able features to the patient. The old-time method of treating these conditions by simply slitting up the tear-duct with a canaliculous knife, and passing the Bowman's probes, from time to time, will not, in my opinion, establish the patency of the duct, and relieve the patient from the annoyances incident to these strictures. Schmidt Rimpler, in the last edition of his work on "Diseases of the Eye," recommends that if the duct does not remain patent after passing the probe for a few weeks' time, it should be discontinued, as the tendency to closure and repeated forcible opening of the duct only tends to keep up irritation, and consequently does no good.

After opening the duct our attention should be directed to the condition of the nose, and if any of the maladies or diseases above referred to are found they should be treated according to the latest and most approved methods, for without attention to the latter, most of these cases cannot be cured. Hence will appear the importance to the oculist of something of an intimate knowledge of diseases of the upper air passages in dealing with these strictures of the tear-duct.

In a case treated by me not long since (a woman from one of the towns of Idaho), a large ulcer of the cornea, accompanied by a great deal of pain, lachrymation, and photopbobia, intense conjunctival injection was also present, and over the lachrymal sac a noticeable degree of bulging. I slit up the duct, and through the inferior puncture made an incision through to the sac, evacuating half a teaspoonful of pus, and washed the sac out well with a bichloride, I to 10,000 solution. This solution was made use of daily for the purpose named, and a Bowman's probe was passed down the tear-duct. Attention was given to the ulcer of the cornea, a solution of atropia and Pagensticher's ointment being used. until the eye was relieved from inflammation.

Now, as regards the condition of the nose in this case I found a marked degree of deviation of the septum on the side corresponding to the affected eye, and with the parts thoroughly under the influence of cocaine, I removed with a Bosworth's nasal saw a portion of bone one inch in length, one-half inch in width, and probably one-sixteenth inch in thickness. Back of this was found a hypertrophied turbinated body, which was removed with a nasal gouge. The

plan of treatment above outlined was carried out for about four weeks, when the patient left for her home. For a number of weeks after leaving here she has, at my suggestion, had her family physician pass the probe once a week, and in a letter received from her six weeks ago she stated that her eye was in good condition, at least she had no annoyance from it.

This case is cited here to show the importance of the pathological conditions of the nose in causing and keeping up these strictures of the lachrymal duct.

I do not believe that all the cases presented to us require slitting up with a knife and passing a probe. Many of these cases may be effectually treated by removing the primary cause, namely, the relief of hypertrophies, hard and soft, and deviations of the nasal septa or errors of refraction. If relief is not obtained by the means just mentioned, then the punctum may be slit by the iris scissors. This failing, the entire. duct should be slit up, and the graduated stretching resorted to by methods already indicated.

The following is a case under my treatment at present:

Mr. E―, aged 27, has had overflowing of tears in each eye for about ten years; has had attacks of phlegmon of the lachrymal sacs, followed by a fistulous opening over the center of the sac in the right eye, and a fistula in the upper lid of the left eye, above the superior punctum. The treatment consisted in slitting up each duct (the left one being almost completely occuded), and passing the Bowman's probe down through the bony portion, washing out the sac with boracic acid and sublimate solutions, and cauterizing the fistulous openings with pure nitrate of silver, in the hope of healing or closing the fistula. This patient, who has been under my care for four weeks, is doing well, and the tears pursue the normal course with complete closure of the fistulæ.

I have been unable to find anything in the condition of the nose, aside from a slight hypertrophic type of catarrh, that would account for the strictures in this case. The old method of placing a stylet of silver or lead in the duct, curved at the upper extremity to hold it in situ, has been long since abandoned, as, I think, it was certainly shown that it served only as an

irritant. The object to be kept in mind is to relieve these parts as much as possible from all sources of irritation.

In regard to the treatment of chronic inflammation of the tear-sac, it has been recommended. to pass an instrument shaped much like a canaliculous knife, roughened at its extremity, down into the tear-sac, and by friction to thoroughly break up the lining thereof, in the hope that this may destroy the integrity of the walls, and overcome the chronic suppuration.

In Fuch's work on "Diseases of the Eye," cauterizing either with the galvanic or chemical cautery, is recommended. The latter plan I have made use of in several cases with good results. A. von Graefe advises, in the obstinate class of these cases, to cut down through the skin, dissecting out the sac and bringing the lips of the wound together. Under strict antiseptic precautions, sloughing seldom takes place, and a good result follows.

