and detach the membrane from it. When the probe is introduced in Mr. Bowman's method, from the canal, it enters the sac behind the tendo oculi, and is in a better position for finding, as it were, the orifice of the nasal duct. But to make this proceeding as easy as possible, the author uses larger probes (Nos. 5 and 6, which are the only ones used for this purpose) slightly curved at each end in two different directions within the terminal inch or inch and a half, while the central part (or that held by the finger and thumb), is straight, and they are cylindrical in their whole length. The effect of this is that when the probe is inserted into the sac, and brought into a vertical position, a slight rotation of it on its long axis makes the lower point, which is in search of the orifice of the duct, describe a small circle; and by slightly varying the inclination of the probe and making gentle pressure at the same time, with slight rotation, the point never fails to enter the duct. The right and left probes have opposite curves, to suit the inclination of the duct.

The probe is known to have entered the nostril by the depth to which it has entered compared with the external position of the nostril, and also by its coming in contact with the floor of the nose. It is allowed to remain there for a few minutes, or is immediately withdrawn, according to circumstances.

In any ordinary case of chronic inflammation of the sac, the cure is regarded as well begun, and often half accomplished, as soon as a full-sized probe has thus passed into the nose through the whole course of the natural channels. To repeat the probing is a very simple process, the enlarged punctum being always ready to admit it, and the proceeding being usually more easy each time it is practised. The probing is repeated every day, every other day, every three or four days, or every week, according to the progress of the cure and accidental circumstances. It usually becomes at once easy for the patient to press mucus or pus from the sac, as it is secreted, both by the canaliculus and nasal duct; he is enjoined to do this very frequently, and hot fomentations are used if required. It is common to find in a few days that no more pus is formed, and in a few weeks that mucus ceases to accumulate. In many cases the relief to the epiphora is immediate, and the patients are made at once much more comfortable, losing all that distress that has been occasioned by the distension of the cavity of the sac, and the congestion of its lining mem

brane.

Rather more than a year ago Mr. Bowman contrived a mode of inserting a style by the canaliculus, and leaving it for a certain time in the passages, in order to open them on the principle of the old style. The style was made to taper rather suddenly at one end, and it was bent at about a right angle, so that the thick part should be placed vertically in the sac and nasal duct, and the thin part horizontally in the canal. The length of the thick part was adapted in each case by the surgeon, so as to extend from the point at which the canal enters the sac downwards as far as the floor of the nostril, on which it rested, being thereby prevented from falling too low and burying itself out of sight. The proper length was ascertained previously by measurement by a probe. The horizontal part was, in like manner, adapted to reach to a point of the canal midway between the caruncle and the punctum, and a bend was given to it, making it lie exactly within the canal, concealed from view in the channel formed by the slitting up of that passage. The material was silver, and the ends, after being cut to the requisite length, were carefully rounded, and the thin one tipped with sealing wax.

These bent styles, when suitably adjusted, Mr. Bowman found could be generally worn with very little inconvenience for a few days, and admitted of being readily removed and reinserted, and he still employs them when the stricture is dense and obstinate, or when a rapid opening of it is required. But they sometimes occasion trouble, and become a source of irritation, and they may even produce ulceration of a portion of the canal if badly fitted, or if left in too long, as, for example, when the patient has absented himself during the treatment.

Mr. Bowman therefore prefers to treat the obstructions in almost all cases by the intermittent use of the probe, as already described, and especially as the

results by that method are so satisfactory. He does not recommend the bent styles for general adoption.

In speaking of the rapid relief or cure of cases thus treated, such general and local means as are familiar to all are not neglected. They are useful as aids, but without the surgical interference would be unavailing. Nor is it represented that all cases get well at the same rapid rate, or that relapses never occur. Unfortunately these cases of obstructed ducts generally occur in subjects more or less debilitated, scrofulous, or otherwise unhealthy, and there may be complications of disease of neighboring parts or of the Schneiderian membrane. But all these inconveniences belong to the old method even more than to this, the advantage of which is that it effects the opening of the passages in the most simple way conceivable, and with the least possible interference with the natural structures. It, therefore, seems preferable, not merely in itself, but also inasmuch as it is able to be employed in the required degree and extent, and in that only, at a period of the disease however early, and under all contingencies of relapse; and therefore, if generally adopted, it may be expected to alleviate the severity and diminish the number of these distress ing affections, which have been hitherto hardly less troublesome to the surgeon than to the patient.

