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been susceptible of the stimulus and had ulcerated, itwould have been fortunate, but it only thickens to defenditself from the disease; for we find Nature has madeinternal parts less susceptible of such stimuli, the ulcera-tion only taking place next the skin, so that it would,perhaps, be better for us if Nature would sometimes varyfrom her usual course. This internal thickening is some-times so great as to unite the external part of the nose tothe septum, and render the operation of perforating the osunguis less successful. Opening the old passage seldomsucceeds, as it is very liable to become diseased again, as instrictures of the urethra, which are so apt to recur, and herebougies cannot be had recourse to occasionally, as in theurethra. The operation, however, should not be done pre-cipitately, as the duct often clears of itself, and the patientgets well."Amongst the predisposing causes of acute inflammation of

the lacrymal sac, pregnancy appears to be one of the mostcommon, perhaps on account of its depressing influence onsome constitutions, and partly, too, from the confinement toone room and want of exercise, to the constipation which sooften accompanies it, and to the general derangement of thehealth. It is not unfrequent during lactation, and Galezowskistates that lacrymal troubles often supervene suddenly,owing to violent and spasmodic efforts made duringdelivery.

I have not the least doubt that obstruction of the naso-lacrymal duct terminating in abscess is frequently associatedwith a carious tooth, adding one more to the numerousophthalmic affections that are associated with, if not directlyattributable to, dental disease. The periostitic inflamm&.tion which exists at the root of the tooth either spreadsover the surface of the bone, and so leads to thickening ofthe membrane covering the ascending lamella of the superiormaxillary bone, or the inflammatory process at the root ofthe tooth may possibly extend through the bone itself. Ineither case the mucous membrane becomes reddened andchronically swollen and congested, and when it is remem-bered that the inferior orifice of the nasal duct in the mem-brane is often only a small slit or round hole, it is easy tounderstand that a comparatively small amount of swellingmay lead to the complete obstruction of the passage and tothe retention of the tears in the sac. The very position andform of the swelling show that the obstruction is situated atthe lower orifice of the tube, and before the lacrymal abscessdevelops, not only may some epiphora exist, but the region ofthe tooth and the part of the upper jaw extending towardsthe nose may, by carefully applied pressure, be found to betender. I saw a lady who illustrated these remarksexceedingly well. In her case the right upper canine toothbecame carious, the eyes being perfectly healthy. Somemonths after the tooth was affected she noticed that herright eye had become "watery." Whilst she remained atrest in a warm room no overflow of tears occurred, butexposure to cold air immediately compelled her to haverecourse to her handkerchief for this eye. For a long timeshe had little pain in the tooth, though the caries wasgradually extending through its substance. At length andsuddenly, without apparent or known cause, lacrymal abscessformed, and, after causing considerable erysipelatous inflam-mation of the cheek, burst through the canaliculi, throughwhich, when the inflammation had subsided, matter could forsome time be squeezed when gentle pressure was applied overthe region of the sac. The sequence of events seems here tobe tolerably clear. The carious tooth caused periostitis, whichat first obstructed and then caused complete closure of theinferior orifice of the nasal duct. Suppuration of the liningmembrane was then occasioned by some cause, such as theaction of cold or the entrance of some pathogenic germ, andthe tube being elsewhere pervious, the purulent contents of ’,the sac were discharged through the canaliculi. I can I,imagine no better evidence of the action of a diseased tooth ’iin the production of lacrymal obstruction and abscess. I do Inot wish to insist too strongly on this connexion, but I thinkthat in all cases of obstructed duct, where no cause is I

immediately recognisable, it is expedient that the teethshould be examined, and, if found diseased, that the patientshould be placed under the care of a competent dentist. In

many cases probably extraction would be the safest plan,but on this point I am not able to express a confidentopinion. If the abscess be allowed to burst spontaneously,and even in some cases opened secundU1n artem, the apertureby which the pus has escaped remains patent, and a fistulaacrymalis results.

Congenital fistula of the lacrymal sac has occasionallybeen noticed. Thus Steinheim describes a fistula of theduct opening upon the surface of the upper lid, and believedto have existed at birth. Terson reports two cases of thesac, but whether congenital or not is uncertain. bZanz t

writes: "It is still doubtful whether a congenital fistula ofthe lacrymal sac has been observed, though the possibilityof its appearance as an occasional failure of the nasal ductto close is not to be denied.’ In this case it should beviewed as an arrest of development. Whelock Rider 7has recorded what appears to be an indisputable case. Thepatient was twenty-one years of age, and presented abouthalf an inch below the inner canthus and over the course ofthe lacrymal sac the opening of a canal sufficiently largeto admit for a short distance upward and inward a No. 8Bowman’s probe, but it could not be made to enter the sac.The integuments about the opening and the walls of thecanal were slightly indurated. Efforts at expiration withclosed nostrils caused some clear fluid to exude. The fistulawas noticed when the patient was only a few days old.

