OPTOMETRY LIB, H. A. STOCKWELL OPTOMETRIST BERKELEY. CAUF. OPHTHALMIC SURGERY BEARD OPHTHALMIC SURGERY A TREATISE ON SURGICAL OPERATIONS PERTAINING TO THE EYE AND ITS APPENDAGES, WITH CHAPTERS ON PARA-OPERATIVE TECHNIC AND MANAGEMENT OF INSTRUMENTS BY CHARLES H. BEARD, M. D., FELLOW OF THE AMERICAN COLLEGE OF SURGEONS; SURGEON TO THE ILLINOIS CHARITABLE EYE AND EAR INFIRMARY; OCULIST TO THE PASSAVANT MEMORIAL HOSPITAL, CHICAGO; EX-PRESIDENT OF THE CHICAGO OPHTHALMOLOGICAL SOCIETY; MEMBER OF THE AMERICAN OPHTHALMOLOGICAL SOCIETY, ETC. SECOND EDITION, REVISED AND ENLARGED WITH 9 PLATES, SHOWING 100 INSTRUMENTS AND 374 OTHER ILLUSTRATIONS PHILADELPHIA P. BLAKISTON'S SON & CO 1012 WALNUT STREET OPTOMET Copyright, 1914, by P. Blakiston's Son & Co. ' II K ■ M A I' I. K . !■ H K S S . Y O U K • I' A OPTOMETRY LIBRARY PREFACE TO THE SECOND EDITION. The present edition contains ^^ per cent, more text and 80 illus- trations more than did the iirst, yet the contents have been so con- densed that the size of the book has not been materially increased. Important new matter has been introduced throughout, and two new chapters, one on "The Newer Operations for Glaucoma," the other on "The Surgical Treatment of Detachment of the Retina," have been written. Among the descriptions of valuable surgical methods that have been inserted are those relative to Toti's and Butler's operations upon the lacrimal canal, Elschnig's and Motais' methods for tendon advancement, Rogman's and Wicherkiewicz's for epi- canthus, Angelucci's for ptosis, Verhoeff's and Green-Ewing's for entropion, Terson's for ectropion, Falchi's for central coloboma of the upper lid; Buedinger's restoration of the lower lid, using cartilage of the ear, and Meisner's restoration of the entire lid, using the whole thickness of the helix; a large section, embodying the Schobel- Kuhnt methods of conjunctivo-keratoplasty, has been added; like- wise, the newer measures for keratoconus and those for corneal grafting, and the improved technic for anterior syncchiotomy. In the chapter on Extraction of Cataract the new features include Elschnig's simple extraction with peripheral incision of the iris, Homer Smith's preliminary capsulotomy, Hulen's vacuum extrac- tion of the lens in its capsule, and the latest phase of the "Indian Operation." The alphabetical index has been elaborated. The author is most grateful for the many flattering comments upon the former edition that he has received from the medical profession and press both in his own country and abroad. M758S65 PREFACE TO THE FIRST EDITION The selection of the matters discussed in the following pages and the manner of treating them are the results of the careful study and practical application of the involved principles made in hospitals, dispensaries, and in private practice, extending over a period of twenty-six years. They began while the author was a student under Agnew and Knapp, in 1883, were later continued in England and on the Continent of Europe, and have ever since been diligently prosecuted. There has been no separate work on the surgery of the eye published in the United States for nearly half a century, and but little written upon the subject in connection with the more general treatises on ophthalmology, if we except the admirable contribu- tion of Knapp to the System of Norris and Oliver some twelve years ago. The object here has been to supply a work that would embody not only what experience has taught and judgment prompted as being the more valued measures of all countries, but, in particular, those of our own country. The presentation of portions devoted to the history of the dif- ferent procedures is deemed of great importance, but to keep them from appearing obtrusive they have been made as concise as practicable. The classification followed has seemed the logical one to adopt. The chapter on the extraction of foreign bodies from the interior of the eye has been placed in a class of its own instead of with the operations upon the globe. In the author's opinion, the handling of foreign bodies in the eye is a subject apart, the methods employed in their diagnosis, localization, and extraction vii VIU PREFACE involving so much that is not in line with other branches of ophthalmic surgery. In viev^r of the fact that the illustrations have been chiefly the fruits of his individual labor, the writer begs his confreres not to consider them in the hght of mere pictures or from the stand- point of artists, but as conceptions of how these things should appear by one with considerable experience in the matters de- picted and with a little facility in the power of delineation. In closing, the author offers his sincere thanks to all others who have been instrumental in supplying whatever of merit this volume contains. Charles H. Beard. Chicago. LIST OF CONTENTS. CHAPTER I. PAGE Para-operative Technic i The preparation of surgeons, assistants, patient, instruments, and dressings. Sterilization, anesthesia, blood-letting; in short, all appliances, applications, and methods employed in connection with ophthalmic operations and with their after-treatment. CHAPTER II. Instruments and their Management 53 The approved qualities and forms of the instruments used in ophthalmic surgery, and what features are commendable and what objectionable in them, with reasons and explana- tions. Minute descriptions of models, and, in conclusion, the manipulation or handling, and the care or maintenance of eye instruments. CHAPTER III. Operations upon the Appendages of the Eye. The Lacrimal Apparatus 120 The surgical treatment of affections of the lacrimal canal, together with detailed descriptions of the principal oper- ations performed upon the entire lacrimal apparatus, both secretory and drainage. CHAPTER IV. The Appendages Continued. Operations upon the External Muscles of the Eye 158 The different kinds of squint and a history of the surgery of the defect. The technic of the leading measures for its correction, including tenotomy, advancement, shortening and lengthening of tendons and check ligaments, and the acci- dents and complications that may occur. Critical consider- ations of methods of advancement. CHAPTER V. The Appendages Continued. Operations upon the Lids. . . . 207 Eversion, epilation, and electrolysis of cilia, methods for chalazion, canthoplasty, tarsorrhaphy, and epicanthus. CHAPTER VI. The Appendages Continued. Operations for Ptosis 230 Kinds of ptosis, history of the surgical measures devised for it, with the principles underlying them. Descriptions of the technic evolved in the leading methods for righting the fallen lid, and an extended summary dealing with the different procedures and their relative values. ix X LIST OF CONTENTS CHAPTER VII. PAGE The Appendages Continued. Operations for Entropion, Ectropion and Blepharoplasty 253 Operations for spastic entropion, cicatricial entropion and trichiasis, with the history and evolution of such surgery. Ectropion, its varieties, such as spastic, mechanical, mucous, atonic, and cicatricial. Blepharoplasty in all its phases, as.by sliding and pedunculated flaps, by dermic and epidermic grafts, etc., with exhaustive detail of technic under each of the several headings. CHAPTER VIII. The Appendages Continued. Operations upon the Conjunctiva. 329 The surgery of partial and total symblepharon, and_ the restoration of the conjunctival cul-de-sacs. Pterygium, true, false, and recurrent, and appropriate surgical measures for the different kinds, including excision, transplantation, ligation, cauterization, and skin grafting. Peritomy and peridectomy. CHAPTER IX. The Appendages Continued. The Surgical Treatment of Trachoma ■ 3^3 Historical. The classification of methods mto mechanical, chemical, and operative. Details of technic relative to each class, as scraping, massage, expression, cauterization, radiation, and excision. The last comprises all forms of excision, whether of conjunctiva alone or of that membrane combined with excision of the tarsus. CHAPTER X. Operations upon the Globe 379 These relate first to the outer walls of the globe— comprised by cornea and sclera. Measures for foreign bodies in the cornea, corneal cautery, paracentesis, massage, keratoplasty, anterior staphyloma, conical cornea and tattooage. The scleral surgery includes sclerotomy, anterior and posterior, cyclodialysis, trephining, amputations, exenteration, enuclea- tion, and the substitution of a prothesis in the globe or in Tenon's capsule. Operations upon the iris. Iridotomy, irito-dialysis, irito-ectomy, synechiotomy, and iridectomy in all its forms and phases. CHAPTER XI. Operations upon the Globe Continued. Extraction ofCat.vract. 497 Preparation of the patient and of the eye. Description of approved technic for the various forms of extraction. Ex- tended commentary on the accidents and complications incident to extraction, their causes and their remedies. Discission of primary and secondary cataract, couching or depression, and suction. Extraction of the lens in its capsule. The history of extraction and its instrumentation, with concluding dissertation on the modern corneal section. LIST OF CONTENTS XI C A AFTER XII. PAGE The Newer Operations for Glaucoma 623 How the different measures seek to accomplish their purpose. Simple anterior sclerotomy. Pression massage, or malax- ation after anterior sclerotomy. Objections to extensive scleral openings. Combined anterior sclerotomy. The ob- ject of the iridectomy. Sclerotomy of Herbert, of Bjerrum, of Wicherkeiwicz and of Beard. Van Lint's T-shaped sclerot- om^^ Sclerectomy. Perforating sclerectomy of Lagrange and of Holth. Trephination of the sclera. Trephination — Elliot's. Different forms of trephine. Beard's instrument and method. Formation of the conjunctival flap for trephination. Non- perforating sclerectomy of Bettremieux, and the theory as to its mode of action. Fistulous tracts by means of silk thread. Review of the different methods. CHAPTER XIII. Operations for Detachment of the Retina 660 Nature and varieties of detachment. Classification of the surgical measures devised for its cure, and how they seek to accomplish their end. Simple scleral puncture. Thermo- or galvano-cautery. Bull's discission of restraining bands. Elschnig's modification of Mueller's procedure. Deutsch- mann's operations, Bettremieux's nonperforating sclerec- tomy in detachment. Subconjunctival injections. Why antiglaucomatous operations tend to cure detachment. Sta- tistics as to surgical and nonsurgical measures. Reasons for making careful and repeated ophthalmoscopic examinations. CHAPTER XIV. Operations upon the Orbit 670 The surgery of foreign bodies in the orbit. Kronlein's operation and its modifications. The removal of tumors. Incisions of the orbit evacuant and diagnostic. Exenter- ation, partial and total. CHAPTER XV. The Removal of Foreign Bodies from the Interior of the Eye. . 687 Their abstraction from the anterior chamber; from the iris; from the posterior chamber; from the vitreous chamber. Their localization in the eye and in the orbit. Magnet operations and their technic. CHAPTER XVI. Alphabetical Index. 729 OPHTHALMIC SURGERY. CHAPTER I. PARA-OPERATIVE TECHNIC. Asepsis. — Under favorable conditions all incised wounds tend to heal per primam intentionem, and, as remarked by Snellen, this is especially true of wounds of the eye. If they are allowed proper coaptation and left undisturbed, the only bar to primary union is some form of infection. Under thorough asepsis, then, nature can be confidently relied upon. Yet, when we consider the status of our knowledge relative to the value and the means of asepsis, how often are we reproached by our operative results! Notwithstanding the degree of perfection we have reached in the science and the art of surgery the advantage is still on the side of the operator who is most thorough and consistent in carrying out antiseptic precautions, rather than on the side of mere skill. What has been aptly termed an "antiseptic conscience" is a necessary attribute of every one in any way concerned. To this must be added an aseptic conscious- ness and subconsciousness, as well. For, unless we accjuire actual habits of surgical cleanliness, and try to impart them to all those around us, the most elaborate and up-to-date preparations are being forever rendered futile by some little inadvertence, like soiling a finger or an instrument by contact with an uncleansed object. The key-note to asepsis is sterilization. This is of two kinds, relative and absolute. The first refers to the preparation of the hands and persons of surgeons, attendants, patients, and of the parts concerned in the proposed surgical measure. The second is applicable only to inanimate objects, such as instruments, articles used in making applications, the materials for dressings, etc. Obviously vital animal tissue cannot be subjected to this form of sterilization Therefore, in the use of purifying solutions upon it, one is inclined to make up in abundance what is lacking in strength. Preparation of the Hands and Forearms.— It is well to include the hands and arms of the patient as well as those of the o])crator I 2 PARA-OPERATIVE TECHNIC and all of his aids in this process. They arc first scrubbed with good soap, liquid or solid, and tepid water, by means of a brush that is not too stiff. The nails are trimmed, cleaned and scrubbed with the brush. The hands are then rinsed with pure warm water, using the brush. After drying on a sterile towel, they may now be anointed with a mixture of alcohol, glycerin, and one of the highly antiseptic essential oils, as that of cloves or of cinnamon, to be immediately followed by a good rubbing. This has the property of great penetration, entering into the ducts of the sweat and sebaceous glands, and permeating the deeper layers of epithelial masses. Lastly, they are washed lightly in sterile water and wiped perfectly dry on a sterile towel. Allowing the hands to dry spon- taneously is not so cleanly, as the moisture catches dust. The oft- repeated washing of the hands with solutions of irritating antisep- tics like sublimate, formalin, and carbolic acid has the effect of making them sore, and rough with dead epidermis, without in the least rendering them less infectious. A soap impregnated with a grinding material is excellent for hands that are inclined to be rough. Gloves. — The more important and exacting operations upon the eye are performed without the surgeon's fingers ever coming in contact with the field of operation. Hence, the wearing of rubber gloves on his part would be not only uncalled for, but when the ex- treme exactness of most ophthalmic surgery is considered, positively unadvised. For all of his assistants, however, to wear them, were both prudent and desirable. Especially is this true as regards those who make and handle the cotton sponges, or thread, or any object that actually touches the site of operation. Sterilization of Instruments. — There are three methods more or less in use for this purpose, that by dry heat, that by moist heat, and that by strong antiseptics. It need hardly be said that this proceeding takes ])lace immediately before the operation. When prepared by dry heat tlic instruments arc put into some form of stove or oven, of which there are many efficient kinds on the market. Here they are ex})osed for twenty minutes, or longer, to a temperature of 300° V. This is ;i])])licablc to all kinds of instruments, even to those with ixory handles. In winter, or in \crv moist weather, the door of the o\fn is icfl o\)vn for a few moments after the heat is started, in order to ])revent the (juick corrosion of fine edges and points that comes from condensation. Sterilizing in a llame is fatal to anv instrument. STERILIZATIOX BY MOIST HEAT 3 By Moist Heat. — It is customary to put in this class sterilization by means of live steam, in an autoclave, under })ressurc. In rcalitv, if carried out to the letter, this is a form of dry sterilization. In this country eye instruments are rarely subjected to this process. The method most in vogue and most to be recommended is by boiling. Contrary to many adverse statements and comments, I believe this method the best for all kinds of eye instruments. That is, just as appropriate as any for the finer cutting implements. True the instruments must be manufactured with a view to being so treated. They must have metal handles — be all of metal, in fact, and the procedure must be conducted by one who knows and does full duty in the matter. The metal of the vessel used for the boiling should not be capable of entering into any chemical action with the contained solution that would be deleterious to the instru- ments. I cannot do better than give a description of it as practised in the Illinois Eye and Ear Infirmary. All the more delicate in- struments are placed in a metal rack, provided with a handle and with a clamp which holds them securely, the points and edges of the sharp ones having been previously tested on the trial-kid. The rack projects beyond the extremities of the instruments so that they cannot be jammed against the boiler. There is a separate com- partment in the boiler for this rack. The coarser and non-cutting articles are dropped carefully into another compartment. The boiler contains a solution of sodium hydrate, or borax, one to two parts per thousand. The presence of the salt serves to elevate the degree of ebullition and to restrain oxidation. The solution is perfect — ^i.e., there must be none of the salt undissolved. The instruments are not put in until the water reaches the boiling- point. Of course the boiling ceases the moment they are immersed. One waits, then, until it begins again before starting to time the sterilization. The time should not be less than ten minutes. Fifteen w^ould not be too long. The instruments are then lifted out drained, and laid on sterile towels on the trays of the serving tables. It would be well to have a small oven in which to dry them quickly just before using. The plan, so generally followed, of putting them fresh from the boiler into some liquid, there to remain till used, is not consstent with good surgery. It is not pleasant to either operator or operated to have water dropping into the eye from the instru- ments; besides, since the sterilization of the hands is only relative, infection could, in this way, be carried from the fingers into the 4 PARA-OPERATIVE TECHNIC wounds. If i)romptly dried the moment they are removed from the sterilizer one need have no apprehension as to the points and edges of the fmest knives. If left in the air, covered with moisture, oxidation becomes at once very active, and it is precisely the thin edges and sharp points that will suffer most. All sutures are boiled ready threaded in their needles. If to be treated with paraffin, or other waxy material, this is best put on afterward, as the consider- able handling necessitated by the threading is apt to contaminate the suture. Reeve, of Toronto, boils his cutting instruments in oil, to avoid corrosion. By Strong Antiseptics. — ^This is the least sure and satisfactory method, and must ever be one of expediency, not of choice. It consists in letting the instruments lie for 15 minutes or longer in a bath of one of several liquids. The commoner are 40% formalin, 95% phenol, 95% alcohol, and pure chloroform. They are then taken out and washed in sterile water. This is an uncertain proc- ess, for if there be the thinnest possible film of any fatty or albu- minous substance on the instrument it acts as a barrier to disinfec- tion. Moreover, all these fluids attack the steel with some degree of activity. This form of sterilization is made much surer by wiping the instruments repeatedly, and hard, with sterile, soft linen just before putting them into the bath. If done intelligently, this also enhances the polish and the keenness of the trenchant articles wiped. It is not a bad idea to have the cloth wet with the antiseptic. It was the practice of Agnew, of New York, to wipe his Graefe knife long and hard with soft linen, before the days of antisepsis, to render it cleaner, brighter and sharper. Preparation of the Patient. — This is divided into general and local. General preparation is of two kinds, physical and mental. General preparation may be begun at an indehnite time previous to the operation, and should never, in case of major operations, be started less than 24 hours previously. First, on entering the hospi- tal come the taking of the histories, family, ])ersonal, and clinical, then the physical examinations, general and local. These include urinalysis, inquiry inlo llie state of circulatory and vascular systems (if subject is not young), nose, tliroat, lungs, heart, digestion, etc. The bowels are emptied by l)r()ken doses of calomel followed by citrate of magnesia or salts, or by castor oil. Tlie diet is li([uid or verv light, if the operation is to be under narcosis, or if the PREPARATION OF THE PATIENT 5 subject is nervous or apprehensive, it is well to give a small dose of morphin, or chloretone, or bromid of sodium, forty to sixty minutes before the start for the surgical room. The patient is questioned as to cough, and, if general anesthesia is contemplated, as to behavior in any former narcosis. Both eyes and their ap- pendages arc thoroughly examined and the results recorded. Partic- ular care is directed to the condition of the pupils, the fundi, the cornea, the conjunctiva and the lacrimal canals. Bacteriologic investigation of even the healthy appearing conjunctiva is of positive advantage in that an incipient pathogenic or pyogenic infection may be discovered and disaster averted by a postponement of the proposed operation. The vision, the refraction, fields, etc., are noted. The subject must be made as clean as possible, but it is best to leave it to the discretion of a trained attendant whether or not regular tub bathing and shampooing be resorted to. Along with all this goes the mental or psychologic preparation. The beauties and advantages of hospital life and treatment are extolled and instructions given as to how best to profit by them, how friendly everyone is to everyone else, etc. Incidentally the patient is put through a system of training in the matter of turning the eyes in various directions, opening and closing them without undue effort, and of having them touched and handled. Unless there is some positive indication, no local preparation is inaugurated prior to one hour, or even 30 minutes, before the operation. The use of antiseptics in the conjunctival sac and of bandages for a day or two beforehand is omitted as worse than useless. ]\Iuch of this subject is given in the chapter on Extraction, Suffice it to state here that, by way of local preparation, the eyelids and surrounding areas are scrubbed with sterile soap and warm water, followed by rinsing with warm sublimate solution 1-2,000, the subject mean- while keeping the eyes tightly shut. The supercilia are not shaved unless extra heavy. The cilia are washed, and the lids manipulated to empty the Meibomian and other ducts along the free borders. The cilia before extractions and iridectomies are coated by wiping them with cotton wet with benzin, and, lastly, the conjunctival sac is copiously douched with warm boric acid solution. A light boric acid dressing is then put on the eye and fixed by a simple muslin strip tied on diagonally, to be left till the time for the opera- tion arrives. The hair of women is neatly combed back and braided. The nails arc manicured and the hands are scrubbed. 6 PARA-OPERATIVE TECHNIC The patient is taken to the operating room in night clothing, i.e., all ready for bed. The eye is copiously tlooded with warm boric or salt solution before, during, and after the operation. One at- tempts by this liberal use of a mild antiseptic to make up, as it were, for one's inability to employ a strong one. Sterilization of all dressings, such as bandages, cotton, gauze, and of gowns, caps, masks, inhalers, etc., is done by means of the large steam autoclaves. Usually the various articles are done up in stout cotton bags, which are securely tied. They are not removed either from the sterilizer or from the bags until needed. All ap- pliances, applications, implements, and drugs, of whatever descrip- tion, used before, during, or after the operation, are sterilized by either dry or moist heat. Everyone who has a duty to perform in connection with an opera- tion is clad in a sterile gown and in a cap to cover the hair. Nurses and aids wear gloves, while the surgeon and his immediate assistant have mouths and beards covered by masks. Surgeon's Operating Masks. — "The principal object of these convenient ap])liances is to protect the operative field against in- fection from the expiratory efforts of the operator and assistants Sr^.. / h lM<;. r. Mikuli. Kic. 2. — Mikulicz mask. in talking, coughing, sneezing, etc. They supersede the use, for the same purpose, of plain pieces of gauze tied over the lower part of the face around to the back of the head. By the laller method, however, asitle from its being a far less convenient one than the other, to say nothing of the discomfort to the wearer, there was always more or less danger of having the operator's hands con- OPERATING MASKS 7 taminated by coming in contact with the hair while in the act of tying the gauze at the back of the head. This and other objections to wearing some sort of shield have been done away with by such wire masks as we illustrate; these may be easily attached to the head in a manner similar to spectacles, requiring only the handling of the mask itself, which should be previously sterilized. Wilson, of Bridgeport, has attachments on the mounting of his operating spectacles for holding the gauze mask. "One of the two best-known patterns of these wire masks is that of Mikulicz, which consists of a wire framework so made that Fig. 3.— Tuttle's mask. Fig. -Tulll when covered with two thicknesses of gauze stitched to all sides, it effectually co\crs the nose and mouth of the wearer when it is placed in position. It is instantly adjusted to the head, and when not in use a number of them may be nested and temple bars folded over, so as to take up a minimum amount of room. "The other pattern now being rapidly adopted by many leading surgeons and hospitals, as fulfilling the purpose admirably, is known as Tuttle's mask. This is a modification, by Dr. Edward C. Tuttle, of a somewhat similar contrivance used in some European hospitals; and while they are also made of wire, they are different in construction from those first described, as will be seen by comparing the illustrations shown herewith. On these frames the gauze is to be attached only to the upper part, but for the entire length of same, back to the very ends of the temi)le bars, so as to allow the gauze, after the mask has been put on, to hang down lO to 18 inches 8 PARA-OPERATIVE TECHNIC over the front and sides of the head, covering also the ears; the lower part of the gauze is then placed underneath the operating gown before the latter is buttoned up, affording protection in every needed way. It will be seen that the bottom part of the frame stands out from the lower part of the wearer's face in such a position as to hold the gauze away from it, thereby insuring comfort. "Of the two kinds of masks herein described, the first mentioned has the advantage of being instantly adjusted to the head, whereas the other, even though it may take a trifle longer to put on, is pre- ferred by many on account of its giving the desired protection in a more complete way. It is well to note that where an operating cap is worn with a Tuttle's Mask, only the eyes and their immediate vicinity are left exposed, while the remaining portions of more than the entire front half of head and neck are completely covered. Furthermore, it should be remembered that both types mentioned are so constructed as not to allow the gauze to rest against the face of wearer, thereby enabling him to feel at perfect ease, which is not the case where gauze alone is worn; also that the wire temple bars may be easily bent, so that the masks can be readily adjusted to fit almost anyone." The Operating Room. — The best sort of operating room, de- scribed in a general way, is one that is dry, commodious, that is well ventilated without opening windows or doors, easily heated in winter, and that has an abundance of light. Particularly desirable is a broad north window. This insures a uniform light without interference by direct sunlight. If this window be set at an angle of 30° to 45°, inclining inward, it is preferable to a perpendicular window. Operations wherein corneal reflections can be a disturb- ing factor are made easier by a window thus inclined. With the patient lying on the table, feet toward the vertical window, as is the favorite position, unless the table be so far removed from the window as to greatly reduce the illumination, the image of the window lies inconveniently high up on the cornea. Now, if the window were tilted toward the table, just in ])ro])ortion as the slant of the window would increase up to 45°, just in the same degree would the reflex be lowered. This is illustrated by the accompanying drawings. A and B represent the left e\'e of a subject lying on a table with feet toward the window. .1 shows the image of a vertical window and B that of one inclined inward about 40°, the distance of the table from the window being the same in both instances. Next ANESTHESIA 9 in choice to the inclined window as a source of light is the \crlical, though to get the best illumination the table would be placed diagonally, with the foot near the window. A sky-light is not satisfactory. Perhaps the best all-around light is the artificial, for by the use of portable electric photosphores, or other electric hand-lamps, and large biconvex lenses, one can get whatever intensity is desirable, and can cause the reflexes to fall wherever they are least in the way. Fixed lights, or those adjustable kinds supported by their own stands, are much less convenient. They are in the way, require a fresh adjustment for each change of position or movement of the patient, and the surgeon may, at a critical moment, find that his hand casts a shadow upon the operative field. In the hands of an assistant of the right sort the hand lamp can be Fig. ■A, Reflex near vertical window. B, Reflex near inclined window. made to fulfill every requirement. Walls, ceilings, floor, woodwork and furniture of the room are all white and of materials, or covered with materials, that most readily admit of washing, fumigating, or vigorous disinfection generally, ^^'indow shades are of a material easily cleaned, and work from below by heavy gilt (metallic) picture cord, so as to raise the least amount of dust in being put up or down. No pus cases and no re-dressings are allowed in the clean operating room. Anesthesia.— Instead of the classification " local ' ' and " general," it would be simpler and better English to distinguish these two con- ditions by the terms anesthesia, meaning the loss of sensation in any particular part of the body due to the contact of the sensory nerves supplying that part with a drug that causes temporary paralysis, and narcosis, meaning that condition of general stupor and uncon- sciousness, resembling sleep, caused by the wide diffusion of the poisonous drug in the circulation. Thanks to local anesthetics the eye-surgeon is now enabled to dispense with narcosis for the vast lO PARA-OPERATIVE TECHNIC majority of operations. Indeed, there is no surgical measure resorted to by the oculist for which narcosis is not, now and then, omitted. Local. — Local anesthesia is produced, in eye surgery, in several ways; as by the instillation of solutions of anesthetics into the con- junctival sac — applicable to operations upon the mucous membrane or upon the globe. Instillation of the same solutions into open surgical wounds — applicable to operations upon the globe or its appendages, and by the infiltration method of Oberst, or the com- bined infiltration and cocain method of Schleich; the last two being applicable only to operations upon the appendages. Another form of local anesthesia proper to mention is that by freezing with the spray of anesthyl or plain chlorid of ethyl or other highly volatile substance. This serves well for the incision of abscesses of the lids or orbit, especially in children or excessively sensitive adults. Of course, the eyeball must be protected from the cold. So far ophthalmic surgeons have had little or nothing to do with the intraneural method of Gushing, and nothing with the spinal anesthesia of Corning and Bier. Of all the local anesthetics cocain, after twenty-five years of trial, still retains its supremacy. Its maximum of efficiency can be obtained with solutions varying in strength from 2 to 4%. Stronger solutions only serve to increase the objectionable qualities of the drug. Holocain stands next in popularity. It is effective in solution of only 1%, and has the advantage of retaining its proper- ties longer than cocain. The chief objections to cocain arise from overdosage or prolonged application. This leads to dryness and desquamation of the corneal epithelium, to dilation or relaxation of the blood-vessels, and to hypotonicity of the globe. The first favors infection, and the last two cause hemorrhage. The third objection is turned to a virtue, however, in glaucoma, where cocain, notwithstanding its mydriatic efi'ect, may be used with impunity not only as an anesthetic, but also as a remedy. The first effects of cocain on the normal eye are contraction of the blood-vessels and perfect anesthesia. Hence, it is most ex])edicnt to o])erate during the ])rimary stage in so far as il is possible. To this end the instillations should not be begun longer than ten minutes before the operation. A good rule is to start tlii' boiling of the instruments and the application of the cocain simultaneously. Four drops with two-minute intervals is sufficient. Jf the eye be hyperemic it is less INFILTRATION ANESTHF.SIA II susceptible to the drug, but it can be blanched by adrenalin, and then anesthetized. A convenient and highly efficacious form of cocain application is the fresh sterile cocain ointment. This has such staying qualities that a single laying-on is enough. More- over, it is said not to disturb the corneal epithelium when fat instead of water is the vehicle. Ramsay recommends a few drops of 5% chlorctonc solution, along with the cocain, to offset the harmful results to the epithelium. It has been often denied that there is aught accomplished by dropping cocain into the open wound in operations upon the appendages, but the facts do not seem to up- hold the denial. Infiltration Anesthesia. — It had long been known that a dense inhltration, of the skin, for instance, caused anesthesia of the part. Oberst, in 1889, turned this to account by producing artificial infiltration, by means of a hypodermic syringe and distilled or salt water preparatory to the making of incisions. Schleich, in 1889, went further, and added a modicum of cocain (1/8 to 1/4%) to the fluid for the syringe. Both these methods are rather exten- sively employed in the surgery of the lids. A wheal, or a series of wheals, of edema is raised at the site of the proposed operation by introducing a fine hypodermic needle nearly its whole length into the skin, and gradually withdrawing it as the liquid is injected. To be free from danger, if the Schleich method is used, either the cocain should be in very minute quantity or else the ring of a clamp should be thrown around the wheal to prevent the solution from entering the general circulation. The anesthesia is absolute, but the changed aspect of the tissues, and the swelling, are against the procedure, as is also the greater post-operative reaction which ensues. A good formula for the solution is that of Guttman, of New York, to wit: Natr. chlorid 0.2, cocain hydrobrom. 0.05, aqua destill., 100. Narcosis. — It would seem that tliere are always to be a certain number of operations, such as iridectomies for acute glaucoma, enucleations, extensive plastic measures, not to s])eak of those upon the timid and the very young, etc., that must be done under narcosis. How choose a narcotic? This is a matter-that is largely a question of natural selection. That is to say, it is decided mainly by the conditions — the age and physical state of the patient, the character of the operation, etc. My preference would be for ether, preceded by nitrous oxid, all things being equal, but I would not give ether 12 PARA-OPERATIVE TECHNIC to persons of advanced age with diseased lungs or kidneys or to those with bronchitis. For these, provided the operation were of short duration, I would choose nitrous oxid followed by ethyl chlorid— or even the latter alone— or either alone. Chloroform is the nicest of all narcotics, but the dangers— one death in a little over three thousand — to my mind, more than counterbalance its advantages. Nitrous oxid is the safest, but it is impracticable for any but the briefest operations. Ether is practically as safe- one death in 15,000. The risks with ether are almost nil and those of chloroform are greatly lessened if they are given properly warmed, and after the most approved methods. A tyro ought never to be entrusted with the narcosis, and constant watchfulness is necessary on the part of the most skilled anesthetist. It is important that the psychic state of the subjects be favorable. To this end they are encouraged and cheered in every possible way. In addition to these suggestive measures those who seem to be tilled with dread or fright are given a dose of some calming drug — 1/6 to 1/4 gr. of morphin, 5 to 10 grains of chloretone, or 30 gr. of bromid of soda, 45 minutes to one hour before taking the anesthetic. The more composed the patient the more quiet the first stages of the narcosis, and the freer the post-narcotic period from nausea and shock. The practice of bringing the patient into the operating room in a perfectly conscious state, there to be confronted by surgeons and attendants, all gowned, and by a great array of paraphernalia- suggestive of blood, completely demoralizes certain timid subjects and is much to be deprecated. The narcosis should be produced either in the private room or in a special anesthesia chamber. Above all, perhaps, is the importance of making the period of narcosis as brief as possible. In general surgery it is not so much the operation that counts for fatal results as it is deep and prolonged narcosis. During any operation on the eye, the mucus which so frequently accumulates in the mouth and throat during the administration of ether, is most objectionable, as it necessitates stopping the operation for its removal and endangers the field. This excessive secretion may be most effectually prevented by the hypodermic administra- tion of atropin sulphate gr. 1/200 to 1/150, combined with morphin suli)hate gr. 1/16 to 1/8, about one hour before the operation. Inhalers. — As to inhalers the simplest apj^aralus is usually the best. The drop method on a simple, gauze covered wire inhaler for ether and chloroform is about as good as any. I prefer DRESSINGS 13 Jordan's inhaler for eye operations as there is a notch for the nose at the top, and the handle projects over the chin, thus putting the hand that holds it out of the way. Where this is not at hand, the cone of towel and i)aper with absorbent cotton to hold the liquid, for ether, or a simple towel or napkin for chloroform, will answer the purpose. The subject is first made to breathe with the inhaler in place, but uncharged with the anesthetic. The latter is then gradually added. Screaming children may have a deep cone, i.e., with plenty of air space, saturated with ether clapped on at once, trusting partly to asphyxia to produce sleep. Along with the tanks of nitrous oxid there is always one of oxygen, and hypodermic syringes are provided, ready loaded with strychnia, brandy, or other stimulants, nor is there wanting the means for making infusion of salt solution. All these things to be used in an emergency must he prepared and on the spot. The patient is carefully watched for an hour or two immediately after the narcosis for the double purpose of noting his physical condition and of preventing injury to the eye or derangement of the dressing by some unconscious act. Dressings. — ^The materials that compose modern eye-dressings are not of great variety or overnumerous, but their forms and modes of application, at the hands of the different individuals, are diverse as well as interesting. Relatively few seem to be so precise and exacting as a matter of such prime importance demands. If the surgeon himself is negligent and slovenly in this respect what can be expected of other attendants like internes and nurses ? Gauze. — This fabric does not enter so largely into the needs of the opthalmic surgeons as into the requirements of those who practise other branches of the art. It comes in sealed packages, supposedly ready for use, but it is well to sterilize it again if means are at hand for doing so. For the most part plain gauze — not impregnated with any drug — is employed. This should be of soft texture and highly absorbent. Borated gauze is interchangeable with the plain and stands sterilization perfectly. Certain of the impregnated gauzes, however, as the moist ones, lose their properties by the process and must be used directly from the can. Iodoform gauze is useful chiefly as a packing, e.g., in the form of tents for abscess cavities. Bichlorid gauze is apt to be irritating, especially to the skin of many patients. Cotton. — The quality of absorbent cotton as found on sale is an uncertain thing unless one knows and can obtain i)articular 14 PARA-OPERATIVE TECHNIC brands. The best cotton is white, clean, of long fibre, and is instantly absorbent. It comes neatly laminated, and with the great bulk of the fibres running lengthwise of the bolt or roll. A distinctive feature is its feel. It is clingy to the touch, and when rubbed between the fingers the fibers show great friction. Poor cotton is not white, not clean, is shoddy, or of short fibre, is irregularly laminated, and, because of the oil remaining in it, does not readily absorb liquids. To the touch it has a silky feel, and when rubbed between the fingers is slippery. Absorbent cotton is used either plain or borated. It cannot be trusted without being freshly steril- ized. The roll of cotton is not made into pieces of appropriate size by cutting, but by pulling. When cut, the edges are too thick and abrupt. Bandages.— These are made of white flannel, gauze, muslin, or netting, cut into strips of suitable width and length. For a pressure bandage flannel is probably the most fitting fabric, because of its elasticity. This same quality makes it objectionable for general use; besides, it is rather warm for summer. Muslin, ex- cept it be of the sleaziest, is too stiff and unyielding. Gauze makes a fine bandage, but to be good it is expensive. The material that seems most nearly to fulfill all requirements is a good quality of white mosquito netting. This was first employed for eye bandages at the Illinois Eye and Ear Infirmary 26 years ago. Its use has now become almost universal in this country. The choicest kind is quite white, is well covered with sizing, has a moderately small mesh, is free from bars of heavier weaving, and costs, now, about 80 cents per bolt. The bolts each contain a single piece eight yards long and two yards wide. The length is just right for one double or for two single bandages. It is so folded that by opening the bolt very slightly one has a strip 1/2 yard by 2 yards, containing sixteen thicknesses. By pinning this to a cloth on a table, it can be cut with heavy shears— or pinned to a regular cutting table, can be more accurately divided with a strong, sharp knife. Thus, a cut of 18 inches will make a strip 8 yards long. The strips are exactly three and one-half inches wide They are nicely rolled, and the end fastened with a pin. The goods must be folded straight, and the cutting done with exactness, else the bandage will be on the bias and ravel badly. This bandage is applied wet- soaking wet. With a little practice it can be put on quite smoothly. It conforms to the head and, when dry, has staying qualities that EANDAGINC. 1 5 are truly remarkable. The netting 1)an(lai(le ol" the liead rather than at the back. Fig. 14 represents a patch much emijloyed at the Illinois Eye Infirmary. Beneath each is worn the regulation dressing, as described further back. Indeed, the object of all bandages and their substitutes is merely the holding of the dressing in place. ?"if;. 15. — Rins^f's maslc over Ijinocular l)andagc. Protective Masks and Shields.— Many an operated eye, particularly after extraction, has been injured by a knock or a blow received on top of both bandage and dressing. It was to prevent such accidents that these were devised. One of the best is the mask given by the late Frank Ring, of New York, and shown in Fig. 15, It is of sateen— black without and white within. It is treated with a heavy size in the making, then moulded into form, and can withstand considerable pressure without indenting. There are large concavities to receixe the dressings, it fits nicely 24 PARA-OPERATIVE TECHNIC over the nose and is held on by four strings of black tape. Although it is made double, or binocular, it can easily be adapted to a single eye-dressing by merely cutting a good-sized hole on the side of the eye left open. Unfortunately, one will serve for a single case only, which is a slight drawback in a large charitable hospital, though not in private practice, as the mask is not expensive. I have long had in mind the idea of having made, after the Ring model, an aluminum mask, but with a circular opening ready-made at the cen- ter of each of the dressing concavities. Say these openings were one inch or an inch and a quarter in diameter, the mask would still afford ample protection from the usual sources of injury, and would be adapted to either monocular or binocular dressings. Fig. 1 6. — Fuchs' wire mask. They could be manufactured economically by the stamping process, would be light, and could be cleansed and used over and over, indefinitely. Emerson, of New York, has also devised a practical protective mask. It is of wire, and in form is almost a counter- part of that of Ring. Fig. i6 shows the monocular wire mask of Fuchs. This is also made in binocular form. The last admit of vision in the unoperated eye if the dressing is left oft". Figs. 17 and 18 represent rather cumbersome modifications of the Fuchs masks. Any of these may be used without the bandage, or the intervening cotton pad, or other dressing. Fig. 19 gives an idea of the metallic shield of Snellen. It is a shell-shaped contrivance with openings through which run the white tape by which it is kept in position. Shades. — x\fter the eye has sufilciently recovered to leave off the dressing it is usually not in condition to be exposed at once to the full glare of light, to the air, and to the dust. Then it is that shades, goggles, and coquilles are put on. Shades also arc monocular I'ROTECTIVE GLASSES 25 or binocular. Single shades are made of celluloid, llesh tinted, or, like the patch, of black silk, double, and with cardboard between the two layers. Double shades are most often made like the visor of a cap, and are of celluloid or papier machc. They are not worn to hold dressings in place and none should ever be placed beneath them. Any handy seamstress can make the single shades, the necessary materials being tougli cardboard for stiffening, black Fig. 17. — Wire shield, or mask, for one eye. Over monocular bandage. silk or satin for covering, and black tape for tying on. They are usually made, a number at a time, by the nurses or other attendants about hospitals, are sterilized, used for a single patient, for a few days, then destroyed. The tape is tied straight around the head, just above the eyebrows, and the shade hangs in front of the eye ^vithout touching even the lashes. Fig. 20. Protective Glasses. — These are mounted either as spectacles or nose-glasses — pincc ncz. They are either plain glass or lenses 26 PARA-OPERATIVE TECHNIC to suit the peculiar refraction of the wearer. In many instances the glasses are flat and of ordinary size, but they fuliill their office better if they are decidedly concavo-convex and of extra large lateral dimensions. These are called coquilles. They should never be of pressed or moulded glass, as they are then irregular concave lenses, which are very trying to the eyes, but should be ground into the proper form. Their protective qualities are due to their Fig. i8. — Double wire mask. color. Formerly, they were shades of green, then of blue, then of violet; later they were graded "smoke," or gray; and now orange or amber is de regie. Theoretically, they should be either deep amber or orange-scarlet or gray. In tlic first two instances they would act as ray-filters to eliminate the actinic and irritating portion of the light, viz., the violet and ultra-violet; as do the gray-green glasses recommended by Holla uer, of Basle,' or those of the tint ' Archives of Opli., Jan., lyio. CLEANSING AND REDKESSING 27 called "chlorophilc. " In the second, ihcy would merely serve, according to the density of the gray, to reduce the intensity of the light. It is desirable in fitting coquilles to have them sit as close as possible to the eyes not to touch the lashes. Goggles. — The original of these were of plain glass — green or blue — surrounded by wire screens that rested snug against the lids, the whole being held in place by a rubber band around the head. Villainous things they were, too. Of recent years, especially since Fi< .la.i^i the advent and rise of the automobile, there has been a veritable deluge of different improved styles, so that one were hard to please if he cannot be suited with a pair. ' Their glasses may be had in any tint, and some of them arc about all that could be desired in the wav of ])rotectivc glasses. Cleansing and Redressing. .\11 the beneficient results hoped for from a given surgical operation have often cither not been 28 PARA-OPERATIVE TECHNIC realized or have been turned to actual disaster by inattention to some essential detail in the more immediate after-treatment. Many a prolapse of the iris after extraction, for example, has occurred through carelessness on the part of the one who removes the first dressing and applies the second. It is also safe to assert that sim- ilarly many an eye has been infected. The inconsistence of a large proportion of surgeons as regards their attitude toward the patient at the time of the operation and after the same is curious to behold. During the first few days not only is skill and care in handling needed, but trained supervision as well, to the end that the first signs of threatened complications may be detected in good sea- son. When practicable, the patient is taken to a room especially pre- pared for the dressing — that \s, favorably prepared — for a room used only for such purposes might be the least favorable. The air of the apart- ment must be as free as possible from dust. Great tact is resorted to in properly adjusting the patient's mental state to the occasion, for there is often more apprehension relative to "the first dressing" than to the operation itself. Persons of consider- able intelligence are apt to have very vague notions as to what it means to have the eye "dressed," and a few words in explanation serve to relieve the situation as regards all concerned. Everything needed must be thought of and at hand. Towels are put around the patient's neck and around the head to cover the hair, and a catch-basin is placed beneath the chin. In most instances it pleases the patient to be allowed to hold the basin, as he feels that he is helping the cause. He is cautioned to keep both eyes gently closed, and not make any effort to open them until told to do so, and that he must never squeeze them. The bandage is cut, and is so stripped off as to leave the pad of cotton covering the eye. This is usually stuck more or less tightly to the lids, so as to require soaking slightly by dropping warm boric acid solution behind it with a dropper to make it let go. After cutting and removing the bandage, and placing the towel over the hair, it were best that the dresser put Fig. 20. — Monocular shade. REDRESSING 29 on a pair of sterilized ru1)ber gloves. I know this is seldom done, but it is the proper thins^. The warm solution for use with the cotton sponges is in a glass llask or in an ordinary eight-ounce bottle. From this it is poured ui)on the sponges, over the catch- basin. It does not comport wiili true cleanliness to dip the sponges into a vessel of liquid with the lingers, especially if they be not gloved. Always warn the dressee as to what is about to be done. The mere touching of a finger to the forehead or of a sponge to the lids might otherwise cause a tremendous start and a squeeze. He is also told not to put up the hands. What follows here refers mainly to rases where the operation has been upon the globe. The first sponge is made dripping wet. It is oblong, and one end is allowed to project well beyond the tips of the fingers to avoid giving the eye an unguarded poke or thump. This loose end is raked gently back and forth over the eyelashes to soften the dried dis- charges from the eye accumulated along the palpebral fissure. FolloW'ing this, another sponge, but wrung dry this time, is lightly drawn along to drink up the moisture clinging to the lashes. After the first sponge, all of them, while wet, must yet be in a more or less absorbent condition — that is, they should take from the parts they touch rather than give. Observance of this point j^revents driving polluted solution from without into the eye. Several wet sponges are used about the lids, brow, nose, cheek, and temple, always beginning at the center of the area to be washed and ending at the periphery, i.e., never going back to the lids or to the cilia with a bit of cotton that has touched the adjacent surfaces. A sponge is never re-wetted and again applied. By way of a finish, a pledget is squeezed hard, and with it the parts are sponged to free from drops. The lids of the unbandaged eye are also often glued together, so that it, too, should be bathed, then opened, by the dresser — not by the dressee. With oblong sponge in the fingers of one hand one proceeds, with the thumb of the other placed over the upper rim of the orbit, gingerly to lift the hd of the operated eye. If it is still stuck the wet sponge is again brought into requisi- tion; meantime repeating the command that the patient make no attempt to move the lids himself. When it is seen that both eyes are free to open he may be asked in a quiet manner to open the eyes and to look in any desired direction, and to avoid snapping and nipping of the lids. Having been assured that the patient has proper control of the lids, one may proceed more thoroughly to cleanse 30 PARA-OPERATIVE TECHNIC lashes, free borders and canthi; using the long end of sponge. Cleansing and inspection are made to consume the shortest time consistent with prudence, not to expose the eye unnecessarily to harmful agents. Whatever is indicated in the way of medication or other attention is now disposed of and the eye re-dressed as per instructions given under "Bandaging." Each time, as one is about to make the application, irrigation, instillation, or the like, it is made known to the patient what to expect. It is neither safe nor pleasant, as regards the party most directly interested, to have things put into and upon the eyes without any sort of warning, even when deftly and gently done. How much worse, then, to have them dropped from heights, squirted forcibly, and shot in, or dabbed on with a splash! The Removal of Sutures. — It is a curious fact that there is al- most as much dread of this performance on the part of our patients as of the operation that makes it necessary. Sometimes there is even more. This is something they have not counted upon and nerved up for, and it is faced with a poorer grace in consequence. Hence, great adroitness is often required to bring them to the point of calm submission. They must be disabused of the idea that the thread is tightly adherent to the flesh and that the instruments are put in actual contact with the parts involved. On the other hand, it is well to have impressed upon them the dangers of leaving the sutures in situ after the lapse of a certain period. Indeed, this is not a sophism got up merely to influence the mind. Sutures should be got rid of just as soon as they have served their purpose, and this is much earlier than many seem to suppose. After that they not only continue to act as foreign bodies but, worse yet, they, together with their canals, form most alluring open roads for the entrance and growth of bacteria. Ordinary cutaneous and con- junctival sutures ought not to remain longer than 48 hours. A few special ones, such as advancement and ptosis sutures, would better be left longer — from 4 to 8 days. If the sutures are outside of the conjunctival sac they are first softened and cleansed with a moderately strong, warm, antiseptic solution, and wiped fairly dry. The most suitable instruments for the purpose, to my mind, are a pair of small, but stiff, dressing-forceps and a pair of small, blunt- pointed scissors, curved on the flat — Stevens' stral)ismus scissors, for example. Toothed forcc])s do not seize the tliread readily. It is indispensable that the scissors cut well at the very extremity SPONOKS 31 of the blades. It is best to ha\e (he ])alienl |)r()ne upon the table, though he may sit U])riglit. In either case the head would better be steadied by an assistant. The same helper may also hold the lids apart when the sutures are inside the pal[)ebral hssure. But, in the latter case, unless one is pretty sure of his patient, and his assistant, it were better to use a blepharostat at once, the eye having, of course, been cocainized. The operator steadies the hands on some contiguous part, and watches closely the tendency of the operated, so as to be in the closest touch in order to anticipate moves or to move with him, thus avoiding sudden jerks upon the thread. In taking out cutaneous sutures an end of thread is grasped with the forceps and so pulled upon as to draw the suture well out of its canal on that side; it is then cut close up, the scissors being held with the convexity of the blades upward. In this manner one obviates pulling a soiled portion of thread — a part that has lain on the outside of the skin — through the entire stitch canal, to possibly infect it. A wet cotton sponge is held, or laid, con- veniently near, on which to wipe forceps or scissors. There is usually slight bleeding which may require sponging. The stitches all removed, the parts are again bathed with the antiseptic and sponged. Sponges. — The natural sponge, as a part of the surgeon's armentarium, is a thing of the past, having been, quite properly, superseded by the artificial kinds. They are made chiefly of cotton or gauze— preferably the former. Indeed, gauze sponges are seldom used in eye surgery. The regulation shape is fusiform, and the sponges vary in size according to the nature of the operation with which they are to be used. Those destined for the surgery of the conjunctiva and the globe are the smallest, measuring, when freshly wrung, about two inches from tip to ti]), and one- half inch across at the middle. For operations upon the lacrimal apparatus, for enucleations and the grosser plastic operations they are larger, and less fusiform. Tlie properly most essential in a sponge is great absorptivity. It is not alone suiTicient that the cotton from which it is made is highly absorbent, the sponge must be compressed and damp. Dry cotton, no matter how fitting the quality, lacks this property; and so does damp cotton if in a loose wad. Besides, dry cotton is most objectionable in surgery because of the detached fibres getting into the wound and clinging to the instruments. To the most effective the si)onge must be nncly and 32 PARA-OPERATIVE TECHNIC tightly wrung out of the solution with which it is impregnated. It is a mistake, therefore, to make and wring, then sterihze them in the autoclave, and consider them ready for use. They are made too dry and too loose in this way. They should be freshly prepared from sterilized cotton. The hands of the one who makes them are clad in aseptic rubber gloves. Pieces of suitable size are pulled from the roll of cotton and fashioned into shape by the fingers and by rolling with the palms. They are then dropped into the antiseptic solution, covered securely, and left there till needed, when they are wrung again with the gloved hands, a few at a time and put on or in some sort of server. It should be remembered that the tips are the working parts, hence, they should be handled at their middles by both the surgeon and the aid who passes or uses them. By the operating table is an enameled jar with in- verted cone for cover, and truncated by an opening. Into this the discarded sponges are dropped, and not scattered promiscuously all around. Nurses and assistants need considerable training in the matter of sponging before venturing to help in this capacity at an operation. It is no mean art. They must know when to take the initiative, and when to wait for an order to apply; when to hold out the sponge for the operator to wipe an instrument upon, etc. The corneal epithelium is to be spared contact with the sponge whenever practicable. Applicators, Brushes and Swabs.— An applicator may be of metal or wood. It serves merely at the handle for a brush or a swab. Of the metals silver is probably the best adapted to the purpose. Excellent wood applicators are found ready made in tooth-picks, especially those made of bamboo, called Japanese. The great advantage of these is their extreme cheapness, admitting of throwing away after once using. Whatever the material, the eye applicator must be delicate and light. One and one-half to two mm. thick at the large end, thence gradually tapering to a point, or nearly, and ten to twelve centimeters in length. Not infre- quently metal applicators are seen that are roughened, or nicked, for a short distance from their working ends. This will do in a wooden one, that is not used a second time, but is a serious draw- back in a metal one, for reasons given further along. The same objections may be urged to the probe, or bulbous pointed applicator. Formerly, camels' hair brushes were used in the treatment of eyes. In the light of modern medical science they would be deemed abomi- SWABS AND BRUSHES 33 nations, and justly so. The ideal brush, or swab, is now made of absorbent cotton wound onto an applicator. It all lies in the manner of the winding whether the brush or a swab is the result. The difference between the two is just what the names imply — the brush ha\ing a pliant free end and the swab being a compact bunch. To make a brush a small quantity of cotton is taken from the roll and its irregularities of outline are pulled off till it assumes the square shape shown in Fig. 21. It is so held between the left thumb and index that the fibres composing it run horizontally. The small end of the apphcator is laid diagonally across the upper right hand corner (Fig. 21 a), and the shaft of the applicator is revolved with the other thumb and index away from the maker, at the same time the right thumb and finger help the instrument to get hold of Fig. -a, Ti) make a brush, b, To make a swat the extreme corner fibres of the cotton. As soon as these begin to wind on, the left thumb and index take a firmer hold on the cotton, to make the winding tight. All that remains is to continue turning the applicator till all the cotton is wound on, and the brush is made. If it seems too long or uneven, the fibres are pulled out till it assumes the proper dimensions. To make a swab or firm mop, one takes the same thin, square bit of cotton, but before starting to turn the applicator, which is laid on just as for the brush, the fibres are made to run in the vertical sense (Fig. 21 b). The winding is begun as before, but when it has got well under way, the fibres that would otherwise project beyond the end of the shaft, are turned back- ward by the left index, and the turning kept up until all the cotton is on and smoothed down into a good, firm, rounded mass. In both instances the cotton is wound on very tightly. In this way the implement will bear sterilization. No roughening is needed to keep the cotton from slipping off. If made properly, the cotton 34 PARA-OPERAXrV^E TECHNIC will only come off by unscrewing it, as it were, i.e., turning the shaft in the opposite sense, or toward one. In this way it may be stripped off" at once, whereas if the shaft is roughened the cotton will not strip. The brush is employed when the remedy is to be painted or penciled on, the swab when it is to be rubbed on. The swab is also useful in putting ointment into the eye, as well as for rubbing it on. Droppers. — By the term eye-dropper is commonly understood the combination of small rubber bulb and glass tube with narrowed extremity. The word pipette is sometimes used as interchangeable. The last is literally "Httle pipe," and refers to the old medicine dropper, or drop-counter, which consists of a glass tube without the rubber bulb. The small end of the tube is immersed in the liquid and when enough has flowed in, the finger is clapped onto the larger end. The tube may then be lifted out and no liquid will escape till the finger is raised. Both appliances are useful in ophthalmic practice. The pipette is only adapted to the gentle instillation of one or several drops, while the eye-dropper may, in addition, be used for a forceful and copious flushing. This is true, at least, of those with the larger bulbs, for glass and rubber can both be filled. Those with tiny bulbs are specially designed to make it impossible to fill them full — an admirable thing in an unsterilized dropper, as the rubber cavity contains a powder that contaminates. Whether the narrowed extremity is curved or straight makes little difference, though the straight one is more easily cleaned, and will enter more readily into the mouths of vials. The smaller the opening in the end and the sharper the end itself, the smaller the drop that is formed, and small drops are sometimes preferable to large ones. The pipette is free from some of the annoyances caused by the rubber, is easily sterilized, and is sure to work and not to leak. Who has not seen the dropper, in careless hands, made to suck back, by relaxing the hold on the rubber bulb while the tip is in fluid, like blood, or pus? In truth, allowing the tip of either dropper or pipette to actually touch the parts is inexcusable. Much vexation — even calamity — has been caused by getting droppers mixed, putting borric acid solution, for example, into a glaucomatous eye with a dropper that has been used for atropin solution. To obviate this, the bulb may have marked upon it, with indelible ink, the name of its particular drug; or the rubber may be of a different color for each of the more mischief-making solutions. INSTILLATION 35 The method of instilling drops with cither the cyc-droi)j)cr or the pipette deserves a word. A few drops care drawn into the glass tube, the forefinger of the free hand is placed just beneath the lower lid, which is lightly depressed, to open the lower cul-de-sac, the patient is told to look upward, the dropj)cr is approached till Fig. 22.--ALinncr of inakiii'/ instillation with its tip is about one-eighth of an inch above the center of the free border, when a drop is squeezed out and allowed to touch at that point. It immediately enters the conjunctival sac — attracted by the moisture on the inner side of the lid (Fig. 22). If the patient cannot control the lids, the middle fmger holds up the upper lid while the index depresses the lower. In cases of children and 36 PARA-OPERATIVE TECHNIC excessively touchy persons, it is made easier by putting them flat on their backs. The drops should never fall from a height, but should either be made to touch the free border, or be let fall a few millimeters only into the inner canthus. If the cul-de-sac is full of tears, the drop will simply cause an overflow and be wasted. A sponge is first used to exhaust the tears. The systemic effects of poisonous instiflations can be, in great measure, prevented by having the patient compress the canaliculi with the forefinger. It need hardly be urged that the finger must be there before the drop is put in, else the first winking of the lids will draw the solution into the lacrimal sac. This precaution is especially advisable when the instillations are repeated in quick succession. ^Irrigators or Douches. — These refer to various appliances by which quantities of liquid are brought into contact with the eye for Undine, b, Morax compte-gouttes. c, Wickerkiwicz douche, d, Tumbler to show relative size. therapeutic purposes. They work by (i) pouring, as from special vessels, the stream being directed by a spout and controlled by placing the finger as a valve over a separate opening; or by (2) gravity, as from elevated reservoirs, when the stream is directed by a rubber tube and controlled by compressing the tube; or by (3) ejection, as from some form of syringe, in which the stream is directed as in either of the foregoing, but is controlled by pressure upon a rubber bulb. To the first belong the divers glass and enameled flasks known as undines, compte-gouttes, etc. (Fig. 23); to the second, the fountain syringes, the percolators, and the tube syphons; to the third, the bulb syringes, bulb-syphons, and hand-sprays. The eye-dropper is but a form of bulb-syringe. The glass flasks are most appropriate EYE CUPS 37 for gentle washing of the eye. They are neat and eleanly, and the stream is gentle except they be held loo high. They are necessarily of limited capacity in order to be convenient to hold with one hand, therefore adapted to the less copious and prolonged irrigations. Those in the second category are just the ones designed for irriga- tion on the larger scale. The reservoir is of soft rubber, enameled metal, or glass, and may be of any desired size. Some of them are quite elaborate, having means for heating, thermometer attach- ment, etc. Reservoirs of glass, however, will always appeal more strongly to the aseptic instinct, because of their transparency, and their adaptability to all modes of sterilization. The force of the stream is governed by the height to which the source is elevated, and, to a limited degree, by compressing the tube with the fingers. There are different devices by which the licpiid is delivered to the eye after passing through the rubber pipe. The simplest is a nozzle composed of the glass tube of an eye-dropper. Then there are the multiple vent-nozzles, some form of which is very desirable in irrigation of the upper cul-de-sac, particularly in purulent conjunctivitis. Among the simplest is one of, glass, celluloid or hard rubber, of flattened, rounded shape, after the manner of Jaeger's lid spatula, with several openings in the free, or specialized, end. An effective, though rather complex attachment is the irrigating retractor of Lagrange (Plate VIII, No. 93). x\s to the ejectors, their name is legion, and they are, on the whole, least to be recommended, as they are, for the most part, complex, unreliable, and Fig. 24.— Agnew's eye , , r^, 11.1 c si)ray for one hand. bunglesome. The one uncompounded style 01 ' ^ this class is the rubber bulb alone, or the bulb with glass spout, as represented by the common eye-dropper. Their streams are steady, intermittent, or broken into spray. Among the last, one of the least objectionable as well as of the earliest, was suggested by Agnew, of New York, and is known as the Manhattan Eye-douche (Fig. 24). Its extreme compactness enables one to manage it easily with one hand. Eye Cup or Bath.— This is the primitive douche. It is a small cup whose lip is designed to fit snugly just within the bony rim of the orbit. It is filled and put into position with the head thrown far forward— prone. The head is then inclined in the opposite 38 PARA-OPERATIVE TECHNIC direction, or supine, and while the cup is held close, the eye is al- ternately opened and shut. This serves to bathe the cornea and part of the ocular conjunctiva, but, as the lids fit almost water-tight to the globe, the lic^uid does not reach the fornices to any great extent. Irrigation or Douching. — All solutions must he freshly made and of the purest ingredients it is possible to obtain. As a rule, the liquid for the procedure is warm, ioo° or more. It is thus more agreeable and more efficacious. The patient may sit or lie. Towels are placed round neck and over hair. A catch-basin is held — usually by the patient — to catch the overflow\ If the posture is sitting, the basin is held as in Fig. 25, except that it is put more \ Fig. 25. — Manner of liolding catch-basin. Sitting, toward the side upon which is the eye that is being treated. The concavity of the basin is held tight to the neck, and it must be seen to that no part of the towel gets in between neck and basin, so as to overhang, or project above the rim, for this would form a drain that would lead the liquid down the neck. If the posture is lying, the basin is held close beneath the ear and angle of the jaw, as in Fig. 26. Same precautions. The lids are washed and sponged with absorbent cotton. The lids are everted, one at a time or both at once, and the warm solution poured gently on them. The lids OINTMENTS 39 are replaced, the upper one is raised by placing the thumb over the upper rim of the orbit, the patient is made to look down, and the stream is played over the cornea and conjunctiva. The gaze is then ordered upward, the lower lid is depressed by the index, and the lower fornix is irrigated. All the while, the vent of the irrigator, whatever the kind, is held close up, so as not to shock the eye. The cornea, in particular, soon becomes intolerant of the douching unless the force and the temperature of the stream are just right. A very strong jet is justifiable only for the dislodg- ment of a sticky discharge. Under proper conditions, no un- favorable reaction follows prolonged and copious irrigation. Fig. 26. — Manner of holding |)us-t)asin. Recumbent. Ointments. — The fatty media of ointments suitable for use in the eye are chiefly vaselin, lard, castor and olive oil, and lanolin, or a mixture of these substances with varying proportions of bees- wax or paraflin, to give greater firmness. They keep the contained medicament much longer in contact with the cornea than do the aqueous solutions, hence, prolong the effect. Moreover, they do not pass through the lacrimal canal, so that, in case of poisonous drugs, such as atropin, there is less likelihood of intoxication, which 40 PARA-OPERATIVE TECHNIC makes them peculiarly applicable as regards children and women. As this is not a chapter on ocular therapeutics, but one on the technic of applications, the aim here is to indicate the manner of handling and putting the ointment into the eye. The most con- venient, preservative, and sanitary receptacle for the ointment is the collapsible tube of block tin. A very few have ingredients that are not compatible with the tin. Next to this is the light-proof glass, or porcelain box, with screw-cap and paraffined washer. The tube, or box, should be small — holding two dr. to 1/2 oz. Large quan- tities are not admissible, as the ointment should be quickly renewed. Fig. 27. — Method of applying ointment. The ointment is applied by means of the cotton swab wound on an applicator, as described a little further back, or of a naked, smoothly rounded silver probe. If the swab is used, it is first moistened with boric acid solution. This keeps the cotton from taking up too much of the ointment and also causes it to let go easier. The requisite quantity — say, a mass the size of a split pea — is lifted from the box, or squeezed from the tube, as nearly as possible on the very extremity of the instrument. The lower lid of the patient is depressed with the left index, while, with the middle finger, the upper lid is supported. The patient is told to look upward, the ointment is approached to the eye with the probe held in a horizontal position, and parallel with the palpebral fissure, the handle pointing outward; the end holding the ointment is laid gently in the lower cul- de-sac, the patient's lids arc then closed, and the probe withdrawn toward the temple, leaving the ointment behind (see Fig. 27). Caustics. — The peculiar chemical energy of these substances, when brought in contact with living tissues, makes them at once either most serviceable or most pernicious^ — all depends upon the conditions and manner of contact. Among the more common caustics used in ophthalmic practice are alum, sulphate of copper, nitrate of silver and carbolic and chromic acids. They are em- ployed pure or in mitigated substance, or in aqueous solution. Mitigation and solution both mean simply dilution to lessen the severity of the agent. The first is accomplished by mixing with the caustic an inert powder, usually nitrate of potash or borate of soda; the second by the strength or percentage of the solution. The pure, the mixed, and the mitigated substances are all to be had at the pharmacists in sticks, or crayons, ready pointed, fast in holders and with cap to cover. If the crayon needs sharpening this is best done by rubbing it on fine sand-paper, care being taken to keep do\vn the dust; that is, the rubbing should not be done in a draught, and the sand-paper should not be flirted about. Whether applied pure, mitigated or dissolved, the touch to any part of the eye, particularly of the more active caustics, should be by a Ime point. For the solutions, the cotton brush on the applicator is used. The eye is bathed and sponged, the part to be touched is wiped dry with a bit of gauze, then the caustic is applied. As the object is to affect only the diseased area the caustic must be scrupulously kept from spreading to the healthy tissues. If done with the crayon, there will be little tendency to spread so long as nc moisture comes in contact with the spot treated. Hence, in touch ing any part within the palpebral fissure, it is necessary to keep the tears all away by means of the little, spindle-shaped cotton sponge. In order to strictly localize the application when in solution and with the brush, it is essential that there be no super- fluous fluid in the brush. That is, there should not be so much that when the contact is made a drop will be given off, to run down over the healthy surfaces and injure them. The tip of the brush is first touched to a sponge. Here, too, the tears must be kept away, just as in using the crayon. The application having been deemed sufficient, if within the conjunctival sac, the action of the caustic is always nullified at once by ])lentiful douching either with warm 42 PARA-OPERATIVE TECHNIC solution of boric acid or of something that will neutralize chemically, as, of common salt, for example, when the caustic is nitrate of silver. It contributes much to the comfort of the patient if a drop of cocain solution is put in just before the application, and another just after the douching. Heat is most grateful and beneficial to the eye in most all of its Fig 28. — Thermaphore. inflammations and painful affections. It may be applied either dry or moist. A primitive mode of using dry heat is to heat some salt in a skillet, tie it up in a woolen stocking and lay on the eye. A more up-to-date mctliod is by means of hot water in a rubber bag, but the first will still answer in a i)inch. Yet other simi)le APPLTCATIOX or IIKAT 43 modes arc to heat small ])a(ls of cotton or wool in an oven or Ja])anese muff-warmer or, best of all, beneath a hot Hat-iron. Amoni,' the more scientific methods is that by the llicrninphorc, illustrated in Fig. 28, and that l^y the electric pad. 'J'he thermoj)hore con- sists of a double tank for the water. The hot water Hows outward from one tank through a rubber pipe, passes through a rubber coil (A), thence returns through another tube to the other tank, 'i'he heat is supplied by a gas-burner or a s])irit lam]). The one shown in the illustration has four sets of pipes and four coils, suitable for both eyes of two persons, or one eye each of four. The coil is wrapped in a small towel before a])i)lying. In lieu of the elaljorate heating apparatus one may use a jug of hot water, placed some- what higher than the patient's head. From this the water is syphoned through tube and coil, and thence to another jug on the floor. The supply jug is wrapped in woolen cloth to retain the heat. The electric pad consists of a resistance coil contained in an asbestos envelope, and connected by insulated conducting wires with the socket of an ordinary incandescent lamp. The heater is wrapped in dry flannel before using. The temperature of either pad or coil must be carefully watched to avoid burning the skin. If the source of heat is not continuous the application is renewed every few minutes. The duration of either procedure is from 5 to 30 minutes. The temperature is usually as high as can be endured or just short of doing harm. Moist heat may be either i)lain or antiseptic. The simplest form of either is that of bathing or douching. To bathe the eye with a hot liquid the i)atient would better sit erect, so that there is a minimum of blood in the head. Stooping over would cause congestion. The water or solution is contained in a bowl or basin, held close u]) beneath the chin, and is dabbed on, over the closed lids, by cotton, gauze, or a ])iece of clean soft linen. The conjunctival douche is applied as already directed. Or the applications may be in the form of fomentations — plain or antiseptic, such as small pads of cotton or wool, wrung out of the very hot licjuid, or out of moderately hot, and further heated under a flat-iron. This obviates burning the hands of the attendant. As soon as the pad is in place it is covered with a dry flannel cloth or other non-conducting material. Of course, the heat from the rubber or the electric coil may be made moist, plain or antiseptic, by keeping the wrapping of the coil wet with the ap- propriate liquid. 44 PARA-OPERATIVE TECHNIC A convenient and effective method of applying moist heat, often employed by the author, may be thus described: The patient may sit or lie. In either case a catch-basin is held, as pictured on pages 38 and 39. A tuft of absorbent cotton is dipped in hot sterile water, or antiseptic solution, and laid on the closed eyelids. It should be large enough to cover the whole palpebral region, and not more than 1/8 inch thick when wet. Upon this an attendant lets the liquid gently fall from an eye-dropper. In this way the heat is constant, the liquid percolating through to the skin without produc- ing any shock, the patient is not disturbed, as in using applications that need frequent renewal, and the attendant is spared the necessity Fig. 29. Fig. jo. Leitcr's coils of soft rubber tubing for dry or moist heat or cold. of putting the hands into the hot liquid. Cold may l)e apj)lied in the same manner. Cold finds its chief indication in severe, acute inilammations of the conjunctiva, and immediately following injuries of the eye or its appendages. Like heat, it is applied dry or moist. Dry cold is most often from cracked ice, in a rubber bag, laid on the closed lids. A good plan is to syphon ice-water through a very small rubber tube from a large vessel, placed just a little higher than the patient's head through a coil laid on the eye, thence, through a still smaller tube to another vessel (Figs. 29 and 30). This has been called mediate irrigation, and may be either dry or INDICATIONS FOR HEAT AND COLD 45 moist, Leiter's lead coils are too heavy for use u|)on the eye. Moist cold is best transferred to the eye by bits of old, heavy table-linen. This is more absorbent than new linen. One need hardly say llie linen must be aseptic. Pads two to two and one-half inches square, and composed of several thicknesses, are wrung out of ice-water and laid on the lids. A more convenient way is to put a large block of ice into a pan or basin and lay six or eight of the linen pads onto the block. They are patted down into good contact, and, when one is wet through, it is placed smoothly over the eye. Every minute thereafter the used pad is put back on the ice and a fresh one put on the eye. The patient is apt to take a sort of grim pleasure in making the applications himself and can be, with impunity, intrusted with the task. Indeed, this is true of most of the applications of heat and cold. The author has found the following a most convenient and highly effective manner of applying moist heat or cold: The patient may be either seated or recumbent. A catch-basin is so held as to fit snugly to the neck on the side of the affected eye. A moderately large pad of absorbent cotton is dipped into the liquid — hot or cold — that is to be applied, then laid, without squeezing, on the closed lids. The attendant then drops the liquid from an ordinary eye- dropper continuously over the pad of cotton. The cotton remains soft and in perfect contact with the skin, the temperature is evenly maintained, the eye is not shocked by too sudden sense of heat or cold, the patient is not disturbed by any changing of the applica- tion, nor of having the eye hurt by an unguarded finger-bump, and the attendant is spared the discomfort of putting the hands into the liquid. Madame Bonsignorio, p. 200, in giving the indications for heat and cold in ocular therapeutics, says that, generally speaking, heat is sedative and calming, but should never be applied when there is much secretion present nor when there is edema of the conjunctiva. She classes in six categories the eye affections to which heat and cold are appropriate: 1. In the diseases afrigorc; iritis, vernal catarrh, Jicat. 2. In other forms of conjunctivitis, cold. 3. In corneal infections with edema, especially in serpent ulcer, cold. 4. In inflammations of the appendages of the globe, such as phleg- mon of the orbit, abscess of the lids, and acute dacrvocvstitis, cold. 46 PARA-OPERATIVE TECHNIC 5. In glaucoma and retinal hemorrhages, heat, moderate and prolonged. 6. In the deeper inllammations, where there is no tendency to suppuration, like papillitis, chorio-retinitis, cyclitis, and iritis, heat. Most authorities have written that heat is better applied for a longer time than is cold. With this I do not agree, but rather believe with the minority that short sittings of intensely hot applications have much the same effect as prolonged ones of cold. Three to five minutes of the first will accomplish more good, however, than one hour of the second, or than one-half hour of i\v& first. Certain it is that fomentations should not be kept on for twenty and thirty minutes each, and thus kept up for hours. The effect is then much like that of a poultice, and this we all know to be bad. In general, I prefer short sittings for the hot applications— three to ten minutes, as hot as can be borne— 115° to 125° F. for the moist, somewhat higher for the dry, and with intervals not too short — not over four to six in twenty-four hours, unless there is severe pain which is relieved by the heat. The intervals may then, in a measure, be regulated by the paroxysms of pain. Massage. — As it relates to the surgery of the eye, this mode of treatment is useful mainly in connection with paracentesis or iridectomy for glaucoma. It is, however, a most valuable and important accession to ocular therapeutics in general. Its principal virtue seems to lie in the clearing and quickening eft'ect it has upon the local lymphatic and venous channels. Massage is plo.in, or medicamentous, manual {digital, rather, as concerns the eye); instrumental, that is, when an implement of some sort, as a glass rod or a swab, intervenes between the hand and eye; mechanical, as when made by a vibratory machine; and electric, as when per- formed with the electrode of a galvanic or other current. The technic of digital massage is given in the chapter on paracentesis of the cornea, and that of instrumental in that on the surgical treat- ment of trachoma. Tissue Injections. — Among the varying therapeutic tissue injections practised in ophthalmology are the hypodermic, or subcutaneous, the intramuscular, the suh-conjunctival, the sub-tenonian, and the intraocular. They are all made by means of the ordinary hypodermic syringe. The simplest and best form of this instrument is that in which all is of glass save the needle. The barrel has a scale of minims marked on its exterior. The inner surface of the TISSUE INJECTIONS 47 barrel and the outer surface of the piston are ground so tliat they fit exactly one upon the other. The nub at the extremity of the barrel is threaded to screw into the needle. Such a syringe with- stands all standard means of sterilization, and may be kept ready in a strong antiseptic solution. The needle is of platinum, is kept scrupulously sharp, and is sterilized by boiling. The socket contains a soft-rubber washer to prevent leakage. To use, the Ixirrel is filled before the needle is screwed on, then, having put the needle on, the latter is pointed straight upward to expel the air. Enough of the liquid is then shot back into the receptacle to bring* the i)iston to the proper mark on the graduated scale. The hypodermic injection is administered by picking up a fold of skin and plunging the needle into the fold coincident with its long axis, and so as to just miss the tips of the thumb and linger holding the fold, and the fluid is forced slowly in. The plunge of the needle is positive and quick — not hesitating and slow. In this way one gives strychnia and other stimulants to overcome the evil effects of narcotics and shock in the operating-room, and morphin for its quieting influence and for the pain after the operation. It matters little upon what part of the body the fold of the skin is chosen. Having withdrawn the needle, the part is gently massaged to favor quick absorption. It goes without saying that for any form of tissue injection the parts involved are aseptically prepared. In the intramuscular injection the chosen muscle is suddenly and deeply stabbed with the needle, avoiding the larger blood-vessels and the underlying bone. This is the kind usually employed for the administration of solutions of the mercuric salts for their constitutional effects. For the subcon- junctival injection the eye is washed, douched, and cocainized. The lids are held apart by an assistant with lingers or retractors or by the blepharostat. The patient is directed to look up, a vertical fold of conjunctiva is picked up with broad-jawed fixation forceps, just below the cornea. The needle is passed into the lower half of the fold, tangential to, but not hugging, the globe, and pointing somewhat downward. The contents of the syringe, usually some lo or 12 minims of solution, are then exhausted, causing a large bleb of conjunctiva to rise. The syringe is withdrawn, the lids carefully closed over the bleb, and the eye bandaged. This is the form employed in the less virulent infections of the globe after opera- tions, for the local eft"ects of mild antiseptics, like weak salt solutions and mercuric solutions. The most all-round satisfactorv solution 48 PARA-OPERATIVE TECHNIC in mild cases is the physiologic salt. It is followed by little distur- bance when used alone, and is not so painful nor so apt to result in small round-cell infiltration of the conjunctiva as are the stronger salt solutions. None but chemically pure salt is admissible. They are specially useful in the treatment of the lingering forms of uveitis following certain extractions, and certain iridectomies for chronic irritative glaucoma, particularly those characterized by recrudescences. The subtenonian injection is, as its name implies, into Tenon's capsule. Another name is intracapsular injection. It is one of the sheet anchors in the treatment of severe septic infection threatening panophthalmitis. The eye is prepared and the lids held apart as for the subconjunctival injection. Cocain, however, often has little effect, owing to the hyperemia and inflammation that are apt to be present, so that it is advisable in cases of very sore eyes and demoralized patients to narcotize with nitrous oxid. The bottom of the external conjunctival cul-de-sac is seized with strong fixation forceps in such a way as to include a fold of the outer check ligament, the eye being meanwhile in adduction. This is drawn forward (upward, one might better say) and the needle passed backward, deep into Tenon's capsule, following the sheath of the external rectus. The regulation dose with us consists of 12 minims of i% salt solution in which are dissolved i/ioo gr. of mercuric cyanid and 1/25 gr. of dionin. A small dose of acoin or morphin is sometimes added to alleviate the suft'ering that is almost inevitable afterward. Dionin has come to be regarded as an almost necessary ingredient of the last two forms of tissue injec- tions. It adds greatly to the local disturbance which ensues. In fact, the reaction is often so great, and of such a character, as to be positively scarey, especially to a novice. Fortunately, the benefit is, as a rule, commensurate with the reaction, and the latter is, therefore, welcomed. A subsequent injection is not given until the visible results of the previous one have passed away, except in desperate cases. Between mildly reacting injections 2 days, and between the severer ones four to six days, is about the average time — but if speedy loss of the eye is threatened, they may be given daily. If the pain during the reactive stage be great, fomentations as hot as can be borne, are applied to the closed lid, and hot douches to the conjunctival sac. The therapeutic value of these subcon- junctival and intracapsular injections is due, in all probability, to several causes — partly to osmosis, partly to local antisepsis, BLOOD-LETTING 49 and largely to local counter-irritation, and, when dionin is ])rcscnt, also largely to their lymphagogue properties. Intraocular injections are such as are employed in artificial ripening of cataract — into the lens substance — and, in detachment of the retina — into the vitreous or beneath the retina. They cannot be called true and tried measures and have no real place here. Blood-letting. — This venerable tliera])cutic measure seems now to hold a higher place in ophthalmology than in any other department of medicine. This is true, at least, of local or topic blood-letting. General blood-letting, or venesection, is now often resorted to in the treatment of the eye, and it is regaining some of its ancient prestige at the hands of the internists. It is especially valuable for lowering high blood-pressure before operations for cataract and glaucoma. Other names for the last mentioned are phlebotomy and artcriotomy, as indicating whether a vein or an artery is opened. The effects of a general blood-letting (a moderate bleed, say from eight to ten ounces) are seen in a diminution of the blood pressure, though not for long, and on the pulse which undergoes temporary acceleration. In feverish patients the temperature falls and breath- ing is calmer but these effects arc fugitive. The number of red corpuscles is reduced after blood-letting and then slowly returns to normal. Blood-letting is formally contra-indicated: in the young, in old age, in cahexia from any cause, in anaemia and convalescence. With regard to the hour for blood-letting, avoid the digestive period because it might cause vomiting. As to quantity it is not customary to exceed ten fluid ounces. A pint is a maximum rarely reached, nevertheless in strong robust subjects the process may be repeated in from 24 to 36 hours. Bleed- ing may be depletive or depurative. The Operation of Venesection or Phlebotomy. — The patient should be seated in a chair or in bed, rather than recumbent, es- pecially where marked effects are desired, as the more rapidly the blood is abstracted the less will be required to lower the force of the circulation. Standing might induce syncope prematurely, while the prone position might allow too great an abstraction of blood before syncope, which is Nature's danger signal, had been produced. Septic phlebitis is the most serious complication to be feared after phlebotomy, and should be guarded against by rigid asepsis. 