contents of the sac by digital pressure and repeated irrigation of the eye without the use of the knife or probe. He quotes Vossius and certain French authorities in favor of gentle treament. He strongly urges this palliative treatment in preference to any instrumental applications. In support of Peter's theory, Lange reports a case of blennorrhea of the lacrymal sac in a child five days old. Pressure upon the sac was followed by a discharge of laudable pus from the nasal cavity of the same side, but none came from the lachrymal canals. All symptoms of lachrymal obstruction disappeared in a few days. Heddæus confirms the observations of Peters, but differs from him in thinking that the mechanical expression of the contents of the sac is unnecessary. Konigshofer, in discussing the epiphora in children, says that dacryocystitis or dacryostasis neonatorum, according to his observation, is mostly a temporary blocking of the passages by mucus or a persistence of a thin epithelial closure of the nasal end of the duct. All cases observed by him were cured by industrious expression of the lachrymal sac, a passage of the sound being necessary in only one case. Landolt, in treating of obstructions in the lachrymal passages of the new-born, has this to say in regard to the treatment: according to his observations it is never necessary to split the puncta. He dilates the punctum with a conical sound and injects either a bichlorid solution 1 to 5,000, or 10per cent. solution of boric acid into the sac with an Anel's syringe. An important cause of a catarrhal condition in the lachrymal duct, and more especially in the nasal cavities, is the presence of adenoids in the nasopharynx of these little patients. Three cases have come under my observation during the last two years, where a condition of watery eyes was associated with the presence of adenoids and where the removal of the latter caused an entire disappearance of the eye symptoms. I make it a practice to examine the nasopharynx of every infant brought to me with a catarrhal and watery condition about the eyes, and if adenoids are discovered they are removed immediately, no matter how young the patients. Before writing this article, and after consulting the various works on ophthalmology to see what the authors had to say in regard to epiphora in infants, I addressed letters to twelve ophthalmologists and asked them to answer the following questions: 1. Have you ever seen any case of stenosis of the lachrymal passages in infants which you thought was due to spasmodic contraction, the result of a reflex irritation? 2. What treatment do you use for lachrymal stenosis in infants? To these letters I received seven replies, as follows: Dr. H. Knapp: 1. No. 2. I leave the lachrymal trouble alone, as it commonly rectifies itself by the development of the nose. Dr. E. Gruenig: 1. I can not recall a case of lachrymal stenosis, either in infants or adults, due to spasmodic contraction. 2. In cases of lachrymal stenosis in children I probe under ether, using Theobald's probes. Dr. William Cheatham: I. No. 2. I have seen, I think, as many as five cases of stenosis of the lachrymal duct in infants, all relieved by one to three probings with Bowman's No. 1, without incision of the punctum. Dr. Swan Burnett: 1. I have never seen a case of stenosis of the lacrymal passages in an infant which I thought was due to spasmodic contraction. 2. The few cases of dacryocystitis in infants that I have seen I have treated in the usual way by opening the canals and treating the sac. I don't remember that I ever saw a case of stenosis not due to inflammation. Dr. Adolph Alt: 1. I do not remember having ever seen a stenosis of the lachrymal passages in infants which I thought was due to reflex contraction. 2. The cases of stoppage in infants, if not due to the infection of the mucous membrane of the drainage apparatus, I have always referred to an epithelial adhesion, and this usually gave way to one or two probings. Dr. George de Schweinitz: 1. I have never seen a case of stenosis of the lachrymal passages in an infant which I thought was due to a spasmodic contraction, the result of reflex irritation. 2. The treatment I use for lachrymal stenosis in infants depends entirely upon the etiology. Many of the cases get well without any treatment except some irrigation of the conjunctival sac and nares; they get well simply because in the development of the nose a preexisting contraction of the passage disappears. Others, evidently dependent upon a nasal catarrh in the broadest acceptation of the term, get well by nasal treatment. A few with a good deal of purulent secretion are associated with stricture and seem to me to demand the same treatment that a similar condition in adults requires. I very rarely, however, and I have seen a good many cases, have found it necessary to divide the canaliculus and pass probes. Dr. Samuel Theobald: 1. No. 2. I have met with a good many cases of blennorrhea of the lachrymal sac in infants, accompanied with epiphora. In most of these cases there was not an actual stricture of the duct (such as we meet with usually in adults), and they have gotten well without operative interference. My favorite remedy is a collyrium of hydrarg. bichlorid 1-24 grain, sodium chlorid 3 grains to ounce of water. This is to be dropped into the inner corner of the eye three times daily, each application to be preceded by an attempt to empty the lachrymal sac by pressure with the finger-tip. Occasionally it happens that no benefit results from this treatment. Then, after it has been thoroughly tested for some weeks, I resort to operation, slitting the canaliculus and probing the duct. In all my cases a cure was established by the use of an astringent wash to the conjunctiva in connection with massage over the lachrymal sac. In no instance was a probe used. I can imagine some cases where it is neces sary to slit the canaliculi and pass probes into the nasal duct. Palliative measures, such as the use of astringent washes, accompanied by massage over the lachrymal sac, will accomplish the necessary result in all but exceptional cases, even if the treatment has to be continued for several weeks. I believe that the canaliculus should never be slit, and thus destroying forever the contractile effect of the sphincter around the puncta. At the same time it is necessary to see that there is no blocking of the nasal passages with inspissated mucus. Cleansing of the nasal passages should be as routine as the cleansing of the eye. I am firmly convinced that many cases of epiphora in infants will be relieved if more judicious attention is given to the nasal cavities. 25 mt SOME REMARKS UPON THE OPERATIONS FOR INGUINAL AND FEMORAL HERNIA. BY W. S. ELKIN, A.B., M.D., ATLANTA. It is not my purpose in presenting this paper to suggest any new operation for the radical cure of inguinal hernia, but to endeavor to impress upon the members of this Association the importance of having their hernia cases submit to an operation that has practically no mortality, and is in most instances attended with brilliant results. In the discussion of this subject I will confine myself to the operative treatment of inguinal and femoral hernia. The operative treatment for hernia dates back to Celsus in the first century, who operated upon nonstrangulated hernia in children between the ages of six and fifteen years, but advised against operative interference in strangulated hernia. He exposed the hernia sac by a free incision, and, after reducing the contents, ligated it high up and cauterized the portion beyond the ligature. In the fourth century many ingenious methods were advanced in connection with this operation, some of which have been revived and are now in vogue as new operations. In the seventh century Paul of Ægina suggested as a necessity in connection with this operation castration. In the middle ages, besides castration, many other variations in the technique of herniotomies were introduced, such as ligation of the sac, invagination of the sac and scrotum, and cauterization. It was not until the tenth |