CONTINUATION OF THE ORBITAL REGION.

Diseases of the eyelids—tissues entering into their composition. Suppuration in the eyelids. Obstruction of punctum lachrymale. Ecchymosis-treatment. Entropium-its effect. Ectropium-comparative inconvenience and danger to the eye -operation for entropium and ectropium. Hordeola or styes. Fncysted tarsal tumors-treatment. Wounds of the eyeball — treatment — intrusion of foreign bodies-mode of removal. Diseases of the jaws. Osten-sarcoma of the jaw-malignant character-extirpation -mode of operating. Tumors from the antrum and upper jaw not always malig. nant-operation for removal-mode of proceeding- -case. Region of the neck.

Ab.

Character of the neck —anatomical relations. The pharyngeal region-its limits-the pharynx subject to the lodgment of freign bodies-their extraction-opening the trachea. scesses-evacuation of the pus-necessary precautions-case. Ulcers in the pharynx. Anterior region of the neckdefinition. Supra hyoideal region "cut throat" treatment Laryngo-pharyngeal region. Frequency of wounds in attempt at suicide-wound of lingual artery-case. Various attendant considerations, and mode of treatment.

tumors.

Diseases of the eyelids.-Before we begin to treat of the diseases of the eyelids, it is proper to give some consideration to the various structures which enter into the composition of these parts, as it is evident that the eyelids must be liable to the diseases incident to each of their tissues,-these are, skin, cellular membrane, muscular fibre, tendon, fibro-cartilage, mucous membrane, and the

cilia.

Of the skin of the eyelids there is little further to remark than that it is subject to the eruptions common to the integuments of the other parts of the body; and there is nothing peculiar to it beyond what may arise from its extreme tenuity.

The cellular membrane is remarkable for
XLII.-1075. June 7, 1848.

the freedom of the connection between its cells. The muscular apparatus of the eyelid, in common with the muscular system of other parts of the body, is subject to no other disease than that arising from morbid irritability, producing a constant twitching or "winking" of the eyelids. The tendon of the levator palpebræ, which is inserted into the fibro-cartilage, constituting the tarsus, is, like all tendinous tissues, as well as the fibro-cartilage into which it is inserted, from its slight degree of vitality, readily disposed to slough under a very slight degree of inflammation. When the tarsus becomes affected it frequently leads to great interference with the functions of the lid. The mucous membrane of the eyelids is also liable to the peculiar discases of this tissue, such as ophthalmia, &c. The structures connected with the hairs of the cilia sometimes become diseased, and this also constitutes one of the morbid conditions to which the eyelids are liable.

Suppuration of the eyelids.-Owing to the loose character of the cellular membrane of the eyelids, they are very liable to suppurate under inflammation, whether it proceed from disease or injury; and as this affection causes great swelling, and interferes with the motion of the upper lid, it is necessary that the matter should be early evacuated; and as it usually attacks persons of a weak strumous habit, tonic medicines will also be requisite. In erysipelas such abscesses often occur, and unless the matter is let out sloughing very soon results. In evacuating the matter the incisions should be curved, following the direction of the fibres of the orbicularis palpebræ muscle, so that the cicatrix may be hidden in the natural folds of the skin of the eyelid, and the deformity avoided that would result if the incision were at right angles to the muscular fibre. Small circumscribed tumors frequently obstruct the punctum lachrymale, so as to cause a flowing of tears over the cheek. This may be mistaken for fistula lachrymalis; but the comparatively slight pain in palpebral abscess, and the great inconvenience attendant upon inflammation of the lachrymal sac, constitute the diagnostic distinction between them. In opening the abscess, great care must be taken not to injure the punctum lachrymale, as permanent disease would re

sult from its obliteration.

Ecchymosis. - Extravasation of blood into the eyelids, technically termed ecchymosis, frequently results from external injury. The removal of this coagulum by incision should never be attempted, as a few leeches, and poultices composed of the bryony root scraped and mixed with bread, will be generally found sufficient to the purpose.