4 50 PARA-OPERATIVE TECHNIC The hands of the operator, the instruments, and the field of opera- tion having been rendered thoroughly aseptic, a bandage or cord is tied about the middle of the upper arm, with moderate firmness, o as to arrest the venous flow without interfering with the arterial. Grasping a stick, or roll of bandage, or merely closing the hand tightly will then cause the veins to become prominent (Fig. 31). The median basilic is now fixed by pressure of the left thumb, and, with a sharp cataract knife or bistoury the vein is opened (not divided) obliquely to its long axis at about its middle point. The middle portion of the vein is chosen as being farthest removed from the brachial artery on the outer side and also from the internal cutaneous nerve on the inner side. The first is separated from the basilic vein only by the semilunar fascia of the biceps tendon and may be located by its pulsation, and the second lies on top of the vein, just where it joins the common ulnar vein. Blood will pro- bably flow from the wound in a full stream; but if it does not, bleeding may be promoted by alternately opening and closing the hand. The blood should be collected in a graduated bowl, so as to estimate the amount withdrawn. Ten to twenty ounces will be necessary. It is best to have a sphygmomanometer attached to the opposite arm so as to measure the blood-pressure from minute to minute. The pulse will also indicate when the req- uisite eft"ect has been produced. When this is accomplished apply a dry aseptic compress, and secure this by a figure-of-8 bandage around the elbow, and place the arm at rest until the wound is healed. Occasionally neuralgic pain is caused by the implication of some of the fibres of the internal cutaneous nerve in the cicatrix. Local blood-letting, as practised by the eye specialist, consists in extracting quantities of blood, varying in amount from 1/2 oz. to 2 oz., from a limited area external to the outer canthus by means I, Opening basilic vein, cephalic vein, vein. 4, Basilic vein. 5, Internal cutaneous nerve. 6, Brachial artery. Only the semilunar fascia of the biceps separates median basilic vein from brachial artery. ARTIFICIAI. I.i;i:( II 51 of leeching The leech may ])e natural or arliticial. The best natural leech is tlie Scan(lina\ ian \aritiy, which is lo be had in most of the larger pharmacies. Each one is ca|)able of drawing nearly 1/2 ounce of blood before becoming gorged and letting go. Two of them are suflicient, for if it is desirable to abstract more than I oz. one may increase the quantity to the proper measure by encouraging the aflcr-blrcdiiii^. This will, in many instances, continue till made to slop, which is easily accomplished by holding a tiny bit of absorbent cotton tightly on the bite with the linger. The bleeding having ceased, the cotton is left sticking to the spot. Preparatory to either mode of leeching, the temple is rendered aseptic. Unfortunately, the natural leech cannot be sterilized, but, fortunately, it is naturally a cleanly thing, even if it does live in mud. The most suitable j)lace to aj)])ly the leech, either living or artificial, is that which is on a lexel vrilh the outer canthus, and just external to the outer rim of the orbit. When two or more leeches are applied their heads are ])laced close together I r^iG. S2. — .\ruficial IfC'ch. and in a horizontal line. One who is ex])erienced in applying the leech can guide the animal's head accurately to the point selected for the bite by holding its body in the folds of a na])kin. The tyro would better use a leech-tube. Into this the leech is dropped, big end lirst. The mouth is in the small end that is forever reach- ing out. If the leech does not take hold readily, lightly scraping off the epidermis with a scalpel or putting a drop of milk on at the spot will induce it to do so. Having once begun. to draw blood, it is allowed to remain attached till it falls off. The used, or "stripped" leech is never so good as a fresh one. There are several kinds of artificial leeches. The one bearing the name of Baron Heurteloup is still the favorite. Recently the elaborate scari- fier that formerly went with it has been omitted. The leech is shown in Fig. ;^2. It consists of a metallic ])iston with asbestos packed head fitting \erv tiglitly in a ghiss cylinder and worked by 52 PARA-OPERATIVE TECHNIC a ihumb-scrcw. The skin is scarified at the point indicated for the leech-bite, the free end of the cyHnder is moistened, applied to the part, and the air gradually exhausted by turning the screw. The relief and the improvement that result from leeching are often re- markable, though not usually immediate; from 6 to 24 hours may elapse before the benefits are apparent. It is difficult, therefore, to conceive of the modus operandi. Can it be the mere topic depletion whereby the pain is relieved by freeing the sensory end-bodies from pressure, and the inflammation reduced through quickening the circulation in the blood and lymph channels by the ensuing relax- ation? Hardly. The natural leech seems to be more effective than the artificial, and for this reason I have sometimes wondered if it were not because of its more potent psychic effect. CHAPTER II. INSTRUMENTS AND THEIR MANAGEMENT. "lis doivent etre, pour le praticien, des objets sacro-saints; des objcts auxquels il ne laisse toucher personne de profane, qu'il considere lui-meme avec amour a cause de leur perfection, avec respect a cause de leur desti- nation. II apportera le plus grand soin, non seulement a leur choix, mais aussi a leur enireiien" — Landolt. "They should be for the practitioner, objects almost sacred; objects not to be profaned by vulgar hands — that he regards with fondness because of their perfection, and with respect because of their destination. He will exercise the utmost care not only in their selection, but also in their maintenance." Thus wrote my friend and teacher, nearly 30 years ago, in a little work called "A Box of Instruments^ While with him, he commissioned me to translate it for publication in this country. I sent the English version to a friend in New York who consigned it to oblivion as concerned the ophthalmic world, by turning it over to a journal for general medicine. It was deserving of a better fate — by reason of its subject matter. This, then, would seem a fitting time and place to revive some of the excellent precepts and principles embodied in that book, and to add thereto whatever seems appropriate, in order to bring the subject abreast of the time. The word management in the above caption refers to both the manipulation and the care of instruments. First, as to the instruments themselves: What are the qualities requisite and desirable in them ? This is a broad question and one of many sides. I shall attempt to answer it, not assuming the r61e of an oracle, but as one who has taken an active interest in the mat- ter, both practical and theoretical, for the past two and one-half decades. Much has been written concerning the instruments of the "Vienna School," of the "Parisian School," of the "Berlin School," and of the "London School," but little concerning the ''American School"; therefore, an effort will be made to show also something of what our countrymen have done in the line of surgical instruments for the eye specialist. Of the myriad instruments that have been conceived as applicable to ocular surgery, the vast majority have 53 54 INSTRUMENTS AND THEIR MANAGEMENT not stood the test of time; and it is, after all, remarkable how few really are necessary or desirable. Every surgeon and every maker of surgical instruments, even down to every salesman, has his own ideas on that point. The writer has great respect for the pecu- liar notions of others, especially, in this instance, if they be those of a confrere. So long as his work comes up to the standard, no matter how peculiar his notions, all honor to him. But his imple- ments may not be above criticism. As to the maker, he is prone to regard the matter solely from a mechanical standpoint, without taking into consideration the human element that figures so largely in the material upon which the instruments in question are employed. With regard to the salesman — well, his business is to sell; and as a proof that he fully understands it, witness the manner in which he beguiles the artless and aspiring tyro into stocking himself up with a lot of articles he will never use. The first great requisite in any mechanical contrivance is efficiency, but the maximum of efficiency should be attained along with the maximum of simplicity. And surgical instruments are, perhaps, peculiar in demanding the most rigid enforcement of this law. These are the key-notes. Close after them come such other at- tributes as grace of outline, delicacy of parts, and elegance of finish. They should be simple in the sense of being uncomplicated, as also in that of being plain. These properties are conducive to both cleanliness and dexterity — hence, to safety and success. They should be as light as is consistent with adequate strength, which is also an advantage in their use; hence, the need of delicacy of parts. And they should be pleasing to the eye — of their possessor, at least. This were argument enough for the grace of outline and the elegance of finish; but there are decidedly practical reasons also. One is actually capable of better effort when there is present a conscious pride in his means; again, the smoother and truer and brighter the surface, the easier to maintain, therefore, the demand for attractiveness. Another most excellent tiling in connection with the operative equipment — especially of the oculist — is a certain uniformity, or harmony, of the corresponding ])arts of the different articles. In the form and size of tlie liandles, for example, as also in the size of scissors rings, the length of scissors branches, and in the angle at which the blades of keratomes are set. To be sure, this cannot be carried out to the letter, on account of the inevitably great dif- HANDLES 55 ference in bulk. But most of the smaller instruments in daily use can be made to conform to this principle. There are undeniable advantages in the habitual feel of the instrument imparted to the fingers in this way, not to speak of those as to appearances, that such a collection would enjoy, over a heterogeneous assortment. Among the most obvious essentials in all instruments is superiority of material. This is especially true of the cutting instruments. Unfortunately, this is a quality of which it is difficult to judge beforehand. A few years ago all of our finer steel instruments were made in Europe, and the names of Collin, Liier, Richter, Windier, Weiss, and a few others were not merely guarantees of high quality, as they are still, but they were the and the only ones. Nowadays good and bad instruments are made "all over," and one must take his chances. Certainly the best of those turned out in the United States are second to none. Thus, in a general way, is answered the question as to what are the qualities requisite and desirable in a surgical instrument. And what is true of these as a whole is true of those pertaining to any branch. Now, to particularize. Following Landolt's classification we shall begin with the instru- ments with handles. "And 'n passing, let us bestow a word upon this feature of the instrument — a feature of greater importance than many seem to think. Is it not the intermediary between the hand that guides and the part that engages? Is it not through it that the sensitive fingers of the operator are made aware of the resistance their movements encounter; these fingers which put in touch with the work the reason that contrives, the intellect that seeks, and the power that executes?"^ The handle was formerly made of ivory or bone, but these materials have now, quite properly, yet reluctantly, been discarded for metal, such as aluminum, to admit of boiling. Yet ivory is an ideal material. Its weight is just right. It is a poor conductor of heat and cold, and its best quality is a peculiar adhesiveness. "Clings to the fingers," as Landolt says. Their rectangular, or rather, octagonal form has, with equal propriety, been retained. The classic form is that of a slightly fusiform, quadrilateral beam with chamfered edges. The heaviest part of the beam is at the junction of the first and middle thirds, where, in cross section, it measures 4.5x6 mm. From here it gradually tapers to either extremity, where the cross sections each ^ Passages in quotation marks are Landolt's. DESCRIPTION OF PLATE I. 1. Arlt scalpel, medium. 2. Arlt scalpel, large. 3. Beard scalpel, extra convex. 4. Beard scalpel. 5. Sharp straight bistoury. 6. Blunt curved bistoury. 7. Beer (or Barth) knife. 8. Weber lacrimal knife, straight. 9. Weber lacrimal knife, curved. 10. Agnew lacrimal knife. 11. Graefe knife. 12. Bent lance keratome, small. 13. Bent lance keratome, large. 14. Bent lance keratome, medium. 15. Neuter cystotome. 16. Graefe cystotome. 17. Knapp cystotome. 18. Beard cystotome. 19. Pagenstecher knife needle. 20. Knapp knife needle. 21. Beard blunt dissector S6 PLATK SCALPELS 59 represent a rectangle whose sides are 3x4 mm. for the free end and 3.5x4.5 mm. for the other — not allowing, of course, for the chamfer. The regulation length is about 10.5 centimeters. This size and shape are common, or should be so, to knives, including lances to needles, knife-needles, cystotomes, hooks, curets, wire-loops, spatulas, spoons, spuds, and retractors. There are several reasons for its existence: First, it is handy to hold and to manipulate, adapting itself nicely to the pulps of the fingers. Second as all the working parts arc attached with their flats in the same plane as the greater transverse diameter of the handle, one feels, in turning the handle on its long axis, just how much rotation he has imparted to the instrument. This is of the greatest value in such acts as the making of the corneal section, and in the cystotomy of a cataract operation. One can always know the position of the blade or other implement by noting that of the greater width of the handle. The edge of the blade or the point of a hook moves in the sense of the greater width. Moreover, the name of the maker is supposed to be stamped on the side o the handle that corresponds to the back of the instru- ment, so that, unless it be a blade with double edge, an additional, and often serviceable, sign is given. Landolt suggested that, while none of these instruments should have round handles, the sides should be equal (square in cross section) on instruments one of whose offices is to rotate in working, such as cystotomes and needles. It is just as essential to know the position and direction of the blade of a cystotome as that of a knife. It often disappears behind the iris, but one can be absolutely guided by the two lateral dimensions of the handle, in applying the point to the capsule, and in giving those two quarter turns that are such an important part of the cap- sulotomy. The little difference in the two opposite sides does not interfere with rotation. Then, as to the needle, it, too, has its blade — a double-edged one. It is the proper thing to withdraw it from the anterior chamber, for instance, in the same sense that it entered; but, with the blade hidden in an opaque lens, as is often the case, and the aqueous most likely evacuated, this would not be so easy if there were not the handle to point the way. So much for the handles. Next, for the instruments which they carry, together with a few notes as to their manipulation. Let us begin with the Scalpels. — Of these there should be at least two — one after \'on Arlt's model and another with a blade of sreat convexitv. Arlt's 6o INSTRUMENTS AND THEIR MANAGEMENT is excellent for use in many ways, yet the other, while just as good for all around work, is superior under certain special conditions. The knife in question is one devised by the writer about fifteen years ago, though the latest modification of it has even greater con- vexity of edge. (Plate I, Fig. 3.) Orignially intended mainly for use in blepharoplasty, it has become my chosen knife in most in- stances where a scalpel is needed. It owes its individuality and its value to the extraordinary convexity of that part of the edge which is situated near the extremity of the blade. The length of the latter is about 2.5 centimeters, and its width, at the broadest part, 7 to 8 mm., while Arlt's is 3 to 3.5 centimeters long, and its greatest wddth is 5 to 6 mm. With the ordinary scalpel, held pen-holder fashion, according to rule, and with incisions of average penetration, the extent to which the edge engages the tissues is very slight, being limited to the point and several contiguous millimeters. Even with the handle as near as possible to the horizontal as is consistent with this manner of holding the handle, the length of available edge is less than one-fourth of the whole. Therefore, as regards the cutting quahties of any but the terminal third of the blade, it were as well that they did not exist. It is desirable, then, that the trenchancy of the part concerned be heightened in the utmost. This is precisely what is aimed at in this scalpel. A single point, like that of the bistoury or the Beer's knife, is insufficient, for the reason that it soon loses its keenness; whereas, the extended con- tact unavoidable with an edge of low convexity, is yet more unfitting, because it is less guidable and requires more force on account of the friction. The special configuration of the blade under consideration offers an efficient mean between the two extremes. If held fiddle-bow fashion, as would seem to be the preferable for its use in general, its incisive qualities are truly remarkable. It has the added property of being able to cut nearly as well in pushing as in pulling— 2i veritable fiddle-bow action. With it such measures as the Streatiield counter-grooving of the tarsus, the intermarginal incision to receive the graft in restoration of the free border of the lid, etc., arc particularly facilitated. The custom of making the free extremity of the handle into a blunt dissector or of making "double-header" instruments of any description is to be decried as not in keeping with advanced ideas. Besides, there is little to l)e gained in time or convenience by their use. Who has not seen in the well-known Daviel's spoon combination KNWES , 6 1 the persistence with which the cyslolome member tried to get caught into things while the spoon member was occupied? The very diminutive scalpels often seen may have a place in ophthalmic surgery; if so, the writer has never found it. Bistouries.— Two of these also. One having a long, straight- edged blade, with good, stiff back, joined to the handle by a strong shank, for work such as deeply thrust incisions for orbital cellulitis. The blade should be at least 4 centimeters in length, and 1/2 centimeter wide at the hilt, gradually tapering, by the back, in a slight curve to the point. The other smaller, wnth blade curved, concave on the edge, and extremity neatly blunted. Its length should not exceed 3 centimeters, and its greatest breadth, which is also at the base, scant 3 mm. This has been called a probe- pointed bistoury, and is most useful in enlarging openings, or fistulous tracks, into suppurating cavities, or leading to foreign bodies in the orbit, etc. It would also answer, in a pinch, for extending an inadequate corneal section in extraction. Beer's Knife. — One of these is sufficient, and it should be of the true Beer, or, rather, Barth, pattern, i.e., not of convex edge, like the old Beranger cataract knife, but straight both edge and back, and somewhat smaller in all dimensions than that of Beer. Three centimeters long and 8 mm. at the widest point is ample, w^hereas the original w^as 4 centimeters long by i centimeter for the rise of the hypotenuse. Although no longer employed in the capacity for which it was intended, yet for the incision of hordeola, and of chalazions by the Agnew method, through the border of the lid, there is no knife its equal. Lacrimal Knife. — Owing to the few occasions, these latter days, for Bowman's operation, a single representative of this class is enough; and my choice would be for that of Agnew. The blade, including the probe, is i 1/2 centimeters, of which the probe and its neck comprise a trifle more than one mm. The back has a slight convexity, and the edge a more decided one. The greatest width is at the middle, where it measures 2 mm., and it is connected with the handle by a round, malleable iron shank, about 31/2 centi- meters long. The object and advantages of this last feature, in adapting the knife to the overhanging brow and permitting of its entrance into the nasal duct, are too well known to dwell upon. The Weber knife is lacking here, and the neck of its probe, being too long and curved, renders it liable to snap off in the tissues. 62 IMSTRUMENTS AND THEIR MANAGEMENT Graefe Knives. — One could manage to get on with three cataract knives, provided he were within convenient distance of a reputable instrument maker or repair shop, but from four to six would not be considered an excessive number. Graefe knives, in common with all keratomes, are the most exacting of all the ocular instruments as to their keeping. This is especially true of the point. No matter how faultless the edge, if the point is not perfect the instru- ment, for the moment, is worthless. So exceedingly delicate is it that the merest touch against the box in which it is kept, or against the tray or dish in which it is cleansed, or against the towel in wiping it, and it is out of service. For these reasons it is advisable to have a reserve supply, and, in preparing for an extraction or iridectomy, to make ready two such knives lest one should come to grief. The blade of the most approved model is 30 to 32 mm. long, full, strong, 2 mm. wide at its base, where it joins the shank; at this point also it is full 1/2 mm. thick, and from here both width and thickness decrease by insensible degrees toward the extremity, till, within 4 or 5 mm. of it the width is reduced to less than i i / 2 mm. From here the lines converge, in a slight curve, to form the point. An error, often found in connection with the Graefe knife, is that the more pronounced narrowing of the blade begins too far back, and that, instead of the opposite sides approaching in the correct outward sweep, they do so in straight lines. This makes a long, needle-like point, that is extremely frail and difficult to keep in order. On the other hand, too abrupt a termination, while not so objectionable as the kind just described, is also objectionable in that it lacks penetrating equalities. These defects are more apt to be acquired at the hands of unskilled repairers than to be present in the new instrument. The back is scrupulously rounded. Blade and handle are connected by a pedestal-shaped shank fully 1/2 centimeter long, which must be strong and firm. Lance Keratomes. — It would be well to have not less than four, say two with blades of average dimensions, the third of somewhat larger, and the fourth of smaller measurement. This knife is usually referred to as the keratome, and, although strictly speaking, it is not any more of a keratome than any other knife that is used to incise the cornea, usage has made it more entitled to the name than the others. Its origin was, in England, as "the bent lance." and it came to be known in Europe as the "English lance-knife." It has undergone many modifications and been put lo many uses. CYSTOTOMES 63 The present model is essentially that given by Friedericli Jager, and its employment is almost exclusively confined to corneal incisions for iridectomy and, in short, all operations requiring a linear, corneal opening, of relatively limited extent. Czermak recommends it for making the intermarginal incision in restoration of the border of the lid in trichiasis. The blade is almost an equilateral triangle, the measurement from heal to point in the median line, consti- tuting the altitude, being greater by one mm. than that across the base. The dimensions of the average size, of which it is well to possess two, would be 9 mm. for the base and 10 mm. for the altitude. Those of the other two 7x8, and loxii mm., respectively. Jager's blade was set at an angle of about 45° to that of the handle. This has been found too great a bend for any but the most deeply sunken eyes. The most convenient angle for all around utility is about 35°. And I quite agree with Knapp in recommending, as has been stated, that all the keratomes be set at the same angle. These four, at any rate. On rare occasions a narrower and comparatively long blade, and an ordinary one, of good size, mounted on a bayonet shank (Bader's) would come handy — the first, for instance, in certain optic iridectomies, and the second for extraperipheral iridectomy in a subject with great overhang of brow. Landolt's well-known keratome with the broad curved shank, and the blade with rounded corners, is a practical instrument, but as it requires special manipulation because of the peculiar construction of the shank, one should have either all or none of this style. Cystotome. — One is a necessity^ — two would be almost a luxury. Those in the market are mostly modifications of \'on Graefe's. It would be better if they were the original model, for it is a splendidly conceived instrument. The outline of the blade is very suggest i\e of the side view of a goose's head (Fig. S3) It will be obser\-ed that the back of the head of the goose is well rounded, and that the throat, from beak to neck, is a light concavity Now, what passes in this country as the Graefe cystotome is commonly an ugly, angular affair, something like that shown in Fig. 34, being a mere spike, or peg. The back of the head is a right angle that catches in the incision and in the iris; and the throat is another angle in which rust and bacteria can accumulate. The idea seems to prevail that only a scratching point is required in a cystotome— that a cutting edge is a superfluity; and, doubtless, many a bungling capsulotomy is the result. A mere point does not ntt, it simply 64 INSTRUMENTS AND THEIR MANAGEMENT tears. The point punctures the anterior capsule, and, unless there is an edge, and a sharp one at that, to make an incision, the alleged capsulotomy is nothing but an indiscriminate laceration. Knapp's cystotome is an example of an incisive one, but it too is objectionable by reason of its angularity. Someone has given to the Graefe cystotome a small cutting extension backward which adds to its efficiency. The author has used for the past ten years a cystotome on the Graefe principle, only the head of the goose is larger, and the trenchant part is prolonged a little way into the neck (Fig. 35). Fig. ^3. Fig. 34. Fig. 35- Fig. -,6. Continuing the simile, the tip of the beak is on a lower level than the top of the head. In other words, the back of the blade is a parabola. This disposition of the point makes it easier to introduce and to push beneath the iris than if it were on a level, as is the Graefe cystotome, or actually in advance of the rest of the blade, as in the Knapp (Fig. 36). From the back of the head to the tip of the beak is 2 mm. The center of the crescent that constitutes the blade is I mm. wide, or even 11/2 mm. The shank measures 22 to 25 mm. The objects in having it larger than the Graefe are to make of it a cut- ting instrument of greater significance, thereby enhancing the pre- cision with which it can be guided and inspected, and, in a measure, to forestall the ravages of those who afterward put it in order. One grinding w\\\ often reduce a smaller cystotome to a bare remnant, and leave no semblance of its former shape This instrument is not so large, even at the beginning of its career, as to make its size an objection. Of course, it is not presumed that the entire edge of the blade will engage in the cai)sule at any one o])eration, but it is there, and ready to cut, if called upon. Contrary to what has been said relative to tlie length of bhide in the cvslotome, I KNIFE AND STOP NEEDLES 65 have noted, time and again, both in operating upon pigs' eyes and upon the human subject, that the tiny spike of the pseudo-Graefe instrument, especially after a few improvements ( ?) at the hands of the sharpener, failed to so much as touch the capsule in places. With the anterior chamber empty, and the lens bulging forward, its anterior convexity is rather increased, so that, with an insignificant blade, unless one takes pains to see that the point is applied, by lifting the handle, the shank will rest on the summit of the lens, in starting the capsumlotoy, and the point be thus kept from reach- ing the capsule. Knife Needle. — One of these would be thousands. Were this article to specify the model, it would be that of Knapp. Not the pigmy thing only 3 or 4 mm. in length one sometimes sees going under this name, but a blade of respectable proportions, or about 8 mm. long and i 1/2 mm. wide. Nor should it have a shoulder, or offset, where knife and shank unite, as is most often the case. This goes with a jerk through the incision made by the knife. Pagenstecher's discission knife is also a first-class instrument, and is well suited for discission by the way of the corneal base, or the conjunctival route, which is fast becoming the only method. The advantages of this mode, together with a method of preparing old worn Graefe knives for use in the operation, in place of needles, or knife needles, is given in the chapter on Discission. Stop Needles. — The various types of discission needles, like the long, straight, spear-pointed, the sickle, etc., have mostly fallen into disuse. One among them, however, is still in favor. This is the stop needle of Bowman. As it owes its prolonged life to its value in the operation of dilaceration, it is best to procure a pair of them. In view of the fact that in this procedure the needles are passed through transparent cornea, they should be gotten up in manner so slight and dainty as to insure a minimum of traumatism. The little rhomboid terminations ought not to exceed 2 mm. in length by i mm. in width. It is best to have the edges lightly convex, as this not only helps in penetration, but also gives lee-way for sharpening without spoiling. The size of the shaft between rhomboid and shoulder should be 6 to 7 mm. long by 3/5 of a mm. in thickness, and the larger, or upper, part of the shaft should not leave off suddenly, leaving a square offset, but should taper — but rapidly — into the lower part. By this arrangement there is no sharp angle to catch dirt, no corner to injure the corneal epithelium, 5' 66 INSTRUMENTS AND THEIR MANAGEMENT and, most important, the sloping shoulder serves as a stopper to keep back the aqueous. Tattooage Needle. — This is an instrument seldom needed except in a large charitable clientele, and there they are supplied. Besides, as the cases are not usually emergency ones, there would be time enough to get the instrument after getting the patient. However, the instruments for the procedure are described under Tattooage of the Cornea. Blunt Dissector. — For shelling out tumors, extirpating the lacrimal sac — in short, for use wherever blunt dissection is indicated; also for loosening the periosteum in total exenteration of the orbit, the writer has had constructed a modification of Fenger's blunt dissector. Its blade is lanciolate, lightly curved on the flat, has a suspicion of transverse rounding out on the convex side, and a low, longitudinal, median rib on the concave side. Its length is 3.5 centimeters, and it is 6 mm. wide at its middle. (Plate I, 21.) Sharp Hooks (Plate II). — One, or possibly two, of different pat- terns, would be ample in this line. This is an instrument whose place, in certain emergencies, no other instrument can quite fill. There are two well-known classes of the sharp hook, viz., that which is very minute, and whose bend is short. This class, of which there have been a number of modifications, goes back to Beer. Its surviving representative is that which bears the name of Tyrrell, and whose crook is precisely like that of a button-hook. The other class is descended from the vectis, of Gibson, but is more closely identified with Von Graefe. Here the bend is either angular or but slightly curved and is much less acute. The first-mentioned kind was destined solely for an iris hook, and as such it has chiefly been used. If, however, it is given less of the backward bend, that makes it like a button-hook, and the crook is opened out somewhat, it makes an excellent instrument with which to deliver rather tough cataracts that are loosened and are well forward — generally more or less within the anterior chamber — yet, that it is not practicable to get out by pressure. The other hook has none of the backward bend in beginning the crook, but goes off from the shank almost at a right angle, and is very slightly curved. Its appearance is more that of an old-fashioned dissecting tenaculum in miniature. This is, by far, the most suitable instrument with which to go fishing for luxated cataracts that lie deeper, that is, behind the iris, and for the softer ones that are in the anterior HOOKS 67 chamber. It can be dug deeper into the lens, and more readily than the other, and if it becomes entangled in tissue that is not wanted, it can be more easily extricated. For remarks on its ad- vantages over other traction instruments in cataract operations see chapter on the Immediate Accidents of Extraction. Suffice it to say in this place that, although it is a simpler matter to scoop out such lenses, along with other things, than to catch them deftly on the hook without disturbing the other contents of the globe, there can be little question as to which is the better method. Could I have but one of these hooks, I would choose the one last described. These hooks should be of the best steel, and exceedingly fine and delicate. The length of the more curved one ought not to be more than one mm., and that of the straighter should be i 1/2 scant. Blunt Hooks. — There are also two kinds of blunt hooks, but one kind and one hook is enough for anybody. Their only difference is as to size. Both were designed as iris hooks, i.e., for catching the pupillary border, not as was Beer's, for catching in the stroma. The larger is attributed to Himly, and is about as lumbering a thing as can well be imagined. The other is known, in this country^ as Tyrrell's. It is, truly, a tiny button-hook, seeing that it has not only the form, but the blunt point, as well, and is much more dainty than Himly's. In the sometimes difficult task of seizing with forceps the funnel-shaped iris of aphakial eyes, for instance, and for the extraction of some adherent and much shrunken cataracts, Tyrrell's blunt hook will come nobly to the rescue. Its form and its smooth, round point peculiarly fit it for its insertion and with- drawal through the corneal wound, The mode of using it is described under Agnew^s Blunt Hook Operation. Squint Hooks. — There are three standard sizes of such hooks, and at least one of each should be provided, for each size has its appropriate uses. There is a vast difference in the crooks of squint hooks. Some makers seem to think that all that is de- manded is to give to a round rod of steel of definite size a given bend. But those who understand the exigencies of the instrument know that the correct fashioning of its working extremity is no mean job, either as to the configuration of the bend or as to that of the metal comprising the bend. The bend is far from a right-angle one, as has often been stated. It may be best described as an arc of a circle. True, the chord of the arc makes a right angle with the long axis of the stem or shank. And it must be insisted upon that DESCRIPTION OF PLATE 11. 23. Bowman stop needle. 24. Tattooage needles, round form. 25. Tattooage needles, flat form. 26. Beard extraction hook. 27. Tyrell blunt hook. 28. Stevens squint hook. 29. Graefe squint hook, medium. 29'. Graefe squint hook, large. 30. Prince divulsor. 31. Silver spatula. 32. Tortoise-shell spatula. ;^;^. Daviel spoon. 34. Bunge exenteration curet. 35. Pagenstecher e.xtraction spoon. 36. Round curet. 37. Olive curet. 38. Saw-edge curet. 39. Beard exenteration knife-spatula. 40. Weber wire loop. 41. Snellen wire loop. 42. Grooved foreign body spud. 43. Flat foreign body spud. 68 PLATE IT. IRIS SPATULA 71 the chord be that of a true circle— not of a parabolic curve. In the Graefe hook, which is the largest of the three sizes recommended, the radius of the arc is 5 mm., its height, or rise, is 2 mm., and the length of its chord, which, as said before, is at 90° to the stem, is 9 mm. In the intermediate hook— suggested, I think, by Landolt — the chord measures 7 mm., and in the smallest, that of Stevens, it measures 5 mm., the rise, and the radius being proportionately less The sides of the hook are flattish, i.e., in cross section the crook would represent an oval, whose short diameter is constant in every part of the bend, being about 1/2 mm. for the largest and the intermediate, somewhat less for the smallest. The long diameter of the oval in the Graefe hook, gradually increases from 2/3 mm. at the center of the curve, to i 1/3 mm. at the free end, the same being true, though relatively less, as to the other two. The extremities in all are smoothly rounded. This form gives a crook that is readily inserted beneath a tendon, is not so slight as to allow the latter to slip off easily nor so pronounced as to be difficult to dis- engage The Graefe hook is adapted to the work of picking up the tendons in enucleation, and that of holding the tendon, well spread out, for the placing of sutures, etc. The medium hook answers for the same purposes, but is better adapted to the picking up of the tendons in tenotomies and advancements. The Stevens hook is, preeminently, the hook for the partial tenotomy. It is remarkable to what an extent the Graefe squint hook has become an all-around handy instrument. As examples of its uses are the following: In extirpation of the lacrimal canal, if the hook is passed beneath the sac as soon as that organ is oposed, the dissection is greatly facilitated by working the hook up and down between cupola and the nasal duct. In the removal of the corneal portion of a pterygium it serves admirably as a divulsor. In the withdrawal of bits of iron or steel from the interior of the eye through a wound or incision, the hook may, on occasion, and with advantage, be inserted at the opening, then put in contact with the tip of the magnet, instead of introducing the tip itself. It is employed to express the lens in the extraction of cataract, especially in the "Indian" operation. It is frequently made to act as a retractor in holding a])art the lips of incisions. Iris Spatula.— The tortoise-shell spatula is an ideal instrument, and the hard-rubber one but little inferior. Unfortunately, they 72 INSTRUMENTS AND THEIR MANAGEMENT cannot be — at least, they are not — fastened to the metal handle in a manner that will allow of their being boiled. They can, of course, be made aseptic by other means, but there is a sense of security in being able to boil all the instruments, for a particular operation, that comes of no other method of disin- fection, so that every one should be boilable. The best spatulas, to my knowledge, that conform to this principle, are those of silver and of gold. If of the last, in order to have the re- quisite strength and elasticity the fineness of the metal should not exceed lo k. The blade, including the shank, is 3 1/2 centimeters long, and is i 1/2 mm. wide throughout, and not more than 1/4 mm. in thickness at the middle. It should be lightly curved on the flat, and the edge thinned down to the point just short of trenchancy. The extremity should be rounded and, if anything, there should be less thinning of the edge at that point than along the sides, to pre- vent wounding the iris in poking. It must be seen to that the metal spatula does not have a wiry edge nor become nicked. Extraction Spoons. — Here too it is a pity we cannot con- sistently enjoy the luxury of tortoise-shell, but we must content ourselves with either solid or German silver. Two are required- one for use behind the incision, the other to make pressure from below; the first flatter and broader than the second. The name spoon is really applicable to the model of this instrument only so far as it concerns the external form, i.e., there is no bowl to the spoon — it is solid or plain. They are not intended for scoops nor for curets. Earlier spoons had a concavity because they were used to scoop or lade out something — usually more or less of the cataract. Its presence, however, in the expression spoons of to- day is about as useful as the appendix or any other rudimentary organ; and also, like the appendix, it is simply a place for things to lodge. The outline of the spoons is like that of a pear, but, unlike ordinary spoons, the broad end is the one that is free. Their long axes measure about 8 mm. The smaller spoon measures 4 mm. at the widest place, and the larger 5. The smaller is a trifle over a millimeter in thickness, the larger, a trifle under. The back is a regular convexity, i.e., without a longitudinal rib, and the front is perfectly flat. The edge is faintly rounded and smooth. The broader spoon is the same as that of Weber, excepting that it is not hollowed out, and the other, very similar to that of Graefe, though, in addition to the concavity, the latter has a great curve CURETS 73 in the shank that supi)orts it. In the shank of each of those here described there is a gentle bend in its terminal third. Curets. — Called also Sharp Spoons. Every outfit should con- tain several of them. One or two fair-sized ones for the curetment of granulating pus cavities, for example. If two, it were well to have one of them fenestrated, as this kind is easier both to clean and to sharpen. Obviously, it is not so well fitted for the double pur- pose of scraping and scooping. Then, too, let one be circular and the other oblong. Their greatest diameters should not exceed seven mm., nor the smaller four or five. The depth of the bowl must not exceed i 1/2 mm., and it is important that the edge should have a moderate tlare. Then, a small curet with finely serrated edge for such work as the obliteration of the sac or cyst wall in the operation for chalazion and for getting rid of little islands of the uvea in exenteration of the sclera is invaluable. It may be either round or slightly oval, measuring about 3 mm. across. Without going too extensively into curets, one might also venture on the acquisition of one for loosening the contents of the globe in exenteration. The most suitable form for it would be oblong and thin, and with a decided flare to the edge. For this purpose the writer prefers his exenteration knife-spatula. Exenteration Knife-Spatula. — This is an improved instrument invented by the writer ^ for the removal of the contents of the sclera in the operation of exenteration of the globe (Plate II). As its name indicates, it partakes in qualities and uses of both knife and spatula, being a little too dull for a knife, and too sharp for a spatula. It consists of two parts, a blade and a handle. The blade is double- edged, is about 4.5 mm, wide at its broadest part, where it joins the shank, and gradually tapers to the extremity, where it is neatly rounded. Its length is about 2.5 centimeters. It is curved on the flat for two-thirds of the distance from tip to base, to correspond to the meridional concavity of the sclera, and transversely convex on the outer surface to fit the equatorial concavity. Its inner surface is flat. The edges, while not so keen as is the edge requisite in a Graefe knife, are, nevertheless, tolerably trenchant. The rounded end is blunt— not bulbous— so that puncture of the sclera may be easily avoided The handle is of aluminum, to admit of boiling, and blade and handle are united by a nicely modeled shank. Wire Loop. — This is sometimes referred to as Fenestrated 1 Ophthalmic Record, July, 1905. 74 INSTRUMENTS AND THEIR MANAGEMENT Spoon, which is a very poor name, yet one sees now and then a wire loop so clumsy that it might well be thus designated. It is needless to state that the object of this instrument is the delivery of a cataract that is luxated or has dropped into the vitreous. Seeing that it is employed at a time when there is a large corneal incision through which the vitreous is either escaping or on the verge of doing so, it is of the highest importance that a wire loop introduced to bring out the lens be so constructed as to cause the minimum of displacement. It must, therefore, be made of wire that is as fine as is consistent with the force exerted, and the spread of the loop must not be needlessly wide. If the wire is stiff and strong — as it should be — its diameter need not be more than 1/3 mm. The greatest width of the older Graefe loop, was at least 6 mm., and its total length was i centimeter. Weber modified the loop by simply stretching it out, as it were, making it 4 mm. wide and I 1/2 centimeters long, but leaving the same coarse wire. Snellen, while adopting Weber's loop, reduced the size of the wire. Next to the open sharp hook, this is the best instrument for ex- tracting lenses that cannot be expressed, and, in inexperienced hands, it is the very best. Snellen's modification of Weber's would be my choice. Lid Retractors (Plate VIII). — For three score years the retractor of Desmarres has stood alone. Its inventor called it an elevateur, because it was originally destined for the upper lid alone. The only change that has been made is the accentuation of the bend, i.e., in the present model the hook of the lid-holder is not so widely open. The trough of the older retractor measures i 1/2 centimeters across the top; in the newer model it is only i centimeter. It is better to have two of these, one for each lid of adults; a larger for the upper lid, the length of the trough of the lid-holder measuring 16 to 17 mm., and a smaller for the lower lid, with trough only 12 to 13 mm. The smaller will also answer for the upper lid in cases of small children. Those with heavily gold-plated lid-holders and shanks are preferable, and their cost is not excessive. Fenes- trated retractors have no special advantages over the solid. Fisher's retractor (see i)age 551) is a very handy instrument in that the s]n-ing- like handle lies fiat upon the head. A very objectionable feature often noted in connection with the handled instruments, such as lance keratomes, cystomes, spoons, curets, scjuint hooks, and wire loops, is the extreme length of the SCISSORS 75 shank. A length of 35 mm. in this part is not uncommon, and even 40 mm. has been observed. To hold these properly by the handle places the fingers too far from the working part, too far from the eye operated upon, and from the patient's face. Twenty-tw^o to 25 mm. is about the desirable length. So much for the instruments of uniform handles; now for those with uniform rings and branches, or the Scissors (Plate III). — In commenting upon incongruous types of scissors that one often sees in the oculist's kit, Landolt says, " When- ever we are confronted, among ophthalmic instruments, with the reminiscences of the grosser surgery from which ours sprang, it is most often in case of the scissors." What was true at the time this was written is true to-day. Not only are many of the scissors destined for eye surgery conspicuously coarse and big, but many of them — yes, the majority — are lacking in the quality of their steel, and faulty as to the articulation of the blades. As with the scalpels, it is mainly the terminal portion of the blades that is concerned while they are in use. But, if the coaptation of the blades is not perfect, it is just this part that suffers most. A defect that occurs with exasperating frequency is the failure of the edges to overlap, or pass each other, at the end of the blades, or ''forking." This comes of the greater wear in this location and of the sharpener failing to adjust matters as he should. The instrument will have a longer life, without undue shortening of its blades if these over- lap very decidedly when new. Landolt thinks that the automatic fastening is, in a measure, responsible for the inferior cutting qualities of some scissors. Arguing that, because of one's ina- bility to tighten the fastening when the scissors get loose, as can be done with those that are joined by a screw, the only recourse is to cramp the blades by pushing forward the thumb ring and pulling back that of the finger. This may be true, but I have been unable to detect any difference in the working of the two kinds. The advantages are largely on the side of the automatic when it comes to a question of keeping them free from rust and filth — that much is certain. With regard to the rings — these are supposed to accomodate, one the thumb, and the other, the third finger up to the first joint. They will then be large enough for any but digits of extra volume. The problem is solved by letting the regulation pattern conform to this principle and compelling the acromcgalian to have his y6 INSTRUMENTS AND THEIR MANAGEMENT scissors made to order. With respect to the branches, there is no good reason why they, too, should not be standardized as to length, seeing that the variations in the dimensions of the blades are not so great as to be in the way. With the thumb and ring finger inserted as stated, and the middle finger resting upon the outside of the adjacent ring, as is the correct position for holding the scissors, the length of the branches should be such as to permit the tip of the index to fall naturally upon the pivot of the blades. (See Fig. 37). This means, for the average hand, a measurement of about 5 centimeters from the pivot to the junction of branch and ring. Any marked increase of this length tends to cause wabbling, and any material decrease restrains freedom of action through cramp- ing the fingers. The scissors used by the oculist are all so small that whatever latitude is necessary in making the relatively slight differences in strength need not affect the aperture of the rings nor the length of the branches. It is merely a question of the weight of Fig. 37. — Manner of holding scissors. these parts and of the proportions given to the blades. Those that have branches 4 mm. wide by 3 thick, and blades 31/2 centimeters long, 8 mm. wide and i 1/2 mm. thick at the base are strong enough for any of the usual work. The daintiest iris scissors have branches 2 1/2x2 mm., and blades 21/2 centimeters long, 5 mm. wide, and I mm. thick at the base. It follows, therefore, that there are no great differences in size after all. A question that has often occurred to mc is: TT7/y do so many pairs of scissors have sharp points? The instrument does not advance by puncturing at two contiguous points, then uniting these points by tearing the intermediate tissue! Tlic cutting point is STRABISMUS SCISSORS 77 that just where the edges intersect, which constantly moves forward as the blades are closed. The tissue that is being divided is caught in that angle. There can be no office for those needle-like extremities excepting to do mischief. They should be abolished. The tips would simply need to be blunted by slightly rounding them. It is even doubtful if there is now any branch of surgery in which incisions are made by first piercing the tissues with one sharp blade, then closing down the other to effect the cut. Formerly this was not an uncommon practice. It is at present confined to the trades. Neither is there any more a place for the elbowed scissors, with one blade probe-pointed, though they are still with us, emeritus, as it were. But enough of generalities. Let us make a few selections. Strabismus Scissors. — -Those generally acknowledged to be best adapted to squint operations are so small as to be only one grade heavier than the iris scissors described a little way back. They are lightly curved on the flat. To be more exact, the radius of the curve is 4 centimeters, and the bend is regular. This is a sharp enough curvature for any scissors — in fact, it is about what is proper for all of that character used in eye surgery. Yet one often sees them with a curve having a radius of only 3 centimeters. And, that the scissors may work smoothly and be easier kept in order, it is essential that the curve maintain about the same radius throughout. I say about the same, for it must be remembered that this cannot be mathematically true of curved scissors, as the curve of the inner blade must be a trifle greater than that of the outer. This is shown by the fact that when the blades are closed there is always a narrow, crescentic space between them. The blades of the strabismus scissors are about 27 mm. long, and 5 mm. wide at the base. From here they taper to the extremity, where the width of the two, with the scissors tightly closed, is one mm. and the combined extremity is nicely rounded. Broad, clumpy ends would better be rejected. In order to be strong enough, the base of the blade should be i 1/2 mm. thick plus, and, at the end, fully 1/4 mm. This form of scissors has a more extended range of application than any other eye instrument, and one should possess at least two pairs, though it were well to have the second pair just a shade heavier — not longer. Stevens' strabismus scissors are useful but not notably better, for the work for which they were designed, than are those just described; and it even seems that, by reason DESCRIPTION OF PLATE III. 44. Strabismus scissors, small. 45. Stevens strabismus scissors. ' 46. Blunt strabismus scissors, medium. i 47. Blunt scissors, curved, medium. j 48. Sharp scissors, curved on the flat. \ 49. Enucleation scissors, medium. j 50. Enucleation scissors, large. 7« ENUCLEATION SCISSORS 8l of the peculiar narrowing down of their extremities, they "buckle" easily and are difficult to maintain. Enucleation Scissors. — Having the last-named heavier scissors, a special pair, for cutting the optic nerve, are not really necessary. To sever it, together with the surrounding vessels and nerves, would put no strain on scissors of this strength. Yet it is perfectly fitting to get the extra pair. They should be but a trifle heavier than the stronger strabismus scissors. Their blades might be 3 centimeters in length, and their extremities a trifle broader. I have a pair that I purchased in Vienna, while a student there, the branches of which are 9 centimeters long and the blades 4 centimeters. The base of the blades is one centimeter in width. They were regularly sold for enucleation scissors. They look now as if they belonged to a veterinary kit. Terson,^ of Paris, is the originator of a pair of enucleation scissors that appeal strongly to one's sense of practicality and fitness (Fig. 38). The blades are perfectly smooth and slightly curved on the flat. They are of precisely the same lateral dimensions, so that when closed their borders are exactly even. Their extremities are broadly rounded. Their most striking peculiarities lie in the fact that the inner or concave blade is extremely thick, while the outer, or convex Fig. 38. — Terson's enucleation scissors. one, is proportionately thin, and that neither blade is beveled or cut away at the side corresponding to the edge. The thick blade holds or pushes the globe forward at the time the optic nerve is severed. Straight Scissors. — Two pairs of straight scissors are needed. One extra strong pair, with blades 31/2 centimeters long and 8 mm. across the base, for canthotomy, cutting mucous grafts from the lip, enlarging cutaneous incisions, etc. One blade should be heavier at the end than the other, and neither must be sharp-pointed. The second straight pair are built on delicate lines — blades 27 mm. long and scant 5 mm. across the base, and with the combined rounded ends i mm. wide. These are best for making straight incisions in the conjunctiva and in a number of ways. 1 Annales d'Oculist, Dec, 1905. 6 DESCRIPTION OF PLATE IV. 51. Small iris scissors. 52. Luer's iris scissors. 53. Straight blunt scissors. 54. Enucleation scissors with hemostatic clamp. 55. Canthotomy scissors. 56. Straight sharp iris scissors. 57. Sharp-pointed angular scissors. PLATE IV. IRIS SCISSORS 85 Iris Scissors. — It is customary among oculists to have a pair of extremely delicate, curved scissors exclusively for cutting the iris. .The smaller pair of strabismus scissors would do in an emergency, though their points are a little too thick for cutting the membrane close to the cornea. The blades of the regulation iris scissors are about 21/2 centimeters long, 4 mm. across the base, and taper down to a fine, not keen, point where the thickness of the two superposed ends does not exceed 1/3 of a mm. Such scissors are also useful in the excision of minute tumors of the conjunctiva and about the lid margins. They have largely given way to the De Wecker's Forceps Scissors (Plate VII). — Many of the merits of this valuable instrument are discussed in the chapter on Iridec- tomy. It is marvelously contrived, yet simplicity itself. The scissors arrangement is peculiar in that the blades are not united by a pivot. The fastenings are high up, one nearly midway of the branches and the other at the top. The lower one is so constructed that, in closing the wings with the fingers, it forces the branches apart. This constitutes the spring that keeps the blades open — or opens them after closure. The blades are about 7 mm. in length and about i 1/2 mm. wide at the base. The ends of the blades are made both blunt and sharp, or one blunted and the other sharp. For my part, I prefer to have them both blunt. The scissors are set at an angle of 125° to the branches, or a reverse angle of 55°. The entire length of the branches, including the button at the top, is a little more than ten centimeters, and their greatest width 8 mm. These are the dimensions given the instru- ment by De Wecker and by his instrument maker, Matthieu. Common faults of it, as it appears in the shops, are heaviness, too strong a spring, and want of proper coaptation in the blades. The great advantage the forceps scissors possess over ordinary iris scis- sors is, that by the upright position in which the instrument is held while making the excision of the iris, the hand is brought close up to the site of operation, which adds immensely to precision. Besides their legitimate office of cutting the iris, they are also valuable for ex- tending an insufficient corneal section in the operations for cataract. Other Forceps Scissors. — Any than those of De Wecker are seldom employed; yet there are times, as, for example, when one has to deal with a dense membranous cataract, a closed pupil with aphakia, that defies all other means of establishing an opening, when a tiny species of scissors, suitable for work in the anterior 86 INSTRUMENTS AND THEIR MANAGEMENT chamber, becomes an absolute necessity Fortunately, these needs are found in the Charriere capsule scissors or the Dowell iris scis- sors. The tirst is patterned after the ingenius Desmarres' capsule forceps; the second enjoys a most fitting model all its own. Its curved and forceps-like branches and its diminutive pivoted blades make it superior to Charriere's as regards manipulation. A fair- sized, not too peripheral, incision is required. This brings us to the Forceps. — This group is composed of many classes, and of all llic instruments comprising our selection, the greatest number going under one common name will be representatives of the said classes. As it is with the scissors, the great trend of instrument makers is to manufacture eye-forceps that are too bulky and clumsy, to make their springs too stiff, and to neglect properly tempering the steel, especially in those with the more delicate extremities. Fixation Forceps (Plate V).— There are various kinds of forceps used in ophthalmic surgery more or less for the purpose of steady- ing, or fixing, the parts. By way of distinction, therefore, the name is almost wholly restricted to that which is employed to immobilize the globe in operations that involve it or its external muscles. Among other kinds are the rat-tooth, mouse-tooth, advancement, and lid forceps, etc., so, as each of these is well named, we may, with propriety, restrict the term fixation forceps as stated. This instrument is made either with or without a catch for locking the jaws. The lockable kind is fast falling into disuse, especially for operations under local anesthesia, in which the globe is opened, because of their startling effect upon the patient in unsnapping the catch. In narcosis this objection does not hold, but it is some- times impossible to make the thing let go instantly, as, for example, when the virtreous is escaping. The catch is useful at times, however, therefore it is well to have one pair with, and one without it. In all respects save those referring to the locking device, the two instruments are alike. The best and most elegant forceps of all classes, to my notion, are those made in Paris, and the dimen- sions here given relate to these. The total length of the fixation forceps is ii centimeters and 3 mm., and the greatest breadth 8 mm. The articulating portion of the jaws is 4 mm. in extent, is provided with sharp, angular teeth that dovetail together, and is slightly concave to fit snugly against the sclera. Those in which the teeth cross each other, so as to project slightly from the jaws wlicre the forceps is closed, are surer to hold. When the teeth are FIXATION FORCEPS 87 insignificant or worn down, the holding power is not to be depended upon. As to the locking variety, it behooves one to see that the catch works easily and smoothly. In case the hold seems insecure, it can be made firmer by picking up the conjunctiva and tissue beneath in a rather large fold and giving it a twist. Barr s Fixation Forceps.— W. A. Barr, Chief of Clinic in the author's service at the Illinois Eye Infirmary, has so modified the Fig. 39. — liarr's fixation forceps. ordinary model as to greatly improve it (Fig. 39). The change consists in imparting peculiar curves to the terminal portions of the prongs, and a given angle to the jaws. These curves and angles enable the operator to apply the forceps to the globe in such a manner that the hand which holds the instrument is neither cramped nor in the way. Beard's^ Fixation Forceps, with the collaboration of Mr. V. Miiller, an instrument maker of Chicago, the writer, a few years Fig. 40. ago, set about attempting to improve upon the models of this in- strument in general use. The chief aim was to produce a fixation forceps that would not necessitate the awkward bend at the wrist, and the placing so much in evidence of the hand that steadies the eye in such operations as extractions and iridectomies. The first product of the effort was an effective, though rather too com- plicated affair, whose jaws emerged from one end of a tube by pressure of the forefinger upon a knob at the other end. This was abandoned in favor of the model shown in Plate VH and Fig. 97. This is an adaptation of Mathieu's forceps-scissors to the needs in question. The scissors blades are left off, and in their place are the members of the forceps. Instead, however, of moving in the same sense as the scissors, the lower portions of the instrument are given a quarter turn, so that they are set in a position at right angles to that of the *See Ophthalmic Record, Feb. 1907, for more desirable text on this forceps. DESCRIPTION OF PLATE V. 58. Fixation forceps without lock. j 59. Fixation forceps with lock. 60. Rat-tooth forceps. \ 61. Mouse- tooth forceps. ,! 62. Strabismus forceps. ^ 63. Dressing forceps. J. 64. Median tooth iris forceps. 65. Forster capsule forceps. j 66. Wecker capsule forceps. .j 67. Knapp capsule forceps. 68. Toilet forceps. ^ 69. Correct cilia forceps. ■ . 70. Large cilia forceps. ^ && PLATE \- Mmmm V iil''"'!'''Sli MOUSE-TOOTIT FOECEPS 91 scissors. Thus it is not necessary, in lixing the globe to turn the tips of the lingers holding the forceps to such extent that they ])()int toward the operator (Fig. 41), and the forceps hand is got out of the way and out of the light (Fig. 42). Rat-tooth and Mouse-tooth Forceps. — These two kinds are, as their names would inij)ly, distinguished only by their size — except- FiG. 41.— Position of hand hoMin.t,' --traiglu forceps. ing that, rarely, the larger has a couple of extra teeth. The general proportions of the rat- 00th forceps are the same as those of the fixation class. The jaws, howe\-er are not extended laterally, but are flush with the extremities of the branches. The teeth are very strong and about i mm. in length There are usually three teeth, so arranged that the one, in the center of one jaw, fits nicely between the two in the other jaw, and, when closed, the extremity of the forceps is smooth, i.e., the teeth do not project. The mouse-tooth 92 INSTRUMENTS AND THEIR MANAGEMENT forceps is but a smaller type of the same instrument, though it never has more than three teeth. It measures lo 1/2 centimeters in length and 6 mm. where broadest. The larger kind can be very well dispensed with, and its place be taken by the catchless fixation forceps. But the smaller is an absolute necessity. Indeed, rather than invest in one of each kind, it would be well to get two of the Fig. 42. — Position of liand holding Beard's forceps. mouse-tooth. When the mouse-tooth forceps is defective, it is usually as regards the teeth. They lack size and strength or they do not interlock perfectly. Dressing Forceps. — These are exact counterparts of the mouse- tooth forceps excepting that, instead of teeth, the inner aspect of the jaws presents a series of transverse serrations. A mistake often seen in the make-up of this forceps is that only the terminal tips of the jaws come in ap])osilion williout undue pressure upon the IRIS FORCEPS 93 branches. There should be contact for two or three mm. without squeezing. This is the most suitable forceps to aid in removing sutures. It also makes a good, all-around, toilet-forceps, and is valuable for handling the thread in advancement operations. One is a plenty. Iris Forceps. — There exist a great number of varieties of this instrument, yet there are but two in ordinary use, and they are all that one needs to procure. These are distinguished only by the disposition of their teeth, and are known as median-tooihcd and Z)ac^-toothed. In general construction, the median-toothed is like the mouse-tooth forceps, the only difference being in the size and shape of the extremities. The terminal thirds of the branches are cut down to about 1/3 the dimensions of the mouse-tooth, and they are made to end in a gentle curve that lies in the same plane as the fiat of the branches. This curve extends for one centimeter from the end of the forceps, and it has a radius of about 6 mm. There is considerable diversity in the inclination of the chord of the arc that constitutes the curve, with reference to the axis of the forceps. As it is with the blades of the lance-keratomes, so should it be with this inclination, i.e., it should be the same in the several forceps. A convenient angle for the chord is 45°. That is, the grand angle is 135°. The roughening on the branches that serves to give it a safe hold to the fingers is situated lower down than it is in the mouse- tooth forceps. This is the forceps for all uncomplicated iridectomies. For iridectomies in cases where there is posterior synechia, or for those in aphakial eyes, etc., the back-tooth iris forceps is the more serviceable. Here the teeth, instead of being situated between the opposing ends of the branches, arise from the back, or convex, edges of the branch terminals. In the one instance the bite of the teeth is at right angles to the axis of the forceps, and in the other, parallel with it. In one, the teeth are flush with the ends of the blades, in the other flush with the back edges of the blades, and on one side with the end also. It is a serious fault in this variety to have the teeth at a little distance from the end of the branches on both sides, for in attempting to seize the iris that membrane might be pushed down, out of reach of the teeth, by the free end of the forceps. The back-tooth forceps often have five teeth — two fitting the interspaces of three. Forster's are thus. Sometimes there are more than five. Again, the teeth are directed somewhat backward and project in interlocking; or they are made bayonet 94 INSTRUMENTS AND THEIR MANAGEMENT fashion, i.e., arc made to occupy a ])lane still farther back than the posterior edge of the jaws. Such arrangements have very doubtful advantages and some serious drawbacks. The projecting teeth make them difficult to insert without catching, and, with the long, sharp, projecting teeth, there is danger of wounding the lens if the latter is present. Indeed, these more savage instruments are only fitted for capsule forceps. (Page 556.) Capsule Forceps. — For the occasional thickened capsules, and for those of adherent lenses, a forceps is needed for tearing the membrane off and extracting it— a rrachement. Those that bear the name of De Wecker serve the purpose well. They are some- thing between the ordinary back-tooth forceps and those exaggerated ones just mentioned in that their teeth occupy a very slight offset at he back of the jaws. This forceps can be made to do very well in place of the back-tooth forceps. Like all the small toothed forceps they must be closely watched to see that the teeth are neither broken off nor out of line with their notches. An important point in the selection of iris and capsule forceps, if not, indeed, as regards that of all the ophthalmic forceps, is to make sure that the springs by which they open are not too stiff". "In order to manipulate an instrument with the greatest delicacy and certainty, said manipulation must, like the simple hold between the fingers, call for the least possible force. In other words, the strength which we must exert to hold our iris forceps shut destroys just that much of the nicety and precision in handling the instru- ment and of the daintiness of touch. While insisting upon it that the springs be soft, let it not be understood that the branches, or members, themselves should be flexible. On the contrary, they must be firm and rigid. This principle is illustrated by examining certain forceps and noting that the extremities of their jaws open, instead of closing, when their (too weak) branches are pressed upon. Rotary Iris and Capsule Forceps.— To this class belong those of Liebreich and of ^latliicu, and their advantages are explained in the chapter on "Operations Upon the Iris." Toilet Forceps.— For making the toilet of the eye after iridecto- mies and extractions the dressing forceps arc not well adapted, being too straight and too big. Hence, the small, curved toilet forceps of De Wecker, are recommended. This is nothing more nor less than or(h'nary iris forceps, dc])rivcd of their teeth and supplied, FORCEPS CONTINUED 95 instead, with the fine crosswise roughening similar to the dressing forceps. Like it, too, there should be contact of the jaws for a short distance from the ends of the branches— say for about i mm. Cilia Forceps. — A scientil'ically wrought cilia forceps is not always to be had. Most of them arc ])a(l. Landoll says, "I can- not fancy what evil genius ]nirsucs this lilllc instrument. It seems to be fated to bear a form that is neither graceful nor suited to its purpose. Time and again, and unceasingly, cilia forceps are fabricated that have jaws as big as shovels, heavy enough to crack nuts, and, in shape, suggestive of the hoofs of a horse placed base to base" (Plate V, No. 70). It is precisely this horse-foot construc- tion that constitutes the objection most frec^uently found in cilia forceps. That is to say, the area of the opposing surfaces of the jaws is too great or it reaches too far from the tip. Hence, in at- tempting to pull out a fine hair, through squeezing together the branches the proximal edge of the broad articulating facet acts as a fulcrum, to pry open the distal parts of the jaws, and the hair is let go. An effective cilia forceps would be about 85 mm. long, 8 mm. wide in the broadest places, and the branches should be of good thickness (Plate \', No. 69). The roughening for the fingers should be carried to within 1.5 cm. of the extremity of the jaws. The latter should not be more than 2 to 2.5 mm. wide, by 1/2 mm. deep, and should have their articulating surfaces elevated i mm. above the inner planes of the branches, and be perfect with respect to coaptation. To interpose a peg or pin between the branches in such a way that it will not permit of their being bent inward by too much pressure of the fingers is a good idea. Moderate pressure in epilation gives better results than does excessive. Advancement Forceps.— To those who feel the need of forceps for clamping and holding the tendon in squint operations, I would recommend Prince's advancement forceps. Their jaws are set at an angle, in the plane of the flat of the branches, consist of one spiked member and one correspondingly perforated one — or, in technical phraseology, of one male and one female member. For the rest, the instrument is identical with the locking lixation forceps. This is a simpler and more effective tendon-clam]) than is that of De Wecker. Trachoma Forceps. — This subject is treated of in the chapter on the "Surgical Treatment of Trachoma." Lid Forceps and Clamps (Plate \'l). — In this class are included DESCRIPTION OF PLATE VI. Prince advancement forceps. 71 72. Prince expression forceps. 73. Knapp expression forceps. 74. Noyes expression forceps. 75. Kuhnt expression forceps. 76. Warlamont adjustable lid clamp. 77. Beard lid forceps. 78. Desmarres lid clamp. 79. Wilder chalazion forceps. 80. Hunt chalazion forceps. 96 PLAl'E VI. HEMOSTATIC FORCEPS 99 not only all the forceps used for holding and fixing the lid, but also the lid clamps. In fact, the two instruments cannot be separated into distinct classes, as one merges into the other. True, there are lid forceps and lid clamps, pure and simple, but more often it is a combination of forceps and clamp. The modern lid forceps spring from " Jager's T forceps. The original is still in use, as it deserves to be. Of course, it needs a locking attachment. This should be either the sliding catch or the old-fashioned screw, for in these the force of the grip can be regulated. The spring catch does not admit of any adjustment, either as regards grip or thickness of lid. Du- jardin's T forceps, on the same principle as Jager's, are too savage, because of their teeth. Lid clamps are usually some modification of that of Desmarres, i.e., the essential features are a plate to go beneath the lid, a ring, whose circumference coincides with the outer border of the plate, and a slide, or a screw, to lock the branches. Knapp and Snellen enlarged the plate and left off that part of the ring corresponding to the free border of the lid. In order to still further enlarge the field for operating within the ring, Warlomont has devised an expansible plate that spreads out like a fan. This is placed, unexpanded, into the upper fornix, when, by turning a screw on the end of the handle, the moveable parts of the plate can be made to flare so as to put the cul-de-sac upon the stretch. The ring coincides with the expanded plate. This is evidently an im- provement over the older models when it is a question of the more extended entropion operations, for example, as greater scope is afforded for free incisions. But for smaller operations, like chalazion, etc., the others are just as good, and they are far simpler and easier as to their keeping. For chalazion, Wilder's clamp is handy. (See "Chalazion.") For fixing or steadying the lid and for clamp- ing it to prevent hemorrhage in restoration of the free border, as also in median tarsorrhaphy, and to fix it in electrolysis of the cilia, the lid forceps invented by the writer^ (Plate VI, No. 79), is an efficient instrument. The branches, being attached at the ex- tremities of the jaws, are out of the way for work on either side of the clamp. Hemostatic Forceps. — One must have two or three of the lightest pattern — Tate's or Halstead's model. Those with long branches — measuring 9.5 centimeters from the pivot to the extremity of the rings — are less in the way than ihe short, or dwarf, kinds, as ' Ophthalmic Record, Jan , 1905. DESCRIPTION OF PLATE Vll. 8i. Liebreich rotary iris forceps. 82. De Wecker's forceps scissors. 83. Sand's needle forceps, with duck-bill. 84. Knapp's needle forceps. 85. Noyes iris scissors. 86. Dowel scissors. 87. Todd tendon tucker. 97. Beard fixation forceps. 08. Halsted mosquito hemostatic forceps. PLATE VII. NEEDLE FORCEPS IO3 the latter necessitate placing the hand that liolds them close to the seat of operation. The jaws, from ])i\()t to end, sliould not exceed 2.5 centimeters. The working extremity of the jaws should be 2 mm. wide, and slightly rounded. The branches are best if light and elastic. Those with a series of notches for the catch are con- venient, simple, and effective. Needle Forceps. — Those constructed upon the principles em- bodied in the still highly approved instrument devised by Sands, of New York, are the favored of all eye surgeons. The circular jaws of the Sands forceps have mostly been discarded for the more desirable duck-bill jaws, and instead of deep grooves for receiving Fig. 43. — Stephenson's needle forceps. the needle, thus limiting the number of positions in which it can be placed, the surfaces of the jaws are either simply roughened or else they are lined with metal softer than steel, such as copper. It has been urged that, without the grooves, curved needles are more apt to be broken. This is contrary to my observation. Some clever genius — some say Knapp, some De Wecker, some Weiss — thought to turn the free end of the lever toward the handle, whereas, in the Sands model, it is toward the jaws. This arrangement puts the hand that holds the instrument further away, and permits not only greater freedom of movement, but more room for handling the other implements concerned in the operations. The snap catch is to be preferred to the slide, as its manipulation is easier and causes less joggling. It adds to steadiness and leverage if a transverse plate is attached on the side opposite the catch, whereon to rest the forefinger. This plate is lightly guttered to ht the index. The closer the lever, or the catch, to the jaws, the less unsteadiness in letting go of the needle, hence those needle forceps that, like hemostatic forceps, have the catch at the ends of the handles are objectionable. It would really seem more scientific to employ a simple grip forceps, without a calch, wlienever practicable, as the shock and twisting consequent u])on tlie unlocking are doubtless pernicious. Needle forceps without any form of lock or catch are, however, of doubtful value in any kind of eye surgery. The great DESCRIPTION OF PLATE VIII. 88. Jaeger lid spatula. 89. Mules repositor. 90. Mellinger-Beard blepharostat solid lid holders. 91. Mellinger-Beard blepharostat fenestrated lid holders. 92. Landolt nasally operated eye speculum. 93. Irrigation retractor. 94. Small Desmarres retractor. 95. Desmarres retractor. 96. Terson enucleation shield. 100. Conical dilator. 104 PLATE VIII. lU.KI'IIAkOSTATS 107 objection being that I hey cannol be so deflly turned about in the hand to assume the \arious re(|uisile i)()sitions without dropjjing the needle from their grasp. In order to obtain more freedom and ease of handhng, one often shifts the hand back to the extremity of the handle. This is a movement of which the catchless forceps will not admit. Moreover, there are certain advantages in using a needle-holder that can be conveniently handed to the operator ready "loaded" by an attendant. A good model of the simpler forceps is shown in F'ig. 43. Blepharostats (Plate VIII), or eye speculums, as they are popu- larly called, can be quickly disposed of. There is no end to their variety, but, since the appearance of the Mellinger speculum, most of the others have been relegated to the scrap-heap. Practically all of its predecessors had branches, of greater or less length, pivoted at one extremity, carrying lid-holders of divers configuration at the other, and bearing, somewhere between the branches, a more or less complicated locking, or setting, device. As a result of the increasing divergence of the branches in the opening of these blepharostats, the tendency is to pry the lids farthest apart at the free end of the lid holders. Gaupillat dared even put pivoted lid-holders on, to obviate this defect. Then, the catches, ratchets, screws, levers, and things with which the locks were operated— contrivances more cantankerous, especially at critical moments, it were dilTicult to imagine. Both these faults were done away with at once in the Mellinger instrument. Its branches remain parallel in all stages of separation, and its locking is accomplished in a truly automatic manner. The tighter the lids grip the holders, the more rigid the branches, yet no degree of gripping can interfere wdth instant closure of the blepharostat. Moreover, the lids can be forced apart by simply pressing upon the ends of the sHdes. The first of these blepharostats were unnecessarily heavy and big, and the length of the handle or lever portions of the branches was out of pro])()rtion to that of the arm portion. Some years ago the writer suggested the lengthening of the handles and the shortening of the arms, thus affording more leverage for the operator's fingers, and less for the patient's lids; and also the lightening and reducing of the whole mechanism so as to make it more delicate and compact. Two years ago he set about making an improvement in the lid-holders and in the spring, especially designed for cataract operations. One objectionable feature of the majority of lid-holders had l)een a IC8 INSTRUMENTS AND THEIR MANAGEMENT bar that rested beneath the \u\. ]\Iany and many an eye has been sacrificed to this, i)articuhirly in operations for the extraction of cataract, by its catching in the wound. Another was that the cilia and the ducts opening in the Hd border were suffered to polkite the site of operation. The Landolt model has not the bar, but it has the other objection. Only the old, solid lid-holder of Weiss, (or Laurence) was free from both. Yet in all other respects, the Weiss blepharostat is a ^•ery clumsy affair, the lid-holders being merely two straight gutters, adapted neither to the curve of the free border nor to the convexity of the globe. Gaullipat and Lang overcame one of these defects by making the bottom of the trough convex, in order to fit the concavity of the lid-margins. In addi- tion to this curve the blepharostat shown in Plate \' IK, No. 90, has another at right angles to the first, by which the inner wall of the gutter is made to conform to the convex surface of the globe, and the outer wall to that of the outer surface of the lid. Moreover, the inner wall of the trough is made decidedly lower than the outer, so that its rim will not press up in the fornix, as such pressure tends to produce spasm of the orbicularis and to restrict the rotation of the globe when the patient attempts to look downward, the very direc- tion in which he should look during most operations. The impor- tance of this feature will be appreciated when it is remembered that the conjunctival sacs of many of the cataract subjects are shrunken and the cul-de-sacs shallow. The comfortable way in which the lids are held apart with this form of blepharostat reduces the inclination to squeeze, and the eye can be rolled upward repeatedly without risk of eversion of the corneal flap. The shape of the lid- holders renders them a trifle less easy to put in place than some others, but this is not to be considered in comparison with the readiness and safety with which the instrument may be removed. I first thought that it would be needful that one should have a pair of such blepharostats — a right and a left — with a smaller, straighter trougli for the lower lid. This was found to be an error. Indeed, the manner in wdiich the present form depresses that lid gives unusual opportunity for manipulation of the fixation forceps. The whole appliance is made of solid nickel, hence easily kept bright. Tlie arms, being flat, can be easily bent, in the fingers in order to adapt the blepharostat to the varying prominences of eye and temple. This obviates any need of the jointed arms which were also a part of the very ingenious Gaupillat blepharostat of some twenty years ago. PROBES AND NEEDLES . lOQ With regard to the spring, it was discovered that its loose ends could become jammed in the slot through which glide the slides, and that so tightly as lo make any movement of the arms impossible. Besides, the springs were made of steel, which soon got rusty and out of true. At my suggestion, the Messrs. Miiller, who made the modified instrument, put on spiral springs of non-corrosive material, and with the wire at their extremities soldered into a continuous circle. The spring has barely sufficient strength to keep the grooves of the lid-holders applied to the free borders and not strong enough to stretch the eye open too forciljly. Jager's Lid Spatula, or Horn Plate. (Plate \III, Fig. 88.) — This well-known and serviceable implement must be in every oculist's outfit. Lacrimal Probes and Sounds are discussed in the chai)ter relating to the surgery of the lacrimal apparatus. I beheve, how- ever, that Weber's conical sound is not mentioned there. This is Fig. 44, a valuable instrument, but rather than have the "double-header" kind, I would choose two distinct instruments, having the top portion merely for a handle (see Fig. 44) . Sewing Needles. — Aside from a very few special kinds, the ophthalmic surgeon habitually employs the various grades of regularly curved needles. The radius of the main extent of the curve of the finest needles is about i centimeter. From this they gradually increase up to about 1.7 centimeters, which is about the radius of the coarsest. The length of the needle corresponds to about 1/3 the circumference of a circle. More highly curved, or those including more than 1/3 of the circumference of the circles thev represent, are not, as a rule, desirable. A si)ecial needle, for use in advancement operations, is described under "JMuscular Advancement." All needles are supposed to have sharp edges as well as sharp points, and their eyes should be smooth and rounding where the thread strain falls, and a large as practicable. The so-called self-thrcadcrs are all right for most operations, but for those in which it would be disastrous to break the thread, they are not to be trusted, for they cut the strands, thus causing both ir- regularity and weakness. no INSTRUMENTS AND THEIR MANAGEMENT A certain number of ordinary probes and cotton carriers, pref- erably silver, and our selection is complete. Manipulation of Instruments.— In this connection, Landolt, with characteristic terseness, remarks, "Just as, by the mere act of grasping a foil and putting himself on guard, the classic fencer is distinguished from the pretended swordsman, so is a surgeon of correct training, the moment he touches an instrument, dis- tinguished from the autodidactic operator. The last may succeed, for example, in extracting a cataract without losing the eye— his work, as a whole, may be attended with fairly good results— but no one will deny that, in point of perfection of results and number of successes, the advantage will always lie on the side of right training." How obtain this training ? Assuredly not standing around oper- ating tables and " looking on !' ' One would as \vell try to become an expert billiard player in the same way. A start can be made under the instruction of one fitted to teach. Not necessarily a linished nor a famous operator. Surgery, in this regard, is like music — not all who excel in imparting a knowledge of the art are adepts in its execution, and vice versa. Having been grounded in the elemen- tal principles, constant practice is indispensable. In the beginning only upon the fresh eyes of animals fixed in a mask and upon those of the cadaver. Later, upon those of the living human being, but always, during periods when sufficient opportunity is not afforded for this, keeping up, at least, the work on the animals' eyes. Then, to train the fingers to that suppleness and precision of movement that are of inestimable value to the eye surgeon, all manner of odd moments are utilized. It suffices for this simply to go through with, over and over, the dift'erent motions appropriate to the more important surgical measures, either with the instruments pertaining thereto, with purely make-believe articles, such as pens or pencils, or with imaginative ones, holding nothing. While those move- ments pertaining to the wrist and forearm are not to be neglected, those of the fingers come first. In addition to nimbleness and guidableness, the fingers must possess delicacy and sensitiveness of touch. These are attained both by systematic exercises, similar to those given the blind in teaching them to read, and in acquiring knowledge of many external things, and by the scrupulous care of the hands, particularly of the skin thereon. The avoidance of needless wetting of llie hands with solutions that destroy the epider- MODES OF GRASPING mis, by wearing suitable gloves when engaged in any work or exercise that would otherwise lead to roughness of the skin, etc. The great advantages to be gained from ambidexterity are too well recog- nized to be dwelt upon here, but unless the surgeon is truly ambi- dexter it were far more wise and prudent to sacrifice the mere personal advantages, or conveniences, to precision and safety as regards the operation and its result. Modes of Grasping Instruments.