may terminate in intraorbital abscess with caries or necrosis of the bony wall, or in resolution, leaving a thickening of the periosteum or an exostosis.

3. Caries and Necrosis of the Orbit. These affections, as we have just said, may supervene as a consequence of periostitis. Still, the disease often begins in the bone itself, and maybe situated either in the depth of the orbit or at its margin, and in the latter case it by preference attacks the inferior and external or superior and external part.

When the affection occupies the bottom of the orbit, it generally causes pain, exophthalmos and a general febrile reaction. Caries of the orbital margin manifests itself at first by edema and swelling of the affected lid, accompanied at a.later stage with inflammation of the conjunctiva. After a considerable length of time, the purulent collection gives rise to fluctuation, and finally pierces the integument of the lid, or opens into the conjunctival cul de sac. The pus from such an abscess has the characteristic fetid odor of osseous caries.

After the abscess has burst, the inflammatory symptoms of the skin and conjunctiva do not completely disappear, and the suppuration continues.

A fistulous opening is thus formed, which leads to the rough surface of the denuded bone, or to a movable osseous sequestrum. The external orifice of the fistula is covered with fleshy granulations; its margins become inverted, and, when the swelling of the lid has abated, contract adhesions with the bone. Again, the tarso orbital fascia is also often drawn towards the diseased portion of the osseous wall, and its shortening is frequently the source of ectropion of the lid.

The fistula may temporarily close up, in which case the escape ol the pus is prevented, and the inflammatory phenomena (exophthalmos, pain, fever) reappear. The disease may thus be continued for years before the secretion ceases. Should, however, a sequestrum be elimi nated at an early period, the course of the disease is much more rapid Etiology. Orbital phlegnion may supervene after severe illness Thus it may be secondary to typhoid, scarlet, or puerperal fever, or to purulent meningitis, glanders, etc. ; it may also follow the penetration of a foreign body into the orbital tissue, or any operation performed on the lachrymal gland or sac. It sometimes accompanies erysipela of the face and lids. Lastly, it is common in orbital periostitis.

Periostitis may set in after a contusion or a wound in the neighbor hood of the orbit, or it may be an extension of inflammation from the periosteum of the adjacent cavities the frontal and maxillary sinuses the cranial cavity. It occurs more frequently in early life than in the adult.

Caries of the orbital walls is often observed in scrofulous children, as a consequence of some exciting cause e. g., a contusion or a blow. Sometimes the caries of the nasal bone, so frequent in the syphilitic diathesis, extends to the orbital cavity. In the same way, other changes in the adjacent cavities may cause suppuration and perforation of the orbital walls.

Lastly, caries or necrosis affecting the superior orbital wall sometimes occurs in advanced life without any well ascertained cause.

The prognosis of orbital phlegnion is not of itself serious when uncomplicated with periostitis, for the disease rapidly subsides after the evacuation of the purulent material. It, however, is rendered serious by the possibility of the extension of the inflammation to the cranial cavity, and by the effect it may have on the eye, the vision of which may, as already described, be destroyed.

In periostitis, the gravity varies with the seat and phase of the disease. When it has been detected in the early stages, when it is situated near the orbital margin, and when the abscess has been opened at once, the affection may subside without extending to the neighboring structures. But, on the other hand, when the periostitis is localized in the depth of the orbit, there is then a danger of its extending to the cranial cavity, and of its producing a thickening of the periosteum or an exostosis with permanent exophthalmos, more or less complete blindness, or paralysis of the ocular muscles.

The prognosis of caries and necrosis of the orbital walls is always serious. When the disease affects the orbital margin it may give rise to ectropion; in the depth of the cavity it may extend through the optic foramen, the sphenoidal and spheno maxillary fissures; or the pus, after perforating the orbital plate, may enter the cranial cavity. Again, in sickly children, prolonged suppuration may lead to exhaustion and thus prove fatal.

Treatment. Except in cases of injury to the orbit, we must abstain from all antiphlogistic treatment: Locally we may use hot poultices, aromatic fomentations, mercurial and belladonna ointment as an inunction. Our general treatment must take into account the indication furnished by the state of the patient's health, and by the presence of any diathesis (syphilitic or scrofulous).

As soon as we have reason to suspect the presence of pus, it must at once be evacuated by an incision. When we are in doubt as to the presence of pus, we should make an exploratory puncture with a narrow bistoury in the oculo palpebral furrow at the level of the orbital margin. If the fluctuation is distinct, the abscess should, if possible, be opened through the mucous surface ; but, if this be not possible, it should be opened through the lid. We may sometimes be compelled to penetrate deeply into the orbital cavity, which has in the adult total depth of about centimetres (equal to about inches). It these cases, a sharp bistoury is inserted between the eyeball and the wall of the orbit, at the point at which the phlegmonous swelling seem to have most widely separated the ball from the orbit.

In puncturing the abscess, we must keep in mind the direction taken by the orbital wall, along which the knife must be made to advance.

Thus, for example, on the internal side of the eye, the bistoury should be directed obliquely backwards and outwards; on the externa side, obliquely inwards and backwards, following the horizontal direc tion. The knife should always be pushed very gently forwards, a otherwise it may pierce the bony plate.

As a general rule, it is better to make the puncture too soon than too late.

If the puncture is made too soon, it may give issue only to a very small quantity of pus, or perhaps only a little blood may escape, bu by this puncture the intensity of the affection is diminished, partly by the freeing of the inflamed tissue, partly by the escape of blood, and b the opening of a few small cavities which are filled with pus. Besides these small abscesses will open more easily in the canal of the wound than at the surface of the integuments, and we may expect to see th pus escaping through the incision, even although it may not do so at th time of puncture.

When the abscess is emptied, we should abstain from injecting th cavity with tepid water, for the water may find its way into the cellula tissue, and increase the inflammation and suppuration. We should however, carefully explore the cavity with a probe, and thus ascertain the condition of the periosteum and of the bone which it covers. I we find that the periosteum is thickened, or even separated by the pus it is of the first importance to incise it deeply, in order to relieve th painful tension of the periosteum, and to prevent a more extensive separation.

When the probe reveals the presence of a bony sequestrum, it should be extracted, the wound being enlarged if necessary. In all these case it is necessary to inset I t a small drainage tube of perforated rubber. If the suppuration gives rise to an unhealthy and scanty pus, we may inject antiseptic, solutions. At a later period we may use weal astringents, or a slightly irritating ointment spread on a piece of lint which should be inserted instead of the drainage tube.

When the surface of carious bones ceases to be rough, and when we feel that the abscess is filled with granulations, we may cease th drainage and allow the external wound to close.

The prominence of the eyeball, which sometimes remains after the abscess is cured, should be checked by a compress and bandage. Any cicatricial contraction of the integuments can be removed only by an operation at a later period. We may also attempt to prevent it by temporary occlusion of the lids.

ART. II Wounds of and Foreign Bodies in the Orbit. Emphysema. Hemorrhage.

1. Wounds of the orbit may become serious either from the secondary inflammation of the orbital tissue and from periostitis to which they may give rise, or by the direct penetration of the wounding