In the treatment of chronic inflammation of the tear-sac, the use of astringents is highly useful. This is especially true of the newer derivatives of silver nitrate. I regard argyrol, 15 to 20 grains in distilled water, as an exceedingly valuable remedy in these cases. And if the conditions be such that we cannot see the patient every day, we may give him a 10 per cent solution of this remedy to use himself. Protargol is also valuable in these cases, but this should be somewhat stronger than the previous astringent. Adrenalin chlorid, 1 to 10,000, is highly useful in these cases.

We must not overlook the fact that errors of refraction cut an important figure in causing many of these cases of overflow of tears, and when these errors exist they ought to be corrected. Then, too, the general health should not be overlooked, and proper attention should be given to the correction of any deviations from the normal as regards the general health. A gradual process of dilatation with Bowman's probes, from No. 1 to No. 6, is usually sufficient in the majority of cases.

From the foregoing the following summary might be made:

1. Strictures of the lachrymonasal duct, in the majority of instances, are due to disease of the nasal mucosa or to bony hypertrophy of the tur

binated bodies, or deviations of the nasal septa, and occasionally to error of refraction.

2. A rather intimate knowledge of the conditions indicated, with their proper treatment, is an essential factor to success in the care of disease of the tear-channels.

3. In the foregoing pages I have endeavored to suggest the means that are more generally recognized as the most efficacious in relieving the nose of those obstructions and sources of irritation which are known to cause, in the majority of instances, strictures of the tear-channels.

DR. S. L. BRICK: Unfortunately for me I was absent when the paper was read. I just heard the last word as I came in. I assume the paper was on the usual lines, and the doctor guaranteed to me that the paper would be principally upon lachrymal stenosis and the relation that catarrh has to the production of this condition. Almost all such strictures are due to catarrhal conditions or anatomical malformations of the nasal region. The cause is always below. I have never seen a case where the stricture was caused by conjunctivitis. I cannot, of course, intelligently discuss the paper because I didn't hear it. Of course, the treatment of lachrymal troubles is purely surgical, nothing in a medical way can be done, and my success of late years has been better than formerly. Formerly we were taught to use small probes, but since using large probes the results have been more marked, and one can in almost all cases promise the patient absolute relief by using large probes.

DR. LYMAN SKEEN, JR.: I have seen a good deal of work along this line, and will agree with others that the case is surgical, and it is not an uncommon thing to resort to total extirpation of the sack. Many cases of this type are very refractory, and a relief of the condition entirely is not uncommon.

DR. A. E. LYONS: As Dr. Brick says, I think he does right in those cases in using large probes. Many of our cases of such stricture can be opened up and cured by the use of Bowman's probes.

DR. M. A. HUGHES (Essayist): I have nothing further to say. I have the authority of an eminent specialist in Philadelphia, and he says he never uses a probe larger than a No. 8, which would be perhaps two millimetres in diameter. He says he gets his best results from these probes. Of course, the paper I have given is only an outline of what should be followed out in the way of treatment. I thank the gentlemen for their kind attention.

There are quite a number of so-called varieties of dysmenorrhea, due to certain pathologic conditions of the uterus, tubes, and ovaries. Various. classifications are given by different authors, such as neuralgic, congestive, inflammatory, obstructive, membranous, ovarian, etc. In order to make this paper as brief as possible only the ovarian variety will be discussed.

Many women between the ages of 16 and 40 suffer intensely from ovarian dysmenorrhea. Most of these patients give a history of their periodical suffering as beginning a year or two after menstruation became established, and increasing in severity from year to year in spite of all medical treatment. There are also some cases where the dysmenorrhea does not come on until somewhat later in life, say, at the age of twenty. Sufferers from ovarian dysmenorrhea are not confined to any distinct class of society. They They are found among all classes, in the country on farms, as well as in the villages and cities. They are usually, however, according to the writer's observations, persons who have done a great deal of worrying during the years of their physical development. Some of these patients enjoy quite good general health, aside from their periodical suffering, while others are almost complete phys

ical and mental wrecks.

All of the severe cases of ovarian dysmenorrhea among the married that it has been the opportunity of the writer to study gave a history of never having been pregnant. In all of the cases examined with a sound it was found that the cervical canal was patulous.

Patients suffering from this form of dysmenorrhea have ovaries that are covered with a tough and greatly thickened serous covering. Under this covering are found small cysts, varying in size from that of a small pea to a small marble. The periodical pain seems to be in proportion to the thickness and the extent that this covering

*Read before the Western Surgical and Gynecological Association at Milwaukee, Wis., December 28 and 29, 1904.