— A great deal depends upon degree of pressure exerted by the lingers upon the object held. Too tight a grip tends to tremor, lack of motility, and general awkward- ness; too light a one, to want of precision and to actual escape of the instrument from the fingers. The happy mean, then, would be to grasp light enough to insure the greatest freedom of move- ment consistent with a secure hold. After this comes the exact position of the lingers relative to the part grasped. This varies both as to the character of the instrument and as to the use it is being put to at the moment. First, as to the instruments with handles. Much has been said about the "penholder fashion" of holding eye instruments. This is a poor illustration. A penholder is held steadily by the tip of the thumb, the pulp of the index, and the inner side of the first phalanx of the mediiis. The motion im- parted to the pen is mainly that of the forearm. No turning, or rotation of the implement is practised or required. Obviously, it is quite another matter when it comes to guiding the objects under consideration. The great factors in the manipulation of the handled instruments are the thumb and the index. Between these the handle is grasped, and by them it is rotated— solely, as concerns its long axis, and partly as regards the other axes. To these ends, the two are placed more directly opposite, even in the so-called pen-holder grasp, than they are in writing — many times di- rectly opposite, with their pulps applied^ — and the medius plays a de- cidedly secondary part Fu;. 45 -Pen-holder in both holding and guiding (Fig. 45). Its functions are to lightly support the grasp and to give an occasional touch in guid- ance. Rotations of the handle, on its transverse axes, are accom- INSTRUMENTS AND THEIR MANAGEMENT plished in great measure by turning the entire forearm, though it is surprising to what an extent trained fingers can effect these movements also. The wrist-joint — i.e., whole- hand movement — is called into requisition much less often in ophthalmic than it is in general surgery. Upper-arm movements are to be limited, but in no Fig. 46.-1.1 extraction right. ^^.^^ restricted. Detailed specification as to the exact manner of holding and directing each of the instruments with handles would, without practical demonstration, be only tedious and confusing. More can be ascertained rela- tive to the grasp by look- ing at the accompanying illustrations, than by writ- ten descriptions (Figs. 45 to 51). Besides, many points in the manipula- tions, peculiar to individ- ual operations, are given in connection with the -In extraction left. Fig. 47. technic of the procedure as it occurs in the body of this book. For the rest, the reader must look to other sources. A word, however, as to the "fiddle-bow" method of holding the scalpel, as shown in cut (Fig. 48). The name, while a little more appro- priate than that of "pen- holder" to the grasp in point, only describes it in part. For here the index is usually placed on the upper side of the handle, near the end that carries the l)lade. The ])ul])S of the second and tliird fingers are placed side by side about midway of the handle, on one side, and the thumb on llie olhcr side, jusl ()p])()site. The Utile linger is best Fig. 48. — Fiddlo-ljow. 'OSnioX OF SURGEON "3 left free. This mode is specially conformable to incisions ihal arc made from left to right, as regards the ojierator, or from right to left when executed with the left hand. Then, too, the position of the surgeon with resjject to his patient, as in extractions and iridectomies, has much to do with the manner of holding and manipulating certain instruments. If one stands at the head, for a cataract operation, for example, the Graefc knife is pilled toward the operator in making the section; if for an iridec- tomy, the keratome is pushed away from him. Whereas, if one stands at the side of the table, or facing the patient, the opposite is true — the Graefe knife is pushed, and the keratome is pulled. The same is true of the other instru- ments, that is, the technic of their handling is reversed. With the sec- tion upward, in the usual direction, and standing at the head, the tips of the iris forceps are pushed into the anterior chamber, the iris is seized and pulled out. The spoon that de- livers the cortex is pulled. Standing at the side these movements are Fig. 49 made in the opposite sense. Each of these positions has its advantages, and ophthalmic surgeons are fairly well divided as to their choice in the matter. It is best to study carefully one's aptitude, and facility of maneuver, in each place •f occupancy, then to adopt, and remain constant to, the one to which he finds himself better fitted. As concerns the control of the patient's "line of regard" the position at the side would seem the preferable one. If, for instance, the patient hears the operator say "Look at me," he will instinctively direct the eyes toward the sound of the voice, whether he can see or not. Said direction will be slightly downward, and is precisely that which is the most favor- able for the entire operation of extraction. Of course, to stand in- variably in cither place one must be ambidextrous. The handling of instruments other than those with handles is treated of further on, where occasion demands. The method of holding the scissors is given on page 76. A word here as to turn- ing them over while in the hand. This is a maneuver that is in fre- quent requisition with curved scissors. The index is removed from 8 -Manner of holding kera- tome — pulling. 114 INSTRUMENTS AND THEIR MANAGEMENT its position with tip resting on tlie pivot, and dropped back to place it opposite the medius. These two serve then to hold the scissors, while the third finger and thumb are removed from the rings. This is done in the order named, and the third finger, on emerging, gives the ring that it just left a push to turn it in the direction of the thumb; this, in turn, on coming out, pushes the other ring toward the third finger, and the latter is at once inserted. The thumb is then put into the remain- ing ring, and the tip of the index put back in its place on the pivot. To be able to manipulate scissors equally well with either hand is an art acquired by a very few surgeons. It is highly con- venient in that it often ob- FiG. so. — ^^anner of holding keratome- pushing. viates changing one's position bodily. The handling of iris and capsule forceps is peculiar in that it rests almost exclusively with the fingers (Fig 51). The pulps of index and medius are placed on one branch, one at either extremity of the roughened area, and the thumb in the middle of the other roughened area. The jaws are advanced into the an- terior chamber by a sort of pulling backward on the part of the index and a pushing for- ward on that of the me- dius, the thumb being, meanwhile, the pivot, so to speak, on which the instru- ment turns. In withdraw- ing the jaws, precisely the reverse occurs. This is one place where the mid- dle finger is called upon for some fine work. The Care of Instruments. ManiKT of holding iris forceps, pushing. First as to the receptacles in which they are kei)t or in wliich they are carried. A great deal has been said in ridicule and dis])aragcment of the ornate cases, all lined INSTRUMENT I5()XF,S II5 wilh silk and \cl\cl; coNcred with morocco, and j^arnished willi ihe name of the owner in nourishes of gold, the idea being that tiiey were unfit for holding surgical instruments because of one's inability to wash and scrub them; that they should be manufactured only of materials thai will bear being boiled or immersed in powerful antiseptic solutions. Now, while it is true that those fancy things are somewhat out of harmony with the recognized principles under- lying modern surgery, it is, after all, really only a matter of taste or fashion whether one keeps his instruments in boxes bedecked with beautiful stuffs or in those of hard wood and metal unadorned. The box in neither case is of itself antiseptic, nor are the instru- ments presumed to be ready for use the moment they are taken from the box. If the decorated box will not bear soaking in strong antiseptic liquids, no more will the others. The silk and vehet and the leather can be w^ashed clean w^ith naphtha and disinfected with formalin, and that is sufficient for any. Granting, then, that one is at liberty to choose the material for his instrument cabinets and his instrument boxes, I, for one, would select hard wood. The rarer and finer and harder the wood, the better. A glass shelf or two might be allowed in a cabinet, but there should be no grand array, flauntingly exposed to view in plate-glass show-cases, suggestive of a pathologic museum. For the most part, these should be made up of very shallow drawers, of the same wood as the rest. The location of the drawers is such that none is inconvenient because of being too near, or too far from, the floor. Each drawer has its lock, and, in addition, a device to prevent it from being drawn clear out of the cabinet. In these, however, only the instruments in constant use should be kept. For the handled instruments there w^ould be racks of the corresponding wood or of ebony, and each notch therein should be fitted to, and set aside for some particular instrument, and the different objects should be arranged according to their characters, i.e., the retractors, the spoons, the hooks, the knives, the needles — • each group should have its allotted space. The scissors and straighter forceps would have their drawers and racks, and be held in their places by delicate springs. The jaws of the forceps would be kept closed by the action of the spring that serves as a rack. All articles, such as blepharostats, odd-shaped forceps, etc., and those not easily damaged would be loose in the drawers, or in separate compartments therein. For the more j^articular odd Il6 INSTRUMENTS AND THEIR MANAGEMENT ones, their indi\idual compartments in the drawers should have hinged or sHding covers. There will always be a certain treasured assortment to be guarded apart, to be spared the vicissitudes of ordinary handling — good new, or newly repaired, knives and scissors and the like. And none shall be left in boxes standing about for thoughtless ones to overturn or meddle with. Super- posed trays, with racks, etc., are apt to be the cause of more harm than of good to the instruments, by falling, tipping, jamming and crushing. For transporting small selections of instruments for appointed operations, at hospitals or other places, a series of small boxes, each containing from one to four or five articles, is better than putting all or any considerable number into one container. If a box be let fall, or if one is lost, the consequent damage or loss will, in this way, be minimized. The more delicate or more valuable the instruments, the fewer in a box. Knives are placed in the racks edge downw^ard. An exception is made as regards lace-knives, which are placed pointing to the left. These boxes can be put together in a leather bag or, what is better, stuck around in the different pockets of one's clothing. The rounded nickel boxes with racks, and holding springs projecting from the under side of their lids are splendidly adapted to carrying in the pocket. For the non-cutting instruments all that is needed is the plain nickel box, with rounded corners — i.e., without racks or springs. A layer of absorbent cotton is put in first, then the instruments, then enough cotton laid on top of them to prevent rattling about. If forceps are put into such a box, each should have a section of rubber tub ng slipped over its branches to keep its jaws closed. Before boiling, the rubber must be removed, else a tarnished streak will appear at the place it occupied. Also, in boiling, the delicate ends of instruments should be wrapped in, or wound with, absorbent cotton, to protect them from injury. All knives should be clamped in racks before boiling. To Protect From Rust. — If steel instruments are put away dry they seldom rust. Especially is this true of those that are kept in dry buildings and of those in daily use. Such as are out of present use or arc being kept for any reason would better be given a coat of cocoa butter, vaselin, or lard. This refers not only to the plain steel instruments, but also to those plated with nickel; for steel in these is often exposed in places. Apropos of nickel ])lating, it should cover all steel instruments except the blades of knives, CARE OF POINTS AND EDGES II7 the edges of scissors, and the jaws of forceps. The custom of leaving it off iris forceps and a few others is inexpHcable. After using, these instruments are washed first with cool water to remove blood, etc., then immersed in very hot water, and, lastly, wiped with soft linen, then dipped in benzin or gasoline, and allowed to dry spontaneously. This last process has the effect of leaving upon the metal an insensible coating of oil which effectually prevents rust. While it is no more than proper that the water should be sterile in each instance, it is not necessary to use any antiseptic. These are only for use preparatory to the operation. It need hardly be ex- plained that the reason the instruments are not put directly into the scalding water after being used is because blood, or other albu- minoid substances with which they are soiled would be thus coagu- lated and made difficult to get off. It has been asserted in many quarters that the process of boiling both corrodes and dulls steel instruments. This is not borne out by experience and observation. If one's experience is that his instruments have suffered in this manner he has probably failed to observe that it was due to something else than the mere boiling. Most often it is because they have remained wet for a time after having been taken out of the sterilizer. Sometimes it is the result of impure water used for the boiling. As an extra precaution against rust, it is important to put a little sodium carbonate (NagCOg) 1%, or sodium hydrate (NoOH) 0.25% into the w^ater. Of all the kinds of moisture to which instruments are exposed, there is none more corrosive than that from sweaty hands. Therefore, after handling only, it were better if the article were washed in hot water and dried. Wiping without previous wetting would not suffice to remove the salts deposited on the metal from the evaporated perspiration. Seeing, however, that this will rarely be done, let it be urged, at least, that they be thoroughly wdped. Our instruments are put through hot water after cleansing with the object of insuring rapid drying, and not that one may dispense with the wiping of them. The drying is as essential as the washing, and the time to do it is while the instruments are fresh and hot from their bath. It is of special importance that attention be given to all angles, joints, etc., to make sure that no moisture remains in them. Care of Points and Edges.— The worst enemies of these are careless and untrained attendants about hospitals and offices, and Il8 INSTRUMENTS AND THEIR MANAGEMENT conscienceless and unskilled workmen in the repair shops. The lirst knock them about, rattle them together, and jab them into things, and the second grind them out of all form and substance, and deprive them of their temper or rightful hardness. Hence, the less these persons are intrusted with our sharp instruments, the ])ctter off we shall be. If the bottom of a vessel containing liquid into which instruments are to be immersed is covered with two or three layers of gauze it will keep them from sliding abeut and being damaged. Certainly, as concerns the more delicate and responsible articles it were decidedly to the advantage of those most interested, i.e., the patient and the operator, if the surgeon himself took sole charge of their care and maintenance, even to the sharpening of them. He who is not already schooled in such matters can usually acf(uire the requisite training without difficulty. If he cannot be an expert, he can at least become enough of a dab. Unless a knife or a needle meets with some accident, as a fall or a jam, whereby the edge or the point is positively damaged, no grinding upon them is ever necessary. They are then never dull in a gross sense. All they need, even after having been repeatedly used, is honing and polishing. These are best accomplished by means of a fine strop and the best of rouge pomade. Pastes contain- ing gritty substances, as, for instance, pumice or emery — no matter how linely these substances are powdered — are ruinous, and ought scrupulously to be avoided. If a point be broken or turned, or if a blade be nicked, the proper remedy is cautious grinding on a whet-stone of good quality, with the liberal use of vaselin or cold water. The great desiderata are to obtain the maximum of keenness or of trenchancy with the minimum loss of substance and to preserve the correct model of the working ])arl of the instrument. Testing. — The most suitable material on which to test the degree of shar])ness of eye instruments is known as French trial kid. This means ihc thinnest and most delicate tanned kid — preferably of an animal that has not gone to tlie full term of gestation — and not split goatskin nor the still more objectionable shagreen, which is made from horses' hides. The instrument is commonly tested with the kid stretched over a drum. I ])refcr to dispense with the drum and mani[)ulate \hv leather with the lingers The ])oinl of a knife or a needlr, lo be right, must pass llirough tlic kid without a jog or au(h'ble tick, and almost without sensil)le resistance. Kera- KNIFE TESTING IIQ tomes, bistouries, cataract knives, and knife-needles should have their entire edges tried, from point to heel. In severing the kid they should not emit a distinct sawing or ripping sound. This indicates a too-pronounced serration, which is only appropriate to the larger scalpels and to the grosser instruments generally. A single puncture or incision is sufficient, as repetitions only result in loss of sharpness. To try scissors they are closed down tightly, making a cut in the kid, then removed from it with blades still closed. If the points hang or catch the leather in the least the condition of the instrument is faulty. Either there is dullness at the extremities of the blades or else there is a tendency to fork. Both are bad, for the reason that the very tips of the blades constitute in the scissors the only parts that actually engage the tissues. Wantonly opening and shutting scissors, when they are not in real use, is highly pernicious, as it spoils their edges, producing roughness and grating. This can be made to disappear, when not too far gone, by passing the edge of the thumb-nail or other smooth object of similar hardness along each blade, pressing /ro;;z the flat, or articulating side, toward the bevel. A BALANCE FOR KNIFE TESTING. Smith, Priestly, Birmingham (Ophth. Review, Aug., 1903), has devised a simple instrument to determine by actual measurement the pressure which we have to emplo)' to cut or puncture the leather of the test-drum. It resembles a see-saw in miniature. One arm of the beam carries a small drum covered with the thin white kid (shagreen) sold for this special purpose; the other is marked with a scale indicating grammes, and carries a sliding weight which gives to the drum an upward pressure varying from o to 18 grams. To test the point of a knife the drum is placed in a horizontal plane, the point gently pressed against the leather, and the weight moved until the knife persistently punctures the leather instead of depressing the beam. All punctures should be made in the transverse diameter of the drum so as to be at the same distance from the fulcrum. To test the edge, the drum is placed on edge, vertically, and the knife, passed through a slit in the leather, is pressed downward without thrusting or sawing. Using a given piece of leather for all, a number of knives may be compared and placed correctly in order of merit. We can measure the effect on a given knife of immersion in boiUng water, of antiseptic fluids, or of use, and compare various models of puncturing or cutting instruments. Good Graefe knives, new or newly sharpened, puncture at a pressure of I to 2 grams. They cut at from 10 to 14 grams, and with a tight leather some of them at 8 grams. As a rule, they cut more easily near the point. Cataract needle-knives cut at 14 to 18 grams. Cystotomes, new, punctured at 4 to 8 grams; resharpened, at 10 to 18 grams. CHAPTER III. OPERATIONS UPON THE APPENDAGES OF THE EYE. THE LACRIMAL APPARATUS. Dilating the Punctum. — Probes or sounds and the canulas of lacrimal syringes up to one millimeter in diameter may be passed through the undivided punctum by first stretching this opening somewhat. The measure usually suffices to reestablish the punctum when superficially closed. The Most Suitable Instrument is the conical probe or stylet of Landolt (Plate VIII, No. loo), a modification of Bowman's "di- rector." The kinds commonly on sale by the dealers in surgical instruments have cones that are too long, slender, and sharp. Their excessive length and slenderness are objectionable because they necessitate a maximum of entrance into the canal with a minimum of dilatation of the punctum. The point of the excessively long ones might bring up against the lacrimal fossa ere the stretching was sufficient. Their sharpness of point is objectionable for the reason that it is apt to wound the walls of the canal, causing false tracts, etc. The cone, then, should not exceed two centimeters in length, gradually tapering from a diameter of two millimeters at the shank to that of one-third of a millimeter at the point. The latter should be neatly rounded or, better still perhaps, have an olive-shaped bulb whose greatest diameter could be one-third to one-half a millimeter. Every eye surgeon, doubtless, has noticed with what facility a tiny bulbous extremity on knife or probe will enter the punctum. The dilator or stylet should have a handle to itself, i.e., not at one end of a handle that it shares with another instrument at the other end. These double instruments, of which a number have been made,. do not conform to correct ideas of modern aseptic surgery. To Dilate the Punctum, the patient may lie on a tabic, but ii is better that he sit in a low chair, A towel is put over his hair. The operator stands behind the chair for the lower puncta, and offers his chest as a support for the patient's head. Supposing it is the right lower punctum, the left thumb is placed midway of the lower lid, ])rcssc'(l down li,i:;ht on llic lower rim of llie orl)il lt> 120 LACRIMAL PROBES 121 slightly evert the punctum and put it on the stretch toward the temple to resist the inward pull of the probe. This pressure by the thumb helps also to steady the patient's head. The patient is told to look upward, the probe, anointed with sterile vaselin, is inserted vertically, then immediately turned to the horizontal and pushed along the canaliculus till the dilatation is deemed sudicient and thus held for a few moments. When the progress of the cone becomes a little difficult, slight rocking of it on its long axis will aid its further entrance. If syringing or probing is to follow the dilata- tion, an assistant stands by, holding the lacrimal probe or syringe, as the case may be. When it is time to withdraw the dilator, this is resigned to the assistant, the operator takes the probe or syringe, places the tip of the canula at the punctum, and, still holding the lower lid down and out and patient looking steadily up, the as- sistant withdraws the dilator, and before the opening has time to contract, the canula or probe is introduced. Treatment of the lacrimal canal with dilator and syringe will often result in closure of the punctum within a very few hours because of the rawness and tissuring induced about its rim. To prevent thi whenever i)racti- cable during the early period of handling a smooth stylet dipped in vaselin should be inserted a little way two or three times a day. Probing the lacrimal canal is resorted to mainly for ex- ploration and for rendering it patulous throughout. It should be seen to that the tip of the probe is nicely rounded — in no way sharp nor angular. The latter are common faults with small probes. Fig. 52. — Probe of Bowman. Plain tip. The probes most commonly employed are those devised by Sir Wm. Bowman nearly tifty years ago (Fig. 52). They consist of three double-ended instruments, i.e., six probes, made of silver, each bearing midway a shield to indicate the direction of any bend or curve that may be given to the probe while in use. The shield also bears the figures denoting the sizes. The diameters of those of to-day are graduated by one-half millimeter from one-half up to three millimeters. There are various other forms of the lacrimal probe, notable among them the series devised and successfully managed by Theo- bald, of Baltimore. It comprises sixteen instruments graduated 122 OPERATIONS UPON THE APPENDAGES OF THE EYE by one-fourth millimeters from one-fourth to four millimeters. Most eye specialists do not favor those that exceed four or five millimeters. Whether the upper or the lower route be selected as the better way from punctum to sac would seem to be largely Fig. 53. — Bowman probe. Bulbous tip. a matter of individual choice. Much can be said in favor of either, though the lower canaliculus is favored by the majority and is the one now in question. Bowman's probes are always serviceable, though the bulbous tips go best (Fig. 53). The writer^ employs a series of gold sounds that he devised several years ago, represented actual size in the accompanying illus- tration (Fig. 54), and finds them both serviceable and easy of ma- nipulation. Nos. I and 2 it was thought best to have made of ten- A/° 7 -o /V°J A^°rocedure are the evacuation of an abscess of the lacrimal sac that threatens to break externally, the relief of congenital atresia or stenosis from traumatism or inflamma- tory processes, foreign bodies, such as short hairs, fragments of the beard of grain, and the so-called dacryoliths, or "tear-stones," in the canaliculi, and rarely, the dislodgment of a foreign body that has entered the lower orifice of the nasal duct; to make prac- ticable the employment of the larger probes and of thorough calhe- terism and for curettage of the sac. Yet other indications are sometimes found, such as eversion of the inferior punctum and new growths. There are three good reasons why an abscess of the lacrimal sac should not be permitted to rupture through the overlying in- tegument — the obliterating adhesion, the ugly scar, and the hazard of a fistula. The operation is not made so often as it formerly was, for the reason that the use of the syringe for treatment of ordinary dacryo- cystitis has largely supplanted the method of systematic and progressive probing that was once so poular. But a single instru- ment is required, viz., some one of the various modifications of the Weber canaliculus knife. Agnew's (Plate 1) is the one preferred by the writer. Its probe point has not the long, slender, easily broken neck of the Weber model. The edge of its blade is slightly convex, which gives better cutting power than if it were straight, and it has a long shank of tough, malleable iron that can be bent to meet the exigencies of an overhanging brow. Cocain or any local anesthetic is of little value for the opera- tion unless previously injected deep into the canal, and it hardly justifies the use of general anesthesia. Previous dilatation of the punctum is unnecessary and only adds to the patient's discomfort. The operation upon the lower canaliculus, the one usually chosen, is performed with patient and operator in positions described 132 OPERATIONS UPON THE APPENDAGES OF THE EYE for passing a lacrimal probe, and the method is much the same. Given the right, lower canaliculus to incise, for instance, the napkin- covered head of the patient is pulled back and pressed against the operator's chest. The contents of the sac are expressed when possible. The knife is held in the right hand. The left thumb is laid heavily on the right cheek or malar bone, for the three-fold purpose of slightly everting the lower lid, stretching it tightly toward the temple, and fixing the patient's head. An assistant holds the patient's hands and he is requested to look upward during the entire operation. The knife is inserted vertically at the punctum, then lowered to the horizontal, with the edge looking upward and back- ward. Having proceeded thus far, it is good practice to pause for an instant, see that the position of the blade is just right, take a firm hold upon the handle, bear hard outward on the lid, to make taught the canaliculus, push the knife straight inward until the point stops against the inner wall of the sac, then, while holding it there, bring up the handle, hugging the brow, through an arc of ninety degrees or more, owing to the length of the cut. The plane of the incision, instead of being vertical, is inclined toward the operator. The extent of the incision must be regulated by the peculiarities of the case or the end to be attained. If this be to admit of the use of somewhat larger probes or canulse than can be readily passed through the normal punctum (a la de Wecker) the length of the cut need not exceed three or four millimeters; in other words, an enlarge- ment of the punctum. If a greater opening is desired, the incision may extend to the caruncle. According to v. Arlt, this means about three-fifths of the length of the canaliculus, or it may reach the common duct. In no case, unless for phlegmon of that cavity, is it advisable to extend a free incision into the sac for fear of per- manently disabling the internal canthal ligament. If it is desired to pass the knife through the whole length of the lacrimal canal, as the handle nears the vertical the edge of the blade is turned slightly toward the front and pushed down into the bony portion, as per the directions just given for probing. The knife is brought out and the operation is finished. As the kndo oculi lies in front of the lacrimal sac, it is quite practicable to ])ass the blade through the sac and nasal duct, in order to divide strictures without seriously, or at all, wounding it, provided the edge is not turned too much forward. In the hori- zontal progress of I he knife tlirough the canaliculus, tlie anatomy of SLITTING THE CAXAI.KULUS 133 the parts must be borne in mind, i.e., that the anterior half of the hicrimal fossa belongs to the superior maxilla and is thick and lirm, while the posterior half belongs to the thin, yielding lacrimal bone. Hence, if the blade were thrust inward with great force, unless it were directed toward the anterior half of the fossa, it could i)erforate the bone and enter the nasal cavity. Stilling's practice of multiple division of strictures of the deeper portions of the canal, for which he designed the knife that iK-ars his name, has been supplanted by systematic and graduated probing. Stricturotomy, as a prelude to forced dilatation of both the mem- branous and the bony portions of the lacrimal canal, however, is still extensively practiced. The correct location for the slit is in the posterior superior wall of the canaliculus, hence the necessity for directing the knife with edge slightly backward. Were it along the top or superior wall, it would be unsightly and, worse still, the function of this part of the canal would be destroyed. Even when placed in the most favorable position possible, be it long or short, this incision greatly interferes with the drainage of the conjunctival sac. The suction of the lacrimal sac, caused by the alternate contraction and relaxation of the orbicularis and Horner's muscle, through nictitation, is spoiled by the slit, and this alone is a frequent cause of epiphora. The fact that gravity puts the burden of draining of the conjunctival sac mainly upon the lower canaliculus is a strong argument in favor of slitting the upper one and preserving the lower whenever practicable. Should the surgeon prefer to wield the knife with the right hand for both eyes and the left canaliculus is to be divided, an assistant stands behind the patient to hold the head, and the operator in front. Otherwise it is behind for the right eye and in front for the left. The rest of the method is the same as for the right eye, save, of course, that the inclination of the cut is away from the operator. In making the operation upon either of the upper canaliculi, as also in dilating and probing them, the surgeon's position, be he ambidextrous or not, is in front of the patient, for both eyes. It goes without saying that the inclination of the blade or the position of the slit is here backward and downward. Bandaging is not required after slitting of the canaliculus. The subsequent care of the case comprises merely bathing with 134 OPERATIONS UPON THE APPENDAGES OF THE EYE \-crv hoi water or antisL'])tic washes and the appropriate use of sound or syrins^e. Removal of a triangular section of the posterior wall of the lower canaliculus, as first practised by Critchett, of London, for cversion of the punctum, with epiphora, seems to have fallen into disuse. This consisted, first, in slitting up the canaliculus as far as the caruncle, in the usual way. Second, a vertical snip with scissors, extending down two or three millimeters from the punctum, on the inner aspect of the lid. Third, the joining of this with the inner end of the first incision, or the resection of the triangle thus formed. The idea was that the secretions of the eye would thus be provided with an open drain. In effect, it proved to be a delusion, as lacrimal drainage is not accomplished through gravity. Moreover, such a piling up of conjunctival growth took place about the site of the operation as to effectually block any sort of outiiow. Arlt pro- duced a form of epicanthus to relieve epiphora in cases of eversion of punctum where the orbicularis was paretic. In closing this subject, there is one injunction the observance of which cannot be too strongly insisted upon, viz., as a rule, avoid the use of the syringe immediately after that of the probe or knife. This is to prevent the unpleasant or serious results of forcing the injected liquid into the cellular tissue. This rule may be departed from in cases that are famihar because of a number of previous probings where the passing of the instrument has been such as to insure freedom from traumatism, but the syringing should be done very cautiously. When probe and syringe are both to be employed in a given case, if practicable, the probe should follow the syringe. If not, it were better to let at least twenty-four hours elapse be- tween the two acts. Incisions of the anterior exterior wall of the lacrimal sac have been made in cases of dacryocys oblcnorrhea, for curetment. as when that portion of the Iractus is tilled with granulations, to give access to the cautery for its obliteration, and for the evacua- tion of ])us in phlegmonous inllammation. Opening of the anterior wall . 14S. INJECTIONS INTO THE SAC I4I To obviate too free entrance of the parairin into the nose and throat it should not be too hot, but somewhat thick — like cold molasses. Where degenerative changes in the wall have not been too great, the difficulties attendant upon the shelling out of sac are appreciably lessened by having it thus made into a firm tumor. One of our internes, recently serving in the Illinois Eye and Ear Infirmary, Dr. Fullenwider, suggested the use of fine, dental plaster which seems to answer yet better than the paraffin. Those substances, the paraffin melted (previously boiled) and the plaster, made into Fig. 61. — Broeckaert paraffin injector. a thin emulsion with sterilized water to which a little salt is added, are injected through the dilated punctum by means of the syringe described on page 127, using the conical canula. C. R. Holmes, of Cincinnati, uses a thick paste of starch colored with iodin, and Valude, of Paris, has recommended spermaceti. One must be careful not to use undue force in the performance, else a rupture will occur and the material be driven into the adjacent tissues. Should this occur in the use of a non-absorbable material and steps be not at once taken to remedy, either a permanent deformity or a subsequent operation will be the result. Therefore, if the surgeon is'aware of such an accident before closing the external incision, 142 OPERATIONS UPON THE APPENDAGES OF THE EYE ihe material should be dissected out. The patient should be prone upon his back and all ready for the operation of extirpation. The inferior nasal meatus is tamponed with vaselined cotton to prevent blood or other fluid from entering the nose, throat, and larynx. All pus or other fluid is first thoroughly expressed from the sac and canaliculi, the cavity washed out and the liquid again expressed. If paraflin is put in, it is then hardened by applying crushed ice or a cooling spray, as of chlorid of ethyl, to the overlying skin. If plaster, a few minutes is given for it to set. This throwing in of a hardening substance serves to make a mould not only of the sac, but also of the canaliculi, and does away with the need of inserting probes for purposes of orientation. Prob- ably a less uncertain method of fill- ing the sac, and one as well calculated to facihtate the extirpation, is that of Jocqs, of Paris, which consists in making a small opening in the ante- rior w^all as soon as the sac is reached and packing the entire organ with absorbent cotton. Another feasible plan is to fill the sac with cold par- affin, of relatively low melting-point, by means of one of the powerful in- jectors made for that purpose (Figs. 6i and 62). One of the good points mentioned by Czermak in this connection is the occlusion of the lids during the oper- ation in purulent cases with strips of adhesive plaster. He reasons thus: through the action of the re- tractors in holding open the wound, the palpebral fissure gapes, the corneal epithelium dries and exfoliates or cracks, and discharge from the puncta coming in contact with it might result in serious infection. This, of course, would prevent the use of probes passed into the sac as guides. Anatomical Notes. — The inferior nasal quadrant of the orbital rim is formed by a sharp ridge on the nasal process of the superior maxillary bone. Midway of this ridge is a prominent convexity which is the aulcrior lacrimal crest. Immediately behind this is Fig. 62. -Bcck-Muller paraflm injector. EXTIRPATION OF TIIK SAC 143 the lacrimal groove or thai portion of the latrinial fossa belonging to the superior maxilla. The other, or posterior part of the fossa, is formed from the delicate lacrimal bone, and is bounded at the back by a slight ridge — the posterior lacrimal crest. 'J'he fossa ends below in a short, round bony canal, leading to the inferior meatus of the nose. Fossa and canal lodge, respectively, the lacrimal sac and the nasal duct (see Fig. 63). A sharp oval is marked on the Fig. 63 [, Anterior lacrimal crest. 2, Lacrimal gro()\e lacrimal crest. 4, Attachment of tendo ocul ,S, I'oslerior drawing to show the place of attachment of the anterior branch of the tendo oculi, or internal canthal ligament. This branch is bifid, one prong for each tarsus. Back of this, with only thin fascia intervening, is the upper extremity, or cupola of the lacrimal sac (see Fig. 64), behind which, likewise, is the posterior branch of the tendo oculi, and behind that is the muscle of Horner. The last two are attached to the posterior lacrimal crest. Separating this whole mechanism from the deeper structures of the orbit is a stronger fascia, the septum orhitale. The opening of the united 144 OPERATIONS UPON THE APPENDAGES OF THE EYE canaliculi is seen between the branches of the tendo ocuh. The cupola of the lacrimal sac rises to about the level of the upper edge of the tendo oculi. Fig. 65 shows the arrangement of the blood- vessels of this vicinity. This drawing makes clear why the incision should not lie to the nasal side of the rim of the orbit; and why one should be careful, in loosening the cupola, lest copious bleeding be caused l)y wounch'ng the vessels that connect the facial and the Fig. 64. — I, Anterior branch of tendo oculi. 2, Lacrimal sac. 3, Posterior branch of tendo oculi. 4, Horner's muscle. 5, Septum orbitale. ophthalmic systems. Different subjects vary greatly as to the depth at which lies the lacrimal sac. Position of Operator. — ^This may be a matter of individual preference, but the writer has found that he can work to much better advantage if he stands at the side of the table, instead of at the head; and on the same side as is situated the eye to be opcrated^right side toward the table for the right eye, and vice versa. The Technic. — First step. — With a convex-edged scalpel an incision is made over the sac, beginning just beneath the tendo oculi and extending about two and one-half centimeters down and out, following the natural sulcus that marks the infcronasal rim of the orbit (Fig. 66). In case the subject is one of those in whom the EXTIRPATION OF THF. SAC f45 sac is not deeply situated a shorter incision would suffice, but there is no drawback to one of the length here specified, and the task is perceptibly lightened by having a generous opening. So situ- ated, the incision avoids the larger blood-vessels — i.e., the branches of the facial artery and vein called angular — and the scar is least conspicuous. The tissues are deliberately divided, layer by layer, first the skin, second superficial fascia, third orbicularis, and fourth Fig. 65. — I, Supra-orbital artery and vein. 2, Nasal artery. 3, Angular artery. 4, Facial artery. 5, Infra-orbital artery. 6, Branch of superficial temporal artery. 7, Malar branch of transverse artery of the face. 8, Superior palpebral artery. 9, Anastomoses. 10, Inferior palpebral artery. 11, Facial vein, 12, Angular vein. 13, Branch of superficial temporal vein. 14, Lacrimal sac. 15, Internal canthal ligament. 15', External canthal ligament. 16, Lacrimal artery. 17, Ligament of the tarsus. 18, Tarso-orbital fascia. — {After Testut.) the deeper fascia, so as to come with discrimination down onto the anterior w^all of the sac, and keeping all the while close in behind the anterior lacrimal crest. Caution is required in dividing the last layer or the sac may be opened. Diligent sponging is kept up and the lips of the deepening and broading wound are held well apart by squint-hooks or Desmarre's retractors, or if an assistant is not available, by Miiller or Eversbusch speculum (Fig. 67). Second step. — When the smooth, red membrane composing the offending organ is exposed, blunt dissection or very careful cutting around with dull-pointed scissors is begun: first, loosen the outer 146 OPERATIONS UPON THE APPENDAGES OF THE EYE or lateral side, then the inner or median side, then the back, which lies deep in its fossa, then up about the cupola. The shelling-out of the sac is greatly facilitated by passing a strabismus hook behind it as soon as its body is exposed. This can, by alternately pulling I'iG. 66. — Incision for lacrimal extirpation. After the incision is open the whole is retracted and drawn upward and inward. gently upon it and working it up and down, be made to assist materially in the loosening process. Scrupulously avoid cutting the sac, the canaliculi, the tendo oculi, the inferior oblique muscle, or making an opening in the tarso-orhital fascia or septum orbitale. Retractor of Eversh This last is about the gravest accident that could happen during the operation in question, as it could lead to septic cellulitis of the orbit, to loss of sight through necrosis of the cornea, or through strangulation of the optic nerve, or infection of the choroid, or to death itself, bv ascending meningitis or bv thrombo-plilebitis EXTIRPATIOX OF TlfF. SAC M7 of the sinuses of the dura. Should, hy any chance, a wound be made in this fascia, the o])enin,L!; should l)e thoroui^dily disinfected and tightly closed with silkworm or catgul sutures before continuing the extirpation. In working deep in the lacrimal fossa, remember the frailty of the lacrimal bone composing the posterior half of that depression. Third step.^ — ^After the sac is loosened from all attachments, save the common and nasal ducts, proceed to divide those with the Fig. 68. — Extirpation (jf lacrimal lX'e[) fasiia ojJiMUMi showing' s;i scissors. First the former. Here, if much traction is made upon the sac while in the act, the puncta are apt to be inverted or drawn inward, and in cutting off the canaliculi one risks making button- holes of the lids and skin about them. Having freed the upper portion, it is grasped with broad fixation forceps and held up while the scissors are passed down into the nasal opening to divide the lower end or, as preferred by the writer, to loosen and remove it as far as the nasal cavity. Profuse hemorrhage is rather to be ex- pected, though the above-described manner of making the incision, 148 OPERATIONS UPON THE APPENDAGES OF THE EYE together with firm pressure of its inner lip against the bones of the nose, the use of a broad Desmarres retractor beneath the inner lip of the incision to compress the vessels against the nasal bone (Fig. 68), torsion of the larger spouting vessels, the instillation of i-iooo solution of adrenalin chlorid, or copious douches of very hot water, or, better still, hot sublimate solution will serve to keep the bleeding easily within bounds. IMuller advises the hypodermic injection of adrenalin chlorid and cocain for local anesthesia and control of hemorrhage. His technic is to drop one minim of a 3 per cent, solution of cocain into the conjunctival sac three times, at intervals of two minutes, then fdl the lacrimal sac with a i per cent, solution of cocain. With the hypodermic syringe he now injects a solution consisting of eight parts of I per cent, cocain and two parts i — 1000 adrenalin chlorid, just above the inner canthal ligament, just below the inner canthal ligament, and near the anterior lacrimal crest, injecting 1-3 c.c. at each point. The operation is begun immediately. Every trace of the sac must be got rid of. It often happens that its walls are so tender that, in spite of the most cautious handling, they are torn. I have found that in such instances the fingers may with advantage be substituted for the forceps, to hold it, after free- ing its upper end. If it is highly degenerated and amorphous, one cannot always hope to get it out intact, but must be content to sponge out the cavity as dry as possible, search for detached islands of the walls and mucous lining, pick them up with the forceps and excise them with the scissors. A thickened, tough sac can easily be shelled out entire. Where carious bone is present it is scraped away with a hard, sharp curet, no matter if it be that of the inner w^all of the fossa or lacrimal bone, whereby an opening is made into the nasal cavity. Any granular masses also undergo curettage, and this sort of cleaning out is carried down into the nostril. As a proper finish, a small olive-tipped electrode is used to cauterize the nasal end of the canal. This last, however, miisi not be done so long as the in- flammable gases from the anesthetic are near about, else an explosion will ensue. Once in a while cutting of the internal canthal ligament is an in- evitable part of tlie operation, as when a fistulous opening has been established above it, though the writer prefers leaving it intact whenever possible. The incision is then extended up through the ligament. After the lisliihi lias been dealt with — i.e., its tract has EXTIRPATION OF THE SAC 1 49 been excised — and before closing the external wound, it is best to unite the severed fragments of the ligament by a catgut suture. As much of each canaliculus as practicable, without buttonholing at the punctum, is removed, and if there are any misgivings as to the capacity of what remains to make trouble, they may be obliterated by searing their linings with a delicate galvano-cautery, as per Haab. The opening having been cleansed and the bleeding stopped, it is closed by three or four pretty deep silk sutures, between and beyond which, if needed, smaller and shallower ones may be in- serted. One cannot be too precise in approximating the lips of the incision. Provided the extirpation has been complete, no tent nor drain is put in. This is done only when there is some doubt as to thoroughness. The dressing consists of the usual wet sheet of cotton, the thick, dry pad, and the wet netting, monocular bandage; and sufhcient pressure must be kept up to cause obliteration of the cavity. It is essential that a ball of cotton be placed immediately over the wound, between the wet layer and the dry pad, to insure such obliteration. The sutures are removed just as early as the condition of the wound will allow. If this be in forty-eight hours, all the better. Where a tent is required as a drain or to induce healing by granulation from the bottom of the opening, a strip of iodoform gauze answers the purpose. The wound is closed at either extremity and the gauze is left projecting from the middle. The bandage is changed daily — so is the tent if used — until per- manent closure is effected. Mr. T. Harrison Butler, Coventry, before the British Medical Association at^^ Birmingham, July, 191 1, read a paper describing a new operation for the extirpation of the lacrimal sac. He said it was essentially a modification of Muller's operation. The site of the sac was rendered anesthetic and anemic by the injection of codrenine. The primary incision was through the skin only. It took the form of a half circle with the centre at the canthus. The flap was carefully dissected up, avoiding button-holing or wounding of the veins underlying the nasal side of the incision. The palpebral ligament was then isolated, and the deep fascia split vertically, so as to expose the sac. The sac was freed from its bed with blunt-pointed scissors, and pushed down under the ligament. Then the canaliculi were severed, and the sac drawn down toward I50 OPERATIONS UPON THE APPENDAGES OF THE EYE the duct, twisted to a cord, and cut off. The operation was blood- less and painless, and no retractors were required, only sutures to hold back the flap and secure the ligament. He had done the opera- lion 70 or 80 times, and was more than pleased with the results. Mellcr gives an excellent description in his well-known text- book of extirpation of the sac as performed in Menna. Toti's Operation, or Dacryocysto-rhinostomy. La Clinica Modcrna, Florence, 1904, No. 35, and La Clinica OcuUsta, April- May, 19 10) .—Since the days of Celsus and Paul of Eginus sur- geons have striven to divert the drainage of the lacrimal secretions Fig. 69. — Toti's operation. The heavy curved line represents the incision of the soft parts. from the nasal duct through an artificial bony opening, directly from the tear sac into the nasal cavity, or even into the maxillary sinus. But the opening would never remain patent till Toti tried making it. It seems to have been reserved for him to devise a measure by which the object sought is often, at least, attained. TotVs method of procedure may be thus described: In most in- stances local anesthesia is used, that is, a few cubic centimeters of 2 per cent, novocain solution with three or four drops of adrenalin, 1-1,000, are injected deep into the parts affected by the incision, and 20 per cent, cocain solution is applied to the middle meatus. The others who have ])erformed the operation are divided between the use of local anesthesia and narcosis. \Vhate\er inler\cntion is lOTI S Ol'KRATIOX 151 demanded by the adjacent nasal ra\ily should prcc cde the lacrimal operation. An incision, deserihin,^ almost a semieirele. is made surrounding and concentric with the internal commissure of the lids (Fig. 69). It should be at least 3 cm. in len,«i;th, and, in the main, runs 7jarallcl with the orbital rim. At its middle it lies about 3 mm. to the inner side of the insertion of the tcndo ociili. It is kept perpendicular to the bone, and includes all the soft parts down to the periosteum. This last is then incised from the brink of the orbital rim, just ex- ternal to the anterior lacrimal crest, curving in the same way around the canthal ligament, thence upward and backward and outward to Fig. 70. — Toll's operation, i. Inserlion of lendo oculi. 4. Anterior lacrimal crest. ?. Posterior lacrimal crest. 3. Entrance to nasal duct. 6. Lacrimal bone, or os unguis. 7. Part of lacrimal fossa belonging to lacrimal bone. 8. Fart of fossa belong- ing to superior maxilla. 2. Line of periosteal incision and limit of bone resection continued by dotted line. again reach the brink of the orbital rim, along which it runs till this. ridge disappears at the orbital process of the frontal bone (Fig. 70). The posterior (or external) lip of this incision, together with all that is attached to it, is raised, the loosening extending to the entire lacrimal fossa. The bone resection is begun along the undetached lip of the ])eriosteal incision. It is not necessary that 152 OPERATIONS UPON THE APPENDAGES OF THE EYE it should extend as far back as the posterior extremity of the cut in the periosteum, 1)ut it is imi)ortant that it include all that portion of the superior maxilla comprising the anterior lacrimal crest, the infero-nasal rim of the orbit, and the anterior half of the lacrimal fossa, which is composed of the rising process of the superior maxilla. To remove the portion of this fossa that is formed by the lacrimal bone will often lead into an ethmoid cell. If one of these cells is uncovered it may be resected. The bone resection is carried down posteriorly to the junction of the posterior lacrimal crest and the rim of the nasal duct; and anteriorly as well into this duct as prac- ticable, care being taken, all the while, not to break through into the nose and wound its mucous lining. After drying the cavity, the mesial half of the wall of the lacrimal sac is resected, and a corre- sponding section of the nasal mucous membrane, likewise. To facilitate the last a probe, or carrier, with a ball of cotton wound on it, is passed into the middle meatus, the membrane pushed out into the bone opening, when it is excised with the point of a knife. Before proceeding further an antiseptic tampon is packed in the meatus in such a way as to hold the edges of the mucous opening in close contact with those of the bony one. The wound is then closed with interrupted sutures, and the usual dressing applied, taking the precaution to so build the pad of cotton that extra pressure will be exerted immediately over the site of the new opening. Since the sole aim and end of the operation is the relief of trouble- some epiphora, unless the function of the lacrimal canal, from the conjunctiva to and into the sac is undisturbed, the measure will avail nothing. If one of the canaliculi has been slit, for example, or there exists a stricture at the union of canal and sac, or if there is eversion of the lower punctum, the operation is contra-indicated. Another bar to the procedure is chronic and progressive disease of the adjoining nasal cavity. When done in cases of suppuration of the canal it does not remove the danger of infection of the cornea that may arise from this source. As to the relief of epiphora, this occurs, according to Fuchs, in probably 50 per cent, of the cases. Taken all in all, then, the procedure is somewhat complicated. Obliteration of the Sac— This measure is indicated when, through long-standing suppurati\e disease, with numerous exacer- bations, much scar tissue with extensive adhesions, thickening of the periosteum, bone lesions, fistula, and fungosities exist. The incision is made as for extirpation, exce])t that it includes the front EXTIRPATION OF THE GLAND 1 53 and outer wall of the sac and, if necessary, the internal canthal ligament. After widely separatinj; the Ups, the cut in the front wall is extended into the nasal duct. As much as practicable of the sac is dissected out, the rest, together with the fungosities and the carious bone, removed by scraping with a strong, sharp curet, and lastly, the entire cavity is rather deeply seared with the thermo- cautery. Iodoform gauze packing, the ordinary pad, and bandage compose the dressing, all of which are renewed daily under antisep- tic irrigation, until the wound heals from the bottom. Later it may be necessary to repeat the operation one or more times. Fistula of the lacrimal sac will sometimes require an opera- tion for its cure, when the indications for obliteration or extirpation of the canal are lacking. A tiny fistula that pours out simply tears will usually disappear by the simple operation of opening up the nasal part of the canal by probing, preferably without slitting up the canaliculus, with, perhaps, stimulation of the tract by means of the galvano-cautery. A pus fistula may yield to Bowman's operation, the use of the syringe and the Tansley cannula with potent antiseptics. Failing in this, recourse may be had to the more radical measure of incision and excision of the tract and closure by sutures. In conclusion, a watchword that will bear repeating is, always the conservation of the lacrimal canal whenever possible. Extirpation of the lacrimal gland, taken all over, is an operation frequently performed, yet in the life of even the busiest ophthalmologist in general it is resorted to very rarely. Truc^ classifies the surgical measures here considered, epigrammatically, as follows: The extirpation of the whole gland is an operation of reserve (extremity) . The extirpation of the palpebral gland is an operation Je choix (option) . The extirpation of the orbital gland is an operation de necessite. The indications, are neoplasms, chronic inflammations, de- generations, and persistent, external fistula of the gland, also annoy- ing "epiphora remaining after the permanent obliteration of the lacrimal canal. Like extirpation of the sac, that of the gland is not a measure to be^^adopted lightly. Diseases and some benign tumors of this ' Arch, d'opht., T. xiii, p. 280, 1S93. 154 OPERATIONS UPON THE APPENDAGES OF THE EYE organ (as those from syphilis) are often amenable to other means of treatment. An external, or cutaneous, fistula, if it cannot be healed in the usual way, may sometimes be converted into an in- ternal or conjunctival one, when the former tract either disappears spontaneosluy or is easily dealt with by excision. Lastly, an epiphora that has been profuse before, and for a short time after extirpation of the lacrimal sac, will often cease altogether or become so scant as lo cause no inconvenience. With the passing of the irritation from the affected drainage division of the apparatus, the overactivity of the secretive part subsides. Before proceeding to describe the surgery of the parts, permit a word as to their anatomy. The lacrimal gland is a double organ, consisting of a larger superior portion, the orbital gland, and a smaller inferior portion, the palpebral gland, or, as it has also been called, the accessory lacrimal gland and gland of Rosenmiiller. The former, surrounded by a fibrous capsule, occupies a depres- sion in the bone, under the supero-temporal roof, or angle of the orbit. Situated above and to the outer side of the levator palpe- bral superioris tendon, its inner border almost touches the outer fibres of the superior rectus, and its outer comes near the upper fibres of the externus. In size and shape it is very like an average lima bean. It is an acinose gland, and when stripped of its capsule, it appears as a grayish, red mass of closely packed lobules. The lower, or palpebral gland, only about one-half the size of the upper, is composed of rather scattering lobules, lying just external to the outer third of the upper conjuctival fornix. The lowest lobule is usually found in the immediate vicinity of the outer canthus. It may be above, level with, or even below it. The uoter fibres of the levator tendon pass between the orbital and palpebral lacrimal glands. Each gland has separate and common ducts all emptying into the outer half of the fornix conjunctiva about four millimeters above the convex border of the tarsus. Removal of the whole gland has been accomplished through the fornix or transition part of the conjunctiva. It is done by first making a free canthotomy, everting and stretching upward the lid, till the superior border of the tarsus (now, of course, the inferior) is about opposite the bony rim of the orbit, then making an incision just below and parallel with the tarsus, from the junction of its middle and outer third and extending beyond its temporal extremity. The same incision enables one to !j;cl al and sliell oul l)()lh glands. EXTIRPATIOX OF GLAND 1 55 but the operation is a (lirficull one. The conjunctival openin<<, therefore, is limited in its use mainly to the removal of the pal- pebral gland. Extirpation of the Palpebral Gland. — Cocain anesthesia suffices. When the lid is drawn up, as above described, and the patient is made to look far downward, as he should throughout the operation, the imprint of the lobules can be seen. Should the patient be unruly, or should the eye roll involuntarily up, an as- sistant grasps, with strong forceps, the tendon of the superior rectus, as per Angelucci, a trick that works like a charm to steady both patient and globe, as well as to hold the latter down. A little adrenalin solution, painted on to the sj)ol will cause immediate blanching, when the incision can be made and the gland exposed with but slight bleeding. As advised by Panas, a strong probe may be passed down behind the everted upper lid to bring the gland into better reach of hand and sight. The incision is best made with a small scalpel having a highly convex edge. The wound is held open with the smallest-sized retractors or the tiny strabismus hooks of Stevens, and the gland is loosened first above, then below, by blunt dissection or cutting with stub-pointed scissors. When the lobes are in view and fairly freed from surroundings, they are drawn out and severed from their posterior attachments by cutting w^ith the scissors, from the nasal side and ending at the temporal. At this end there is apt to be some hemorrhage, but it is easily controlled by styptics, clamping, or torsion. Extirpation of the Palpebral Portion, together with the de- generative effect entailed upon the ducts of the orbital gland, will occasionally sufhce for the relief of epiphora. It is well known that atrophy of the conjunctival sac, following trachoma, results in the drying up of the source of the tears, hence the actual cautery has been applied (Chibret and Bettermieux) to the retrotarsal folds and the mouths of the ducts, with a view to the discouragement of further lacrimal secretion or the induction of atrophy of the gland. One ought to avoid unnecessary opening of the orbital fascia, fearing cellulitis, and know how to distinguish the glandular tissue from that of the orbital fat. The first-named is pink and of firmer consistency, the second, yellow and softer. A couple of fine, absorbable sutures are put in to tolerably close the conjunctival incision, or thev mav be omitted, and tlie coniunctiva and skin of 156 OPERATIONS UPON THE APPENDAGES OF THE EYE the canthus are sutured together as per description — see " Cantho- plasty." Canthotomy is often dispensed with in extirpation of the palpebral lacrimal gland. The levator tendon is to be scrupu- lously shunned, because of possible ptosis. A safer, easier, and generally preferable method for the extirpation of the larger gland is by way of the external incision. The Operation for Extirpation of the Orbital Lacrimal Gland. — The supercilia are lathered and smoothly shaved with a razor. For the most part, general anesthesia is demanded. The exact mid-line of the stumps of the outer half of supercilia is chosen for the site of the cutaneous incision, so that most of the scar will be hidden. The convex scalpel is held in the right hand while the indicated line of the eyebrow is stretched over the rim of the orbit by manipulation of the left thumb and index. After cutting the skin from midway of the eyebrow to its outer extremity, the cut is continued just over the outer rim of the orbit to a point about on a level with the outer canthus. It is then deepened until the periosteum is reached, then pulled downward and held open by some form of retractor. A quite fitting instrument for the purpose is the lid speculum of Landolt (Plate VHI). The tarso-orbital fascia, or septum orhitale, is next incised opposite the front border of the gland, and from three to four millimeters beneath the edge of the orbital rim, taking care to keep the inner end of the incision as far as practicable toward the temple, in order to keep out of the way of the levator and its nerve. The gland is laid bare, loosened with curved, dull-pointed scissors, working now closed and held pen-fashion for blunt dissection, again cutting the stronger fasten- ings of the gland — first below, then above — the latter being all the while slowly and steadily drawn forward, until it comes away entire. At this stage, the lacrimal artery is tied, hemostatic forceps applied to other bleeding vessels, and every means resorted to for the prevention of deep hemorrhage. (See Gifford, ^ " Extirpation of the lacrimal gland, causing atrophy of the optic nerve, through hemorrhage into the orbit.") Great care must be exercised to pre- vent injury to any of the external eye muscles or to their nerve supply. The cavity is washed out with sublimate solution and the opening in the tarso-orbital fascia is closed with fine gut sutures. The lips of the outer wound arc put into the nicest possible apposition and held together by a few carefully placed, interrupted sutures of paraf- ' Am. J(jur. of Ophlluilmology, Vol. vi, p. 268. REMOVAL OF ORBITAL GLAND 1 57 fined silk. The usual monocular bandage is applied, excepting that the pad of dry cotton is larger and extends up higher on the forehead. The patient is put to bed and kept quiet and the eye regularly inspected. The silk thread is removed as soon as the healing of the wound will permit. If signs of infection appear, the incision must be at once reopened, at least that portion of it involved by the threatening process, cleaned out, and vigorously treated with strong antiseptics. CHAPTER IV. OPERATIONS UPON THE EXTERNAL MUSCLES OF THE EYE. Strabismus.— This is a very old word, of Greek origin, whose more modern and preferable English synonyms are squint and hderotropia; and all three are terms that refer to an abnormal position of the globe whereby its visual axis fails to meet that of its fellow exactly at the fixation point. Whatever the determining or "exciting" causes of squint— whether errors of refraction, ambly- opias, unawakened fusion centers, etc. — it is certain that faulty muscles are in most cases the predisposing— the real— cause. The vast majority of eyes remain free from strabismus, no matter what the state of the vision, the refraction, or other physical conditions. Of the squinting eyes, approximately only about one-third are amenable to treatment other than surgical. It is of the utmost importance, then, that one should study well each separate case, in order to determine the nature, the degree, and the contributing factors as regards both the eyes and the possessor of them; and that surgical methods should not be resorted to saving when reason- able trial of all other appropriate means has failed to remedy the defect. Then only is an operation indicated. Kinds of Squint. — The deviation of the eye is spoken of as lateral, or horizontal, when it turns out or in; as vertical, when up or down, and as oblique when it is a combination of the two. When the eye turns inward, the squint is said to be convergent (esotropia) ; when outward, divergent (exotropia) ; when upward, sursunivergent (hypertropia), and when downward, deorsumvergent. In pure horizontal deviation inward the eyes are in the position of positive convergence, because the lines of fixation intersect in front of the eyes; and in horizontal deviation outward, they are in that of negative convergence, because the lines of fixation, if prolonged backward, would meet behind the eyes. At a matter of fact, however, in most instances the squint is a mixture of the lateral and the vertical varieties. All squints arc divided into two grand classes, depending upon whether the eyes arc or are not, under certain conditions, able to KINDS or SQUINT I5Q assume their normal relative positions. The older and less rational terms to denote the two classes were non-paralytic and paralytic. Non-paralytic strabismus was called concomitant. The later and better terms arc comitant and incomitant. The lirst includes all those in which the direction of the eyes mij^hl, throuii;!! the influence of the will, the effect of artificial lenses, the action of drugs, narcosis, etc., become normal in any part of the held of hxation. To the second belong all the others, whether the squint be due to paralysis, paresis, from any cause, or to congenital shortness of a muscle. A further classihcation of squint is into constant monolatcraU alternating, and intermittent. In the first class the deflection is always confined to the same eye; in the second, it is first of one eye and then of the other. In the third, the squint is absent part of the time and, when present, may be either monolateral or alter- nating. By far the most common form of squint is the convergent. A still further classification is into primary and secondary squint. The former comprises all save those unfortunate cases in which deviation of an opposite kind has followed the too free severance of a muscle from the globe (overtenotomy) or the prolonged wearing of the full correction for excessive hypero]na. Then there is that state of the ocular muscles in which there is more or less tendency of an eye to wander, and actual squint is prevented only by a corresponding degree of conscious or uncon- scious muscular effort. This is referred to as latent squint or suppressed squint. It is also the dynamic strabismus of Von Graefe, and the heterophoria of Stevens. The same general surgical principles are applicable to all forms of squint— latent or manifest— yet they must be variously modified to answer the demands of individual cases. With rarest exception but one eye squints, while the other fixes, and the two are designated as squinting eye and fixing or working eye. The fact that the squint is confined to one eye does not imply that but one eye is concerned in the defect. As first ])ointed out by Bonders, and since abundantly verified, strabismus is usually a bilateral affection. Nor does it follow that the fixing eye is pos- sessed of a better muscular system than the squinting one. Often the reverse is true. Greater visual acuity, a lesser refractive error, etc., having determined it to do the work. As concerns the cases here in point, viz., those that ultimately require surgical measures, it may be assumed, for all practical reasons, that the defect is purely l6o OPERATIONS UPON THE EXTERNAL MUSCLES a muscular one, and that the muscle usually concerned is that one away from which the eye turns, or its fellow of the other eye; or, as is most often the case, both of them. That is, these muscles are in- eflicient or abnormally weak, rather than that their opponents are overactive or too strong. The last mentioned, hov^^ever, was the original idea, and upon it was based the primitive operation of strabotomy. To this day the Germans call the muscle toward which the eye deviates the Shielmuskel — the squint-muscle — and refer to the one truly at fault as merely the antagonist. Every close and experienced observer, in studying the conditions of the muscle or muscles actually involved in the squint, must have been aware of the anomalies so often present — anomalies of development, of attachment to globe, adhesion to the fibrous capsule, etc. The different surgical means that have been devised for the cure of squint may be thus denominated and arranged according to their origin: f a. Myotomy. 1. Strabotomy ^ ^_ tenotomy. 2. Tendon advancement, or prorrhaphy. 3. Capsular advancement. j a. Folding or tucking. 4. Tendon shortenmg ^ ^_ r,,,,^;^^, 5. Tendon recession. 6. Operations upon the check ligaments. 7. Tendon lengthening. These various measures are employed either singly or combined; as, for example, a muscular with a capsular advancement, to which may be added a tendon resection, or a tendon folding, and so on. I. Strabotomy, or the cutting of an ocular muscle, for the cure of strabismus, like the entire surgery of squint, is of comparatively recent date. The first to conceive of such a thing was the gifted English charlatan oculist "Chevaher" John Taylor,^ in 1738; though he did not carry his idea into effect, contenting himself merely with a "fake" operation, viz., snipping the conjunctiva of the affected eye, then closing the fixing eye by means of adhesive plaster. Of course, the operated eye immediately became "straight." By the time the plaster was removed the operator was ' De Vera causa slrahismi, Lisl)on, 1739. EARLY TENOTOMIES l6l paid and gone to other iiclds. We have some muscle snippers in our own time who could give the smooth Chevalier pointers. A similar suggestion to that of Taylor, i.e., the division of a muscle to correct a squint, was made by Eschenbach, of Rostock, in 1752. Yet, singular to relate, for a hundred years from the time of Taylor's hint no attempt was made to put the notion into actual practice. This was left to be first done, ])ut only upon the cadaver, by Stromeyer, of Hanover, in 1838, and by Dieffenbach, of Berlin, upon the living subject in 1839. Dieffenbach's early operation was essentially a myotomy which concerned the muscle toward which the eye deviated, and as such was both defective and formidable. It consisted in a free opening of conjunctiva and Tenon's capsule, drawing forward the Shielmuskel — the supposed faulty muscle — and the complete severance of its body. Naturally, in an era when asepsis was unknown the consequences were often dire. Septic orbital cellulitis and, moreover, secondary squint, with all its lamentable attendant defects, were so common that after a year or so the procedure fell into dissuse. About this time (1841) Bonnet, of Lyons, published the results of his anatomical researches, which had been conducted with special reference to the relations of the ocular muscles and the various ramifications of the fibrous capsule of the eye, and their bearing upon the surgery of squint. This led to subconjunctival myotomy, which lessened somewhat the dangers of infection, and later, mainly through the efiforts of Jules Guerin (Nantes and Angers, about 1845) to the less harmful and simpler operation of tenotomy, and still later (about 1849) ^^'^n to subconjunctival tenotomy. By these means not only was infection still further barred, but secondary strabismus be- came a less frequent sequel. The operation was taken up with a vim by A. v. Graefe in 1853, and by George Critchett, of London, in 1857, 2.nd improved and refined till, at their hands, it reached practically the status in which it is found to-day. Von Graefe's Method. — The tendon is fully exposed by either a horizontal incision through conjunctiva and capsule of Tenon, passing over the insertion, or, as was most often preferred, by a vertical incision between the insertion and the cornea. The con- junctiva is undermined toward the neighboring canthus with blunt scissors, the Graefe strabismus hook is inserted beneath the tendon, he latter lifted somewhat and severed from the sclera with blunt scissors as close as practicable to its attachment. The hook is l62 OPERATIONS UPON THE EXTERNAL MUSCLES reinserted to secarch for any uncut fibres of the tendon, which, if found, are also divided. Lastly, the conjunctival wound is closed by a fine suture. Von Arlt, of Vienna, made tenotomy after the manner of v. Graefe, save that he picked up the exposed tendon with the mouse- tooth or toothed fixation forceps, instead of with the hook, but used the hook in finding and severing remaining fibres. This surgeon was most circumspect in determining the position and extent of his incision through the membranes, choosing a small horizontal one over the center of the tendon for the lower degrees of strabismus and a freer vertical one over the insertion for the higher grades. If it was feared that the separation of the muscle from the globe was extreme, the aponeurosis of the tendon was included by the suture which finally closed the vertical wound; if not, only the conjunctiva was included. Critchett's Subconjunctival Tenotomy. — With strong mouse- tooth forceps, pressed firmly upon the globe over the lower border of the tendon, just behind its insertion, a horizontal fold of con- junctiva and underlying capsule of Tenon is picked up and cut crosswise with blunt-pointed scissors close to the forceps, if possible dividing both membranes at one snip, though it may be necessary to pick up the capsule in a similar fold and incise it separately. Thus a vertical wound opening is made. The lower border of the tendon is now brought to view by gently lifting with the forceps the fold of membrane still retained in its jaws and touching the wound with the sharpened point of a cotton sponge. A delicate, flattened Graefe hook is then inserted, point up, beneath the tendon, pushing it snug'up to include all the fibres, the forceps relinquished by the left hand for the hook, which is slightly raised. One point of the delicate blunt-pointed scissors is passed beneath the tendon close to its attachment and the other beneath the conjunctiva, and the tenotomy accomplished by successive snips of the scissors, cutting from the heel to the point of the hook. As in the Graefe method, stray fibres that have escaped the scissors are sought and divided. If still greater effect is desired a subconjunctival incision is made vertically in Tenon's capsule, a little back of the point where the tendon was cut. Unless there is a tendency of the conjunctival wound to gape, no suture is employed. Snellen's^ Subconjunctival Tenotomy. — The Utrecht master ' Klin. Monatshl. f. Augcnli., 1S70, S. 26. TENOTOMY 163 has given an invaluable procedure. The conjunctiva and capsule are picked up by strong mouse-tooth forcejjs in one horizontal fold, as in the Critchett operation, not over the border of the tendon but over its center, and, if possible, the tendon itself is contained in the bite, which is made a little back of the insertion. The entire fold is lifted and cut athwart by the blunt scissors close to the forceps, on the corneal side, and the wound peered into to see whether or not the tendon has been nipped. If not, its center is caught up in a longitudinal pleat in which a tiny, perpendicular buttonhole is cut. Still holding up the fold, a small hook is introduced, point up- ward, at this hole, and the upper half of the tendon severed by cutting with the blunt scissors from heel to point of the hook beneath the membranes and between the hook and the insertion. Still holding with the forceps, the hook is placed, point downward,' under the lower half of the tendon, and that, in like manner, is divided. After the example of v. Arlt, if greater effect is desired the incision in Tenon's capsule is extended, subconjunclivally, both above and below. The conjunctival wound may, according to the judgment of the operator, be closed by a thread, or its edges simply cleansed and approximated by means of the forceps. Snel- len, in beginning his operation, sometimes grasps the tissues in the opposite sense, i.e., over the center of the tendon, but into a verti- cal fold. George T. Stevens, of New York, has somewhat modified Snel- len's method into a partial tenotomy and has devised a set of deli- cate strabismus instruments (Plates II and III). Whatever may be said concerning the modification, it is certain that the implements leave little to be desired along this line. The present writer adopted the Snellen operation and the Stevens instruments more than fifteen years ago, and has since employed them in preference to others. The following constitutes the Author's Mode of Making the Snellen Tenotomy. — Assuming that we have to do with a case of convergent squint of the right eye, the eye is prepared and anesthesia — local or general — is produced. Local anesthesia is preferable. The patient lies on a table, at the head of which the surgeon stands. The blepharostat is put in place and the conjunctival sac thoroughly irrigated with warm boric solution, the remains of which are sponged away. If the eye is under local anesthesia, as is the rule, the patient is instructed to look all the while to the extreme right. The outlines of the tendon and in- 164 OPERATIONS UPON THE EXTERNAL MUSCLES sertion of the internus can now be indistinctly perceived. If they are about in their normal positions, the mouse-tooth forceps is placed in contact with the globe, with jaws separated some six or eight millimeters, and just below the center of the tendon in such a way as, when bearing firmly down and closing the forceps, to form aVertical fold three or four millimeters in height, composed of con- junctiva, capsule, and tendon. Holding the forceps tightly, the fold is slightly lifted, and with the Stevens scissors, with their con- cavity directed toward the operator, one essays by a single sturdy snip to cut through all three layers of the fold close to the forceps, thus making in each a small horizontal incision. The forceps, still holding fast, is slightly tilted away from the operator to cause the wound to gape. If the attempt has succeeded, "the bare shining sclera is seen at the bottom of the wound. If necessary, the tip of a cotton sponge is applied to the opening to clear away the blood. The scissors are now exchanged for the Stevens hook, which is inserted, point downward, beneath the lower half of the tendon, close up to its insertion. The fold held till now by the forceps is let go, the membranes below the cut are seized with the forceps and pushed downward so as to expose the point of the hook, behind which, by tilting it, they are caught. Now, making traction outward and upward with the hook, held in the left hand, the lower half of the tendon is severed from the globe close to its attachment, cutting carefully with the scissors from the heel toward the point of the hook. Those who make complete tenotomies will here, of course, divide the entire half of the tendon. It is the writer's invariable practice, however, except in the opera- tion of tendon recession, to leave both borders of the tendon, or at least its lateral fibrous expansions, intact. The section is, therefore, stopped a millimeter or so short of the lower edge of the tendon. The hook is held beneath the uncut border, the scissors are exchanged for the other hook, whicli, in turn, is placed beneath the upper half of the tendon, the I'lrst hook is removed, the membranes pushed beyond its point with the forceps, and, again taking the scissors, the upper section of the tendon is made precisely as had been the lower — that is, sparing the border. The result of the ])rocedure is a small horizontal incision in both membranes and a vertical button- hole in the tendon, which separates all of its more central fibres from their former atlachment. The eye is again douched with the warm boric solution, as it has l)een sexcral times during the opera- ACCIDENTS IN TENOTOMY 1 65 tions with the double purpose of cleanhness and to prevent dryness of the corneal epithelium, and the membranes are carefully re- arranged. No suture is put in. I make this operation only as the first step in muscular advance- ment, never as a single surgical measure. The advancement ])ro[)cr, as described further on, is then proceeded with. Accidents and Complications, Immediate and Consecutive.— While the operation of tenotomy, as performed to-day, is one of the safest of surgical procedures as regards any serious instant mishap or any grave sequel that threatens actual loss of the eye, yet these very things have happened, to experienced surgeons as well as to the tyro, in this branch of his art. Not only are these greater dangers to be avoided by every possible means, but there are a number of lesser untoward Iiappenings to be guarded against. Among the immediate arc: Hemorrhage from the conjunctiva and Tenon's capsule. The larger vessels of these membranes are, as a rule, ])lainly visible and can be avoided by cutting to one side of them. This is j^articularly true of the capsule, where a large vein is seen to extend longitudi- nally over the centre of tendon and muscle, and it is through wound- ing of this that the worst hemorrhages come. The most to be dreaded from the bleeding is a large hematoma, which is in the way, and tends to complicate the healing process. Because of their secondary relaxing effect upon the walls of the blood-vessels, I am very sparing in the use of such things as cocain and adrenalin. Indeed, I have practically abandoned the last, and as to cocain, limit both strength and quantity to the minimum that will produce anesthesia, and attempt to make the operation under the primary effect: one minim of a 2% to 4% solution dropped onto the site of the tenotomy twice, or, at most, three times, with two-minute intervals; then a wait of five minutes after the last drop before beginning the operation, is the rule. Subconjunctival injections of these solutions I never resort to, not so much because of the danger, which is slight, but because of the inconvenience occasioned by the ensuing infiltration. Another source of hemorrhage is indiscriminate cutting about with the scissors beneath the conjunctiva and Tenon's capsule. All such dissection is absolutely uncalled for, and pernicious, save in cases where one encounters cicatricial tissue, as from a former operation. It were also easy, by thus snipping, to wound the deeper layers of the orbital fascia, exposing the fat and risking what is perhaps 1 66 OPERATIONS UPON THE EXTERNAL MUSCLES the gravest accident that ever occurs after tenotomy of a rectus, viz., septic orbital cellulitis. Perforation of the sclera in severing the tendon has often occurred, and is a casuaUy as inexcusable on the part of the operator as it is serious for the operated, yet nothing but the greatest watchful- ness will prevent its happening to even the most skilled and expe- rienced surgeon. To avoid it one should never use pointed scissors, never pull up the tendon strongly and cut obliquely from behind its insertion close down to the sclera, and never cut too much under cover of overlying membranes. Whenever possible the bite of the scissors should be squarely at a right angle to the long axis of the muscle. Tenotomy of the wrong muscle or upon the wrong eye is to be guarded against. To tenotomize the corresponding muscle of the eye not intended w^ere less harmful than pardonable, seeing that squint is usually the result of a binocular defect. Should the opposite muscle of either eye be cut, however, it should be at once picked up and reattached to the globe by one of the various suture methods employed for advancement, though the cut end of the muscle should, of course, be drawn up only far enough to meet the stump from which it had been severed. Of the consecutive accidents, by far the most common come mainly from a too complete section of the tendon. They are: 1. Retraction of the caruncle, leaving only a dark hole where this little body should be. 2. Lack of motility of the globe in the direction of the operated muscle. 3. Exophthalmos, with its attendant widening of the palpebral fissure, or pro ptosis. 4. Secondary squint, or the ultimate deviation of the globe in the contrary direction to that for which the tenotomy was made. Knowing the cause, the preventive is obvious and readily avail- able; yet, having once occurred, the remedy, whilst it may be quite manifest, is not so easy of application. To my mind the proper thing to do, whether secondary strabismus exists or not, is to try to restore the relation of the muscle to the globe, even, if need be, at I he cost of re-establishing the original squint at the same time. This would be a big choice of the two evils and could then be dealt with more intelligently and scienlifically. To widen the palpebral ilssure of the other eye for the proptosis, for example, as has been SEQUELS OF TENOTOMY 1 67 recommended, and even practised, is preposterous. If, on the other hand, one is at once aware of having gone too far in any direction, he ought, then and there, to make an effort to set matters aright. If, for instance, he thinks the capsule has been too greatly pushed back, or too freely opened, or knows that the tendon had been too extensively divided, or that the extreme lateral fibres have been cut on one or both sides, a small, absorbable suture should be so put in as to correct the error. Even after the lapse of two or three days, if it is evident that a blunder has been made along this line, it is not too late to try to rectify the consequences; for, while union may be firm, there being no scar tissue as yet, the parts may be still separated without difficulty. Aside from the bad results of a com- plete tenotomy may be mentioned those of extensive incisions in the conjunctiva and in Tenon's capsule. This is especially true if they are made in the vertical sense. This alone leads to retraction of the caruncle, slow healing, extensive adhesions, granulomata, and other complications. Whether or not one chooses the better direction for these incisions, i.e., the horizontal, he should see to it that there is not undue gaping of the cut edges of the membranes. If exuberant granulations spring up, or a polyp occurs, at the site of the tenotomy, a drop of cocain solution and a snip of the scissors constitute an effectual remedy. In warding off other sequels, such as conjunctivitis, tenonitis, etc., absolute cleanliness of the eye, the instruments — in short of everything concerned — is the best safeguard. Add to this perfect occlusion of the eye and the strictest quietude of the patient after the operation, and about all is done that can be. Often too little attention is paid to the dressing of the eye after this sort of operation. In view of the fact that so many of the subjects are children, one should be all the more exacting in these respects. I lind that the use of the wet netting bandage, and flexible collodion to fix it, makes an excellent dressing in every way. (Described in chapter on Dressings.) Extensive adhesions and scar tissue after tenotomy are to be avoided chielly because by their action in binding the tendon and tension on the check ligaments they restrict the movements of the globe. They are usually the result of un- necessary traumatism at the time of the operation, mostly through futile and aimless poking and gouging with hooks, slashing with scissors, and mangling with forceps. l68 OPERATIONS UPON THE EXTERNAL MUSCLES There is no advantage in a subconjunctival tenotomy over one that is made with the tendon in plain view; much to the contrary. In the first place, one's work is more uncertain, being out of sight, and precision is the key-note to success. In the second, it has been proven that there is less apt to be unfavorable reaction after the open method, seeing that bacteria and blood can be much more thoroughly got rid of. As to dosing the effect of a tenotomy; to assert that so much cutting in a given manner means so many degrees of permanent rotation of the globe away from the muscle- attacked has always seemed to the writer to be the acme of absurdity. Granting that a tendon can be set back a specific distance, what assurance have we that it will remain in that position? It is pretty certain that if the borders of the tendon are both left intact and if the tenotomy has been ac- complished with the minimum of traumatism, the ultimate result will be nil. After the complete tenotomy it would seem to be merely a question as to how much, or how little, harm is done. The result is purely problematical. If the tendon has not been too greatly loosened from its sheath, it may creep back to its place again or it may recede to a greater or a lesser distance, depending upon wherever it can find an attachment or can come to rest. To divide the tendon all from one side leaving a single border uncut tends to produce torsion of the globe. Probably the least doubtful way of obtaining a definite degree of effect is to make section of all but the outermost fibres of the tendon, then resort to one of the several guy-threads such as have been invented by Graefe, Knapp, Griining, and others. These consist mostly in passing a ligature through the episcleral or scleral tissue, close to the cornea on the opposite side to that whereon the tenotomy occurs, whereby the globe is pulled into extreme duction, when the ligature is coiled upon the temple or nose as the case may be, and there fastened with collodionized cotton. The ligature is a source of both pain and danger. Another somewhat less positive but much safer method is to make section of the entire tendon, drop it back the desired distance, and fix it there by a thread. This operation will be described later under "Curb Tenotomy." Were I asked to name the indications for tenotomy of a rectus muscle, I should say buttonholing the center of the tendon at the time an ad\anccm(.'nt is made on its antagonist to ])rc\-cnt, by TENDOX ADVAXCEMF.XT 169 weakening it, the cutting out of the thread used in the advancement, and complete tenotomy only in case of a])normaI sliortness of the muscle, as it is found in certain cases, as, for example, congenital strabismus — -then always with the curb suture just alluded to. These are, in my opinion, the only tit'o indications. 