fistulous opening of the integuments. He probably pronounces the case to be a fistula lachrymalis, and forthwith opens the sac.

It

"Let us distinguish this case from another to which it bears some resemblance, but with which it must by no means be confounded. may happen that the purulent matter accumulated under the integu. ments has actually penetrated the anterior side of the sac, which thus comes to be filled with pus received from without, in the production of which its lining, or mucous membrane, has had no share. This latter case, which, for the sake of distinction, may be called spurious fistula of the lachrymal sac, must be carefully distinguished both from the former, in which the sac is entire though distended with mucus, and from those diseases hereafter to be described, in which the purulent matter that fills the sac is the result of inflammation of the lining mem. brane of the sac itself."

We have indulged in the foregoing extensive transcription, because it furnishes a good specimen of the author's accuracy of observance, and will show the importance of precise pathological knowledge in the treatment of the disease.

Some observations on the causes, prognosis, and the general and local treatment, follow; from which we adduce an extract, that, with the preceding account, will convey rather a comprehensive view of the most important part of this section of the work.

"At the commencement of the suppurative stage, the patient must first of all be placed in a warm and dry atmosphere. A dry linen compress ought to be laid upon the affected integuments. Gentle diaphoretics ought to be given. If the symptoms indicate the formation of a subcutaneous abscess, a warm poultice of bread and milk ought to be applied. Still, we must not leave the matter of the abscess to make a way for itself through the integuments; but, as soon as even indistinct fluctuation is perceived, we must open the abscess with the lancet, in order to save the lachrymal sac, and prevent the formation of a spurious fistula.

"If we are not called till such a fistula has formed, let us beware of all unnecessary introduction of probes and syringes into the sac. By means of a small syringe, the fistula is to be washed out once a-day with tepid water, mixed with a little of the vinous tincture of opium. A small quantity of lint dipped in the same tincture, is then to be in troduced into the abscess, but not pushed so deep as to enter the lachrymal sac. After the fistula has healed, the blenorrhoea which may remain is to be treated as shall be explained in the fourth chapter."

In the form of disease next considered, acute inflammation of the excreting parts of the lachrymal organs, the primary seat of the malady is the mucous membrane of the whole of the excretory parts of the lachrymal organs; this is accompanied with

"Obtuse, deep-seated pain, extending to the nose, and even to the eye-ball; a swelling appears in the situation of the lachrymal sac,

having the shape of a bean, accurately circumscribed, hard, very sensible to the touch, and affected with stinging pain whenever it is pressed. This swelling becomes gradually red, at last extremely red, and then the least touch is insupportable. The papillæ are shrunk, the puncta are scarcely visible; the absorption and conveyance of the tears into the lachrymal sac, and through the nasal duct into the nose, are completely stopped, and a stillicidium, or discharge of tears and mucus, takes place from the nasal angle of the eye. The nostril on the affected side is at first uncommonly moist, but it soon becomes dry, the inflammation extending to the mucous membrane of the nose. The inflammation affects the caruncula lachrymalis and the conjunc tiva, spreading also to the orbicularis palpebrarum, and to the inte guments of the lower eyelid. The redness about the nasal angle of the eye, even with some degree of swelling even to the cheek, gives to the parts, when viewed at a distance, an appearance as if the integuments were attacked by erysipelas; but, on a nearer examination, the ресиliar redness, and all the other characteristics of phlegmonous inflammation, are recognized; and, in the midst of the diffused discoloration and tumefaction, the circumscribed swelling of the lachrymal sac is evident, not merely to the touch, but even to the view."