I am of opinion that in all cases of ecchymosis more injury is done by the incision to remove the coagulum than would be effected by the presence of the blood itself. A spontaneous ecchymosis, or effusion of blood into the eyelids, sometimes occurs, and is characteristic of great constitutional deterioration, and especially of an impoverished condition of the blood. This appearance should at once create considerable alarm; and the treatment required is similar to that necessary in the hæmorrhagic tendencies-such as acids, bark, and generous diet.

Entropium or inversion, and Ectropium or eversion, of the eyelids, not infrequently results either from disease or injury to these organs, but more particularly to their fibrocartilaginous portions.

In Entropium, the free edge of one or both of the eyelids is turned inwards upon the globe of the eye, with the surface of which the eyelashes are brought in contact. Violent inflammation results, and if the disease be not removed, the transparency of certain parts of the organ becomes impaired from a deposition of lymph, large bloodvessels from the conjunctiva shoot across the cornea, ulceration of the latter membrane soon follows, and the eye would perish unless the disease be cured.

Ectropium, or eversion of the eyelid, produces at first much less suffering, as in this case the conjunctival surface of the eye is not subjected to the irritative action of the cilia; but if the disease be allowed to re

main, the tunica conjunctiva of the eyeball being unprotected by the affected lid, and losing the beneficial lubricating influence of the tears, soon becomes inflamed from the action of the air; and by the lodgment of extraneous particles of matter, the inflammation proceeds to opacity of the cornea, and ultimately to the destruction of vision. The deformity in this disease is even greater than in entropium ;-in consequence of the large inflamed mucous surface exposed to view, the cornea ulcerates, the anterior chamber of the eye is laid open, the aqueous tu-, mor escapes, and the organ is very soon completely destroyed. The inferior lid is most frequently the seat of this affection.

These diseases may occur from an altered condition of the tunica conjunctiva, of the skin of the eyelid, or from disease of the fibro-cartilage which constitutes the tarsus. Entropium sometimes results from a relaxed state of the skin of the eyelid, with the exception of that at the ciliary edge, so that there exists an unequal degree of resistance to the orbicular muscle of the eyelids, and a tendency to inversion is established. The deformity arising from this cause may be cured by taking up a fold of the loose skin, and cutting out a longitudinal

slip, after which the excised edges must be perfectly adapted, and kept together by uninterrupted suture, the contraction of the cicatrix removing the inversion. Some surgeons have recommended that the skin should be removed by strong sulphuric acid, but I consider the excision of a portion of the integument far preferable. When disease of the tarsus causes either entropium or ectropium, a portion of that structure must be removed; this is best effected by passing a needle, armed with silk, through the ciliary edge of the lid, so as to give perfect command of this moveable part. A triangular portion of the lid is now to be excised, and the incised edges adapted by suture. The surgeon is able to judge of the quantity which it is desirable to remove, by examining the relation of the lid to the globe of the eye before he operates. When thickening of the conjunctiva produces ectropium, or a cicatrix in it, entropium, the operative means must be applied to this membrane.

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Tumors of the palpebræ frequently interfere both with the motions of the eyelid and with the conjunctival surface of the eyeball the most common of these are hordeola, or "styes," which require little or no further treatment than the application of cold, or a poultice. Sometimes, however, the matter will not make its escape by the process of ulceration, when a small opening should be made, the pus evacuated, and nitrate of silver applied to the wound. I have Cambridge, with so obstinate a case of this lately had under my care a gentleman from

disease that I was induced to call in the aid of Mr. Dalrymple, to consult with him on the propriety of its removal; but as the stye was placed very near to the inferior punctum lachrymale, he recommended merely to lay it open, and touch it with lunar caustic more completely than I had done; but the tumor is not yet, however, perfectly removed.

Encysted tarsal tumors also often produce considerable inconvenience; the tumor gives the sensation as if it were placed between the skin and the outer surface of the tarsus; but if their extirpation be thought necessary, they should be removed from the inner side by everting the lid: usually, however, merely puncturing the sac, and passing a small probe into its interior to break it down, will be sufficient to cure it. Such is the operation usually recommended. I have, however, frequently removed them in the following manner everting the lid, removing a portion of the mucous membrane covering the tumor, and, with a pair of bent-bladed scissors laid flat on the tarsus, cut off the whole tumor.