2. Tendon Advancement. — Dieffcnbach, of Berlin, attempted advancement of the retracted muscle for the secondary scpiint that occurred after one of his myotomies as early as the year 1842, but the results were not gratifying. Guerin,^ of Nancy, was the first to make practicable such a procedure. He, too, was incited to make the operation by a desire to relieve secondary squint, many instances of which were all about — the ugly fruits of the (then) new fad of muscle-cutting. Just the precise technic these surgeons adopted I have not, as yet, been able to ascertain. One of the first published descriptions of an advancement opera- tion is that of Albrecht von Graefe.- It is substantially as follows: Supposing we have to do with a divergent strabismus of the right eye (Fig. 71). The conjunctiva and Tenon's capsule are incised over the insertion of the internus, and its tendon completely severed from the globe. The membranes are then opened over the insertion of the externus, its tendon lifted on a hook, a ligature is passed through the middle of the tendon, close to its attachment, from the scleral side outward. The ligature, wdiich includes about 1/2 the width of the tendon, is tied and given to an assistant. While traction is made with the ligature toward the cornea, the operator gently pushes the hook toward the outer canthus; from 1/2 to 3/4 the width of the tendon is divided by the scissors, some 2 mm. behind the thread. The degree of section is proportioned according to the resistance the mus- cle is supposed to offer against rotation to the other side. The eye is now turned into extreme adduction, and the ligature is fastened 'Ann. d'oculist., vol. xxii, 1849. 2 Arch. f. Ophth., iii, No. i, 1857, p. 342-344. Fig Gracfc's " fadcn operation." OPERATIONS UPON THE EXTERNAL MUSCLES to the nose by diachylon plaster (or other adhesive), care being taken to so place the thread that it will not infringe upon either lid border, i.e., exactly in line with the closed palpebral fissure. If the bridge of the nose is not sufficiently high to hold the ligature clear of the cornea, it is built up by means of the diachy- lon plaster. Such is von Graefe's famed "Faden-operation" (thread operation) that has been so much criticised and ridiculed. As a matter of fact, it is not by any means one of the poorest of the many clever devices of this genius in ophthalmology. It embodies the partial tenotomy of the stronger muscle and the (intended) advancement of the weaker, and provides an ingenious and practical means of holding the globe in a favorable position for the reattach- ment of the advanced mucle. True, von Graef e abandoned it because of injury to the cornea sustained by certain of the operated through contact of the ligature. But with the ligature anchored at the in- sertion, with vertical buttonholing of the tendon, careful fastening of the ligature on the nose by collodionized cotton, and with modern methods as to antisepsis and dressings, this source of danger would cease to be a factor; yet there would still remain the discomfort to the patient, for the pain was said to be severe during the several days the ligature was left in. Where the operation chiefly failed was that the internus (in the case cited) was expected to advance of its own accord and take its new hold upon the globe, instead of re- tracting as it always does. Had this been brought forward and sutured before the guying, the history of the procedure might be a very different one. This was an attempted advancement without a single suture. About this same time George Critchett,! of London, devised his multiple suture operation, which is the parent of most modern advance- ment methods (Fig. 72). It may be thus briefly described: A vertical incision about 1/2 inch long, is made between the cornea and the insertion of the tendon to be advanced, through conjunctiva and Tenon's capsule. This is opened up, the tendon is laid bare and lifted on a strabismus hook, seized near its middle with clamp ' Med. Times and Gazette, Nov., 1S57. Fig. 72. — Critchett's advance- ment operation. LANDOLT S ADVAXCEilENT I? I fixation forceps, and severed from the globe flush with the sclera. If need be, a small strip is trimmed off the cut end of tendon. While an assistant holds the forceps, three separate sutures are passed downward, through the tendon, after having picked up a bite in the overlying membranes, one near each border and one at the middle. The first two threads are carried forward, beneath the con- junctiva, to emerge near the upper and lower limbus, respectively, close to the vertical meridian, while the third is given a similar hold exactly in the horizontal meridian, coming out at the limbus. The middle suture is tied first, to hold the muscle in its proper place, then the other two. When occasion demanded it, a fourth suture was put in. This operation, very slightly changed, is still the favorite method with many ophthalmic surgeons. At the hands of the majority, the fixation forceps has given way to some form of tendon clamp, and the anchorage of the needles is deeper. Landolt,iof Paris, modified Critchett's operation in several im- portant respects, chief among which was the omission of the central suture which he considered, and justly so, to be in the way of a positive and efficient advancement. Landolt^ thus described his method in 1897: "Conjunctival incision close to and parallel with the corneal limbus. No conjunctival bridge for a meridional suture is left, since the muscle then becomes inserted not at the corneal margin, but further back, corresponding to the conjunctival incision. The conjunctiva is not detached far beyond the insertion of the tendon. A small and somewhat flattened hook is passed under the muscle, either according to von Graefe's method or, better, after grasping the muscles with a pair of forceps^ and cutting a small hole. In this manner the whole muscle is brought flat on the hook, whereas, in the first mode, the relaxed muscle may be- come folded lengthwise or the hook become entangled in Tenon's capsule or the muscle fibres. An assistant now draws the muscle forward and away from the globe with the hook, and the operator, with the squint forceps, grasps the muscle at a point 1/3 of its breadth from its margin, together with the surrounding connecti\ e tissue and Tenon's capsule, behind the hook, and then passes a fine curved needle through this entire fold. After this is done on both sides of the muscle, it is pulled up by the four threads and cut be- ^Comptes rendus de ma clinique pour I'annee, 1878. '^ Knapp'^ Archives, vol. xxvi, No. i . , , , * Specially designed by Landolt for use on the ocular muscles, whose teeth are placed obliquely to the long axis of the instrument. 172 OPERATIONS UPON THE EXTERNAL MUSCLES tween the threads and the hook. The tendinous stump is detached close to the eyeball. This is a small resection, which enhances the eflfect of the advancement in moderate degrees of strabismus. In simple insufficiency or small degrees of strabismus, the muscle is detached without resection. In strabismus of high degree, the sutures are introduced far behind the insertion for a more extensive resection. This done, the operator sees if the sutures are well applied. If they are not, he reapplies them, which is very easy, since the inferior surface of the muscle is now exposed. Then one needle is passed for a few mm. through the episcleral tissue, close to the corneal limbus above, while the other is passed similarly below, the muscular plane. The assistant grasps the eyeball over the antagonistic muscle with a fixation forceps and rotates it toward the muscle to be advanced. Thus the operator can tie both sutures without much traction on the enclosed tissues. It is advisable to half tie both sutures before completely tying one. Thus the pre- ponderance of the first suture over the second is avoided. To prevent confusion, white silk is used for one and black silk for the other suture. The muscle, with its covering conjunctiva, not un- frequently rests upon the corneal margin, where, of course, it cannot insert. If the advanced piece should encroach far on the cornea, it may be divided by a cut into two halves, as I have done for years, and both halves will then lie at the corneal margin. Generally the advanced muscle retracts enough to furnish a more favorable insertion. After the sutures are tied, the eyes are irrigated with an aseptic solution and both are bandaged. In con- vergent squint the effect of the operation is increased by paralysis of accommodation. Therefore atropin is instilled into both eyes as long as there is any tendency to convergence. Exclusion of light, rest, and occlusion of the eyes have the same effect. The binocular bandage remains at least five days, for the healing of the wound. In convergent squint it is reapplied for several days more for the above reasons. Then it is replaced by .correcting convex glasses. The sutures need hardlv ever be removed before Fig. 73. — Weber's single suture operation. WEBER S MEIHOI) 173 the sixth or seventh day. In divergent squint, accommodation and convergence assist the operation. As soon as the advanced muscles are firmly attached, one eye is left free. After one or two weeks the methodical exercise of convergence may be commenced," The father of the single-suture advancement was Adolf Weber,' of Darmstadt, who, in 1873, contrived an ingenious though impracti- cable procedure (Fig. 73). After uncovering, picking up, and dividing the tendon as did Critchett, he used a triple-armed suture that was threaded and inserted in the following manner: A fine, curved needle was put on at each end in the ordinary way, but at the middle the thread was doubled upon itself and passed thus through the eye of a somewhat larger needle. While an assistant lifted the tendon, the middle needle was passed through the center of the tendon from the scleral side, thence, also from within outward, through the distal conjunctival flap, the loop pulled through, and the needle removed. The other two needles were carried forward beneath the conjunctiva, one above, the other below the cornea, and brought out near the vertical meridian. They were then carried back and passed through the loop from the corneal side. The assistant tlien released the tendon from the forceps and the muscle was drawn up by the traction on the two ends of thread held together. When the muscle had been brought forward sufficiently the two threads were made into a rather large knot close against the loop so that the suture could not slip.- This measure possesses three points of great merit, in that it is simple, easy of execution, and, best of all, the tendon is drawn forward exactly in the hori- zontal meridian. Unfortun- ately, it has two fatal faults, I'lf'- 74-— DcWccker's modification of above, viz., the thread, although double, traverses the thickness of the tendon at only one place, in consequence of which not only is it more likely to cut out, but, moreover, the center of the tendon is pulled forward in a point, while the lateral portions are thrown toward each other in plaits— not spread out as it should be. ' Lit. Verzeichniss, No. 6, p. 415. ' Haab, in his "Augenoperationen," Mnnich, 1904, mcnlions having seen Horner make the Weber advancement save that, instead of putting both ends of thread through the loop from the corneal side, he passed one end from either side and tied them so as to include the loop in the knot. 174 OPERATIONS UPON THE EXTERNAL MUSCLES DeWecker^ for a time practised a modification of Weber's operation (Fig. 74). Instead of holding the tendon by fixation forceps he, of course, used his own double advancement hook. The real change, however, consisted in the curious mode of disposing of the thread. The loop was drawn far through and cut. Thus there were two threads which the surgeon proceeded to tie— not each end to its fellow, but each to the opposite end of the other thread. It will be seen by the foregoing descriptions that the thread finds its anchorage above and below the cornea save in the Critchett operation, where there is, in addition, a thread anchored between the cut end of the tendon and the cornea. There is another class of advancement methods wherein the only hold of the suture (or sutures) , outside of that in the tendon, is between the latter and the cornea. A few of the more prominent of these will be described. The Pulley Operation of Prince. 2— This is a procedure which, modified by its author at certain stages of its existence, has stood the test of more than a quarter of a century, and is both efficient and original (Fig. 75). Its early name, however, is hardly applicable to its present form. As he first made the operation, and as I had the pleasure of seeing him perform it in 1884 while on a visit to Dr. Agnew at the Manhattan Eye and Ear Hospital, N. Y., while I was house surgeon to that institution, was thus : A vertical thread was put firmly in the episcleral tissue close up to the cornea on the side next the tendon to be advanced • — quilted in for a distance of about 6 mm., and the ends, for the moment, left hanging free. He then exposed the tendon, clamped it with his advance- ment forceps, and severed it close to Fig. 75. — Prince's first, or . i i j i "pulley" operation. the sclera. While an assistant held the forceps, a double-armed thread was passed, from within outward, through the tendon, thus leaving a loop in its under side. Then, while the aid drew the tendon forward, one end of the double-armed thread was laid at right angles across the buried thread at the corneal margin and the latter was tied snugly over it. In this way was formed the pidley. Lastly, the two ends of the other thread were knotted and drawn ' Ann. d'oculist, t. 70, 1873, 225. 2 St. Louis Med. and Surg. Journal, i88r. verhoeff's method 175 taut, advancing the tendon. In order the more readily to distinguish the threads the vertical one, or pulley, was white, the other black. The yielding of the outside portion of the pulley and the bunching of the tendon into a cone, seeing that the traction was all from a single point, after a number of years, caused the author of the measure to very materially change and improve the method (Fig. 76). The pulley thread was omitted, and what had been the second stage of the operation, i.e., the exposing and picking up of the tendon, became the first. The double-armed thread was put into the tendon as before, whereupon one of the needles was made to traverse the tissue alongside the cornea, as had the old pulley needle, all that was left to do being to knot and draw the thread until the desired turning of the globe was achieved. Fig. 76. — Prince's second operation. Fig. 77 — Verhoeff's advance- ment operation. Verhoeff,^ of Boston, has devised a one-suture mode similar, in most respects, to that of Prince, but with one essential difference. This has reference to the fastening of the tendon to the sclera. In the Prince operation the pull of the two threads is straight toward the cut end of the tendon, whereas, in that of Verhoeff, the greater portion of the tendon's width is tied down tightly to the underlying tissue — strapped down, as it were (Fig. 77). The procedure is thus described: A vertical incision is made in the conjunctiva, about 3 1/2 mm, from the cornea, and that membrane undermined up to the limbus. The tendon is exposed, lifted and held with the Prince advancement forceps. The flap of conjunctiva next to the cornea is retracted, one needle of a double-armed fine thread is passed, vertically, for a distance of 6 to 8 mm. through the episcleral tissue, one mm. from the cornea. At its point of exit the needle is again plowed for a short distance horizontally toward the tendon. The lower needle is ' Oph. Record, 1901. 76 OPEEATIONS UPON THE EXTERNAL MUSCLES made now to take this same horizontal course. Both needles are then passed through the tendon, from the scleral side, at a greater or lesser distance behind the forceps, according as much or little effect is needed. The assistant pulls the muscle forward the requi- site distance and the thread is drawn up and tied. That portion of the tendon contained in the bite of the forceps is cut off, the free end placed beneath the conjunctiva, and the wound in this membrane closed by a fine suture. The conjunctival thread is removed on the fourth day; that in the tendon on the eighth. With proper needles and deftness, a very solid support can be gof for the suture in this anchorage, representing, as it does, three sides of a rectangle, and for the lower degrees of squint it must be an excellent procedure. For the higher de- grees, one would suppose it necessitates considerable resec- tion of tendon; ergo, shortening of the muscle. In this class belongs also the operation of Worth. ^ This sur- FiG. 78. — Worth's advancement operation. , r n . a ' ' geon proceeds as follows: A vertical incision about 1/2 in. long is made through conjunctiva and Tenon's capsule, its middle close to the corneal margin. These membranes are retracted to expose the tendon. If the angle of the squint is of high degree, the incision is made curved, with its convexity toward the cornea, in order to allow the membranes to retract more freely. Prince's advancement forceps is introduced, with the toothed blade lying on the con- junctiva, and thus closed. The tendon and its underlying attach- ments are divided with scissors close to the sclera. Two needles, each threaded with a double strand of tolerably thick thread that has been previously boiled to remove the extra coloring matter, then steeped in a sterilized mixture consisting of three parts of white beeswax and five parts of white vaselin, are employed. While an assistant holds up the tendon and superposed membranes, one of the needles is passed inward at A (Fig. 78), through conjunctiva, capsule, and muscle, and brought out at the under side of the tendon. It is again passed through muscle, capsule and conjunctiva, and ' ''Squint," London, 1903. MOTAIS METHOD T77 brought out at B. The l)ilc of the lluTud thus cnch)sc^ about the lower fourth of the muscle with its lench'nous exj)ansion, cajjsule, and conjunctiva. The other needle is similarly entered at A', passed through conjunctiva, capsule, and tendon, and brought out at the under side. It is then again entered beneath the tendon and brought out through the conjunctiva at B', this bite enclosing the upper fourth of the tendon. Both sutures are inserted, before proceeding further, in order that they may be symmetrically placed. The ends of the thread from A' and B' are then knotted tightly at C. The end bearing the needle is then entered at D, passed through con- junctiva, capsule, and tendon, and carried beneath the lower blade of the Prince forceps nearly to the corneal margin. The needle is here passed through the tough circumcorneal fibrous tissue and brought out at G'. The two ends of thread are tlien loosely tied, with a single hitch, at H. The first suture is tlien similarly com- pleted. The anterior part of the tendon, capsule, and conjunctiva are then removed by the scissors just behind where they are grasped by the forceps. The gap is then closed by tightly tying each suture at H H, so that the cut end of the tendon is brought nearly up to the corneal margin at G G'. The longitudinal position on the muscle of the knotted loops A, B and C, and A', B', and C' varies according to the degree of rotation desired. The hold on the tendon in this operation afforded by the knotted arrangement of the sutures insures extraordinary solidity, but it is a question whether or not a certain amount of necrosis would not ensue from strangulation. As for the rest, the anchorage near the cornea, which is of even greater importance, is relatively slight — much more so than in cither the Prince or the \'erhoeff operations. Moreover, the operation would seem to be needlessly complex. Crosswise Suture, or Ligature, of Motais.^ — A very solid fastening is afforded by this method of advancement. A single, double-armed suture, of braided, black silk, is used; the needles being fine, very sharp, and but slighdy curved. A vertical ellipse of the conjunctiva is excised. A large strabismus hook is introduced beneath the tendon, and the latter laid bare for a distance of at least 6 mm. from its insertion. While the tendon is lifted by an assistant with the hook one of the needles is passed, from before backward, through the tendon near its upper border, and 4 or 5 mm. from its ^ L'Opht. Provinc, July, iqii. 178 OPERATIONS UPON THE EXTERNAL MUSCLES insertion (Fig. 79). The same with the other needle below. The lower needle is now made to traverse the substance of the sclera, for 4 mm., in a vertical direction, as near as possible to the limbus, and the other is made to do the same, but about 1.5 mm. farther from the Fig. yg. — Motais' advancement with the ligarute across the tendon, showing the suture in place. limbus. The tendon is divided, flush with the sclera and, with the aid of the loops of thread, and of advancement forceps, the free end is drawn close to the limbus, the suture is pulled down snug, and the ends of thread are tied across the tendon about 2 mm. from its S; '^H?*^,- ^ ^ 1^ . --• Fig. 80. — Motais' iifiit. The tendon has Ije thread tied over (across) i jd, thawn up, and the extremity (Fig. 80). The knot is drawn only moderately tight, as the post-o})erative swelling will sufficiently increase the tension upon the thread. Elschnig's Method of Advancement. — Realizing how neces- sary to successful tendon advancement is a firm fastening to the globe, and hesitating to make it in the thin sclera, for fear of perforating it. ELSCIIXIC. S MKTIIOD 179 has doubtless caused many <)|)luhalmic sur.ifcons lo lake up willi tucking, and other shortening operations, when their actual j^refer- encc was for ad\ancement. 'I'o this class Elschnig's modification of a method by Ohm should strongly appeal. Ohm anchored his sutures in the nearer tendonous expansions of the vertical recti muscles. Here is Elschnig's manner of procedure essentially as he describes it. {Ophthalmic Record, Dec, 1912.) Free exposure of the muscle tendon by vertical incision and dis- section of the conjunctiva (Fig. 81). The tendon is grasped with toothed forceps, and incised with scissors, though permitting the Fig. 81. — Elschnig's method of advancement. Tendon divided; central suture put into tendon. Small cut in sclera. edges, or most lateral fibres, to remain adherent to Tenon's capsule. A double-armed suture is passed, from before backward, through the tendon and out through the opening made l)y the tenotomy. The tendon is stretched by this suture while, with the scissors, it is dis- sected absolutely free from the sclera. In the vertical meridian, and several mm. above the limbus, a needle, bearing number i braided silk, is passed through the conjunctiva and superficial layers of the sclera, in the direction of the muscle lo be advanced (Fig. 82). Tt is then passed through the upper edge of the tendon, somewhat i8o OPERATIONS UPON THE EXTERNAL MUSCLES behind and lateral to the central suture, then, back beneath the conjunctiva, superficially in the sclera, and the outer half of the insertion of the superior rectus, coming out through the conjunctiva 5 or 6 mm. above the point of entrance. A similar suture is applied below, engaging the insertion of the inferior rectus. The corneal lip of the conjunctival wound is raised and a shallow cut is made in the sclera about 3 mm. from, and parallel with the limbus. Both needles of the central, or fixation suture, are passed through the outer layers of the sclera, starting at this incision, and emerging at the limbus. Fig. 82. — Elschnig's method of advancement. Lateral sutures placed. Central one given its scleral anchorage, and all ready to be tied. A single surgical knot is now made in this suture, but the lateral sutures are tightly tied; meanwhile the position and motility of the globe are carefully observed. The knotting of the central suture is completed, and the conjunctival wound is closed with o thread. Klschnig has employed this method for more than twenty years, which speaks much in its favor. The Beard Advancement Operation (Figs. 83 and 84). — The first published account of this procedure appeared in the American Journal of Ophthalmology for March, 1889. Within the past three or four years several articles in tlie ()i)]i(halmic lilcralure of Great BEARD S ADVANCEMENT l8l Britain and the continent of iMirope Iiave been l)roii. 278,1894. Jackson's displacement 199 or cranks, would bear to a wheel. The moment the rotation, in either direction, carried the pivot-like attachment beyond the center of motion the deviation became markedly manifest. Quite recently, Jackson, ^ of Denver, in a paper entitled "Lateral Displacement of Tendon Insertions for the Cure of Strabismus," recommends tenotomy of the inner half, to three-fourths, of the tendons of the superior and inferior recti, or even complete tenotomies of them, and their reattachment to the sclera in a more favorable manner, by suturing. He has practised lateral displacement by partial tenotomy on the superior and inferior recti muscle chiefly for the correction of excess of convergence, and describes his method of operating. He claims this operation is followed by no diplopia and by no more reaction than ordinary complete tenotomy. Jackson considers lateral displacement of the tendon insertions of the superior and inferior recti, in connection with tenotomy of the internus, as an effective and reliable operation for high degrees of convergent squint. He begins with a complete tenotomy of the internus, and through the same conjunctival opening the scissors are intro- duced and the nasal one-half to three-fourths of the tendon of the superior or inferior rectus is divided at its insertion. He strips the edge of the tendon back one-half inch or more from the insertion by means of a strabismus hook. He cites a case where this opera- tion was performed successfully for a high degree of squint, and explains that no protrusion of the eyeball or other bad result has been observed. There are, now and then, instances wherein, after careful study of the muscular anomalies that are present, one is convinced that there is undue tension upon one edge of a broad tendon, and that un- questionably, a well-directed partial tenotomy is indicated. But to make anything like regular practice of this kind of strabotomy is to enter upon delicate ground and to invite indiscriminate intervention in the matter on the part of muscle-snippers. As said before, it is my belief that it is only exceptionally that one need consider the vertical muscles as factors in a squint, at least to the extent of attacking them surgically. And often even when they seem to be directly responsible for the defect, they are only indirectly so, i.e., merely because of a lack of balance or a want of dynamic adjustment on the part of the other two recti. In the ])iv{)lal attachment, just alluded to, had the internus and llie externus been ijournal of the Am. Med. Assn., Aug. 19, 1905. 200 OPERATIONS UPON THE EXTERNAL MUSCLES properly in rein, so to speak — rightly toned — there would probably have been no squint in either direction. Advancement for Secondary Squint. — A goodly percentage of the s(]uints with which one has to deal are of this variety, and, while the surgical measures appropriate to some of them might come under the head of a form of advancement, others constitute a class by themselves, and the surgeon must resort to special methods to meet the demands of the individual case. This class is charac- terized not only by exaggeration of the exophthalmos, retraction of the caruncle, etc., but by that of extent of adhesions and scar tissue as well. If one fears that it will be difficult to obtain a firm forward anchorage for his suture he would better weaken the opposing tendon by a large transverse buttonhole. Then comes the task of procuring the needed raw surface near the cornea with which the tissue to be advanced is to unite. In the worst cases this can be obtained only by a laborious dissection. This can best be accom- plished by the use of very small mouse-toothed forceps and scissors, beginning well back where the tissue is looser, and trying to open up a wide path toward the cornea in the horizontal meridian. If one encounters an island of scar so firmly incorporated with the sclera that it cannot be separated, it may be freshened with a small, very sharp, finely serrated curet. Now the muscle, or the remains of it, must be searched for. If nothing having the semblance of a tendon and aponeurosis can be found — if all is united in one mass with the conjunctiva — a sort of pyramidal flap, with its apex toward the cornea is formed by diverging incisions of the united membranes, putting the regulation advancement suture or sutures in near the apex, bringing the whole flap forward and securing it just as one would a tendon. In this way the deformities, at least, (and usually at most) can be corrected. Yet it is remarkable how much control is sometimes obtained by the reinstated muscle over the movement of the globe. Accidents and other sequels conscfpient upon advancement are, in many res])ects, identical with those atten(hng tenotomy already gi\en. Care must Ije exercised to i)revent operating on the wrong eye, cutting or breaking the thread, etc. The thread should be braided, not twisted, and ought to be previously examined as to strength and c\enness, as well as to see that there are no little breaks in lis strands, 'i'hc use of so-called self-threading needles is prejudicial since llicy arc apt lo cul and make weak places. The CHOICE OF METHOD 201 cutting out of the sutures can best be avoided by usin.t^^ thread of only medium fineness and by giN ing it the ])r()|)rr hold in the tissues. Manifestly one cannot de])end ui)on tiie numberin.t^^ printed or written U])on the spools or skeins of thread by the manufacturers; what is No. i in one make is No. 2 or No. 3 in another, and so on. Thread that has been treated witli a pre])aration of wax or ])ararfin is vastly preferable for se\eral reasons. It does not snarl, it does not make a track for bacteria, and, being nonabsorbent, is easier drawn through the tissues. It holds better because bacteria do not proliferate around it and soften the ])arts. If, at the first dressing, it is discovered that the thread has escaped from some part of its fastenings, the fault may, in some instances, be remedied by the judicious placing of a single new thread in such away as to counteract it. If merely too much dropping back of the tendon has occurred, without cutting out of the suture, I have been able, at times, in the one suture method, to pull the thread up tight again, twist it into a pedicle, and ligate it. Of course, if the thread is left in a bow knot at the time of the operation, the matter is simple enough. Advancing capsule and conjunctiva with the tendon. If this be done in too comprehensive a manner, it leads to restriction of motility by tightening the check ligament in the one instance, and to advancement of the caruncle and obliteration of the semilunar told in the other. Wounding and bruising of tlie parts should not only occur in the minimum degree, but should be kept as well forward as practi- cable so as not to interfere with what Landolt calls the normal unrolling of the operated muscle upon the globe; in other words, the true advancement effect is nullified in proportion as the adhesions reach backward. Enophthalmos after advancement operations has been referred to as an objectionable feature. It is usually insignificant, yet it affords an additional argument for operating upon both eyes in the higher degrees of squint in order to prevent an apparent difference in the width of the pal])e1)ral fissures. GENERAL CONSIDERATIONS ON ADVANCEMENT. Age of Subject. — A s(|uint operation would not, as a rule, be justifiable prior to the age when it could be ascertained whether or not other than surgical measures could avail. There are ex- 202 OPERATIONS UPON THE EXTERNAL MUSCLES ceptions, however, to this rule, as, for example, cases of congenital strabismus with unnatural shortness of the muscle or muscles. If this were suspected, it could be differentiated from spasmodic squint by placing the patient under ethyl chlorid, nitrous oxid, or similar anesthetic, and testing the rotation of the eye with forceps. Then, too, there is that class where, without any brevity of muscle in the direction of the deviation, motility in the opposite direction is so very limited, and the degree of deflection is so high, that it is a foregone conclusion, particularly if the patient belongs to the lower and irresponsible station of life, that it is merely a question as to whether one operates at once or leaves a permanent squint. Choice of Method. — Where there are so many effective modes, this would seem to be largely a matter of individual preference. If one has happened upon or selected a method with which he has become familiar, and been uniformly pleased, he is not apt to exchange it for another. There are a few squint operations for which their authors do not claim universal application, yet any measure that is capable of causing 25 to 30 degrees of redressment of a squint is suflfiicient for all cases, provided both eyes are operated upon. There are relatively few instances wherein the deviation exceeds 50 degrees, and if it is better, as is pretty well agreed, since the affection in question is a binocular one, that the corresponding muscle of both eyes be operated, then the need of bilateral interfer- ence is all the more urgent. In practice, however, we cannot always count upon an opportunity of making a second operation, but may often wish to make a single sitting suffice. If one has scruples against tenotomy as a means of curing squint, he would, then, prefer an operation that, all things else being equal, would give the maximum of effect. But are all things else equal ? The maximum of effect could doubtless be obtained by most any of the shortening processes, either folding or resection, but would the result be in every way as good as after a true advancement ? The advocates of the latter would say, "No!" They believe that to give the muscle the greatest power or leverage over the globe, it should be given an attachment forward of its original one, and it is in this that a veritable advancement mainly consists; that, while there are most excellent measures among the shortening operations, their sphere is limited to the lower degrees of squint. Admitting that they who prefer ad\an(H'mc'nt are right, what kind of an acl\ancenicnt can be reckoned upon lo gi\c the greatest and best effect? For it CHOICE OF MKTIIOD 203 must be remembered that permanent over-efTects, or secondary squints, do not occur after advancement operations except where too much tenotomy has accompanied the operation. Two h'ttle effect, even after both eyes ha\e been operated, is frequent. Moreover, to get very decided permanent effect one must strive for yet more decided primary effect, i.e., over-effect; for some dropping back of the tendon is inevitable. As to the degree of primary effect, one must be guided by his judgment —knowing, as he ought, the angle of the squint and other peculiarilies of the case in hand. In divergent and paralytic squint, it goes without say- ing that the over-eft'ect must be specially pro- nounced. The forms of advancement thai will give the maximum turning of the globe with the minimum resection or obliteration of tendon are those whose sutures begin to take their proximal anchorage beyond the nearer vertical tangent of the cornea (Fig. 94). The anchorage must be beyond the tangent; it will not do to be merely even with it. This is not to imply that those methods wherein said anchorage is between the cornea and the operated muscle are necessarily inferior. * Doubtless there are good measures and bad ones in both classes. Given an equally good one on either side, it becomes simply a question as to whether or not one wishes to in- crease the turning of the globe at the expense of the tendon. Given two equally good measures in either class, it becomes largely a question as to which is simpler. From reading the descriptions one would conclude that there are needlessly complicated procedures in all the classes, but descriptions are apt to be misleading in this respect. Most all the single suture advancement operations have the merit of drawing the muscle straight forward. This is not true, however, of those wherein the thread is knotted in or tied to the tendon. It can be done with the multiple suture methods that have a meridional thread, by tying this first, but this, again, is in the way Fig. 94. — Anchorage obtained in the spaces a and b, i.e., on the corneal side of the nearer vertical tangent of the limbus, affords a more positive advancement than one obtained in the space c. 204 OPERATIONS UPON THE EXTERNAL MUSCLES of a full effect. A certain vertical detlection of the muscle is difficult to avoid in the two suture modes. Another advantage of the single suture is that it facilitates removal. One has merely to grasp the knot with the forceps and cut the suture. If the knot is not held by the forceps one risks attempting to pull it through the stitch canal. It is a curious fact that there is more dread and flinching on the part of the average patient relative to the taking out of the thread than to the making of the operation itself. • This is a strong argument in favor of the catgut suture referred to. A great deal has been said about the advantage of this or that advancement procedure in that the arrangement of the suture or sutures in the tendon tends to prevent its cutting out. From an abundant experience with his own method, both as performer and onlooker, the writer has long since come to the conclusion that it is far easier for the average surgeon to obtain a firm hold for the thread in capsule and tendon than in the globe; and this with regard to an operation where the suture is not tied fast to the tendon by "surgeon's knots." It may be that more is lost than gained by these ligations of the tendon. The object of the accompanying tenotomy being only for its temporary effect, the writer often omits it in the lower degrees of squint, but, owing to the fact that the greater the rotation the greater the resistance of an unweakened opponent, tenotomy has come to be an auxiliary in all whose angle is above 25 degrees. If advance- ment of the corresponding muscle of each eye fails to correct the squint, rather than make a tenotomy to complete the cure, a second advancement is made in case of the first eye operated. I consider advancement preferable to tenotomy for every form of squint, latent or manifest, where surgical measures are at all indicated. Orthoptic and fusion training are instituted at the earliest moment after operating in order to enhance the result. Binocular single vision, however, is not the rule in these cases. But, as Landolt has pointedly said, the best that the most skilled can do is to put the eyes approximately right and rely upon Nature to do the rest. So, by these exercises we strive still further to assist Nature. The length of time one should wait before making a similar oj^eration on the fellow eye must be regulated by circumstances. In children, and all those where there is hope of gaining the end by the help of other means, from six months to a year is not too long. GENERAL CONSIDERATIOXS 205 As regards older subjects, and those with hi,L,di and incorrigible amblyopia, it is useless to wait longer than a month or so. Anesthesia. — Wherever feasible one should make the oj)eration under local anesthesia, and it is the writer's custom even in case of small children — from 7 to 12 years of age — although they are pre- pared for narcosis, to begin under cocain. If they bear it uncom- plainingly, well and good; if not, they are narcotized. .V pretty large percentage of these little ones can be ojjcrated without being put to sleep. The suggestion of Eales,^ of making the tenotomy and first step of the advancement under cocain, and then giving ethyl chlorid or some such anesthetic for the sewing seems a plausible one. The subconjunctival injection of cocain is not free from danger, and makes a mess of the tissues concerned. Three or four drops of a 4% solution made from a good quality of cocain produces perfect anesthesia in most eyes, though it is well to put a drop or two into the wound as soon as the conjunctiva is incised, both for the tenotomy and for the advancement. As to safety, advancement ranks about as high as any operation that is made on the eye. In all my experience I have never seen but a single eye that gave me serious alarm thereafter. This was a dis- pensary patient who was allowed to go home directly from the operat- ing-room, but with instructions to report on the second day. He did not return till the end of the fourth day. The bandage was filthy, the dressing w-as off the eye, and there was septic tenonitis at the site of the advancement, with a deep infiltration in the nearest segment of the cornea. The suture w'as at once removed, the man put under treatment in the hospital, and the eye made a complete recovery. A neat and effective advancement, though safe and sim])le as to detail, is by no means easy of execution, the great dirficulty lying in the deep anchorage required for the sutures in the globe. The older the subject, the more difficult this becomes. To pierce the superficial layers of the sclera for the requisite distance without going through and in such a way that the tunnel of the needle will not be ripped open in drawing the suture through is the key to the situation. Fine needles, of proper shape and irreproachable sharp- ness, together with steadying the globe by holding with fixation forceps the tendon at its attachment, go a long way toward lessen- ing the labor of this step; though nothing but practice will give the 1 Brit. Med. Jour., Jan., 18S8, p. 349. 2o6 OPERATIONS UPON THE EXTERNAL MUSCLES necessary skill. This can be attained to a tolerable degree by operating upon pig's eyes in a mask. To give the lines of anchorage a highly divergent direction serves three important purposes: i. It prevents the thread in its back- ward course to the loop from overlying the cornea. 2. The ad- vancement can be more posi- tive, i.e., it allows the tendon to be drawn quite up to the cornea. 3. Any dropping back or cutting of the thread is minimized in proportion to the degree of divergence, hence magnified in propor- tion as the lines of anchorage approach parallelism. On the other hand, the solidity and security of the anchor- age is increased in propor- tion as its lines become more nearly horizontal, for the reason that the strain of the thread is thus distributed along the sides of the stitch canal, whereas, the more divergent the lines, the more the strain is concentrated at the distal extremity of the canal. These points are illustrated by Fig. 95 ; aa indicate the further ends of the scleral anchorage, situated at five mm. from the cornea on the vertical meridian. This insures a maximum advancement without contact of the thread with the cornea. Now, in order to give greater firmness to the hold of the thread in the sclera it is not inserted along the lines ca, but is made to follow the lines ca. Still greater lateral strain in the anchorage would be obtained by following the lines c'a, or to make them actually parallel, but this would add greatly to the difficulties of the operation. It would also shorten the anchorage. VM V.T. Fig. 95. — The anchorage cannot be long. Essential that distal portion should be deep. CIIAP'JKR V. OrERATIONS UPON THE LIDS. EVERSION. Eversion of the lid consists in turning it so as to expose its conjunctival surface, together with the retrotarsal folds, and to accomplish which the essential feature implies the inverting of the stiffening plate of the lid, viz., the tarsus. The ends sought in everting the lids are manifold, such as examination and topical treatment of the conjunctiva, the removal from it of foreign bodies, the excision of tumors of the tarsal plates and the making of various other operations. Although the performance seems a simple afifair, it is really one involving considerable sleight, and the constant need of the procedure gives it importance. Moreover, the fact that the eye, naturally a sensitive organ, is rendered all the more so by the affections requiring eversion, makes it incumbent on the operator to be deft in its execution. The novice is hardly expected to do the thing without awkwardness, but that so many of the older and more experienced eye surgeons should perpetually exhibit this quality in the little act is truly surprising. Method for the Upper Lid, (Fig. 6). — Standing or sitting in front of the subject, the operator rests the tips of the fingers of his right hand upon the brow; with the thumb and index of the left hand he takes hold of the lashes, tells the patient to look all the while far downward and to refrain from squeezing. He pulls the lid well down on the stretch and slightly away from the eyeball, places the right thumb on the skin opposite the upper border of the tarsus, pressing it downward and backward rather slowly and steadily at first, till, feeling that he has the plate well in hand, he gives a quicker down and back impulse to the upper border and an equally quick forward and upward one to the free border, ending the move in turning the tarsus completely upside down (Fig. 97). The right hand is removed as is the left forefinger, but the left thumb remains to hold the lid everted, by pressing the lashes back against the globe and having for solid support the rim of the orbit above (Fig. 98). If, as is sometimes the case, the lashes are wanting, a 207 208 ()Pp:rati()xs upon, the lids slilT i)robc or similar inslrumcnl is used lo press the convex border of the tarsus down and back, till the free border pouts very de- cidedlv. when with the left thumb it is adroitly shoved up, rolled lie. ()6. — Method of everting; lid. 1" back, and Iield, possibly with the probe left /;/ situ to help (Fig. 99). This instrumental eversion is useful also where the patient is touchy or the orbicularis is spasmodic, but it is best, as a rule, to rely upon tlie liriLH'rs alone. In fad, to be al)le to make a neat eversion with EPILATION 209 the left hand unaided by the right is a most convenient acquire- ment, for the reason that it is so often desirable to have an instru- ment in the right, all ready for use. To do it, the ofllce performed by the left thumb and index is precisely as described for the two hands and in lieu of llie right thumb, the upper border of ihe tarsus is manipulated by the left middle finger. Fig. 97- — Eversion of lid. Stv ond step. Epilation of the margins of the lids is advisable as regards any hairs that are in the way of proper application of remedies, as in blepharitis or for the temporary riddance of any that offend by touching the cornea, or conjunctiva, and is done by means of the cilia forceps (Plate V). The chief requirements of this instrument concern the jaws, 14 2IO OPERATIONS UPON THE LIDS which, to be ri.yht, arc rather broad — two to three milHrneters — slightly rounded at the corners and of faultless coaptation. The depth of the articulating surface is about one and one-half milli- meters and the width, of course, the same as that of the jaw itself. The shanks arc sufficiently rigid to withstand the necessary pressure Fic. ()S. — T>i(l cvcrtc'd and hrld l>y iliunil) on lashes. without bending toward each otlier, as this would cause the ti])S of the jaws to open, sa\'e at their posterior angles, and to Icl go the hair. Lindsay Johnson^ recommends putting a minute (|uaniity of cobler's wax, or resin, between the opposing jaws of the forceps, and ' ()])lithalmoscopc, Nov., 1904. KIMI.ATION genlly heating for a second. The material will spread evenly over the blades and insure a lirm gri]) on the hair. It can be melted and wiped off for cleansing or renewing. Fig. ()(). — Handle of instrument as aid in everling lid. The Method. — Epilation, like eversion, while it can be done, after a fashion, by the merest novice, has, nevertheless, its refine- ments and is cleverly done only by those who have special training. The forceps is held between the tips of the right thumb and index, 212 OPERATIONS UPON THE LIDS jaws up for the upper lid and down for the lower. The bulbs of the left lingers are rested on the patient's brow, he is made to look down for epilation of the upper lid, and vice versa. The left thumb manipulates the upper lid, the left index the lower, slightly everting by pressure, raising, depressing, etc. The jaws are placed vertically astride the hair to be pulled and in contact with the skin at its base, closed — not too tightly — and gentle, steady traction made exactly in the line of the shaft of the cilium, to pluck it out by the root. Quick jerks and sidewise pulls will not do, but result in breaking off, not eradicating. The hairs, especially the tiny ones, seem to require a little time in which to relinquish their deeper attachments. The smaller the hair, a:pparently, the stumpier the free end, hence those that are practically invisible to the naked eye are almost as potent for harm when they touch the cornea as are the larger ones. Focal illumination made by an assistant or by the adjustable lens, attached to a head-band are valuable ad- juncts. For locating the liner ciha the lid must be so managed that the pupil, iris, or nearly closed palpebral fissure will afford a dark background for the illumined hair. Strong convex spec- tacles, or the binocular loop, worn by the operator will greatly assist him. With all these appliances certain extremely fine hairs will remain invisible and must be nipped for cautiously along the whole length of the lid. When the resistance of one is felt or a pimple is seen to rise around it the usual time is given for it to let loose. A wad of absorbent cotton that has been moistened with boric acid or sublimate solution and well wrung is held on the brow beneath the fingers of the left hand on which to wipe, the forceps. As the eye fills with tears, the lids are sponged dry from time to time, for the forceps will not hold the cilia securely when they are wet. Electrolysis of the hair-follicles, something after the method of Michel, 1 as an auxiliary to epilation, is the only sure means of permanently eradicating the cilia, and is particularly applicable to cases of trichiasis where relatively few hairs grow inward, or, as it is termed, distichiasis. The requisite implements are an electric outfit, capable of furnishing a continuous current of from one to five milliamperes. ' St. Louis Clinical Record, Oct., 1875. IIORDKOLUM AND CHALAZION 213 The negative electrode is filled willi a fine, sliarj) ncTdlc (f^old or platinum), the positive, with a s])()n,^e which is moislcncd with salt solution. Provided there is a rhcoslal or controlling switch, one may dispense with a galvanometer; indeed, the best means of regu- lating the energy is to immerse the two electrodes in a vessel of water and gradually turn on the current until the needle throws off a stream of tiny bubbles, indicatixe of the decomposition of the liquid. It is then ready for use. A valuable suggestion is that of Jourdan, of Frankfort a/M., to apply shellac to the needle, then to uncover the point by scraping. This greatly lessens the j)ain, since it protects the sensitive skin. It also pre\ents ])unctiform scars that might otherwise ensue. In order to introduce the needle with precision the operator wears strong, convex lenses or uses the binocular, stereoscopic loop. The patient may sit or lie. A lid spatula is inserted beneath the lid to steady it and to afford a purchase for holding and manip- ulating with the thumb. Or, better still, the Beard lid-forceps is clamped on (Fig. loo). The needle is pushed down alongside the shaft of the hair, till the point is well within the follicle (three to four mil- limeters) and the sponge electrode is applied to the adjacent temple or forehead. As soon as a boiling up of gas occurs around the needle, the sponge is lifted, or the connection button is released, the needle withdrawn and the hair lifted out. Lifted is the word, for if any traction is needed, it is a sign that the electrolysis has been incomplete and, to be effective, must be repeated. The performance is anything but agreeable to the victim, but the pain is much greater if the needle is taken out without stopping the current. Hordeolum. — When this affection has reached the stage of abscess and has not ruptured spontaneously it is customary to make an incision. For this either the Beer or the Graefe knife is suitable. The chief precaution to iK'ar in mind in this connection is to avoid needless traumatism of the tarsus, as the cicatrices thus left often give rise to cysts or chalazions. The opening is, therefore, preferably made through the skin. Chalazion. — The usual manner of removal is by incision and curettage. The tumor is attacked from one of three directions: 1. Marginal Route.— From the free border (Agnew). 2. Conjunctival Route. — From the inner surface of the lid. 3. Cutaneous Route. — From the external surface of the lid. The first is preferable for the removal of the softer or cysloid varieties 214 OPERATIONS UPON THE LIDS parlicularly, when not siUuUed in the extreme ui)per portion of the superior tarsus. The only lustnimcnts needed are a thin, sharp Beer's knife or a straight, keen bistoury and a small, oblong sharp curet. A drop of cocain solution is instilled. The positions of surgeon and subject, as concerns the upper lid (Fig. roi), are the same as for slitting and syringing the lower canalic- l-'iG. loo. — Electrolysis of cilia. ulus ( p. 125). The lid is slightly lifted from the globe by catching hold of the lashes with the right hand, the left forefinger is slid beneath, with the palmer tip in contact with the tumor, the left thumb is put in contact with it on the outside and it is held as one would a pea — in other words, as if the surroundings of the tumor did not exist — and this hold is maintained throughout the entire operation. The lid is turned slightly away from the eye and the incision is made exactly in the mid-line of the free border of the tarsus, the tlat of the blade corresponding to the flat of the lid, and the point aimed at the center of the tumor. Having |jenetrated the chalazion, the knife is rocked slightly, to insure free opening of the wall, and, in with- drawing, the soft contents are squeezed out by pressing together the OPERATIONS FOR CHALAZION Fig. ioi. — Agnew's incision for chalazion. 2l6 OPERATIONS UPON THE LIDS left finger and thumb. Still grasping the tumor, the tiny serrated curet is introduced, the unexpressed contents laded out and the walls of the cavity well scraped. The left finger and thumb feel the movements of the curet and are a guide to its work. As the instrument is removed, they are approached to hold the opposite sides of the opening tightly together and thus held for a few moments, else it would fill with blood and tend to disparage the result. The materials for applying a compressive bandage are ready at hand, so that as the lid is let go, the occluding pad, with its facing layer of wet cotton, is applied, and the simple bandage (p. i6) tied over it. This can be done in such a way that there will be no let up in the pressure upon the site of the chalazion, hence no possibility of a blood tumor forming. Twelve hours is long enough for the bandage to be worn, after which simply bathing the eye with hot water is sufhcient. The advantages of Agnew's method are simplicity and the leaving of neither a visible scar of the skin, nor an irritating one of the conjunctiva. Wilder, of Chicago, has invented a lid-clamp, shaped like the letter U (Plate IV, No. 79). With this he surrounds the chalazion, then injects a few drops of cocain solution through the border of the lid into the tumor. The clamp serves both to keep the cocain from entering the general circulation and to prevent hemorrhage, while the cocain renders the cutting and curetting painless. A drop of the solution previously put on the underlying conjunctiva also helps to do away with the pain of the clamp. Removal from the inner surface of the tarsus, although the favorite mode with a few operators, is chiefly indicated when the inflam- matory process has gone so far in that direction as to have produced either a spontaneous opening or the sprouting up of granulation masses. An incision is not necessary in most instances, merely eversion of the lid, cocain and a drop of adrenalin, and thorough curettage. A clamp and sutures are uncalled for. Other indica- tions than those just alluded to hardly exist for the method in ques- tion, seeing that either the marginal or the cutaneous modes offer superior results. In truth, large chalazions, extirpated from the conjunctival side, have been followed by troublesome trichiasis. The cutaneous opening is resorted to by many as a customary procedure, and has certain advantages. For the hard, fibroid chalazions and those softer ones whose seats are high up in the superior tarsus, tliis is by far the best mctliod. CANTHOPLASTY 217 The instruments needed are a lid clamp (Desmarre's, Plate VI, is probably the most suitable, but Snellen's also answers well) small, mouse-tooth forceps, small scalpel or bistoury, Steven's strabismus hooks, small, blunt scissors, needle forceps, and a fine curved needle, carrying No. i braided silk thread. Narcosis would be admissible only in case of a child, either in years or nerves. A drop of cocain solution is put into the eye to make it tolerant of the clamp. The plate of the latter is slid beneath the lid, the ring made to encircle the chalazion and the screw tightened. This ap- pliance insures hemostasis and steadies the field of operation. The hard, rubber lid spatula may be substituted for the clamp, but it must be held by an assistant. A transverse incision is made (that is, parallel with the free border) over the tumor and extending a short distance beyond it at each end through integument and orbicularis, down to the tarsus, and held open by the little strabismus hooks. The fibres of the muscle are pushed aside, the tumor seized with the forceps, or a minimum-size, short tenaculum does equally well, and dissected with knife and scissors much as one would shell out a sebaceous cyst. If practicable, the conjunctiva beneath the chalazion is left intact, but no part of the abnormal growth is left behind in order to avoid making a hole clear through, as to do so would do no special harm. The opening is cleansed, but not until after the removal of the clamp and the stanching of the blood is the suture introduced. One suffices, and it is taken out after twenty- four to thirty-six hours. The dressing may be the regulation bandage, a patch, or adhesive strips. Canthoplasty. — Technically, this word signifies an operation for the correction of an anomalous condition of the commissure — usually the outer — of the lids and is to be distinguished from canthot- omy or tarsodialysis, which means merely a cutting of the canthus. According to its common acceptation, however, the term is used in both senses, yet with this difference; simple incision of the canthus, without the addition of sutures, is called provisional canthoplasty; and the more finished operation, wherein there is external tenotomy oculi and the divided conjunctiva and skin are stitched together or yet further elaborated, is known as definitive canthoplasty. The Jirst is applied, for example, to the temporary elongation of the palpebral fissure that is made preliminary to exenteration of the orbit, to the enucleation of a globe of extra size, to the extraction of cataract where the conjunctival sac is much shrunken, and to 2l8 OPERATIONS UPON THE LIDS relieve pressure, as in phlegmon of the orbit, in the intense chemosis of gonorrheal ophthalmia, and in panophthalmitis. The second, to permanent extension of the outer commissure for the correction of blepharophimosis, for anchyloblepharon, and for the damaging lid tension in chronic trachoma. It is also an im- portant part of many operations for entropion and is occasionally the sole measure adopted for the cure of spastic entropion. It may be stated in passing that canthotomy, pure and simple, is seldom practised nowadays, as even in most of the instances just given it is followed by sutures. C. R. Agnew, of New York, in 1875, was the first to demonstrate the immense value of canthoplasty as a thera- peutic measure in inflammations of the conjunctiva and cornea, such as the more severe phases of phlyctenular and interstitial keratitis and trachoma. Agnew's method, or cantholysis, a modification of that devised .by Von Amnion in 1839, and the one chiefly in vogue among American surgeons, is here described. The instruments comprise large and small straight, blunt scissors (Plate IV, Nos. 53 and 55), mouse-tooth forceps, needle-holder, and two or three fine curved needles. General anesthesia only when absolutely necessary. Local anesthetics help slightly. The patient lies on the table. First Step. — The canthotomy. The outer commissure is held moderately open by the left thumb and index, one blade of the large scissors is slid into the outer cul-de-sac as far as it will readily go, its edge exactly beneath the angle of the lids and in line with the closed palpebral fissure. The other blade is closed down until it touches the skin, a good grip is taken on the handles, so that the-blades will not "buckle," and with one firm snip the cut is made. This should be from one to one and a half centimeters long, according to the de- mands of the case. Although the cut is usually made in a perfectly horizontal direction, it would seem that in many individuals the scar would conform better to the natural topography about the outer canthus if it were given a somewhat downward inclination. One should l;ear in mind that a part of the accessory lacrimal gland lies in this region and strive not to injure it wantonly. There will be some bleeding, but it usually ceases spontaneously. Second Step. — ^Division of the external canthal ligament. — The free border of I he upper lid is grasped by the left thumb and index, pushed slightly up to oj)en the spaces between the severed skin and CANTHOPLASTY 219 conjunctiva, and the small scissors, closed, are put into the upj)er opening to feel for the ligament. The lid is now pulled forward and toward the nose, so as to make the ligament taut, when the scissors are opened shghtly, the blades are pushed up astride the ligament and it also is cut with a single snip. Some authors state that the conjunctiva is unavoidably incised in dividing the ligament; such is not the case, for with dehcate scissors and a little care, neither the skin nor the conjunctiva need be wounded. If the snip is suc- cessful the lid at once gives way under thumb and finger. If it fails thus to yield, another and more careful effort must be made. The same procedure is repeated on the lower section of the ligament. Third Step.— Placing and tying the sutures.— An assistant opens wide the extended commissure. It wall be observed that the cut in the skin is longer— often very much so— than that in the conjunctiva. Now, all the descriptions of the operation that I have ever read, and all the many cuts that I have seen illustrative of it, teach that the angle of the conjunctival opening should be joined to that of the skin. This is precisely what Agnew insisted should not be done, and ui)on substantial grounds; for, owing to the inequality in the length of the angles alluded to, thus to unite them, means the obliteration of the external cul-de-sac, not only this, but it would require so much stretching of the conjuctiva to make it meet the skin at this point that an unseemly bridle or band would result, the same becoming particularly noticeable and restricting with the globe in adduction. Therefore, following Agnew, after picking up the conjunctival angle with the needle, it is carried outward as far as it will go without any stretching and is joined to the upper lip of the incision (Fig. 102) . Another suture is placed to unite the lower skin and mucous lips, and sometimes a third to perform the same office above, and the operation is finished— unless, per- chance, one chooses to put in a fourth or superficial suture to close the small skin angle thus left unclosed. As each suture is put in, if it be not tied at once, but the two ends of thread are laid together on the temple where an aid places a finger on them to insure keeping them to themselves. They are tied with the canthus stretched open, in order to see that they are true and do not cut out of the conjunctiva. Several other ingenious and effective varieties of canthoplasty have been devised and extensively practised. Attention is called to three: OPERATIONS UPON THE LIDS 1. Richet^ resected a dart of skin and tarso-orbital fascia whose base was the canthus and whose point reached outward horizon- tally one and one-half centimeters. A median horizontal incision was made in the outer wall of the external conjunctival cul-de-sac thus laid bare, and the cut edges were stitched to those of the skin. 2. David Prince, 2 of Jacksonville, 111., made a cutaneous incision, beginning on a level with, and three or four centimeters from the commissure, down and in, parallel with the lower lid border, one- third to one-half of the length of the latter; then from this point out and up back to the level of the canthus, but several millmeters fur- ther toward the temple. The curved angle of skin thus marked out was dissected up from apex to base. A third inci- sion joined this base and the canthus, the upper lip of which was undermined for a centi- meter or more toward the brow, a double- armed suture was put through the point of the curved flap outhned by the first two incisions; it was tucked up into the pocket made by the undermining of the upper lip of the hori- zontal incision, the suture brought out through the skin beneath the supercilia and tied over cylinders of buckskin or other material. The remaining angular opening was closed by sutures, which com- pleted a clever method for combining canthoplasty with correction of moderate ectropion of the lower lid. 3. Chalot (V.)^ makes an incision through the skin only, extending from the canthus outward one and one-half centimeters. This he crosses with a vertical skin incision, made flush with the canthus, the two forming a capital H , supine, against the canthus. The two angles he dissects or undermines, exposing a bridge of conjunc- FiG. 102. — Canthoplasty. Von Amnion- Agnew. ' Trait, d'anat. med. chir., 1851. - Am. Jour, of the Med. Sciences, 1866, p. 381. ^ Trait. Elem. dc Cliir. ct de Med., Paris, iqoo, 3d edition, p. 7: TARSORRHAPHY 22 1 tiva. This is incised above and below, turned outward, and sutured to the angle of the cutaneous incision. Tarsorrhaphy, or as it is sometimes termed, blepharorrhaphy, is an operation having for its object the occlusion of all or a portion (total tarsorrhaphy, or partial tarsorrhaphy) of the palpebral fissure. It is called external, median, or internal, respectively, as it concerns the corresponding division of the fissure. Internal tar- sorrhaphy is sometimes erroneously called median, after the German fashion. Like canthoplasty, the end sought may be a permanent one (definite tarsorrhaphy) or temporary (provisional tarsorrhaphy). Some phase of the operation is sometimes indicated in lagoph- thalmos (paralysis of the seventh nerve with ectropion), in neuro- paralytic keratitis (paralysis of the fifth nerve), in certain forms of reducible exophthalmos, and in traumatic proptosis. It is also helpful in preventing cicatricial ectropion after skin lesions of the lids, such as burns, blastomycosis, etc., in stopping threatened staphyloma of the cornea, and, occasionally, as an adjunct to surgery undertaken for the restoration of the lids and conjunctiva, to hold them in position during the healing process. Total tarsorrhaphy, literally speaking, either temporary or permanent, is not admissible, since in the first instance it means difficulty of reopening the outer canthus should this become desirable later, and in the second, retention of the secretions of the eye. A more or less extensive median operation is better in botli instances. External tarsorrhaphy. Occlusion of the outer portion of the fissure, as first i)raciiced by Walther, was frequently resorted to previous to the invention of the median method. It was done by "scalping" the fids or excising strips of skin containing the follicles of the cilia (Fig. 103) from the outer canthus for varying distances inward, owing to the degree of closure desired and uniting the raw edges by sutures. The method is still resorted to, at times, as a permanent feature, especially in connection with operations for the correction of ectropion of the lower lid, from laxness, and with eversion of the punctum; but it should never be done if one ex- pects later to undo the work. Fuchs is the author of a method of external tarsorrhaphy that could be converted into internal, and which is characterized by great solidity of the union produced between the lids (Fig. 104). Brieflv, it is thus: beginning at the outer canthus and extending 22 2 OPERATIONS UPON THE LIDS inward the desired distance, an intcrmarginal incision is made, whereby the Hd is spht for a depth of live or six miUimeters into tarsal and cutaneous leaves. At the inner end of the sHt a vertical incision is made in the skin half that extends to the bottom of the slit to allow the latter to gape. Corresponding incisions are made in the upper lid with the addition of a second perpendicular inci- sion in the skin half at the canthus. The upper extremities of the two vertical cuts are joined by an incision, and the paral- lelogram thus outlined, and which contains the hair bulbs, is ex- cised. A double-armed suture is passed from within outward at the middle of the denuded portion of the upper tarsus and, in the Fig. 103. — External tarsorrhaphy. (Walthcr.) Fig. io4.^Fuchs' external tarsorrhaphy. same manner, through the skin flap of the lower lid and tied over a cylinder of, some appropriate material. In closing the lids and knotting the thread the inner surface of the loosened skin flap is made to coapt with the raw surface of the upper tarsus. To com- plete the operation, a few, flne, superficial sutures are put in. Internal tarsorrhaphy, or Canthorrhaphy, was first resorted to for the exophthalmos that so often followed the too free tenotomies which characterized the earlier operations for strabismus. It w^as revived, and its technic improved by Von Arlt, who called it median tarsorrhaphy to distinguish it from external t. then the only other kind. Arlt a])])nf(l it to those slight degrees of ectropion of the lower lid, with cNtTsion, or noncontact, of the ])unctuni, thai arc MEDIAN TARSORRIIAI'IIV 223 SO j)ro\-()cati\-c of annoyinji; c|)i{)h()ra, and that arc so unsatisfac- tory as to their trcatnunt by conservative means. It is here that the measure still Inids its chief indication, th()u u f r < ] 1 Fig. 107. — Result of median tarsorrhaph}-. such that the other means cannot be consistently carried out. It is indicated in the severe tarsal form.s of vernal catarrh and in obstinate chronic trachoma characterized by deep infiltration and hypertrophy and degenera- tion of the tarsus, accompanied by persistent pannus and recurrent corneal ulcers. (For description see page 372.) C. Magnani,^ of Smyrna, as a precaution against ptosis, after the operation, before tying the threads to close the wound, opens it wide and puts a double armed suture into the deeper portion of Miiller's muscle, then carries the needles up and back (lid inverted), and causes them to emerge from the skin near the cilia. He, then, closes the wound, turns the lid back into position, and, lastly, ties the external thread ends over a tiny glass bead. If the operation is done after the manner here described, however, there is no extra inclination to ptosis. It will be remembered that there is an inherent tendency in many of these chronically inflamed lids to both ptosis and entropion. The usual dressing is applied, lliough wliether to one or both eyes is a matter which is left to the judgment of the operator. If there are knotted threads touching the cornea, both eyes should be bandaged, the better to insure immobility of the globes. The sutures are removed on the fourth day. 1 Treatise on Diseases of the Eye, 181 i. 2 La Clinica Oculistica, Oct., igo.^, ji. 1460. IS 226 OPERATIONS UPON THE LIDS Operations for Epicanthus, or Rhinorraphy. — Von Amnion^ first described this congenital deformity of the nose and disfigure- ment of the inner canthi under the name it bears, and invented an operation for the correction of the ocuLir part of the defect which he called rhinorraphy. This consisted in pinching up a vertical fold of skin on the bridge of the nose sufficient to rid the canthi of the redundance, marking out the base of the fold in ink, excising it, inserting silver pins, as in the operation for harelip, and closing Fig. io8. — Knapp's Rhinorraph} the opening by means of thread wound on to the pins, figure-8 fashion. This is known as median rhinorraphy. De Wecker^ modified the operation by putting two or three large, curved, threaded needles through the base of the pinch-up fold, in- stead of outlining it. He then cut it out with scissors close to the needles, and brought together the edges of skin with the threads. Knapp^ still further modified the procedure by removing a diamond or rhomboid section of skin, long axis vertical, from the center of the nose, undermining the edge for some distance, laterally, ^ Darstellungen, etc., 6, 1S41. 2 Trait. Comp. d'ojjh., vol. i, p. 180. ' Epicanthus und seine Beliandlunsj;, Arch. f. i\\\\i. Orenh. 1 1 r, S. SQ. EPICAXTIIUS 237 closing with a number of fine interrupted sutures and reinforcing with strips of gauze and collodion (Fig. 108). Arlt^ excised the two semilunar pieces of integument comprising the greater portion of the epicanthal folds themselves, and in ex- treme cases a median ellipse from the nose also. This is known as lateral rhinorraphy. The sutured wounds presented something the form of an X (Fig. 109). Fig. 109. — Arlt's lateral rhinorraphy. The use of silver pins, as in the Von Amnion operation, is apt to leave an ugly scar, as also are de Wecker's large needles and thread. Knapp's small needles and thread, with the auxilliary collodion strips, is a decided improvement in this particular. V. Arlt's method is also a good one, and for it Knapp's small sutures and collodion may be utilized. The extra scar is hidden by the specta- cles which the subjects of epicanthus usually require. Later, and improved surgical measures for dealing with epi- canthus are those of Rogman {Archiv. d'opht., t. XVHI, p. 453) and E. Berger (Ann. d'ocuL, June, 1904) or Wicherkiewicz-Berger. Method of Rogman.— Midway of the epicanthal fold and on a line with the inner angle of the eye, begin two incisions; these are 1 Graefe-Saemisch, iii, S. 443. 228 OPERATIONS UPON THE LIDS carried upward, converging, till they meet, thus forming an inverted V (Fig. no, right eye). Then, the incision nearer the eye is prolonged downward, to form one member of an upright V, of the same dimen- sions as the inverted one. Its apex is on the crest of the fold, and the other member is represented by an incision that is carried upward and inward on the ocular face of the fold, to end on a level with the inner angle of the eye. Thus two flaps of skin are outlined whose length, and whose breadth of base, will depend upon the size of the epicanthal folds. The flaps are dissected free, cut off at their bases, Fig. no. — Right eye, method of Rogman. Left eye, method of E. Berger or Wicherkiewicz. the integument of the fold is undermined, and the two triangular defects are closed by sliding the skin and suturing. Method of Wicherkiewicz-Berger. — Here the portion of excised skin takes the form of the head of a dart, or arrow (Fig. no, left eye). It is outlined in the centre of the epicanthal fold, beginning at a point on the side of the nose, and on a level with the inner can- thus. From here two incisions depart, diverging, passing outward, and extending almost to the crest of the fold. From their extremities two other, shorter, incisions start, converging, also to meet on a line with the inner canthus. The enclosed integument is removed by dissection, and its size is regulated by the degree of effect re(]uired for tile obliteration of the epicanlhus. Lastlv, the skin of the fold is i;pi(A\Tiirs 229 undermined, and the defec I is closed by slidin.i^ the ponl of skin into the angle opposite, and ihrre fixin<^ it with sutures. The author suggests trying the omission of the rliinorraj)hy and. in lieu thereof, the injection of paralTin, to l)uild uj) the bridge of the nose, which in these cases is Hal, and careful [\]m\ studied rocction of the epicanthal folds, free undermining of the cut edges, fine, in- terru[)ted sutures, and the support of gauze, wet with llexible col- lodion. Of course, every precaution must be taken to keep this collodion from entering the palpebral fissures. None but those with skill and experience in the prosthetic employment of parafhn should attempt such use of it on account of the dangers from paralTm embolism. It must be remembered, too, that the mass of paraffin that is put into the tissues has a treacherous way of sometimes changing its form and its location. The results of epicanthus operations are seldom beautiful, whatever the method, because of the usual accompanying congenital anomalies, such as ptosis, microphthalmos, sc[uint, etc. CHAPTER XL OPERATIONS FOR PTOSIS. The original term for falling down of the upper lid was hlepharop- tosis, which, although more expressive as to the actual import of the word, has quite properly been superseded by the abreviation ptosis. This affection may be either congenital or acquired. Con- genital ptosis is not uncommon, and, in a large proportion of the cases, it is bilateral. It is often associated with epicanthus, microph- thalmus, squint, and other connate defects. Acquired ptosis is, in most instances, paralytic; that is, it is the result of paralysis of the levator from disease or from traumatism. Distinctive forms of ptosis are ptosis senilis, from slow progressive atrophy of the levator; ptosis adiposa, and ptosis elephantiastic, or cutaneous ptosis, from redundance and relaxation of the lid tissues; ptosis trachomatosa , from the combined effects of the characteristic infiltration, the blepharospasm and the ensuing shrinkage of the conjunctival sac from trachoma; and ptosis hysterica, or pseudo-ptosis, from voluntary or spastic contraction of the orbicularis. The dropping of the lid is also distinguished as partial or complete. Whether congenital or acquired, the vast majority of cases are fit subjects for surgical treatment. This is divided into palliative or provisional, and curative or definitive. The first consists in the application to the lid of collodionized bands or strips of adhesive plaster, the insertion of restraining sutures beneath the skin, and the wearing of specially designed preventive spectacles, or artificial spring supports, of thin metal or other material, affixed to the lid borders, to act as antagonists of the orbicularis. These temporary measures are seldom resorted to; for, when intervention of any kind is called for, an operation that will give permanent relief is de- manded, or operative treatment. It is rather singular to note how liule attention was paid to ptosis in early times — surgically, at least, l^y the ancients, the affection was, in great measure, confused with entropion and trichiasis; and about the only operation adopted with reference to it was the ex- cision of a horizontal ellipse of skin from midway of the fallen lid, and varying in size with the (k\grcc of the ptosis. No material 230 f'LASSIFICATION OK METHODS 23I change was made in the status of such surgery until i Thirteenth Internat. Cong, of Med., Paris, 1900. 240 OPERATIONS FOR PTOSIS with, the eyebrow, and three centimeters in length. The lower lip of the wound is dissected, and retracted, down to the level of the upper border of the tarsus. About 3 mm. above this border a hori- zontal incision is made through the orbicularis, to lay bare the entire breadth of the tendon of the levator. The latter is picked up with a strabismus hook and divided some 4 mm, above the convex edge of the tarsus. Now, through the stump of tendon adherent to the tai'sus are passed, from before backward, two double-armed Fig. 125. — Angelucci's operation for ptosi; sutures carrying No. 2, or No. 3 braided silk. The threads are then tightly and securely tied, on the posterior face of the tendon, to insure their hold. After this the sutures are passed up, between orbicularis and tarso-orbital fascia, to emerge 3 mm. above the eyebrow, where they are drawn up so as to lift the lid to the desired height, and tied in bow-knots over cylinders. And here the strongest point of the procedure is made apparent, in that it gives the operator such a range, as it were, of control over the fallen lid. The skin incision needs merely to be coapted — not sutured. If there chances to be present, as in certain \arieties of ])t()sis, a redundance of integument, GRUEXIXG S METHOD 24 1 an clli])sc may be excised. Al the end of a day or two the de.i^ree of ele\ati()n of tlie lid ean he modified hy j)unin,i!; out the loo|) of the knot and ti^hteninLi; or loosening the thread as the case demands. Resection of the tarsus as a measure for the cure of ptosis was revived by Sir William Bowman, as an adjunct to resection of the orbicularis, as practised by his friend von Gracfe, At a glance this method would seem to stand in a class by itself, yet virtually it is but an advancement of the muscles normally concerned in lifting up the lid. Bowman removed a portion of the tarsus and the contiguous portion of the orbicularis. Galezowski went still further and excised a strij) that included the whole thickness of the lid. A well-known modification of the Bowman operation is that of Gillet de Grandemont.^ Grucning,- of New York, has, for some time, employed, with satisfactory results, a modified form of De Grandemont's method (Fig. 126). He uses it for almost any ^■ariety of ptosis, and performs it as follows: An incision is made through skin and orbicularis muscle, parallel with, and 4 mm. from, the free border. Skin and muscle are dissected up and retracted. pig 126.— Gruening. A portion of the bared tarsus, com- prising its whole width, from inner to outer canthus, and the whole thickness, including the adherent conjunctiva, is cut out. The vertical diameter of the excised strip varies with the degree of ptosis, though it is always wider in the middle, wdiere it may measure 7 mm., tapering almost to a point at either extremity. The tarsal wound is closed by three double-armed sutures. One needle is passed horizontally through the tarso-orbital fascia, then both needles are passed downward, through the remnant of tarsus, and brought out at its free border, behind the lashes, where the suture is knotted. Thus the lips of the tarsal wound are brought into apposition, and the lashes are given a horizontal direction. The skin opening needs no sutures, 3. Joining the Tarsus with the Superior Rectus.— In cases of ptosis not com])licated with ])aralysis of the sui)erior rectus, 1 Bull, et mem. de la soc, Franc, d'n])!!!., 1891, p. 80. 2 New York Eye and Kar Infirmary Reports, 1904. 16 242 OPERATIONS FOR PTOSIS the late Dr. ParinaucU (Fig. 127), after having everted the upper lid, made a horizontal incision one and one-half centimeters long, in- cluding the conjunctiva, and the upper border of the tarsus at its middle; seized the conjunctiva with fixation forceps near the upper corneal limbus, and rotated the globe far downward; opened up the conjunctival incision, and exposed the tendon of the rectus, raised it with forceps, passed a double-armed suture beneath it, including its aponeurosis. Then each of the needles was passed upward, through the adjacent conjunctiva, thence through the levator tendon, down- ward between tarsus and skin, and brought out, seven millimeters Fig. 127. — Parinaud. Fig. 128. — ^Motais. apart, at the free border. They were here tied over some soft substance, and taken out after four to six days. Motais,- of Angers, has given an ingenious and highly approved ptosis operation, which embodies the Parinaud principle: — a meridional incision of the conjunctiva, beginning over the center of the insertion of the tendon of the superior rectus, or about 7 mm. from the upper corneal limbus — is extended through the retro- tarsal folds, to end at the convex edge of the tarsus (Fig. 128). This is opened and retracted, so as to plainly reveal the tendon, which is then lifted upon a strabismus hook. The hook is worked back and forth in such a manner as to loosen the tendon from its surroundings. A fme, but strong braided suture, armed witli two curved needles, is passed in and out through the tendon near its insertion, so as to include its middle third. To give the thread a solid hold, it has been suggested that it be at once lied. This, liowcNcr, is apl to c()m])licate ^Annd'oc, 1897, 1. cxvii, ]>. '-'• 2 Bull, et m^ni. de la soc, d'opht, de Paris, Nov., iS()S. ii'i;k.\ I'lox !43 Fig. i2g. — Motais. matters in rem()\inii; it. 'I'o ])i\'WiU twisting' of the lon.^uc each thread, with its needle, is kept, or held by an aid. at the corre- sponding canthus till after the next ste]). With knife and line blunt- pointed scissors, a tongue is formed of the portion embraced by the thread, its free extremity cut Hush with the sclera, and the other left at the union of the muscle fibres; i.e., it extends the entire length of the tendon. It must be seen to that the thread is firmly fixed in the end of the tongue. If there be any doubt on this point, the tongue is folded u})on itself and the suture again I)assed through. The surgeon places the tip of his index behind the inverted lid as a guide, and, with the scissors, makes a pocket between the anterior surface of the tarsus and the fascia of the orbicularis. This pocket is wide enough to receive the tongue and reaches almost to the border of the lid. The needles are passed into the pocket, through at its bottom, to emerge on the skin surface of the lid, near the cilia, about 4 mm. apart, and are tied over a roll of antiseptic gauze (Fig. 129). It greatly facilitates the entering of the needles into the depths of the pocket if an assistant will insert an in- strument, like the Ik-ard blunt dissector, in the pocket and pry it open while the needles are being put through. The conjunc- tival opening is closed with the sutures. It were well to have these of catgut and leave them to be ab- sorbed, thereby obviating any disturbance of the lid at the end of two of three days. The thread attached to the tendon is removed at the end of 5 days to a week. Motais' procedure is founded upon the synergy of action existing between the sui)erior rectus and the levator. It follows, theoretically, 244 OPERATIONS FOR PTOSIS that, as a result of ihc cngrafled tendon, natural movements are imparted to the lid. In other words, that in looking up, for example, the lid does not lag behind. ^ For a number of years past I have practised, with most gratify- ing results, a method that combines the principles of the Anagnos- takis-Hotz entropion operation, the tucking of the levator tendon of Eversbusch, and a little of the suture arrangement of Pagenstecher^ (Figs. 130 and 131). A lid horn is put beneath the upper lid. An incision is made along the sulcus, rather in its upper slope than exactly in its bottom, through skin and muscle, and extending the whole length of the tarsus. The divided fibres of the orbicularis are undermined, both above and below, exposing the tarsus and its suspensory ligament. Four curved, one-inch-long needles, carrying two sutures (i.e., double- armed) of No. 3 braided silk, boiled in vaselin-paraffin, are in readiness. Each needle is passed through the lower flap near its edge, from within outward, then through a horizontal fold of the tarso-orbital fascia — really the tendon of the levator — picked up by broad- jawed fixation forceps, thence upward, quilting, or, as Wilder says, "gathering" the septum orbitale, and brought out well above the supercilia. A handy way of picking up the deep fascia at any chosen point, is to first dig the point of the needle in somewhat, in order to lift the tissue, then grasp it, in the horizontal sense, with the jaws of the forceps. The threads are so spaced that the loop left lying inside the lower flap is about six to eight millimeters long, and its middle marks the junction of the middle and end thirds of the tarsus. At first 1 i)Ut the needle through the lower flap of skin and muscle from the cutaneous surface, but soon found that this tended to fold the fla]) horizontally, and to turn its edge outward. The manner of tying the sutures is important. One ])air of thread ends is held between the left thumb and index, while, by 1 For further remarks on the Motais operation sec SitiiiDiary at end of chapter. M)i.h. Record. -Beard's method fur ptos Sectional view. BEARD S METHOD 245 means of small, mouse-tooth forceps, the edge of the lower flap is seized between the corresponding threads, pulled up and rolled backward, and placed in apposition with the tarso-orbital fascia just where the thread enters the fold therein. The two ends of thread are, meanwhile, drawn ii]) pretty well, biil not tightly, and tied in a single surgical knot over a short cylinder of firmly rolled gauze or absorbent cotton. The same is done relative to the (lap and other suture. Before fmishing the knots, it is seen to that the edges of both skin flaps are directed backward; in other words, not coapted one with the other, but that both are in contact with the broad ligament of the tarsus. In this way the resulting cicatrix is completely hidden by a normally i)laced and normally appearing sulcus. Lastly, the sutures are tightened as much as is needed for the desired effect, and are tied in bowknots. In the extreme cases it will be impossible for the patient to close the lids so long as the sutures are in. As this is for only two or three days, during which time a carefully applied dressing and bandage is worn, there is no danger to the cornea. Nothing more is expected of the sutures than to hold the operated parts in their new relations until primary union is assured; that is to say, they are not left in position to suppurate or to cut through. The tension of the threads may be altered at any time within twenty-four to thirty-six hours, if one wishes to qualify the primary results, by merely undoing the bowknot and loosening or tightening the other one, as the conditions demand. In removing the sutures, the rolls over which they are tied are pulled smartly up, both threads are cut off close to the skin and withdrawn by seizing the loop below. In this way no soiled portion passes through the tracks. I consider the Hotz idea, as embodied in this procedure, to con- stitute, probably, one of its most salient advantages, and, taken all in all, theoretically as well as practically, it seems to possess some of the best points of other ptosis operations, and eliminates some of their worst faults. It is adapted to all the ordinary forms of ptosis, the degree of effect being governed by the height of the fold made in the broad ligament of the tarsus, its distance from the ui)per border of the tarsus, and, in some measure, by the distance of the primary incision from the free border of the lid. Narcosis is employed only when necessary. Cocain solution injected into the skin is less of a liel]) than a hindrance. It is usually drop])ed into the o])en wound, but it is of doubtful benelit. 