Mr. Bowman also states that there are cases of an aggravated nature, which have passed beyond the stage at which the above simple treatment is available -where abscess has formed, where the sac is enormously dilated and thickened, where bone is diseased, where styles have been previously worn, and fistulous orifices exist. The hope is, that such cases will gradually now become less frequent.

In a postscript to this paper, contained in the second number of the "Ophthalmic Hospital Reports," Mr. Bowman adds:

"To facilitate the slitting up of the punctum, a minute director may be substituted with advantage for the No. 1 probe as described in the previous paper. It has been made by Mr. Weiss, at the suggestion of Mr. Critchett, and consists of steel coated with gold by the electrotype process. It is sufficiently thick in the stem to give it firmness, and one end is reduced to a very fine size, and grooved to within a line of the extremity, which is of the size of a No. 1 probe. It is used in the same way.

"I may take this opportunity of saying once again how cautious it is necessary to be in the manipulations of the canaliculi, particularly when they are the seat of stricture, and how desirable to proceed gradually from one step to another, not neglecting subsidiary points of treatment. I may also state that when one canaliculus is strictured and the other open, I prefer to proceed with the treatment of the sac and nasal duct through the open canaliculus, leaving the other alone; for a stricture of one canaliculus is often of itself insufficient to occasion any epiphora, and if the sac-inflammation and the stricture of the nasal duct can be cured by probes conveyed through the open canaliculus, the patient is relieved_effectually, even should the other remain strictured, which it often does not. In such instances, however, I always slit up both puncta."

Case of Aneurism of the Arteria Innominata treated by Pressure on the Distal Side. By Mr. EDWARDS, Demonstrator of Anatomy in the University of Edinburgh.

The mode of treatment which was employed successfully in the following case, does not appear to have been tried on any previous occasions.

CASE.-In September, 1856, Mrs. L, æt. 50, was recommended to my care by Professor Simpson. She was a sallow-complexioned woman, with hanging, flabby cheeks; her lips, which were always apart, were livid and drawn down at the angles, and she breathed rapidly. Her countenance presented the peculiar anxious expression of one suffering from a fatal disease. On examining her neck, I found on the right side, above the sterno-clavicular articulation, a tumor, the size of an apple, situated between the sterno-mastoid muscle and the middle line of the neck, which pulsated violently, was soft and compressible, giving to the fingers much the same feeling as a vulcanized India-rubber ball,

PART XXVII.

16

which, though easily compressible, expands again immediately the pressure is withdrawn; and with the expansion of this tumor, fluid seemed rapidly to fill the interior, and to be separated but by a thin partition from the fingers. Another pulsating tumor rose in front of the trachea. They were, though apparently distinct, evidently bulgings out of the same aneurism, as pressure on the one was followed by increase in size of the other. The patient had remarked these tumors about two months before I saw her, and they were, according to her account, increasing rapidly. Any pressure upon them was attended with pain and an increase of cough. She suffered from constant dyspnoea, had entirely given up her ordinary household occupations, and had frequent fainting fits; she rarely ventured even at night to lie down in bed, as, after falling asleep, the laryngeal spasm became so violent that an attendant had to be on the watch ready to administer restoratives. The ordinary internal remedies were tried, but without much benefit.

As I considered that the aneurism was one of the innominata artery, I thought of placing ligatures on the vessels, according to Wardrop's method; but Dr. Laycock, who at my request examined her chest with the stethoscope, considered that the arch of the aorta was also aneurismal, so I gave up the idea of a cutting operation. But it struck me that Mr. Wardrop's principles could be applied to compression, and Mr. Young, of Prince's Street, constructed for me an instrument which I shall endeavor to describe.

A broad leathern belt to go round the chest, and fasten in front with three straps and buckles. On its left posterior and right anterior upper margins are brass buttons. In the middle of its posterior aspect is an iron plate perforated with several holes to admit screws, which attach to it an upright steel rod about eighteen inches long. This rod supports an arc of steel, which is attached to it by a screw allowing a certain amount of motion. In front, this are is perforated by another screw, about an inch long, with a small cross handle; this projects backwards, and bears a conical piece of cork covered with wash leather. When the instrument is applied, the upright is at the back and right side of the neck, which rests in the arc, and, by shifting the lower end of the upright, pressure with the cork can be regulated and efficiently maintained upon the common carotid artery, the conical shape of the cork enabling one to confine the pressure to the artery. A strap is carried over the right shoulder from the buttons behind to those in front; on it slides another cone of cork, which can be adjusted over the subclavian. It will be seen that in principle this instrument resembles Bourgery's tourniquet for subclavian pressure.