The author traces the progress and consequences of this af fection in a very lucid and satisfactory manner: the most frequent results, when the inflammation has been severe, are thickening of the mucous membrane of the whole organ, and obstruction of the canals and nasal duct. The abundant secretion of mucus, being collected, distends the sac, induces inflammation and consequent rupture of its paries, and the matter is evacuated externally through the fibres of the orbicularis palpebrarum muscle and the common integuments: the consequence of this is the fistulous opening, described more particularly and distinctly in the fifth section of this essay. Sometimes, even after this accident, the natural passage of the tears is spontaneously re-established, and the opening in the paries of the sac will heal. The latter occurrence may also happen whilst the nasal duct alone remains impervious; when the pa tient is obliged, several times a-day, to press upon the sac to evacuate its contents. If the wound be permitted to heal whilst the canals and duct are both obstructed, the natural secretion of mucus going on will distend the sac, and induce the disease de scribed in the ninth section under the term mucocele, by Mr. Mac Kenzie; or what is, not so appropriately, called dropsy of the sac by Prof. Beer.

A more mild degree of inflammation, or irritation, of the same parts, constitutes the next variety, chronic blenorrhea of the excreting parts of the lachrymal organs. This is the most common of the diseases described in this essay, and is treated by the author in rather an extensive manner. The various causes, constitutional and local, from which it arises, and the conse→

quent diversity in its character and the treatment required for it, render it impossible to convey much information respecting it in an abstract. A bean-shaped tumor, from distention of the sac, and a discharge of puriform mucus through the puncta, (for the canals are not obstructed,) are the most usual symptoms. Persons of a scrofulous habit are most frequently the subjects of it; and it is usually particularly troublesome, or solely attacks the patient, during cold and wet weather. The more severe consequences of it are fistulæ, from attacks of acute inflammation ending in suppuration; induration of the organ; and permanent obliteration of its canals. The obstruction of the nasal duct, in the first instance, merely depends on the tumefaction of its mucous membrane.

This affection is ordinarily much mismanaged by practitioners in general, from a want of correct knowledge of its real nature. Stillicidium lachrymarum is properly distinguished from epiphora; the former depending on obstruction of the excretory parts of the lachrymal organs, the latter on increased secretion of the tears; and, in the former point of view, cannot with propriety be considered as a form of disease.

In the section on fistula of the lachrymal sac, the author describes, in a particular manner, the different varieties of ulcers connected with the paries of that organ, and the appropriate mode of treatment under the various circumstances in which they appear.

From the chapter on caries of the os unguis, we must transcribe the following passage; it describes what we believe is frequently too true.

"The idea of the frequency of caries of this bone, which, notwithstanding the testimony of Sharp and Janin, has continued to prevail, appears to be founded chiefly upon the mismanaging treatment of surgeons themselves; and, above all, is to be attributed to their rude examination of the parts with probes and other instruments. A patient presents himself with fistula of the lachrymal sac; the idea of caries starts up in the surgeon's mind, and he forthwith takes a probe in order to examine whether there is caries or not; he penetrates the posterior part of the lachrymal sac, touches the bone with the point of the instrument, which he moves about to this side and to that, in order to make himself sure of what he is seeking for; and at last, distinctly feeling the bone, which he has denuded, he pronounces the os unguis to be carious."

Caries of this bone but rarely happens, except from fistulous ulcers of the sac, syphilis, and scrofula; and is, consequently, not a subject for any important measures of expressly local

treatment.

The relaxation of the lachrymal sac, is a consequence of its over-distention by collected mucous or puriform matter in the

diseases described in the third and fourth sections, which has destroyed its natural contractility; and it becomes distended by its own mucus, often still secreted in preternatural quantity, and the tears collected in it, into a bean-shaped tumor. The integuments covering it are scarcely or not at all discoloured; it is not painful, it yields easily, to the pressure of the finger, and never exceeds the size of a common horse-bean. Its contents are discharged by pressure, either by the canals or the nasal duct, according to the direction in which the force is applied.