246 OPERATIONS FOR PTOSIS Summary. — In the foregoing chapter an attempt has been made to give, by describing example ptosis operations, an idea of some of the many different methods, and to illustrate the guiding principle in each instance. In the primitive operation of excising a segment of skin mere shortening of the lid was the aim and the end. Naturally, this can only be applicable to cases characterized by an actual redundance of integument, i.e., cutaneous ptosis, or blepharo- chalasis, for, in general, the lids of ptosic subjects are already too scant. This is particularly true of congenital ptosis, in which the lids are short, flat, and devoid of any sulcus in the skin. In the operation of von Graefe the object was the weakening of the an- tagonist of the levator or the orbicularis, and was manifestly faulty in the premises. The Bowman-Gillet de Grandemont methods are similar to von Graefe's in that they really amount to subcutaneous shortening of the lid; but they are an improvement in so far as they effect an advancement of the elevators of the tarsus. As to the palpebro-frontal ligament of Dransart, as represented in the original operation and in those of Mules, Bishop, Wilder, and others, there is no denying that the results are positive, but they are mainly due to shortening. There is no definite advancement of the normal elevators, the lifting of the lid is relegated almost wholly lo the frontalis, which is but a poor substitute, and besides, a foreign body is left in the tissues; not the least objection to this is that it is sometimes extruded. They would seem to be superior to those other methods that are employed for putting the lid in more direct connection with the frontalis, whereby tongues or strips of muscle are transplanted. The frontalis owes its power of lifting the eyebrow to the fact that its attachment is essentially to the skin; hence, procedures that call for deep or extensive incisions and other traumatism in the superciliary region must result in scars that inevitably limit the natural movement of the parts. Then, too, these engrafted fragments will atrophy, and the eft'ect obtained will diminish with the lapse of time. The palpebro-frontal ligaments are peculiarly suited to cases in which both the levator and the superior rectus arc ])owcrless. In the mode of Pagenstechcr, of gradually tightening ligatures, the object was the coupling of the lid to the frontalis by means of cicatricial cords, and looked to a determinate result through a most precarious and irregular medium, viz., the exciting of an inllammatory or suppurative process. In the procedure of iMcrsbuscIi and liis followers the object souglit is SUMMARY 247 the shortenin,!^ or advancement of the levator, and its futility as a systematic, all-arouud process would apjiear lo lie in the fact that the muscle concerned is, in the great majority of cases, either absolutely inert or of extremely insignificant force. While, therefore, the sphere of these measures is thus limited, they are theoretically suit- able only for a certain small number of cases in which the levator is fairly potent, as in trachomatous ptosis. But, as a matter of fact, they have a much wider range of usefulness, of which more anon. The Motais-Parinaud measures are happily imagined and rest upon a physiologic as well as a scientific basis. Yet they depend for their success upon the integrity of the superior rectus; and in a large percentage of cases of ptosis there is paralysis or marked insufiiciency of the muscle. Theoretically considered, the very pro- nounced drawing forward of the superior rectus that would be req- uisite for the correction of an extreme ptosis by these methods would result in undue tension diplopia and, possibly, vertical squint. They would find their best application, then, to the lower grades of ptosis in which the superior rectus is of normal strength. According to Terson,^ of the considerable number of operations of this kind that have been recently performed, some have been follow^ed by good results, and others not only by failure, but by corneal complications — the latter even leading to anterior staphy- loma. Moreover, the eye is said to be more prone to remain open during sleep after the Motais-Parinaud methods than after other operations for ptosis. Shoemaker, of Philadelphia, in the Annals of Ophthalmology, Oct., 1907, makes certain pertinent remarks as to the Motais opera- tion from the theoretic standpoint. For instance, he says, " Motais claims to supply a perfect physiological substitute for the levator by such a transplantation of the superior rectus tendon. This is not actually the case, but the lid after the Motais operation is held in its new position by anchorage to a fixed point on the eyeball, so that there can be no elevation or movement of the lid through the trans- planted portion of the superior rectus independent of the eyeball." Did the writer of these w'ords bear in mind how slightly, even in the normal eye, the levator can act independently of the elevators of the globe? Shoemaker further says that the tongue or slip of the superior rectus is perfectly inextensiblc if made of tendon, as was the intention, and that if made ten millimeters long, as ^Motais 1 Encyclopedie Fran^aise d'ophtalmologie, vol. v, p. 408, 1906. 248 OPERATIONS FOR PTOSIS specified, it would reach into the muscle and be apt to part upon the slightest tension. Yet he thinks the possible effect to be derived from the operation is great, and when little or no effect is obtained he believes the cause of the failure lies in transplanting the slip among the libers of the orbicularis, instead of securing it to the tarsus, and that this is particularly apt to occur when the stitch is tied on the skin, as the tendon is then drawn away from the tarsus. To be sure that the slip is attached to the tarsus he would suggest the open method, as follows: The first stage of the operation remains unchanged except that in passing the double-armed thread through the prepared tendon slip, pass the needles from above downward, placing the loop on the upper surface. Then make a horizontal incision through the skin of the lid and the orbicularis muscle down to the tarsus a little below its upper margin. Undermine the orbicularis fibres by pushing them upward or backward, exposing the tarsus to its upper margin. Buttonhole Miiller's muscle and the conjunctiva and through this opening carry the sutures with the piece of tendon, and fasten the latter directly to the surface or edge of the tarsus precisely as we do the tendon to the sclera in an ordinary advancement. Having dipped each needle into the tarsus and brought tarsus and tendon slip into direct contact, restore the orbicularis fibres, carry the needles through them and the skin, and tie. Close the wound in the lid with two or more stitches. He thinks permanent paralysis of the superior rectus is not necessarily a contraindication to Motais operation, but may be rather an advantage, and he sees no reason why, in such a case, the whole tendon should not be transplanted and put to some use. A positive contraindication would be a thin, poorly developed superior rectus. The laying bare of the tarsus, as proposed by Shoemaker, doubt- less has its advantages. Not the least of these being the greater facility it affords for the definite and precise disposition of the transplanted tongue. My colleague Wilder has been the first, I believe, to put Shoemaker's idea into execution. This he has done of late in several instances, and expresses himself as well pleased with the outcome. In addition to adopting Shoemaker's proposal, Wilder has added a feature of his own. He reasoned, and rightly, that the Httlc tongue gives hardly more than a single point of su])- port to the lid, and vwn thought that he ()l)ser\ed, in a case that had COMMENTS ON THE MOTAIS MKASURE 249 been operated upon by the Motais method, that the free border of the uj)per lid showed a sort of notch corresponding to the point of attachment of the tongue. To avoid this, as well as to serve as auxiliaries to the delicate tongue in holding up the lid, he places a slowly absorbable suture in the ligament of the tarsus on either side of the buttonhole through which the tongue is drawn, and in such a manner as to slightly fold said ligam.ent. He thus combines with the Motais measure something of that of Eversbusch — or a slight shortening or tucking of the levator tendon. Objections to, or criticisms of, a measure on purely theoretical grounds, no matter how cleverly conceived nor how logically argued, are not necessarily valid nor conclusive. Many reports have been made in ophthalmic hterature of most excellent results obtained with the Motais operation. Notable among those made in this country is that of H. D. Bruns, of New Orleans. The present ^^Titer has performed it in sixteen cases. Two of these were trachomatous ptosis of high degree. In one the lid had fallen completely. Since the upper borders of the tarsi had under- gone trachomatous degeneration, they were excised at the same time, thus allowing the anchorage of the tongue to be made at the middle of the tarsus instead of at the upper border. The outcome of these cases was so singularly gratifying that I wondered if it were not best oftener to combine the operation with a slight excision of the tarsus. I have recently seen a recommendation to that effect by a French author. In the operations just referred to it was necessary first to make a free canthotomy, in order the better to manage the upper lid, there having been considerable atrophy of the conjunctiva. In addition to the two cases just mentioned, my sixteen included ten of congenital ptosis and one from traumatic paralysis of the levator. The results in all of them are far and away the best I have ever obtained in this affection. As concerns the last case operated it was feared for a time that either the tongue had broken, or the suture had pulled out of it, but this fear proved to be groundless. The manner in which the free border of the upper lid keeps out of the way of the pu])il, as the subject looks further and further up- ward, is truly beautiful to contemplate. As regards annoying diplopia, upward squint, inability to keep the lids closed during sleep, etc., I have not observed any of these. It is true, however, that one can, soon after the operation, demonstrate hyi)ertroi)ia. According to this ])hase of the subject, one would naturally conclude 250 OPERATIONS FOR PTOSIS that cases of bilateral ptosis, ha\'ing both eyes operated, would be more likely to escape this complication than would the monolateral ones. I find that in congenital ptosis the lack of power in the superior rectus is main'y due to non-use, for these subjects have no oc- casion to rotate the globe upward. By careful examination it can usually be demonstrated that there is limited function in the muscle. No matter how little there is, the Motais operation is the one, in my opinion, that should be chosen. After the lid is once raised the superior rectus develops more and more its proper function. Herein lies the explanation of a unique and most gratifying feature of the Motais method, viz., the constantly increasing enchancement of the effect for weeks and even months after the operation. The axes of vision in normal eyes are never divergent — never even parallel. They must meet at the object fixed. Hence, they are always more or less convergent. In the visual act by which one earns his livelihood they are, in most instances, strongly convergent. Moreover, it is to be remembered that the superior rectus (together with the inferior rectus) is an adductor muscle. It is important then in transplanting the central portion of the tendon of the superior rectus into the upper lid— or onto the upper tarsus — to place it some- what to the nasal side of the center of the tarsus, in order to give it the most direct action in lifting the lid. To place it in the center, or to the temporal side of the center, would cause it to overlap the outer third of the tendon in the habitual position of the globe. A little study is invited of the accompanying drawing (Fig. 132), which is a tolerably accurate representation, in vertical, median sec- tion, of the tissues concerned in the surgery of ptosis. This will dem- onstrate that any measure which folds or in any way shortens the broad ligament of the tarsus, not only advances the levator and Miiller's muscle, but also tightens up, or advances, the levator por- tion of the tendon of the superior rectus. It follows that, as single, constant measures, the class of operations treated of under the second category, viz., the advancement of the natural elevators, are, perhaps, those deserving of the greatest confidence. Granting that those in tlie first class — the linking of the lid to the frontalis — are as effective in lifting up and holding the lid, the feat is accomplished in an unnatural manner; that is, the lid is ])ulled straight up, not rolled back and up, normally, like the visor of a helmel; moreover, the CHOICE OF MKTIIOI) 2ST forehead is corrugated in the act, thus adding another deformity. We have noted the limitations of those in the third class. All who have had much experience in this branch of ophthalmic surgery will agree that the results of j)tosis operations, taken all in all, are far from brilliant. "It is only with precise appreciation of the peculiarities of the individual case, that one may hope to succeed Fig. 132. — Lev., Levator muscle. S.R., Superior rectus muscle. S, Sclera. U.F., Upper fornix. M, Muscle of Muller. I, Iris. C, Cornea. L, Lens. I, Scleral portion of superior rectus tendon. 2, Levator portion. 3, Conjunctival portion. L.T., Levator tendon. S.O., Septum orbitale. F, Frontal muscle. S-C, Super-cilia. E, Expansions of the levator tendon. T, Tarsus. The lids are represented closed. in this delicate, and special surgery of the lid" (Terson). A correct diagnosis as to the character of the ptosis and a nice estimate as to its degree, are pre-requirements to a fortunate issue. The high degrees of congenital ptosis, with inert superior rectus, are the most difficult with which to contend. It is in these that, according to the writer's observation, the greatest good is to be looked for from those surgical measures that do not rely for their success uj^on a single feature or principle, but uj)on a n'eU-cousidcrcd union of two 252 OPERATIONS FOR PTOSIS or more. In this manner one is not obliged so to exaggerate a particular step as to risk, for example, the production of unsightly and harmful lagophthalmos, but is enabled to obtain a maximum effect with a minimum disturbance of any one of the several parts involved. For the milder forms of partial ptosis all the measures that have just been described readily give satisfactory results in good hands and in well-selected cases. After all, it is here, just as with surgery in general, that subtle something known as personal equation is a tremendous factor. A chosen few seem to be lucky, whatever the methods thev select. CIIAPI'KR VJI. KNTROPION. Entropion, or turning inward of ihc lid upon the globe, is of two kinds functional and organic. The evil results of the condi- tion have reference, mainly, to the damaging effects upon the cornea and conjunctiva caused by the contact of the misplaced eyelashes, or trichiasis; though the deformity, and the pressure, and the rubbing of the warped and shrunken tarsi upon the globe, in the worse forms of organic entropion, are alone suflicicnt reasons for surgical intervention. Functional or spastic entropion usually concerns the lower lid only, and occurs most often in elderly persons in whom the palpebral integument is lax or superabundant. It is then known as senile entropion, and a common cause is the wearing of a bandage. Not infrequently, however, it affects the lower lid of younger sub- jects, when it is accompanied by inflammations of the skin and of the conjunctiva. This form of spasmodic turning in has been called acute entropion. Whate\er the cause or the age of the indi- vidual, they are treated about alike; that is, for the transient or less obstinate varieties simple mechanical means are successfully employed, and for the more stubborn, surgical measures are required. If from bandaging, and it is not practicable to leave off the dress- ing, a strip of rubber adhesive plaster five or six centimeters long, by one to one and one-half wide is applied vertically. About one centimeter of the upper end is first made to adhere just below the cilia, pulled downward slightly, to draw the free border away from the eye— not so much as to produce a decided ectropion— then fastened throughout the rest of its extent. If there is any lacrima- tion, the tears soon loosen the plaster, in which event it is better to gently evert the lid and to paint llexible collodion over the region of the lower half of the orbicularis, taking care to close the eye and otherwise protect it from the ether. A more efticient way is to cut a small slri]) of gauze or other suitable fabric, lay it on tlie part, and glue it down by smearing 2s ; !54 ENTROPION on the collodion (Fig. 133). As with the ])Iaster, the upper end is made fast first, allowed to dry, tlicn drawn down, and the whole made to stick. If the entropion persists in spite of the continuance of such treatment for a reasonable time after the exciting cause has been removed, some form of operation is resorted to as a choice of two evils; for, while lid abscess and c\-en phlegmon of the orbit are Ap ll()ni/.i-(l irauze for sp. •titnijiion of lower known to ha\e resulted from the sort of surgery in question, the trilling risk therefrom, as compared with the sure harm to the cornea and conjunctiva that will follow the ])rolonged friction of the lashes, is not to be considered. If the entropion be still purely spastic, onC of the safest and most effective remedies is canthoplasty, with free division of the external canthal ligament — the cantliolysis of Agnew — as described in its ])roper place. SUTURE OPKRATIOXS 255 One may also ha\c recourse lo one of the suture operations. These, of which a numl)cr have been devised, consist in inserting a thread or a series of threads, vertically in the tissue of the lower lid, that through the tying or through the consequent cicatrizing will correct the entro])ion. The forerunner of most of ihem was that of Hippocrates, who passed a ligature through a horizontal fold of the skin just beneath the free border, and allowed it to suppurate out. Gaillard^ entered from one to three curved needles, carrying silk thread into the skin just beneath the lashes, that penetrated to the tarsus, followed its anterior surface, thus including skin and orbicularis, and emerged, straight below, some fifteen millimeters or more from the point of entrance, according to the degree of redressal required. They were tied tightly and left till their spontaneous release. Arlt- modified Gaillard's method (Fig. 134) so that, in accordance with present ideas, it might be thus described : Two No. 3 braided black silk sutures, previously boiled in vaselin-paraffin and otherwise aseptically prepared, are needed, each of which is armed with two curved needles. With left finger and thumb a horizontal fold of the skin large enough to correct the defect is picked up beneath the affected lid. One pair of the needles is made to penetrate the base of the fold on the same level, two or three millimeters apart, and about the same distance (three millimeters) from the free border — one on either side of the junction of the middle with the outer third of the lower lid. They are passed downward between tarsus and muscle, and brought out as in the Gaillard operation. The other pair is similarly introduced, astride the junction of the middle and inner thirds of the lid. In tying, a cylinder of some soft material is placed beneath both knots and under both loops, wdiilst a large probe or other round instrument is pressed against the tarsus to make it cave inward. A bandage is applied until the sutures are removed at the end of forty-eight hours. Snellen's^ Sutures.— The eye is cocainized. The edge of the lid is seized with a pair of T forceps, or with the lingers, and everted enough to open the cul-de-sac, in the bottom of which the needles are started (Fig. 135). One needle of a double-armed suture is here passed (convexity downward) directly through the whole thick- 1 Bull, de la Soc. med. de Poetiers, 1844. - Die Krankh. des Aug., iii, S. 368, 1S5O. 3 Cong, internat. d'oph., Paris, 1863. 256 ENTROPION ness of ihc lid, just external to the lacrimal punctum, and the other through about four millimeters further outward, while the resultant loop is drawn down into the fornix. The point of each needle is then inserted at its place of exit from the skin, passed upward be- neath the latter — not beneath the muscle — one parallel with the other (their convexities backward), and brought out two millimeters below the cilia. One or two other threads are placed in precisely the Fig. 134. — Arlt's uturc for entropion. Fig. 135. — Snellen's suture for entropion. same manner. The lid is turned outward, over a round instrument of some kind, and the sutures are tied over cylinders and left in three or four days, the eye being bandaged meanwhile. Stellwag's sutures (Fig. 136), like Snellen's, began by loops at the bottom of the lower fornix, but instead of passing iirst through the lid, were directed up and forward between the tarsus and the orbicularis, to emerge from the skin near the cilia. Graefe,' in some cases of spastic entro])ion, picked up a small ' ll.idcll.erg Cong., 1868. SIMPI.K KXCISIOX 01' SKIX 57 vertical fold of skin, two or three millimeters wide, near the center of the free border, passed a thread through its ui)i)er end, lied it, and cut one end off short. This was repeated directly below, over the rim of the orbit, and the two long ends of thread were knotted over cotton or gau/e. One or more were em])l()yed as the case demanded. The excision of a strip of the extreme border fibres of the lower section of the orbicuhiris, through an incision close to the cilia, is Fig. 136. — Stelhvag's suture for ectropion. effective and proper for tlie relief of recent spastic entropion and is sometimes successful after the simple sutures have failed. The simple excision of a section of skin in the form of ellipses, triangles, etc., of greater or lesser extent, after the fashion of the ancients, is still practised, to a limited extent, for functional entropion as well as for the cicatricial variety. The opening is cither closed by suturing or is left raw to heal by granula- tion (Desmarres). 258 ENTROPION Another primitive cure is linear cauterization of the skin along the border. Both these measures are irrational and fogyish. The mere fact that they do away with the entropion in most in- stances does not render them free from censure, and they may be easily pushed to such an extreme as to cause the substitution of one blemish for another, such as lagophthalmos, unseemly scars and ectropion. It is doubtful if sheer redundance of skin is ever the true cause of entropion, but it is certain that the removal of it will pull the lid away from the eye— so might many an odd contrivance. ORGANIC OR CICATRICIAL ENTROPION. UPPER LID. This form, unlike the functional, consists not so much in the malposition as in the malformation of the lid, the chief factors in which are the warping of the tarsus, through the transformation of this body into cicatricial tissue, and the atrophy and consequent shrinkage of the conjunctival sac. The causes are diseases such as chronic inflammations and ul- cerations, beginning in the conjunctiva, the results of infection, burns, and other injuries. The greatest of all agents, both as to its capability and its frequency, in the production of cicatricial entropion is chronic granular conjunctivitis, or trachoma. The countries bordering on the Mediterranean Sea have from the times of their earliest history been peculiarly subject to this affliction, hence, they early began to devise surgical means for the relief of trichiasis, which is the greatest evil of entropion. This form differs in another respect from functional entropion, viz., that it more generally concerns the upper lid. In dealing with entropion from trachoma, therefore, it is well to keep in view the manner of its production; in other words, the clinical characteristics of the disease which produces it, as constituting the rationale for its best and most progressive surgery. The features that have a special bearing may be stated thus: 1. Principal Seat. — The upper conjunctival fornix. 2. The intense photophobia, which is the earliest factor in the causation of entropion. Through it an abnormal development of the orbicularis ensues, especially of the palpebral or inner zone of the muscle which remans after the acute stages of the disease have CICATRICIAL 259 passed. By its action the tension of the lids u[)on the ^lobc becomes excessive, the friction is increased, and the protecting, sharp, inner angle, containing the musculus ciliaris of Riolani, disappears, the free border becomes ivhcttcd down, by absorption, to a feather edge, and the iinderhanging skin contains the lashes. 3. The atrophy of the entire conjunctival sac and the whole of the tarsi that are responsible for the shrinkage and distortion of these parts — a process that, once well under way, seems never to come to an end until death. Nos. 2 and 3 are, probably, both concerned in the bringing about of the varying degrees of ptosis that are so often associated with entropion. The levator gradually yields to the prolonged antagonism of the powerful orbicularis and to the oblit- eration of the upper fornix, through atrophy of the con- junctiva, and becomes per- manently disabled. Incipient, or slight cic- atricial entropion, when the cause of it is no longer active, can rarely be corrected by one of the operations described for the functional kind. Here tissue has been destroyed that must usually be replaced. The first important operation of which there is a definite account is that described in the medical works of .^tius, written in the sixth, and those of Paulus ^Egineta, in the seventh century of the present era. Briefly, it was as follows: The free border was divided vertically, from canthus to canthus, into two leaves — the anterior, composed of the skin holding the cilia and their follicles; the posterior, of the tarsus and conjunctiva. An ellipse of integument, the length of the palpebral fissure, was removed just above the roots of the lashes, and the latter, with their loosened bridge, slid up and fixed to be out of the way. This is the iden- tical operation that was revived by G. Jasche ^ and that, modified by V. Arlt,2 had such a tremendous though ephemeral vogue, under 1 Med. Ztg. Russlands, No. q, 1844. 2 Graefe-Saemisch, Bd. iii, 1874. Jasche- Arlt, No. i. 2 6o ENTROPION the name of " Verabschiebung des Wim])crbodens nach Jiische- Arlt," or, in English, transplantation of the eyelashes (Figs. 137 and 13S). The great faidts of this procedure were: (a) want of a fixed point above for the upper edge of the flap; {h) lack of support from below, so that the cilia gradu- ally descended until they again rested on the eyeball; and (c) no attention was paid to the incurvation of the tarsus; nor {d) to the atrophy of the conjunctiva and restora- tion of the free border; (c) to the relief of lid tension; (/) to drawing up the loose under- hang of the cilia; nor {g) the counteracting of the tendency -Jaschc-Arlt, No. 2. to ptosis. The need (a) was found by Anagnostakis,^ of Athens, wdio chose the upper border of the tarsus (Fig. 139). He made a cutaneous incision the length of the tarsus, only three millimeters from the free border, opened it up, and resected a strip of the orbicularis overlying the upper border of the tarsus, and to the latter stitched the lower lip of the skin incision. The upper lip was not included in the sutures. This method failed in all the other require- ments save (a). Hotz,2 of Chicago, modified this proceeding by making the [)rimary incision higher up and ])aralk-l with the upper tarsal border, to give a normal sulcus with the scar at its bottom (Fig. 140). He passed the sulure^ through the upi)cr lij) of the skin incision also before tying, and ,\nap;nostak 1 Annul, d'oculist. 1. xxxviii, p 2 Archives of (3i)lilhalmology, ^ :S57. •iii, ]) GAYET S METHOD j6i most important of all, insisted ui)on the resection of the lower fibres of the orbicularis — thus partly fulfillinj^ indication (>•). To Hotz is really due the credit of perpetuating the princij>le adduced' by Anagnostakis, and which is so necessary a ])art of the advanced cntro])i()n o})crati()n. More- over, as regards the inception of the idea, Hotz owes nothing to the Greek surgeon. The first to see, and i)artly lo supply, the second want — sup port from below — as well as tlic first to make marginal blepharo- ])lasty, was Spencer-Watson.' This surgeon, after splitting the lid border as per the old Greek method, made as if to remove the ellipse of skin, but left the outer end attached, as he did also the inner end of tlic cutan- eous bridge containing the cilia, as nourishing pedicles. He then caused the two fla])S thus formed to exchange places, and fixed them in their new relations by fine sutures (Fig. 141). Gayet- split the free border and dissected up the long strip of skin, with external pedicle, which he transplanted back of the cilia without sliding up -;the skin containing them, thus partly meeting requirement (d) — or restoration of atrophied tissue (Figs, 142 and 143). A further improvement was that made by Dianoux" who, in addition to the bridge con- taining the lashes, formed a second of integument, above and adjacent to the first. The two were then transposed and Fig, 140. — Hotz. Border fibres excised. [41. — Spencer- Watson operation. ntropion Med. Times and Gaz., vol. xlix, 1874. Annal. d'oculist. t. Ixxxii, 1879. Annal. d'oculist, No. 2, p. 132, 18S2. 262 ENTROPION Fig. 142. — Gayet's entropion operation. sutured. Both were fed by double pedicles, and as soon as practica- ble those of the intermarginal strip were cut (Figs. 144 and 145). Waldhauer^ made the Jasche-Arlt operation, and rather than throw away the excised segment of skin, he covered with it the denuded lower portion of the tarsus — graft without a pedicle, after Le Fort- Wolfe. Van Millingen,- of Con- stantinople, under the name of tarso-chiloplasty, still further improved the methods in question by substituting for the intermarginal skin graft one of mucous membrane taken from the inner lining of the lip. A broad strip of this tissue furnishes the requirements mentioned under both {b) and {d). The originator of tarsoplasty in this connection w^as Streatfield.^ His operation consisted in the removal of a large horizontal wedge of tissue from the upper lid, which was composed of skin, orbicularis, and a small part of the center of the tarsus. ,<&- No sutures were employed, ^ the wound having been left ^-^ to heal by granulation in order to increase the effect of the operation. Thus was the third requisite (c) to the success of this branch of surgery provided. It occurred to Snellen, of Utrecht, to combine this guttering of the tarsus with the Anagnostakis'* method. Fig. the only difference being ' Klin. Monat.sbl., 1897, PP- 47~54- 2 Oph. Review, p. 309, 1887. 3 Royal London Hospital Reports, vol. i, p. ■• Van Gils Beitrage, Utrecht, 1S70, p. 90. -Gayet's entropion operation. Lid everted. 25, 1S5S. ENTROPION 263 that double- armed sutures were used, starling in, through, coming back to the lower skin flap, and tying over glass beads. Chronis^ added canthoplasty and, about the same time, Agnew subjoined external tenotomy or cantholysis to this procedure, and by these means the second requirement of (e) was obtained. Panas- made a similar operation to that of Snellen with two or three highly significant differences, viz., the careful dissecting up of the lower skin flap as far down as possible not to cut through and make a but- tonhole, the passing the sutures through the line of ciha beneath the entire flap (not through it), and the Fig. i44.-Dianoux's entropion operation. fastening them by collodion to the brow (Figs. 148 and 149). This dissection and the drawing up of the lower flap, partly meet requirement (/) . The point wherein it fails of the condition is the fact that the threads push the ciliary strip up instead of pulling it up and putting it on the stretch. A. Pagenstecher^ made an incision just below the upper border of the tarsus, opened - it up wide, exposed the tarso- orbital fascia, which was caught up in a horizontal fold, and through it were passed the sutures that tra- versed the two lips of the cutaneous incision. As a complete operation for cntro- FlG. 145.— Dianoux's entropion operation. ^j^^^ ^^^ proceeding fcU far short, yet it served to obviate the droop of the upper lid and thus met requirement (g). A resume, then, of the fundamental principles of the modern operation for entropion of the upper lid, the measures devised in 1 Rec. d'opht., 1875. 2 Arch, d'opht., p. 208, 1882. 3 Klin. Beob., 1861 ; and A. f. Oph., xxxvi, 4, S. 265. 264 ENTROPION accordance with them and their authors would stand something Hke this: (a) Fixed anchorage for sutures that hold up the flap containing the cilia: the tarsus and the tarso-orbital fascia. Anagnostakis. {b) Support of same from below: transplantation of tissue. Spencer- Watson. (c) Correction of incurvation of tarsus: counter-grooving. Streatfield. (d) Replacing of tissue, to atone for shrinkage of conjunctiva, and to restore the angle of the free border : intermarginal grafts. Spencer- Watson, Gayet, and Van Millingen. (e) Relief of overtension of the lids and accompanying blepharophimosis: canthoplasty, cantholysis, and resec- tion of the border fibres of orbicularis. Chronis, Agnew, Hotz. (/) Redressal of the underhang of the skin at the free border, and the turning up {not pulling tip) of the cilia : dissection of lower lip down to the cilia. Panas. (g) Obviation of accompanying ptosis: tucking of levator tendon. Pagenstecher. The scope of any given operation for cicatricial entropion and trichia- sis of the upper lid will be determined by how many of the six features here enumerated it will be lit for it to embrace. To put it another way, the extent of the surgical interference needed for the relief of a specilierl case will be governed by the number of abnormal conditions that are concerned in the i)roduction or maintenance of the entropion and the trichiasis. If, for instance, only partial absence of the angle of the free border is responsible for the trouble, the simple insertion of an intermarginal graft might furnish the remedy. If entire absence and nothing more, a Hotz operation would l)e added to this with, perhaps, canthoplasty. If complicated with incurvation of the tarsus, counter-grooving must be joined with the other steps, and so on. As a matter of fact, the instances are exceedintrlv rare that are not all the belter for giving groove. A(-.E f)F SUBJECT -^^'5 one's pulicnl ihe bcncfil of ihc whole catc.^ory. For, if all the phases mentioned are not present in the ])articular case. o\vin<^ to the never-ending progressiveness of the affeclion on and on for years after all apparent traces of the primary disease ha\c \ani>he(l — what the several parts of the operation do not accomplish in the way of actual cure, they will achie\-e as preventives. Another element that must be taken into consideration in defming the limits of an operation for entropion of the upper lid, especially when caused by trachoma, is the age of the subject. Those who come to us suffering from this disorder represent c\Try period of life between iW V Fig. 148. — Panas entropion opfvalion. Fic. 149.— I'anas entropion operation. ten and seventy years. I have known three generations of a single family to be under treatment at the same time. Naturally, in view of the perpetuity of the. degenerative changes of the tarsus involved, one must strive for greater effect in cases of children and the younger adults whose lives are before them than in those of the middle-aged and the elderly, if it is hoped that the best results of one's work are to endure till the end. How great, then, should be the effect ? ^lore than twenty years of service as surgeon to the Illinois Charitable Eye and Ear In- firmary, an institution whose outdoor and hospital clientele com- prises some 12,000 new patients annually — of whom a large propor- tion were, a few years ago, admitted because of entropion from 266 ENTROPION trachoma — have given the writer exceptional opportunities in this hne of surgery, both as participant and observer. Unlike those whom we treat in private practice are these wards of the State, When their troubles recur they come back or are sent back to us, and it is almost a daily occurrence to see one return with an ag- gravated type of entropion, who a few years before, had been operated upon and "cured" of the same trouble in the same lids. It sometimes happens, too, that the recurrence is more pronounced than had been the first form. Certainly, the difficulties of the second attempt at restitution are in no way lightened by what was done at the first. On the other hand, it is much to be doubted if a well- made operation for cicatricial entropion has ever been followed by too great an effect. Many a one has resulted in lagophthalmos from un- due shortening of the lid, but not from too great an eversion. Presum- ably this last is possible, but it seems to be only theoretically so. Wherein most operators fail is not that they do not obtain cor- rection of the deformity, for the merest tyro among them succeeds in this, but that their correction does not last. In the pursuit of this branch of plastic surgery, therefore, it would not go amiss to take this as a maxim — excessive immediate effect is necessary in order to insure permanent correction. Technic of the Operation. — The following description em- bodies the author's conception as to the surgical requirements of a pronounced cicatricial entropion of the upper lid, and also the details of his manner of procedure. The operation may be per- formed with or without narcosis. If dispensed with, cocain solution is dropped into the conjunctival sac. The infiltration anesthesia of Sleich is effective in preventing pain, but the swelling of the tissues it produces is highly prejudicial to nice results. The patient is prone upon a table. If both eyes are in need of the operation and the patient can or will submit to their occlusion for a few days, it is decidedly to his advantage, as to time, suffering, and inconveni- ence, to make the two operations in one sitting. One or two trained assistants are needed. First step. The canthotomy (p. 218).— Free division of the external canthal ligament is indicated. Second step. Making of the intermarginal incision that is to receive the graft. The lid is grasped, everted, and held back by the Beard lid forceps (Fig. 150) or by the tips of the lingers placed upon the eyelashes. Where the latter exist in sufficient numbers ALTOC.KTIIKR >67 and length, one may dispense with the forceps. This inslrumenl has proven most serviceable, as il elTcctually fixes the lid and pre- vents bleeding while the making of the cut is in progress. The scalpel, with extra convexity near the extremity of the blade, held as shown in Figs. 48 and 150, is employed. The incision extends from the outer limit of the free border to, but not including the jjunctum. Where manv fail is in makinu; this cut loo short and loo shallow. Fig. 150. — Making the intcr-marginal incisiun for iiiucous graft. If the entire free border is involved I do not hesitate to carry the incision past the punctum, i.e. , to the inner canlhus. An insignih- cant shallow incision will not retain the graft which, to be effective, should sink in till its epithelium is lower than the surrounding lid margin. The position of the incision is in the posterior portion of the substance of the tarsus, rather hugging the boundary between tarsus and conjunctixa; it is four to five millimeters in de])lh. and is made to gape widely ihat one may judge of its capacity. The lid is now turned back inlo place. Third step. The Cutaneous Incision.— A broad lid spalula is pushed into the up])C'r fornix and lield by an aid (Plg. 151). With the same scalpel an incision is mafic ihrough skin and muscle just 268 ENTROPION below, and parallel with, the upper border of the tarsus, except near the extremities where it takes a horizontal direction, extending some- what beyond the vertical line of the cantlnis in either direction. lHr£RKi/{K^-lHH^lHCI9ION :^ w l-'iG. I SI. — "Alloirclhcr opL-ration. Its distance from the free border varies witli the width of the tarsus. Fourth step. Dissection of the Flaps. The lower lip of the incision, with its attaclied jjortion of the orbicuhiris, is Hfled and AT,T()(;i:riii:R >6g undermined, and the larsiis cleanly denuded down lo the ])()int where the cilia are seen to cross between it and the muscle, like black stitches in a seam. For this dissection it is best lo use the hack of the knife-point, and the flap is thus loosened the entire length of the free border. When the cilia are reached, in careful dissection, one feels the point of the knife vil^rate as it chatters in ])assing over tiiem. Ikittonholing at this stage is to be avoided. The U])per lip of tlie incision, with its underlying muscle, is loosened and ])ushed u])ward, so as to exi)()se tlie tarso-orbital fascia (Fig. 151). Fifth step. Resection of the Border Fibres of the Orbicularis. — The instruments are small, mouse- tooth forceps and delicate, blunt- ]3oinled scissors. The upper edge of the muscle clinging to the lower tlaj) is seized with the forceps and neatly excised from end to end in one long strip, the surgeon and the assistant meanwhile taking care of the skin edge to see that it is not nicked an( notched. Sixth step. Counter-grooving of the Tarsus. — The operator steadies the tarsus on the spatula, notes the line of greatest prominence of the horizontal ridge corresponding to the gutter on the inner surface, and witli the same scalpel incises it. The two cuts needed for this purpose are so inclined that they meet at or near tlie ])osterior surface of the tarsus. Jf the conjunctiva should be slightly wounded in the act, it is of little consequence, though it were better to avoid it. The size of the wedge w^ill depend upon that of the tarsus. The incisions will, of course, not go far beyond the ridge, which is often not so long as the tarsus. The thickness of the wedge is usually about two millimeters. Wilder has devised an apparatus for excising the wedge of tarsus. It consists of a pair of small scalpels fixed in a holder. One move- ment suflices for the excision. The ai)pliance is also used by its originator for cutting the cutaneous intermarginal graft for restora- tion of tlie lid 1)or(ler. Fig. 152.— Beard's method for cntroijion. The lieavv black in OS show ilic iiK isions. 270 ENTROPION Seventh step. Inserting the Sutures.— One may use the ordinary curved needles and holder or Reverdin's needle with handle. The needles should be small, fine, and sharp. Large ones cause needless traumatism. No. 2, braided, black, silk thread, boiled in paraffin, makes an excellent suture, of which three are put in, the first one midway of the tarsus and the other two, one on either side five or six millimeters away. Each needle is passed from below, through the lower flap just far enough from the edge to insure a firm hold for forty-eight hours, then through a small, horizontal fold of the tarso-orbital fascia, picked up in the forceps, just above the convex border of the tarsus, thence high up beneath the superior flap, and brought out through the muscle and skin but a short distance below the super- cilia. To make the fold or tuck in the fascia, slightly dig the needle into it just where the crest should be, pull it up and grasp the base of the raised part with the mouse-tooth forceps, so as to form a horizontal pleat and pass the needle through, close to the jaws of the forceps (Fig. 154). Eighth step. Tying the Sutures.— Here the closest attention to the detail of every maneuver is of the greatest moment. The lips of the intermarginal incision will now be found tightly glued together by fibrin. They are parted with the points of the closed scissors and all shreds cleaned out. So, too, as regards the flaps of the external opening. They are lifted up, and all blood, etc., removed from under them, so that they may slide over tarsus and fascia. The central suture is tied first. A double turn is made in the thread and the lower end given to the aid, while the operator holds the upper between thumb and index. The edge of the lower lip of the cut is grasped with the mouse-tooth forceps near the thread to be tied, and drawn up, turned backward and placed in contact with the fascia just where the thread enters the latter, or against the fold. Fig. 153. — Beard's method for entropion. Shows course of sutures. THE "altogether" 27I simply pushing up tlic other flap with its edge also turned backward, just as described for the ptosis operation. While the flap is being thus held, the operator pushes down (or backward, as regards the eye) with the forceps on the weakened tarsus, to make sure that it bends with its concavity outward, closing the newly-made groove, and now surgeon and assistant pull together on the ends of thread and draw it tight, when the former takes both ends and completes the knot. Were the tarsus not pressed down in its middle this way, it might hump or buckle up, i.e., with its concavity downward and actually increase the deformity it was the aim to correct. The sutures, to complete the canthoplasty, are here put in and tied as per description under "Canthoplasty." Ninth step. Making and Placing the Graft. — A wad of cotton wet with warm boric acid is laid over the lids. The patient's lower lip is turned out and gently washed with warm salt or boric solution not scrubbed and rubbed, so as to hurt the epithelium — and a small cotton sponge dipped in boric solution and tightly squeezed is pushed down into the pocket between lip and gums. A pair of large straight scissors, the same as are used for the canthotomy, answer best for cutting out the graft. The lip is caught between the thumb and index, rolled over the medius so as to evert well, the scissors opened very wide, the base of the blades placed firmly on that part of the mucous membrane that usually lies opposite the margins of the gums and, bearing down with the scissors while holding up with the middle finger from below, a long ellipse is excised with one snip of the shears that will fill the intermarginal incision. The piece will include not only the entire thickness of the mucous membrane, but a number of lobules of adipose tissue will be found attached to it. Turn it over, face down, upon the nail of the left thumb (or upon the rubber glove or gauze cot covering the same) and with the small scissors, carefully trim off all the adipose, paring it down to the submucous connective tissue. A very thin, flabby graft is useless. It must have body as well as breadth. In respect to the latter dimension, as time goes on, I am inclined to make the grafts wider than of yore. In extreme cases, they would measure hardly less than seven or eight millimeters at the middle. Rinse it in i% salt or 4% boric acid solution at about 110° F., and place it flatwise in the cut back of the cilia, making sure that the epithelial surface is outward. The tips of tiny spindle-shaped 272 ENTROPION cotton sponges are well wrung out of boric solution and applied about the edges of the graft, to drink up the slight oozing, the lid being all the time held everted as (h'rccted for making the mar- ginal cut. The graft must be am])le in exactly the same proportion as is the intermarginal incision. If the first piece excised falls short of filling the cut, it is better to take a second, suflkiently large, to piece out, squaring and butting together their ends. No decided hemorrhage should be taking place from the wound when the graft is laid in, else a clot will form beneath and inter- fere with proper union. But a slight bleeding, which is always checked by laying in the graft, is an advantage in that it helps to fix and to hold the morsel in position. Sutures would be both useless and harmful, as when quickly put in (i.e., not fussed with too much) and stuck by fibrin, there is no possibility of the graft letting go, except, possi- bly, in removing the dressing (Fig. 154). The latter consists, first, in the usual, thin layer of cotton wet with warm, boric acid solution, carefully applied to the closed lids (p. 15). There is a little point of considerable value that might be mentioned in this connection; after every other operation treated of in this volume, except the one now under discussion, the ap- plication of the first wet sheet of cotton is made by sliding it on to the lids from above, in order to smooth the lashes downward (see dressing after "Extraction"). In this instance the reverse obtains, viz., it is slid upward, for the reason that the primary effect of this operation is to turn the cilia upward, like the feathers in a strutting peacock's tail, and such a manipulation of the dressing tends to heighten the result. To avoid loss of time in the first removal of the dressings, caused by prolonged soaking of the cotton, as well as to ])rcvcnt loss of the graft itself, through having become glued Sliows conipk-lL-d operation. MUCOUS OR SKIN CRAFTS 273 firmly to the cotton, one may place next to the lids a piece of thin soft gutta pcrcha tissue. Upon this, a good-sized ])ad of dry cotton is built up and over all the wet netting roller is applied. The patient is ke])t quiet in bed for forty-eight hours, when the bandage is cut, the cotton removed by soaking with warm, boric acid solution and all the sutures are removed. The identical dressing is reapplied with renewal at twenty-four iiour intervals for a week or more. It will not do to leave off the bandage earlier, else the drying effect of exposure will cause the graft to perish and drop out. Even after the final removal of the bandage, it is well to keep the graft covered for a few days with a film of sterilized vaselin for fear of desiccation. Formerly the wound in the mouth was closed by sutures, but of late nothing is done for it. It heals kindly by granulation and, moreover, most of the subjects are operated without narcosis, and are glad to be spared further "sewing." Conclusions. — In my practice the several procedures just described, viz., canthoplasty, Hotz's method, counter-grooving of the tarsus, tucking of the tarso-orbital fascia, and the insertion of the post-ciliary mucous graft are nearly always combined in a single operation, which at the Eye and Ear Infirmary has come to be known as "the altogether." They are thus united not for convenience, but because experience has taught that by so doing the efi"ect is greater, better, and more lasting. If the same were done piecemeal, i.e., for instance, first the canthoplasty, the Hotz operation a week later, and so on, the ultimate result would be much less satisfactory. Each of the multiple factors concerned in the entropion is attacked by an efiicient foe and the defects are righted in a rational w^ay by judiciously apportioning the efi'ect among the several ills, rather than by giving too great prominence to one or two (Figs. 155 and 156). With regard to the choice qf mucous or of skin grafts for the restor- ation of the free border, ophthalmic surgeons are not in accord. Knapp^ prefers those of skin, claiming that it is the more suit- able, inasmuch as the normal lining of the free border is dermal and not mucous. If one will take the pains, however, to ex- amine a few lids that have been subjected to the operation, he w^ill be readily convinced that the graft after a comi)aratively short time, really takes the place of conjunctiva in that it lies in contact with the cornea. 1 De Schweinitz, Diseases of the Eye. 18 274 ENTROPION Others have urged as an objection to the mucous graft, that its shrinkage is greater than one of skin. Such does not agree with my observation. Indeed, an extended experience with grafts of the three, recognized varieties, viz., those of Wolfe, Thiersch, and Van MiUingen, have led me to believe that the last are precisely those that retain more nearly their original bulk, and for the past ten or twelve years, I have resorted to "chiloplasty." The last bit of skin I made use of to replace the border was put into that of the lower lid where it lay in contact with the globe. Very soon an ugly ulcer appeared on the cornea immediately under the graft. Although not a hair could be found in the patch to cause the irritation, the Fig. 155. — The expression of face bcfi altogether operation." ulcer persisted in spite of treatment. Finally it was remarked, in everting the lid, that, while the surrounding conjunctiva was normally moist, the graft itself remained perfectly dry. This led to the conclusion that the oily nature of the epidermis was a hin- drance to proper lubrication, hence the ulcer. The piece was excised, a graft from the lip substituted, and at once the ulcer healed. The more thoroughly the various steps of the operation have been performed the uglier — from a purely cosmetic standpoint — are its early results. In a few cases so pronounced has been the ectropion, that a crust has formed on I he ])alpebral conjunctiva from exposure lo llie air. This, with llic large red grafts and the inverted lashes, all go to make a ])iclure not overly attractive, yet, GREEN S OPKkA 275 as before stated, I ha\c nc\cr seen peTiiiaiu'nt hypcTcorrc'Clion. But a short while and all iinsi,u;luliness disa])|)cars. Operation of Green for Entropion (Trans. Anur. Ojihlh. Soc, 1880, Vol. Ill, p. 167). — Dcscrifjlion hy Wilder in Wood's "System of Ophthalmic Operations." This operation is intended by its author for those cases of cica- tricial entropion, occurring in trachoma, in which there is marked incurving and a furrow on the conjunctixal side of the tarsus. It is done in three stages: Fig. 156. — The expression of face ten days after " the altogether operation." First Stage. — The upper lid is held firmly everted with the fingers. With a round-pointed scalpel an incision, parallel to and 2 mm. from the row of openings of the Meibomian glands, is made through the tarsus, in extreme cases extending from near the inner to the outer canthus. This incision (Fig. 157) is carried through the entire thickness of the tarsus, but does not extend into the muscular layer, as in the operation of Burow. Second Stage. — The lid is then replaced and a strip of skin not exceeding 2 mm. in width is excised from the anterior surface of the lid. The lower lashes, and the tissue removed should be only skin and connective tissue, leaving the muscle intact. Third Stage. — -Fine silk sutures, armed with small curxed needles, are passed as follows: A needle is introduced at the edge of the lid, just behind the row of eye lashes, and brought out just within the wound in the skin. The needle is then reintroduced into the 276 ENTROPION upper border of the skin wound, passed deeply backward and upward to graze the anterior face of the tarsus, and brought out I cm. or more al)o\e the point of entrance. Three such sutures are passed and, when tied, not only strongly evert the ciliary border, but close the skin wound. The lashes are held in the everted position by collodion applied to them until the widely gap- ing wound in the tarsus has nearly healed, as it does by granulation. Ewing ipphthal. Record, October, 1907, p. 490) modifies this operation in an important way, endeavoring to partially fill in the gap in the tarsus by means of conjunctiva. Fig. 157. — Green's operation for entropion. Beginning at the posterior margin of the free border of the lid, he dissects back the conjunctiva from the tarsus to a distance of -4 or 5 mm. along the whole length of the lid. (This seems to be a detail of some difficulty, because of the intimate relation of the tarsus and conjunctiva.) Retracting the conjunctival flap, he makes an incision through the tarsus exactly as in the Green operation. To aid the assistant in strongly everting the ciliary border during the placing of the sutures, he introduces a temporary stitch in the surface of the tarsus, so that traction on it will cause the tarsal wound to gape widely, as in P1g. 1 58. For the upper lid. seven or eight fine, double-armed loop sutures are then introduced; for the lower four or five suffice (Fig. 159). The needles are first passed about 2 mm. ai)arl, through the GREEN S OPERATION •77 edge of the conjunctival flap which was dissected back; then through the bottom of the wound, back of the tarsus bearing the cilia, to emerge on the skin just back of the cilia. For convenience in remov- ing the sutures and to prevent them from cutting too deeply into the skin, all the stitches are tied over a fairly large No. 12 strand of catgut, placed along the edge of the lid, thus making a kind of quill suture. Tightening the sutures draws the conjuncti\-a into the wound and strongly exerts the edge of the lid. Fig. 158. — Ewing's modifuation of Green's operation. A serious and not infrequent sequel of operations for cicatricial entropion from trachoma is ulceration of the cornea. This occurs even in cases that had previously escaped this complication. ]\Iore- over, these ulcers are apt to be centrally located, just where they can do most harm to the \ision, and heal least readily. One can- not, therefore, use too many ])recaulions with the \ie\v to their prevention; first, as to the choice of the case — never one in which the trachomatous process is still active; second, as to the preparation of the eye — make copious irrigation of the conjunctival sac with warm mild antiseptics immediately beforehand; third, as to the operation itself — not needlessly to injure the corneal epithelium by such things as too much cocain, broad spatula, or lid-clamj)s. 278 ENTROPION nor by going Ihrough the entire thickness of the lid with the needles, thus pricking the cornea or leaving a loop of thread where it will rub that membrane. The effect of the free and prolonged instillation of cocain solution is unquestionably wrong in that it results in the drying and exfoliation of the corneal epithelium. A very few drops before beginning the operation is sufficient, and it should be seen to that the eye is flooded from time to time with warm boric solution. An additional safeguard would be the instillation of a few drops of a 25 to 50% solution of argyrol when about to apply the final dressing. This preparation is not only an effective antiseptic, but it is otherwise harmless, and, besides, has the property of remaining in the con- junctival sac for several days. Fig. I =59. — E wing's operation for entropion. ORGANIC ENTROPION. LOWER LID. Cicatricial entropion of the lower lid does not lend itself so well to the surgical methods described in connection with that of the upper. Here the conditions are different. The transformation of the tarsus, the absence of the width of the free border, disappearance of its posterior angle, etc., do not figure so prominently as in the other case. Lid tension, the tension of the border fibres of the orbicularis, strain of the shrunken conjunctiva, and the blepharophimosis are the things chiefly to be contended against. These, together with the anatomi- cal peculiarity of the inferior tarsal plate— that is, in being only about one-half the witlth of the superior one— necessitate a mode of METHODS OF IWXAS AXI) {'.RAF.rK 279 handling quite special. It is true, ho\ve\er, thai absence of the free border occasionally constitutes the main fault, and the i)lacing of an intermarginal graft the best remedy. The prime indications are to release the lid from the binding pressure of the contractile and shrinking tissues, by resection of the border fibres of the orbicularis, by canthoplasty with cutting of the external canthal ligament, and by piecing out the conjunctiva with grafts of skin or mucous membrane. These measures may, in occasional instances, be supplemented by the judicious employment of operations for the shortening of the adjacent integument. Fig. 160. — Panas' operalion for entropion. Fig. 161.^ — Graefe's operation for entropion. Among the best of these is that of Panas^ (Fig. t6o). The resulting cicatrix corresponds to the natural topography of the region. It is executed as follows: two vertical incisions, each about one centimeter long, are made through skin and muscle, one near the outer canthus, the other near the inner, their upper extremities close under the cilia. Their'jower ends are joined by a horizontal incision through skin only. The flap thus outlined is dissected up to the very roots of the eyelashes, everted and a strip of the premarginal fibres of the orbicularis is excised. A parallelogram is trimmed from the lower edge of the loosened flap, its width proportional to the amount of shortening demanded, and the open- ing closed by fine sutures. V. Graefe gave a method that has often done good service (Fig. 161). Three millimeters from and parallel with the free border, 1 Mem., These de Paris, 1873. 280 ECTROPION an incision is made through skin and muscle, extending nearly the entire length of the lid. A triangle of skin, whose base rests on the middle of the first incision, and whose size is governed by the degree of effect aimed at, is excised — muscle not included. The strip of skin and muscle lying next to the margin are caught with forceps and dissected from the tarsus until the cilia are exposed, taking care not to buttonhole, and the attached fibres of muscle removed with scissors. The two corners of skin are undermined and the whole opening closed by small sutures. If still greater effect is wanted, a triangular piece of the tarsus may be excised, base down- ward, or in the opposite direction to that of the skin triangle (see dotted lines in accompaning cut). The curious operation for entropion of the lower lid that bears the name Flarer-Stellwag^ was made by "scalping" the lid, turning the abscinded strip upside down and replanting it. ECTROPION AND BLEPHAROPLASTY. The name ectropion which is the exact opposite of entropion, refers to an eversion or turning outward of the lid, either partial or total. The degree of eversion varies between that slightest of all partial forms, wherein the lower punctum loses its suction on the globe by the merest separation therefrom, to that most extreme of total ectropion, where, through extensive destruction of the in- tegument surrounding the palpebral fissure and the subsequent contraction, both tarsi are not only inverted, but drawn widely asunder so as to expose the entire area of the conjunctival sac. For convenience, we may separate the varieties of ectropion into four grand divisions, which, given in the inverse of theii: importance or frequency are, (a) Spastic, (b) ^Mechanical, (c) Atonic, and (d) Cicatricial. Spastic ectropion, muscular ectropion, acute ectropion, arc several names that denote the same condition, and alTcct mainly the lower lid. Spastic ectropion has its beginning in some sudden swelling of the conjunctiva or advancement of the globe that tends to push forward the free or straight border of the tarsus. At the same time the backward pull of the orbicularis, through normal contraction upon the convex border, together with the continuance of the outward push of the border, completes the eversion by over- 1 Flarcr:Renexioni sulla trichiasi, etc. Milano, 1828. Stellwag, v.c. : Ein neues Vcrfahren gegen einwiirtsgekchrte Wimpcrn. Allgcm. Wr. med. Ztg., 1883, Nr. 49. MECHANICAL AXD CICATRICIAL 251 coming the action of the marginal fibres. 'J'lie eclroi)ion once ac- complished, the latter llbres only serve to maintain it. This condi- tion, when exaggerated, may be termed blepharo-jjaraphimosis. Mechanical ectropion is really a less acute form of the above, in which both lids may be involved, and, in cases of long standing, is characterized by structural changes in all the tissues of the lids, but more ])articuhirly the innermost. The active force is referable to exophthah-nos, ectasia of the globe from staphyloma, tumors, etc., or to growths and chronic swellings, hypertrophy, etc., of the con- junctiva {mucous ectropion). The perverted action of the or])icu- laris, alluded to, figures here also. Atonic ectropion chiefly concerns the lower lid, and may be due to (a) paralysis or paresis of the orbicularis — paralytic ectropion — or (b) relaxation of all the tissues of the lid, with lengthening of the free border — senile entropion. As a complication of this form, hypertrophic conjunctivitis of the lower lid and epiphora occur, and can easily be mistaken for a purely mucous ectropion. Cicatricial Ectropion. — In this variety, the eversion is the in- direct result of a burn, other injury, or disease that destroys all or a part of the skin of the lids. The destruction that causes ectro])ion rarely extends deeper than the superficial fascia, or, at most, the orbic- ularis. When the deeper leaf, viz., the tarsus and conjunctiva, is carried away, that is another affair. The principal agents in bringing about the condition are the contraction of the scar and, after the eversion is pretty well established, the anchylosis in the external sulcus. The location and extent of the scar will determine those of the ectropion. As to the surgical means adopted for the correction of ectropion, they will depend mainly upon the nature of the defect. For the purely spastic kinds, it will ordinarily suffice to remove that which is most active in producing it. Treatment of the conjunctivitis, or whatever the cause, putting on strips of adhesive plaster to keep the palpebral fissure closed, and bandaging, if the condi- tions will admit of this. If, however, there is strangulation from the muscle-cramp, an immediate canthotomy (p. 21 8) with free cutting of the external canthal ligament is needed. For the mechan- ical form, as in the spastic, attention to the ulterior cause is often the sole means, be it the ablation of anterior staphyloma, the re- moval of a tumor of the globe, tarsus or conjunctiva, or the relief of a transient exophthalmos. Should it be from a more lasting but 282 ECTROPION benign and reducible exophthalmos, median tarsorrhaphy would likely be the most eligible recourse (p. 223). Mucous ectropion of the lower lid will, in most instances, yield to local medical treatment, together with adhesive or collodionized strips to support the lid, and bandaging. Failing in this, one would far better try one of the simpler surgical procedures, such as the insertion of a Snellen^ suture, rather than the emlopy- ment of more radical measures, or resort to such irrational and primitive methods as cauterization or excision of the offending conjunctiva. An excellent means of holding up a sagging lower lid for an extended period, as well as for the better closure of the palpebral fissure in certain cases of lagophthalmos, is by the use of the contrivance in- vented by the writer for the coaptation of shin-wounds in general surgery. - This consists of a strip of tarlatan ribbon, near one selvage of which is attached a row of tiny flattened hooks, similar in shape to those employed in connection with ''eyes." -A strip of this is fastened, by flexible collodion, hooks up, to the lower lid; and another, hooks down, to the brow. The two are then laced, with a suitable cord, the lids approximated as nearly as desired, and the cord tied in a bowknot. The Snellen Suture.— A No. 2 braided thread of silk, boiled in paraffin and armed with two curved needles, is gotten ready. The eye is cocainized. The needles are passed down into the most prominent fold of the exposed conjunctiva, obliquely through the tarso-orbital fascia, at its junction with the tarsus, on down and forward to emerge from the skin opposite the rim of the orbit Wan Gils Beitrage, p. 90, Utrecht, 1870. 2 Described in a paper read before the Chicago Medical Society, and i)ub- lished in the Medical Recorder for June, 1903. Fig. 162. — Snellen's suture for ectropion. VF.RIIOEFF S SU'ITRK '83 (Fig. 162). They cnlcr about one-half centimeter apart, and their courses very sHghtly diverge. Two or, at most, three such sutures are placed and each pair is tied over a cylinder of gauze or tubing. The tension put upon them is just sufficient to cause a slight entropion. They are left in for several weeks or until suppuration appears around them, the eye being meanwhile bandaged, with daily renewal and cleansing. Silver w^ire is preferred to that of silk by a number of surgeons, the assumption being that the metal is better tolerated. I think, however, that if the silk is thoroughly boiled in paraffin, so that it will not act like an open path for the entrance of bacteria, that it will be found superior to any other material. Verhoeff's Suture and Button Operation. — -While attending the last (1913) meeting of the American Ophthalmological Society, Verhoeff , of Boston, described to me a meas- ure he had just devised for such forms of ectropion as the atonic and the mucous. It seemed so well conceived that, immediately upon coming home, I tried it, and with most gratifying results. The technic is briefly as follows: A rather long, and slightly curved, needle, armed with No. 2, braided silk, is passed through the skin, beginning at a point 3 or 4 mm. above, and twice as far to the temporal side of, the outer com- missure (Fig. 164). It is pushed along beneath the skin, parallel with the margin of the lower lid, and not more than 3 mm. from the line of cilia, as far as its length will conveniently permit. It is then brought out, and reinserted through the same hole at which it emerged. It is worked farther along, again brought out, etc., till it reaches the point just above, and internal to, the inner commissure, which corresponds to that where it was first introduced. (See dotted lines in drawing.) It is here brought out and passed upward through one of the two holes of an ordinary, pearl shirt-button, and downw^ard through the other; after which it is made to go back, in VrgvU-Rolx-rtson suture for ectropion. 284 ECTROPION the same manner, but by a route about 3 mm. farther from the lid margin. . Both ends of thread arc then passed upward through the holes in another button, and, after having been sufficiently drawn up, are tied in a bow-knot. When it comes to the second dressing, if there is undue tension upon the suture, it may be relaxed by undoing the bow and letting out the thread. On the contrary, if the suture is too slack it may be drawn tighter. Indeed, its tension may be modified at any time as long as it is left in place. This will be from two to three weeks. It is not the intention to have the thread cut through the lid, nor to cause suppuration, as in some of the old ligatures. It does give rise to a certain amount of scar tissue which Fig. 164. — Verhoeff's suture and button. together with the firmness, and length of time it holds up the \k\, brings about the cure. Argyll-Robertson^ devised a knot which he used in conjunction with a lead plate. The needles of a double-armed suture were passed from in front, through the whole thickness of the lid, eacli one about six or seven millimeters from the middle line, and two millimeters from the border. Then carried free over the conjunc- tiva and, entering at the bottom of the cul-de-sac, were brought out on the cheek some thirty-two millimeters below the lid margin. 1 E(linl)urL;li Clinical and Pathological Journal, 1S83. FUKALA S SUTURK 285 Fig. 165. — Fukala's suture for ectroi)ion of ncision and le lower liii. Before tying the ends over tubing a lead j^latc (25 x 6 x i milli- meters), with ends and corners smoothly rounded, was slid beneath the threads lying on the conjunctiva. The objecl of the ])lale was to straighten the out-curve of the tarsus and the infold of the fascia resulting from the ectropion (Fig. 163). Fukala^ is the author of a combined suture and incision operation that has met with approbation. Jaeger's lid spatula is put into the lower fornix and an incision made through skin and muscle, down to the tarso-orbital fascia, ten to twelve millimeters from the free border, parallel with it, and somewhat longer than the palpebral llssure. The upper flap, with its muscle, is undermined up to the cilia and the fascia is exposed. Three sutures are introduced as follows: the needle is passed through loosened skin and muscle four millimeters or more from the border, thence carried upward, between muscle and tarsus, and passed straight through to the con- junctival surface, close up to the cilia. It is taken back the same route, only three millimeters away. One thread is placed in the center and one near either canthus and tied over sections of tubing. In closing the incision with interrupted sutures they are made to dip in and out of the tarso-orbital fascia, much after the manner of those used in Hotz's operation for entropion. The chief feature is the doubling of the skin flap upon itself (Fig. 165). Angelucci- makes a similar operation in all save that no sutures are used. Atonic ectropion, whether the result of actual paralysis of the or- bicularis or from a senile atrophy and relaxation of the tissues of the lid, requires practically the same surgical treatment, though the age of the subject, and the j)rospect of a cure, as in the case of certain paralyses of the seventh nerve, would have a tendency to qualify the means. Three dominant principles underlying most of the operations that have been undertaken for this variety of ectroj)ion, are: (i) 1 Berliner klin .Wocli., i8gi, S. 287. - Rev. gen. d'Ojjht., i8g8, Xo. 9. 286 ECTROPION shorlening the free border by excision of a wedge therefrom, (2) the l)ushing up and shortening by means of sliding flaps and excision of a triangle of skin at the external canthus, and (3) the narrowing of the palpebral fissure, or the holding up the drooping lid, by one of the forms of tarsorrhaphy, or combinations of these. The fact that the lid in this variety of ectropion does not so much incline to inversion of the tarsus as to a festooning or sagging downward of the free border, constitutes one of its most distinctive features. In other words, in cases of long-standing senile ectropion, the lower lid becomes so elongated that it is impossible for it to coapt nicely with the globe, even if the original cause of the ectropion were no longer active. This peculiarity was noticed by physicians Fig. 166. — Adam' atiun fc in the early days of modern medicine and the first operations con- ceived for righting the defect were directed to this fullness. Such was that of Sir William Adams ^ which is the forerunner of all those that include excision of the tarsus. This surgeon was bold enough to excise a gore from the very center of the lid (its size regulated by the amount of surplus in the lid) that included the whole thickness. To hold the edges of the notch in apposition, he put in, as near as practicable to the border, a surgical pin, on to which was wound a figure-of-8 ligature. For the rest, fine inter- rupted sutures (Fig. 166). Von Ammon,2 not satisfied with the cleft often, and the conspicu- ous scar always, left in the middle of the lid, took the gore from the outer canthus (Von Ammon-Adams operation) (Fig. 167), then ])roceeded as did Adams; yet not, as has been slated in some texl- 1 Practical Obs. on Ectrop., 181 2, p. 4. 2 Zfits. f. Aut(., i, R. 529. KUHNT-MUELLER 287 Fig. 167. Von Anion's modification of Adam's operation for ectropion. books, as did Wallhcr, ' who included the oulcr e.xlremilics oi both lids for the correction of double, i.e., upper and lower, ectropion (Fig. 168). It has been urged against these operations, when made at the outer canthus, that the site is situated too far from the point most desirable to effect, viz., the vicinity of the punclum. Certainly, those made in the center have as many faults. Of later years, Kuhnt- has given still another moditica- tion of the original Adams operation. The accompany- ing illustrations, taken from Terrien's excellent work on eye surgery, will describe the method better than words (Figs. 169 and 170). It will be seen that the skin is not included with the tri- angle cut from the tarsus and conjunctiva. While there is no doubt of the ability of the operation, in many instances, to relieve the ectropion, there is the risk of the cutting through of the marginal sutures, and the leaving of a permanent nick. Then, too, the decided folding of the skin at the border is objectionable. L. Miiller^ sought to remedy these shortcomings — and not without a degree of success — by altering Kuhnt's method, as per the illustrations (Figs. 171 and 172), also taken from Terrien. The sutures that close the widest part of the tarsal V are held on one side by skin, and the slack of the latter, instead of being taken up in one pleat, is divided among several. Helmbold,^ in order to obviate the tuck of skin made at the center of the lid in the Kuhnt operation, removes a triangle of skin corresponding to that of the Walther. 1 Sj^st. der Chir., vi, 1S28. - Beitrage z. operativ. Augenh., i»»3, J« 3 Kl. Mbl. f. Aug., Bd. xxxi, 1893, S. 11 4 Klin. Mbl. iSg-j, p. 283. Jena. 3- ECTROPION tarsus, but further out, splitting the Hd between them The two clefts thus made are sutured separately. These procedures are equally applicable to certain cases of cicatricial ectropion as, for example, from a small scar that may be included in the excised portion. A quite satisfactory way, hit upon by the writer, of deal- m ing with the defect in ques- tion, is to make canthotomy and extend slightly the skin cut, then loosen around, be- low, remove a small triangle of skin containing a few cilia, force out — skin as it were — ■ the outer extremity of the lower tarsus, grasp it with fixation forceps, and while skin and conjunctiva are retracted, pass a No. 2 silkworm, or catgut, suture through, from without, at a distance from the cut end proportioned to the length of the proposed shortening, after which the superfluous bit of the tarsus is abscised. Now, a small triangle of integument and muscle (base in) is cut from the upper lip of the canthotomy, exposing the ex- ternal canthal ligament. Through the latter is passed, from within, the suture just put into the tarsus, the ends are knotted and cut off short, wliile the skin o])ening is united by line black silk ■^ , , . . , Fig. 170. — Kuhnl, No. J. sutures, and the conjunctival incision is left to itself. The buried suture is afterward absorbed or encapsuled (Fig. 173). The second category of operations for atonic ectropion have for their object the pushing, or pulling, the lid into place by the excis- KUHNT-MUELLER 289 ion of a triangle of skin and muscle near the outer canthus, the mobilizing the surrounding edges, and the closure of the gap. I, Fig. -Miiller, Xo. i. The first of these was that of DiefTenbach.^ This consisted in making a horizontal, cutaneous incision, beginning at the outer commissure, whose length was governed by the amount of lid slack to be taken up. From the extremities of this incision two others were made, in a downward direction, so converging as to unite in forming 1 Zeis Handbook f. pi. Chir., 1838. 19 290 ECTROPION Beard's operation for elongated lower lid. an equilateral triangle. The skin and muscle thus enclosed were extirpated. The outer edge of the lower lid was pared off for a distance coinciding with the length of one side of the triangle. The skin at the inner side of the angle and beneath the outer half of the lid was undermined, the whole lower lid slid out- ward, closing the angular opening, and the coapt- ing edges were sutured. Thus the pared, or raw, part of the lid margin becomes the lower lip of the primary, or hori- zontal, incision (Figs. 174, 175)- Method of Szyma- nowski.i — With a view to the elimination of the downward traction of the scar on the outer commissure and also to the enhancement of the effect, this surgeon has changed the form and axis of the Dieffenbach triangle (Fig. 176). That is, he places its apex at the commissure, extends one short side up and out, gives it a long, vertical base; then a third side, of intermediate length, leading back to the canthus. In other respects the method does not differ from Dieffen- bach's. Thus, the upward slant ^^,,^:^^ ^ ''>^^;^^^\; of the short side gives the pro- cedure added capacity for lifting up the lid, and the long, narrow cicatrix, extending as it does both up and down from the level of the commissure, does not tend x.. v , , x- Fig. 174. — Dietfcnbach, No. i. to the latter's displacement. The effect, moreover, is easier to dose than is that of the older operation. The outer portion of the lid border kT> is prepared by removing its edge to a depth sufficient to include the hair follicles, and for a distance commensurate with the surplus length of the margin. The incision AB, made about at right angles to the tangent of the curve 1 Graefe-Saemisch Ilandb., Bd. iii, S. 466. MF/niOD OK TKRSON !9I =^^^^^?^ Fic. 175. — Dierfcnl)ach, No. 2. of the upper border, sliould be somewhat lon,L,'er than AD. UC is nearly three times and C\ twice as long as AB. In undermining, to mobiHzc the skin and mus- cle, only the side AC is loosened, ^^ and to the extent indicated by j^ if the dotted line, leaving the other two fixed for supports. In closing, the opening D is sutured to B. A strong point in this sort of operation is that the elongation of the tarsus is definitely disposed of. The third class of operations for this kind of ectropion is composed of the several operations for tarsorrhaphy— or blepharorrhaphy— already described (pp. 221-225) for occlusiofi qf some portion of the palpebral fissure. It may be the external tarsorrhaphy of Fuchs, the internal (German median) of v. Arlt, or the median of Panas. He would rather trust to one of the other pro- cedures mentioned in connec- tion with this subject or, in ex- treme cases, to a combination of more than one of them. For example, a resection at the outer commissure in conjunction with a Snellen suture, where the ectro- pion is a mixture of the atonic and the mucous types or, if the operation made at the canthus failed to reinstate the punctum, one could resort later to such a procedure as that of Wharton- Jones (Figs. 184-185) — placing the apex of the V directly beneath the punctum, so that the maximum of pushing upward of the lid would be where it would do the most good. In the event of an incurable paralysis of the orbicularis, with ectropion, the most satisfactory single operation, taken all in all, is probably the median tarsorrhaphy. It will more surely re- lieve the troubles from epiphora and from exposure of the globe and prove more lasting as to its benefits. Method of A. Terson. — ^This is a simplification of that of Fig. 176. — Szynianowski 292 ECTROPION Szymanowski. A strip of the thickened conjunctiva, extending the entire length of the lower lid, is dissected out (Fig. 177). The upper incision by which the strip is outlined is slightly below the level of the canaliculus, and the lower somewhat above the bottom of the fornix. The tarsus is spared. A triangle composed of skin and orbicularis, with its base toward, and just outside of the external canthus, is also dissected out. The skin and muscle in the direction of the eye is undermined, and the triangle closed as shown in the illustration, Fig. 178. The conjunctival opening is left to close spontaneously. "Strap" Operation of Argyll-Robertson.— This is a cleverly Fig. 177. — Method of A. Terson. designed method, peculiarly adapted to ectropion wherein the ever- sion is chiefly confined to the outer half of the lower lid. Near the outer canthus is excised a wedge-shaped piece of tissue, including the entire thickness of the lid. This disposes of the excess in the length of the free border. To bring the cut edges of the resulting notch into approximation, and to hold up the lid, a strap of skin is fashioned as shown in the illustration (Fig. 179). The extent to which the lid must be drawn up can be accurately dosed by simply pulling the strap upward and outward along its groove. The overlapping end of the strap is then cut off and the remainder of it is fixed by suturing (Fig. 180). Operations for Cicatricial Ectropion and Other Blepharo- plasty. — It is customary to make two subjects of the above terms BLEPIIAROPLASTY '■93 and to treat ihcm separately. Technically, one means a turnin.t,' out of the lid from a cicatrix and the other, plastic surgery, for the restoration of the lid. Seeing that some part is destroyed in almost all cases of the ectropion under discussion and must be restored, it is a pretty difficult matter to disunite the two, even in theory, and as to actual practice, they are one. In all that has been written on " blepharoplasty " a vast majority of the cases cited have been those of cicatricial ectropion. An operation for the restoration of any part of the nose is rhinoplasty; for any part of the lip, chilo plasty— why go on trying to perpetuate "a distinction without a difference?" Fig. 17S. — Method of A. Terson. This is the most common, as well as the most serious form ot ectropion and the most difficult to handle. A glance at the more frequent causes of partial or complete destruction of the eyelids and the kinds of cicatrices they leave may not be amiss. First in the list stand burns from fire or chemicals. These are apt to be deeper, in the first instance, seeing that the victim often receives the injury as a helpless babe, or invalid (epileptic), and the contact is prolonged; while, in the second (those from strong caustics and acids) they usually affect the skin only. Next in point of frequency is epithelioma, or rodent ulcer, which, when situated in the region of the tarsus, usually destroys the whole thickness of the lid within the ulcerated area. The scars from syphilis and lupus, like those from 294 ECTROPION lire, althou<^li the disease is primarily from the skin, are liable to penetrate beyond it. Another cause of cicatricial ectropion that has come well to the front, particularly in the vicinity of Chicago, is blastomycosis or blastomycetic dermatitis. The resulting scar rarely reaches below the superficial fascia. The gra\-est cases will sometimes tax the resources and per- severence of the surgeon to the utmost and, unfortunately, exhaust those of the patient completely. As before hinted, the nature of the primary injury and its extent considered together with its date, will govern in the choice and compass of the surgical measure Fig. 179. — ^\rgyll-Robertson's strap operation — incisions selected for the relief of the ectropion. Now and then one meets with an eversion of the lid from a scar so slight that the mere subcutaneous division of a restraining band or the excision of the entire cicatricial mass, followed by the mol)ilization and righting of the tarsus and closure of the ojjcning, with perhaps conscc[uent massage and stretching of the affected skin, will lead to perfect cure. As a rule, howe\-er, the indispensable element i)i the surgical management of cicatricial ectropion as ivell as in blepharoplasiy, in general, is ihr replacing of lost substance, whicli refers mainly lo the skin. STRAP OPERATION 295 There arc four ways of oljtainin.L; llie borrowed integument and of bringing it to its new situation to fill the defect : 1. By fashioning and mobilizing flaps of the adjoining skin and putting them in place by simple sliding or interchanging. Autoplasly by the French method. 2. By cutting pedunculated Haps from the nearby skin, not necessarily adjacent to the defect, and moving them into position by turning or twisting of tlieir pedicles. Autoplasly by the Indian method. 3. By entirely detaching pieces of skin of various dimensions from a distant locality and transplanting them in or about the lid. Autoplasly {or heleroplasty) by cutaneous grafts. Fig. 180. — Argyll-Robertson's strap operation — result. 4. By transporting a pedunculated flap, formed from a remote part of the patient's body or from the body of another individual. Autoplasly {or heleroplasty) by the Italian method. The first two refer, of necessity, to autoplasty pure and simple, and to that only. That is, the integument is taken from the same individual, and from the immediate vicinity, or from one but slightly removed. The third mode, w^hile usually autoplastic, is occasionally heteroplastic, in that the material is taken from another person, or it has, in rare instances, been zooplastic — got froin skin belonging to one of the lower animals. The fourth, although 296 ECTROPION not of necessity autoplastic, has, as far as it concerns blepharoplasty, never been anything else. It were vain to attempt an enumeration of the various operative schemes of more or less merit that have been devised for cicatricial ectropion, much less to think of describing them. Let it suffice, therefore, to detail a few representative procedures, under the several headings, and to present certain other examples by means of pictures that will speak for themselves. I. The first (French) mode is best adapted to cases in which the loss of lid tissue and that of the surrounding skin has been relatively small. This is not to say that the method is applicable only to partial or circumscribed ectropion. On the contrary, the latter may be complete, and affect either one or both lids. And part of the available integument may be cicatricial, yet it must be not deeply scared over any considerable area, and must be capable of being loosened from beneath, and made into sliding flaps, excepting for such limited portions as will admit of being excised without being detrimental to the gen- eral result. Tarsorrhaphy, provisional or definitive, was a necessary adjunct '^ . ' to most of these operations, but it may ^"""' often be omitted, and the ultimate Fig. i8r. — -Yon Ammon. ., , . , . , , . , eftect heightened by overlappmg the lids, and fixing the operated one by collodion or other means. Given an ectropion from a deep circumscribed cicatrix with its long axis vertical, and that cannot be readily excised, as wdien con- tinuous with bone, one may have recourse to the process of Van Ammon (Fig. 181). This consists in surrounding the cicatrix by an elliptical incision, removing its top to a depth corresponding with that of the contiguous skin, and leaving the rest to be buried. Free dissection is made all about the opening, the lid is righted, pushed up high onto the globe, and the wound closed by interrupted sutures. For ectropion of the lower lid, from a deep scar of moderate size, if not too near a commissure, the old operation of DiefTenbach is still practised. The adherent portion is encompassed by three straight incisions that form a triangle with its base near and parallel with the free border. The area thus enclosed is excised. From WHARTON-JONES 297 either extremity of the incision formin<^' the base of the trianj^le, start a short incision, each about one-half the len^^th of said base, both lightly curving, the one down and out, the other down and in. The upper li]) of llic whole incision is undermined up to the lid border, and the lid turned back into position. The lateral flaps are dissected up and brought together, the resulting lines of union present- ing the shape of a capital T. External tarsorrhaphy completes the operation (Figs. 182 and 183). It is rather curious to note that von Graefe, according to Baudry,^ applied the same operation, minus the tarsorrhaphy, to entropion of the lower lid. Fig. 182.— Dieffenbach. Fig. 18;. — Dieffenbach. A classic operation for cicatricial ectropion of either upper or lower lid, is that of Wharton- Jones, slightly modified by Sanson (Figs. 184 and 185). Two converging incisions, beginning near the free border, are made to include the scar and meet beyond it, like the letter V, upright for the lower lid, inverted for the upper. The triangular flap is loosened from its apex to its base at the cilia, and the surrounding skin is undermined. The lid is righted and the approximating lips of the incision are joined by sutures, the lines of juncture now resembling a Y instead of a V. Tarsorrhaphy may be added, or the lid may be anchored by collodionized strips of gauze to the cheek (if the upper) or to the forehead (if the lower). Such an operation has a great advantage over those like that of Dieffenbach in that it does not call for a further sacrifice of integu- ment, and should have precedence whenever practicable. Von Graefe conceived the idea of correcting extensive ectropion of the low^er lid by making a flap the whole width of the lid and extending downward ten to twelve millimeters. He split the lid into its two leaves, the anterior composed of skin and muscle, the ^ Technique Operatoire, Paris, 1902, p. 700. 298 ECTROPION posterior of tarsus and conjunctiva, by an intermarginal incision the entire length of the palj)cbral lissure. From the ends of this ran two vertical cuts, extending as far as the lower rim of the orbit. The flap thus outlined, was dissected up, the ectropion corrected and the tarsus, together with the overlying flap, forcibly drawn upward. The flap was then joined to the adjacent skin by interrupted sutures, beginning below, for about one-half the distance. The top or elongated corners of the flap were rabbeted (Fig. 186 a he). The upper edge, thus shortened, was put upon the stretch and stitched to the free border of the tarsus, the ends of thread being left long and fastened, in a pad of collodionized cotton, to the were placed in the remaining a compressive bandage. The Fig. 54. — Wharton- Jones, No i. forehead. A few shallow sutures vertical skin openings and over al chief objection to this operation lies in the fact that new tissue is not supplied to help the graft in supporting the lid. F. Jaeger 1 devised a thoroughly rational and practical operation for cicatricial ectropion of the upper lid, where the ciliary border was so displaced as to lie close to the supercilia. It may be classed as a sliding-flap method. He made cutaneous incision as long as the palpe- bral fissure, close to and parallel with the margin, un- dermined the tarsus and turned the lid down into ])lace. If the border seemed much elongated, he excised from the center a wedge that included the entire thickness and brought by means of a surgical ])in and /x:^}^ ■ir,. 