Mrs. L had worn this instrument for several hours of two days, when I was alarmed by observing that the tumor had visibly increased in size. Its walls felt thinner, and the contents were distinctly fluid. The bruit de soufflet was very loud, and the pulsation violent. The treatment, however, was continued, and the pads adjusted so as to stop all pulsation in the branches of the external carotid and in the right wrist. On the fourth day the tumor, though larger than when the instrument was first applied, was much harder and less compressible. The tracheal portion still, however, pulsated violently. Every morning, for the first two weeks, I adjusted the apparatus, at the same time manipulating the tumor rather roughly, with the view of breaking up the fibrine in the sac. But she soon learned how to apply it for herself, and, finding decided benefit from it, bore the treatment cheerfully. She said it was irksome, but never complained of pain.

After the first week the laryngeal symptoms entirely disappeared, and did not return, and she had no more fainting fits; but she complained of some impediment in swallowing, as if some hard body stopped the food in its passage down the gullet. I now feared that the apparent improvement was deceptive, and that the tumor was increasing towards the oesophagus; but as this symptom disappeared with the gradual decrease in the bulk of that part of the aneurism which we could judge of by external examination, I now conclude that it arose from the solidification of the contents of the sac in close apposition to the gullet.

By the end of three months she was well enough to lay aside the instrument and resume her former household duties. She repeatedly walked a distance of

three miles and back to my house, and passed tranquil nights. The external part of the tumor was then, and is now, the size of a nut, and hard; the tracheal portion has entirely disappeared; the aortic aneurism seems to have made but little progress, and, with the exception of attacks of neuralgia in the face and head, and a chronic cough which troubles her every winter, she has been in good health since. She gave up the instrument more than ten months ago. Before she began to use it, a surgeon of great experience told me he expected the external tumor would burst in a day or two, and Dr. Laycock was of the same opinion. Of course, I cannot hope to avert the fatal termination we must always expect in thoracic aneurisms; but I am convinced, and so is the patient, that the compression of the vessels beyond the aneurism was attended with marked benefit, and was the direct cause of its hardening and subsequent rapid decrease in its size.

The Enlarged Prostate, its Pathology and Treatment; with Observations on the Relation of this Complaint to Stone in the Bladder. By HENRY THOMPSON, F. R. C. S., M. B., Assistant Surgeon to University College Hospital, Consulting Surgeon to the St. Marylebone Infirmary, &c.

This work is of a thoroughly sound and practical character. It contains a large amount of new matter and original thought, and it fairly and fully states what had been done by previous investigators in the same subject. It is a work, indeed, with which few readers can be dissatisfied.

The anatomy of the prostate, and the anatomical characters of the enlarged organ, form the subjects of the first two chapters; and here we find the result of not less than seventy original dissections and a careful examination of the dissections contained in the different metropolitan museums. What these results are may be seen by turning to the abstract of a previous paper which will be found in a former volume (xxv. p. 153), and here we will only say that the two points upon which most stress is laid are-first, that the third" or "middle lobe" is a diseased and not a natural portion of the prostate; and, secondly, that there is an analogy between enlargement and tumors of the prostate and those of the uterus.

The alleged causes of senile enlargement of the prostate are treated of in the third chapter, and here, after stating the views generally entertained on the subject, enlargement of the prostate and uterus are shown to be identical in their nature, and probably in their causes.

