of the ear. Another incision was then made, beginning at the lower border of the wound and carried down to the lobe of the ear, after which it was dissected up, care being taken to dissect only the integument with a small amount of the underlying tissue. Care was also taken to preserve the vitality of the flap by means of a towel wrung out of a hot bichloride solution. After it was thoroughly loosened it was slid over into place and trimmed so as accurately to fill up the gap left by the excision of the growth, and made fast by interrupted sutures. Silk was used in this case, and in all there were twenty-four sutures, which were dusted over with boric acid, then covered with wet bichloride gauze, over which some absorbent cotton was placed, and the whole secured by means of a roller bandage. On the following day the patient was resting easily, suffering no pain, with pulse and temperature perfectly normal, consequently the dressing was not removed. On the second day, however, the dressing was removed, and the line of sutures was found to be perfectly dry. It was then redressed and allowed to remain closed for two days longer, after which the sutures were removed and the dressing left off. So that in this case we had union by primary intention without the slightest trace of pus, and the patient, as you see her to-day, has this malignant growth removed and an eyelid which is quite serviceable, answering all necessary purposes, and presenting no special disfigurement, save two lines of cicatrices which will gradually grow less (Fig. 4).

The third case to which I desire to call your attention is that of a child, John L., aged one and one-half years, who met with an accident some months ago which produced a wound of the right upper eyelid, which became infected and suppurated, resulting in the complete destruction of the eyelid. The cicatricial band of tissue which had formed had contracted in such a manner as to leave a condition of extreme ectropion. The palpebral conjunctiva was turned out, forming a bulbous mass completely covering the eyeball. The conjunctiva, of course, being very much irritated by its exposure to external influences, the only result in a case of this kind would be a destruction of the exposed conjunctiva and an ultimate loss of the eyeball. The method of procedure first contemplated was the operation known as Wolfe's, which consists in the transplantation of a flap without a pedicle; but the results of this operation are so varied that it was decided best not to employ it in this case, but to use instead a sliding flap with a pedicle. The technique of the operation was as follows. The child was placed under a general anesthetic, in this case chloroform being used. After cleaning the parts thoroughly with a solution of bichloride one to

five thousand, an incision was made about two millimetres from the edge of the lid and parallel with it, extending from the inner to the outer canthus, and a similar incision was made along the, orbit, parallel with the orbit, the inner point uniting with the lower incision, the outer extremity being three millimetres above the lower incision, thus including the entire amount of cicatricial tissue, which was then excised, care being taken not to include the underlying muscular fibres. The bulbous mass of conjunctiva was then turned in and the lids placed in position. In this case I did not suture the lids together, as is recommended and as is very frequently done, but the lid was simply allowed to remain in place. The next step was the preparation of the flap to fill in this gap. The flap was taken from the temple by making a vertical incision at the extremity of these two parallel incisions, carrying it upward and slightly forward, but not allowing it to encroach on the tissue of the forehead. Another incision was made, beginning at the upper extremity of this incision, carried downward and slightly backward, so as to leave a flap about six millimetres in width. This was then carefully dissected, with a small amount of underlying tissue, and was then slid into place, covering the defect of the lid, when it was found to be accurate without trimming. In this case, as in the other, care was taken to preserve the vitality of the flap. After all bleeding had ceased, the flap was secured by means of interrupted sutures. The gap left by the removal of this flap was then drawn together by several interrupted sutures, the edges of which approximated very nicely, after which a dressing similar to the one described in the foregoing case was applied. The wound was allowed to remain closed for forty-eight hours, after which it was opened and all found to be doing nicely. It was redressed, and opened again two days after, at which time the sutures were removed, and in this case, as in the former one, we got union by primary intention. So that at the present time, a few months after the operation, we have the child with a useful eyelid, which can be opened and closed at will. The only deformity at present is a somewhat thickened eyelid and a vertical scar on the temple. This thickening of the eyelid has gradually become less, as no doubt some of you have noticed, since you have had the privilege of seeing the patient several times during the healing process, and the eyelid will probably improve very much as the child grows older. At any rate, we have given the child a useful eyelid and preserved a perfect eyeball, which no doubt would have gradually been destroyed if the ectropion had persisted (Fig. 5).

In performing plastic operations great care and deliberate judg

ment are essential. Do not be in haste to operate, but carefully consider what you intend to do and how you are going to do it. When at all possible, use a flap with a pedicle, and always bear in mind that your flap will shrink, and that due allowance must be made for the shrinkage. The flap should be about one-third larger than the space to be filled; then, with proper care and neatness, you are quite sure to achieve success.

TREATMENT OF TRACHOMA BY EXPRESSION

AND BY OTHER METHODS.

CLINICAL LECTURE DELIVERED AT THE NEW YORK POLYCLINIC.

BY THOMAS R. POOLEY, M.D.,

Professor of Ophthalmology in the New York Polyclinic; Surgeon-in-Chief to the New Amsterdam Eye and Ear Hospital.

GENTLEMEN,-This boy, whom I have shown here before, has had both of his eyelids subjected to the operation of expression of the trachomatous follicles. The operation is quite painful, and cocaine anaesthesia does not seem to be sufficient to allay the pain; hence the operation, under these circumstances, is not apt to be done so thoroughly. You notice that in the eye operated upon under general anesthesia there are no trachomatous follicles to be seen, and the lid is almost well. The result is certainly far more satisfactory than that which would follow in the same time from the use of the sulphate of copper or other similar means. The expression of the follicles may be done with instruments, preferably with the forceps of Noyes or Gruening, or the roller-forceps devised by Knapp; but most convenient of all is the use of the perfectly clean finger-nails. The operation is exceedingly tedious and uninteresting, and I think that any device which would control the hemorrhage would be a valuable help in the performance of the operation. The conjunctiva is naturally very vascular, and this condition is much increased when trachoma is present. The hemorrhage which accompanies the operation of expression prevents you from seeing distinctly how thoroughly you have removed the trachomatous follicles. I think in the future I shall not only employ ether, but shall also thoroughly cocainize the eye, for cocaine, if employed to a sufficient extent, is a good hæmostatic. It is almost impossible to treat thoroughly all the follicles present, but do

1 I have given up the use of the finger-nails and now use Knapp's roller-forceps altogether.