1S5. Wharton-Joncs, No. 2. ogclhcr the edges of the notch 'igurc-()f-8 ligature. Figs. 187 Jaeger-Dryer, Novo blephar. inelliodus, 1S31, p. 28. GRAEFE S METHOD 299 and 188). The u])i)t'r edge of ihc ojjcn ellipse was dissecled for a considerable distance, that is, the skin of the entire brow as far as the middle of the forehead and out to the temjjle was loosened, and the whole drawn down to cover the openin,^, and the wound closed by sutures. In the light of modern methods, the triangular excision of the free border alluded to in this oijcration would be made at the outer Fig. 186.— a, b and c, Graefe's operation for cica canthus, a la \^on Ammon- Adams, or after the Kuhni-:\luller mode (only in upper lid). The lid would be drawn away down, overlap- ping its fellow, and f^xed to the cheek by collodion, and the large raw opening would be covered either by a i)ediceled flap or by a graft. One of the earliest and best examples of a sliding-flap operation for blepharoplasty is that devised by Dieffenbach,i ^yhjig professor of surgery in Berlin, about 1835. The process could be applied 1 Casper's Woch., Bd. i, S. 8. 300 ECTROPION to restoration of the outer leaf or of the whole thickness of the lower lid, and was as follows: by removal of the offending tissue, a triangular opening, with base upward, was made below the eye Fig. 187. — Jaeger's operation for ectro- pion of the upper lid. Dotted line is line of incison. Fig, 188, — Same lid turned down. (Fig. 189), ahc, taking care to conserve the conjunctiva. From the outer canthus, extending horizontally outward for a distance equal to the length of the palpebral fissure (or to the base of the triangle) , another incision, hd, and from the extremity of this one, down and in, and parallel with the outer side of the triangle, still another, de. The trapezoid flap thus marked out, was loosened from summit Fig. 1S9. Fig. 190. Figs. 189 and 190. — Dieffenbach's blepharoj)Iasty, e.g., in the removal of a growth. to base, slid over, bringing b to a, then sutured internally to the skin and superiorly to the conjunctiva. The secondary bared space, bde, was left to heal by granulation (Fig. 190). To-day this space would be covered by a graft. Indeed, Angelucci and many others have so treated this space. Angelucci broadened the top of the SZYMANOWSKY 301 flap as shown by ihc doUcd lines, and employed a pedunculated flap from the temple for the secondary defect. Szymanowsky,! with the view to a closer approximation of the secondary defect, and in order to obtain more tissue for replacing loss in the lower lid, extended the incisions according to the dotted lines (Fig. 189). P^or the restora- tion of the inner lialf of the lower lid, Arlt modified the operation as shown in Fig. 191. To avoid the outward stretching of the new lid and the displacement of the external commissure that would result from the Dieffenbach procedure, Harlan, - of Philadelphia, made the rather elaborate operation pictured in Fig. 192. The broad space beneath the eye was narrowed as much as practicable by undermining and bringing the lower edges together before sliding the flap into place, and the same was done with the second triangle on the temple. Thus, not only was the secondary defect reduced in size, but so elevated as, by its healing, Fig. 191 Fig. 192. — Harlan. not to exert an evil influence on the position of the lids. Another advantage claimed was that, being stitched on either side to sound skin, the nutrition of the new lid was better assured than if, on one side, it were left to form the margin of an extensive granulating surface. Harlan's operation was for an epithelioma involving the entire lower lid. Three years afterward, "the canthus was in normal position and the deformity was slight." ^ Graefe-Saemisch, iii, S. 476. ^ Norris and Oliver, p. 11 7-1 18, 1S9S. 302 ECTROPION A pure specimen of the sliding-flap operation is that devised by Knapp,^ and made for the repair of a lower lid whose inner two-thirds were sacrificed in the removal of a chancroid. Flaps were constructed as per the lines in Fig. 193. After excision of the section containing the ulcer, the two flaps, having been dissected loose from free end to base, were butted together and sutured. The result was excellent. Fig. 193. — Knapp. As a good illustration of a totally wrong principle in a sliding-flap operation, I would cite the method of Burow.^ Here the triangle of skin, aed (Fig. 194), is excised and thrown away, in order that, in the mobilized integument, d may slide to a and a to 6 and close the openings. There is no chance of supplying suitable borrowed tissue for the secondary defect. In other words, the loss of tissue contiguous to the eye is exactly doubled. Much more rational is Fig. 194. — Burow. the Dieffenbach operation, wherein the resulting raw surface may be covered by a pedunculated flap, cut from skin more remote from the lids, or by a cutaneous graft. Method of Blepharoplasty for Central Colobomaof the Upper Lid. — (By Professor F'ranccsco Falchi, of Pavia, Italy.)^ The 1 Archiv. f. Oph. xiii, 1, S. 183. * Berlin, 1856. ^ Archiv.f. Augent., LIX Band, Heft 3, 1908 FALCHI S METHOD 303 coloboma may be con.s^cnital or a((|iiirc(l, the procedure is applicable to either. It has been demonstrated to be thorou.^hly practicable and successful. Fig. 195. — Falchi's method of biepharoplasty for central coloboma of the upper Fig. 196. — Falchi's method of biepharoplasty for central coloboma of the upper lid. First Step.- — Freshening raw the whole free border or the inter- marginal spaces, of the affected eye. >,i j Second Step. — ^Freshening the raw edges of the coloboma and 304 ECTROPION forming it into a sharp angle. This is best done with a convex scalpel, cutting upon the Jaeger horn plate as a base. It can also be accompHshed with small, straight scissors (Fig, 195). Third Step. — ^A perpendicular incision upward from the outer commissure, the entire width and thickness of the lid, the conjunctiva included (Fig. 195). Fourth Step. — ^Closing the notch in the upper lid by sutures, and tarsorrhaphy of the inner two-thirds of the upper lid with the corre- sponding portion of the lower (Fig. 196). Fifth Step. — ^Skin incision outward and slightly downward, from the external canthus, somewhat greater in extent than the outer third Fig. -Falchi's mehod of blepharoplasty for central coloboma of the upper lid. of the lower lid margin. From the outer extremity of this another incision upward, parallel with the one made vertical to the commis- sure, and extending to the tail of the eyebrow. The flap thus out- lined is dissected up, slid over, and stitched both to the adjoining flap and to the outer third of the lower lid margin. At the temporal side there now remains a triangular defect into which is fitted a Wolfe graft from the inner side of the upper arm, according to the principles laid down under "Dermic drafts" (Fig. 197). In order to obtain the iK'st results both eyes are kept bandaged for one month. The eye is re-dressed at the end of forty-eight hours, and daily after that. The sutures are removed in fourteen to sixteen days, but the adhesion between the lid borders is not INDIAN METHOD 305 severed until six weeks to two months have elapsed since the operation. 2. The Indian Method. — In the ancient days of India there was endless strife between the black races, with their ugly flat noses, and the lighter Aryan invaders, with their boasted nasal prominence and beauty. Hence, the nasal feature soon became the target, not only for ridicule and scorn, but for actual violence — legal and otherwise. Hence also the Hindu surgeons were early in devising means for the restoration of the mutilated organ. Among their methods was that of building up the lost portions of the nose by transplanting pedunculated flaps of skin from the adjoining cheek. When the same was applied to the plastic surgery of the lids, it was referred to as the Indian method. Blepharoplasty was not practiced to any ex- tent, however, until the third decade of the nineteenth century, and almost all the earlier attempts were after the Indian method — that is, Fig. 198. — Fricke. by rotation of pedunculated flaps, taken from the nearby skin, with more or less twisting of their pedicles. The first to claim having successfully restored a lid in this way was Carl Ferdinand Graefe.^ In 1818, this surgeon, after several years in trials of various means, reported some of his experiences. Among them was the building up of the lids by both this and the Italian methods. In the same article (p. 19) it is stated that Dzondi had essayed the renewal of the lower lid by a flap taken from the cheek, but had failed. The procedure was systematized and given its flrst real impetus by Fricke,^ His operations related mainly to the correction of ci- 1 Journal of v. Gracfe and Wallher, ii, p. 18. 2 Bildung neuer Augenlider nach Zerstorung und dadurch hervorge- brachter Auswiirtswendung derselben. Hamburg, 1829. 3o6 ECTROPION catricial ectropion — ihe tarsus, conjunctiva, and free border having been intact. Fricke's perfected operation \vas as follows: given a case of complete cicatricial ectropion of the upper lid, for example, an incision was made between cilia and supercilia, parallel with the rim of the orbit, the tarsus loosened from its attachments, and Fig. 199. — Blasius. turned down into place, thus leaving an oval raw surface (Fig. 198). A flap, somewhat larger than the oval, was cut from the forehead and temple, whose base, broader than the body of the flap — not a pedicle in the strict sense of the word — was situated a little external to the margin of the orbit and slightly above the operated lid. Before turning the flap into its new position, the bridge of skin Fig. 200. — Blasius. between the two raw areas was excised sufliciently to receive the pedicle or base. It was found that this was more satisfactory than to allow the pedicle to lie on top of an isthmus of skin, with the view of cutting and trimming it later. The flap was held in place by numerous sutures, and the gap from whence it came, or the sec- ondary defect, was left to heal by granulation. FRICKK AM) 15I.AS1US 307 So far as it goes, this (>])crati()n of Frickc is cssfnlially tlic sanu- as performed by his successors and by many sur<,a'ons for the same deformity to-(hiy. The variations have been mainly as to the region from which the llaj) was laken^this has been covered but •^^M «X-,-}v. Fic. 20 -Denonvilliers. in what manner is a matter that has been governed by the judgment of the operator and by the pecuharities of the case. Blasius,^ for the restoration of the entire lower lid at one time, took a flap, pedicle inward, from the side of the nose and the forehead. (Fig. 199.) At another time, for replacing the lower lid, pedicle outward, from the temple and forehead (Fig. 200). For an ex- treme ectropion of the whole lower lid, Denonvilliers utilized an enormous flap, cut from in front of the ear, with pedicle just external to the outer canthus (Figs. 201 and 202). For the repa- ration of an angular loss of sul^stance— external or internal- -the 1 Med. Zeit, Miirz. 1S42. 3o8 ECTROPION bifurcate pedicle, as first employed by Hasner, serves admirably (Figs. 203 and 204). For a yet more elaborate restitution of a commissure, the process of Richet^ is cited. The primary defect was an inferoexternal ectropion, from an adherent scar of the orbital rim, with fungus growth. After crescentic excision of the diseased portion a and righting Fig. 204. — Hasner. of the lid (Fig. 205), a provisional tarsorrhaphy was made and the threads were attached to the brow by collodion. Next, the flaps b and c were fashioned (Fig. 206), which were interchanged and sutured to cover the defect as shown in Fig. 207. ■-A -Richet. Fig. 206. — Richet. Some years ago, I- reported the restoration of the entire right lower lid and the outer third of the upper by a mitten-shaped flap formed from the cheek. The breadth of the mitten was so great at its widest portion that it was impossible to approximate at this point the edges of the secondary defect, and a cutaneous graft, taken from the arm, was put in to fill the space; Fig. 208 shows 1 Recueil d'ophtalmologie, 1873. 2 Am. Jour, of Ophthalmology, June, 1897. LANDOLT S METHOD 309 the result three years after the o])eration. The case was that of an elderly woman, and ihe parts had been destroyed by a rodent ulcer. In place of borrowing skin to one side of a commissure, above or below, as in the examples just given, the llap has l)ecn taken from one lid to replace tissue lacking in the other, Landolt^ made from the upper lid a bridge, or double pcdiceled llap, to restore the lower lid that had been de- stroyed by a carcinoma. An incision was made through skin and muscle, two milli- meters from and parallel with the upper margin, and extending at either end some- what beyond the canthus. This was re- peated seven or eight millimeters higher fig. 207.— Richter. up, and the intervening strip of skin and muscle was loosened throughout its length, except at the ends. The conjunctiva was separated from the lower free border, from canthus to canthus, sufficiently to receive the flap, which was transposed to fill the gap and there stitched. The upper lip of the superior opening was undermined, and the skin drawn down and sutured to the lower lip. At the proper time the pedicles were cut and trimmed to fit (Fig. 209). Panas^ made a regular practice of taking from one hd and giving to the other, though through a single pedicle left near the outer canthus, and he usually subjoined provisional tarsorrhaphy. This robbing of Peter to pay Paul would seem hardly justifiable if suitable tissue for the flaps could be found outside the longitude of the palpebral fissure, for the reason that it is inadvisable to have the hulk of the secondary defect contiguous to the lid margins. This brings us to a consideration of such c^uestions as the prepara- tion of the lid and the selection and outlining of the flap. Besides the principle just stated, there are a number of others to be observed in this connection. Before proceeding to mark out the skin that is to be transplanted, its new site is opened up and carefully prepared, so that its size and shape may be apparent, and all bleeding may be stopped in due time. If, as is most often the case, the operation is for the correction of ectropion, an incision is made through 1 Archiv. d'oi)ht, 1885, p. 492. 2 Clin, opht., 1899, p. 31. 3IO ECTROPION the skin, three or four milHmeters from the free border, whose length somewhat exceeds that of the everted part. The lips of this immediately retract, and the opening thus formed is deepened till muscle or underlying fascia is reached. The free border is seized by fixation forceps and pulled toward its normal ])Osition, the dissection being meanwhile carried toward the convex bor- der of the tarsus. The latter and the orbicularis are spared; that is, the restraining cicatricial bands are divided without cutting Fig. 2o8.^Beard. Restoration of lower lid and part of upper by mitten-shaped flap. the muscle and the tarsus, and the anchylosis between the tarsus and underlying tissue is entirely freed. "The removal of all scar tissue," once thought im]jerati\e, is no longer so rigidly insisted upon. The harder masses are best gotten rid of, pcrhai)s, but to attempt the excision of all of it is not feasible. The same allowance is made for the subsequent contraction of the oval bared space thus created, as for that of the skin that is to cover it. Hence, this preliminary opening up is made extreme; to such a degree, for example, that for complete ectroi)ion of the upper lid its free border would o\crlap the lower lid and lie upon LOCATING THE PEDICLE 31: the cheek, opposite the inferior portion of the rim of the orbit or even below it. The more recent the injury that caused the misplace- ment, the greater must be this overcffecl. U the ()|)craii()n is to restore the lid after removal of a growth, or the excision of an ulcer that involves the whole thickness, the conservation of the maximum amount of the conjunctiva is important. For the entire upper (or lower) lid or any |)art external to the middle, the pedicle is best situated about on a level with, and close to, the outer canthus, and the long axis of the flap should be directed upward (or downward). Some of the older surgeons have ad- l'"iG. 2oq. — Landoll. vised that a flap to replace the upper lid be taken from the malar region, and one for the lower from the temple, for the reason that the strain of cicatrization in the secondary defect will, in this arrange- ment, tend to enhance the desired effect. As regards the body of the second bared space, however, it signifies but little, yet, as con- cerns the position of the pedich\ il docs make a dilTerence. On account of its ])roximity to the original defect, to elevate il for the lower lid and to depress it for the upper, contributes to its success. Moreover, in male subjects, it is difficult to fashion a flap from the cheek without including the hair follicles of the beard, and the presence of hairs in the flap — no matter how few or small they may be — is objectionable. Yet we have seen patients exhibited with great gusto who had been furnished with a new set of eyelashes borrowed from the supercilia. For circumscribed defects situated more to- ward the nasal side of the lids, the glabellar and nasomaxillary regions offer the more lifting skin for j)edunculated flaps; and whether or not they are taken from the former for the lower lid and from the latter for the upper, as advised by many surgeons, the pedicle at least should be slightly higher than the canthus when the lesion is 312 ECTROPION of the lower lid, and vice versa. If only scar tissue is available for the flap, it also may be utilized, provided it is superficial, movable, and not too greatly contracted. In the matter of choosing a flap, it is often not so much a question as to what one would like to have, as what one can get. In cutting the subsidiary integument, if it lies close to the inner canthus, the lacrimal canal is to be respected, and if in the malar or infra- zygomatic region, the duct of the parotid gland is to be avoided. As has been intimated already, the pedicle should be situated as near as practicable to the primary defect, and the body of the sec- ondary defect more remote. If a desirable skin area can be reached by moderate elongation of the pedicle, it may be so extended, but a roadway or bed should be opened through the intervening bridge of skin where to inlay this long neck, rather than have it lie on top. It is hardly proper to refer to the pedicle as a neck, seeing that such a term implies a considerable narrowing. It were better, perhaps, to call it the base of the flap, since to be adequate for the nourishment of the rest of the peninsula, this portion must be little, if any, nar- rower. Slender pedicles and long-drawn-out points to flaps are both serious faults, as they favor gangrene. For the pedicle to be skimp, as to length, is equally grave. This means undue stretching and constriction. It would far better be too long than too short, especially as more or less swelling is to be expected after the opera- tion. It is well to remember that the greater the degree of torsion of the base required to put the flap in place, the greater the amount of shortening, and allowance must be made accordingly. Indeed, it were prudent so to lay out the flap as to necessitate the minimum torsion in rotation — all things else being considered-^as this alone tends to strangulation. It pays to study carefully the original cicatrix, particularly with the view to ascertaining the lines of greatest strain. Here is where the overeffect must be most pronounced, which concerns both the ]uepa- ration of the lid — extensive opening up; and that of the Jlap — surplus width at the points indicated. Provisional tarsorrhaphy has been extensively practised as an adjunct to blepharoplasty. In the correction of cicatricial ectro- pion, however, where the re])air is made with flaps or grafts, the procedure so far from being of advantage, is a ])osili\c (letrimcnl, in that it prevents the getting of tliat very ])ronounce(l primary overeffect which is an in(lisnensal)k' cicnienl of success in these LARGE WOLFE GRAFT 313 operations. No doubt, the employment of it has had much to do with the discouraging experiences so many surgeons have had in such surgery. In order that the ultimate result of an operation for cicatricial entropion, of the kind in question, may be sullicient, not only must the eversion be rectiticd, but the opening up of the ellipse whereby the correction is brought about, must be so extreme that the border of the operated lid lies considerably beyond that of its fellow. If it be the upper lid, the free border reaches the lower rim of the orbit; Fir.. 210. — Larfre Wolfe frraft. if the lower, the lid margin reaches the upj)er corneal limbus. Sutures are seldom required to maintain the lid in position if these principles are observed; and when put in may do more harm than good. Neither have I found a place for the excision of a gore from the free border that is so often referred to. Whatever elongation of the edge of the lid that may be present at the moment, will. surely disappear in the healing process. Figs. 210, 211 and 212 refer to a case of total ectropion of the lower lid corrected by the author. Here the Wolfe graft when 314 ECTROPION laken from the arm measured three by four inches. The elliptical bared space left after righting the lid measured one and one-fourth by two and one-half inches. On account of its great size and weight, where the upper edge of the graft was stitched to the free border of the lower lid, the suture ends were left long and fastened to the forehead by collodionized gauze (Fig. 210). Fig. 211 shows the result one month later. Fig. 212 shows the arm defect and bracket incisions in which Thiersch grafts have been planted. Same as Fig. 210. Result. The Preparation of the Flap. —Having opened up to the fullest extent, and otherwise i)ut in readiness the place that is to be repaired, and covered it with a pad of cotton, wet with boric-acid solution, an exact pattern of it, as to size and shape, is cut out of a ])iecc of sterilized gold beaters' skin, tin foil, or gutta-percha tissue. This is laid on to the integument chosen to supply the subsidiary tissue and the flap is outlined, except at its base, with the point of a scalpel. To do this an incision is made, through the epidermis only, parallel with the edge of the pattern and at least one-half a centimeter from it. LAKC.K WOI.KK (.KM ,^1S In order to allow for both the marked i)rimary and the very considerable secondary shrinkalied to i)lastic surgery of the eyelids, this method is of recent date, yet, like that of pedunculated flaps, in its relation to certain other features, as rhinoplasty, for example, it is of ancient origin. It, too, was practised by the ancient Hindu surgeons. The grafts are referred to as dermic or epidermic, according as they com])rise the entire thickness of the skin or only the epithelial layers. Dermic Grafts were first used in blepharoplasty by Le Fort.' His earliest attempts were with pieces of skin cut from the arm, that included the fat, and were large enough to cover the entire defect. As they were mostly failures, he conceived the idea that they were too thick. With this in view, in subsecjuent trials he pared down the grafts at the back, removing the adipose and part of the connective tissue, and had the satisfaction of seeing them survive. In Great Britain and America the process was ])0])ularized through articles by Wolfe, ^ of Glasgow, in which he reported suc- cessful blepharoplasties with the Le Fort method and gave original details as to technic. The dermic graft is, therefore, referred to in these countries as the Wolfe graft and on the continent of Europe, as the Le Fort-Wolfe. It may be added that the method has never ceased to find favor in the eyes of English-sj^eaking oj)hthalmic surgeons, having attained, in the United States, a specially strong footing, where it is employed with almost as much conlidence as is that with pediceled tlaps. In truth, it is often chosen in ]:)reference to the latter to obviate the extra scar on the face. Their thickness or body, renders them peculiarly fit for rej)lacing loss of substance in the lids. In France and Germany, however, it is jiretty gen- erally decried, except as a last resort, a method of necessity and not of choice, i.e., only em])loyed when suitable material cannot be obtained, in the form of nai)s, from the neighl)oring integument. ' Bull, de la Soc. de Chir., 1S72, p. -!,q. 2 Brit. Med. Jour., 1876, and Mod. Times and Gaz., vol. vii, p. 608. 320 ECTROPION Valude/ for instance, speaks discouragingly of it, having operated seventy-seven times, using Wolfe grafts for the loss of substance, with but fifteen successes. Whatever may have been the chief causes leading to the failures of our European colleagues, it is certain that immensity of grafts and of persevercnce did not figure largely among them. The habitual vice of the graft in question is shrinkage. Its average capacity in that line is enormous, to offset which its original size must be proportionately vast. This is the master key of the situation. Yet knowledge of, and heed to, this property do not always suffice, even when accompanied by the utmost precision in all other respects. Here is where persistence comes to the rescue. Some of the most gratifying results are obtained only after re- peated operations, each one as extended and thorough as its pre- decessor. According to the observation of C. Garre,- the really useful part of the graft is limited to the deeper layers of the epidermis, and to transplant the corium, which is destined to undergo connective- tissue degeneration, merely retards the union of the Malpighian portion with the underlying vascular network and favors excessive ultimate contraction. As a further proof that the last word with regard to the dermic grafts has not been said — that there resides therein some subtle beneficent quality that will one day be regularly utilized — cases can be cited wherein this bit of borrowed skin has neither shrunken nor degenerated, but has regained its color, almost immediately after being transplanted, and has not changed so much as to even shed its epithelium. This has happened several times in my practice. But with our present knowledge, the Wolfe graft is ex- pected to shrink more than any of the other varieties, both primarily and secondarily. As a rough estimate, one might state the total contraction, from first to last, at something like 75%. Hence, in outlining the graft, the area inclosed would be about four times that of the defect to be covered. Panas^ states that one condition particularly favorable to success of all autoplasty is the implantation of the flap or graft in the midst of a plaque of scar tissue. Thanks to the retractile nature of the cicatrix, an incision or opening made therein, instead of narrowing ' Archiv. d'opht., T. ix, p. 289, 18S0. 2 Beitriige z. klin. Chir., iv. 3 Maladies des Ycux, 1894, t. ii, \t. 174. I'KKl'AkATloN OF C.UAKT ,^2 I or slirinkin,^;, actually expands, cwn lo the extent of a((|uirin,^ (l()ul)le its lirst area. Xelaton, who hrst called attention to tlii> inii)orlanl fact, also observed thai in order to j^ive the openinj^ this (jualily the llaj) (or graft) should rest on normal tissue. Thus it comes about that in ])alpebral autoplasty after burns, for example, a llaj), a])])ar- cntly inade(iuale, may serve for the complete reparation, provided, one takes care to remove all scar tissue from the i)lace it is to ()ccu|)y. This is not always feasible, especially when the cicatrix is \ery deep or adherent to bone. In such cases some o])erators (Wichcr- kiewicz among them) advise secondary grafting, i.e., not applying the supplementary skin until the defect is well covered with granula- tions. Removal of scar tissue from the defect is more urgent in graft methods than in those with sliding or pediceled nai)s. The size of the graft is limited only by that of the bared space it is to occupy. In fact, a single piece, sufficiently large, is preferable to two or more smaller ones. De Wecker^ with the idea of better insuring the survival of the transported integument, tried cutting it into squares whose sides measured from one-half to one centimeter, which were placed on in the form of a mosaic; but it was found that the small fragments did not "take" more readily than larger ones, and, moreover, shrinkage and scarring were greater. Preparation of the Dermic Graft.— The lid defect is i)ut in readiness the same as for a flap, save that in case of the graft the primary effect must be yet more extreme. A certain area of the delicate, hairless skin at the inner side of the upper arm or of the leg or thigh is washed with green soap and boiled water and thoroughly rinsed with boric acid or salt solution. The skin over the inner border of the left bice])s (of right handed patients) is probably the most suitable, all things considered; yet in the case of a feminine subject likely to take ])ridc in bare arms, the thigh would be a better location for the scar. The graft is outlined with the aid of the pattern as per the instructions for the flap, except that the ratio of its size to that of the defect should be about four- fold, instead of double, and, there being no pedicle, of course the pattern is completely surrounded by the incision. The usual shape of the section of skin is that of an ellipse, or oval and as it is impor- tant that the long axis of the graft coincide with that of the defect. Orientation is facilitated by first dissecting up the extremities of the oval and putting a line suture through each from the epithelial 1 Annal. d'oculist., 1872, p. 62. 21 322 ECTROPION side. If this is not done the primary shrinkage is so great the moment the piece is excised that it is then difficult to place it properly. As soon as one end is loosened enough, the cotted or gloved fingers are substituted for the forceps to hold the piece, and the entire dis- section is completed with the blunt scissors, exercising care to avoid injury to the basilic vein. Should the skin on the inner aspect of the thigh, just above the knee, be chosen, which is probably the next most fitting, cutting into the long saphenous vein is to be guarded against. These two large veins can be seen through the skin, as they lie just beneath the superficial fascia. Unlike the flap, the graft after having been severed is freed from all its adherent fat. It is then dipped in boric or salt solution or not as the judgment of the operator shall decide, laid on, according to its dimensions, and carefully spread out. The contained sutures are inserted at the corresponding ends of the defect and tied. Additional sutures are put in only where they would seem to be absolutely necessary. If, as often happens, the graft adjusts itself nicely to its new location, these are best omitted. The dressing and after-treatment are identical with that described for pedunculated flaps. Until the lid operation is finished and the bandage is applied, a pad of cotton wet with sublimate solution, one to three thousand, is kept on the wound in the arm. Since before Urban ^ signaled their abandonment in this particular, the writer has never allowed mercuric solutions to come in contact with the graft nor with the operated lid, because of their coagulating efTect and the damage they inflict upon the epidermis. The last attention having been bestowed upon the eye, the edges of the opening in the arm are widely undermined and approximated by interrupted sutures. Should this require undue tension upon the skin, it is relieved, where greatest, , by bracket incisions (Fig. 212), or, preferably, the opposite edges of skin are approached only so nearly as practicable, one to the other, and the gap afterward filled with a Thiersch graft. If bracket incisions are made, the spaces between their lips may be similarly covered. Iodoform powder is dusted on, iodoform gauze laid on, then a pad of cotton, and over all a muslin or wet netting bandage. Every precaution should be taken to prevent disturbance of both the eye and the arm dressings. A good way is 1 Deutsche Zeit. f. Chir., 1892. DERMO-EPIDERMIC GRAl-TS 323 to fix the bandages in ])lace with flexible collocHon, as described under "Eye-dressings." It is well to fix the arm in a sling beneath the clothing, the better to guard against exposure of its wound, which is quite prone to infection. The graft is at first blanched, but at tlic end of twenty-four hours, if it has "taken," something like its normal tint is present. A little later — say on the second day — it becomes of a rosy hue. About the end of the third day begins the shedding of its epithelium, when it again appears whiter. After this process is completed the patch takes on a color that is, for a time, redder than that of the surrounding skin, but its ultimate color is a shade whiter than that. If the transplanted tissue or any part thereof perish, it may be from one of several causes, chief among which are gangrene (white, livid, or dry), secondary hemorrhage beneath, stitch-canal or super- ficial infection, phlegmon, and erysipelas. These are all accidents that either happen very early or not at all. A later sequel, coming sometimes many days after the graft has become viable, is a progres- sive ulceration. For sloughing, hemorrhage, and gangrene, little can be done. Infections are to be treated by removal of sutures, copious and frequent irrigations with mild antiseptic solutions used quite warm, etc. An excellent remedy for the ulceration alluded to is the painting of the raw surface with a 12% solution of silver nitrate, followed by thorough washing with warm salt solution. Epidermic and Dermo-epidermic Grafts. — The epidermization of parts denuded of skin was first conceived and accomplished by the distinguished surgeon, Reverdin,^ of Geneva. To assist and hasten the healing of certain indolent varicose ulcers, Reverdin cut, with a lancet, from the skin of a limb, epidermic flaps, which he subdivided into bits containing only a few square millimeters, and deposited them on the granulating surface in the form of small disseminated islands. It was demonstrated that the method stimu- lated the cicatrization in raw surfaces of limited. extent, but was less efficacious for larger ones. To better meet the latter condition. Oilier^ made the grafts of considerable size — ten to fifteen millimeters long, by one to three millimeters wide — and purposely included a portion of the corium {dermo-epidcrmic graft). He carefully removed all cicatricial tissue in the preparation of the defect to be repaired, and waited 1 Bull, de la Soc. de Chir., 1869. 2 Comptes rendus de I'Acad. des Sciences, 1872. 324 ECTROPION for the surface to granulate before applying the graft. The latter was held in place by strips of diachylon plaster. This species of cutaneous graft was first employed in blepharoplasty by Lawson.i In preparing it, the skin may be separated from its original location, as directed for the Wolfe graft, and then pared down very closely with a razor, cutting well below the epidermis. Thiersch^ adopted the method of Oilier, but with certain modifications, the most important among which was that he declined to implant the graft upon a granulating surface {secondary grafting), placing it rather upon a freshly prepared raw one (primary grafting). If granula- tions were already present, they were shaved off to conform to the principle in view. This, according to the same author, ^ is that granulations make an unfavorable base for the transplanted integu- ment, for the reason that they of themselves produce a layer of scar tissue. He also made the pieces thinner than did Oilier. Eversbusch-i advised that this form of graft be cut as thin as possible— translucent in fact— the blade of the knife or razor show- ing through during the section. This constitutes the true epidermic graft, known in this country under the name of Thiersch and in Europe under that of Thiersch-Eversbusch. While it is less effective, owing to its lack of body, for the restoration of the lid than the Wolfe graft, it has the advantage in most instances of shrinking less. In point of ability to survive, the two varieties would seem to be about on a par. Whether concerned immediately in the lid operation or not, the transplanting of epidermis will often be found a valuable adjunct thereto, as, for example, to make a patch when, after a few days, a flap or dermic graft chances, through ulceration or other mishap, to have its epithelium destroyed or when an unavoidable gap remains in a secondary defect. The Thiersch method is as follows: the primary defect having been prepared as for the flap of the Wolfe operation (or if granula- tions are present, they are removed), the inner side of the upper arm or of the lower third of the thigh, is washed with soap and sterile water, rinsed with lM)ric acid solution and thoroughly dried with gauze — not with cotton, on account of the loose fibres that cling to the parts. The tliigh ofl'ers fewer diniculties to the cutting of 'Lancet, Nov. iq, 1870. 2 Berlin, klin. Woeh., 1874. ' Arch. f. klin. Chir., Bd. xvii, 2, S. 318, ff. 4 Muncli. nicd. Woch., 1887, Nr. 1, u. 2. HOTZ S METHOD 325 the L^raft ])ccause of its slight convexity, and nii_i^hl be jjreferable to the patient as tlie site of liie resulting scar. The chosen skin is put moderately upon the stretch, while with a keen, lonj,' hladed razor, that has been thoroughly boiled, enough of the epidermis is shaved oiT- -if possible, in one piece— to cover the entire defect. It greatly facilitates the severing of the graft to have both the razor and the skin perfectly dry, and the lower side of the blade anointed with sterile \aseline or castor oil. The blade is held flat and firm and the cutting is accom])lishe(l l)y a long, slow, sawing motion. When properly done, the blade of the razor can be seen through every part of the graft, and the resulting raw surface is thickly speckled over witli tiny bleeding points that mark the spots where the tips of the more i)rominent papilke have been cut off. To cause the skin to present a flat surface to the razor I have profited by an ingenious suggestion of AI. I>. Harris, of Chicago, whereby a straight-edged object, such as the lid of a cigar-box, is dragged along in advance of the razor. The graft is at once laid on wdiere needed, without previous dipping into boric or salt solution, and slid directly from the razor on to the defect. Here it is nicely spread out, after which any overlapping edges are trimmed with the scissors to lit. Few, if any, sutures are put in. The usual dressings, comprising a thin lamina of cotton, wet with hot, saturated solution of boric acid, next to the skin, a thick pad of dry cotton so built on as to pre\ent undue pressure on the graft, over this a generous piece of gold beater's skin, tin foil, or gutta-percha tissue, and over all the wet netting bandage, fastened on with flexible collodion. For fear of carrying syphilitic, or other infection, grafts ought never to be taken from another individual if they can be gotten from the patient. An effecti\'e method for the disposition and fixation of cutaneous grafts in operations for cicatricial ectropion is that of Hotz.^ In order to prevent the shrinkage of the graft from acting with full force upon the free border, he divides the wound area into two sections, one representing the bared surface of the lid proper and the other that beyond the lid, each of which he covers with a separate Thiersch (or Wolfe) graft. The lid graft is anchored by sutures to the strip of skin at the free border of the tarsus (upper lid) or to the tarso-orbital fascia beneath the tarsus (lower lid). The second division of the bared space is then covered by an unsutured graft. 1 Archives of Ophthalmology, vol. xxxii. No. 3, IQ03. ^26 ECTROPION Before implanting the grafts, two strong silk threads are put through the edge of the reposited lid, it is made to widely overlap its fellow, and the threads are fastened to the cheek (or brow) by collodionized cotton or gauze. By thus fixing the edges of the lid graft to firm supports, both its shrinkage upon itself and its traction upon the free border are counteracted. Moreover, by this arrange- ment, the contraction of the ultratarsal graft is not so directly transmitted to the tarsal one. ±-^ Hoiz. Fig. 214. — Hotz. In some instances, Hotz, instead of transplanting a graft to cover the tarsal portion, utilizes the cicatricial skin already overly- ing it, which he dissects up in the form of a semilunar Hap that is left adherent along the lid margin. The bands of scar are divided, the lid is turned into position, drawn over its fellow, and fixed by ligatures and collodion as just described. If it be the upper lid, the free border of the flap is stitched to the upper border of the tarsus; if the lower, to the tarso-orbital fascia and the remain- ing wound surface is covered by a Thiersch graft into which no sutures are ]nit. If there is decided elongation of the free border, a ])ortion is resected at the outer canthus (sec Figs. 213 and 214). 4. The Italian method, or auloplasty by means of a pedic'eled llap taken from a distant pari of the body. This, like blepharo- plasty by cutaneous grafts, is api)lical)k' lo cases where llie destruc- ITALIAN METHOD 527 lion of the lids and the adjacent skin is such as to render the use of the local integument impossible or undesirable. The method was invented several centuries ago by a Sicilian surgeon of the name Branca, and ])racticed by himself, and afterward by divers other members of the same name and family for the restoration of the nose. It has also been known as the Tagliacotian method, in honor of Gaspard Tagliacozzi, who, in 1597, wrote a treatise on it. It consisted in i)rei)aring the part to be reconstructed and loosen- ing a tongue of skin from some available portion of the arm or hand. After granulation was well established in both defects, the Hap was brought into position by binding the member bearing it securely to the head. Owing to the length of time required for the granulations to appear, added to that for the healing process, and to the great inconvenience occasioned the patient, the proceeding was abandoned. In 1816, however, it was rescued from oblivion by Carl Ferdinand Graefe, who employed it in a modified form for blepharoplasty. Among other improvements, this surgeon hit upon that of putting the flap into place at once without waiting for the granulation of the surfaces to be united. The method has found scant favor in the eyes of modern surgeons, still less in those of their patients. In this country it has been resorted to with success by R. H. Derby 1 to replace the lids lost in an extensive burn of the face. Still more recently it has been revived in France by Prof. Paul Berger,- the Parisian surgeon. In this admirable report, among much else of interest. Professor Berger details four cases in which he applied the Italian method to blepharoplasty. In three of them the reparation concerned the lower lid, and in the fourth both the upper and the lower. In the last case, death occurred from iodoform poisoning on the day previous to tliat which was set for the severing of the pedicle. Mode of Operation (Berger). — An exact pattern of the lid defect is cut out of oil silk or court plaster, the arm is approached to the eye, and the point that makes the easiest and most natural con- tact is marked in ink, as the site of the pedicle. The pattern is then laid on in such a manner ihal the pedicle will be neither twisted, stretched, nor compressed, and so outlined tlial the area of 1 Trans, of the Am. Oph. Society, 1885, p. 141. '^ Cong. fran. de Chir. seance du 9 otobre, 18S9, 4 session, p. 361. 328 ECTROPION the lla}) will be one-fourth to one-third greater than that of the model. The subcutaneous fat, as well as the superficial fascia, are included with the skin. Near the pedicle, the ajjoneurosis is slightly raised in order that the nourishing vessels may be free from pressure. All the wounded vessels of any size are tied. After many trials Berger adopted, as the fixing apparatus, a leather corset provided with a collar and cap, all articulated by laces and straps and strengthened by steel braces. A laced leather gauntlet, ex- tending from the hand to a point above the elbow, put on and strapped to the cap, holds the arm firmly to the head (Fig. 215). Numerous fine, superficial, silk sutures are put in to hold the flap while, near the pedicle, a few, deep, strong ones are inserted Salol, boric acid, or iodoform powder (the last used guardedly) is dusted into the nooks and upon the other parts. Over this, gauze or a thin layer of cotton, wet with boric acid solution; on this, padding of cotton, and overall a bandage. Liquid food and constant w^atching by an attendant. Quiet in bed for four or five days, then propped up for a short time at intervals. After a week, sitting in an easy-chair, and eyen walking cautiously about the room. The pedicle is divided near the end of the second week. In order to accustom the patient to the constrained posture and to the manner of performing such functions as sleep, alimentation, evacuations, etc., as well as to test the immobility of the parts concerned in the blepharoplasty, it is well to have him wear the apparatus for a few days before the operation. 15. — Berger's method. to aid in resisting traction. CHAPTER YIII. OPERATIONS UPON THE CONJUNCTIVA. SYMBLEPHARON. Literally, this term means an adhesion or a clinging together of the eyelids In its true sense, however, it refers to a union of the palpebral with the ocular conjunctiva, or to the severer con- dition wherein the lid is firmly adherent to the globe, .\mong the more frequent causes are burns from lime, molten metal, acids, etc. Owing to gravitation and to the exposed situation of the lower ])art of the conjunctival sac, it is more often affected than is the upi)er. The extent of the adherence varies from that of a tiny isolated bridge to that in which all traces of a cul-de-sac are lacking, and the entire inner aspect of the lid is united to the ball. Symble- pharon is designated as outward, inward, upivard, and downward, according to its location. For convenience in reference, the dilTerent grades are classified as follows: 1. Symblepharon anterius, commonly s])oken of as circum- scribed, is the simplest form, and is so named because the junction between the opposing portions of conjunctiva does not reach the fornix. 2. Symblepharon Posterius, Partial Symblepharon.— This class comprises the intermediate grades, or those in which the attachment extends to the fornix, but in which the cul-de-sac is not wholly obliterated, nor is there marked cicatrization of the bulbar conjunctiva. 3. Symblepharon Totalis, Complete Symblepharon.— Under this heading are included all the more pronounced cases where the attachment involves the whole of one or both lids, and the cul-de-sac is utterly eft'aced. In the exaggerated instances there is often ankyloblepharon also. Some authors (Fuchs among them) state that blindness, or at most, quantitative perception of light, is a necessary accompaniment of total symblepharon. This is by no means true of the commonest form, viz., that in which the entire 329 330 OPERATIONS UPON THE CONJUNCTIVA lower lid is grown to the globe, even when, as often happens, the conjunctival adhesion covers the greater portion of the cornea; nor is it invariably true of that in which both lids are attached through- out. Though in many instances sight has been restored only by the additional operation of iridectomy. Surgical intervention is a crying need in all cases, whether blindness exists or not. Among the objects sought are greater motility of lids and globe, better vision, relief from pain, improved appearance, and the making of a socket for the wearing of a prothesis. The same principles are concerned in operations for symblepharon as in those for blepharoplasty, and the means are also similar, viz., by: A. Sliding flaps of conjunctiva. B. Pediceled flaps of conjunctiva or skin. C. Mucous or cutaneous grafts. A and B refer to autoplasty only; C to autoplasty, heteroplasty, and zooplasty. No intervention is admissible while contraction is still active in the adhesions. 1. The surgical treatment of the first group (symblepharon anterius) presents no special difficulties. It usually suffices, for the narrow bridges, merely to cut them with blunt scissors, or with a blunt bistoury and grooved director, and to watch for reat- tachments which, occurring, are at once broken loose with a probe. If the division of the symblepharon leaves a decided opening in the ocular conjunctiva, fine silk sutures are put in to close it. If a tag of the mucosa is left hanging to the lid, it is not severed until after the healing of the bulbar wound. If the bridge is fast to the cornea, the latter is first freed by careful dissection. In cases where the defect is so large as to cause undue stretching of the conjunctiva, in closing it Arlt advised the making of a bracket or relaxing incision on either side. 2, The handling of the second class of cases, or partial symble- pharon, is, in the main, attended with great satisfaction, though they often call for much planning and perserverence. The easiest to deal with and the most frequently encountered is what is known as'^the columnar form, in which a tliin, or rclati\'cly thin, bridle uniting the lid and globe reaches into the fornix and many times implicates the cornea. When it occupies the up])er, lower, or outer AlU/r S METHOD M^ P^iG. 2i6. — Arlt's operation. cul-(lc-sac, ihc operation usually adoijlcd is thai of v. Aril.' Manner of doing it : Jf the conjuncti\a is fast to the cornea, the so called pterygoid symblcpharon, the ^ y^c^y^- apex of the adhesion is held with /'^y^/^^^^ delicate sharp-toolhcd forceps, and the dissection made with the bulge-edged scalpel. To aid in this step, some surgeons lirst put a suture through the apex to hold by. If this is done, the thread should be double-armed and so inserted as to make the loop lie crosswise, near the tip of the apex, and u|)on the out- side, so that the same suture may be used at a later stage of the operation. As this means difficulty to avoid cutting the thread, it is better to dispense with the procedure. Having passed the limbus, the dissection is carried on with small, blunt, curved scissors to the very bottom of the cul-de-sac — really farther, as a rule, than mr"" to the limits of the fornix. An incision is then made with straight blunt scissors, on either side of the bridle and close to it, from apex to base, if practicable, converging the two near their ends. If the double-armed suture has not already been put into apex as described, this is now done, the pocket at the base of the flap is pulled wide open, the needles inserted at its bottom, brought out through the skin, side by side, and tied over a cylinder of gau/.e. The edges of the bulbar opening are undermined and united by fme silk sutures, the knots of which are not too tightly tied (Figs. 216 and 217). 1 Graefe-Saemisch, Bd. iii, 1874, S. 43Q. Aril's operation. 332 OPERATIONS UPON THE CONJUNCTIVA Teale-Knapp operation. When the loosening of the hd from the eye leaves a defect too broad to be covered by simple lateral mobilization of the mem- brane, pedunculated flaps are fashioned from a part some- what further away and turned in to till the gap — a method first practised by Teale.^ In detaching the symblepharon, if only its point involved the cornea, this surgeon made an incision across the growth, at the limbus, and left the corneal portion which was supposed to dwindle away from atrophy. The rest he separated in the usual way and (in downward symbleph- aron) took a vertical flap from either side of the cornea (Fig. 218); the two were disposed one above the other on the de- fect, to cover it, stitched together, and, also, to the cut edge of the pterygoid above, and to the lid flap below. The secondary de- fects were closed by simply drawing the conjunctiva to- gether by sutures (Fig. 219). Teale,2 at a later period, made an arched bridge flap from the lateral and upper conjunctiva which he slid down over the cornea, and stitched into position, to fill the opening left by cutting away of a downward symblepharon. Knapp^ combines the method of Teale with that of Arlt. In downward attachment with corneal ])oint, for example, he frees the cornea and separates the lid to its base, turns tlie llap tluis ' Ophthalmic Hospital Reports, Oct., Fu;. 219. — Teale-Knap Report of Fourtli Internat. Cong, of Oph Graefe's Arch, xiv, i, 1868, p. 270. Lone [87,:;, SYMBT.F.rTr.\TU)X ^_^T, formed down, an Annal. d'oct., t. 60, p. i 21-126, 1873. SYMBLEPIIAROX 335 (1873) StcUwag, of Vienna, experimented with the same, also with mucosa from the mouth and from the va<,M"na. The rabbit's conjunctiva has been tried by hundreds since then, f,'cnerally with some degree of immediate success, but the uUimate resuUs have been uniformly disappointing. Thinking to profit by its greater toughness, Panas' essayed the effect of transplanting the conjunctiva of the dog — to no purpose. Just as with that of the rabbit and the mucosae of man, there ensued a gradual pushing up, or shallowing of the cul-de-sac till at the end of a few months — nothing. After a day or two the epithelium comes off, and two granulating surfaces are found in contact, and neither the insertion of an artificial eye, a plate of metal, nor any known force will stop the relentless prog- ress of the obliteration. It is not improbable that some one will ere long hit upon the much-hoped-for method of permanently relieving symblepharon by the transplantation of mucous membrane. When this is found, it is likely that conjunctiva of some kind will be the mucosa selected, on account of its appropriate texture, the other kinds being far too meaty. The method pursued has usually been, first, to detach the symblepharon completely, to copiously irrigate the cavity with salt or boric solution, stop all bleeding, and then cover the lids with a pad wet with the same solution. If the rabbit's conjunctiva is chosen, it is better to have ready two of them, in case of an accident to the first one used. The animal is chloroformed, its eye cleansed with the salt or boric solution, two or several sutures are put into the conjuctiva through small cuts, by which the area to be excised is marked off and by which also the piece is managed after de- tachment. If this is not done, it is next to impossible then to tell front from back. The lid to be repaired is pulled far away from the globe, the latter is rotated strongly upward (the operation being for a downward symblepharon), the borrowed piece, with or with- out previous dipping in the warm solution, laid in right side out, the contained sutures fastened to the surrounding tissue, and as many others put in as are needed. To finish, loop threads are put down through the middle of the graft, brought out on the cheek and tied over cylinders of gauze to form the cul-de-sac. Some operators wait for these to cut out. It 1 Mai. des Yeux, t. ii, p. iSi. 336 OPERATIONS UPON THE CONJUNCTIVA is a good plan lo lay on a piece of sterile oil silk or similar stuff before inserting the looij threads and pull it, folded, clown with the graft, as recommended by Thilliez.^ Or one could employ the paraffined lead plate, as detailed later. If a one-piece graft is not large enough, two may be joined together and handled as one, or one may be applied to the globe, the other to the lid and their lower edges stitched to the tissue at the bottom of the newly-made pocket. Where the rest of the bulbar conjunctiva is fairly normal, one may, as advised by de Wecker, combine the transplanting of Teale or Knapp (p. 332) with the mucous grafting. 2. Pedunculated skin flaps, under existing conditions, probably offer a greater measure of success than do mucous grafts, for the cure of total symblepharon, yet these, too, are far from reliable. A pioneer in their use for this purpose was Taylor.- He took the flap from the lower lid, in a case of downward symblepharon, with its base toward the nose. After loosening it up, he cut a vertical slit through muscle, fascia and conjunctiva, near the pedicle of the flap, pushed the latter through, twisted it 180° on its long axis, and stitched it to the inner side of the lid with its epidermis next to the globe. The outer defect was then closed by sutures. Chisolm^ made the same operation, except that the pedicle was left at the tem- poral side. Harlan^ for a case of total lower symblepharon, formed a bridge flap (with relatively narrow pedicle at either end) on the cheek below the lid, cut through into the bottom of the newly prepared fornix along the upper edge of the flap, pushed the latter through the opening, twisted the pedicles to bring what had been the lower edge on a level with the free border, and stitched it in phce with its epithelium facing the eyeball. The result was only a partial success. Panas^ in a similar case cut a flap from the temple and one from the cheek, carried them through a buttonhole in the outer orbito- palpebral furrow, applying one to the lid and the other to the globe, their cuticular surfaces in contact. After they had become firmly adherent, their pedicles were cut and the buttonhole closed. For total symblepharon of both lids, the same surgeon took a large flap, the shajje of a tennis racket, from the temple, pedicle near the orbit, ' Jour, des Sc. med. de Lille, 1898, p. 143. - Med. Times and Gaz., i, July, 1876, p. 4. ^ Virginia Med. Monthly, 1877, p. 180. ■* Trans. Am. rj])h. Society, iSgo. 5 Mai. des Ycux, T. ii, p. 182. CUTANEOUS GRAFTS 337 turned it in through the palpebral fissure, and put the raw side in apposition with the two freshly dissected tarsi. At the end of three months the flap was bisected horizontally, to reestablish the open- ing between the lids. The operation was undertaken to enable the patient to wear an artificial eye, the cornea having been destroyed by sulphuric acid, but the object was not attained. In a case of double total symblepharon, in which heteroplastic and other autoplastic procedures had been tried in vain, Samelsohn^ succeeded in the manner following: from the skin of one lid he borrowed a quadrilateral flap, which was left attached along the ciliary border, and turned it into the palpebral fissure to line the posterior surface of the opposite lid. Union having been established, the flap was severed at its base and the measure was repeated, from the other side, for the fellow lid. The principal cause of failure in most of these flap operations has doubtless been neglect to construct a capacious artificial cul-de-sac and to provide means for its preservation. Panas, with his two flaps for the restoration of the lower fornix, fulfilled the first condition, but not the second. To cover only one side of the raw pocket made by separating the lid is clearly a lame procedure. The most formidable foe to be combated in this surgery, is the progressive ankylosis between lid and globe, which tends to efface one's work. As a support for the transplanted tissue — to keep it in place — in coaptation with the surface it is to unite with, and to mold the cul-de-sacs — glass or porcelain eye shells have long been employed. The trustiest weapon for the purpose would seem to be a properly fashioned plate of soft metal, as described, along with other means to the same end, in the next section. With a view to the prevention of a rela])sc, Scott- everted the lid, put it on the stretch, and fixed its free border to the skin with the aid of fine silver sutures, keeping the eye occluded until the transplanted tissue took. 3. Cutaneous Grafts. — The transplantation of skin by the Le Fort- Wolfe method, to replace lost substance in the surgical treat- ment of sym.blepharon has, like that with mucous grafts, proven of little value. Their great thickness, and the excessive degeneration and shrinkage which they usually undergo, having necessitated their abandonment. Of late years their use has been confined mainly to ^ Heidelberg Congress Report, 1892, p. 149. - Lancet, Jul}' 31, 1897. 338 OPERATIONS UPON THE CONJUNCTIVA the restoration of the cul-de-sacs in cases where the ,^lobe was absent. C. H, May/ of New York, has reported the successful " transplantation of a large Wolff (Wolfe) graft, forming a new lining for the orbit and permitting the wearing of an artificial eye." The graft was wrapped around a porcelain support and the whole, placed in the new-made socket, where a few fine sutures united the edges of the piece with those of the conjunctiva. Epidermic grafts, on the other hand, afford the best known means of repair for the defect under consideration. They were used, to a limited extent, in symblepharon operations by v. Arlt, in small patches upon a granulating surface, after the manner of Reverdin. Later, more extensively and in broader pieces, by Eversbusch- and many others. Czermak^ gives an ingenious procedure for total symblepharon of the lower lid, founded on a method of epidermization by Evers- busch. The palpebral fissure is extended to the outer rim of the orbit by a horizontal incision with the scalpel. From the outer extremity of this another is made, down and in, along the orbito- palpebral furrow, till it reaches a point one and one-half centimeters below the inner canthus. The incision is deep enough to include the whole thickness of the lower lid, which latter is dissected up in the form of a flap with its pedicle inward. The flap or lid is then turned back over the nose, the bleeding is stopped, and the raw surface of the globe and orbital contents covered over with a Thiersch graft. The entire area is dusted over with iodoform powder and covered with a piece of tin-foil, or gutta-percha tissue, well smeared on both sides with vaselin. This covering must extend beyond the outer and under borders of the wound and be pushed snugly into the angle at the base of the flap. Above it must overlap the cornea. If the latter is transparent, gutta-percha tissue is chosen instead of foil. The graft is made to cover the lower half of the cornea also. Now another epidermis graft, correspondingly large, is laid on the tissue (or foil), epithelium downward, and the flap is turned back into place. Both lids are now covered with a piece of gutta tissue greased witli vaselin, and, ()\er all, the regulation coUon pad and roller bandage. The foil or tissue keeps tlie two grafts apart while they heal. As soon as they have l)ecome firmly adherent, ' Arch, of Oph., vol. xxx, No. 5, igoi. 2 Miinch. med. Wochschr., 1887, Nr. i u. 2. 'Aug. Operatioiu'n, 1803,1). ,i°''- TIIIERSC'ir GRAFTS 339 with confi.miralion like thai of llic llap. an incision is mack- alon,-^ the margin of the ])o>UTior (Icfi-cl. that nuisl run cxaclly as (\U\ the one by which the llap was originally outHncd. Jn this way a cut is made thai, by the contraction of the surrounding tissue, is seen slightly to gape. Then the whole convex edge of the llaj) and that part of the upper edge near the point, made by the first or horizontal cut, is freshened with the scissors and sutured lo the surrounding skin. 'J'luis is formed a deep culde-sac. A linear scar remains, of course, and the lower lid looks i)uffy, "but faults like these," says Czermak, "are not to be taken into account in such desperate cases." He considers the operation of special utiliiy in making a new socket for holding a glass eye. But it is in the United States that the em])l()yment of epidermic grafts in this connection has been attended with the highest degree of definite success. Hotz^ advocated the use of Thiersch grafts to replace the destruction of conjunctiva in extensive symblej^haron. Among the first signal triumphs in this country was one at the hands of C. H. May- (in May, 1897) of New York. There was total symblepharon of both lids. A number of large epidermic grafts were used which were kept in place by a porcelain shell resembling an artilicial eye. The result was perfect. Four years after the operation it was still so. In April, 1899, the same surgeon,'' after vain attempts to relieve an extensive lower symblepharon by older methods, detached it freely and placed a large Thiersch graft over the defect thus made. This, too, was kept in place by means of the porcelain shell. The cornea was transparent over two-thirds of its area, yet the shell was well tolerated. In addition, the graft was stitched to the margins of the raw surfaces l)y delicate sutures. The graft adhered promptly and the symblepharon was cured. Fifteen months afterward the effect of the operation had nol dimin- ished. In July and August, 1899, by two successive operations, Hotz^ relieved a nearly complete symblepharon of the upper lid, covering the raw surfaces, after dissection, with broad Thiersch grafts. Knowing of ]May's use of the porcelain shell to hold the graft in place and having no such shells at his disposal, he "cut from a ihin sheet of lead an oval disk large enough that when slij^ped under the lids it would till the whole space from the retrotarsal sulcus of the 1 Annals of Oph., April, 1893. 2 Reported in the Archives of Oph., April, 1899. ' Reported in Arch, of Oph., vol. xxx. No. 5, 1901. ■•Oph. Record, Nov., 1899. 340 OPERATIONS UPON THE CONJUNCTWA upper lid to that of the lower lid, and shaped and molded it so as to fit accurately the curvature of the ball. A Thiersch graft, taken from the arm, was spread out smoothly over the plate, epidermis toward the lead, in such a manner that it covered the upper two- thirds of both sides of the plate. Thus mounted, the plate was inserted under the lids as we insert an artificial eye. The lid borders were united by three sutures." The eye was dressed, and lid sutures removed on the fourth day. Although the graft was adherent throughout, the plate was worn four days longer. The second operation was for the purpose of piecing out with a Thiersch graft a small area that the first one failed to cover. The eye was sightless and the operation was to make a prothesis practi- cable. Dr. Hotz has just informed me that the patient is wearing the glass eye wiih perfect comfort at the present time (March, 1906). In November, 1901, Hotz^ presented at a meeting of the Chicago Medical Society a case wherein he had cured almost total lower symblepharon in a similar manner. Instead of the large plate, filling the entire conjunctival sac, as in the first case, he used one the size and shape of the inner aspect of the lower lid, with four small holes through it near the upper edge. The plate was covered with the graft, put into the new cul-de-sac and fastened along the free border by silk sutures passed through the perforations and through the lid. Two supplementary operations were required to complete the cure in both of these; the lead plate also was used, but the sutur- ing together of the lids was omitted. Fifteen months after the first operation and three after the last the lid was free, easily evertible, and there was perfect motility of the eyeball. In this case, the greater part of the cornea was transparent — had escaped in- jury — and the sight was preserved. At a meeting of the Ophthalmic Section of the Philadelphia Medical Society, April 17, 1900, Oliver reported a case of complete restoration of the conjunctival sac by a single epidermic graft. Indeed, since the publication of Hotz's and May's first articles on the subject such operations have been made by ophthalmic surgeons all over the land and, in numerous instances, with most gratifying results. A notable series of six cases was reported and exhibited by H. W. Woodruff- at the meeting of the Chicago Ophthalmologic Society, February 10, 1903. Three had been relieved of high-grade Med. Recorder, Dec., iqoi. 1 Chicago Med. Recorder, Dec - Annals of Oph., .MarclT, 190,: WOODRUFFS MKTHOl) 341 or total symblepharon and three, where the globe had been enu- cleated and the cul-de-sacs had been effaced, were furnished with new sockets. Woodruff thus describes his mode of procedure: "The patient should be under a general anesthetic, preferably chloroform. The eyebrow and skin about the eye, and the surface from which the graft is to be taken should have been previously thoroughly cleansed with green soap and hot water, washed with alcohol, and bandaged. Immediately before the operation is begun the field is freely flushed with boric acid solution. If a pscudopteryg- ium is present, it is first dissected from the cornea, and the lid is thoroughly freed from its attachment to the eyeball, and the cul- de-sac must be made large in all dimensions. Cicatricial bands should be removed entirely. Bleeding is checked by hot water. A plate is now cut from a sheet of block tin, which will snugly fit into the new-formed cul-de sac. The corners are rounded off and the edges smoothed with the scissors or file. If the case be one of symblepharon, and there is danger of the plates rubbing on the cornea, it may be cut out in the center to the extent required. Four holes are made for the sutures, two at the outer and two at the inner angle of the plate, to correspond to the lid margin. A razor which is known to be in good condition is used for removing a thin layer of skin, about one-third wider and more than three times as long as the plate. In the method known as Thiersch's the trans- planted flap includes only the epidermis and superficial layer of the dermis. The graft is best taken from the inner surface of the arm, which is put on the stretch by firm pressure with the hand, and made flat by pressure with the razor while cutting. The graft is transferred at once to the plate, and folded over it with the raw surfaces external. Plate and graft are then pushed into the cul de- sac, and sutured to the lid near its margin, tying them over small rolls of gauze. The lids may be sewed together and dressed with gauze, and bandaged in the usual way. Both eyes should be bandaged as long as the plate is in place, and absolute quiet main- tained. The plate is removed in four days, and more freedom allowed the patient." This is essentially the method as generally employed in America. It will be observed that Woodruff speaks of having used plates of block tin. This is probably a cleaner metal for the purpose than is lead, less affected by the secretions of the eye and the fluids in the raw tissues, though in other respects there is no choice between 342 OPERATIONS UPON THE CONJUNCTIVA them. Woodruff continues, "The particular advantages claimed for the use of the plate over any other method of skin grafting are: " I. It enables one to place the graft at once in the position wanted. " 2. It holds it down in the very bottom of the artificial cul-de-sac until it has adhered, so that the raw surfaces of the lid and ball in no part can again unite with each other in this angle, and, even when the graft Hves, gradually push it upward, as, in my experience, it does, unless the plate is used. "3. We secure, with the plate, accurate approximation over the whole extent of the graft, and rest." Weeks, of New York, at the Congress of Ophthalmology, Lucerne, 1904, gave a method for the restoration of the conjunctival cul-de- sacs that he declared to have been highly successful in cases of anophthalmos with obliteration of the socket. He believed that the procedure owed its efficacy solely to the fact that a fixed point of attachment was found for the graft in the periosteum at the rim of the orbit. In addition, however, he had made use of a plate for the support of the transplant. In this instance the plate is gutta-percha, such as is employed by the dentists under the name of "base-plate." A piece of this is cut to the desired outline, molded to shape after immersion in hot water, and its form definitely fixed by putting it in cold water. The first step of the method is the making of a free canthotomy, in order to obtain room to operate. Only one fornix is restored at a time. The lid is detached almost to the margin of the orbit, and the cavity packed with cotton wet with normal salt solution. A Wolfe graft is rapidly cut from the arm, freed from subcutaneous tissue and dipped in the warm salt water. It is then folded, epithelium inward, and three double- armed sutures passed through at the bottom of the crease, leaving loops, two millimeters long, on the cutaneous surface. The sutures are next put through the periosteum of the orbital rim, from the bottom of the newly formed cul-de-sacs, and out on the cheek. The graft is helped into place while the sutures are all drawn down, and threads are tied over rolls of iodoform gauze. Small interrupted sutures fasten the graft to the conjunctiva of the lid and to that of the ocular stump. Now the plate is inserted and, lastly, the stitches put in to close the canthotomy. The deep sutures are left in for ten to fourteen days, those in the conjunctiva are removed in one week. The i)late is left in situ until all shrinkage ceases in the fiap. RESTORATION OJ' ( TL-DK-SACS 343 'JI1C writer, havinij; found the ,theil., iS68, S. 2O7. 35- OPERATIONS UPON THE CONJUNCTIVA The body of the pterygium is seized with fixation forceps and detached with a narrow cataract knife from near the hmbus to and including apex, boldly cutting through the epicorneal tissue so as to leave nothing of the growth behind. The scleral portion is in- cised along its upper and lower borders and the cuts prolonged in a curved direction into the upper and lower fornices. The whole is then loosened from the eye in the form of a triangular flap which is split horizontally into two equal portions. The part representing the gray infiltrated head is cut off. The tip of each half is stitched into the corresponding angle formed by the upward and dow^n- ward prolongations into the fornices. To cover the remaining defect, two vertical incisions are made in the conjunctiva, beginning at the limbus, extending up and down for several millimeters, getting further from the cornea as they advance. Thus two squarish I,': ^ Fig. 227. — Desmarres, jr.-Knapp. Fig. 228. — Desmarres, jr.-Knapp. flaps are outlined which are undermined and joined together by two sutures. The better to fix the various flaps and to keep them from overriding the cornea, the suture furthest from the cornea is made to include the conjunctiva at the apex of the angle between the two halves of the divided pterygium (Figs. 227 and 228;. Both eyes are bandaged for twenty-four hours — afterward only the operated eye — though the patient is advised to use the uncovered eye as little as possible the flrst week. The threads arc removed PTKRYC.IUM 353 in five or six days, liolli lliis and Dcsniarrcs' arc true transi)lanta- tion operations. ]\IcReynolds,i of Dallas, has, by a most ingenious and effective modification of the original Desmarres operation, given new im- petus to the transplantation method in this country. The present writer is among the many who can testify, from experience with a number of cases, to the excellence of the procedure. The different steps of the operation, as described by its author, are as follows: 1. Grasp the neck with strong narrow forcejis. 2. Pass a Graefe knife through the constriction and as close as possible to the globe; then, with the cutting edge turned toward the cornea, shave the growth smoothly from that membrane. 3. With the fixation forceps still hold the pterygium and with slender straight scissors divide the conjunctiva and the subconjunctival tissue along the lower margin of the pterygium, commencing at the neck and extending to the canthus, a distance of 1/4 to 1/2 inch. 4. Still hold the pterygium with the forceps and separate the body of the growth from the sclera with any small, non-cutting instrument. (A Hat (}raefe strabismus hook serves admirably.) 5. Now separate well from the sclera the conjunctiva lying be- lovv^ the oblique incision made with the scissors. 6. Take black silk thread, armed at each end with smallest curved needles and carry both of these needles through the apex of the pterygium from within outward. Separate one from the other by sufficient amount of the growth to secure a firm hold (Fig. 229). 1 Journal of the American Medical Association, Aug. 9. 1902. 23 -McReynold's modificalioii of Desmarres', Sr. 354 OPERATIONS UPON THE CONJUNCTIVA 7. Then carry these needles downward beneath the loosened conjunctiva lying below the oblicjue incision made by the scissors. The needles after passing in parallel directions beneath the loosened lower segment of the conjunctiva, until they reach the region of the lower fornix, should then emerge from beneath the conjunctiva at a distance of about 1/8 to 1/4 inch from each other. 8. With the forceps lift up the loosened segment of conjunctiva and gently exert traction upon the free ends of thread, which have emerged from below, and the pterygium will glide beneath the loosened lower segment of conjunctiva, and the threads may then be tightened and tied, while the surplus portions of thread are cut off, leaving enough to facilitate the removal of the threads after proper union has occurred (Fig. 230). It is very important that no incision be made along the upper border of the pterygium, because it would gap and leave a denuded space when downward traction is made upon the pterygium. If the head of the pterygium is very large, it is cut off before the pterygium is drawn down beneath the loosened segment of of the cornea occurs, McReynolds ply trims away the offending portion of conjunctiva. This is more a burying than a transplanting of the pterygium. The writer would urge, as a precautionary act of no little impor- tance, that before proceeding to draw the pterygium down into the prepared pocket, the blepharostat (or retractor) be renu)\-e(l. The effect of this instrument is, by its pushing the conjunctiva up into the fornix, to greatly limit the extent to which that membrane can be drawn down. This is ])articularly necessary in cases of Fig. 230. — McReynold's modification of Desmarres, Sr. conjunctiva, sim If any overlapping PTERYGIUM 355 elderly subjects and in those afflicted with chronic intlammations of the conjunctiva, and whose cul-de-sacs are, in a measure, obliterated from atrophy. It is also highly advisable, before actually putting the growth in its new place beneath the conjuncti\'a, to take it by its head with the forceps, pull it down and note and mark the j)lace where it fits best. The younger Desmarres,^ for large pterygia with trun- cated apices, divided them in two and transplanted similar to Knapp, but, like Desmarres the elder, he left the scleral defect uncovered. Galezowski,- after mobiliz- ing the pterygium, put a double-armed suture through the apex, tucked the growth back beneath the semilunar fold, or the caruncle, where he brought the suture out and tied it. 3. Ligation. — In connec- tion with the surgery of ptery- gium, this measure, though still occasionally resorted to, may be considered obsolete. Its origin is associated with the name of Szokalski.-'' This o])erator passed two curved needles beneath the pterygium, one near the apex, the other near the base, both being attached to the same thread (Fig. 231). The thread was then cut close to the needles. In this manner three ligatures were made, two single and one (the middle) double. The single ones were tightly knotted. The third, formed by the loop of thread, served to detach and lift u]) the i)terygium. At the last this thread was made into a slip-loop around the pterygium and the ends fastened to the cheek by means of collodion. After a few days the growth perished and was excised. P"iG. 231. — Szokalski's ligature '■ Lemons cliniques sur l;i chirurgie oculaire, Paris, 1874, p. 302. - Maladies des ycux, 1S88. ^ Roser u. Wundcrlich Archiv., 1845, ^r. 2. 356 OPERATIONS UPON THE CONJUNCTIVA Von Arlt,^ in a case of cicatricial pterygium, following blenor- rheic conjunctivitis, cast two ligatures around it and allowed them to cut through. The pterygium soon after disappeared. 4. The thermal cautery as a single measure for the removal of ptervgium, though it has been, to a limited extent, used in this capacilv, is not especially to be commended. Its only place, in this connection, would seem to be in conjunction with other means more strictly surgical. For example, Martin,- of Bordeaux, after having practised ablation of the growth, made several successive cauteries on the site of the corneal implantation, by means of a strabismus hook heated to redness in the flame of a spirit lamp. Panas^ did the same, only with an olive-tipped thermocautery. Chibrct^ made a similar operation to that of Galezow^ski, just men- tioned, but before rolling the pterygium upon itself, he applied the galvano-cautery to its posterior, or raw, surface. This was supposed to hasten the atrophy of the growth. Deschamps^ affirmed that cauterism of the corneal portion, when well done, especially if combined with a good scraping, rendered any sort of conjunctival autoplasty inutile, and that the cure was rapid and permanent. Most all authorities agree that it is highly indiscreet to cauterize the episcleral part of the wound opening. It should also be borne in mind that the electric cautery is, in this respect, an instrument whose emplovment should be confined to the most experienced and skillful hands, as in any other than these, because of its tremendous energy, its work is sure to be overdone and deep scars be the result. Unless one is sure of himself, it were better to employ for the purpose the iron made red-hot in the flame. The actual cautery is particularly helpful in getting rid of the infiltrated head that sometimes thwarts one's efforts at dissection and scraping, and whose complete removal is of the utmost importance. Starkey,*^ of Chicago, recommends the galvanic current for the treatment of pterygium, but not to the extent of actually burning the growth, ])ut for its milder electrolytic effect. Among the other procedures employed as adjuncts to pterygium operations may be mentioned conjunctival autoplasty by means of mucous grafts' ^ Operationslehre, S. 381. 2Annal. d'oculist, 1881, p. 144- 3 Maladies des yeux, 1894, t. ii, p. 265. ^Archiv. d'opht., t. xi, p. 528, 1891. 5 Bull, et mem. de la Soc. franc, d'opht., 1895, ]i. 510. 6 Journal of the Am. Med. Association, Sept. i i, 1898. 7 S. Klein, Allgem. Wiener med. Zeitung, 1876, Nos. 3 and 4. fai.sk pteryc.ium 357 and of Thiersch skin grat'ls.^ The last menlioiied took from behind the ear an epidermic graft somewhat smaller than the scleral defect, and, in order to prevent overlapping of the corneal margin, fastened it in with two fine sutures at a little distance trom the liml)us. Grafting is applicable to cither ablation or transplantation, and the method of Hotz is an excellent one. Thin epidermis furnishes more suitable material for the purpose than does mucous membrane. It is more easily kept in position, it docs not become red and meaty, it is less likely to perish, and its whiteness, lying as it does upon the sclera, is a positive advantage. Such accessory measures are, of course, reserved for the larger pterygia only. False pterygium, also known under the names cicatricial pterygium, pscndo-ptcrygium, and pterygoid, refers to an irregular growth of conjunctiva taking place upon the cornea, as a result of burns and other lesions, and its approach may be from any direction or from several different points at the same time. Under this head- ing may also be placed that unfortunate class of cases wherein there have been recurrences of the pterygium after operations for its re- moval, and there is a sclerotic degeneration of the cornea, or a condi- tion resembling the so-called keloid cornea. Where these are present, are not progressive, and the sight is not greatly diminished in conse- quence, one would better abstain from further operative measures. The exaggerated forms tend more or less to restrict the movements of the globe and to produce strabismus, which constitute additional indications for surgical intervention; and they are often associated with symblepharon (symblepharo-pterygium). In its surgical treat- ment, therefore, false pterygium involves many of the principles which are concerned in operations for symblepharon as well as most of those just described in connection with the true form. No set methods can be laid down for their operative handling, as they present so great a variety that each case must be separately reckoned with. Great care should be exercised in the process of uncovering the cornea where the destruction of that membrane has been deep, lest the anterior chamber be opened. Oi)lical iridectomy is occasionally required in connection with cicatricial pterygium. The tendency of pterygium to return after operations, seems to depend upon the manner of its removal. Failure to cure does not hang so much upon the specific method that is chosen, nor, as was 1 F. C. Hotz, of Chicas:;o, Klin. Monatsl)!. f. Au.L,uMih., i8q7, p. 6io. 358 OPERATIONS UPON THE CONJUNCTIVA formerly supposed, upon any inherent proneness of these growths to recidivate, as upon the neglect or the lack of certain essential condi- tions. Among the causes of non-success stress is laid upon the following : (a) Failure to properly cover the scleral defect or so to iix the covering as to keep it away from the cornea. (b) Incomplete removal of the growth from the cornea, especially the head. (c) Want of care in placing the conjunctival sutures. Pulling and tearing the delicate membrane, using needles and thread that are too large, and taking with them bites that are insufficient. (d) Leaving a thick growth of episcleral tissue at the corneal margin. (e) Operating when the whole conjunctiva is hyperemic or inflamed. (/) Inadequate bandaging and allowing the patient too much liberty during the first few days after the operation. The causes (a) and ((/) are those that are, perhaps, most often operative. After having removed a pterygium, no matter by what method, if the sclera adjacent to the cornea is left exposed over an area, say of one-half a square centimeter, the defect were better covered at once. A most satisfactory manner of doing this is by means of a Thiersch graft, as first practised by the late Professor Hotz, of Chicago. The graft is taken from the inner side of the upper arm or from behind the ear, and is cut so that it bridges the conjunctival gap in the vertical sense, but is narrower in the lateral sense. It is placed in the middle of the scleral defect and held in position by two sutures, one above and one below. Thus the graft keeps clear of the cornea. Thiersch epidermic grafts are preferable to those that are shaved from the mucous membrane of the mouth, because they remain white, while tlie mucous grafts never lose their redness. Besides, the latter do not lie so smoothly, but become bunchy from thickening, and from lateral contraction. It is of the utmost importance that the patient be instructed to clean the dead epithelium from the graft every day or two with warm boric acid solution and a cotton swab. The other cause of recurrence referred lo under (d) — leaving a thick growth of ei)iscleral tissue al)out the corneal margin — can RECURRENT PTERYGIUM 359 be rendered inoi)erative by scrajMnj^ away this growth very thor- oughly, leaving the sclera quite bare. Gifford/ of Omaha, in an article on "Recurrent Pterygium," cites Knapp's well-remembered warning, viz., "Pterygia that have relapsed after one or several operations and have the aspect of a keloid scar should not be meddled with." Gifford then says, "The condition of this class of patients is so dei)lorable that it would be unfortunate if this verdict of so high an authority should be considered final. 1 hiwe seen several of these cases, and my experience has led me to an entirely different opinion." And, further, "My experience indicates that all of these bad cases of recurrent pterygium can be cured if a large enough Thiersch llap or epithelial lip-flap is ])ut on. In doing the operation it is impor- tant, in dissecting back the conjunctiva, to clean the cornea and sclera very thoroughly and to be sure that the flap is well attached to the globe before the lids are allowed to close. The device which I have adopted of fixing the globe in a position of abduction by means of a guy-thread put through the tendon of the external rectus and fastened to the skin outside the external canthus with coUodionized gauze to prevent displacement of the flap may be necessary in some extreme cases. But if the flap is pressed down firmly with an absorbent cotton toothpick swab, slightly moistened, so as to bring its entire under-surface into close contact with the globe, and the lids are held open for three to five minutes thereafter, then both eyes kept closed with a rather firm bandage, with plenty of cotton, for 48 hours, failures from displacement of the flap will be rare." In a])plying the latter it is sometimes necessary to tuck the edges in under the loosened conjunctiva, and I have once or twice protected the well-applied flap by temporarily drawing the conjunctiva partly over it with a suture. The flap should be slid directly from the razor to the globe. It should be cut large enough, and, after cover- ing the defect on the globe, the excess on the temporal side is trimmed off so as to leave bare the cornea and a strip of sclera about 1/16 inch wide between it and the flap." What appears at a glance to be a recidivation is sometimes but the vascularized and otherwise changed condition of the cornea in the locality that had been occupied by the pterygium. This may or may not wholly clear up. The immediate status of the vision 1 Ophthalmic Record, Jan., 1909. 360 OPERATIONS UPON THE CONJUNCTIVA after the removal of pterygia that encroach even very shghtly upon the pupillary area is apt to be disappointing, owing to the fact that there is usually some disturbance of the cornea which extends be- yond the apparent limits of the growth. A little time is required for this to disappear. PERITOMY AND PERIDECTOMY. According to the researches of Hirschberg the Arabian surgeons, early in the Middle Ages, made circumcision of the cornea for the pannus of trachoma. In the year 1862, Fournari or Furnari,^ of Paris, afterward of the University of Palermo, published the description and the results of his experience with an operative measure which he claimed to have employed with success while previously, for twenty years, a resident of x\lgeria. The author called it tonsure de la conjondive bulbaire. It consisted in the excision of a ring of the conjunctiva immediately surrounding the cornea and the applica- tion of nitrate of silver to the annular defect, together with the scarification of the anomalous corneal blood-vessels. Afterward the operation was named peridectomy, and still later syndectomy, both of which words refer to the removal of the aforesaid ring of conjunctiva, and, strictly speaking, should be so used in contradis- tinction to peritomy. This last is a term that was applied by Critchett, of London, to a modiiication of Furnari's operation, which he devised. The chief change suggested by Critchett was that the word implies, viz., the substitution of a simple circum-corneal incision for the excision. What Critchett really did, then, was to rehabilitate the'old Arabian measure. The indications for peritomy and for peridectomy or syndectomy are the same, to wit, a pertinacious vascularity of the superficial portion of the cornea, whether consecutive to trachoma, interstitial keratitis, leucoma, or aught else. The measure has also been resorted to with marked success, especially in Great Britain, for episcleritis, iritis, herpes ophthalmicus, purulent conjunctivitis, and even for glaucomatous tension. Peritomy was further modified by Agnew, of New York, and was one of his favorite means of dealing with persistent pannus. Having iQaz. med. de Paris, 1862, Nos. 4, 6, S, 10, 12, 14 et Annal. d'oc, 1863, t. xlix, ]). 272. PKRITOMY 361 been the forluiialc obscrxcr of nnicli of .