permitted to rise only with the understanding that no violent exertion was permissible.

Although not strictly pertinent to the surgical treatment of this affection by scleral puncture, I desire, in closing, to refer to a case quoted in the former lecture (loc. cit.), which had been treated with instillations of eserine according to the recommendation of Guaita, who states that under these circumstances he has obtained amelioration of the symptoms and increase of the visual field, although there was resumption of the symptoms on ceasing the use of the drug. In one of my cases thus managed, the accompanying diagrams (Figs. 12, 13, and 14) illustrate graphically the effect of the instillation of this myotic drug. Although there was slight increase in the size of the visual field,

FIG. 15.

Diagram of the visual field of the case treated with eserine. Result after three years' use of

this myotic.

central vision did not improve. This patient has reappeared within the last few days, and I insert a diagram of the field of vision as it is at present (Fig. 15), obtained with the aid of a candle-flame, and exhibiting only a small patch down and out where there remains lightperception. Strange to say, this patient, a highly myopic woman of twenty-eight, has used the eserine solution (a twelfth of a grain to the ounce twice a day) almost continuously since the original fields were mapped out, now more than three years ago. Certainly no improvement could be ascribed to the effect of the drug.

FIG. 1.-Anna L., congenital ptosis, before the operation.

FIG. 2.-Anna L. after the operation for the relief of ptosis.

CONGENITAL PTOSIS;,

EPITHELIOMA OF THE EYELID; OPERATION FOR THE RELIEF OF TRAUMATIC ECTROPION.

CLINICAL LECTURE DELIVERED AT THE WESTERN PENNSYLVANIA MEDICAL

COLLEGE.

BY EDWARD B. HECKEL, A.M., M.D.,

Lecturer on Ophthalmology and Otology at the Western Pennsylvania Medical College; Oculist and Aurist to the J. M. Gusky Orphanage and Home for the Aged of Western Pennsylvania, and the Home of the Friendless, Pittsburg.

GENTLEMEN,-The cases before you are not strange to most of you, as I have referred to them on several occasions. My chief object in bringing them here again is to show you the results of a few plastic operations on the eyelids. In order to get the full benefit of a case, it is necessary not only to witness an operation, but to follow it in its subsequent course.

The first patient whom I introduce to you is Anna L., aged fourteen years, who consulted me in March last. Her father gave the following history. The left eyelid has drooped ever since birth, completely covering the eyeball and presenting a peculiar appearance, such as is photographed in the picture which I pass around (Fig. 1).

Parents are always ready to assign some cause for any defect that may be present in a child. In this instance the father states that the patient was one of twins, and that her twin brother's foot had pressed against her eye during intra-uterine life, producing the condition present. By a supreme effort the patient was able to elevate the lid by a contraction of the forehead, due mostly to the action of the occipitofrontalis muscle. Upon elevating the lid with my finger, the eyeball presented a perfectly normal appearance, and followed the other eye in all its excursions, except when the eye moved upward, showing that the superior rectus muscle of the eyeball was likewise involved in the paralysis. The pupillary reflex was normal. The vision of the left eye was, that of the right eye was 8.

The refraction, as shown by the ophthalmoscope, was found to be about normal in each eye; in other words, the condition was that known as congenital ptosis. In many of these cases (which are rare, however) we find the patient able to elevate the lid by a supreme effort of opening the mouth,—that is, by depressing the lower jaw. In this patient such was not the case; even when the lower jaw was depressed, the upward movement of the lid was slight, scarcely more than when the jaw remained closed or fixed. Congenital ptosis, as stated by some authorities, is usually found to be bilateral; but in this case it was monolateral, being confined to the left eyelid. The treatment in such a condition, of course, would be purely surgical, although it is never advisable to operate upon a congenital case of ptosis in early youth; by that I mean at the age of three or four, for very frequently these cases improve as the child grows older, sometimes regaining almost their entire functional activity; consequently an early operation might prove in later years an over-correction.

The operations devised for the relief of this condition are numerous, and the mere fact that such is the case is indicative of one thing,— namely, that no single operation is suitable for all cases; and it is an operation which should be coolly deliberated upon before undertaking it, for there are certain dangers connected with it: you may operate and under-correct, that is, after the operation is completed, the eyelid may still droop some, enough perhaps to interfere with the pupillary space; and, on the other hand, you may over-correct,—that is, interfere with the patient's closing the eye, and hence expose the eyeball to all sorts of external influences, which may eventually lead to corneal ulcers and complete destruction of the eyeball.

The chief object of an operation in this case was a cosmetic one, as the left eye is amblyopic, and will very likely remain so, though some improvement in vision is to be looked for. As it was, the young lady presented a rather peculiar appearance, the left eye remaining closed at all times, and consequently detracting very much from her general appearance.

The old method of operating upon such cases as this was that devised by Von Graefe, which consisted in the excision of some of the fibres of the orbicularis muscle. The object aimed at was dual: first, the weakening of the orbicularis, which is the antagonist of the levator; and, secondly, the subcutaneous shortening of the lid. The effect of this operation, in most cases, was but slight, and the result disappointing. Since then other operations have been devised, the principle of which depends upon the fact that the occipito-frontalis muscle can