toxin in vitro may be quite useless in treatment. It is therefore clear that the greatest importance must be attached to the prophylactic use of the serum, for this purpose patients are recommended to sleep during hay fever period always with their bedroom windows shut and to apply the 'Pollantin' regularly every morning a few minutes before getting up, both to the eyes and the nose."

"Exposure to the open air should be limited to a few hours at most. By this means according to experience a patient can guard himself from attacks for several hours, often indeed for the whole day. The use of the antitoxin is not followed by any ill effects, nor does it create a habit.' The use of subcutaneous injections is cautioned against as the results prevented its recommendation.

The paper concludes with a series of cases which have been treated in different places in Europe, nearly all of which point to its usefulness as a prophylactic.

OPHTHALMOLOGY AND OTOLOGY.

Under the charge of G. STERLING RYERSON, M.D., C.M., Professor of Ophthalmology and Otology, Medical Faculty, University of Toronto.

EXTIRPATION OF THE LACHRYMAL SAC FOR THE CURE OF DACRYOCYSTITIS.

Dr. E. W. Stevens, in Colorado Medicine, discusses the methods. and indications for this procedure in the June number as follows:

In the whole field of ophthalmic surgery there is probably no class of cases which gives more annoyance to the surgeon and discomfort to the patient than those of inflammation and stricture of the lachrymal passages.

As usually treated they are practically never cured. The patient is subjected to the annoyance of tears flowing over the margin of his eyelids, producing in many cases an eczematous eruption on the cheek. The regurgitation of the contents of the sac extends the inflammation to the conjunctiva, setting up and keeping up a chronic conjunctivitis. A large proportion of cases are liable to repeated attacks of acute inflammation of the sac with infection of the surrounding tissues and the formation of an abcess.

The point of greatest importance, however, in the pathology of dacryocystitis is the danger of an accidental abrasion of the cornea becoming infected by the contents of the lachrymal passages, and thus producing a septic corneal ulcer with all its attendant perils.

Of the pathology of dacryocystitis there is little or no difference of opinion. Stricture of the duct is admitted to be the chief, if not the

sole cause of the affection. Stricture may be brought about by extension of inflammation from the nasal mucous membrane, the cicatrization of ulcers in, or in the neighborhood of the nasal duct, the presence of polypi or other tumors and by injury or disease of the neigboring bones.

We may in general terms, divide the treatment of lachrymal obstruction and dacryocystitis into two heads: (1) Conservative treatment, (a) by small probes, and (b) by large probes; and (2) radical treatment by extirpation of the lacrimal sac. The probe treatment is usually supplemented by the injection of antiseptic and astringent solutions, and particularly is this true of those surgeons who use small probes through an intact canaliculns; amongst whom are such distinguished ophthalmologists as Von Mitchell, of Berlin, Schroeder, of St. Petersburg, and Adelheim, of Moscow. The majority of the European surgeons, however, first slit the canaliculus as a preliminary to probing, although it is exceptional for them to use large probes.

On the other hand, the American school of ophthalmologists influenced by the teachings of Williams, of Cincinnati, Noyes, of New York, and Theobald, of Baltimore, lays great stress on the importance of using large sounds in order thoroughly to dilate the stricture. There can be no question regarding the great superiority of this method of treatment as compared with the use of small probes.

The duration of treatment will extend to months and years, and there is usually a relapse even after an apparently excellent result has been attained. Frequently the patient, discouraged and weary of the long and painful course of treatment and hopeless of ever arriving at a permanent cure, is lost sight of.

The radical treatment of this affection consists in the removal of the lacrimal sac. The following is the method of removing the sac advised by Rollet, of Lyons, France. An incision about 15 mm. long, but varying in accordance with the size of the tumor, is made, starting from the level of the internal palpebral ligament and descending at first perpendicularly and then being directed to the outer side. It thus describes a curve running parallel to that which is formed by the crest of the ascending process of the superior maxilla which can be felt with the finger. The aponeurotic layer which covers the external wall of the sac is next incised. This is followed by a dissection of the fibrous layer, thereby exposing the anterior wall of the sac. The postero-internal portion of the periosteum and the external wall of the sac is next freed by means of a cutting raspatory. The cupola of the sac is next disengaged and the whole sac cut away from its attachments at the level of the nasal duct. The last step is to currette the nasal duct. After the

arrest of hemorrhage a flat dressing is applied, but neither drainage or sutures are used.

The scar is usually insignificant and hard to see. Suppuration is cured immediately the operation is performed, as well as all irritation and inflammation of the conjunctiva. The watering of the eye disappears with the cause of the hypersecretion, namely, lachrymal inflammation, and it is only when exposed to wind, dust, smoke, etc., that any epiphora is observed. In about 67 per cent. of cases no abnormal lachrymation exists.

Many ophthalmologists only resort to extirpation of the sac when other means have been fully tried in vain. On the other hand, Volckers, of Kiel, after performing over 500 extirpations, recommends the operation in all but the very mildest cases. He considers lachrymal obstruction to be a standing menance to the safety of an eye amongst the laboring classes, since working men and women cannot submit to a long course of treatment, while they are the very people most prone to receive slight eye injuries.

Fuchs, of Vienna, resorts to removal of the sac under the following circumstances: (1) When extensive cicatricial contractions are present or when the nasal duct is completely obliterated; (2) when atony and dropsy of the sac are present; and (3) when the patient's circumstances forbid a prolonged course of treatment.

