exposed, then with the finger nail, a hair-pin, small spud made for the purpose, or any article that may be at hand, lift the edge of the eye over the margin of the lid and allow it to slide out on to the cheek.

It is well to carry out these manipulations over a bed or sofa, as the eye is very likely to be let fall, and will break if it comes in contact with any hard substance. An artificial eye wears out in from twelve to eighteen months.

ABSCISSION.

Abscission is the removal of the portion of the eyeball (including the ciliary region) situated in front of the attachments of the recti muscles, these being left intact. The object of this operation is to leave a movable stump, on which an artificial eye can rest and be moved in harmony with the movements of the sound

one..

Abscission is indicated in staphyloma occupying the whole or greater part of the former situation of the cornea, the remainder of the globe retaining its normal

curvature.

The operation should be thus performed (for position of patient and operator see Fig. 32, p. 204). The instruments required are a wire speculum, toothed forceps, strabismus scissors, a triangular cataract knife, a curved needle and silk. The patient being thoroughly under the influence of an anesthetic, the wire speculum should be placed between the lids, the conjunctiva divided all round close to the corneal margin (as for extirpation) and dissected back to the desired extent.

Then with the curved needle a single suture should be passed through the edge of the divided conjunctiva at five or six different points, so as to surround the

wound in it in much the same manner as the string surrounds the mouth of an ordinary bag, and the ends of the silk left hanging on the patient's face.

The staphyloma, the whole of the ciliary body and sclerotic corresponding to it, should then be removed by transfixing the globe with the triangular knife, just in front of the insertions of the internal and external recti muscles, cutting out upwards in front of the insertion of the superior rectus and finishing the removal by a sweep of the knife in the opposite direction.

The silk should then be drawn up and tied, by which means the conjunctiva will be made to cover the wound in the globe, and lint wetted with boracic acid lotion, and a bandage applied. Some reaction often follows abscission, and a good deal of swelling of the lids and conjunctiva may occur. The patient should be kept in bed for two or three days, fresh dressings should be applied daily for a week, after which a shade only is required.

As soon as the parts have firmly healed (in the course of six weeks or two months) an artificial eye may be worn.

Abscission should be performed in preference to excision of the globe in children; the presence of the stump left prevents to a great extent the shrinking, or nondevelopment of the orbit, which will occur if the eyeball is removed entirely. In older persons excision is generally to be preferred, as the stump left after abscission is liable to become troublesome, and in the very old is prone to suppurate.

EVISCERATION.

Abscission is rapidly being, and I think should be entirely, replaced by "evisceration" of the globe, an

operation which will probably take the place of excision in a large number of cases, possibly in all except those of malignant disease.

Evisceration can be performed as follows:-The position of patient and operator should be as at Fig. 32, p. 204. The instruments required are a needle armed with silk, fixing forceps, speculum, triangular cataract knife, excision scissors, a piece of india-rubber tubing about four feet long to act as a siphon and a vessel containing a solution of boracic acid (gr. x. to 3j.).

The patient having been anæsthetised, the conjunctiva should be divided all round, close to the cornea, as for excision. The cornea should then be separated from the sclerotic by cutting all round the sclero-corneal junction with the triangular knife; the iris, ciliary body, and choroid, with the retina and vitreous enclosed, should then be removed by passing the excision scissors carefully between the choroid and sclerotic all round the interior of the globe, the sclerotic being meanwhile held by the cut margin with the fixing forceps. These parts may often be removed as a whole; if the choroid tears, any portions left should be brushed out with pieces of cotton-wool held in another pair of forceps, this must be done carefully as the object of the operation is to remove the whole of the contents of the eyeball, leaving nothing but the sclerotic. As soon as the evisceration has been completed, a stream of boracic acid solution should be directed from the india-rubber tube into the cavity of the sclerotic, and kept up until the bleeding, which is rather profuse, has materially lessened or stopped; two quarts or more of the solution may be required. Whilst the washing out is going on, a continuous suture should be passed through the cut edge of the conjunctiva in the same manner as described for abscission. When sufficient of the solution has been used, the suture should be

drawn tight, and the two ends tied together. A simple fold of lint wetted with boracic lotion should be laid lightly over the closed lids, and secured by a turn of bandage round the forehead, no pressure being applied over the lids, so as to give free exit for blood and discharge, if there be any; the lint should be kept wetted with boracic acid solution, and fresh pieces applied two or three times a day. Some swelling of the conjunctiva follows, and in some cases, a good deal of febrile disturbance, the temperature rising to 101° or 102° for a night or two after the operation. The patient should be kept in bed for two days or longer if necessary, and then allowed to get up and go about. The parts will have soundly healed in about a fortnight, and an artificial eye may be worn six weeks or two months after the operation. The result is a more or less movable stump on which the artificial eye rests, and with which it moves to a considerable extent.

CHAPTER VII.

PROTRUSION OF THE EYEBALL AFFECTIONS OF THE ORBIT-TUMOURS OF THE EYEBALL, ETC.--PANOPHTHALMITIS-REMOVAL OF FOREIGN BODIES FROM THE INTERIOR OF THE GLOBE.

Protrusion of the eyeball.-As many diseases of the orbit and to a considerable extent tumours of the eyeball itself, cause more or less protrusion of the globe, it will be well to say a few words on this subject before describing the morbid changes which may give rise to it.

The symptoms are obvious enough, and do not require description. The causes are the following:

1. Inflammation within the orbit, either with or without the formation of abscess.

2. Hæmorrhage into the orbit.

3. Vascular protrusion of the eyeball.

4. Exophthalmic goitre.

5. Tumours within the orbit; nodes, exostoses, malignant growths, cysts, nævi, etc.

6. Enlargement of the eyeball itself from (a) growths, malignant or simple; (b) inflammation and suppuration of the whole eyeball (panophthalmitis).

7. Paralysis of its muscles, allowing the globe to drop forwards, and thus assume an unusual prominence.

Double vision is generally complained of in protrusion of the eyeball if the sight of both eyes is fairly good. The ill effects of the abnormal position are seen both in the globe itself and in the lids. Should the protrusion be so great that the lids cannot be closed over the eyeball the cornea will be left unprotected and may become opaque, and afterwards ulcerate or slough. If the pro