"The treatment consists in the use of two distinct means, each of which, as may be seen by the testimony of Pellier and others, is, when used alone, apt to fail.*

"The first is the compression of the sac; and here let it be observed, that the present is the only case in which compression of the sac is useful. In any other disease of that part, this practice would produce the most destructive effects. The compression must be carefully applied, constantly continued, and gradually increased. Machines have been invented for this purpose, but they never fulfil with precision all these conditions. We cannot, by such an instrument as Sharp's or Petit's compressorium, the first invention of which we owe to Hieronymus Fabricius, keep up a regular and an increasing pressure: the compressing surface, upon the least occasion, especially during the night, is disarranged; and the patient is hindered from pursuing his business by the presence of such an apparatus. Graduated compresses, then, are to be preferred; over these a firm leather pad, of a proper form, is to be placed; and the whole is to be supported by a narrow roller passing round the head. In this manner, the pressure takes place exactly upon the part which ought to be acted upon; it can be daily increased; the pad cannot, even when the patient is very restless, be shoved aside; nor need such an apparatus prevent him from following his ordinary employment, even out of doors."

"The second part of the treatment consists in the application of some astringent fluid, both to the external surface of the tumor, and to the internal surface of the relaxed sac. A great variety of astringents might be mentioned as proper for this purpose; such as the sulphate of iron or of copper in solution, an infusion of oak-bark, or diluted alcohol. The graduated compresses are to be moistened twice or thrice daily with the astringent fluid which shall have been selected. A small quantity also of the same fluid is to be dropped into the lacus lachrymarum, and left to be absorbed by the puncta, the patient be ing laid in a horizontal position, and the compresses somewhat relaxed, but not removed.

"Such is the method of curing a disease, which I have shuddered to see treated by incision of the sac, and the passage of various instru

* POTT-Observations on the Fistula Lachrymalis. Works. London, 1808. Vol. i. page 252.

PELLIER DE QUENSY, Cours d'Operations sur la Chirurgie des Yeux. Paris, 1790. Tome ii. page 207.

ments through the nasal duct; operations which are to be regarded as the more severe in such cases, because they are wholly unnecessary. As for the Anelian injections, the direct injury of the papillæ, and the over-distention and consequent atony of the puncta, so that they can no longer absorb the tears, are only some of the bad consequences of such a practice. Such injections in this particular case would be attended also by a momentary over-filling of the sac, which would be just undoing with the one hand what we were effecting with the other."

In the mucocele of the lachrymal sac, the tumor is accompanied with a purplish colour of the integuments, and it often attains the size of a pigeon's egg; it is very firm to the touch, and its contents cannot be evacuated by pressure, because the canals and ducts are both totally obstructed.

"The colour of the integuments in mucocele has led some authors to describe this disease under the name of varix of the lachrymal sac; and the hardness and size of the tumor, added to its colour, have frequently led those charlatans, who were formerly but too often intrusted with the care of the diseases of the eye, to extirpate the. lachrymal sac affected with mucocele, under the idea that they were removing a cancerous tumor."

In the appropriate treatment of this important form of disease, the question is not whether the tumor only can be removed, for this can always be effected by laying open the sac, and turning out its contents: the important question is, whether or not the natural passages can be restored.

Obstruction of the lachrymal canals and nasal duct, are the affections best understood by the English and French surgeons, being those to which their attention has been chiefly directed in their views of the diseases of the organ under consideration; yet the observations of Mr. Mac Kenzie on these subjects will be perused with advantage.

Our observations on this essay have occupied a much greater space than we usually devote to so small a work; but this has necessarily arisen from the very concise manner in which the author has himself treated the different subjects it embraces: he has effected this as closely as is consistent with perspicuity of pathological description and practical utility. This is a circumstance which will contribute much to favour the benefit that will ensue from his labours, by rendering general the possession of this work by practitioners of surgery. This is no unimportant merit, at a time when productions in medical literature are so numerous, and in general so expensive, as they are at the present period.

We hope to see Mr. Mac Kenzie pursue the course he has here commenced: there are many other points in the pathology of eye, and the parts subservient to it, on which he might ad

the