ABSTRACT OF THE

Introductory LectureDelivered at the opening of the Winter Session of

ANDERSON’S COLLEGE, GLASGOW,BY J. R. WOLFE, M.D., F.R.C.S.E.,

SURGEON TO THE OPHTHALMIC INSTITUTION, AND LECTURER TOTHE COLLEGE.

AT the outset the lecturer referred to the great advancesrecently made in medicine and surgery, as exemplified inthe discovery of new drugs and in the operations now per-formed on several parts of the body which were formerlydeemed to be beyond the reach of the surgeon. He thusshowed that students now entering on their medical studiesenjoyed many and important advantages which could notbe offered to their predecessors. In this way the pleasureof the study had been considerably enhanced, but at thesame time the responsibilities laid on students had be-come much heavier. Amidst the crowd of practitioners atpresent no one could push his way to the front by simplyrepeating other people’s formulae; it could only be doneby independent thought and indefatigable industry. Dr.Wolfe then proceeded as follows :-"The department of surgery which is my own province

has made rapid strides since the discovery of the ophthal-moscope by Helmholt’z. Previous to that discovery nearlyall was guess-work, but by that instrument we have revealedto us all the deep tissues of the eye, the very commence-ment of an affection of the retina, optic nerve, vitreousand choroid, and even diseases which may exist inthe more distant parts of the organism, such as thebrain, heart, lungs, and kidneys, as well as constitutionalcachexia. The discovery gave such an impetus to thestudy of eye diseases and to the development of eyesurgery, that, thanks to the numerous labourers in thatdepartment in different parts of the world, ophthalmologymay now be said to have approached the nature of anexact science.

" Among the eminent men of our profession who flourishedin France during the Second Empire, such as Nélaton,Trousseau, Velpeau, Claude Bernard, &c., whose laboursI have reported in THE LANCET of that period, no onedeserves greater credit than Desmarres. By his brilliancyof conception and dexterity of execution he may be saidto have revolutionised ophthalmic surgery. He was the firstto show us how great is the liberty which may be takenwith all the tissues of the eye, provided they be properlymanipulated. He not only gained great victories over dis-ease himself, but laid the foundation for future progress.The one eminent disciple of Desmarres who was destined togain world-wide renown in ophthalmology was Albrecht4 Klin. Monatsbl., B. xiii., p. 303. 5 Presse Med. Beige., 1873. p. 227.

6 Graefe : Sämisch Handbuch d. Ges. Aug., B. ii., p. 113.7 Knapp’s Archives, vol. xiii., 1884, p. 263.

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v. Graefe. Fired with the enthusiasm of Desmarres’ teach-ing, he subsequently established an ophthalmic clinique inBerlin and became the founder of the ophthalmologicalschool of Germany. When visiting La Charit6 in Berlin theother day, I saw with no small degree of pride the monumentwhich has been erected to v. Graefe. This is the first publicmonument erected in that city to a private person, all othersbeing in honour of royal personages and generals or otherpublic functionaries. The distinction confers equal honour onthe memory of our eminent confrere and on the Government ofthe German Empire. It shows that the old spirit of the nation-love of culture, appreciation of professional merit, and in-terest in all that benefits mankind-is still alive and hasnot been deadened by love of military glory. Herein lies the

pledge of the future stability and prosperity of the nation.The statue itself is a beautiful life-like image of the man, butI could not help thinking that a lancet used in iridectomy,by the introduction of which operation he conferred a greatboon on many sufferers, would have been more appropriatein his hand than an ophthalmoscope, an instrument inventedby Helmholtz; nor could I help feeling that the symbolicgroup on each side of the statue was so paltry and insipid asonly to disfigure the monument. Graefe was peculiarlyfortunate in living during what may be called the goldenage’ of ophthalmology. There was such an absence of pro-fessional and national jealousy that he obtained the support,not only of the whole of the medical profession of

Germany-without which, he himself said to me, he couldnever have tested the efficacy of his cure of glaucoma byiridectomy,-but also that of the Vienna, French, and otherforeign schools. One great service which he rendered tothis department was the founding of the Archiv fii,.Ophthalmologie in conjunction with Arlt and Donders, thelatter of whom published in this journal his famous paperson Refraction and Accommodation of the Eye, which nowforms the canonical book of oculistic surgery. I, however,think it very unfortunate that Graefe’s last work has notproved a success. I refer to his method of extracting cata-ract. At the meeting of the International OphthalmologicalCongress at Paris in 1867, at which the operation was dis-cussed, a report on the results of the new method was readby Otto Becker, then of the Vienna school. It was

violently attacked by Professor Hasner of Prague in theAnnales d’Oeulistiques. I objfBcted to it at the time as posi-tively bristling with dangers. Notwithstanding the unfavour-able report of the Vienna surgeons, which I deemed conclusiveagainst it, it is still practised, and human eyes have been sacri-ficed in great numbers, both in this and other countries. In theold operation we never heard of sympathetic infltLmmationof the other eye, but in connexion with Graefe’s cases cameunder my own observation in which the eye operated onhas had to be removed and the other has become inflamed.It is very curious that in the most recent apologies forfailure the micro-organisms are held to be responsible-thepoor bacteria have to bear the whole blame. I regard thisoperation as calculated to tarnish the fair fame of v. Graefe,as the two groups are a disfigurement to his statue, and Itherefore hold that it ought to be excluded from oph-thalmic practice. I speak strongly on this subject becauseI know the misery which is caused to families by suchdisasters." When I was asked to address you to-day on ophthalmic

