Congenital ptosis

atrophic spots in the choroid outside of the macula, no changes can be seen. During the last year I have examined the eye every few weeks and no change has occurred during this period. The boy attends school, has no trouble with his eye, and is apparently in robust health. I have reported his case, as it is the only one in which such complete restoration of vision followed after two attacks of profuse hemorrhage in the vitreous body, that I have seen during the twenty-five years that I hav.e been in practice. Cases of hemorrhage in the vitreous in young people are not very common, and recurrence of the hemorrhage has also been noted by several authors, but so far as I know no detailed histories of such cases are on record.

atrophic spots in the choroid outside of the macula, no changes can be seen.
During the last year I have examined the eye every few weeks and no change has occurred during this period. The boy attends school, has no trouble with his eye, and is apparently in robust health.
I have reported his case, as it is the only one in which such complete restoration of vision followed after two attacks of profuse hemorrhage in the vitreous body, that I have seen during the twenty-five years that I hav.e been in practice. Cases of hemorrhage in the vitreous in young people are not very common, and recurrence of the hemorrhage has also been noted by several authors, but so far as I know no detailed histories of such cases are on record.
A CONGENITAL PTOSIS CASE AND OPERATION. Cases of congenital double ptosis are somewhat rare. I have had four upon which I have operated, and I have seen several operated upon by other surgeons. The only operation which I have seen performed, and which I have myself performed previous to the case which occasions this paper, has been the so-called Von Graefe's, that is, the removal'of a paralellogram, or semi-lunar shaped piece of the lid, and orbicularis muscle. These operations, so far as my observation goes, have always been unsatisfactory, either not benefiting the patient much, or else not leaving sufficient lid tissue to cover the cornea during sleep.
The case which I take great pleasure in showing you to-day consulted me on Jan. 26, I895. It was a very marked ptosis, the palpebral opening was quite short, and reduced to a mere slit, the patient had 'but very small power over the upper lid, and was obliged to throw the head back considerably in order to see anything in front of him.
The palpebral opening being so short, an operation for its elongation was necessary before attempting to operate upon the ptosis, so upon Feb. 14th I performed the usual canthoplasty upon both eyes, under cocaine. Upon March 4th I operated for the ptosis, doing an operation which is practically a combination of the Panas and Von Graefe operation, as follows: I made two perpendicular and parallel cuts,-A, B, C, D,one-quarter of an inch apart, and extending from the upper orbital margin to within two lines of the edge of the upper lid. These cuts were united at the upper extremity by a horizontal incision,-A, C,and then the ribbon of tissue was dissected up and permitted to drop down upon a wad of cotton lying upon the cheek, which was kept moistened with warm Panas solution. Then a curved cut was made from H to G, and E to F, following the crease which shows the upper limit of the tarsal cartilage, and a straight cut was made from H to B, and from D to F parallel to and about two lines distant from the lower border of the upper lid. The derma and the orbicularis embraced within these cuts was then carefully dissected off, leaving the whole tarsal cartilage clean and denuded of tissue.
This denuded surface was carried a trifle beyond both the internal and external canthi. The cut edges, H, G, and E, F, were united to the cut edges H, B, and D, F, respectively, by interrupted sutures.
Then a Graefe's knife was entered at A C and passed beneath, and brought out upon the forehead just above, the eyebrows, and slight lateral cuttings were made so as to give room for the passage of the ribbon of derma which had been dissected up at the first stage of the operation. Then passing a strong suture into the upper edge of this ribbon of derma, it was used to draw this ribbon up into the cut made beneath the eyebrows and brought out upon the forehead, and when drawn up sufficiently tight, so as to leave no folds of tissue or puckerings, it was cut off smooth with the forehead and fastened there by two small sutures. Then several sutures were placed from A to G, and C to E, uniting the edges of the ribbon -which had been slid up as described -to the bordering derma, and the operation was finished.
The whole operation was done under -cocaine, using it first hypodermically, and then having it dropped upon the cut surfaces at short intervals by an assistant.
The dressings were pieces of linen moistened in a cold solution of boric acid and biborate of soda, and changed often night and day until the parts had healed completely.
The sutures were removed from day to day as seemed advisable. There was no swelling or formation of pus. The ribbon of tissue under the eyebrows caused some little pain for two days, but this passed away, and there was no annoyance thereafter.
The results to me were very satisfactory, much more so than any of my previous operations, and as one of my friends, who has had great experience and opportunities for observing such cases, said, " He had never seen so perfect a lifting of the upper lid with so perfect a covering of the cornea when the eye is closed." The only point upon which I am anxious is what will become of that ribbon of derma which is buried under the eyebrows. DISCUSSION.