In cases of loss of portions of the eyelids,

The

In wounds of the eyeball, the danger accruing depends upon the extent and depth of the lesion. The first great object, in case of such an accident, is to subdue at once the inflammation by strict antiphlogistic means, and opening the temporal artery should almost always be had recourse to; for, if the inflammation be allowed to pass into a chronic state, instead of being completely subdued, the delicate tissues of the eye are almost certain to become impaired, and the power of vision be either wholly lost or permanently diminished. It is hardly necessary to mention that the patient should be kept in a state of darkness, upon low diet, and the bowels freely acted upon during the progress of his cure.

Foreign bodies are often intruded into the eye, more especially since the establishment of railroads; they are, however, easily removed by everting the upper lid: by turning it over a probe pressed just above the tarsus, nearly the whole of the conjunctival surface may be thus exposed, and any small particles may be easily removed by the corner of a cambric handkerchief; if, however, a particle of iron, or such-like substance, should become imbedded in the cornea, it must be removed by a "couching needle:" cold lotions, or leeches, may afterwards be required to subdue inflammation.

Diseases of the jaws.-The jaws are subject to disease, which frequently renders their removal necessary; they, therefore, occupy a prominent and highly important position in the surgery of the region of the face.

Osteo-sarcoma sometimes attacks the lower jaw. (Vide Fig. 1.) The malignant character of this disease, which is indicated by its physical characteristics and the peculiar diathesis of the patient, renders its extirpation the only alternative for the surgeon. To remove the portion of the lower jaw thus contaminated, a bold and extensive incision must be made through the soft parts covering the bony tumor, the course of the knife following the curvature of the jaw close to its lower margin. An incision is then to be made at either end of the first incision, and at right angles to it; one portion of the integument is to be dissected from the jaw upwards, and the other downwards, so that the bony tumor is completely exposed. The jaw is now to be sawn through at the extremities of the first incision; and when divided, must be depressed and everted, so that the soft parts adhering to the inside may be dissected off; the muscles at.

and the bone, thus liberated, removed. facial artery is generally divided in the first incision, and had better be tied immediately, or steps. It is necessary to extract a tooth at the hæmorrhage interferes with the after the point where the jaw is to be cut through, and this should be done previous to the operation, whether the chain or common saw be applied. If the chain saw is adopted, it must be passed behind the jaw, close to the bone, by means of a needle: the action of the saw being from within to without. After the removal of the bone the soft parts are brought together, and retained by suture. If the disease be situated so near to the condyle as to preclude the possibility of sawing through between the diseased part and the articulation, the disarticulation of the jaw must be resorted to. In this case the saw is employed only on the symphysis side of the disease; and when the soft parts are dissected off, as in the former case, the surgeon takes hold of the diseased part of the bone, and directing it outwards and slightly backwards, opens the front part of the temporo-maxillary articulation, continuing the knife backwards so as to divide the ligaments of the joint, then cutting through the temporal and pterygoideus externus muscles, the diseased part is extirpated. Bleeding vessels are then to be secured, and the edges of the wound neatly approximated, and maintained in coaptation by sutures. If there be any enlarged glands, or other signs of the propagation of the disease to the surrounding tissues, it would be equally useless and cruel to recommend this operation.

Tumors growing from the antrum(vide Fig. 2)-frequently lead to the most dreadful deformities, interfering, at the same time, with the functions of the eye, nose, and mouth; but as these growths are not always of a malignant character, the removal of large portions of the upper jaw for their extirpation may be regarded as an admissible operation, when the diagnostic marks offer a just hope of its effectiveness. The mode of performing this operation is as follows:-An incision is to be made, commencing on the outer side of the orbit, and carried through the cheek to the angle of the mouth; a second incision is to be made through the commissure of the upper lip, extending quite to the septum of the nose, and continued upwards so as to separate the ala from the cheek, passing also up the side of nose, exposing the nasal process of the superior maxillary bone; a flap is thus formed, which may be turned upwards, exposing the whole of the tumor; or if it be so large, or situated so far back, that