mittent contraction of the ciliary muscle is present, it often masks a considerable amount of hypermetropia and may at times make the hypermetropic eye appear to be myopic. If it exists with myopia the degree of short sight is increased.

Symptoms.-Severe and constant pain in the eyeballs and forehead, increased on any attempt to use the eyes, and associated with some anomaly of refraction (generally hypermetropia); inability to see either near or distant objects distinctly; these symptoms being modified or entirely removed by the use of a mydriatic.

Treatment.-Paralyse the accommodation by the constant use of atropine (gr. iv. of sulphate to i. of water) or other mydriatic, and accurately neutralise any existing anomaly of refraction or astigmatism.

CHAPTER VI.

THE EYELIDS AND CONJUNCTIVA.

Congenital anomalies.-Absence of the eyelids; a failure of closure of the foetal fissure, leaving a cleft in one or both lids (coloboma); ptosis, complete or partial; development of a third lid; pigment spots, moles, nævi, and warty growths, have all been occasionally met with.

Ulcers. Simple ulcers, primary venereal sores (chancres), tertiary syphilitic and cancerous ulceration, are sometimes met with. The first three require to be treated on general medical principles; the last by operation, if the disease has not proceeded too far.

Phthiriasis.-The pediculus pubis (crab louse) is sometimes found amongst the eye-lashes close to the margin of the lids. The edges of the lids appear to be covered with scabs and crusts somewhat resembling tinea; on close examination the insects themselves will be discovered adhering closely to the margin of the lids, their eggs being attached to the lashes near their bases.

Treatment. The daily use of some kind of mercurial preparation, none being better than the Ung. Hydrarg. Ammoniatum.

Paralysis of the obicularis muscle occurs in some cases of facial paralysis: there is inability to close the eye, the lower lid falls away from the globe, there is considerable collection of lachrymal secretion at the inner canthus, and constant watering of the eye consequent on the displacement of the lower tear punctum and want of the proper movements of the lids.

Treatment.-General medical treatment should be

adopted.

Spasm of the orbicularis muscle may occur from long-continued intolerance of light, consequent on affec tions of the cornea.

Treatment must be directed against the corneal affection. (See Diseases of the Cornea).

Spontaneous twitching, more especially of the lower lid, popularly known as "live blood," is met with in some cases of hypermetropia, or in persons whose digestions are out of order; it is very probably a symptom of undue contraction of the ciliary muscle.

Treatment. Correction of existing hypermetropia, instillation of atropine, and attention to the general health.

Acute inflammation of the eyelids may occur during or after acute diseases (measles, scarlatina, etc.), in the course of erysipelas, as the result of injuries, or in connection with severe inflammation of neighbouring parts, e.g., purulent ophthalmia. The swelling and redness are usually considerable, and the eye cannot be opened; the inflammation generally ends in resolution, but may (especially if it result from measles, scarlatina, etc.), go on to the formation of abscess, or even to sloughing of the skin.

Treatment.—Locally, fomentations with hot water or decoction of poppy-heads; if an abscess forms it should be opened—preferably through the conjunctiva. The patient's general health should also be attended

to.

Stye (hordeolum) is a small red, and painful swelling situated on the outer surface of the lid near its margin, and consists in a circumscribed inflammation of the lid, dependent on morbid change in the Meibomian glands. Styes generally occur in weakly, delicate

persons; several may appear simultaneously, or there may be a succession of them; they give rise to considerable irritation, and are often extremely painful. The inflammation usually goes on to suppuration.

Treatment. Fomentations, poultices, the administration of tonics, and good living. When pus has formed, the little tumours should be opened. Suppuration may be prevented by rubbing the red oxide of mercury ointment into the swellings as soon as they appear. Pulling out a lash in the centre of the stye may sometimes shorten its duration.

Tinea (ophthalmia tarsi blepharitis). Patients suffering from slight tinea present themselves with scurf attached to the margins of the lids; in the more severe forms with yellowish-brown, dry, and closely adhering crusts. The lashes are often scanty, many of them having fallen out.

It

On removing the crusts the margin of lid will be found ulcerated, fissured and easily bleeding. The disease consists in inflammation and ulceration in and about the follicles of the lashes; it runs a very chronic course, often lasting for years in spite of remedies. occurs most commonly in delicate children and young adults. In old cases the margins of the lids are much thickened giving rise to redness and eversion of the lower lids with displacement of the tear puncta, and consequent watering of the eye. This condition is known as "lippitudo."

Treatment. Slight cases can generally be cured by the use of a lotion containing 10 grs. of boracic acid to the ounce of water, applied three or four times a day, and of mild nitrate of mercury ointment (one part of the ordinary nitrate of mercury ointment to eleven of lard),*

* The ointments employed in the ophthalmic department at Guy's Hospital are now almost invariably prepared with vaseline instead of lard.

smeared along the margins of the lids night and morning.

The patient should be directed to remove all the crusts by bathing with warm water or a weak alkaline solution before applying the ointment. Iron or cod-liver oil, or the two combined should be given internally in delicate subjects.

More severe cases should be treated by pulling out the lashes and removing the scabs with forceps, and then applying solid nitrate of silver to the raw surface left.

In cases where the lower tear punctum has become everted the punctum and canaliculus must be slit up. (See Part II., Chapter II.).

Injuries.-Wounds of the eyelids, however extensive or ragged, should, after having been thoroughly cleansed, be brought accurately together; they will usually heal readily enough. Should there be any loss of substance, an endeavour must be made to prevent contraction of the resulting cicatrix causing distortion of the lids.

Ecchymosis of the lids (black eye) frequently occurs as the result of blows, and may be caused by leech-bites or operations, and occasionally as the result of strain as in whooping-cough.

Treatment. Most cases may be left alone, but if it is desirable to get quickly rid of the effused blood, a cold poultice made of equal parts of the scraped root of black bryony and bread-crumbs should be applied. The poultice should be kept on as long as the patient can bear it. The application is often accompanied by a good deal of stinging pain.

Emphysema of the lids sometimes occurs from rupture of the mucous membrane of the nose, air being forced into the cellular tissue of the eyelids on sneezing