Most operators will find themselves in accord with the generalization of Herman Knapp, that extirpation is indicated in all those conditions in which "an important lachrymal disease can not so well or not at all be cured otherwise."

LARYNGOLOGY AND RHINOLOGY.

Under the charge of PERRY G. GOLDSMITH, M.D., Belleville, Fellow of the British Laryngological, Rhinological and Otological Society.

THE TREATMENT OF TUBERCULAR LARYNGITIS.

S. E. Solly, M.D., Colorado Springs, in a paper read at the recent meeting of the American Laryngological, Rhinological and Otological Society (reported in June Laryngoscope), notes the very high mortality from this disease and the hopelessness with which it is too frequently combated. He thinks the chief reason for the high mortality is the almost invariable pulmonary disease and more important the feeble resistance found in the individual, as shown by the extension of the disease from one organ to another during the first stage of the attack,

furthermore, the local treatment of laryngeal tuberculosis to be successful demands special skill, experience, courage and patience on the part of the physician and faith and fortitude on that of the patient. Though we are able to save comparatively few cases of this disease, we are able, by judicious local treatment, to save a large number from the direful distress of an unchecked tubercular laryngitis.

The first essential of treatment is to place the patient under the best hygenic conditions, especially the open air treatment in a good sanitarium. The second is a change to a good climate of which the preferable elements are in their order, dryness, sunshine, cool air, and a high altitude. The third is local treatment by an experienced laryngologist. Solly lays stress upon absolute rest of the voice-a point too often. neglected. Pulmonary tuberculosis is not unfrequently preceded by a non-tuberculous laryngitis, which often masks its approach to the invasion of the larynx by tuberculosis. Attention is drawn to the necessity of attending to the nose and naso-pharynx. Solly thinks these regions should be treated as radically as the case demands and the general condition of the patient permits, more can safely be done than is usually thought. Cold inhalations are usually best, especially the compound tincture of benzion, one part; glycerine, one part; and alcohol, one and a half parts. This is also of great benefit to the bronchitis, accompanying tuberculosis of the lungs. In cases of tubercular infiltration of the larynx, without ulceration, he advises sub-mucous injections of about 30 minims of a 15 per cent. watery solution of lactic acid, preceded by an injection of cocaine and adrenalin. Lugol's solution, with an equal quantity of alcohol or glycerine, painted lightly over the parts, is also of service. When there is decided pain, particularly on swallowing, there is in most cases an ulcer which may be seen, owing to swelling on the parts. A frequent seat is the under surface of the epiglottis. The pain produced by these ulcerations is markedly lessened by the use of pure lactic acid. If curettage is necessary, it is best employed about three days after the use of lactic acid. Orthoform is not recommended by the author. Solly concludes his paper by saying that most physicians are far too timid in handling a tuberculous larynx, resorting in their blindness to superficial treatment, and to sedatives in their mistaken kindness, when in most cases they had far better use the radical measures herein indicated."

Harland, Laryngoscope, June, 1904, cites an interesting case of excessive hemorrhage following the removal of a faucial tonsil with a Matthieu tonsillotome. Various astringents and styptics were used but recourse to the Paquelin cautery was eventually necessary.

X-RAY THERAPY AND SKIAGRAPHY.

Under the charge of JOHN MCMASTER, B.A., M.D., C.M., Toronto.

X-RAYS AND INTERNAL FLUORESENCE.

Numerous reports are to hand by different x-ray operators of thefavourable effects of x-rays upon malignant lymphoma, or Hodgkin's disease, on lympho-sarcoma and in the different forms of leukæmia. Morton, of New York, has used, in some of these varieties of lymphosarcoma, internal fluoresence. He administers 10 grains of quinine bi-sulphate, or fluoresence, half-an-hour before making the exposure, and claims better results than without it.

Trials should be made of this therapy in all these otherwise fatal maladies and the results noted. At present, it seems as if great possibilities are open to experimenters along these lines. Pernicious anæmia is another form of blood dyscrasia that may be amenable to x-ray influence, especially under internal fluoresence.

X-RADIANCE IN EPILEPSY.

A considerable number of cases of epilepsy of varying duration have been given x-ray treatments, and the results reported in the Journals. When the condition has not been established for a long time, the results are very encouraging, and especially is this the case in young subjects. It is generally accepted that x-ray treatments, if not pushed beyond the proper limit, stimulates protoplasm into greater vital activity, and this may be the cause of the improvement in this class of cases.

Dr. Brantt, New York, gives three treatments a week, beginning with five minute exposures at fifteen inches distance, and by degrees increases to ten minutes at ten inches. A different part of the skull was exposed at each sitting, and a tube of high penetration used. The hair drops off usually near the parts exposed, but returns again later in stronger growth. In some cases the bromides can be dispensed with; in others, small doses prove beneficial. In young subjects a gain of weight soon results, and a marked improvement in the mental faculties takes place. The impediment of speech, which occurs in severe cases of long standing, has been removed by the raying; and the attacks, which numbered from six to ten a day, would be reduced to one every two or three weeks.

It is to be hoped that these results will be confirmed by others. I recall a case where I took two radiographs of the head with a view of locating the cause of the seizures. He had no attacks for over two months following the exposures.