DR. H. D. NOYES of New York. -I can answer the question regarding the fate of that piece of skin. You will never hear from it again, and never have any thickening. I have buried pieces of skin in the same way and had no trouble. This method is an ingenious one, and an improvement on many others. The suggestion to take a narrow strip is better than cutting a broad one. In accordance with an article which appeared in the Journals within the last year, I have adopted the opinion of the writer, whose name I have forgotton, that it is not necessary to use cocaine in these operations. He claims that by the use of physiological salt solutions if the injections ends in the derma, if your needle be not allowed to go beyond the skin proper, you will get all the anaesthesia that you can from cocaine. You avoid the risk of constitutional poisonous effects of cocaine. I cannot yet verify all the claims of the writer. In operating on cases of congenital ptosis I have sometimes attempted the wrinkling up of the levator palpebrae muiscle. I have only recently had one success in my endeavor. I had never been able to find the tendon of the levator so as to isolate it from the surrounding parts. The last time I made my incision down through the skin and orbicularis muscle at the same stroke, and with the parts stretched and blood vessels emptied by pressure of the fingers I ran a probe under the muscle and put a suture in deeply, gcing to the margin of the orbit, and succeeded in my endeavor. Tansley, he has done in an eleg,ant way what I tried to do to rectify the deformity remaining after completing an operation upon the lines laid down by Panas. I found a bad wrinkle in the lid after drawing the lid up by traction upon the narrow tongue of skin, and to remedy it I removed a small triangle of skin on either side of the base of the flap, but not as accurately as Dr. Tansley has done. His method demonstrates the advantage of removing some of this skin before elevating the lid as described by Panas.
DR. LucIEN HOWE of Buffalo. -As reference has been made to the use of cocaine in these operations, and the discussion seems to turn in that direction, I would add that the rule for the use of cocaine injections by the method referred to is to put in the point of the syringe and inject a drop or two of the fluid, and then feeling the way along the line of the incision continue the injections as the tissue fills up.
DR. G. C. HARLAN of Philadelphia. -A satisfactory operation for ptosis consists in subcutaneously taking out a piece of the cartilage. The lid is grasped in Snellen's clamp, and the amount of elevation needed having been measured while the patient is looking forward, a semi-lunar piece of cartilage is removed, the edges brought together and the skin closed over it. The width of the piece removed corresponds, at the highest point of its convexity, to the amount of elevation required. It is recommended to have the plate of the clamp made of horn that the knife may cut down upon it without injury to its edge. I have performed the operation several times, and have been pleased with the result. It was described by de Grandmont in a French journal, whose title I cannot now recall.
DR. SAMUEL THEOBALD of Baltimore. -As to the anaesthesia in these cases I have obtained very excellent results from cocaine without the necessity of injections at all. If the incision necessary is only skin deep it is possible to obtain absolute anaesthesia. I might mention a case operated upon the other day. I wished to transplant some skin flaps by Thiersch's method from the arm to the eyelid in a little colored boy. After having had the skin of the arm washed and sterilized, I put on a pledget of absorbent cotton, soaked wth io% solution of cocaine and covered this with a bit of protective rubber tissue. The tissue was put on to prevent evaporation of the cocaine solution. After about twenty minutes the anaesthesia was absolute, and the grafts were shaved off without any indication of pain. The grafts took perfectly, the cocaine, seemingly, having had no bad effect upon their vitality. There was one little spot about the center of the lid wound which I failed to cover at the first operation, and exuberant granulations sprang up at this point. I shaved them off, and taking a new graft from the arm simply laid it on the spot, and it united very promptly. The soil seemed very unpromising, but the graft took perfectly. DR. W. B. JOHNSON of Paterson.-Dr. Schleich is the name of the surgeon who invented the method of local anaesthesia that Dr. Noyes referred to. Dr. Wurdemann illustrated the theory at the meeting of the American Medical Association held at Baltimore in May last. The process is the production of cedema in the tissues, and the claim that it can be done with salt solution as well as with cocaine can be made good. After the operation there is apt to be pain in the tissues if salt solution alone is used, and it has been suggested that a solution containing small quantities of salt, cocaine, and carbolic acid in sterilized water be uised. It is then to be made ice-cold before using and injected into the skin into the epidermal tissue, and not in the areolar tissue beneath. The point of the needle is inserted but a short way into the epidermis, and injecting a few drops raises a slight wheal. After this first puncture is made no pain should be felt. The introduction of the syringe HOWE: Lens in the Eyes of Rodents.
further is to be made just within the edge of the wheals as they are successively formed. The condition of oedema of the deeper tissues can be produced, and if the idea is the removal of a tumor the needle may be gradually passed beneath the tumor and the injection carried on all around it. I saw Dr. Wurdemann demonstrate the procedure, using a very weak solution of cocaine, and must say its effect was almost marvelous. There is one objection, however, to this method, and that is that in the cedematous tissue it is difficult to follow the line of operation.
DR. GEO. C. HARLAN of Philadelphia. -It is a question whether any of the subcutaneous injections are better than applications of cold. I recently suffered with a felon which required lancing, and simply held a lump of ice upon the part for a few minutes. There was no pain when the incision was made, and no complication of any kind afterwards.
DR. 0. F. WADSWORTH of Boston.-I have found that, when the operation is a short one, and only a small piece of skin is to be removed, gradually increasing pressure by pinching the skin between the fingers will generally give sufficient anaesthesia to allow operating without much discomfort. Several years ago, when making sections of the eyes of rabbits, my attention was called 'to the fact that the antero-posterior diameter of the lens was decidedly greater in proportion than that of the humanveye. Since then I have noticed the same peculiarity in other nearly related animals, and it occurs to such a marked degree in some of the rodents that it appears worthy of mention. It is well known that the lens in the eye of the fishes is globular, for, as the rays pass from a medium of one density into another but slightly different, a lens of such a form is necessary to bring the rays to a focus on the retina. It is not surprising-, either, that the lens in the amphibians should