\,!j;ni'\v's hrilliaiU work, the present writer was led to ado])! ihe nuihod, has employed it many times, and almost in\-ariahly willi .L;ratif\'ini!; resuhs. Il ma}' be thus described: Agnew's Method. — ^Thc eye is carefully cleaned and put under cocain anesthesia. The lids are held apart by the blepharostat. The globe is fixed and the conjunctiva manipulated with, delicate mouse-tootli forceps. The conjunctiva is incised all the way around with a |)air of small curved scissors whose points are slightly blunted, but wdiose cutting power, especially at the extremities of the blades, is absolutely irreproachable. It is advisable that the cut be as close to the limbus as possible, hence these qualities in the scissors are insisted upon. Now the mouse-tooth forcei)S are exchanged for the broad-jawed fixation forceps. While the eye is steadied with these, the severed conjuncti\a is pushed backward, all around, to a distance of about five milli- meters, by means of a convex-edged scalpel. Willi this same instrument the episcleral tissue is also scraped away till the sclera is quite bare and, wdiere practicable, the scrapings are excised. The larger trunks of the corneal vessels are gently scratched longi- tudinally with the point of the knife, or, what is perhaps better, each of them is touched where it crosses the limbus with a small, red hot, bulbous electrode. No clots of blood nor shreds of fibrin should be left about the field of operation. The eye is douched copiously with hot boric or hot salt solution, and the regulation monocular netting bandage is put on. The reaction is usually insignificant. Upon removing the bandage, if it is found that the conjunctiva is creeping forward, it were best to loosen it up with a blunt instrument, push it back, and smear with vaselin. L. Webster Fox,i of Philadelphia, has recently made a plea for the rehabilitation of peridectomy, and states that in loS such operations, performed by him wdthin the past three years, the results had been most gratifying. He further states, "The operation as performed at present consists in excising a strip of bulbar conjunctiva 2 to 5 mm. wide surrounding the cornea. The vessels on the cornea at the limbus are scarified by means of a Beer's knife, butnocautcrant is employed. The eye is anesthetized by the instillation of cocain (5 per cent, solution), and excessive hemorrhage may be controlled by the application of adrenalin solution, i to 1000. This is tlie 1 Annals of Ophthalmology, Oct., iqo,^, p. 615. 362 OPERATIONS UPON THE CONJUNCTIVA operation referred to as peridectomy, and should always be combined with treatment directed toward tlie underlying cause of the corneal vascularity." I believe with Fox that the operation, whether it be j^eritomy or peridectomy, particularly the former, has been unjustly maligned. Among those who speak disparagingly of it is no less a person than Knapp,^ who says, "I have performed it (in reality peridectomy) a number of times. The result was too uncertain and the danger of sloughing of the cornea was ever present. I think the operation has been generally abandoned." The last two statements are most surprising. j\Iost surprising still, the distinguished author falls into the popular error of confounding peritomy with peridectomy, for he calls the operation by the first name and says that it "consists in the removal of a strip, from 5 to 8 mm. in breadth, of conjunctiva around the cornea." In view of the fact that the vast majority of cases wherein such surgery is indicated concerns eyes whose conjunctival sacs are already shrunken, makes peritomy, in my opinion, by far the more rational procedure of the two. Instead of sustaining a loss the conjunctiva is made to gain, in that the pushing back of the bulbar portion tends to deepen the previously contracted fornices. As to the dangers, I have never seen any untoward consequences from the operation. It is generally admitted, however, that these measures are only to be resorted to when those of a less radical nature have failed to restore to the cornea its transparency. According to Panas,- the worst forms of pannus — those known as crassus and sarcomatoid — ■ are positive contraindications, for which, among other -modes of treatment, he suggests pericorneal cauterism, or igneous peritomy. For large scattering vessels that have become a iixture in the cornea, I have sometimes caused their disappearance by destroying a small section of each trunk at or near the limbus by means of the galvano- cautery. 1 Norris and Oliver's System, 1898, p. 853. ^ Maladies des yeux, t. ii, ]). 230. ciiArrER IX. THE SURGICAL TREATMENT OF TRACMIOMA. Measures more or less surgical have since the earliest times been employed for the relief of this wretched malady. These measures may Ijc classed as: 1. Mechanical, 2. Chemical. 3. Operative. Chief among the mechanical are: (a) Scraping, or scratching. (b) Expression, or squeezing. The chemical are: (c) Cauterism. . (d) Radiation. And the operative: (e) Curettage. (J) Excision. (g) Canthotomy (and canthoplasty), (h) Peritomy (and peridectomy). It is worthy of remark that all of these measures, as used in this connection, with the possible exception of electrolysis, radiation and canthoplasty, are as old as history itself, or nearly so. I. MECHANICAL TREATMENT. (a) Scraping or Scratching. — This is probably the most ancient of any of the methods enumerated. Under the same heading one may class massage. Primitive peoples afflicted with trachoma, in seeking relief from the itching and otlier irritating effects of the disease, early learned to evert the lids and rub the granulations. For this purpose they usually sought some implement with a rough surface or a sharpish edge— hg-leaves, bits of broken ]iottcry, 363 364 SURGICAL TREATMENT OF TRACHOMA etc. Capt. Cook, on his first visit to one of the hitherto unknown isles of the Pacific, saw a native mother holding in her lap a tra- chomatous child whose everted lid she scraped with a chip of wood.^ Hippocrates, to remove the granulations, made use of a tightly wound mop of raw wool. The name of the mop was Ophthal- moxistron, and of the scrubbing ophthalmoxysis. Paulus, of ^gineta, employed a similar instrument which he called a blepharo- xystron, and the operation he named blepharoxysis. With these crude things they rubbed until they exposed the tarsus, then applied powdered drugs or the cautery to the denuded part. Severus decried these rude procedures, preferring massage. This was either simple, that is, with the bare finger or other smooth object, or medicamentous, that is, with the addition of unguents, etc. There have been numerous revivals, within modern times, of the exact principles involved in these ancient practices, and to the same end, though, naturally, with improvement both as to the manner and means. The first modern revival by Woolhouse, in England, at the end of the i8th century, yet with an instrument little in advance of the original ones, seeing that it was a brush made of barbS of grain. The next was by Borelli, in 1859; then, later, by several others; and still more recently (1891) by a number of French oculists and a few in other countries. The French have called the process variously — as Brassage, raclagc, graltage, etc. It is not an extremely bad measure, but it is far from being as good as some others. That of massage, on the other hand, is a most excellent one; particularly the medicamentous kind, recommended some years ago by Below.'' This consists in rubbing strong solutions of sublimate, 1-500 up to i-ioo, into the infiltrated conjunctiva. After an experience of ten years with like methods, I most heartily commend it to my colleagues. Since the introduction of the organic silver preparations I have found this form of massage particularly effective. There is hardly a stage of the affection to which it is not applicable, though it is specially valuable where other means are contraindicated. The writer proceeds as follows: "The lids are cleansed externally with warm boric acid solution. They are ^ To prove that such pristine practices have not wholly passed, the writer, not long since, knew a young man who carried in his vest pocket a fragment of window-pane with which he would, from time to time, scratch the upper borders of his inverted tarsi. The trachoma bodies in this instance were scarred veterans, and the noise that he made with his "scratting" was anything but musical. ''Jour, (le med. russo, 1885. KXl'RKSSION 365 then everted and a single drop of adrenalin solution i)Ut onto the conjunctiva. A small hard mop is made by winding absorbent cotton on the tip of a carrier. This is dipped into a very hot solution of sublimate, about 1-250 in strength, the lid is again everted and the affected conjunctiva rubbed. The rubbing should be lU'ilhcr too delicate nor too rough, and not prolonged beyond a minute or two, dip])ing the mop in the hot sublimate now and then, but never leaving an excess of liquid on it, to run down over the cornea and healthy portions of the conjunctiva. Then, without replacing the lids, the whole mucous sac is copiously irrigated for another minute with 4% boric acid solution, as hot as can be borne. And, lastly, a drop of cocain solution is put in. This is repeated with two-day intervals, and, on the alternate days precisely the same is done excepting that a 50% solution of argyrol is substituted for the sublimate. If properly carried out, there is no irritation after either treatment." (/;) Expression of the lymphoid material from the trachoma follicles, in order to hasten the cure, is by no means a recent idea. It was formerly accomplished by means of the finger-nails, and was called unguipressio. A number of attempted revivals of it had occurred in the last century, as, for example, by Eble (1828), Pilz (1854), and Cuignet (1873). It was not, however, until its strong advocacy by Hotz,^ of Chicago, in 1886, that its day really arrived; and it looks as if it had come to stay. Hotz lirst used his thumb-nails, but soon had the jaws of a pair of old angular forceps made smooth for this purpose. If I mistake not, this was the original expression forceps. Then followed, in 1891, Prince's ring-forceps, Noyes' trough-jawed forceps and Knapp's roller forceps, all in quick succession (see Plate VI). The next year the writer suggested a ring-forceps made of tortoise-shell as an improvement over the steel, in that it would not admit of the same forceful application — hence less severe. The common fault of these instruments is the inevitable traction exerted u])on tlie membrane in stri])ping the follicles. Even that of Knapi), designed after the princi])le of a mangle, does not overcome this objection. Could one invent a practical roller forceps in which an intrinsic force, other than the pull on the handle, would impart the rotation to the tightly clamped rollers, it would be ideal. Say a band, chain, gear, or screw. Lacking this, 1 Archives of ( JiilnlKilmolos^V, vol. xv, i8S6, p. 147. 366 SURGICAL TREATMENT OF TRACHOMA the best and most available instrument is the cxpressor of Kuhnt, the working part of which is composed of two coapting, perforated metal plates. The perforations are so arranged that no two come opposite, one to the other, and the expression is effected by simple pression, i.e., without traction. In cases of advanced gelatinous degeneration of the fornices, the mere inversion of the lids causes 232. — Kuhnt's expressor. laceration and bleeding. For these Kuhnt has had constructed what, he terms a modified expressor, one plate being perforated and the other solid. This he inserts beneath the uninverted lid, finds the infiltrated tissue, and makes gentle pressure. The expressers Fig. 233. — Kuhnt's expressor. are made of varying shapes and sizes, in order that one may reach any part of the conjunctival sac (Figs. 232, 233, 235 and 236). Since writing the foregoing paragraph my attention has been called to an expression roller designed by W. Norton Whitney, M. D., of Fig. 234. — ]Modifie(l Knapp roller of Whitney. Tokyo, Japan, with the object of obN-iating traction on the conjunc- tiva (Fig. 234). In this modification of Knaj^p's forceps one of the rollers is replaced by a fiat washboard-like terminal, over which the remaining roller is made to pass, so that the fold of conjunctiva between these two surfaces can be subjected to the necessary pressure without EXPRESSION 367 pulling or stretching it unduly. This motion is ohtained by means of a double hinge at the v\u\ furthest t'roin the roller. The pieces of this end, which are usually welded together, are, in the modified form, separated by a piece of metal three-eighths of an im h long, which is connected by hinged ])()ints with the arms of the forceps. The forceps are held in the o])erator's hand somewhat as a j)en- holder is held when writing. A ring in the u|)per roller arm for the index finger and a little boss on the lower or tlal terminal arm enable the operator to keep the instrument steady. Expression is highly efficacious in selected cases. It shortens the course of trea ment, forestalls ulceration of the cornea, ])revents pannus, and reduces cicatricial contraction to the minimum. It is almost painless under the topic application or the submucous injection of cocain. It is simple of execution, and safe as to con- sequences. Patients may be operated on and allowed to depart at once for home, provided they live within calling distance, being instructed to keep quiet meanwhile and to bathe the lids with very hot water. For it must not be understood that they need no after- treatment. For one thing, it must be [particularly seen to that ad- llF-«l«!liil^= Fig. 235. — Kuhnt. hesions do not form between contiguous portions of the membrane made raw by the operation. To this end, during the lirst days thereafter, frequent examinations and, mayhap, the use of a probe, are needed to prevent the formation of cavities and pockets. These would only help to obliterate the already shallowed cul-de-sacs. Repetitions of expression are rec^uired as long as any lurking follicles can be discovered, always with a wholesome mistrust of the fornices and the semilunar fold; and appropriate medical treatment is to be continued until the cure is complete. The technic of the process of necessity varies somewhat with the kind of instrument employed, but is mainly such as common sense and a thorough knowledge of the nature of the disease and of the tissues involved would dictate. The principal things to be avoided are undue traumatism of the conjunctiva and injury to the 368 SURGICAL TREATMENT OF TRACHOMA corneal epithelium. The prolonged action of cocain, it must be remembered, is bad for the cornea. Every infiltrated follicle must be sought out and emptied at the one sitting. After finishing and before replacing the lids, free irrigation of the entire conjunctival surface with hot boric acid or normal salt solution is indispensable. The time for expression is toward the end of the first, or at the beginning of the second, stage of the disease, i.e., when the granules have become soft or "ripe." This condition occurs when the in- filtrated follicles take on a grayish or yellow-gray tint. Then the affected folds and lobules of the fornices are plump but quiet. It is [^^^"■■■ ■^ Fig. 236. — Kuhnt. then that the trachoma bodies assume the appearance so often re- ferred to as that of "frog-spawn" and of "boiled sago." All authorities agree in advising against expression in acute trachoma, or during the first half of the chronic stage, or in a blennorrhagic period, be it in the beginning or during an exacerbation. The most violent outbreaks call for the mildest measures. This is one in- stance where a desperate case does not demand a desperate remedy. 2. CHEMICAL TREATMENT. (c) Cauterism.— In its broadest sense this termrefers to the use of both escharotic mineral substances or caustics and the actual or thermic cautery. Caustics will not be considered. The ancient Greeks and Romans and the physicians of the Middle Ages regularly resorted to cauterization for affections of the conjunctiva, and often in conjunction with scraping or scarifying. To judge from de- scriptions in their writings, of the implements with which it was done, and from relics of the same that have been preserved, they seem to have taken great pride in these outfits. The first in modern times to employ the cautery for trauchoma was Samel- sohn, in 1857. He selected the more advanced cases for its applica- tion, touching the separate follicles with a tiny tip of a galvano- cautery (punctate cauterization). Reich (1888) and Burchart (1889) were strong sui)j)orters of the galvano-cautery for trachoma. CURETTAGE 369 but rightly limited its use to the recent cases. Indeed, it is ad- missible at an earlier stage than any other surgical measure. For the extensive inliltrations, to be ])roperly applied, it is very tedious, requiring many sittings. But for isolated granules and as an auxiliary to other forms of treatment, it is most excellent. To hasten matters, (i. J. indsay- Johnson, of London, has resurrected the ancient combination of scarification and cauterism, first in- cising the conjunctiva horizontally with his triple knife and then tracing the cuts with electrolysis. Neither thermic nor galvanic cautery nor electrolysis have had many partisans of late. They mostly add to the scarring. ((/) Radiation. — Much is hoped for in the treatment of trachoma or, rather, much has already been accomplished and much more is hoped for from the comparatively new therapeutic agents — X-rays and radium. Like caustics, they hardly have a place in this treatise, and the reader is referred for details of their management to other sources. Sufhce it to state that none but those thoroughly con- versant with the properties of these subtle things should attempt to avail themselves of their virtues, for they are as potent for evil as for good. 3. OPERATIVE MEASURES. (e) Curettage. — Along with this goes scarification, and both are but phases of primitive methods, such as pricking, scratching, and scraping. The Arabian surgeons Isaac Judeus and Rhazes, a thousand years ago, recommended the sharp spoon for getting rid of trachomatous follicles. Its use was again brought to the front by Bardenheuer, of Cologne, in 1877. The best known and most approved method of employing it is that of Sattler, of Leipsig. After incising each individual follicle, this surgeon proceeded to lade out its contents with a very small curet. Like cauterism, it is not adapted to voluminous infiltrations because of its tediousness and the increased cicatrization that it causes. Unlike it, however, it is not suited to the earliest stages, but to the scattering granula- tions that have escaped other kinds of treatment. (/) Excision. — The fornices, especially the upper, are the store houses or reserve stations of the trachomatous infection. And, as regards resistance to the attacks of any ordinary antagonist, the deeper recesses of the upper fornix are veritable strongholds. They 24 370 SURGICAL TREATMENT OF TRACHOMA often successfully resist all medical and mechanical treatment. ll is from these that start the relapses that have made the han- dling of these cases so discouraging. Not only does the upper fornix afford the best harbor for the poisonous germs, but the best soil as well. So that, when cured cases are again exposed to a trachomatous environment, the upper fornix has been oftenest the site of a reinfection. Knowing these things doubtless, as well as the fact that the cutting out of a fold of swollen or infihrated conjunctiva is often mentioned in the Hippocration and other old medical writings, may have been the motive behind the active recourse to surgery in fighting the tremendous epidemic of trachoma that in Europe followed the Wars of the Empire. It is certain that these considerations actuated Bendedict, in 1822, to remove an occasional fold from the cul-de-sac, and Galezowski, in. 1874, to excise the three upper retro-tarsal folds bodily. Galezowski's experiences with the measure must have proven most satisfactory, for he has been in- dustriously at it ever since. Who has not seen the cavalier manner in which he went about it! Seeing that the tarsus was also often the seat of the trachomatous affection and its complications, Heisrath, of Konigsberg, a pupil of Jackson, in 1882, proposed, in fit cases, adding to the exsection of the fornix that of the diseased portion of the adjoining tarsus. Heisrath's idea was taken up and elaborated by \^ossius and by Kuhnt. The last-mentioned has been especially instrumental in furnishing details as to the indications and in working out an ap- proved technic. So closely identified is the School of Konigsberg, i.e., now, Professor Kuhnt, with everything pertaining to trachoma and its handling that it (or he) is rather looked to as the fountain- head of such lore. It is to this source, therefore, that the author is indebted for most of what follows on this subject. In this connection there arc three kinds of excision, to wit: 1. Simple. 2. Isolated. 3. Extirpation. I. Simple excision means tlie removal of a strip of the infiltrated conjunctiva, its dimensions being regulated by the requirements l^resent. Kuhnt restricts its application almost exclusively to the lower fornix. Its indications are: EXCISION OF TARSLS 37 1 First. — \\'hcn the other methods ha\e failed or when there are recidixations. Second. — When the tarsus or llie bulbar ronjuncli\a are be- coming involved. Third. — When there are corneal complications. Fourth. — When the i)atient comes from a trachomatous district and will go back lo il. The operation is contraindicate;l when the conjunctiva is at all scant. Technic of Simple Excision, Lower Lid. —A few minims of a io% cocain solution are dropped into the conjunctival sac, and a few drops of a 6% solution of the same are injected into the folds themselves. The upper lid is held back by an assistant with a sublimated cotton sponge. The patient is made to look far up- ward, the operator e\'erts the lower lid with his left hand, while with his right he takes a pair of curved scissors, places them, convexity downward, on the conjunctiva, and begins the incision from the outer side. The plica semilunaris, if also affected, would better be left for another sitting. If deemed necessary to excise it at once, the resulting wound should not be continuous with that in the fornix, else an ugly scar will ensue. Sutures are usually omitted. After the instillation of atropin and dusting the opening with airol, the eye is bandaged. The dressings are removed at the end of 48 hours, and the conjunctiva is washed with sublimate solution, 1-5000. 2. Combined excision consists in cutting out the trachomatous transition folds together with the atlected part of the adjacent tarsus, and its sphere is limited to the upper lid. The lower tarsus never requires exsections. The indications for this muco-tarsal excision are: First. — In all chronic forms of trachoma, with characteristic follicles, associated with intlltration of the tarsus, whether the cornea is involved or not. Second. — In extensive chronic trachoma of the fornices and palpe- bral conjunctiva, independent of the condition of the tarsus, if the cornea is involved or about to be. Third. — In gelatinous trachoma, even when mainly confmed to the iornices, if the convex edge of the tarsus shows typical thickening. Fourth. — In already cured trachoma of the fornices if the jialpe- bral conjunctiva and tarsus are gelatinous — especially if, in addition, there is secondarv affection of the cornea. 372 SURGICAL TREATMENT OF TRACHOMA The conlraindications are: First. — Recent cases without corneal com])Hcalions. Second. — The achent of the stage of scarring, and the granular process has ceased or is in the act of ceasing. Third. — ^Marked tendency to shrinkage (Xerosis) of the con- junctival sac. Technic. — The eye is prepared as for simple excision. The upper lid is everted and two pairs of special fixation forceps, with catches, are made to grasp the tarsus near its extremities, in the horizontal sense, and are locked. An assistant, standing at the patient's head, takes the forceps and rotates them so as to still further turn the lid, the patient meanwhile being directed to look forcibly down- ward, thus bringing the fornix into view. The first incision, through conjunctiva only, is parallel with the convex border of the tarsus, and far enough back to include the diseased folds. The purplish muscle of Miiller is here to be avoided. Three sutures are now put through the posterior lip of the wound from the epithelial side, and it is undermined nearly to the globe, while making traction on the threads. The two forceps are now removed, the operator seizes the free border with a Blomer's forceps and the aid places a Jager spatula behind the inverted lid as a support for the second or tarsal incision. This begins at the inner and extends to the outer canthus, uniting the extremities of the first incision, and includes both con- junctiva and tarsus. It curves slightly toward the first incision so as to leave greater width of tarsus at the center. The widest part of the island thus surrounded should not be more than i 1/2 to 2 centimeters. The tarsal portion of the island is carefully dissected out with blunt-pointed scissors, hugging the outer surface of the tarsus, and avoiding the orbicularis and the muscle of ]Mullcr. The lid is closed, the sutures drawn down straight, the point where each emerges from the free border is noted, the lid turned back, and the needles put through the remaining strip of tarsus at the points indi- cated, coming out on the conjunctival surface. The threads are tied in single knots, the lid again turned down, and the patient directed to open and close the eyes. If there be any puckering of the lid, it may be best to evert and make further dissection of the posterior fiap before tying finally. Ends of thread an inch long are left to facilitate removal. Before the bandage is applied scopolamin is instilled and airol dusted on. The bandage is changed on the EXCISION OF TARSUS 373 third day, and on the sixth chiy the sutures are removed and the bandage left off. The author has made a number of these combined excisions at the Illinois Eye Infirmary during the ])ast five or six years, and would suggest certain modifications of the technic as just given. First, with regard to the fixing and everting of the upper lid. Instead of Kuhnt's forceps, which are hurtful, and in the way, a Walker lid evertcr is used (Fig. 237). This instrument is wonderfully effective and convenient. An assistant can hold it with one hand and, by simple twisting or rolling movements, can give any degree of eversion desired, and can expose the fornix "perfectly. I consider it more Fig. 237. — Walker's lid everter. efficient than a retractor, or a Groenholm spoon, or any other form of everter I have yet seen. Second, as concerns the incision through the tarsus. Instead of making it perpendicular to the plane of the tarsus, he would make it slanting upward, as shown in Fig. 238, where the heavy black line indicates the parts excised. This conduces to less unevenness in the resulting cicatrix. Third, as to the placing and tying of the middle suture. The usual way is to pass them first through the flap, from the conjunctival surface, then through the remnant of the tarsus to emerge and be tied on the conjunctiva. Now, to avoid contact of the knots with the cornea, which is danger- ous as well as painful, he would advise the use of a fine, double-armed suture, introduced as follows: one needle is passed through the flap of conjunctiva from the epithelial side, then through the remnant of tarsus, coming out at the free border almost in line with the cilia (Fig. 239). The other needle is made to pass through the tarsus in a similar manner, but slightly in front and to one side of the track of the first needle. Both needles are not put through the flap of conjunctiva. The two ends of thread are tied over a long slender 374 SURGICAL TREATMENT OF TRACHOMA cylinder of gauze or absorbent cotton that will fold upon itself without getting into the palpebral fissure. Only one is required, and on either side of it, one passed in the ordinary way. Or one may bring the ends of the double-armed suture out through the skin near the free border where it is tied over a roll of gauze. (Fig. 240.) The two outer sutures are knotted in the usual way, i.e., on the conjunctival surface. Indeed, if the exsection of tarsus reaches almost to the free border and, as is often the case, the angle there, with the muscle of Fig. 238. — Excision of tarsus. The heavy black line surrounds portion excised in extreme cases. Riolani has been whetted away, the second needle is not needed — the end of thread being simply brought around to be tied to its fellow. Kuhnt considers the combined excision the best prophylactic against pannus. 3. Isolated Excision of the Tarsus. — In this i)roce(lurc all of the upper tarsus but a narrow strij) at the free border is excised; but the overlying conjunctiva is s])ared. Kuhnt, its author, considers it valuable in the cicatricial stage after the original disease has disappeared, leaving a thick, infiltrated tarsus, exciting pannus, and as a preventive of ptosis and slow atrophy. It is also deemed useful in cases of shrunken and incurvated tarsi, as a relief from entropion, wliether or not pannus exists. EXCISION OF TARSUS 375 Fig. 239.— Combined excision of the tarsus. Disposition of sutures. Fig. 240.— Combined exi ision of the tarsus. Showing the two ways for the central suture. 376 SURGICAL TREATMENT OF TRACHOMA Technic. — An assistant grasps the margin of the hd with the Blomer forceps, everts it, and places beneath the now inverted tarsus the Jager spatula. The operator makes an incision through, and the whole length of, the tarsus 2 1/2 mm. from the free border, taking care not to wound the fascia underlying the orbicularis. The conjunctiva is dissected from the tarsus, leaving the latter exposed. The cartilage is then separated from the pretarsal connective tissue up to the convex border by means of blunt-pointed scissors, and, lastly, it is detached from the levator tendon. As a rule, sutures are not required. The after-treatment is the same as for the combined excision. The operation just described is, I believe, comparatively seldom resorted to. The combined excision, however, is in constant requisi- tion in Konigsberg. Kuhnt alone has performed it more than 5,000 times. He sums up the results thus : 1. The course of the disease is shortened, the time required for a case being, on an average, six weeks, including after-treatment. He declares that expression cures only 10% of the cases, while excision cures 50 to 60%. 2. Secondary corneal disease is prevented, or, when present is more quickly cured. 3. The mechanical ptosis is corrected. 4. Recurrences are less frequent. The objections to the measure that have been urged are too much loss of conjunctiva, limitation of ocular movements, and serious cicatricial contraction. To obviate the first, Kuhnt operates only upon eyes with sul^cient conjunctiva. As to the second objection, he counsels the invariable conservation of the bulbar conjunctiva, even when it is infiltrated, and treating it by medical and mechanical methods. With respect to the third, it is declared that since only portions of the conjunctiva and tarsus are excised and all the deeper tissues are avoided, the resulting scars are superficial — hence harmless. It is rather singular that so few operations of cither simple or combined excision are made for trachoma in this country. We have large areas in the State of Illinois where trachoma is endemic and has been for fifty years or more. Vast numbers of the victims are treated both in Chicago and in St. Louis, yet one rarely hears of even simple excision; more rarely of combined. Two reasons occur to me for this: First, the character of the peoj^le. They are OPERATION FOR PANNUS 377 of a peculiar tyi)c^shiftless and ignorant beyond belief — and from some unexplained cause, the majority come for treatment in the very last stages of the disease. Second, as regards the minority who come in the early or middle stages, they are, for the most part, so circumstanced, either from being cared for in a charitable institu- tion, or from having nothing to call them home, that they are content to worry along with conservative measures. When it comes to a discussion of more radical steps the surgeon in charge, unlike our European confreres, in like situations, has precious little to say in the matter. The reason we do not make enucleation of the tarsus (isolated) oftener in these old cicatricial cases is, I fancy, because of the high state of efficiency to which the combination operations for trachomatous entropion and trichiasis have been brought in the United States. A New Method of Operating in Pannus. — Primrose,^ William, Glasgow. This writer describes a very simple operation which he has found satisfactory; it consists in causing an extravasation of blood into the subconjunctival tissue around the cornea, which by mechanical pressure and irritation sets up localized inflammation and thus causes obliteration of the vessels which vascularize the cornea. The point of a small sharp-pointed knife is passed through the conjunctiva 2 or 3 mm. from the cornea, made to puncture one of the large blood-vessels, and then withdrawn. The conjunctival wound should be as small as possible and oblique; in this way there is no external hemorrhage; the subconjunctival bleeding is arrested by pressure of the extravasated blood upon the vessel walls, and thus many of the smaller vessels are closed; this mechanical action is increased by the information of a coagulum, the fibrinous part of which shrinks. "Extravasated blood acts as an irritant, probably chemical as well as mechanical, so a non-infective inflammation is set up which re- sults in the absorption of the blood-clot. This process acts as a counterirritation to the inflammation of the corneal tissues and so tends to remove the seat of inflammation and the supply of blood from the diseased cornea to the clot, where the effects of the inflam- mation are comparatively trivial. By the time the blood-clot has disappeared the blood-vessels in the cornea affected by the operation have shriveled up and the cornea has regained much of its trans- parency. The whole pannus may be treated in this way at one iThe Lancet, April 21, 1906. 378 OPERATIONS UPON THE CONJUNCTIVA time or the operation may be repeated from time to time, only a part of the pannus being treated each time. The latter is always advisable when the pannus is marked, as the inflammatory reaction is sometimes very severe and accompanied by a good deal of pain. Ahhough the structures in the anterior part of the eyeball are all more or less affected by the intlammation, this is easily controlled and subsides in a few days with the application of suitable remedies." In the classification of surgical measures for trachoma given at the beginning of this chapter occur two other operative ones, viz. : (g) canthotomy and Qt) peritomy. The technic and the indications for them have been given elsewhere in this volume, and they are mentioned here only by way of completing the list. CHAPTER X. OPERATIOXS UPON THE GLOBE. FOREIGN BODIES IN THE CORNEA. About two-thirds of all the foreign bodies that enter the eye find lodgment in the cornea. Fortunately, most of them are tiny particles that strike with feeble momentum, such as bits of cinder, iron, emery, etc., and do not penetrate beyond Bowman's membrane, and, once located, their removal is simple. Whatever of difticulty attends the operation is, usually, that of fmding the offender and keeping it in view. A particle so minute as to be in\-isible to the unaided eye can be the source of great and prolonged irritation. Such a foreign body is particularly hard to see when its color offers no contrast to that of the iris or pupil and when it has but recently entered the cornea. After resting in the same place a few days a tiny zone of gray infiltration surrounds it, which serves better to reveal its position. If the characteristic symptoms are present and careful inspection in bright daylight and with the use of convex lenses and focal illumination fails to show the foreign body, recourse is had to artilicial light and the binocular loop. The patient is placed where a good artificial light is near on the side of the affected eye, almost any kind of light will do, but if it be an unground incandescent electric lamp, it were better to cover the bulb with a sheet of white tissue-paper. Again, oblique focal illumination by means of a 2- or 3-inch biconvex lens, of large diameter, while the operator wears, strapped to his head, a binocular loop. Search is made by directly concentrating the rays upon the epithelium, i.e., kcc{)ing the image of the lens as much out of the way as ])()ssible. If this fails, a broad image of the lens is thrown on to the cornea, and in the area of this reflection is sought a break that might indicatfl the mote. Specks of transparent substances, like glass or sanee will sometimes elude any form of seeking except the last. If the quest prove specially trying, a drop of 1% fluorescin solution ]nit on the cornea would aid by causing a tiny green stain at the site of the foreign body. Throughout all the scrutiny the patient is told to 379 380 OPERATIONS UPON THE GLOBE turn the eyes in various directions to favor the search. Having once found the foreign body, it is easily seen afterward. If the eye has not already been prepared, it is now. One should be as scrupulous as to cleanliness of everything concerned as if for an extraction of cataract. Warm boric acid solution is the best thing with which to bathe and douche the eye. Cocain, or its analogue, is all that is needed in the way of anesthesia. I have never yet had to resort to narcosis, yet one can imagine how this might become necessary. In cases of little children, they are put in the position described under "Applications and Dressings." If there be much hyperemia, a drop of adrenalin chlorid or similar solution is put in just before the anesthetic to blanch the conjunctiva. The best all-around form of instrument is the sharp, grooved spud or gouge (Plate II, No. 42), thoroughly disinfected. A dis- cission needle is also a good instrument, provided it is not too sharp. The foreign body being of the kind that requires artilicial light to show it, the lens to illuminate the spot is held by an assistant. If no one is by to help, the best substitute is one of the several forms of lens-holder. This is a head-band with jointed ball-and-socket bracket for carrying the lens, and is made fast to the patient's head. If this is not available, the patient, if one of average intel- ligence, can be made to focus the light, meanwhile supporting the hand that holds the lens against the cheek. Mode of Procedure (Fig. 241). — The patient, with a towel cover- ing the hair, is placed in an ordinary chair of suitable height, behind which stands the operator. No lid speculum is used, as this would necessitate fixation forceps also. The head is held firmly against the surgeon's breast by pressure of the base of the left palm on the forehead, while the eye is held open and the globe is steadied by pressure of the first and second fingers, the first upon the upper lid and the other upon the lower. The patient is made to look in the direction that gives the best view of the foreign body, which is lifted out in such a way as to produce least disturbance of the corneal epithelium. The practice of using very blunt instruments or of wiping the foreign body off the cornea with a mop made by wrap- ping cotton upon some small implement cannot be too strongly discouraged. If it be a particle of iron or steel, a reddish stain will be left behind; if a cinder or bit of emery that has entered the eye while very hot, its bed will be a whitish eschar, and, if some days have elapsed since the accident, it matters not what the nature of the rOKKIGN BODIES IN THE CORNEA 381 substance is, a layer of softened tissue will surround the forei.^m l)()dv. in e\erv case the little excavation should be scraped clean by a sort of rotary handling of the gouge. If this is not done, the condition of the eye may be worse than before. In the process of loosening the foreign body and cleaning out its bed it is best that, in a general way, the movements of the point of the instrument be Fig. 241. — The removal of a foreign body from the cornea hy the aid of focal illumination. directed toward the center of the operative held and from every part of the periphery. Thus one avoids leaving tags of epithelium and iiaps of Bowman's membrane around the place to harbor bacteria and increase the dangers of infection. After the operation, another copious douching of the cornea with warm boric acid solution and 382 OPERATIONS UPON THE GLOBE instruction that the eye be bathed a time or two in very hot water, and all is done that most cases require. A class of corneal injury common in the United States is that from exi)losions of gunpowder, and requires a management ({uite peculiar. The unburnt grains go rather deeply into the cornea, but rarely perforate it. To dig at them, particularly when the injury is recent, but results in further traumatism without attaining the main object. Even when one succeeds in removing a grain, it is broken, and a black stain remains behind. It is best to wait from 48 to 60 hours, meanwhile watching the eye and keeping it from infection by mild antiseptics, and under other appropriate treatment, when it will be found that the grains have become loosened. If the eye is then irrigated copiously with boric acid solution, cocainized, the patient put in the recumbent position and a few drops of H^O, instilled, the lids being held apart to allow the liquid to overlie the cornea, most of the impacted foreign material, be it powder or other debris, will come away. The peroxid attacks the softened envelope, and the gas that is generated forces the foreign body out. At the same time, the powder that is in the lids and face is treated by rubbing the skin vigorously with absorbent cotton wet with the peroxid. Larger foreign bodies have often to be dealt with difTerently. It may be that one has struck the cornea so obliquely and with such force as to have plowed its way for some distance beneath the sur- face. It were best here to slit up the track of the foreign body before attempting to dislodge it. Or, again, a particle may have stopped just short of dropping into the anterior chamber and yet not be ac- cessible by forceps, and so nearly through that it were unwise to use the gouge. In this case one might have recourse to the method of Des- marres, viz., that of passing a broad needle or Beer's knife through the base of the cornea into the anterior chamber immediately beneath the foreign body. Upon the ensuing evacuation of the aqueous, the blade of the instrument will tend to press the piece upward, and, at the same time, form a solid foundation upon which to work. If the foreign body be of steel or iron, however, and so imbedded that it cannot readily be got at witli other instruments, it can surely be removed by some form of magnet. Jf sufficiently loose, a horse-shoe magnet or the Gruening i^ockel-magnet. If more tightly fast, the Hirschberg electro-magnet or the giant electro-magnet of ilaab, or a modification of it. Traction should, of course, be from the same direction as that in which llie foreign body entered. More ABRASION OF THE CORNKA 383 explicit instructions for the use of ihe n-ia,u;nel are .i^iven in the chapter on "Foreij^n Bodies within ihe l\ve." Alropin and an occlusion banda,u;e, in addition to the mild anliseplic irri,n;ali()n , are the rule in the severe cases. ABRASION OF THE CORNEA. This consists in scraping, shaving, or excising from the cornea varying amounts of its substance for the removal of o])acities. It is a very old procedure, having been practised long before Galen's time. This surgeon employed it for certain forms of superficial corneal opacity. Malgaignc^ having concluded from experiments u])on animals that half the thickness of the cornea could be re- moved without leaving an opacity, proposed giving the opera- tion a much wider range of application. Notwithstanding, the fact remains that, owing to their depth and the replacing of the lost substance by opaque tissue again, very few of the many forms of opacity will yield to such treatment. This is not to say, how- ever, that the operation has not a wide sphere of usefulness. This is particularly true of the scraping method. Indications.— It is most frequently indicated in deep slow ulcers, such as those at or near the center that have been left from phlyctenular keratitis, the removal of foreign bodies, etc. These, being so removed from the vascular zone, often become filled with a mass of detritus and all efforts at repair cease. It has also been extensively used in the more active, infectious ulcers of the cornea, principally in the serpiginous. Mcyerhofer,- instituted a method for the treatment of such ulcers that has been extensively followed, viz., curetment of the ulcer and its infiltrated border with a small sharp spoon, filling the remaining cavity with iodoform ])o\vder and bandaging. The lost substance is thought by many to be replaced much more quickly and with less opacity after abrasion than after the cautery. In the days when collyria containing suba- cetatc of lead was such a universal remedy for "sore eyes," abra- sion was frequently and successfully called into requisition for the removal of the peculiar, opalescent metallic deposits they occasioned. One rarely sees them nowadays. Other indications are the thick- ened, opaque ei)ithelium resulting from ])annus, tlie so-called girdle- ^ Annal. d'oculist., 1843-45. 2 Kl. Mbl. F. A. S. 151, 1884. 384 OPERATIONS UPON THE GLOBE shaped opacity, the black film caused by powder explosions, and characteristic chalky deposit consequent upon certain chronic diseases of the eye, especially those of the uveal tract. This deposit, which has also been called " ribbon-shaped keratitis," is most distinctive in appearance, resembling nothing so much as the frothy, glistening white stuff one often sees overlaying portions of the cornea in elderly people, and that has been expressed from the Meibomian ducts. Leber has recently shown that it is calcific de- generation of Bowman's membrane. It yields readily to abrasion. The nebulous opacities, which result from superficial keratitis, have sometimes been removed in this way. Indeed, as it is a relatively harmless procedure when done under favorable conditions, it ought oftener to be tried where there is any likelihood of the opacity being shallow. The operation is simple and easy. Local anesthesia is best when practicable; when not, chlorid of ethyl or similar narcosis. The lids are parted by the blepharostat and the eye steadied with fixation forceps. The scraping instrument may be a small, very sharp spoon or small convex-edged scalpel that is exceptionally keen. In scraping it is best to work always from the periphery of the spot toward its center so as not to leave the edge of the sur- rounding layers loosened and lifted up. One has only to scrape until clear or sound cornea is reached, irrigate thoroughly, and bandage. A septic condition of the conjunctiva or of the lacrimal canal are contraindications. The shaving and excision processes are not so much to be recom- mended. In the first, the opacity is pared away by means of a knife or curved lancet. In the second, the edge of the area is out- lined with the point of a knife and the flap dissected out with tiny forceps and knife. The Surgical Removal of Corneal Scars.— Wiener, of Saint Louis, [Oph. Record, Sept., 191 1) read a paper, illustrated by lantern slides, before the Chicago Ophthalmological Society, May 15, 1911, in which he described a method he had employed on various animals and man. It consisted of making an incision perpendicuhir to the surface of the cornea along the line of the scar; then cutting from the middle of this line through the scar to be removed. The cornra is then picked uj) carefully with a sharp hook and dissected away until it can be more firmly grasped with a forceps, it Ix-ing urged to keep in the same shcalh in wliicli wr start. It is dilficult to gauge the first CORNEAL PAUTERY 385 incision so as to <^^o (k-cp fnou.u;!! and \c'l nol |)uiu turc ihc Dcscemct's membrane. Ikil this skill is ac(|uii\(t with practice. The after-care is just as one would treat any corneal wound; the less interference the better. Cleanliness is of paramount importance. The microscopical specimens showed that the epithelium covers the resected area in from five to se\en days. It e\-entually assumes its normal thickness and appearance. The cornea proper ])ecomes gradually clearer and thicker, although ne\er attainin.u; the normal thickness. Age seems to have little influence on the result, as in one patient on whom the author operated two years ago at the age of 69 years, the vision was improved from hand movements to ability to count fingers at ten feet, with improvement still continuing. The photographs presented showed the appearance of rabbits with white scars from cauterization, and pictures taken later after the scar had been resected. The point especially made prominent was that the operator must keep in the same layer of the cornea in which one starts by virtually peeling it away. The operation is not advised in active corneal infiltrations, but only in persistent corneal scars. It is a delicate and difficult procedure which only the skilled surgeon should attempt. In selected cases, visual and cosmetic results are obtained which no other methods within our present knowledge can supply. In the discussion it was suggested that the surgical procedure advocated by Dr. Wiener might change the thickness of the cornea to such a degree that a very annoying irregular astigmatism might possibly result. The members thought that the procedure could hardly commend itself at the present time to ophthalmic surgeons. The work done, however, by Dr. Wiener, they considered a valuable contribution to the subject, and hoped that from it would come results of permanent value. CORNEAL CAUTERY. Cauterization in some form or another for the treatment of aft'ections of the eye has so wide a range of em|)loymenl and, as a surgical measure, its application in most instances is so similar, that opportunity wull be here taken, once for all, to say a few words rel- ative to its use in "eneral as well as to that in connection with the 386 OPERATIONS UPON THE GLOBE cornea. For the rest, it will be treated of under the different headings wherever it finds a place. One distinguishes three kinds of cautery, viz., i. the chemic; 2. the thermic, and 3. the electric. The first includes those sub- stances which, brought in contact with the tissues, cause an eschar by various forms of chemical action, such as nitrate of silver, for example. Their modes of application are described in the chapter on that subject. The other two refer to those where heat alone is the agent which jjroduces the decomposition and are identical in their effect, the only difference being as to the manner in which the heat is generated. The second kind is usually spoken of as the actual cautery, and the third as the galvano-cautery. The thermic cautery has been an adjunct to surgery since the earliest days of medicine, and the instrument to receive and apply the heat has been made of a variety of materials. Its best modern representative is a platinum wire of suitable dimensions and shape of tip, supplied with a handle of wood or other non-conductor of heat. In an emergency one can easily improvise such a cautery from a bit of wire or other small metal implement. The best means of heating it are the flame of a spirit lamp or that of a Bunsen burner. "Cherry-red" is the term used to denote the degree of heat which is most serviceable. The Paquelin appliance is also a handy form of actual cautery. As concerns the electric cautery, since its introduction by Legroux^ it has largely supplanted the other two in the hands of the ophthalmic surgeon, partly because of the greater convenience. A small storage battery weighing 6 or 8 pounds will supply an ample current for many operations. Moreover, seeing that the home of the oculist is in the city, he can always have access to the street currents, which he converts to this use either by means of a transformer or of a ]jcrmanent l)altery and rheostat. Even the electrodes, handles and i)lalinum ti])s can be interchangeable between the portable and the stationary apparatus. The handle and wires should be as light as possible, and the button for making and breaking the current should be easily manipulated by the tip of the forefinger (Fig. 242). The form of the ])oints is a matter of individual preference. Per- ha])S the Ijcst ada|)te(l lo all-around work is the simple, almost closed loop of rcnind or slightly flattened wire, though the olive tip is excel- lent in many cases (Fig. 243). > Ann. (I'oculist. t. 8i, p. i8i, 1879. CORNEAL CAUTERY 387 The cleclro-caulcry has enjoyed a deserxed det^rec of ])0|)uhirily in the Irealmenl of corneal ulcers, but the necessary accessory eciuipment for its use is frequently not available when it is most needed and it is always open to the objection of a clumsy handle and difficult regulation of the current so as to produce the desired amount of heat. Tlie demand for a sim])le, effecti\-e, and ever-ready instrument lias ])roduced Wordsworth's cautery (Fig. 244), consisting of the regulation instrument handle and shank, on the end of which is a copper bulb about five millimeters in diameter. The end of the shank is bent at an obtuse angle so as to allow a "ood view of I-"iG. 242. — Klectric cauici Tile conductors go over operator's shoulder. the field of operation. One side of this copper bulb is drawn out into a blunt protuberance for use in the cauterization of compara- tively large surfaces, while at another point on the bulb is attached a delicate, short platinum rod for use on small surfaces. The bulb and point will remain sufficiently hot to cauterize for several min- utes after being heated to a cherry-red over a flame. To Make the Cautery.— The eye is prepared and anesthetized. The speculum is put in and the globe held by fixation forceps. Having seen to it that the apparatus is in working order, an assis- tant supports the electrodes while the surgeon applies the tip. Some prefer to lay the cold tip on and heat it m situ. Seeing, however, 388 OPERATIONS UPON THE GLOBE that the performance should be a mere touch, it would seem that greater precision can be attained by holding the wire close to the place to be burned, heating it to the right color, then deftly making the contact. If the tip is allowed to become white-hot (incandes- cent) its energy is too great, and besides, the light startles the pa- tient. The touch must be particularly quick as regards the cornea, lest steam be generated in the II i? ^ ""^Ni aqueous. It is much better to " 'i " ^ make several brief applications than attempt too much with one. Since the year 1873, when Martinache, of San Francisco, first called attention to its vir- tues in the treatment of ulcers of the cornea,''- the cautery has come to be a standard remedy for all such infectious diseases as ser- fascicular, annular, dendritic and rodent ulcers, ulcerated wounds, and the ulceration incident to purulent ophthalmia. In addition to the rules governing the general method of ocular cautery just given, there are a few points relating to corneal cautery in particular that it were well to mention. If, for instance, the ulcer is filled with curdled pus or other debris, it had better be cleaned out beforehand, as otherwise the operation would be cluttered. Then, if a drop of a 1% solution of fluorescin is put on at the cornea, it will materially help one to distinguish the diseased tissue from the 2 3 4 Fig. 243. — Cauterj- tips. pent. Fig. 244. — Wordsworth-Todd cautery. sound, for the resulting green tint will not only show the lateral dimensions of the ulcer and its zone of infiltration, but also their depth. Czermak recommends touching first the infiltrated portion, making a series of small burns close together, and, lastly, the center or ulcer itself, the last either by the small points or by a somewhat larger tip. Descemet's membrane should be spared whenever ])ossible. It is the great safeguard of Ihc anterior chamber. Not to wound it * Pacific Med. and Sur. Journal, Nov., 1S73, p. 294. INCISIONS OF THE CORNEA 389 when the ulcer is (Iccp rc(|iiircs great dclicac}- in iKindlinLi; the lip. To puncture it with the cautery also increases the risk of comjjlica- tions. If hypopyon, which ordinarily can be i<^nored, should be present, it would obstruct the perforation and ])re\ent healin,<,^ The eye is bandau;ed after the operation and the ])atient kept quiet. If necessary the cautery may be repeated. Another form of corneal ulcer in which cautery gives most gratifying results is the narrow, deep, round, central one, especially when this is complicated by a tiny hernia of Descemet's membrane. When these conditions are present there is, often apparently, no attempt at spontaneous healing. I liave seen such cases that remained unaltered for months. It might be that the subject was young — as they mostly are — in perfect health, and receiving every other appropriate form of treatment for the eye, even to the pressure bandage. If any change occurred, it was a slow one for the worse. This was probably from pressure of the protruding membrane on the tissue which surrounds it, for there is always a narrow ring of gray next the hernia that, I take it, indicates a mild form of pressure necrosis. One or, at most, two, applications of the galvano-cautery will effect a speedy cure. Of course, in this instance, Descemet's membrane is instantly perforated and the aqueous spurts, but, owing to the absence of infection, and to the small size, and position of the opening, no trouble with the iris ensues. Incisions of the Cornea; Paracentesis. Function. The number of indications for opening the anterior chamber that have, first and last, been supposed to exist, is infinite. In truth it has, perhaps, a broader field of alleged utility than any other opera- tion that is made upon the eye. The following arc some modern applications: I. In Acute Glaucoma, whether (a) Idiopathic or (h) secondary. a. Given, a case of acute glaucoma, with great pain, hyperemia, chemosis, etc., and it is not practicable to give a general anesthetic for iridectomy. It is well known that cocain has no effect in such cases, yet it would be possible to make a simple incision at the base of the cornea with far less additional suffering on the part of the patient than to go ahead with the iridectomy. Having relieved the tension, the iridectomy, if still necessary, could be made after a few days under cocain. Moreover, the chances of loss of vitreous and of choroidal hemorrhage would be lessened by the preliminary incision. b. In acute secondary glaucoma, such as that from the swollen 39° OPERATIONS UPON THE GLOBE lens after discission, and after accidental traumatism, paracentesis is imperative. Under these conditions the procedure is usually accompanied by the extraction of lens substance. I have had occasion to make the operation in fulminating glaucoma due to dislocation of the lens into the anterior chamber, not daring, for the moment, to attempt extraction. 2. In certain cases of blood in the anterior chamber. Ordinarily these are let alone, and the blood is promptly absorbed. If, on the contrary, it remains for 5 to 7 days without appreciably lessening in quantity, it would better be got rid of, as it may lead to the so- called spongy iritis or organized clot and other dangers. When present as the result of an injury, the blood could cause a foreign body within the eye to be overlooked. Haab mentions the pos- sibility of a hyphema occurring and obstructing the pupil in a case where one is interested in ophthalmoscopic observations, as, for instance, the de\-elo])ment of a neoplasm. 3. In Iritis and Iridocyclitis. — At the height of the inllam- matory process there often comes a time when, because of the hyper- emia, etc., the iris and the ciliary muscle cannot be made to respond to the mydriatics and cycloplegics employed, nor do soothing reme- dies serve to relieve the severe pain in and about the eye. As was pointed out by Abadie,i free punction of the cornea makes the eye more responsive to treatment and the patient more comfortable. Under these conditions the operation would need to be performed under narcosis. There is another class of cases of uveitis, mostly chronic, characterized by descemetitis, increased depth of anterior chamber, cloudiness of vitreous, recurrent intraoculariiemorrhages (or not), and, rarely, notable disproportion between the amblyopia and any apparent cause for it. These, too, are sometimes helped by ])aracentesis; and, as they are among the most tedious and trying of all our charges, and the operation is, to say the least, harmless, one is justified in trying it. 4. In ulceration of the cornea that threatens to ])crforate, wlielher there is hypoj)yon or not. Ai)r()i)os of tlie last, before the time when the jjrofession had learned to rely upon the efficacy of antiseptic treatment for these infectious conditions, it was the rule to make paracentesis in cases of h\-])()p\()n. Consecjucnlly, eye after eye was lost. This was true e\en in the earlier |)eriod of anlise])tic medicini', when the case was haxing this treatment in ' (iaz. (k'S lio])il;iu\, p. 2i(), 1S74. PARACENTESIS CORXE.^-: 391 addition. Al ])rescnt, eye after eye is saved by disre.«,'ardin,i< the hypopyon, using copious irrigation with mild antiseptics, atropin, and, above all, the roller bandage. Paracentesis in any form, according to the Saemiscli or otherwise, has largely given way to the non-operative treatment. 5. In Conical Cornea. — (See section on Kcratoconiis.) 6. In Embolism and Thrombosis of the Retinal Vessels.— Paracentesis of the cornea has been suggested as an adjunct to massage. One would hesitate before making the operation, how- ever, in cases of advanced arteriosclerosis. It would seem from the researches of Fuchs,i relative to the nature of panophthalmitis and the course of the infection therein, that paracentesis may fmd an extension of its sphere in helping to save from enucleation some of the eyes thus afflicted. Von Graefe,- proposed punction of the anterior chamber in glau- coma simplex, as a sort of guide as to whether or not an iridectomy would prove beneficial. One is often put in a quandary when dealing with this disease. For example, in spite of other means of treatment the sight is fast going and the fields rapidly dimin- ishing, yet one shrinks from an iridectomy, and posterior sclerotomy is out of the question. As a tentative measure, one may make para- centesis. If the symptoms improve for a time, one is encouraged to essay the excision of iris. The Operation.— Narcosis is required only for highly inllamed and sensitive eyes, especially when the patient is shattered from suft'ering, and for small children. Where there is much softening of the cornea or tremendously high tension, conditions that would make squeezing of the eye dangerous, the blepharostat would better be omitted and the lids held apart by an aid with retractor or fingers. The best form of keratome is a small iridectomy knife, except there be extreme shallowness or obliteration of the anterior chamber, when a narrow Graefe cataract knife is preferable. The incision should be sufficiently peripheral to lie within the vascular zone of the cornea, but its position with regard to the circumference will be determined by circumstances. When blood or pus is to be evacuated, the proper point is downward. In other cases, as in glaucoma from a swollen lens, when it is possible a portion of the iris will have to be incised upward, and so on. 1 Arch. f. Augenh., Iviii, 3, S. 391. * A. F. O., XV, 3, 211. 392 OPERATIONS UPON THE GLOBE The globe is steadied by ilxation forceps, the point of the keratome is made to enter the anterior chamber just as in the incision for iridectomy. When tlie bhide has been pushed far enough, the handle is tilted further backward to avoid wounding the lens during the escape of aqueous, and tlien turned slowly to one side so that the knife will pry open the cut and drain the anterior chamber. Just here is when the patient is apt to feel the greatest pain, sup- posedly from the contact of the sensitive iris with the cornea, and is liable to squeeze or move the head. It is for this reason and also to prevent prolapse of the iris, that the aqueous must not be allowed to gush out suddenly. The knife is slowly withdrawn, if need be extending the incision in its exit, as in iridectomy. If the Graefe knife is chosen, the incision is made by puncture and counter- puncture, as in extraction, though, of course, its extent is much less. The section is finished slowly. After this the spatula may be used to pry open the wound or, at least, to depress its posterior lip. If blood or pus is to be evacuated, it may be coagulated and refuse to come out wdth the aqueous. In this event an injection of i% warm salt solution by means of one of the syringes for lavage of the anterior chamber may be used to w^ash out the clot or curd. If the iris escapes in spite of proper care in making the incision, it can usually be replaced with the spatula. If not, the prolapse must be excised. The eye is bandaged in the regulation way. A distinctive method of paracentesis is the incision of SacmiscJi,'^ and one that has been extensively employed in the different infectious ulcers of the cornea. The original mode was to make the incision as nearly as possible in the center of the ulcer. Alfred Graefe and Meyhofer taught to make the cut as a tangent to the ulcer and thus slit the infiltrated border, and that in the direction of its greatest progress. Saemisch also came to make it somewhat similarly. Since part of the object of the incision was to drain and relax the infiltrated tissue, as in orbital phlegmon, this would seem ralicmal. A narrow Graefe knife is used; the blade is entered, edge forward, at one extremity of the affected area, and brought out at the other extremity, in its passage being made to open the anterior chamber; i.e., l)y puncture and counlcr-])uncture. The incision is reopened daily by a small probe or prol)c ])ointed lacrimal knife till the ulcer is no longer a menace. The constant leakage of aqueous is believed to prevent infection of the deeper parts of the eye. 1 Ulcus Serpens Cornea und seine Behandlung, Bonn, 1S70. MASSAGE OF THE GLOBE 393 Manifestly, the same precautions must be taken against squeezing out of the crystalline, etc., as in other forms of paracentesis. The operation is difficult with the Gracfe knife in certain meridians upon deeply set eyes, a difficulty that can be overcome by the use of a small sickle-shaped blade. Anterior synechia, leiicoma adherens, and glaucoma, the natural sequels of septic processes in the cornea, not to mention panoph- thalmitis, arc more frequent after paracentesis of any kind has been resorted to in the treatment of kerato-hypopyon. Paracentesis and Massage in Glaucoma.— In cases of chronic or intermittent or irritative glaucoma — in short, in any but the acute idiopathic variety— these are therapeutic measures that cannot be too strongly recommended. They are harmless and cause the patient little inconvenience, yet often effective in the highest degree. The paracentesis should be thorough and very slowly made. Within from 6 to 12 hours afterward the eye is washed outwardly with warm sublimate solution, the contents of the Meibomian canals are greatly expressed, the eye and the entire conjunctival sac are copiously irrigated with warm boric acid solu- tion, and a systematic course of massage is begun. This may be either direct, i.e., by a smooth instrument, such as a glass rod with rounded end, applied immediately to the globe; or indirect, i.e., by the fingers applied exterior to the lids, the mode accredited to Pagenstecher. I prefer the last. The massage may also be either plain or medicamentous. The use of myotics in conjunction with the massage is most always indicated. These can be in the form of solution or ointment — simple or combined. The ointment is usually preferable as it clings more tenaciously to the parts chiefly concerned, and, besides, facilitates the massage as a lubricant. Simple pilocarpin muriate or eserin or both together or, to what is probably better, these two combined with cocain. The latter is the pek so warmly commended by Wicherkiewicz, who, by the way, has been one of the foremost advocates of this kind of massage. The author has of late used vnth apparently good results a mixture of eserin, cocain and dionin. Modus Operandi of Massage.— The same rules here given are applicable to ocular massage in general. Hands and eyes are care- fully prepared. The patient sits facing the operator. The work is done with the thumb or with the first finger, which is clad in a delicate rubber cot. jSIassage of any particular part of the globe, 394 OPERATIONS UPON THE GLOBE except of the cornea, is made witli the ])atient lookin,^ in the opposite direction. Thus, for the u])i)er ec^uatorial region the eyes are rotated far downward, etc. By noting the position of the other eye one knows what part is being rubbed. The upper lid is utilized for the upper half, or rather quadrant, of the bulbus, and the lower for the rest. First, circular movements are made, say in the direction of the liands of a clock. Second, this is reversed. Third, move- ments in straight lines across, up and down, and diagonally. Fourth — and this is an important movement— by backward strokes, following the meridians of the globe. These are repeated, in regular sequence, over and over. The degree of pressure exerted may vary from very light to pretty firm, owing to the needs of the case, and in accordance with the judgment of the masseur. The intervals between sittings are from a few hours to an entire day, as the case demands. The duration of the massage is from two to four minutes for a single eye. By covering each thumb with a cot, both eyes can be done simultaneously. Anointing of the lids or the thumbs is inadvisable; though sterile vaselin or other ointment or i% salt or 4% boric acid or other solution should be put into the conjunctival sac. If ointment is employed, one application per sitting is sufficient ; if an aqueous solution, two or more instillations are made. Ocular massage, intelligently practised, is a most valuable adjunct in the treatment of most affections of the eye. It is peculiarly precious in diseases dependent upon degenerative changes in the circulatory apparatus, like glaucoma, the so-called albuminuric retinitis, arterial and venous thrombosis of the retina, intraocular hemor- rhage, and embolism.^ Paracentesis by Galvano-puncture of the Anterior Chamber. — Haberkamp- has sought a measure which would be practicable without preparation and which might be done in a consultation room or at the home of the i)atienl. While he claims no originality in the procedure he proposes, he has been unable to find it mentioned in the literature. The method is a paracentesis by galvano-puncture of the anterior cliamber the healing of tlie i)uncture being slow, a ])r()l()nged effect is had, greater than would be the case from an onh'nary paracentesis. Haberkamj) reports two cases treated by this method. 'JMie first case was cured; in the second the patient 1 Bicrruiii, of ("uiu'iiIki-ch, vrry stroiiKlN' rcconiiiu'iids iirossion massage, over'the center of tlii' rornoa only after paracentesis and iridectomy for chronic Kl:itic<)ma.—A'0/7/j. Provinc, March, 1909. 2 La Ciinique Ophtahiiologique, July 10, 1905. CONICAL CORNEA 395 was blind from fulminating i^laucoma, suffered agonizin,^ ])ain, and enucleation was at first deemed essential; galvano-puncturc stopped the pain and the necessity of removing the eye was done away with. This, in llie opinion of the present writer, would be a delicate undertaking at the hands of one not skilled in the use of the cautery; as overheating of the acjucous, with consequent injury to the iris and the crystalline, could easily be brought about. Conical Cornea; Keratoconus; Staphyloma Pellucidnm. — The first two terms describe the abnormality better than does the third, since it is the shape of the cornea that gives name to the defect without any special reference to its transparency, for in many instances considerable opacity exists. The apex of the cone is seldom at the center, being for the most ])art situated below the center. Keratoconus is of two kinds — primary or idiopathic and secondary. The first is peculiar to young subjects, beginning about the age of puberty, and gradually increasing till well into adult life. It is bilateral, and seen oftener in females than in males. The second is the result of disease of the cornea, with consequent stretch- ing and thinning. It is frequently monolateral. Either kind may lower the vision almost to zero, irrespective of any opacity, when surgical intervention becomes urgent. Many and ^•aried are the surgical measures that have, during the last century, been devised relative to this condition. The first were directed more to improvement of the vision than to the re- duction of the cone. Travers and Tyrrell, for instance, in the second decade of the i8th century, made optical iridectomy, and later Critchett and Bowman attempted to substitute the danger- ous operation of iridodesis. The first to institute a procedure for the actual cure of the deformity was Fario,i in 1839. He re- moved a wedge-shaped piece from the summit of the cone, dressed the eye, and allowed the wound to heal without suturing, and declared himself satisfied with the results. Sichel and von Graefe, near the middle of the 19th century, sliced off the tip of the cone, preserving Descemet's membrane, then, after a day or so, touched the spot with mitigated stick. The cautery was regularly applied until healing occurred. After this the tip of the cone was punctured, the aqueous drained, and attempts made to maintain the fistula by subsequent punctures, with the object of still further flattening the cornea. If necessary, an optical iridectomy completed the 1 Mem. delta Med. contemp., 1839. 396 OPERATIONS UPOX THE GLOBE surgical treatment. Bowman, in 1869, removed the whole thickness of the apex with a trephine of his own invention. He later modified the measure by leaving the posterior layer. Several days thereafter, the floor of the excavation was perforated, and regularly reopened for a period of two or three weeks. Such a procedure could not be applicable where the usual amount of thinning exists at the summit. De Wecker and Warlomont also had their trephines. Bader^ removed an oval flap from the apex, now stitching the open- ing with fine silk or silver wire, again leaving it to close of itself. All of these operative processes, while credited with a modicum of success, were, on the whole, both unsatisfactory and hazardous — ■ the last, mainly because of the great reaction, of infection, and of iris complications. No better results followed the method of excising a segment from the base of the cone, tried by Quadri, Roosbroeck, and others. Gayet,^ to avoid these dangers, practiced cautery of the apex, to perforation. Abadie,^ to obviate central opacity, moved the cautery from the apex to the more peripheral portions of the zone, respecting the posterior layer. Since the introduction of the thermic (or electric) cautery for this purpose, cauterization of the apex has largely taken the place of excision. The difference in the size of the resulting scar, after excision and cautery, is very slight, particularly if the cautery is, as it should be, limited to a small area. One beauty of the cautery is that it is its own antiseptic. Since Tweedy's^ report, the weight of opinion is largely in favor of cautery ivith as against that without perforation. Knapp^ indorses perforation. This surgeon has had made a special round tip for burning the cone. This he lays on cold and heats till it perforates. He gives a timely caution as to overheating of the aqueous, consec^uently of the lens and iris; even cites a case in which he supposes he produced a cataract in this way. This would seem to be another argument in favor of heating the tip before making the contact. Kalt iSoc. fran{. (Fopht., 1899, \). 423) at the suggestion of A. Terson, made median tarsorrhaphy, after the manner of Panas, keeping the lids closed for from six months to a year, and found it cffecti\c for the moderate degrees of conicity when early api)lie(l. 1 Lancet, 1S72. 2 Lyon mcdicale, xxx, 1S79. sThbse de Guiot, 1887. * Trans, of Oph. Scy. of the U. K., Jan. 28, 1892. ^ Norris and Oliver, " Diseases of the Eye," p. 82 5, 1 898. CONICAL CORNEA 397 Accordin,^ to recent reports, it would seem that conjunctiN-al keratoplasty, as an auxiliary to the cautery, is destined to pro\e of vast ser\ice in the surgical treatment of this alTection. As examj^les the methods of two well-known operators will he cited. The first is that of Gruncrt, of Bremen, who reports having treated eleven eyes of eight patients by it. He first uses an electrode with a flat tip. Beginning at the upper limbus, the cornea is cauterized for a length of 2 to 3 mm., the burn reaching into the parenchyma; then, with the finest tip, this line is extended into an ecjuilateral triangle, one apex being continued as a fine line to the center of the cone. Two days later the chief operation is done under narcosis. The slough is scraped oft', the cornea is split, along the middle of the burned line, from the center to the limbus. The central meridian of the cornea is then covered with a conjunctival bridge after Kuhnt's method (see page 406). Four weeks later the flap is transplanted back. Grunert mentions the following details: The pupil must be con- tracted ad minimum, by eserin, before the beginning of the chief operation. After careful removal of the slough the conjunctival bridge is formed, preferably from the external scleral conjunctiva. It should contain as little subconjunctival connective tissue as possi- ble. It should be laid experimentally over the perpendicular merid- ian of the cornea, the sutures put in and tied, to see if it lies tense, and covers at least a width of from 5 to 7 mm. The sutures are then loosened, the flap put aside, and the cornea slit. The point of a Graefe knife is passed i mm. below, through the center of the cone, the sharp edge up, as in slitting an abscess. The knife point is pushed to the angle of the anterior chamber, the handle elevated, and the exact middle of the burnt line is slit up to the scleral border. After the aqueous humor has flowed off the cone collapses, forming many small folds. The conjunctival flap is now laid over it and fixed with sutures. It lies loosely, with the anterior chamber opened, and becomes tense only when the chamber forms again. Later, as it contracts, its tension increases, and is exerted upon the cone. The patients are left in bed for six to eight days with a double bandage. At each change of dressings eserin or pilocarpin is instilled. When the sutures do not cut out spontaneously they are removed on the sixth day. The lower part of the flap retrogrades slowly to- ward the side, as it lies on intact corneal epithelium. Four weeks after the chief operation the conjunctival bridge is restored to its 39o OPERATIONS UPON THE GLOBE original bed, leaving the small portion that had become adherent to the denuded surface of the cornea. In some cases it had become atrophic, so that a transplanting appeared useless. It then was simply cut away. Four weeks later the part of the flap covering the burn, not becoming atrophic, is removed or trans- planted back, Golovine, of Moscow (Translation by Fox in Ophthalmology, April, 191 2, in a case of idiopathic keratoconus, cauterized the summit of the cone by means of a fine thermocautery over an area 3 mm. in diameter. Although the cauterization was as superficial as possible, it was seen that the apex was so thin that it was perforated and the anterior chamber emptied itself. Atropin, zeroform, and dressings applied. During the next ten days the anterior chamber reappeared and disappeared, the irritation of the eye increased from day to day, a pericorneal injection menaced the entire anterior segment of the eye, and at the site of the cauterization one saw the orifice of a fistulous passage. The patient suffered only when the anterior chamber had been reformed; on the contrary, when it emptied itself, felt himself relieved. Xeroform, dressing, eserin (in place of the atropin of earlier days). April 24. Second cauterization. (The first was April 12.) April 25. The eye is inflamed, there is no anterior chamber. April 28. Third cauterization; no change, excepting a slight edema of the lids. May 3. Conjunctival autoplasty of the wound by Reverdin's method, dressing, eserin. May 4. Again, no amelioration, the graft has fallen off, and there is no anterior chamber. May 5. Conjunctival transplantation according to the method of Kuhnt. (See chapter on "Keratoplasty.") A strip of the external segment of the bulbar conjunctiva deli- cately raised at the middle, is brought directly over the wound previously revived by means of a small curette. Maintained at its two extremities by its pedicles, the strip is fixed to the conjunctiva at the level of the limbus by a certain number of threads. May 6. The autojjlasty has a good a])})earance, but there is no anterior chamber. May 8. Reappearance of the anterior chamber. May 10. The anterior chamber is deepened. CONICAL CORNEA 399 May 12. Anterior chamber normal, the pupil distint lly xisihlc The stitches removed. May 14. Section of the supcricjr jx'diclc, and on May 20, of the inferior pedicle of the tlaj). Toward the end of the month of May the patient left the clinif, havin.L!; in the center of the cornea of the left eye a perfectly spherical conjunctival graft, 4'mm. wide and firmly fixed. As medicament: one drop of eserin daily. Five months later the patient was again examined. A central, round leucoma, 3 mm. in diameter, replacing the primitive graft and a ])erfectly spherical, normal cornea. The pupil reacted to light and there were no synechia. V=(with —4 spherical, 4 cyl.) 0.4. October 15. An optical iridectomy upward and inward. Oper- ative procedure normal. The patient was seen again in May, igii, that is to say, one year after the first operation. The cornea is spher- ical, normal, vision =0.7 without lenses. He later continued his studies (being a medical student) and was able to make delicate microscopic investigations. Elschnig,' of Prag, has for the past 15 years been an enthusiastic advocate of the galvano-cautery for keratoconus. He believes that one of the essentials of success is the prompt vascularization of the cauterized area, which increases the density and lessens the extent of the resulting cicatrix, and causes greater flattening of the scar. In order to hasten this vascularization he connects the deep eschar at the summit by a more superficial one, running in a broad strip to the nearest portion of the corneal limbus. Because of the eccentric position of the apex in most cases, neither the denser scar nor its bridge-like extension interfere with vision through the normal pupil. If it should so happen that the tip of the cone is central, tlie i)rofound burn is placed to one side so that the scar will not encroach too much upon the pupil. He considers subsequent iridectomy unneccessary or harmful, though he may afterward tattoo the opacity in such a way as to prevent diffusion. He uses the dull red heat. These measures, if not more potent for good than the older ones, have at least been less productive of harm. The author believes with Panas that, all things considered, the more conservative measures are the best, except for the extreme cases. These consist in the prolonged use of myotics and the 1 Wiener klinische Rundschau, 1904, 20. 400 OPERATIONS UPON THE GLOBE pressure bandage, as advocated by Weber, ^ and Mohr.- Continued pressure alone is probably the most efficacious of any single means. The writer had occasion a short time since to cause removal of the lenses in a case of high myopia and conicity of the cornea by a series of discissions. The treatment consisted in incising the capsule through puncture at the bass of the cornea — done with a Graefe knife, the use of atropin, and bandaging. The duration of treatment for each eye was about six months. There were three discissions in each, a good deal of reaction following the second and third. The ultimate flattening of the corneas was truly remarkable. The best ^•ision with glasses before the operations, etc., was 20/70, both eyes; the best after the year's treatment 20/30+ both. Here the annulment of the myopia, W'hich had been 26 and 24 diopters, would account for most of the added sight, but I attributed much of it to the reduction of the cones. Certainly, thorough trial of the less radical measures should precede any operation that involves special risk. These would be, prolonged wearing of compressive bandage (best netting, put on wet), the cotton of the pad being carefully built on, first tilling in the depressions in the lids around the globe, and the dressing renewed daily, when 2 drops of 2% solution of the nitrate or muriate of pilocarpin are instilled. This kept up as long as improvement continues. I teach the mother or other member of the family how to apply the bandage, and it is surprising how patiently, constantly and for how long a time -the patient will submit to the process. If no progress is made, repeated paracentesis of the cornea is subjoined, to which might, as an ulterior measure, be added the application of a small galvanic tip, in three or four short meridional hnes, near the base. If these measures failed of material improvement, I should still advise against more drastic surgical treatment save where the ectasia is very great and the vision very poor, so poor, indeed, as hardly to be called useful. True, much depends upon the condition of the fellow eye. If this ])e possessed of fair sight, one may venture further. Staphyloma of the Cornea. Anterior Staphyloma. — By this term is understood those forms of ectasia of the cornea which de- velop in consequence of disease, such as ophthalmia neonatorum, accidental wounds, as from the blades of knives and scissors, and » A. S. O., x.xii, No. 4, p. 215, 1876. 2 A. S. O., x.xiii, No. 2, p. iSo, 1877. CONICAL CORNEA 40I surgical operations, such as iridectomy and extraction. The staphyloma is known as total or ])artial, according as the whole cornea or only a portion of it is involved in the bulging. Blindness is a necessary accomplishment of the total form, not of the partial. The surgery of total staphyloma dates from ancient times. The Greeks and Romans as early as the Alexandrian period practised ligation for its removal. A needle and thread were run through the center of the base. The thread, which was left double, after being pulled well through, was cut near the needle. Of the two threads thus formed, one was used to ligate each half of the staphyloma, ^tius, early in the Christian era, improved upon this method by employing two needles put through the base at right angles one to the other. Thus, when the double threads were pulled through and cut, four ligatures were made, one for each quarter of the tumor. Am- brose Pare, in the i6th century, in case of a staphyloma that pro- truded beyond the lids, amputated it bodily. Beer, of Vienna, in 1805, gave a method that, under the name of abscission, became classic. By means of his triangular cataract knife he made puncture and counterpuncture in the horizontal meridian at the base of the elongated cornea, directing the edge of the blade forward and downward, cutting out within the base below, then, with the scis- sors, he made a similar incision upward, completing the abscission. Of course, the lens and part of the vitreous often escaped by the enormous opening. George Critchett,^ of London, to keep back the contents of the globe after the Beer abscission, first inserted threaded curved needles, convexity backward, from above downward through the ciliary body, about 3 mm. apart, left them projecting from the sclera at either end to serve as bars to the vitreous, etc., while the staphyloma was removed. The needles were then passed on through, leaving the sutures in their places, the last being tied to close the wound. Not liking the idea of passing needles and threads through the sclera, and especially through the ciliary region, Knapp,2 using fine curved needles, put them through the con- junctiva and superficially into the sclera, as show-n in Fig. 245. Beginning just external to the vertical meridian, a little back of the base of the cornea, one needle was put through the conjunctiva and quilted for a distance of 4 or 5 mm. horizontally outward, brought out, carried below the cornea, and i)assed in the same way, but from 1 Royal L. O. H. Reports, vol. iv, p. i, 1863. 2 Archiv. S. Oph., Bd. xiv, i, S. 273, 1868. 26 402 OPERATIONS UPON THE GLOBE without inward. The thread was not drawn down between the two points, Init left stancHn,^ in a long loop. A second suture was introduced in the same manner internally. The Beer abscission was then made, the two loops drawn down across the extremities of the wound, and the opposite ends of thread tied. Mrtually, the two threads play the role of four vertical sutures. De \Vecker,i modified Knapp's procedure. He first incised the conjunctiva all around the base of the incision, dissected it back somewhat, and put into it a purse-string suture; abscised the corneal ectasis after Beer, and tightened the thread drawing the conjunctiva tightly closed over the opening in the globe. De Wecker, about 1883, wisely con- cluded to make complete exen- teration of the globe before closing the wound. Kiichler,- of Darmstadt, sim- ply incised the staphyloma hori- 'zontally, straight through its center, after the manner of his Querschnitt for extraction, re- moved the lens, and allowed the wound to cicatrize. Such is a brief history of the !(,. 24,v— vnapp. development of the operation of abscission, for total staphyloma of the cornea, a measure that is now, happily, fast becoming obsolete. Ophthalmic surgeons are be- ginning to realize the folly of a procedure that only makes the operated eye a greater menace to its fellow. That is to say, the portion which is admitted to be the source of sympathetic inflam- mation, viz., the uvea, was not only left behind, but left in condition more potent for mischief; that the stump is unsightly without a prothesis, yet that the latter is sui)])orted even better after exentera- tion; that there are three objects for removing a total staphyloma — to correct a deformity, to prevent sympathetic inflammation, and to make a suitable stump over which to wear an artificial eye. The old method fulfllled only the minor indications. Of course, where both eyes are blind it does not matter. Wlien the eye is highly glaucomatous or that of a subject well along in years, ex])ulsive '.\nii. (!■ 2 Ilcidrll cvsroii) ( UAikix 403 choroidal hcmorrha,ti;c is apt lo follow ahlalion. (iradualiy, iherc- forc, the o])eralion, withoul cxcnlcralion. has lost favor, and the one unlh has found it. Xolwithstandin,^ the fad that a nunil)er of surgeons still resort to the first form, the writer believes that it has had its day, and deserves no better fate. Partial staphyloma, or cystoid scar of the cornea may be any thing from (a) a tiny bead no larger than a pin-head to a tumor the size of a pea, centrally located, and composed only of Descemct's membrane, translucent or whitish in color, and more or less thick- ened; or (/)) a globular mass of varying si/e, situated somewhat less centrally, composed ])artly of changed iris tissue, and dark in color in proportion to the amount of pigment or the thinness of the outer covering, and is in full communication with the anterior chamber. Again (c) it may occupy the extreme periphery, where it is made up . in great part of the iris, is of many sizes, and is connected with the aqueous chamber only by a fistulous tunnel. The last two are prone to progressiveness, often reaching enormous proportions — the latter especially; eventually dragging in the ciliary body and other parts of the globe. Hence, it is of the greatest importance that surgical measures be instituted at the earliest possible moment. (a) A touch of the heated cautery tip or a simple incision, with proper rest and bandaging afterward, is usually sufhcient for the smaller kind. A very few will be found of sufficient size to oblige the cutting out of an ellii)tical piece. This is done with cataract knife and iris scissors, in conjunction with a conjunctival covering. [b) Glaucoma is a frequent attendant of the second variety. If the tumor is of incipient size and quite recent, amounting to a simple hernia of the iris, one may be able to mobilize the iris with the spatula, then draw it out somewhat with iris forceps, and snip it off, or to cause its disappearance by one or two a])plications of the cautery. Tf the tumor is larger, particularly if the intraocular tension is high, an iridectomy will be required in connection with cautery or incision or abscission, whichever of the three, in the judgment of the operator, is called for. For these more trouble- some cases with shallow anterior chambers, a very narrow Graefe knife, one that has been reduced by many sharpenings, will be found invaluable for making the incision to get at the iris; a pair of minia- ture forcejjs scissors will sometimes enable one to excise a ])oriion where, by reason of its union with tlie cornea, it could not be drawn out bv forceps in the usual wav. How much benefit is de- 404 OPERATIONS UPON THE GLOBE rived from the iridectomy and how much from the paracentesis and bandaging, it were im])ossible to say. Xo hxed and precise rules can be given for the manner of procedure in these cases — the conditions are too variable. (c) If the cystoid scar has not reached proportions too consider- able, it is best to adopt decisive measures while it is yet time. The cyst-like tumor must be freely opened by an incision with a Graefe knife, all of the included iris removed that seems practicable, and what cannot be consistently taken away disconnected as thoroughly as possible from that within the eye. Having cleaned the floor of the cyst, the fistula is sought and touched with the cautery. Bandag- ing and rest in bed for four or five days complete the cure. If the ectasia has become so great and far-reaching as to make this form of treatment inexpedient, iridectomy, light cautery of the most prominent part of the tumor, the instillation of myotics, prolonged bandaging, offer perhaps the best alternatives. The cautery may be repeated as many times as it would seem to be necessary, and, if done so lightly as not to cause evacuation of the aqueous, it were well to add paracentesis for this purpose. The walls of the staphyloma are commonly of extreme thinness. The effect of cautery is not only to help the iridectomy, the paracentesis and the bandaging in bringing about flattening, but it tends to cause thickening and strengthening of the wall through the building up of connective tissue. The support afforded by snug bandaging, if continued for weeks or months, will of itself cause a deposit of connective tissue that could not occur if the eye were left free. Conjunctivo-kerato- plasty, as next described, is a valuable adjunct in many of these cases. KERATOPLASTY AND CORNEAL GRAFTING. The first relates to conjunctival keratoplasty. Conjunctivo-keratoplasty.