valuable appliances in the treatment of lachrymal malconditions) often without cutting the punctæ or by enlarging the punctæ either by dilatation or by making a small cut (Figs. I and 2). Such treatment should be applied daily until drainage

Fig. 2

is complete, and pus has ceased to form, and followed up for some time afterwards at less frequent intervals; then the patient should be given a saturated solution of boric acid to use at home morning and evening, according to the method suggested by Dr. Geo. M. Gould. The patient lies down and fills the cavity at the internal canthus (formed by the nose on the inside, the supra-orbital bridge above, the infra-orbital bridge below, and the eye at the outside) with the boric-acid or argyrol solution, then he works the solution into the canal by massage with the forefinger.

It is surprising how many cases there are which can be drained by syringing without the necessity of resorting to the knife or probe. The inflammation subsides, and the stricture gradually dilates as the swelling decreases and drainage is effected. Adrenalin is of service at first in securing temporary drainage.

The treatment by probing is one with which you are so familiar that I will not describe it. It must be resorted to in many instances, but I wish to emphasize the suggestion that it is often not necessary and frequently harmful. When much inflammation is present, probing injures the delicate lining to the canal, resulting in the production of scar tissue and strictures, sometimes bringing about the formation of cicatricial adhesions, when, before the probing, the stricture was caused only by inflammatory swelling. Furthermore the extensive slitting of the canaliculus, and the use of large probes, is almost bound to destroy the suction function of this apparatus, and it must be remembered that this suction

has much to do with the carrying off of the lachrymal secre-, tion.

Another matter which I wish to emphasize is the value of canulæ. When made of the correct form and material

(gold or gold-plated, for silver will corrode and cause irritation in the course of time) and well fitted, they will be found in many cases, which cannot be cured by syringing or probing, to be effectual not only in preventing suppura

tion, but in serving as drainage for tears. The canula which the writer has used was devised by Dr. L. Webster Fox. The gradual curve allows the fluid to gravitate, and also prevents the tube from burying itself in the soft tissues.

The under surface at the bend rests over the infra-orbital ridge. The canula is so made that a small probe can be pushed through it to facilitate its introduction. Figs. 4 and 5 are r-ray pictures of the canula in place showing a partial side view and a front view.

The following are indications for extirpation of the lachrymal sac :—

I. In cases of suppurating dacryocystitis where an eyeball operation, such as iridectomy or for cataract or glaucoma, has to be performed.

2. In cases of suppurative dacryocystitis which the customary treatment outlined above,-of probing, the use of canulæ, or syringing,-fail to cure.

ing.

3. In old people or those who cannot endure the prob

4. In cases of acute suppurative dacryocystitis recurring after supposed cure.

5. Some cases of lachrymal fistula.

6. In cases of suppurating dacryocystitis occurring in patients whose occupation subjects them to corneal injuries and consequently corneal ulceration,-machinists, railroad employees, etc.

Dr. R. A. Reeve, in Posey-Wright, describes the operation, and then manifests his opinion that the procedure is not easy by the following remark: "If this is not feasible the sac should be cut out piecemeal." Dr. C. R. Holmes says "I do not consider the extirpation of the lachrymal sac and gland an easy operation, if performed in such manner that we shall have primary union of each wound and no injury of adjacent parts. This is especially true of the sac,” and he adds: "The administration of an anesthetic is absolutely necessary for the perfect performance of the operation."

A good description of the ordinary operation will be found in the Archives of Ophthalmology, Vol. 32, No. 4, 1903, by Arnold Knapp.

Extirpation of the lachrymal sac performed in the classical manner is not a simple procedure, because there is so much hemorrhage, and because the sac is indefinitely outlined and consequently ofttimes has to be removed piecemeal. The first operation I witnessed was not skillfully done despite the fact that the results were good (the operation was performed by myself), and I choose to think that the difficulty arose, not so much from the evident awkwardness

and inexperience of the operator, as from the method which the surgeon was attempting to follow. This prompted me later to devise the operation which I will describe. My first operation in which this method was used was in March, 1903. Lately I have endeavored to secure the literature upon this subject, and have not found this method described, though I have secured an excellent paper by C. R. Holmes, presented at the A. M. A., in 1898, in which occurs a paragraph that makes evident the fact that he was at that time endeavoring to attain the object which is accomplished by the method here described, so that I presume ere this he, and perhaps others, may have practiced the same procedure. Since, however, the method has not been described, I believe it is of sufficient value to warrant its presentation. Allow me to reaffirm that while I am a firm believer in extirpation of the lachrymal sac in certain cases, I still continue the more conservative methods of probing, syringing, and the use of canulæ in hopeful cases. In this paper I shall not take up your time in the discussion of extirpation of the lachrymal gland.

Performed in the ordinary manner, the operation consumes considerable time, is inexact, as the operator does not know whether he has removed the entire sac, and it is altogether a formidable procedure. The operation is therefore one which many ophthalmologists hesitate to advise though the efficacy in many cases cannot be questioned, for the results, when the operation is properly performed, are highly satisfactory in curing blennorrhea with all its attendant symptoms, excepting epiphora, and even this symptom improves on account of relieving the septic inflammation. Again, the operation is refused by patients because it requires time and the administration of a general anesthetic. The description of the operation follows:

After the patient has been properly prepared, the contents of the sac is pressed out through the canaliculus (usually already slit), and the sac is then thoroughly and repeatedly irrigated with boric-acid solution and also with argyrol or other antiseptics. By means of a paraffin or other suit

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