(b) Knowing that mucous flaps usually shrink to almost two-thirds of their original size, one should be very careful that the original flaps are large enough. It is safer and wiser to err on the safe side and have your flaps too large, rather than an exact size of the exposed surfaces or smaller, for should your flaps be not large enough and shrinking occurs, small areas are left unprotected with epithelial covering, and a reunion is the inevitable result.
(c) The flaps should consist of mucous membrane only, and no submucous tissue at all.
(d) The operation should be performed as speedily as possible, so as to have mucous flaps with full vitality in them, and so as not to keep them immersed for too long a time when their vitality is bound to suffer. A good deal of the surgeon's time is here taken up in arresting, by means of a swab or sponge, the capillary oozing from the exposed surfaces, and again I strongly advocate the use of adrenalin chloride as a rapid and most powerful local styptic.
(e) There should be no tension of the flaps as they occupy their new positions, and this is obtained by having large enough flaps.
(f) There should be a liberal application of fine delicate sutures to help and keep the flaps in their correct positions.
{g) Great attention should be paid to the fornix. One is apt to neglect this sulcus, but I believe it in a measure decides the result of the operation, for if it be not properly and adequately covered, adhesions are bound to take place, resulting in a certain amount of fixity of the root of the eyelid and constant discomfort to the patient and most probably a subsequent entropion with its attendant disasters.
(h) The flaps during the interval between their detachment and adjustment (which should be as short as possible) should be kept moist and warm. The application of the long narrow piece of mucous membrane for the fornix is rather difficult and tedious, requiring a deal of patience, but the after-results amply compensate the surgeon for this little extra trouble.
I am of opinion that three flaps of mucous membrane properly applied and ligatured into position, véz., one for the ocular surface, one for the palpebral surface, and the third one to fill up the sulcus of the fornix answers all purposes and gives better results. It is this little toilette of the operation that I attribute the success of my cases with absolutely free movement of the lid.
In cases where there is a very small surface to cover with conjunctiva one can easily do as Teale advocates, viz., obtain it from the conjunctiva of the eye from either side of the cornea, or as a bridge-like flap from above the cornea; but even here we often meet with cases in which the non-adherent or non-diseased parts of the ocular conjunctiva are inflamed, hypervascular, discolored or somewhat contracted, and these eyes can ill spare any conjunctiva. One can more readily and easily obtain liberal flaps from such a large mucous surface as the mouth than from an already partly diseased eye, which cannot afford to spare any of its mucous covering.
In this article I do not mean to put this operation as a new one before the profession, but, as a modification of that of Stellwag and of Riverdin, the latter consists in covering the exposed surfaces with small pieces of mucous membrane obtained from the mouth.
In Class (3) Severe—When the whole of the lower eyelid is adherent to the eyeball, the same procedure as I recommend in class 2, viz. division of the adhesions and transplantation of mucous flaps from the mouth should be tried. Harlan, Kuhut and Snellen, however, advocate a covering of ordinary skin and not mucous membrane for the exposed surface of the lower lid, and this they obtain by making a skin flap from the skin below the lower margin of the orbit, and turning it up as on a hinge and slipping it through another long incision made above this flap on a level with the lower orbital margin, and which incision, being made right through the entire lid, acts as a button-hole for the skin flap to be passed through. This skin flap is next sutured to the inner surface of the lower eyelid. This skin, after some time, becomes modified and somewhat resembles mucous tissue, but does not act in the same way, as the hairs which develop are bound to irritate the conjunctiva and cornea and set up irritation.
When both lids are adherent they may each in turn be separated and covered over with flaps of mucous membrane either from the mouth or from a rabbit. When anklyoblepharon is present, and this, being generally the result of a burn, is almost always accompanied by symblepharon, it can be remedied by a division of the adhesions between the two eyelids, but in these severe cases the cornea is usually so destroyed by the original cause of the disease that operative measures are more or less useless unless there is a chance of obtaining some visual results.
A Mirror of Hospital Practice.
A NOTE ON STIFFNESS OF THE ARM AFTER AMPUTATION OF THE BREAST, AND A GOOD WAY OF AVOIDING IT.
By F. P. MAYNARD, M.S., F.R.C.S, MAJOR, I.M.S.
Civil Surgeon of Darjeeling.
Every surgeon is unpleasantly familiar with the stiff and frequently oedematous arm only too often left after an amputation of the breast, the. operation having in every other respect been a