— The use of the bulbar conjunc- tiva, by loosening and transposing it, as a means of preventing, protecting and healing corneal lesions, is probably the most salutary, and far reaching in its benefits, of all the more recent acquisitions to ophthalmic surgery. It was only in 1873 that the idea was first put into practice, and that by De Wecker. In ablation of anterior staphyloma he loosened the conjunctiva all around the cornea, back to the equator of the globe, put in a purse-string suture, and after the excision of the sta])hyloma, closed the opening by drawing the KERATOPLASTY 405 conjunctiva over it {Annal. d^oculisl., LXIX, p. 51, 1873). When he feared infection after extraction, he resorted to the same expedient. Three years later appeared reports of the very elaborate work of Scholer, of Berlin, along this line, which appeared both in the Jahresbericht and in Die Augenklinik zu Berlin, for the year 1876. He gave further observations a year later (Berliner kl. Woch., XLVI, W fc Fig. 246. Fig. 247. 1877). Scholer employed both conjunctival grafts and sliding and pedunculated liaps, and for such diverse lesions of the cornea as perforating and nonperforating ulcers, gaping wounds, with or with- out iris prolapse, fistulas, cystoid scars, and beginning staphyloma. Strange to say, no one else took the matter up until 1884, when Kuhnt, unapprised of Scholer' s work, conceived of similar measures. These Fig. 249. he soon elaborated upon, widening their scope, and refining their technic, to such a degree that his name has become identified with this branch of surgery. The methods as practised at present are by either sliding large sections of conjunctiva over more or less extensive segments of the cornea, or by pedunculated flaps. The graft is rarely used. The first is particularly serviceable when the part to be covered is at, or near, the periphery, as cystoid scars, perforating sclerocorneal injuries, crescentic, and annular ulcers and operative incisions (Fig. 246). 4o6 OPERATIONS UPON THE GLOBE The conjunctiva is incised for a short distance vertically to the cornea, on ehher side of the wound, if the latter is small and quite peripheral, then undermined with a curved iris spatula, severed at the limbus, drawn over the defect, and secured with a suture at each free corner. If a more extensive area is involved the cornea is simply circumcised, and the coniunctiva dissected loose with the scissors, to the requi- lu,. 2-^0. Fig. 251. site degree, drawn over, and fixed with two sutures (Fig. 247). In this manner, by completing the circumcision, the whole cornea may be covered, the conjunctiva being held by the two sutures (Fig. 249) or by the purse-string suture. Pedunculated Flaps. — These are of two kinds, those with a single pedicle, called tongue fiaps, and those with double pedicle, or Fig. 252. Fig. 253 bridge flaps. They are best suited to lesions whose location is more or less remote from the ])eri])hery, and the affected space is more circumscribed, although ihey ma\' be adapted to any region of the cornea. When feasible the tongue llap is best made with its attached ])()rtion abo\e. it is fashioned by first incising the conjunctiva. KKRAIOIM.ASIY 407 ])aralk'l with the liml)us, al a dislancc lluTcfrom, and to an extent, commensurate with the desired width and len,L;;th of the tlaj). I-'rom the extremity of this, and corres])onding to the free end of the llap, another incision to the liml)us. The jjortion within the an.u;Ie thus formed is dissected from the e])iscleral tissue, and the ton, Schmidt's Jahresb., x.xxv, 1839. " Ann. d'oculist, 1843. 'Trans. London Congress, 1873, pp. 189-194. s A. S. A., xxiii, 2, S. 79, 1887; xxiv, 2, S. 335; xxiv, i, S. 108, 1888. CORNEAL CRAFTING 41I for a much l()n,ti;cr lime. Knapn' relates having seen a patient pre- sented by von Hijjpel at the 1887 meetin,-,^ of the Heidelberg ()]jlithal- mologic Society, on whom he had made such a keratoplasty more than a year previously. "The i)iece was still tolerably transjjarent, and the patient had useful sight." The ultimate fate of the best results so far obtained has been loss of the restored sight through clouding of the graft. jl^It goes without saying that the operation is not to be thought of in anv case where vision can be restored bv any other known means, i^S^^ ''m[\^^l^^ Fig. 256. — Von Hippel's trephine. such as iridectomy. Seeing that the Descemet's membrane and even the deepest portion of the corneal tissue proper must be transparent, the cases to which the method is applicable are rare. The graft may be made in any available part of the cornea. If the iris should be in the way of vision it should be excised. The operation of partial keratoplasty after von Hippel is brietly as follows: Local anesthesia. First, one makes an estimate as to the thickness of the leucoma. This is done by lightly pressing upon it with a blunt stylet, and testing the degree of resistance. Usually the trepan would be set to cut the depth of about 0.75 mm. The diameter of the disk should not exceed 4.5 mm. The eye is steadied, and the trephine, wdiich works automatically by a spring, is made to cut to the indicated depth. The instrument is removed, and, with delicate forceps and knife, the upper layers of the outlined j^ortion carefully dissected out, leaving a flat, transparent bottom to the excavation. A young rabbit is chloroformed, the tre])liine is set for 1.5 to 2 mm. (for here the whole thickness is removed), the 1 Norris and Oliver's System, 1898, p. 832. 412 OPERATIONS UPON THE GLOBE graft is excised, and quickly transferred to its destined place. The eye is closed and bandaged. No sutures are used. Zirni modified this operation in 1905 by using a graft from a human cornea instead of from that of a rabbit. The trephine is used as in the von Hippel method. Eserin is instilled if the anterior chamber is present. Zirm gives, as essentials for the successful performance of the operation, deep anesthesia, strict asepsis, the avoidance of antiseptics, and the protection of the graft between two pieces of gauze, moistened with sterile physiologic salt solution, and keeping it warm in steam until it can be placed in position. The graft is held in position by two conjunctival sutures which pass over it in such a way as to form a St. Andrew's cross at the center. In the case reported the patient, a man 45 years old, had 5/50 vision; 5/20 with a convex lens, and J 13, seven months after the operation. Transplantation of Graft from Human Cornea previously preserved in Antiseptic Fluid.— A. Magitot, of Paris {Jour. A.M. A., July 6, 1912) contributes an interesting article upon this subject. Believing that the only human transplantation that has given encouraging results is homoplasty, i.e., from man to man, he undertook to obviate some of the difficulties of obtaining suitable tissue by preserving enucleated eyes. In this he was actuated by the work of Carrel, of the Rockefeller Institute, in connection with the blood-vessels. In consequence of much research and experiment, Magitot was enabled to keep viable the eyes of animals twelve to fourteen days after enucleation. The corneas of living animals into which grafts from the preserved eyes were inserted, were found transparent at the end of eighteen months. A slight irregular astigmatism was the only indication of the place at which the trans- plantation was made. Emboldened by the success of his experi- ments, he tried the method on the eye of a fourteen-year-old boy, with opacity of the cornea from burn of quicklime. The entire cornea, with the exception of a small area ujnvard and inward was opaque. As the result of an optic iridectomy at this place the lad had vision of 2/17. Into this cornea Magitot put a graft from a human eye, enucleated for absolute glaucoma, and that had been preserved, in a particular manner, for one week. The operation is thus described: The false pterygium was first all completely dissected off. Then a rectangle, about 4 mm. in height by 6 mm. in length, was exsccted from the opaque cornea. TATTOOAGE OF CORNEA 413 The cavity was made as deep as possible without perforating Descemet's membrane, and in such a fashion that the edges of the wound were true and perpendicular. Finally, a piece the same size was cut from the preserved cornea and applied to the prepared spot. The article thus concludes: "It is now nearly a year since the operation was performed. The graft persists and is still perfectly clear. Its transparency is much greater than that of the small area beneath which the iridectomy had been made. The graft has the appearance of a pane of glass, or of a small window, in an opaque wall. The irregular astigmatism, which inevitably follows any form of keratoplasty, has greatly diminished. The visual acuity, through the graft, has reached 1/7, that is to say, a degree that is more than sufficient for the patient to find his way about, and that permits him to read printed characters of a fairly large type." TATTOOAGE OF THE CORNEA. The staining of the cornea in cases of leucoma, partial or total, is of ancient origin. Galen practiced cauterizing the surface with a red-hot stylet and afterward rubbing into the raw area powdered nut-galls mixed with iron or a mixture of powered pomegranate bark and a salt of copper. The first to make use of tattooage proper, i.e., with a needle and India ink, which is the most approved substance, was Taylor, the noted English quack oculist, near the middle of the i8th century. At first the ink was put into a cannula, inside of which the needle was worked. It is, however, to De Wecker^ that we are mainly indebted for a distinctive method and largely also for the technic of the modern operation. The object of tattooage is either optic or cosmetic. The indica- tions for optic tattooing would be found in such cases as aniridia, albinism, coloboma of the iris, and in diffuse nebulosities of the cornea — the last in order to make the vision more net. In these conditions, of course, the area of the cornea corresponding to the pupil would be left clear, and the pigment made to occupy the per- ipheral zone. In this way the photophobia would be lessened and the visual acuity increased. The sphere of cosmetic tattooage is limited to the hiding, or rendering less conspicuous, of opacities of the cornea. Both kinds can be made to serve useful ends, for, even as to the second, it is an indisputable fact that little blemishes of face ' 'Union med., mars, 1870, and Chirurg. oculaire, p. 181. 41-4 OPERATIONS UPON THE GLOBE and figure constilulc a decided handica]) in the great bread-winning race as regards both male and female. The method of procedure is the same in both kinds of tattooage. The instruments are blepharostat, hxation forceps with broad jaws and no teeth, one instrument containing four needles in a compact bundle for work in a circumscribed area, one with four needles in a row for broader areas, and a tiny curved spatula for applying the ink to the surface to be tattooed (Plate II, Nos. 24 and 25). The needles must be quite sharp. The best grade of India or Chinese ink, in cake, is approj)riatc for all cases, excepting where hazels and browns are to be simulated; for these admixtures of sepia of vermilion and ultramarine are required. A piece is cut or broken from the cake and sterilized by baking for half an hour at a tem- perature of 150°. It is then taken in sterile forceps or crayon- holder, dipped in water or, what is probably better, a solution of gum-arabic, and rubbed in the bottom of a paint saucer, dipping occasionally for a fresh drop of the liquid, till a few drops of a thin black paste are obtained. If done rightly, this process is tedious. The finer the subdivision of the particles, the better. Of course, the ink must be used as soon as prepared. The colored pigments may be procured in fine powder, then washed, first in water, then in alcohol, then in ether; evaporated in a sand-bath and, lastly steril- ized as above, and mixed with aseptic gum-arabic solution. Technic of the Operation. Local Anesthesia.— After washing the conjunctixal sac with boric acid solution, the cornea is dried with the tip of a small cotton sponge from which the moisture has been well wrung. Some operators prefer to mark the pu])illary area with the edge of a sharp cylinder and to remove the epithelium within the circle before applying the pigment, but this is unnecessary. A drop of the ink the size of a pinhead is taken up with the s])atula and de])Osiled exactly on the spot to be tattooed. If the area is small, with the bunched needles one pricks the spot through the mass of ink. 'Hie needles are jabbed in both perpendicularly and obliquely, and until the color is sufficiently dense. The aim is to get the ink deep in the corneal substance without perforating. If rather free bleeding occurs, it may be stopped for a time by adrenalin solution — else the operation sliould l)e ])ost])oned. Indeed, a single sitting never suffices for an effective and lasting result; from three to five or even more being re(|uire= Fig. 259. — Elschnig's spatula, or diaiysis. Indications for Cyclodialysis : 1. In secondary glaucoma, especially with anterior synechia due to wounds, ulcers or cataract extraction. 2. In glaucoma where the other eye has been lost by severe hemorrhage following iridectomy. 3. In the aged or infirm where it is considered dangerous to keep the patient in bed as in iridectomy. 4. As a preliminary operation where iridectomy is dangerous on account of very high tension, no anterior chamber, atrophic iris and wide pupil, as it lowers the tension, and there is no danger of striking the lens during its performance. 5. When the lens has been dislocated and fallen into the vitreous chamber. Iridectomy, for the secondary glaucoma of such cases, is not feasible because of the certainty of losing vitreous. Contraindications. Seclusio pupillai, iris bombe, sarcoma of the choroid, or active iritis. Accidents and Complications. Immediate. 1. Failure to cut all of the scleral fibres. The spatula will then go only about i mm. forward. 2. Hemorrhage from cyclon or scleral vessels or ciliary vein. 3. Running of spatula into a good scleral spur. 4. Detachment of Descemet's membrane from the corneal stroma, indicated by corneal cloudiness. 426 OPERATIONS UPON THE GLOBE 5. Iridodialysis — which is infrequent. 6. Hemorrhage from Schlem's canal, as its inner wall is formed by the ligamentum pectinalum and the fibres of the ligament are broken and split up. Consecutive Accidents. — \\'hile the operation is of too recent origin to permit one to judge as to its remote effects, tumors, which are apparently implantation cysts, have been observed to occur at the seat of the operation as early as a few wrecks after its performance. Two such cases have been seen by the writer. Results of Cyclodialysis. — Lowering of tension — immediate if aqueous is permitted to escape, gradual if the aqueous is not allowed to escape, so that the maximum effect is not produced until from one to three days after the operation. These results may be permanent or of only a few days' duration. In some cases, especially in absolute glaucoma, there is no improvement at any time. It is not known in just what way these results are produced, whether by establishing an outflow through the peri- choroidal space or through the canal of Schlem. It seems probable, however, that the good results which occasionally follow this procedure are due to freeing the angle of the anterior chamber, and not to permanent choroidal detachment. Excision and Trepanation, or Trephination, of the Sclera. Sclerectomy. — Removal of a portion of the sclera was first under- taken for cystoid scars or staphyloma consequent upon penetrating wounds. Coccius,! transfixed the center of the tumor wdth a fine Graefe knife, cutting out parallel with the base, held the lips of the in- cision closed with a tenaculum, and completed the excision with for- ceps and scissors. More recently, in a similar case, Fage- incised the overlying conjunctiva, put three catgut sutures through the base of the ectasia, made the exsection, as did Coccius, and then tied the sutures. The loss of vitreous was slight, and the result satisfactory. The idea of first placing the sutures was taken from the Critchett operation for corneal staphyloma. Taylor, Argyll-Robertson and De Wcckcr, tried trephining the sclera in absolute glaucoma, but had few imitators. In this connection, however, it may be mentioned that Frohlich,^ of Berlin, reports that, in four out of five eyes with absolute glaucoma, and that were as hard as stone, he ' Heilanstult fur armc Augenkranke zu Leipzig, 1S70, S. 35-36. 2 Gaz. des hop. de Toulouse, 1894, iS aoQt. 3K1. Mbl. f. A., Mai, 1904. SCLERECTOMY 427 had succeeded, by trephination, in reducing the tension to normal or subnormal, ridding them entirely of inflammation, and in per- manently relieving llicm of ])ain. He proceeds thus: Cocain; incision of conjuncti\a along lower border of externus, and along outer border of inferioris, extending nearly to cornea, where they are joined. The flap is raised and turned back toward the equator. \'on Hijjpel's trephine, with 5 mm. crown, set for the thickness of sclera only, is used for the excision. On removal of the disk, if retina and choroid are not sufficiently ruptured by vitreous, they may be punctured. The conjunctival flap is put in place and sutured. The scleral wound takes care of itself. Of late years sclerectomy has been extensively employed in glaucoma (Chapter XII), and to some extent in detachment of the retina. Parinaud,i put a needle, tangent, into the outer portion of the sclera over the center of the detachment, and lifted up a cone. Through this, and parallel with its base, he passed a Graefe knife so as to excise an ovoid piece 4 or 5 mm. in diameter. The choroid should not be injured. The choroid could be punctured afterward, and, if need be, the puncture repeated after 7 or 8 days. A bold and extensive operation of sclerectomy for detachment outward is that resorted to by L. Miiller.- The patient was narcotized. Temporary resection of the outer wall of the orbit by Kronlein's method. Excision of the orbital periosteum, exposure of the external rectus, and the inferior obHque, and their severance from the globe. Excision of a strip of sclera 10 mm. ividc by 20 mm. long, extending from 2 mm. behind the attachment of the externus to the posterior pole. Five silk sutures inserted, and all without the sUghest injury to the choroid. The choroid was punctured and the threads tied. When the subretinal fluid ran out. The retina immediately became reattached, the held of vision became normal except for a small central scotoma, and the sight, which had been reduced to counting fingers in lower field, rose to lingers at 3 meters. Galvano-puncture has been tried by De Wecker and others, both for detachment of the retina and for circumscribed staphylomas of the sclera, but the results have not been encouraging. (See Chapter on "The Surgical Treatment of Detachment of the Retina.") 1 Bull, de la soc. franf., d'opht., 1S84, p. 77. - Wiener kl. Woch., Apr., 1903. 428 OPERATIONS UPON THE GLOBE SUTURING SCLERAL WOUNDS. Small wounds, and even pretty extensive ones that are meridional, may often be left without sutures, simply cleansed, extruding vitreous snipped off, and the conjunctiva stitched over them. But if the scleral wound inclines to gape, it should be sutured. If the scleral and the conjunctival wounds correspond, the same threads may include both; if they do not, it is best to close the scleral opening with absorbable sutures and the conjunctival with silk. Indeed, it is usually deemed best to see to it that the two openings do not corre- spond, even if apiece of the conjunctiva constituting one lip of the wound must be excised to avoid coincidence. The wound is not only freed from dirt and vitreous, but from shreds of choroid and retina, should these be present. Double-armed, interrupted sutures are preferable, so that the needle can be introduced from within on both sides. The thread should, if possible, be made to include only the outer layers of the sclera, and in no case should the uvea and retina be included either in the wound or in the sutures. The thread or gut should be very tine and the needles of exceptional sharpness. Fage/ gives the following reasons for suturing scleral wounds: 1. The prevention of deep infection. 2. Holding back the contents of the globe. 3. The avoidance of fistula, cystoid scar, and staphyloma. 4. The resulting scar is more regular, less contracted, and conduces less to detachment of the retina. 5. The healing process is shortened. Czermak- makes a rule of suturing all scleral wounds that exceed 5 mm. in length. Even the subconjunctival ruptures are sought out, trimmed up, and sutured. If the lens has escaped beneath the conjunctiva, of course it is let out. Francis' Method of Closing Scleral Wounds. — To obviate suturing the sclera in traumatisms that cause openings in this tunic, Francis, of Buffalo {Trans. Section on Oph., A. M.A., 1913) conceived the happy idea of a])])lying, to their closure, the principles of con- junctivo-plasty. 'Lhc method is suitable to scleral wounds of any shape or extent, and running in any direction, except those that are near, and parallel with, the cornea. Technic. — After thorough cleansing, all tags are trimmed down. 1 Ann. d'ocul., cxii, \i. 262, 1894. 2 AugenilrztliclK'n ( )i>c'rati()ncn, ]>. 690. CLOSING SCLERA WOUNDS 429 presenting ^•it^eous clipped and the wound edges made ready for coaptation. By means of a squint hook the conjunctiva, on all sides of the lips of the wound, is loosened from the sclera. Double armed, fine silk sutures are employed, one or two on either side, depending upon the size of the wound. The needles are j)assed through the conjunctiva, from the under surface, near the margin, at one side of the opening in that membrane. The needles are then carried for some distance beneath the conjunctiva at the other side of the open- ing, passed up through (Fig. 260), and the thread drawn up and firmly tied. The result is to draw a flap of sound conjunctiva snuglv Fig. 260. Figs. 260 and 261. Fig. 261. -Frances' method of closing scleral woiuids over the scleral wound. The surface of this flap is carefully abraded, as to the epithelium, by gently scraping with a convex scalpel. The conjunctiva at the other side of the opening is now pulled over in a flap, and stitched down in the opposite direction (Fig. 261). Thus the wound is covered by a second layer of conjunctiva, and corre- spondingly reinforced. In drawing over the flaps it is important that the thread be well drawn up, and firmly knotted, else one of the most important features of this operation will be lacking, namely, sufl&cient traction upon the globe in the region of the injury to bring, and to hold, the edges of the scleral wound into close apposition. If the scleral wound is of such a size, and so located, that the operator deems it wise to suture the sclera as well, this should be done before the surrounding conjunctiva is loosened. As these sutures are to be 430 OPERATIONS UPON THE GLOBE buried they must be absorbable. Here the surgeon has the choice of such materials as silk-worm or catgut, kangaroo, and rat-tail. The latter is well adapted to the work in hand, being strong and extremely pliable. The last quality minimizes the size of the stitch- canal. The sutures are lubricated with sterile olive oil, or paraffin- vaseline, to facilitate the sewing and to insure filling of the stitch-canal with an impermeable, aseptic substance. That the needles must be exceedingly fine, and as sharp as it is possible to make them, is a fore- gone conclusion. They are made to penetrate the sclera slantingly, and to emerge in the edge of the wound — not to go clean through. Francis has never used scleral sutures since adopting the super- posed conjunctival flap procedure. The following points are men- tioned in favor of the double thickness of conjunctiva as compared with the single: 1. The traction exerted by the two flaps holds the scleral wound lips in firm apposition. 2. The resulting scar is thicker, firmer, and more unyielding. 3. The two layers of sound con- junctiva protect the contents of the globe from outside infection. NiieP has contrived a most in- genious and effective arrangement of the thread for closing corneo- scleral ruptures, as well as for the wound left after the removal of a cystoid scar in that locality. The suture is double-armed. One needle is quilted into the sub-conjunctival tissue for a distance of 2 centimeters at, and parallel with, the equator, i.e., for a distance of i centimeter on either side of the meridian of the wound. The threads are then crossed over the center of the wound, and each needle carried beneath the conjunctiva, in the episclera, close to, and half-way around the cornea, where they arc brought out together and tied (Fig. 262). EXENTERATION OF THE SCLERA. (eviseratio bulbi.) Seeing tliat this operation consists in making an opening in the front wall of the globe and the removal of its entire contents, the 1 Ann. d'ocul., .\cix, 1S8S, p. 270. Fig 262. — Nuel's suture. EXENTERATION 431 author has taken the liberty of classing it amon<^ the oi^crations ujK)n the sclera. In this way it can better be kept distinct from the operation of simple incision of all the tunics of thejrloi)e; that has been commonly called evisceration. Indeed, it would be belter if the term evisceration were dropped from the mechcai (Hcti(;naries altogether, since it has precisely the same etymologic significance as exenteration, and is the preferable word in common parlance, wliere exenteration is rare. About a century ago, Wardrop, of Edinburgh, as a cure for the sympathetic ophthalmia of horses, advised incision of the cornea of the exciting eye, and the removal of the lens and vitreous, suggesting at the same time that a similar procedure might be applied to the human eye. The first to put the suggestion into effect was Barton, ^ who employed it for the removal of fragments of copper from the eye. As has already been stated on page 402, De Wecker, about 1883, added exenteration to his tobacco-pouch modification of Critchett's ablation. Frohlich,- in 1881, "removed the front section of the globe and scooped out the contents of the scleral capsule," with the hope of escaping the grave consequences that sometimes follow enucleation. Alfred Graefe^ adopted exenteration for most cases for which formerly enucleation had been practiced. He excepted those in which there was, or threatened soon to be, sympathetic ophthalmia. This surgeon was the tirst to plan for the operation a definite technic, the main points of which are as follows: The upper lid is held up by an assistant with a Desmarres retractor. Supposing it to be the right eye, the operator grasps the conjunctiva at the external corneal limbus with fixation forceps, while the as- sistant does the same only 5 mm. further back in the horizontal meridian. The intervening tissue is put upon the stretch, but without pressure upon the globe, and with a convex scalpel a small vertical incision is made, close up to the forward forceps, carefully carried in until the blackness of the ciliary body shows. Now, with delicate, blunt-pointed scissors, the incision is extended between the sclera and the cornea till the two meet at the corre- sponding point on the opposite side. Here Bunge's exenteration curet is inserted between sclera and uvea, convex side out, and the two tunics separated, cutting in succession the vorticose veins, the ciliary arteries and nerves, and finally the neck of the optic nerve- 1 Crampton Med. Gaz., London, 1837. 2 Klin. .Mbl. F. S., 1881, S. 30. 3 Tagb. der 57. Vers. Deutsch. Naturf. u. Aerzte, Magdeburg, 1SS4. 432 OPERATIONS UPON THE GLOBE head. Having seen that only the bare sclera remains, the cavity is washed and the opening closed by from 3 to 5 vertical sutures that include both conjunctiva and sclera. The reaction after this operation is usually considerable, the chief features being chemosis, particularly of the lower half of the conjunctiva, and swelling of the upper lid. The chemotic mem- brane often projects beyond the palpebral fissure, and is very slow to disappear. There is, moreover, needless sacrifice of the outer wall of the sclera. To obviate this, Gifford, of Omaha, quite properly, omitted excision of the cornea, making the exenteration through a simple horizontal incision, thus causing less reaction, and securing a more ample stump. The writer, who had previously made only the De Wecker opera- tion (described in chapter on Anterior Staphyloma), seeing the advantages of Gifford's method, adopted it. He had noticed, however, that the stump, after all methods where the long axis of the wound lay in the horizontal meridian, was always characterized by a deep cleft, lying in the same direction and reaching far back into the sclera on both sides — really a folding of the globe upon itself, causing it to resemble a grain of barley. This determined him to make the opening vertical, though still, like Gifford, without the excision of cornea, except in cases of anterior staphyloma, when just enough is removed to cause adequate flattening. A long, narrow, vertical, pointed ellipse is ample for even a pronounced staphyloma. In either case, the ends of the incision or the points of the ellipse are extended sufiEiciently far into the ciliary region to give ingress for instruments and small spindle-shaped cotton sponges. The operator grasps the center of the wound on one side with fixation forceps (without catch); an assistant does the same on the other, and in such a way that, by rotating the instru- ments, the cornea and sclera can be rolled back like the turning up of a sleeve (Fig. 263). A knife of special design, first described in the Ophthalmic Record, July, 1905, is used to dissect the choroid from the sclera (Plate II, No. 39). The blade, ivhich is not ovcrsharp, is double-edged, curved on the flat so as to lit into the scleral cavity, and has a rounded extremity. This serves to sever the roots of the iris, the ciliary body, the veins, arteries, and nerves, but for fear of perforating with the knife when it comes to the optic nerve the assistant takes both forceps, the surgeon holds choroid and retina witli broad-jawed forceps, and cuts the tissues at the limina cribrosa EXENTERATION 433 with small, curved, bIunt-i)ointC(l scissors, which c()mj)letes the exenteration. Co})ious irrigation of the cavity with hot sublimate solution, I-2000, is now used, for the double purpose of checking the hemorrhage, so that one may see that every vestige of the con- FiG. 263. — Beard method of exenteration. tents has been removed, and of antisepsis. Any relics of the uvea are scraped away with the knife or sharp curet. A small flattish curet with finely serrated edge is best. Having been assured that nothing is left behind, the opening is immediately closed by several 28 434 OPERATIONS UPON THE GLOBE horizontal silk sutures, allowing the oozing blood to iill the scleral capsule if it will. No attempt is made to stop the moderate oozing of blood, but rather it is encouraged, by mild curetment if necessary, so as to insure a clot of sut^cient size to fill the scleral capsule, with the view to its becoming organized, thus adding to the efficiency of the stump. The eye is bandaged in the usual way. For some reason there seems to be even less chemosis following the vertical incision than the horizontal, and the cleft, just alluded to, does not ensue. In case after case the parts involved have remained abso- lutely quiet. The sutures are removed after 3 or 4 days. Union is usually by first intention. If it is not, a small round hole may appear, which slowly closes. I have never seen any harm come of it. There is pretty free bleeding wdiile the separation of the choroid is going on, but it does not materially interfere. Of course, the lens and the vitreous escape as soon as the globe is well open. Exenteration is indicated in all instances where it has been the custom to make enucleation, save where exists sympathetic ophthal- mia, a neoplasm of the globe, or phthistis so advanced that only a tiny, shapeless button remains. I would not even except those in which sympathetic trouble is impending, nor would I those in which it is already present but for the popular prejudice of the profession. Yet more, I would, and do, add all the cases of total staphyloma of the cornea. For, as before stated, ablation of the staphyloma ful- fills none of the indications, or, if any, does it poorly, while exentera- tion meets them all and meets them well. For all but the cases mentioned as exceptions, it is not only a much better pro- cedure than enucleation, in view of the objects desired, but all the evidence points to its being a safer one. All those parts that have been deemed a menace to the fellow eye are as effectually gotten rid of as by enucleation. As to the growth of new nerve structures within the exenterated sclera, discovered by Forget,^ and mentioned as a possible source of discomfort, if not of danger, it would seem quite as easy for this to occur within the capsular envelope which remains after enucleation. As to the conditions for the wearing of a prothesis, they are vastly more favorable where the walls of the globe are left intact than where they have been taken away entirely. Made according to the principles just given, there being no inflam- matory reaction, not only is an extra large stump afliorded for filling out the orbit and giving to llie artificial shell something like • Arcli. d'opht., t. xii, 1892, p. 693. ARTIFICIAL VITREOl^S 4^5 suitable prominence, bul the muscles are all left willi their original attachments, and in their normal relations, so that its mo\ements are reas()nal)ly exlensi\e and natural. The Substitution of an Artificial Vitreous Body. In spite of the greatest care in, and of only a minimum of reaction after, the operation of exenteration, the shrinkage of the stump becomes, in time, considerable, and, in consequence, its motility becomes much restricted. With the \-ie\v to supplying a larger and more mo\able permanent stump, ■Nlules.^ of Glasgow, conceived the idea of placing in the exenterated sclera a hollow glass ball. Encouraged by the immediate results of the procedure, ophthalmic surgeons every- where followed Mules' example, and a few became enthusiastic over it. After a few years, however, even those who had in the begin- ning been most captivated grew less ardent. Too often the ball refused to remain im])risoncd. The measure was mostly abandoned. Some, who had been won by the really great plausibility of the method, began to cast about for spheres of dilTerent substances and of different construction. Kuhnt, for example, tried silver; Keal, gold; Bryant (of Omaha), fenestrated aluminum, etc. The material that seems, at the present time, to promise most in this connection, is paraffin. Living tissue will bear incori)oration with this substance more tolerantly than with any other thus far in- troduced. There are two ways of filling the sclera with iJaraflin: I. By closing the opening in the globe and overlying membranes by a common purse-string suture, or by suturing them separately; then injecting into the scleral cavity the melted jjaratYin. This is the method of Brockaert, also that very successfully followed by Ramsay, of Glasgow. 2. By fashioning the sphere of hard paraffin beforehand, and inserting it in the cavity after the same manner in which Mules employed the original ball of glass. This is the mode recommended by Oatman, of New York, and is probably the more desirable as to precision. Balls of paraffin having a high melting- point — 140 degrees and over — are prepared by fusing, filtering, and sterilizing, then rolling, while yet warm and plastic, with the protection of rubber gloves. In size, they should vary from a diameter of 12 mm. to that of 18 mm., according to the capacity of the sclera they are to occupy. They are kept ready for use in a glass jar filled with a 5% solution of formaldehyd. Before being placed within the sclera, the ball is rinsed withasolution of bichlorid, 'Trans. Ophthahnolog. Society, 1885, vol. v, p. 200. 436 OPERATIONS UPON THE GLOBE 1-2000. If the opening in the sclera is sufficiently large, the ball may be put in place with ordinary dressing forceps. Usually, however, it will be found more convenient to introduce it with the aid of the Mules inserter (Plate \'III, No. 89). All bleeding is previously stopped by means of hot bichlorid irrigation. The scleral opening is closed over the sphere in the vertical sense, i.e., by silk sutures, placed horizontally. If the conjunctiva has been first incised around the cornea, chromicized catgut is used to close the sclera in the manner just stated. The conjunctival opening is then drawn together in the horizontal sense — or, by interrupted silk sutures placed vertically. Purse-string or tobacco-pouch sutures are not admissible. The eye is dressed in the usual way and left for 48 hours before redressing. Not only is the most rigid asepsis necessary, but it is indispensable that the character of the coapted lips of the scleral opening is such as to insure primary union, else the ball will surely be extruded. Whereas, after exenteration with- out substitution of the artificial vitreous, it matters but little whether the adhesion be prompt or delayed. Amputation of the Anterior Segment of the Globe. — Guerin, Saint-Ives, and Heister, in the i8th century, advised, when practi- cable, to remove the front half of the eyeball, instead of making a complete excision of the globe in order to facilitate the wearing of a prothesis. The procedure was considered applicable to cases of malignant tumors confined to the section to be discarded and to total staphyloma of the cornea. The operation consisted in the ablation of the cornea, the iris, and the cihary zone, leaving intact the insertions of the straight muscles with their capsular coverings. The scleral incision should be started with a cataract knife, and finished with blunt-pointed scissors. The remainder of the uveal tract, with the retina, is then to be curetted out, and the cavity kept packed with antiseptic gauze until healing occurs. If the operation were done to-day, the scleral opening would doubtless be closed, at least ])artially, by suturing. Amputation of the Posterior Segment of the Globe. — Nicati.^ ])erforms this operation as follows: A horizontal (or vertical) in- cision is made into the conjunctiva on the inner side of the globe. The internus is seized, divided through its tendon, and guarded by a catgut suture, which is passed through the tendon and the con- junctiva. The capsule is separated above and below and the optic ' Archives d'oiilithalmolngie, June, 1003. IRIDOTOMY 437 nerve is sectioned in the ordinary manner. The posterior i)ole of the eyeball is caught by a tenaculum and drawn forward. The obliques are detached from it and it is drawn through the con- junctival opening, after which the posterior portion of the globe is exsected up to the insertions of the rectus muscles. The tendon of the adductor is secured to its stump, and the conjunctival opening is closed. An accumulation of blood behind forces the cornea forward, but this is removed by compression and absorption. Nicati claims that the convalescence is more rapid than after enucleation, and the results are an excellent stump with the conjunctiva and cornea entire. He asserts, also, that sympathetic ophthalmia is avoided, but th s must be open to question, seeing that there is no provision for the removal of the anterior portion of the uvea. Moreover, the operation is difficult, and involves dangers of deep infection not in- curred in those previously described. None of these operations possess that virtue, dear to the heart of the pathologist, of preserving a perfect specimen for the laboratory as does enucleation. OPERATIONS UPON THE IRIS. IRIDOTOMY — IRITOMY. This has for its object the making of an opening or pupil in an otherwise imperforate iris by means of a simple incision, and of the several operations made upon this membrane it is the oldest. The idea originated with Thomas Woolhouse,i of London, who pro- posed, in case of loss of sight from posterior synechia, to tear the iris asunder from behind, with a needle entered through the sclera as if for couching (scleronyxis) . Whether or not he made the opera- tion, is not known. It is known, however, that 17 years later, another English surgeon, and a pupil of Woolhouse, William Cheselden,2 put the idea of Woolhouse into practice for closure of the pupil in eyes where cataract had been depressed. Heuerman,^ of Copenhagen, changed the point of entrance to the cornea. Guerin,4 and Janin,'^ observ.ng that the needle of Cheselden tore, rather than cut, the iris, first made a corneal incision, then made the iridotomy with small curved scissors, one blade of which was 1 Exp^r. de differentes oper. aux yeux, Paris, 1711. 2 Philosoph. Transactions, 1728. 3 Abhandlungen v. d. Chir. Operationen, Kopenhagen, 1756. * Traits sur les mal. des yeux, Lyon, 176Q. * Mem. et observations sur I'oeil, Lyon, 1772. 438 OPERATIONS UPON THE GLOBE pointed and the other blunt. Guerin made a crucial incision in the iris, Janin, a bow-shaped. Maunior,i in cases of atresia of the pupil, with atrophy of the iris, thrust the pointed blade of the scissors behind the iris in two places, making a V-shaped incision, base peripheral. The inclosed piece was not excised, but merely al- lowed to retract. Bowman, ^ of London, who was, from first to last, an advocate of iridotomy, invented scissors whose points served as a keratome, whereby the operation could be accomplished with a single instrument. The operation of iridectomy having, in the meantime, become popularized, it for a time largely superseded that of iridotomy. The latter w^as again brought forward by von Graefe, in 1869, as an efficient measure for those forlorn cases of closure of the pupil, atrophy of the iris, and flattening of the an- terior segment of the globe from iridocystitis following a cataract extraction. \'on Graefe at first employed the method of Heuer- mann. The matter was taken up with a will by ophthalmic sur- geons, having been specially pushed by Bowman and De Wecker. The last-mentioned brought to bear all his wonted ingenuity, skill, and industry, refining and elaborating the procedure until he not only evolved for it a system of technic that has remained standard, but devised also kindred measures and the rules governing them for cases not adapted to iridotomy. Conspicuous among these were his irito-edomy and irito-dialysis. His labors in this line included the invention of several instruments, the most valuable of which is his forceps-scissors, wdiich embodies the principle of the Liebreich iris forceps, and which, in some form, is still the favorite instru- ment for all sections of the iris. The corneal incision he made with a stop-lance, similar to the paracentesis knife of Desmarres. The advantage of this instrument over the ordinary keratome is that there is no danger of penetrating too deep, or even, as could happen, to the extent of having the entire blade enter the anterior chamber. De Wecker's Methods of Iridotomy. — In cases of occlusion of the pupil, with presence of the crystalline, he made a corneal in- cision opi^osite that part of the iris zone where the pupillary border was least adherent. Through this he inserted, closed, the blades of a ])air oi his scissors, both points of which were blunted. When approaching the puj)il, the blades were slightly opened, one of them passed behind the iris, taking care not to wound the lens capsule, the 1 M6m. sur Toper, de la pupille artif., 181 2. 2 Med. Times and Gazette, 1852, p. 35. IRITO-ECTOMY 439 blades still wider opened and puslied further in. a cut made, the in- strument slitj;htly rotated and another cut made, thus loosening a pointed llap, apex inward, like that of Maunior (Figs. 264 and 265). For complete atresia of the iris in aphacic eyes either the point of the keratome, while engaged in the corneal incision, was made to pierce the iris at a suitable spot for inserting the scissors, or else the operator used a pair of scissors, one blade of which was sharp- pointed, and with this the membrane was transfixed. The cut could be single or double. De Wecker's irito-ectomy and irito-dialysis are applicable only to cases of closure of the pupil where the lens is absent. Irito- ectomy is a combination of iridotomy and iridectomy, or, in other words, intraocular iridectomy. In this operation the corneal incision and the primary incision of the iris are made simultaneously Fig. 264.^11 Fig. 265. — Result. and with the same knife. Where a relati\-ely small opening in the iris is desired, an iridectomy knife is entered at the limbus toward w^hich the iris is drawn, and a corneal incision made as if for iridec- tomy, except that the blade is directed backward at such an angle as to make a corresponding cut in the iris close to its periphery. The blunt-pointed forceps-scissors are then put in at one extremity of the wound, one blade passing behind the iris, and a snip is made toward the normal pupil center. The scissors are withdrawn, put in at the other extremity of the corneal wound, and a similar snip made, the two cuts meeting, wdiereby is completed the excision of a triangle of iris. If a larger iridectomy is wanted, a large, linear, corneal incision, which includes the iris, is made with a Graefe knife near the limbus opposite the point toward which the pupil is drawn, and the triangular piece cut, as just described. Here, how- ever, before making the final snip to complete the section, iris forceps 440 OPERATIONS UPON THE GLOBE is introduced at the other end of the corneal incision for the double purpose of holding the piece for the cut and removing it from the anterior chamber when severed. In order to facilitate the making of the iris incision when it is made one step with that of the corneal, as soon as the point of the knife is well within the eye it is tilted so as to pry open the cut and evacuate the anterior chamber, which causes the iris to advance close to the cornea. The advantage of such (scissors) operations is that they insure a minimum of traction on the root of the iris and upon the ciliary body, hence it suffers less traumatism and remains more quiet afterward. This is not true of those iridotomies made with needle or knife alone except in instances where the instrument can be made to cut. Usually, after the point of the knife or knife-needle has passed through the iris, all cutting ceases — it is merely tearing. The chief objections to the scissors, or knife and scissors methods, are the too free incisions in the globe, often lying wholly in the clear cornea, entailing undue loss of aqueous and vitreous, thus causing other dangers, and that they are, on the whole, complicated and difficult. Irito-dialysis. — DeWecker considered a measure of last resort in those troublesome cases where, in addition to closure of the pupil, there existed adhesions between cornea and iris, and especially in such of these as had not been benefited by other means. It consisted in making the primary combined incision with keratome or stop- knife near the center of the cornea, and facing that segment of the periphery where the iris was most nearly normal. The intro- duction of the blunt-pointed scissors, one blade behind the iris, and making two diverging cuts, one from each end of the first iris incision, and reaching to the outer border of the iris. The interven- ing segment of iris was then forcibly torn from its fastening and extracted by means of strong straight forceps. This procedure was naturally often productive of very unpleasant reaction. Modifications. — A few of the many modes of performing the foregoing o])crations will be here mentioned. Iridotomy. — Milles^ and Nacati,- instead of making the corneal incision at right angles to the course of the iris fibres, recommend making it parallel therewith in order the better to direct the cut 1 Royal Oph. Hosp. Rep., x, 3, 1882, p. 403. * Ann. d'opht., iii, 1883, p. 403. IRIDOTOMY 441 of the scissors across said fibres. SichcP and Schcrk^ reverted to the Heuermann-Graefc method, but each with a knife, or rather a knife-needle, of his own invention. Sichel's instrument was something like his discission needle, only the tiny blade, instead of being curved, was straight, and resembled in form the Zehendcr cataract knife. The Knapp knife-needle does not differ ma- terially from the iridotome of Sichel. Scherk's was compli- cated, having on the handle an attachment whereby the little lance-like blade could be given a sawing motion. Of all forms of simple iridotomy I prefer that of Gayet.' This is essentially the same as that given in the chapter on " Discission of Secondary Cataract" as the method of Pagenstecher. Gayet used an ordinary Graefe knife, punctured the anterior chamber at the base of the cornea, the flat of the blade parallel with the plane of the iris; the handle was then slightly raised, the iris pierced and incised, without enlarging the corneal wound, by making the blade describe a small arc. Now, it is next to impossible to make a clean cut of the iris or of a membranous cataract (and discission is but a phase of iridotomy) by mere pressure of the edge of the knife, no matter how keen it may be. The membrane will only be pushed along and torn. But a little sawing motion imparted to the blade, however slight, will cause it to cut. In sawing with a sharp knife, it is difficult to prevent harmful wounding or extension at the point where it engages the cornea. To avoid this, I have the edges of the Graefe knives, which are used both for discission and iridotomy, made dull and smooth, for the first two-thirds of the distance and sharp and wiry for the last, or end, third. The operation can be done in this way without any loss of aqueous, which cannot be said of the knife-needle method. This form of knife, particularly if the blade be somewhat smaller in every way than that of the regulation cataract knife, is one of the most manageable of instru- ments. The old and worn-down Graefe knives can be thus utilized. The corneal wound is insignificant and, being in the vascular zone, heals at once. If one is careful to make the iris incision at right angles to the direction of greatest strain of the fibres, and no inflamma- tion of the membrane follows, a permanent round or elliptical pupil will result. Should the iris tissue be such as not to retract, or should 1 Klin. Mbl. F. S., XV, 1877, S. 273. 2 Klin. Mbl. F. S., xxi, 1883, S. 315. 3 Prog, m^., No. 35, 1880. 442 OPERATIONS UPON THE GLOBE the new pupil close from iritis, there is still time to resort to irito-ectomy. Modifications of Irito-ectomy.— Tyrcll's blunt-hook method. The primary corneal incision is made with a lance-keratome, the blade of which is made to traverse the anterior chamber to a point just beyond the limits of the proposed pupil. Here it is passed through the iris, when, by a sort of rocking motion, the cut is enlarged. The knife is withdrawn, the blunt iris hook is inserted, flatwise, at the corneal wound, pushed across to the iris wound, given a quarter turn so as to catch the hither edge of the cut, the membrarie drawn a little way outside of the corneal incision, and a small piece cut off with scissors. This measure is less complex and difficult than the intraocular scissors methods, and done with less dragging upon the iris than is the operation of irito-dialysis. It is the same as the procedure described by Knapp^ as "irido-cystec- tomy." The writer was led to adopt it for many cases of membranous cataract and closure of the pupil after extraction by the splendid results he had seen obtained for the procedure at the hands of the late Cornelius R. Agnew, of New York. Fig. 266.- — Incisions. suit. To obviate traction upon the iris, Abadie- devised an ingenious mode for irito-ectomy, by which he obtained a quadrilateral pupil. Two parallel incisions of the cornea, 5 or 6 mm. apart, made with the lance-keratome, the first one smaller, the second larger and made to pierce and incise the iris to form one side of the opening. Introduction of tiny forceps-scissors at the larger, and extending the iris cut in this form (Fig. 266). Withdrawing the flap with iris forceps or hook at the smaller corneal incision, and cutting it off its base (Fig. 267). 1 Norris and Oliver's System, p. 792. 2 Ann. d'ocul., 1888, p. 261. CORKLYSIS 443 OPKR.VrJOXS FOR SYNECHIA. CoRELYSis. Anterior and Posterior Synechiotomy. These ojjcralions liave for their object: 1. The cure of the defect itself, i.e., the severance of the iris from its attachment. 2. The affording of rehef from the irritating effects of the synechia. The lirst constitutes true synechiotomy. In the second instance, the breaking up of the adhesions is apt to be but partial and incidental. As the synechia is said to be posterior or anterior, according as it concerns union of the iris with the crystalline lens or with the cornea, so is the synechiotomy posterior or anterior. Corelysis is the term that distinguishes posterior synechiotomy, Wenzel, of Paris and London, in the latter part of the i8th century, was the first to practise posterior corelysis. He broke the adhesions with a needle introduced by way of the anterior chamber, and the measure was resorted to only when the lens was cataractous. A little later, Beer did the same by means of a tiny sharp hook. The first to make the operation in cases where the lens retained its transparency was Streatfeild,^ of London, at whose hands the procedure attained a degree of popularity. He first made an incision with the keratome, then attacked the synechia with an instrument that he called a spatula, but that was, in reality, a tiny knife bearing at the extremity of the blade a blunt hook. Weber, ^ of Darmstadt, also devised a method and a synechitome, the latter being a knife-hook with blunted point. The operation is not with- out danger to the lens; besides, the adhesions often refused to yield, or yielded only to recur. Moreover, iridectomy, it has been demon- strated, is a better remedy for the irititis, etc., that sometimes result from pronounced synechia posterior. A few slight, isolated attach- ments arc usually harmless. For these reasons the operation has fallen into disuse. Anterior Synechiotomy, Anterior Synechia. — Here the involvement of the iris is not so much an adhesion to the cornea as it is an incarceration, the extent 1 Oph. Hosp. Rep., 1857-1860. 2 A. f. O., i86o-i86i. 444 OPERATIONS UPON THE GLOBE of which varies greatly — from a few fibres caught up by a linea- or punctate scar, to the inclusion of the greater portion of the memr brane in a leucoma {leucoma adherens). The surgical treatment applies more to the second category just mentioned, as, aside from a few special measures and instruments relative to the synechia itself, most of the operations are but phases of those already described in connection with the iris. When the synechia involves only the pupillary border, the freeing of the iris from the cornea is called sphincerolysis; when a more extensive area, iridolysis. Here follow a few of the methods of dealing with small synechias. Von Arlt,^ in cases of small, anterior synechia, advised passing a lance-keratome into the anterior chamber, advancing the point to the adhesion and trying to cut it by a rocking motion of the blade from side to side. Bowman first made a small incision through the cornea, then introduced a probe-pointed lacrimal knife to divide the synechia. Meyer^ essayed to sever the attachment with a small, blunt-pointed sickle, passed into the chamber through an incision, and advised cutting from the periphery toward the pupil. Of course, it was necessary that a space existed in the meridian of the synechia between cornea and iris. Lang^ used two knife-needles, one blunted at the point. With the sharp one he punctured the cornea obliquely near the site of the adhesion, then substituted the blunt one, with which, in the withdrawing, he freed the iris. Operation for Synechia Anterior. — Straub, Amsterdam (Tyd- schr. V. Gen., August 22, 1908) speaks in the Medical Society in Amsterdam, November 27, 1907, about the danger early or later of anter. synechia leading to higher tension. Perhaps that the process, which produced it, changed more in the angle of the anterior cham- ber, as we notice in the living eye; or the displacement of the iris changes the chamber lymph and a stronger lymph current than in the normal eye results. If it should be possible to free the iris from the cornea, this would be preferable over an iridectomy — mostly opposite to the synechia. Schulck's method promotes the origin of synechia anterior. This can be prevented by making the in-and-out- opening in the limbus. It can be used for a broad synechia, the so- called leucoma adherens, where the place and extent of the growing together cannot be judged well. A von Graefe knife is only fit to cut in a direction about horizontal. P'or a more vertical incision this 1 Operationslehre, S. 341. 2 Handb. der Augenb., Berlin, 1883, S. 108. ' Oph. Hosp. Rep., vol. xii, 1889, p. 356. SYNECIIIOTOMY 445 knife must be replaced by one with a shorter blade, which makes an angle of about 60° with the handle. Straul) had such knives made by Moria in Paris. One needs two knives, each being the other's re- flected image. He has also two similar knives with blunt point to cut away remnants. This principle is from Lang. Straub takes hold of the conjunctiva opposite to the place where he wants to make the wound; he thrusts Taylor's knife through the limbus opposite the middle of the synechia. The point of the knife is thrust near the cornea through the tissue, which connects iris and cornea, so that a button hole is made in the middle of the synechia. It is sometimes possible by turning the knife toward right and left to cut off the side parts of the synechia, but great care is necessary with a shallow anterior chamber. He therefore puts his blunt knives through the puncture opening, probes until the instrument passes into the button- hole, pushes it then more forward and cuts off the rest of the synechia, the right bridge with the knife curved toward the right, the left bridge with the left curved knife. Is the scar so oblique that its middle cannot be reached easily, then one has to incise opposite the end of the scar, which is the nearest to the corneal margin. Then usually only one knife is enough. Artificial illumination is necessary. Straub considers that these improvements have made the operation for anterior synechia so easy and safe, that now to a patient recovered with anterior synechia can be proposed the exci- sion of this contact, just as one recommends to a patient iridectomy after iritis, when he has recovered with an extensive posterior syn- echia. Sometimes a bridge is left, but as the iris remains in its plane this has no importance. As the anterior chamber fills quickly the wounds remain separated. Author's Methods. — Since it is desirable that the anterior chamber be not emptied during the manipulations of the knife, every precaution is taken to prevent the patient from squeezing the globe by contraction of the orbicularis. To this end the eye is thoroughly anesthetized by cocain, and the lids are held apart by retractors in the hands of a competent aid. If pressure upon the globe can be avoided the chamber may be kept intact, using the lance-knife, till the final withdrawal of the knife, and, using the Graefe model, it need not be emptied at all. Anterior synechias of considerable extent can be severed most satisfactorily with either of these instruments. The best form of lance-keratome is one much after the model of Agnew's that is, long and narrow of 446 OPERATIONS UPON THE GLOBE blade. The globe is fixed by being seized with the broad-jawed forceps near that part of the limbus directly opposite the point it is proposed to puncture with the lance. This puncture is started just back of the union of conjunctiva and cornea. The blade is pushed across the chamber until its point is well beyond, and with its edge in contact with, the synechia. Now, twisting the handle so as to firmly engage the adherent portion of the iris, the latter is divided in the withdrawal by a sort of slicing movement of the blade. The greatest objection to the lance is the inevitable emptying of the chamber which ensues at the finish of the operation. This may, and sometimes does, result in the reunion of the iris and cornea. Hence, more recently the lance has been replaced by the discissions knife described on page 585. By reason of the fact that, with this instru- ment, the evacuation of the aqueous can be forestalled, the freeing of the adhesion is more likely to be permanent. As with the lance, the puncture is begun well back of the apparent limbus, or in con- junctival tissue. The objects here are to insure rapid healing, there- fore, safety from infection, and to obtain a long wound-canal, which is a strong safeguard against escape of the aqueous. This minia- ture Graefe knife offers another advantage in that only the terminal 6 mm. of its blade have cutting qualities, thus permitting the opera- tor to impart a slight sawing motion to it without risk of enlarg- ing the wound of entrance and spilling aqueous. When the anterior synechia is complicated by traumatic, secondary cataract, as is frequently the case, it is unwise to attempt too much at a single sitting. Having dealt with the anterior synechia after the manner last described, rather than turn one's attention, for example, immediately to an opening up of the obstructed pupil, it were best to apply the bandage at once. Further twisting and revolving of the knife would almost certainly result in emptying the chamber and, probably, also in the breaking through into the vitreous. The matter of ridding the pupil of the secondary cataract, or that of dividing any irido-capsular adhesions, one can, with far greater prudence, leave for a subsequent intervention. For the more extensive adhesions between cornea and iris, a number of simple and combined measures have been employed— a few^ of them effective, many ingenious. Naturally, the phase of irido- corneal adhesion that has specially concerned the surgeon is that where exists blindness from incarceration of the entire sphincter. I have seen Dr. Agnew obtain the o])ject sought in sucli a case IRIDKCroMY 447 by inserting his angular lance as if for an ordinary optic irideclomv, then piercing the iris just short of where it entered the cicatrix, and pushing the point into the ])Osterior chamber, thus freeing the iris sufficiently to admit of a small iridectomy, which he at once j^roccedetj to make. Again, where the limited space between cornea and iris would not i^ermit tlie handling of the lance-knife, the same surgeon would accomplish the end thus : A very narrow Graefe knife is i)assed into the anterior chamber close down to the limbus, the iris is partly severed from the scar with the point of the knife, counter- puncture made, the section completed, the loosened segment of iris pulled out with forceps and cut off. For elaborations of this branch of ocular surgery the reader is referred to the second volume of Czermak-Elschnig's '^Augcn- arztlichen Operationen," p. 189, where are given descriptions of the very original methods of the Hungarian ophthalmic surgeon Schulek. IRIDECTOMY. This is a surgical measure whereby a portion of the iris is excised. The first iridectomies on record were probably those made by Daviel^ to facilitate the removal of cataract. It was Reichenbach,'- however, who first proposed partial excision of the iris as a separate and independent procedure; and for making the coloboma he de- signed a sort of punch or trephine. Janin about 1772, cut oil a prolapse of the iris that had occurred in an attempt to make an iridotomy, and remarked how little was the tendency of the resulting pupil to close, as compared with that produced by the older opera- tion of iridotomy. The elder deWenzeP made numerous iridec- tomies in conjunction with his cataract cases, either at the time of the extraction or afterward, to create an artificial pupil in atresia of the iritic membrane. These operations were mostly of the sub- corneal variety, i.e., the sections of the iris were made within the anterior chamber, in contradistinction to the pre-corneal kind, as usually practised, wherein the portion to be removed is withdrawn with a traction instrument before being severed. The great Viennese ophthalmic surgeon, George Joseph Beer, was the ])ioncer 1 De Wecker, "Reminiscences historiques, etc.," Arcli. d'opht., t. xiii, 18Q3. -Dissertation, Tubingen, 1767. 3 Traitc de la Cataract, Neuremherg, 1788, p. 188. 448 OPERATIONS UPON THE GLOBE of the latter mode, which he first conceived in 1806. Not only this, but he greatly enlarged the sphere of the measure by applying it to cases other than those wherein the lens was opaque or was absent, as in staphyloma and opacities of the cornea, for artificial pupil. He also gave a correct method of technic and fitting instruments for the making of the operation. His broad, triangular cataract knife was used for the corneal incision, which he made as close as possible to the sclera. If there was no posterior synechia, the sphincter was caught by a small sharp hook, pulled out, and the section made with small Daviel scissors. If adhesions w.th the anterior capsule or cornea existed, the withdrawal was by means of tiny toothed forceps. The operation underwent slight modifications at the hands of Beer's immediate disciples, as Walther, Langenbeck, Rosas, Chelius, Flarer, and the two Jaegers, Karl and Friederich; in England, at those of Gibson and Tyrrell, and, in France, at those of Sichel and Desmarres.^ The last mentioned added iridorrhexis, or tearing of the iris from its periphery, to increase the breadth of the coloboma. But it is to the most distinguished pupil of both Beer and Desmarres, viz., the immortal Albrecht von Graefe, that the world is indebted for the inestimable value of iridectomy as a curative agent, espe- cially in recurrent iritis and irido-cyclitis,^ and in glaucoma.^ Did the fame of this versatile and subtle genius in ophthalmology rest only upon this last-named discovery, it were enough, and more, for all time, and the beneficient results thereof were an all-sufficient monument. As may be inferred from perusal of the foregoing historic sketch, where the chief offices of iridectomy are touched upon, the forms and uses of the operation are varied. The principal kinds and their indications may be thus tabulated: KINDS OF IRIDECTOMY AND THEIR INDICATIONS. 1. Preparatory iridectomy, or that which is employed in con- junction with the extraction of cataract, 2. Optic iridectomy, or the making of an artificial pupil for visual purposes. 3. Therapeutic iridectomy, that which is undertaken for the cure or for the prevention of morbid processes in the eye. 1 Traits des maladies des yeux, 1855, T. ii, p. 542. 2 Arch. f. Ophth., ii, 1856, S. 202. 3 Arch. f. ()])litli.. iii, 2, S. 456, 1857. OPTIC IRIDECTOMY 449 1. Preparatory iridectomy is, as has been stated, the oldest form of the operation. It is, moreover, the purest form of iridec- tomy. It is made either immediately preceding the extraction, thus constituting the combined operation, or some weeks or months previously, when it is called preliminary iridectomy. Combined iridectomy was the original kind, having been that of Daviel and of ophthalmic surgeons in general, for more than loo years following the introduction of the operation of extraction. It was first in- tended merely as an aid to the delivery of the cataract, as in cases of rigidity of the pupil, luxation of the lens, etc. Later, the pro- cedure was resorted to in order to prevent iris entanglements (Schifferli, 1776), and, still later, with the view of warding off iritis and suppuration of the wound (Graefe, 1850). The late Prof. Mooren, of Berlin, in 1862, was the author of preliminary iridectomy, which he practised with the idea of lessening the dangers of sup- puration after operations for cataract. 'The chief objects of pre- paratory iridectomy, as practised to-day, are to facilitate extraction — particularity as regards removal of cortical remains and to forestall iris complications as sequela; of extraction. Some eye surgeons make preparatory iridectomy only as occasion demands, as in com- plicated cataract, the others never omit it. In this connection the operation is treated of under "Extraction of Cataract." 2. Optic iridectomy, also called iridesis and coremorpho- sis, as we have just seen, is next, in point of age, to the pre- paratory variety. It is indicated in atresia, iridis, or where the normal pupil is obscured by opacities of the cornea, as partial leucoma; or of the lens, as large pyramidal and zonular cataract; in occlusion of the pupil, in subluxation of the crystalline with great reduction of visual acuity — in short, w^henever it is possible by the excision of a portion of the iris to restore or to greatly improve the sight. The resulting coloboma should be small, to insure a clean image, and, when practicable, should not extend to the periphery, because of the imperfect refraction and senile changes that characterize this region. As to the position of the artificial pupil, when one has the option, it is customary to place it downward and inward. Really, provided it does not lie beneath the lid and is not too eccentric, the situation of the opening is, dioptrically considered, of little or no consequence. Indeed, as regards the lens, this is a matter to be decided solely by the site of the opacity, and, as concerns the cornea, by data obtained from careful 29 450 OPERATIONS UPON THE GLOBE Study of the available parts of that membrane. To this end, it is of the utmost importance that not only the degree of transparency of the different areas be ascertained, by means of strong focal illumination and magnifying glasses, but that one takes into con- sideration their curvature, as revealed by such implements as Placido's disks, the ophthalmometer and the ophthalmoscope. Especial care should be given the opthalmoscopic examination, since transmitted light and a strong plus lens will reveal corneal areas practically opaque on account of diffraction, which could not be seen by other methods of examination. That portion of the cornea which is freest from opacities and irregular astigmatism should be chosen as the sight of the coloboma. These investigations are to be made, whenever possible, with full mydriasis, before subjecting the patient to the operation. In zonular cataract and in subluxation of the lens, one must be fairly sure that increased vision will ensue, for the best made optic iridectomy is apt to prove disap- pointing in these defects. A piece of card-board or other dia- phragm, stenopaically perforate, used in such a way as to cause a narrow pencil of light to pass through the different parts of the dilated pupil will, occasionally, solve the problem in question. In many instances, however, the area of clear cornea is so limited that the location of the coloboma becomes, not a matter of choice, but of necessity. If one be obliged, by the exigencies present, to make the iridectomy in an unfavorable position, other artificial means may often be evoked for heightening the visual results. If, for example, it be extremely peripheral, cylindrical lenses can, in many cases, be fitted with benefit. If diffusion is caused by the light that passes through thin opacities in the immediate vicinity of the clear spot selected, the image can be sharpened by tattooage (see page 413). The same may be done to advantage in the event of too large a coloboma, by way of "stopping down," as it were. Now and then it happens that one is confronted with a patient whose only hope of obtaining a modicum of sight is through the making of an opening in the iris beneath a tiny area of cornea situated at the extreme i)eriphery. If the incision encroaches upon this area, the ensuing scar will cloud the new pupil. One has, then^, the choice between entering the angle of the iris through a long wound-canal by way of the adjacent sclera, or of making a com- bination of irido-dialysis and iridectomy, as resorted to by Panas. This surgeon would make the corneal incision on the side o]ij)Osite OPTIC IRIDECTOMY 45 T reach across the ]iui)il willi the lOrcc])s, seize the iris iK-nealh UK- spot of clear cornea, lear it from the peripliery, willulraw, and excise. Both methods are dilficult. A drawback to the artificial pu])il is its I'lxidity, nolwithstandinj^ the varying intensities of illumination. It was to obviate this that Adams, in 1812, and Himly, in i843, proposed displacing the natural pupil in the desired direction by drawing the iris into the corneal wound and there leaving it to be incarcerated — iridendeisis. It was to the same end that Oitchetl, in 1857, devised his operation of ligature of the iris — iridcsis, or iridodcsis. This consisted in making a small incision with a broad needle or lance-knife as near as possible to the base of the cornea, withdrawing with cannula- forceps the nearest portion of the sphincter, throwing a delicate silk ligature around the part brought out, leaving it thus for two days in order that the iris might become firmly adherent in the wound, then cutting off the extrusion or allowing it to slough. These measures proved excellent in so far as their optic effects were con- cerned, seeing that they gaveanarrow, movable pupil, but disastrous as regarded their physical consequences — among the last having been iridocyclitis, glaucoma, and sympathetic ophthalmia. Hence, their respective vogues were short-lived. As a safe substitute for them, in the year 187 1, Pope,^ brought forward his method of making an optic iridectomy without dividing the sphincter of the pupil. With a very narrow keratome he entered the extreme periphery of the anterior chamber by way of an almost scleral wound, allowed the aqueous to drain slowly to avoid a prolapse, seized with line, slightly curved forceps, the iris in the center of the exact spot to be excised, and withdraw, taking care that the pupil- lary border came not into the incision. Then, with small curved scissors, just as much was cut off as was held by the forceps. If a round coloboma was wanted, the scissors blades were held at right angle to the direction of the corneal wound; if an oval section was preferred, the blades were held parallel with the wound. The remaining portion of the pulled-out iris was gently replaced. Such an artificial pupil has certain advantages — among them being its small size, its slight disfigurement, and the little tendency it has to widen or to be drawn toward the root of the iris. Singular, that the procedure has so few advocates. One reason is, doubtless, the popular belief that double vision — polyopia — and a double 1 Arch. f. A. u. O., ii, i, S. 192-197. 452 OPERATIONS UPON THE GLOBE pupil — polycorla — go together. Such, however, is not hkely to be the case even when the normal pupil is unobstructed, much less so when it is obscured, as is precisely the condition for which an optic iridectomy is made. Another reason for the relative rarity of the measure is the difficulties that attend its proper execution. These, however, should not stand in the way. If, for instance, the sphincter should be inadvertently embraced in the section, the result amounts only to an ordinary iridectomy. If merely a thread-like bridge at the very border of the pupil be left behind, it amounts to the same, since it will most probably atrophy and disappear. The really substantial difficulty lies in the making of the ideal, perfectly peripheral, primary incision, which will be described under the "Technic of Iridectomy." I have several times of late, had recourse to this form of iridectomy when a highly eccentric pupil was demanded, and commend it most heartily. The common practice of introducing a blunt hook or other instru- ment to get rid of a pupillary bridge accidentally left in the operation of optic iridectomy— or any, save in preparatory iridectomy— is to be deprecated. Sphincterectomy. — The most eligible method of optic irid- ectomy, w^here existing conditions permit the more centrally placed coloboma, as in central leucoma of the cornea, is what is called sphincterectomy, and is that with which Critchett replaced his un- fortunate iridesis. Briefly described, the manner of performing it is as follows: Incision 3 or 4 mm. in extent with a narrow keratome, beginning in the opaque zone at the sclero-corneal junc- tion. If deftly made, the knife may be quickly withdrawn without loss of the aqueous and without causing the iris to follow the blade into the wound. These two things are desirable for two reasons, viz., a certain depth of the anterior chamber favors the manipulation of the iris forceps, and having the iris spread out in its normal relations is conductive to the accurate dosage of the excision. With fine, moderately curved, back-toothed forceps (or median-toothed), the iris is seized near the pupil, drawn out sufficiently to expose the pupillary border, and a small triangle of the uveal lining, and, with a single snip of the curved iris scissors, or the De Wecker forceps scissors, the blades crosswise to the primary incision, a small piece, comprising a little more than the sphincter itself, is excised. The unsevered portion is gently replaced THERAPEUTIC IRIDECTOMY 453 with the spatula, the eye washed with ;i mild anlisei)tic sokition, and the dressings apphed. 3. Therapeutic Iridectomy.— This variety of irideclomy is cither prophylactic or curative or both. In the iirst capacity its chief indication is in a. Recurrent Iritis or Irido-cyclitis.— In the second caj^acity therapeutic iridectomy llnds its main oflicc in b. Glaucoma. — It is both remedy and prevenli\e in certain instances of c. Foreign bodies in, tumors, parasites, and prolapse of, the iris, a. Iridectomy has proven of great value in cases of partial posterior synechia, characterized by relapses of iritis, provided the operation is made in an interval when the eye is absolutely quiet. This is especially true of cases where exists exclusion of the pupil more or less complete. For these, the excised portion of iris need be only of small dimensions, and no necessarily peripheral, except there be a tendency to glaucoma. In complete exclusion of the pupil, unless there be occlusion besides, the coloboma is made to reestablish communication between the anterior and posterior chambers, and is best made upward, so as to lie beneath the upper lid; if the exclusion is incomplete, however, the position of the coloboma will be determined by that of the free section of the pupillary border. This is ascertained by noting the effect of a mydriatic upon the contour of the pupil. Associated with these conditions the iris is apt to present the symptomatic appearance known as "crater-shape," and iris bombe, due to a bulging forward of the free middle zone by pressure of the aqueous in the posterior chamber. It must not be supposed that this peculiar configuration of the surface of the iris always indicates that the middle zone is not adherent to the lens capsule. The apparent bellying forward may be but the swelling caused by the infiltration or the thickening to which this region of the iris is more prone, and there may be total posterior synechia. Under such conditions, iridectomy under- taken for either therapeutic or optic purposes, is almost sure to be a disappointment; for, aside from the difficulty of making an ade- quate incision, it is usually impossible to excise any but the stroma of the iris, leaving the uvea still adherent to the capsule. True, most gratifying results can, exceptionally, be obtained even where the plight is most unpromising, as note the case of Mrs. K., cited under "Specially Complicated Extractions." In these extreme 454 OPERATIONS UPON THE GLOBE cases, however, where there is total posterior synechia, especially where exists, in addition, occlusion of the pupil, obliteration of the anterior chamber, and, above all, glaucomatous tension, iridec- tomy and extraction combined, after the manner of deWenzel (see page 562), is oftenest the more fitting measure. If, on the other hand, the intraocular tension is markedly low, its association with the other features just enumerated constitutes a positive contraindication as regards iridectomy and extraction. Neither could a few isolated points of adhesion between iris and lens be construed as a cause for iridectomy unless, perchance, all other forms of treatment have failed to stop the repeated attacks of iritis. b. Iridectomy for Glaucoma. — It is herein that the operation performs its highest function. This is particularly true of it in con- nection with acute idiopathic glaucoma, in which relation it has been termed antiphlogistic iridectomy. Whatever the variety or the grade of the glaucoma— whether acute (fulminant), subacute (intermittent), chronic (simple), secondary (symptomatic), absolute (degenerative), or congenital (hydrophthalmus), the same surgical principles are applicable, though the technic and the instruments by which the several steps are accomplished vary with the demands of the case and are treated of in detail later. Iridectomy, as regards its indications in glaucoma, has many limitations. In simple or chronic glaucoma it is admissible only when there is unmistakable overtension, either constant or inter- mittent or as a last resort. In absolute glaucoma it may, perhaps, be tried when there is also glaucoma of the other eye. In mono- lateral absolute glaucoma, except the progress of the affection is sufficiently well known to exclude the possibility of an intraocular tumor, such as melanosarcoma, the eye must be enucleated at once. In acute hemorrhagic glaucoma it is allowable. In acute idiopathic and acute secondary glaucoma following operations and injuries, the indications are positive, imperative, and immediate. The steps themselves are notably specialized, and are, in most respects, the direct antithesis of those in oi)tic iridectomy, that is to say, the in- cision must be as nearly scleral as practicable; its extent must exceed that which is rc(|uire(l merely for getting at the iris, being usually equal to about onc-fiflh thai of ihe corneal limbus; the coloboma must be broad and reach 10 the very root of the iris; the location of the coloboma is a fixed one, i.e., in the ui)per segment of the iris. THE I'll'II, I\ IRIDKCTOMY 455 c. Therapeutic irideclomy of the third class is, as stated, both prophylactic and curative; moreover, in order to fulfill the first three indications mentioned under this heading, viz., foreign bodies, tumors, and parasites in the iris, the methods to be employed par- take of those appropriate to both o])tic iridectomy and that for glaucoma. To remove a clean foreign body which has but recently become entangled in the iris, for example, the length of the primary incision shall not be greater than is ample for proper manipulation of the forceps, nor placed back of the limbus, except when the situation demands it, nor the piece of iris excised be much larger or more peripheral than is sufficient to include the offending sub- stance. Given, a sarcoma of the iris, however, while the same holds good as regards the incision, the segment excised must not only be larger, all around, than the apparent size of the tumor, but must, in every instance, extend to the outer limits of the anterior chamber, no matter how diminutive nor how centrally placed the neoplasm. The same might be said concerning foreign bodies of a poisonous nature, such as copper, or those around which a])pear fungoid growths or pus. The primary incision will, on occasion, need to be extensive and sclerally placed. The fourth indication in this series — prolapse of the iris — necessi- tates iridectomy when the protruding membrane cannot be re- placed in its normal position, be it the result of disease, of trauma, or of an operation. The modes of dealing with this condition are elsewhere described. GENERAL CONSIDERATIONS RELATIVE TO THE DIFFERENT KINDS OF IRIDECTOMY. ^Models and management of the iridectomy instruments are treated of in special chapters as is also preparation of the eye. Mydriatics and Myotics. — As a rule, neither a mydriatic nor a myotic is greatly wanted in fitting the eye for an iridectomy, though there are exceptions. Some surgeons advise against mydriasis in every instance. It is certainly not admissible in cases characterized by increased intraocular tension and pre-existing mydriasis. Yet a dilated pupil is desirable in certain optic iridectomies; for example, where the border of the normal pupil is hidden by 0])acity of the cornea, for to have the sphincter in view aids precision and lessens risk as to the lens and in the handling of the iris forceps. It also 456 OPERATIONS UPON THE GLOBE has its advantages when the pupil is narrow, particularly if rigidity of the sphincter is suspected, to promote relaxation, if for nothing else. The less traction required to withdraw the iris, the less pain and movement on the patient's part. Any untoward dilation will always disappear with evacuation of the aqueous. To have an extremely wide-open pupil while making the corneal incision would be objectionable, for the following reasons: the bunched up iris would be more apt to get in the way of the point of the keratome, would be predisposed to follow the knife into the wound, and more difficult to properly seize with the forceps. Fortunately, this does not occur except there be glaucoma. Whenever, therefore, it is possible in this disease, to reduce a considerable or an ad maximum dilation by the use of a myotic, the same should be done. Thus the iris becomes better spread out and more accessible. Anesthesia. — Narcosis is indispensable with children, irre- sponsible and timorous adults, and with all eyes that are hyperemic and iniiamed. There is no operation in the whole domain of surgery more exacting upon the care and skill of the operator than is that of iridectomy, and all the circumstances attendant upon the measure should be as favorable as can be made. To have one's patient asleep not only renders him (or her) incapable of doing harm, but gives greater confidence to the operator. Modern methods of general anesthesia and the substances employed, such as chlorid of ethyl and nitrous oxid in conjunction with ether, have eliminated danger to such a degree as to make them applicable to most any subject. Hence, if one has any misgivings as to the patient's be- havior, or as to the difficulties of the operation, he would better in- voke their aid. The anesthesia of chlorid of ethyl alone is sufficient for the simpler and more quickly executed iridectomies. It is im- portant that the narcosis be maintained until after the toilet of the wound is fmished, for much depends upon the thoroughness of this feature. Local anesthesia, too, has its advantages, for by its use the patient is not subjected to the added risks and inconveniences, as from vomiting, etc., consequent upon narcosis, and it is a satisfaction to operate upon an eye that is thoroughly under the control of its possessor. Aside, however, from their other drawbacks in this con- nection, just alluded to, they have others. For instance, as to cocain, if one waits to begin the operation till the iris is anesthetized, there is likely to be mydriasis, injury to the corneal epithelium, and TECHNIC OF IRIUECTOMY 457 secondary dilatation of the blood-vessels, ergo, hemorrhage. These hindrances might be done away with by the choice of some other local anesthetic than cocain, yet still would there remain a large proportion of cases suitable only for narcosis. Adrenalin, or its like, I have found to cause unpleasant after-effects, and by their secondary action they are also conductive of bleeding. Technic of Iridectomy. — The operation must be described in general terms, leaving specific methods and modifications to be dealt Fig. 26S. — Iridectomy (optical here) through the inner haLf of the cornea. Surgeon stands on opposite side. with later. The patient lies on a table. For all upward iridectomies the operator is usually stationed at the head, though a few prefer, for these, to stand at the side nearer the eye, which, of course, necessitates an inverse handling of the instruments, i.e., pulling the keratome in- stead of shoving it, (Fig. 269) and pushing out the iris in lieu of draw- ing it out. For inward iridectomy the favorite place for the surgeon using the bent keratome is on the side opposite that of the eye concerned, (Fig. 268) while in downward and external iridectomies, it is on the side adjacent. The assistant takes position facing the operator. The blepharostat is used, excepting in cases where loss of vitreous is to be apprehended, in which event the assistant holds the upper lid with a Desmarres reactor and the lower with his fingers. The globe is steadied by grasping the conjunctiva and episcleral tissue close up to the cornea, just across from the site of the incision, with strong fixation forceps having no catch. The hold 458 OPERATIONS UPON THE GLOBE of the forceps must be deep and broad. The point of the keratome is j)laced at, or slightly back of, the sclero-corneal junction, with its bhide almost perpendicular to the globe, cautiously shoved in till the thickness of the corneal base has been perforated or till, by the feel, it is known that it has barely entered the anterior chamber. The handle of the knife is then depressed, to bring the blade parallel with the plane of the iris, just above which membrane it is pushed along, taking care that the point engages nothing more, and that neither edge encroaches upon either clear cornea or upon the ciliary Fig. 269. — Miinncr of making keratome incisi facing the patient. body until it is deemed wise to stoj) (Fig. 270). Tliereupon, the handle is further depressed to avoid wounding the advancing lens, the globe is held firmly, without pressing down or lifting up on the forceps, the bhide is gently withdrawn a little way, and most of the aqueous allowed slowly to escape, when the knife is wholly withdrawn. Should one wish to extend the cut in the withdrawal of the knife, the point is swung around in the direction of the proposed extension, but holding the blade pressed close up to avoid j)remature running out of acpieous, tlu- handk' depressed, and the incision lengthened by a steady movement which consists in shoving the whole knife to that side and al the same time withdrawinLT. Where an extra TECIINIC OF IKII)K( TOMV 459 Ion,",' incision is wanted, as in .glaucoma, one makes ihe incision with the view lo such enlargement. To this end tiie incision is begun, say, to the left of what will be its middle, so that in extending toward tlie ri.ght, the location of the wovmd will be where originally planned. The fixation forceps is here removed, provided the eye is under