INFLAMMATION OF THE LACHRYMAL APPARATUS.* THE By G. HERBERT BURNHAM, M.D., F.R.C.8. EDIN., Professor of Ophthalmology and Otology, Medical Faculty, University of Toronto. 'HE Lachrymal apparatus is divided into two parts, viz., that which produces the tears, and that which carries them away. This latter begins at the punctum, then next the canaliculi of the upper and lower lids, the lachrymal sac into which they empty single or united, and the nasal duct, whose lower extremity terminates beneath the n ferior turbinated bone. It is with this latter, or the drainage part, my remarks have to do. A troublesome cause of watering of the eye is either stricture of the punctum or its displacement, or catarrhal inflammation of the canaliculus, or some stricture in its passage, or some foreign substance in its interior. A very delicate probe can be passed through the punctum and -canaliculus to dilate them. Then by means of the lachrymal syringe liquids can be sent in, and in this way the inflammatory conditions can be removed, and the patency of the tract shown. Also, the patient can be given drops to use at home. The liquids which can be used with the syringe are solution of cocaine to dull the sensitive inflamed tissue of the canal, adrenalin solution, and many others. The patient can be given adrenalin solution to use at home by filling with it the inner corner of the eye and allowing it to remain in ten minutes, or so, ia order that it may make its way into the canaliculus. If this should not be satisfactory, the canaliculus can be slit up as devised by Bowman. This operation is especially applicable as a remedy for malposition of the punctum. However, inflammation of the lachrymal sac is that of which I wish especially to speak. Uncòmplicated, primary inflammation of the lachrymal sac is seldom met with, and, if it occur, is usually due to struma, external violence, or the entrance into the sac of an irritating fluid. The usual cause of this inflammation, or dacryocystitis, as it is called, is stricture of the nasal duct. The drainage of the sac being interfered with, the fluid contents accummulate and un dergo pertrifactive changes. In this way a chronic catarrhal inflammation or blenorrhea is set up. The distended sac is continually sending back muco-pus through the canaliculi into the eye. Acute exacerbation may occur. This abscess of the sac is attended by much suffering and const tutional disturbance. Sometimes the redness and the extent of the swelling is so great as to be confounded with erysipelas. The attach runs its course. The tissue over the sac and the integument become Rad before the meeting of the Ontario Medical Association at Toronto, June, 1901. affected. When the pus makes its way through the sac wall into the overlying tissue, the pain ceases and an abscess is formed. At the beginning, an effort may be made by leeching, cold and calomel purging to cut short the attack. As a rule this is futile. When the progress of the attack cannot be stopped then apply freely linseed poultices. When there is fluctuation incise through the integument into the sac and thus give exit to the pus. Later on the condition can be treated by another operation which I shall shortly mention. A close relationship exists between the drainage apparatus of the eye and the nose. The membrane of the duct is continuous above with that of the sac and below with that of the nose. It is very vascular and is a periosteal and mucous membrane. The calibre of the duct varies very much, and in the skull will admit the passage of a probe sometimes of three millimetres only, and again of seven in diameter. Owing to the peculiarities of the lining membrane of the duct, it is easily seen why an inflammation may lead to stenosis of the duct, and later on to the formation of periosteal and tony strictures. This condition never undergoes a spontaneous cure, and, unless treated, is a standing menace to the eye, being a cause of great annoyance, aggravated at times by acute painful attacks. Inflammation of the conjunctiva has very slight tendency to affect the lachrymal sac, as evidenced by its absence in the most severe forms of conjunctival inflammation. The history of the inflammation of the lachrymal sac and strictures of the nasal duct would fill books, I may say. I intend to give the plan of treatment which I have found the most successful. The instruments I use are silver styles of various shapes : probes, Nos. 1, 2, 3 and 4, out of a series of eight sizes; a Bowman's and a Weber's canaliculus knife; and under certain conditions, a Graefe's cataract knife and an Anel's syringe. Having decided to operate by means of a Weber's canaliculus knife, I divide the canaliculus into the sac. The procedure of slitting the canaliculus was devised by Bowman and was a great advance upon all previous methods of dealing with lachrymal obstruction, and facilitated the passage of probes, which bear his name. As this form of treatment was not satisfactory, several oculists, without being aware of the labors, of each other, decided that it larger probes were used the results would be more satisfactory. These probes varied in size from mm. to 4 mm. At the first probing and afterwards the usual rule is to pass as large a probe as possible every other day and allow it to remain in position quarter to half an hour. Then later, once every week, ten days or a fortnight, and, finally, eve v month or two, till the stricture shows no tendency to return, and the blenorrhea of sac and the inflammation of duct have disappeared Styles of lead and silver, if used, are used under protest almost, and would not be considered, if the patient could remain so as to have uninterrupted probing. Then some go on naively to remark that the application of medicated solutions of various kinds has never secured any attention, as they were considered almost useless. With this mode of treatment, viz., the use of as large probes as can possibly be passed and the non-use of medicated solutions, I do not In fact, my procedure is not only different, but I consider much more easily borne by the patient, and also more successful as a curtive measure. Having divided the canaliculus into the sac, I introduce by a syringe a 5 per cent. solution of cocaine, then pass a probe, sometimes Nos. 1 and 2 only, and sometimes Nos. 3 and 4, but never any larger, though the largest of the series is No. 8. I irrigate the whole passage, so that the fluid passes freely into the nose, with adrenalin solution, followed by a solution 1 in 2,000 of permanganate of potash, or any other you may choose to use. Then I pass a silver style and allow it to remain in