1174 SURFACE AND SURGICAL ANATOMY. 
of delicate straight vessels which disappear under pressure and do not move with the con- 
junctiva ; they are the subconjunctival (episclerotic) terminations of the anterior ciliary 
arteries ; in health they are invisible. 
Lachrymal Apparatus.—The lachrymal gland, situated behind the outer part 
of the supra-orbital margin, cannot be felt unless enlarged. By everting and 
raising the upper eyelid, the accessory (palpebral) portion of the gland is seen to 
project beneath the outer third of the fornix, in which situation ‘also the minute 
orifices of the lachrymal ducts may be detected. By gently drawing downwards 
the lower lid, the small punctum lachrymale is seen situated upon a slight papillary 
elevation of its margin about 4 mm. from the inner canthus; the corresponding 
orifice of the upper lid is placed a little nearer the canthus. Normally the 
puncta are directed towards, and accurately applied to, the ocular conjunctiva 
immediately external to the caruncle. By drawing the lids outwards the internal 
palpebral ligament is put upon the stretch, and can be felt as a narrow tense band 
passing transversely inwards to be attached to the nasal process of the superior 
mnaxilla. The ligament’ is a guide to the position of the lachrymal sac, which it 
crosses a little above its centre. Continuous with the lower end of the lachrymal 
sac 1s the nasal duct, which passes downwards and slightly backwards and outwards, 
to open into the inferior meatus of the nose, under cover of the anterior end of the 
inferior turbinal. The lachrymal sac and duct each measure about $ in. in length ; 
the latter is shghtly contracted at its commencement and termination, and it is in 
these situations that pathological strictures of the duct are commonest. Spon- 
taneous rupture of an abscess of the lachrymal sac. almost invariably occurs just 
below the tendo palpebrarum; it is in this situation that the abscess should be 
opened, the incision being made a little external to the angular termination of the 
facial artery. 
The canaliculi lachrymales, lle convey the tears from the puncta to the lach- 
rymal sac, run for the first 1-2 mm. almost vertically to the free margins of the 
lids, and thence parallel to ret Between the canaliculi is the lachrymal caruncle. 
In the various morbid conditions which give rise either to misdirection of the 
puncta or to stricture at any part of the lachrymal drainage apparatus, overflow 
of the tears (epiphora) is the chief symptom. In passing a probe along a 
canaliculus the instrument, in consequence of the bend upon the duct, Is 
passed at first vertically to the margin of the lid, and afterwards parallel to it, 
until the point is felt to strike against the inner wall of the lachrymal sac; to 
pass the instrument onwards along the nasal duct the handle is rotated forwards 
and upwards through a quarter of a circle, and then pushed gently downwards and 
slightly backwards and outwards into the inferior meatus of ‘the nose. 
The tarsal “cartilages” are attached to the periosteum of the orbital margins by 
the orbito-tarsal ligaments which shut off the communication between the subcuta- 
neous tissue of the eyelids and the fatty tissue of the orbital cavity. In fracture 
of the anterior fossa of the base of the skull involving the orbital plate, the blood 
extends forwards between the periosteum and the musculo-fascial envelope of the 
orbit and appears under the conjunctiva. 
To obtain free access to the cavity of the orbit, the surgeon first enlarges the 
palpebral fissure by making a horizontal incision from the outer canthus to the 
outer margin of the orbit, and then, after everting the eyelid, divides the conjunc- 
tiva along the fornix of the upper or lower lid, or of both, as may be desired. 
Nose.—To examine the anterior nares (anterior rhinoscopy) a strong light is 
reflected into the nostril which is dilated by means of a nasal speculum. The 
anterior extremity of the inferior turbinal appears as a rounded body projecting 
from the outer wall of the nose; in turgescence of its erectile tissue it is Hable to 
come in contact with the nasal septum and so occlude the nostril. The inferior 
meatus, situated between the inferior turbinated body and the floor of the nasal 
fossa, is brought ito view by tilting forwards the head. The lower aperture of the 
nasal duct is concealed from view by the anterior part of the inferior turbinal. 
The floor of the nose is horizontal and placed on a slightly lower level than the 
anterior nares. The septum, generally more or less deviated to one or other side, 
is seen when the head is slightly rotated away from the side to be examined. The 
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