medicine and surgery, 1 thought that it would prove usefulto you that I should explain the general principle whichunderlies some operations which I have introduced, and theway in which they have been worked out by me. In search-ing for the safest and best method of operating for cataract,I have, during every stage of the operation, studied all thepossible sources of danger and the surest means of eliminatingthese dangers, and have thus endeavoured to meet everypossible contingency. I have in this way arrived at a methodwhich is absolutely safe-so safe, indeed, that one needhardly ever fear of failure. In twenty cases on which I

operated in the course of one month in the presence of fourof my colleagues, there was not a single hitch during theoperation or in the subsequent treatment; vision restored inall. Some of the cases operated on by me during the presentmonth have been very critical. One patient, seventy-twoyears of age, was discovered to have heart disease ; anotherhad bronchitis and asthma to such a degree as to disturb theother patients; while in a third the cataract was the resultof an injury of thirty-four years’ standing, and in additionto traumatic complications there was a pterygium coveringa great part of the cornea. I have also recently operated

upon one of our citizens at the advanced age of ninety-one.In all these cases the healing process went on without asingle complaint of pain in the eye, and vision was restored.I may mention that the risk in old people lies in the ten-dency the cornea has to collapse, and in consequence of thatcollapse there is a difficulty of removing the whole lens anda probability of subsequent suppuration. But these are

simply facts which must be present to the mind of theoperator, and according to which he must regulate hisincision. It was only by carefully observing how Natureherself cures wounds and injuries that I arrived at a suremethod of conducting this operation."The operation for the formation of new eyelids from

skin flaps taken from distant parts was first suggested tome by the procedure of M. Reverdin, who grafted small bitsof cuticle for the cure of ulcers, and the results obtainedwere tolerably good. I found, however, that when appliedto the face this method gave it a scurvy look, and I wasobliged to try the transplantation of a large flap, endeavour-ing to cut the cutis merely and keep free of cellular tissue.The fact that about one-third of a flap so cut suppuratedproved to me that, though the first part could easily be cutfree of cellular tissue, the knife is apt to go deeper whencutting is continued further. Hence, I concluded that if wewant a large flap of skin to heal by agglutination, we mustfirst remove it and then pare off any cellular tissue theremay be underneath. Though on the publication of my firstsuccess the operation met with no favourable reception, itis now generally adopted. Of all the satisfactory reports ofits success there is none more so than that by Dr. Swanzyof Dublin, who operated in seven cases. He reports that itwas not until forced by the circumstances of a case that heemployed it; now, having found it a most satisfactory pro-ceeding, he much regrets that he postponed its trial so

long.’ To the practice of skin transplantation I was led

by a feeling of sheer desperation. I Here,’ I said to my-self, ’is an eye which might be made a useful organbut must be allowed to waste for want of a flap of skinwhich cannot be taken from the neighbouring part.’ Iwas then compelled to study how the want could be sup-plied. This is also true of transplantation of conjunctivafrom the rabbit.

" By the same feeling I was led to practise another opera-tion-viz., that for detachment of the retina. If surgeonscould remove dropsical fluid from the abdomen and thorax,were oculists to be baffled and pronounce a case incurableon account of retinal dropsy ? It is true we have delicateground to work upon, but this only shows the great neces-sity there is of taking advantage of all the devices ofour art and devise new plans in order to overcome thedifficulty. For what is ophthalmic surgery but simplythe performing, in a delicate and precise manner, ofoperations upon the tissues of the eye which can bedone on a large area in any other region of the body?My first successful case, reported in THE LANCET in1868, was total blindness in both eyes; but such cases

are not very numerous, and the operation had consequentlya hard struggle to come to the front-in fact, six yearselapsed before I had an opportunity of again bringing itprominently before the profession. This case, which hadbeen certified by surgeons of another hospital as one ofdetachment of the retina, was exhibited before the GlasgowMedico-Chirurgical Society and the British Medical Associa-tion at Belfast in 1884. But all surgeons who had tried theoperation in this country had invariably failed, and conse-quentlv more convincing proof was still required. This-was afforded me in the end of the same year, when I wasinvited by two Parisian oculists to give a demonstration ofmy method on patients provided by them. I did so, andwith success. The demonstration was reported in severalmedical journals in France and in this country. By itssuccess great impetus has been given to the operation, andsurgeons have been encouraged to study it more carefullythan they have hitherto done.

" With these explanations you will be able to appreciatesome of our endeavours to extend the sphere of eye-surgery,and to bring within the province of operative interferencecertain groups of cases which have until recently been con-sidered incurable. Nor are the resources of surgery yetexhausted."

Dr. Wolfe, in conclusion, referred to the arrangementswhich have been made for the removal of Anderson’sMedical School to the neighbourhood of tha WesternInfirmary.

T 9.