position. The probes are passed through and taken out at once, so that the whole operation takes but a short time, and is comparatively easily borne by the patient. Then the patient is directed frequently to bathe the parts with hot water. I do not disturb the style till the tenderness consequent upon the operation has subsided, which may be a few days or so longer. On the next visit I withdraw the style, then use the syringe to send in the cocaine solution followed by adrenalin solution, and solutions of permanganate of potash, of argyrol, tannic acid, etc. In this way the sac and duct being pervious are freely irrigated. The style is then replaced. The whole procedure is done quickly with very little suffering, and is a decided contrast to the passing of probes till one is tried so large that, after very firm pressure, it fails to go through, and, if it does, is allowed to remain in position for quarter to half an hour. This procedure of mine quickly stops all discharge, and hence a condition is established which aids very much in the removal of the stricture. In a short time I send the patient away to reappear at stated intervals, gradually lengthening. While the parts have apparently he come healthy, the eye is often annoyed by a little watery discharge, more or less pronounced, which is very disagreeable to the patient and unsa isfactory. This often arises from an unevenness of the floor of the divided canaliculus, caused by firm little fibrous bands stretching across its floor, in fact, more like a rising up of the floor here and there into sharp ridges. This is not noticeable at first, but comes on in the process of treatment. It is found out on passing a probe along the floor of the canaliculus, it meets with little obstacles, which catch its top. These can be easily ridden over, so that it goes on and enters the sa: These little bands act as shallow dams and interfere with the proper drainage of the eye. These I divide as they arise in the course of treatment by a sharp-pointed Graefe's knife. I am always on the alert for these bands. This condition is a point not mentioned, or, if noticed, not paid any attention to, whereas I feel it to be of great importance to the full drainage of the eye. In some cases it is difficult to pass a probe on account of the nature of the stricture. To do so most firm pressure is sometimes needed, so firm that the probe has to be grasped by the hands, and, being sure of the proper direction of your probe, to be forced through, having always the probe so well under command that, when it passes, its course can be stayed. I well remember one case of very severe and long-established inflammation of each lachrymal passage, and which, moreover, had been given up as incurable, when it took me two months to force the passage on one side. In this case, by very firm pressure, I finally made a lodgment in the duct; and then by firm pressure, with both hands on the probe from time to time, finally it went through the natural passage. The results under my form of treatment have been very satisfactory; and, what is as gratifying as success, with very much less pain, discot:fort and dread to the patient than under the treatment commonly advocated. In children chloroform should be used for the first operation; but, in the after treatment of the case on the lines laid down by me, it is not needed, as the suffering is so minimised. IT TUBERCULOSIS OF THE FEMALE URINARY ORGANS. By ERNEST W. CUSHING, M.D. Professor Gynaecology and Abdominal Surgery. Tuft's University, Boston, Mass. T has long been observed that certain cases of chronic cystitis were incurable, and that in spite of every method of treatment the wretched sufferers went on from bad to worse until they perished miserably. In time, as the art of diagnosis advanced, it was learned that these *Read before the Maritime Medical Association, Halifax, July, 1904. cases were tuberculous, and now that we have means of demonstrating the presence of the tubercle bacillus in the urine the diagnosis is easy. Nevertheless for a long time the improvement in diagnosis was of little value,except to establish an absolutely unfavorable prognosis, for it was still found that only temporary relief could be obtained from any form of treatment. When at autopsies, held on persons who had died with tuberculous disease of the bladder, a kidney, and, perhaps, the corresponding ureter, were found to be also greatly disorganized with tubercular disease, it was at first supposed that the infection had ascended from the bladder, involving the kidney secondarily. Finally, however, cases multiplied in which after a tuberculous kidney had been removed, because the principal disease appeared to be located in it, although there was some tubercular disease of the bladder, the result showed that the tuberculosis of the latter organ improved, and finally disappeared under judicious treatment and favorable circumstances. It is now established, therefore, that tuberculosis of the urinary organs is a descending affection, that it first obtains lodgment in the kidney, supposedly deposited there by the blood-stream from some other focus in lung, glands, bone, skin, etc. That the infection then descends with the urine, probably not at first attacking the ureter. That, finally, from some obstruction to the escape of urine from the ureter into the bladder, the current of urine in the ureter is slowed or made to stagnate, and infection of the ureter follows. By observation of a very large number of cases, and a careful study of post mortem examinations the pathologists are able to assure us that tuberculosis of the bladder is rare, except in cases in which the kidney is involved. They have also established the fact that fortunately only one kidney is affected in the vast majority of cases. Clinical experience, and the results of surgical operation confirm these assertions, and also establish the fact that after removal of the diseased kidney the tuberculous bladder is generally curable. The case which I report to-day, and from which I show the specimen, is of much clinical interest, because there were never any symptoms referable to the kidney, and because a long course of life in the open air improved the patient's health so markedly that she, was brought up to a condition fit for the serious operation of nephrectomy, and now appears to be in a position to overcome the tuberculous infection which has become entirely localized. Miss X., age 30, was admitted to my private hospital in February, 1902. She had been healthy as a girl, but for several years previous to the above date had suffered from pain at menstruation. In 1900 she un |