"There is but one other organ in the body which is similarly constituted, as regards the nature of the constituent tissue, and in the manner of its aggrega tion. The uterus, like the prostate, is composed of the inorganic muscular tissue distributed in thick strata, so as in either case to form a thick mass, not in thin planes, as found in all the other organs in which this tissue appears. The tendency to become the seat of local and general hypertrophy, of isolated tumors and outgrowths of a special character, which both organs equally manifest, has also been demonstrated. Starting from this remarkable fact, it is difficult to resist the inference that this tendency to overgrowth, this disposition to generate fresh elements identical in character with those proper to the structure of the organs, has a source common to both, and perhaps inherent as a kind of structural, or perhaps functional necessity. The capability of this structure for exhibiting rapid and enormous increase under certain circumstances, is admirably exemplified by what happens to the gravid uterus. A dormant force is awakened through the presence of the impregnated ovum, and the weight and bulk of the organ is in a few months increased tenfold. Active determination of blood is coincident, and doubtless supplying the materials of nutrition, but not venous congestion, nor any one of the numerous alleged causes of prostatic hypertrophy already referred to. But the uterine function having ceased temporarily or permanently, the organ diminishes and returns sooner or later nearly to its original size. During the latter moiety of the term of reproductive activity, the uterus is exceedingly prone to develop formations, identical in structure with its own, but more or less isolated from the parent tissues, either in the form of tumors or outgrowths, and these are

while the blood in the third bottle, which for a time received the full charge of the vapor, retained its red color and its full fluidity for eight minutes and a half; as long, in fact, as any vapor could be sent through it. When the vapor failed, and air only began to circulate, this blood coagulated feebly, the fibrin separating and floating at the top.

I repeated this experiment frequently, with the same general result." From these experiments it was obvious that in the blood-vapor lay the solvent of the fibrin, and it became a task to ascertain what this solvent itself could be. Those chemical writers who spoke at all about the vapor of the blood, named as its component parts water, carbonic acid, nitrogen and oxygen. Dr. Richardson ascertained by experiment that oxygen rather quickened than retarded coagulation, and that carbonic acid and nitrogen rather impeded the process. "The difference, however, is too slight to give either of them an importance as causes of fluidity." "At this point," writes Dr. Richardson, "I was brought to the same position as Sir Charles Scudamore; with the advantage of feeling morally sure that something remained in the rear which should be sought after" (p. 272).

In no writing had there been any reference to the possibility of ammonia being given off from newly drawn healthy blood, yet there seemed nothing objectionable to Dr. Richardson in such a view, for ammonia can be produced in the body. At any rate it was a fair subject for inquiry wither ammonia was given off from freshly drawn blood; and, if so, what influence it had on blood drawn from the body?

First, then, blood-vapor was tested by being passed over a stick dipped in dilute hydrochloric acid, but no well-known white vapor of chloride of ammonium was given off. A more delicate test was had recourse to. Blood-vapor was passed through hydrochloric acid, the acid was then "poured into a clean evaporating dish, solution of perchloride of platinum was added to it, and the mixture was carefully evaporated in the water-bath. The result was a deposit of crystalline salt of ammonio-chloride of platinum, which was afterwards well washed in a mixture of alcohol and ether" (p. 275). The experiment was repeated again and again, with the same results. The blood of oxen and of sheep was used in the experiments.

Another test was also used, namely, the production of microscopic crystals of chloride of ammonium from blood-vapors, by means of hydrochloric acid. "If a little pure hydrochloric acid be placed in a microscope-glass and held over a solution of ammonia for a moment, and the glass be then gently warmed, a field of the microscopic crystals will be formed" (p. 276). This test was made us of by placing (due precautions being used) a microscope-glass, moistened with hydrochloric acid, above the blood of oxen, sheep, and finally of man, and in every instance the result was most decided, numerous groups of crystals of chloride of ammonium being invariably formed.

Thus, then, it was clearly ascertained that ammonia (certainly in a minute quantity only) was evolved from freshly drawn blood. "That the fact, however interesting, and however contrary to the idea that ammonia would exist in the blood and make the round of the circulation without specific purpose, might after all be a mere coincidence, like the evolution of carbonic acid. The volatile alkali might have other causes than that of holding blood-fluid. It might be a mere excrete. To dig deeper, therefore, into the question, it was necessary to change the line of inquiry, to adopt an approach to the synthetical method, and to ascertain what effect ammonia produces when added to fibrin, or when added to blood" (p. 287).

The effects of ammonia, both in the solid state and in vapor, were examined in numerous experiments, and from them we learn, that ammonia not only possesses remarkable powers, even in very small proportions, of holding bloodfluid, but further, that blood to which ammonia has been added remains but temporarily fluid; that under favoring influences, the ammonia exerts its volatile force, leaves the blood, and allows coagulation. We learn, also, that in excess the solvent effect of ammonia extends from the fibrin to the corpuscles; but that (and this is an all-important practical fact) ammonia, added in more minute quantities, possesses the power of holding the fibrin in solution without