THE FACE. 1377 



ire the minute orifices of the tarsal glands. These glands, embedded in the deep 

 surface of the tarsi, are seen through the palpebral conjunctiva as a row of parallel, 



yellowish, granular-looking streaks. From the deep position of the glands it follows 



bhat the skin over a Meibomian cyst is freely movable, and that to reach the cyst 



in incision should be made through the coujunctival surface of the lid. 



The palpebral conjunctiva is closely adherent to the ocular surface of the tarsi ; 



it the fornix it is loose and contains small lymph follicles, which become hyper- 

 t brophied in the condition known as granular conjunctivitis. The ocular conjunctiva 



is thin, transparent, and loosely attached to the sclera, so that in operating upon 

 *bhe eye a fold of the membrane can be picked up with forceps to steady the 



3yeball. 



In inflammatory affections of the eye the state of those vessels which are visible gives 

 \ mportant information as to the seat of the mischief. For example, in inflammation of 

 phe conjunctiva the posterior conjunctival vessels (derived from the palpebral arteries), 

 : scarcely visible normally, appear as a close network which fades away towards the corneal 

 inargin ; these vessels move freely with the conjunctiva, and do not disappear under pres- 

 sure. In superficial inflammations of the cornea the anterior conjunctival vessels (the 

 jnost superficial of the terminal branches of the anterior ciliary arteries) are seen to 

 j spread in a freely branching manner into its superficial layers. In iritis and deep inflam- 

 mations of the cornea there is a pink circumcorneal zone of vascular dilatation consisting 

 i )f delicate straight vessels which disappear under pressure and do not move with the con- 

 [ unctiva; they are the subconjunctival (episcleral) terminations of the anterior ciliary 

 irteries ; in health they are invisible. 



Lacrimal Apparatus. The lacrimal gland, situated behind the lateral part 



)f 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 lateral third of the fornix, in which situation also the minute 



;:>rinces of the lacrimal ducts may be detected. By gently drawing downwards 



ihe lower lid, the small punctum lacrimale is seen situated upon a slight papillary 



Blevation of its margin about 4 mm. from the medial palpebral commissure , the 



3orresponding orifice of the upper lid is placed a little nearer the commissure. 



Normally the puncta are directed towards, and accurately applied to, the ocular 



3onjunctiva immediately lateral to the lacrimal caruncle. By drawing the lids 



laterally the medial palpebral ligament is put upon the stretch, and can be felt as 



i a, narrow tense band passing transversely medially to be attached to the frontal 



: process of the maxilla. The ligament is a guide to the position of the lacrimal 



sac, which it crosses a little above its centre. Continuous with the inferior end 



of the lacrimal sac is the naso-lacrimal duct, which passes downwards and slightly 



backwards and laterally, to open into the inferior meatus of the nose, under cover 



of the anterior end of the inferior concha. The lacrimal sac and naso-lacrimal 



duct each measure about \ in. in length ; the latter is slightly contracted at its 



commencement and termination, and it is in these situations that pathological 



strictures of the duct are commonest. Spontaneous rupture of an abscess of the 



lacrimal sac almost invariably occurs just below the medial palpebral ligament ; 



it is in this situation that the abscess should be opened, the incision being made 



: a little lateral to the angular termination of the external maxillary artery. 



The canaliculi lacrimales, which convey the tears from the puncta to the lac- 

 rimal sac, run for the first 1-2 mm. almost vertically to the free margins of the 

 , lids, and thence parallel to them. Between the canaliculi is the lacrimal caruncle. 

 In the various morbid conditions which give rise either to misdirection of the 

 puncta or to stricture at any part of the lacrimal drainage apparatus, overflow 

 of the tears (epiphora) is the chief symptom. In passing a probe along a 

 icanaliculus 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, 

 i until the point is felt to strike against the medial wall of the lacrimal sac; to 

 .pass the instrument onwards along the naso-lacrimal duct the handle is rotated 

 i forwards and upwards through a quarter of a circle, and then pushed gently down- 

 wards and slightly backwards and laterally into the inferior meatus of the nose. 



88 