A PRE

of the ovaries exists, and thus prevents the dehiscence of the Graafian follicles. The covering of the ovaries is generally very tense. This is especially found to be so in cases operated upon at a time when the suffering is still great, as the writer has had occasion to observe in a number of instances.

What to do with these cystic ovaries has been a subject for discussion on many occasions. Some surgeons favor oöphorectomy, others resection, and still others advise puncturing the cysts. None of these methods has been satisfactory in all instances. The removal of the ovaries, thereby bringing about the menopause, produces in many cases very bad nervous and mental effects; and this is especially true of women who are naturally of a melancholy disposition. Resection and puncturing the cysts always gives more or less relief for a short time, but the patient will then be obliged either to have a more radical operation performed or to continue to suffer until the menopause, as the following cases will illus

trate:

CASE I.-Miss A, who began to menstruate at the age of 13, but did not suffer much pain at the menstrual period until her 19th year, from which time she grew worse from month to month. She was treated by several well qualified physicians, but no one succeeded in giving her permanent relief. As her suffering got beyond endurance, she was directed to the writer for an operation. A median abdominal incision was made. The right ovary was found to be somewhat larger than normal, and was covered with a very closely studded many small cysts. The portion of thick and tough covering, under which were

the ovary that contained the greater number of cysts was resected, while in the other portion the more scattering cysts were punctured or incised with a scalpel. The left ovary was perfectly normal in size, and its covering thin and soft, and there were no cysts. This patient made

a very prompt recovery, and was entirely free from dysmenorrhea for five periods when the pain gradually came on again, and got worse with each succeeding period until she became fully as great a sufferer as before. She underwent another abdominal section, and the right ovary was again found to contain cysts and the capsule very tense. At this time the, ovary was removed, after which the patient again enjoyed first-class health for over three years; but she is now suffering considerably at her menstrual periods, and in all probability the remaining ovary is also becoming cystic.

It is now over four years since the writer began to remove the thickened covers of the ovaries, and, in most instances, with complete relief of the dysmenorrhea. His success has especially been most gratifying in cases where no tubal inflammation co-existed, and also since his technique was improved by shortening of the utero-ovarian. ligament, thus preventing the ovaries from prolapsing and possibly becoming adherent in a very undesirable position.

The writer has operated upon twenty-six cases, all of whom have improved as nearly as it is possible for him to learn. Some declare that they are entirely well as far as their dysmenorrhea is concerned.

As above mentioned, the married women suffering from ovarian dysmenorrhea gave a history of never having been pregnant; and thus far the writer has no knowledge of any having become pregnant since operated upon, although the menstrual periods have been regular in every respect so far as it is possible for the writer to ascertain. Of the twenty-six patients operated upon, nine were maidens and seventeen were married wo

men.

TECHNIQUE OF OPERATION.-The ovary is brought into clear view through a median abdominal incision; and one hemostatic forceps is placed at the juncture of the utero-ovarian ligament and ovary, and another on the upper border of the broad ligament close to the ovary (lateral). By means of these two forceps the ovary is held by an assistant in the proper position, while the operator makes an incision with a sharp scalpel from the ovarian ligament across the ovary to the attachment of the broad ligament, through the covering, and then carefully dissects one side,

and then the other, down as far as cysts are encountered. The flaps of the covering of the ovary are now trimmed off, preferably by means of a pair of scissors. This having been done the utero-ovarian ligament is shortened by doubling it upon itself in a similar manner as is in vogue in shortening the round ligaments, in order to hold the uterus in a normal position. There is generally some hemorrhage as the base of the ovary is approached, which can easily be controlled by pressure-clamps and fine ligatures.

ADHESIONS. The writer will not be surprised to have objections made to this operation on the ground that adhesions will form after stripping the ovaries of their peritoneal covering. While this may be so in some cases, it is safe to say that they can be limited to the case where there exists, or has at some time existed, an inflammatory condition which produced adhesions that had to be broken up at the time of the operation; but if no other raw or injured peritoneal surfaces exist there will be absolutely no danger of adhesions forming. It has been the writer's opportunity to re-open the abdomen in two of his cases some months after the first operation. One was for an appendectomy in which both ovaries were found to be rather small, but no adhesions whatsoever could be found. The other case was for retroversion of the uterus, where a ventrosuspension and removal of a diseased left Fallopian tube had been made at the time of the operation. In fact, the latter operation was considered of secondary importance. In this case the left ovary was found adherent to the stump of the Fallopian tube, but the right ovary was perfectly smooth, rather small, and entirely free from cysts, the surface of the ovary being soft and smooth.

