THE LACRYMAL APPARATUS 277 



by the fact that follicular formation is sometimes found normally in it, just as in 

 the conjunctiva we meet with simple and trachomatous follicular formation. 

 _ Rochon-Duvigneaud and Tartuferri's denial of ' trachoma of the sac,' because 

 follicles are also found under normal circumstances, is not justifiable. Weber, 1 

 Moauro, 2 Kalt, 3 De Vincentiis, and Cirincione 4 have demonstrated the presence of 

 follicles which they consider to be trachomatous A primary trachoma of the 

 lacryrnal sac can also develop. 5 The means by which the affection is transferred 

 from the conjunctiva into the lacrymal sac is radically different from that of any 

 other form of conjunctival inflammation, in that the trachomatous follicular infil- 

 tration spreads along the canaliculi under the epithelium ; I have preparations from 

 Dr. Stock in which this canalicular infiltration is very easily seen (cf. Fig. 52). 



This must not be taken to mean that all cases of dacryocystitis in granular con- 

 junctivitis are necessarily trachomatous ; many of them are simply catarrhal. 

 The bacteriological examination of the pus from these cases of trachoma of the sac 

 gives the usual findings. According to Augstein, 6 Pneumococci are the most 

 plentiful, and L. Miiller emphasizes the frequency of the influenza bacilli, which 

 are commonly found in the sac under other conditions. 



For the present it is doubtful to what extent the changes whicb occur in the nose 

 in trachomatous patients, and are especially common when there is also a dacryo- 

 cystitis present, are specifically trachomatous. 



The great importance of the diseases of the nose, with regard 

 especially to affections of the lacrymal passages, is due to the fact that 

 changes in the nose by an ascending swelling in the nasal duct (cf. the 

 literature by Eversbusch, second edition of the Saemisch Handbook, 

 1905), or through a stricture, mechanically obstruct the outflow. 

 Nasal bacteria cannot ascend the healthy nasal duct (Bach), and even 

 in the presence of stenosis and dacryocystitis no ascent could be 

 experimentally demonstrated to take place (Hauenschild). Neverthe- 

 less, with an ascending inflammation of the mucous membrane in 

 continue, an upward spread of the organisms appears possible, provided 

 that they are not being freely removed. 



Affections of the neighbouring sinuses (ethmoid, frontal, and 

 maxillary) can also involve the lacrymal sac, chiefly because an acute 

 collateral hypersemia or toxic irritation spreads to the tear passages, 

 producing stenosis and catarrh. With the healing of the original sinus 

 trouble such a condition may immediately disappear. Sinus affections 

 can occur in simple chronic lacrymal catarrh (Kuhnt, etc.), but they 

 are uncommon. On the other hand, in the acute forms, and when 

 a fistula is present, an adjoining sinusitis is common (Peters and 

 Hammer). 7 The relationship varies : the inflammation of the sac 

 may spread to the ethmoiclal sinus, and vice versa. 



From the bacteriological point of view it is noteworthy that, in the 



1 A. f. 0., 1861, viii. 105, Bd. 2. 2 Ann. di Ottal., 1890, xix. 377. 



3 Rec. d'Ophth., 1894, p. 370. 4 Ann. di Ottal., 1890, xix. 362. 



5 See the dissertation of W. Hoffmann (Konigsberg i/Pr., 1896), under Kuhnt, giving 

 statistics of over 3, 000 cases of conjunctivitis granulosa. 



6 Zeit.f. Aug., 1906, xvi. 243. 7 Hammer, Inaug. Dissert., Kostock, 1905. 



