A certain amount of experience, arising from the patient's peculiarities and from possible complications, is always gained by making the single operation, whether the results be good or bad, and the use of this knowledge would surely be a valuable guide, and increase the chance of success on the second eye. Not infrequently it has happened to the most experienced and competent oculist that an eye has been lost after extraction through inflammation or other mishap-whereas later on, guided by his first experience, the other eye has been operated on by the same surgeon with perfect success. Now and then it happens that an eye lost through violent inflammation following a cataract operation, requires to be enucleated because of the sympathetic irritation, before we dare proceed with the operation on the other eye. It is easy to predict what would have happened to the fellow eye had bilateral extraction been performed in such an instance. In this connection I would say that sympathetic ophthalmia is not a frequent but a distinct element of danger to be reckoned with in considering the double cataract operation.

Accidents and the patient's disturbed mental condition following cataract extraction are contraindications to the bilateral operation. The unmanageable patient tossing from side to side of the bed, displacing his bandage, striking the eye with his hand, springing suddenly up in bed and by a strain disturbing the corneal wound, coughing, sneezing, etc., are actual occurrences in the hands of every experienced operator.

I once had a patient, who from a violent fit of coughing, sneezing and vomiting, had a profuse intraocular hemorrhage with complete emptying of the contents of the ball. If one could be happy under such circumstances, I was reasonably so, when I reflected that the

other eye had not been touched. Loss of the vitreous, hemorrhage, panophthalmitis following accidents, glaucoma and possible sympathetic inflammation, with infection from many sources, constitute a chapter of possible accidents with such dreadful results that I feel warranted in asserting that it would be unwise and unjustifiable to extract both cataracts at the same time.

Mental disturbances after cataract operations are of sufficient frequency to cause the surgeon some concern. Occasionally, after several days of confinement with both eyes bandaged, the patient becomes melancholy, has hallucinations and, in rare instances, becomes violent and ungovernable. This condition generally passes rapidly away on uncovering the other eye, even though this is practically blind, and getting the patient into the fresh air. One such patient threw himself through a window, carrying sash and glass with him, while in this temporarily perturbed mental state. Another, who had been a sleep-walker in his boyhood days, eluded his attendant and climbing through a second-story window, leaped to the ground below. Again, I would say, there is some comfort in such cases, when we consider that only one eye has been operated on.

On one occasion Mr. Nettleship, a surgeon of vast experience, after having extracted one cataract under general anesthesia, turned to his class and remarked: "Now, gentlemen, what a temptation the opportunity presents to extract the other. But, gentlemen, never do so, until your patient has fully recovered from the first operation."

Looking at it from every point of view, to my mind, the extraction of cataract is one of the most important of all surgical operations, the whole future of the patient depending on its successful outcome. Answering from

the standpoint of the patient, would one of us willingly submit to the bilateral extraction? I would myself unhesitatingly cry out "No!"

The second part of my subject is quickly answered. "How soon after the operation on the first eye is it safe to extract the second cataract?"

There are competent surgeons who maintain that it is not wise to operate on the second eye at all, if good results follow the first operation. There are good reasons for this conclusion. The frequent disturbance of muscular equilibrium, the confusion due to unequal vision in the two eyes, constitute reasonable grounds for advising against the second operation, provided the first has been a success.

My rule, however, is to operate on the second eye if the patient desires it, but I do not urge the operation. Circumstances should always guide us in selecting the time for the second operation, but except for some special reason, I prefer to wait six or eight weeks, when the first eye has recovered from all reaction, and the general health of the patient has been thoroughly restored. There can be no rule; each case must be its own law, but I am convinced of the fact that in ignoring the patient's desire for haste, we are but adding to his chances of successful results.

LACHRYMAL STENOSIS IN INFANTS AND ITS

TREATMENT.

BY DUNBAR ROY, M.D., ATLANTA.

If one will examine the various text-books on ophthalmology, he will be unable to find any reference to the subject of the treatment of lachrymal stenosis in infants. "The conclusion therefore derived is, that such a condition in infants is treated in the same manner as in adults. This I consider erroneous teaching. Very grave injury would frequently be done to the lachrymal passages of these tender little individuals if the same ruthless probing and cutting were done as is frequently the case among adults. During the last four years of my practice I have had eight cases of lachrymal stenosis in infants, all of which recovered perfectly without instrumental interference, and one case presented some such striking features, whether as a coincident or as a casual relationship I do not know, that I shall take the liberty of referring to it more in detail. In speaking of lachrymal stenosis in infants we must naturally do so in a very indefinite manner, not knowing whether the stenosis is in the puncta lachrymalia, the canaliculi, lachrymal sac or in the duct proper. This could only be determined by delicate probing or post-mortem demonstrations, both which methods being often impracticable. When we speak of lachrymal stenosis in infants we naturally mean such cases as present the usual accompanying symptoms of excess of tears in the conjunctival sac or even flowing out upon the

cheek, some excoriations of the lower lid, and some slight catarrhal condition of the palpebral conjunctiva. There need not have been previously a dacryocystitis, either acute or chronic.

The well-known fact that the mucous membrane in: infants is so susceptible to swellings and edematous conditions will in a great measure account for the stenosis. occurring in individuals of this age. Yet such pathologic conditions do not constitute the whole etiologic factor in these cases.

For convenience I have made the following groupings. of lachrymal stenosis occurring in infants:

1. Stenosis due to Congenital Malformations and Non-development in some Portions of the Lachrymal Passages. Cases of congenital malformation in some portion of the lachrymal passages have been reported by several observers, and in the presence of such must not be ignored, when cases of epiphora in infants are brought to us for treatment. Congenital absence of one or more puncta lachrymalia have been noted by various writers.

Benjamin Travers, as early as 1824, says in his book on "Diseases of the Eye," that he had seen a congenital deficiency of the puncta, but the case was very rare, obliteration being much less so. Schon, in 1828, noted the: fact that puncta had been observed closed entirely in newborn infants, and cites two or three authors who mention the condition or had seen cases. V. Walther states that congenital atresia of the puncta does not occur except in connection with monopsia or micropsia; and Desmarres states that Seiler, Schoen, Carron and others have noted congenital atresia of the puncta mostly in connection with concomitant absence of the eye. The congenital absence,. however, of these puncta have been observed by others, who make no mention of any other congenital defect..