CASE II. Mrs. G-, aged 23, American, married, was admitted to the hospital November 5, 1903. She has always been well, with the exception of occasional attacks of indigestion. Menstruation appeared at the age of 14. The first day of the menstrual period the patient suffered with considerable pain of a cramping character. The second day the pain increased in intensity, and was felt over the entire abdomen. During this last year since her marriage the pain has been worse. The patient has never been pregnant. Upon operation, November, 1903, both ovaries were found cystic, and covered with a

dense fibrous capsule. The cysts were punctured, the capsules dissected off carefully, and the ovaries attached to the cornua of the uterus, which in turn was anchored to the abdominal wall.

Since the operation the patient has complained of pain during the menstrual period, but its severity is lessening each month, and she is improving in general health.

CASE III-Miss A. J. J-, a Swede, aged 23 years, was perfectly well until she had typhoid four years ago. Since then she has menstruated. every two or three weeks. At each period the patient lost an excessive amount of blood. On examination the pelvic organs seemed normal, with the exception of sensitiveness over the ovaries, which was greater on the right side. She was operated upon December 8, 1903, at St. Barnabas Hospital. The ovarian capsules were found to be dense and fibrous, and the ovaries were cystic. After the cysts were punctured and the capsules dissected off, the denuded ovaries. were rubbed with the omentum and replaced in the pelvis. Her convalescence was uninterrupted. Since leaving the hospital she has gained constantly and rapidly. Her entire appearance has changed, and there has been no menstrual pain since the operation. The interval between. the periods is gradually lengthening, while the amount of blood lost each time is markedly diminished. She is gaining in flesh, in color, and in spirits.

CASE IV-Miss B. O, Swede, aged 21 years, has been a teacher in our public schools for three years. Since maturity, which occurred during her 14th year, she has suffered with intense pain at the menstrual periods. This pain invariably began two or three days before the flow was established, continued during the period, and lasted from a few days to a week after the cessation of the flow. Instead of being central or in the uterus, the cramps were in the ovaries, and worse on the left side. On palpation the left ovary and tube were found to be extremely sensitive. The patient had become so reduced in strength from this suffering that she has been unable to teach since the autumn of 1903.

On operation both ovaries were found to be cystic and covered with dense, fibrous capsules. After the cysts had been punctured the capsules

were dissected away, the wound was closed, and the patient put in the lithotomy position. In order that the woman should be doubly protected from a recurrence of her dysmenorrhea, the cervix was thoroughly dilated, although the cervical canal was perfectly normal.

This patient is entirely free from all pain at her periods, and her general health has very greatly improved, it being almost a year since the time of operation.

CASE V-Miss M. N-, an unmarried woman, aged 23 years. This patient says she has never enjoyed rugged health. Since the establishment of the menstrual flow, at 13 years, she has been troubled greatly with dysmenorrhea as well as with sensitive and sore ovaries. She is the only one of her family who is similarly troubled. Her work, she thinks, has largely aggravated the trouble. Being a dressmaker, she frequently runs the sewing-machine all day. in the above quoted cases, the dense capsules were dissected from the ovaries. After the operation, in February, 1903, she was greatly relieved for several months. Her general health is somewhat better. The pain, however, has reappeared at the beginning of the last three periods. It lasts for the first few hours or until the establishment of the flow.

As

CASE VI.-Miss S, aged 21 years, began to menstruate at the age of 13, and has since been a great sufferer at her periods. She also suffered two attacks of appendicitis, on account of which she was sent to the writer by her physician. Since she gave a clear history of ovarian dysmenorrhea, a median incision was made in order to examine the ovaries at the time of the appendectomy. After the appendix was removed the ovaries were found to be cystic, and therefore the serous covers were dissected off and the utero-ovarian ligament shortened. After nearly a year the patient is still free from all pain.

CASE VII-Mrs. B, aged 28. Married. four years, never pregnant, suffered intense pain at her monthly periods, the pain lasting about two weeks. There was great tenderness in the ovarian region, especially on the left side.

This patient has been a sufferer more or less since her 16th year, but she seemed to grow worse from year to year. All methods of treat