as bleeding, mercury, antimony, &c., exert not the slightest influence in modifying it. All practical ophthalmic surgeons will set their seal to this statement. Nor is this to be wondered at, since the real cause of the acute symptoms is left in full force.

Reflecting on these points, it seems that two indications are especially required: 1st, to relieve the pressure and re-establish the equilibrium between the containing and the contained: and, 2d, to leave for a time a sort of safetyvalve to prevent such equilibrium from being again disturbed. With a view of effecting this double object, Mr. Critchett recently performed the following operation. He introduces a broad needle through the cornea, close to its junction with the sclerotic, and allows the aqueous humor to escape. He then draws out a portion of the iris with a blunt hook, and leaves it in the wound; or, if it protrude much, he removes a portion, and leaves the remainder in the wound. The immediate effect of this operation is to remove the tension of the globe, and relieve the pain; the secondary effect is the gradual and steady improvement of the sight; and the remote effect is, apparently, the removal of the tendency to fresh attacks. The idea of puncturing the globe for the purpose of relieving tension in cases of internal inflammation, is very old. It was suggested and practised by Mr. Wardrop and others, and ever since Mr. Critchett has lectured on diseases of the eye, he has advocated the treatment; and in a lecture published in the "Lancet" of September 9th, 1854, he relates a case in which he put this plan in practice with a very successful result, and urges the treatment of similar cases.

Recently Von Gräfe, of Berlin, has practised a modification of the operation in a large number of cases of acute and chronic glaucoma, his plan being to remove a large piece of iris. The objection to the method of mere puncturation seems to be the rapidity with which the wound heals, and the tendency to relapse into the former condition of tension. And the advantage of drawing out a portion of the iris seems to be to allow time for the adjustment of the normal tension, and perhaps also the establishment of a communication between the anterior and posterior chambers.

Mr. Critchett's object in the present paper is briefly to relate some cases of acute and subacute inflammation of the globe that have recently been subjected to this operation.

CASE 1.-In June, 1857, I was requested by my friend, Mr. Goude, of Cheapside, to see a middle-aged lady suffering from the following symptoms. Her right eye was the seat of deep aching pain, of an unremittent character, great intolerance of light, and lachrymation; the sight was so imperfect that the back of the hand could not be distinguished from the front, and the fingers could not be counted. The sclerotic vessels were highly injected; the pupil was fixed and widely dilated, and the humors looked dull and dirty; the left eye had been inverted and defective from infancy.

It appeared that this lady had been attacked with severe pain and inflammation of the right eye about a week previous to my visit, resulting in dimness of vision, which had gradually increased. She had been cupped on the temple, and subjected to rather active antiphlogistic treatment, without any apparent mitigation of the symptoms. When I saw her I found the pulse quick, weak, and irritable, and the spirits much depressed by the severity of the pain, and by the dread of impending blindness; the appetite was bad, and sleep much interrupted. I placed her under the influence of chloroform. I then passed a broad needle through the cornea, close to its junction with the sclerotic, and with the blunt hook drew out a portion of iris, some of which I cut off, leaving the remainder in the wound. The immediate effect of this operation was entirely to remove the pain, to restore the natural tension of the globe, and slightly to improve vision. The pain never returned; and from day to day the sight gradually but steadily improved, until at the end of three weeks average-sized print could be read; and at present the sight is as good as before the attack. The pupil was of course altered in shape, but had recovered about its average size and mobility.

CASE 2.-About two months after this first case, the wife of a large Sussex farmer sent for me, suffering in the following way. The left globe was the seat

of acute inflammation. The pupil was so widely dilated that the iris presented merely a narrow ring. The anterior chamber was diminished in size, and the humors were of a dull aspect, and could not be lighted up with the ophthalmoscope. Vision was so much obscured that only the dim outline of objects could be made out. There was constant severe pain in the globe, the constitutional powers were at a very low ebb, the pulse very small and feeble. No sleep could be obtained, and there was distressing nausea of the stomach.

An interesting feature in this case was, that the right eye had been attacked in a precisely similar manner about nine years ago, and at the end of six weeks, in spite of very active local and constitutional treatment, sight was entirely lost. I then found a fixed and widely dilated pupil, a hard globe, secondary cataract, and all the evidences of a spoiled eye. Immediately I was called to this case I performed the same operation as in the one I have just related. Considerable care was required not to wound the lens, which was thrust somewhat through the pupil and near the cornea. The result was most striking and satisfactory. The pain and sickness immediately ceased and did not recur; sight steadily improved from day to day, and in three weeks the patient returned into the country, able to read a good sized print. The pupil became much smaller and active. I have since heard a very favorable report, and that the sight is as good as ever it was.

CASE 3.-This case came under my care at the Royal London Ophthalmic Hospital. William Almerott, a man æt. 34, a working engineer, was led to me on September 4th, having lost all power of recognizing objects, and retaining very little sight beyond the mere perception of light. On examining the case the left eye was found in a state of chronic inflammation, the sight having been entirely lost from injury. About five years ago the right eye was the seat of acute inflammation of the globe, with widely dilated pupil, and a thin layer of lymph over the surface of the capsule of the lens. The history of the case was curious and instructive.

About five years ago, when at work, a piece of metal flew into the eye, wounding the cornea and sclerotic, the iris and lens; this was followed by severe pain and inflammation, and by total loss of sight; the globe became soft and diminished in size, but remained tender to the touch, and at times was painful. Since then the man has had occasional attacks of dimness in the other eye when at work, which lasted some hours, and then passed off entirely. Five days before I saw him he was seized in the night with intense agonizing pain in the globe, which lasted several hours, and in the morning he was nearly blind. A medical man was sent for, and he was placed under active antiphlogistic treatment. The pain did not recur, but a dull aching remained in the globe, which was of stony hardness, and the sight remained in the same condition as when he was led to me. All my previous experience induced me to take a most unfavorable view of this case. The intensity of the pain, the rapidity with which previously good sight had been nearly destroyed, the extreme dilatation of the pupil, the dulness of the humors, and the evidence of inflammatory effusion on the capsule, all conspired to give a gloomy aspect to the case. It was, therefore, with feeble hopes of success that I proceeded to operate. When under the full influence of chloroform, I first removed the injured and diseased globe, and then performed the same operation as I have previously described on the right eye, drawing out a piece of iris and leaving a portion in the wound. On recovering from the effects of the chloroform he stated that he was now quite free from pain, and that he could see better than before the operation. Since that time he has had no return of pain; the sight steadily improved from day to day, and at the end of a fortnight he could see to read moderate-sized print, though everything still looked misty, The pupil, though of course altered in shape, has recovered its normal size and responds to the stimulus of light; the thin layer of lymph is still visible over the capsule, and it seems probable that the same slight cloudiness of vision will remain, though not to such an extent as to prevent him from following his employment. I think this is the most striking and satisfactory case I have yet had. It illustrates forcibly the injurious sympathetic effect of a damaged and spoiled eye, in which a smouldering inflammation still lingers, upon its com

panion; inducing, first, attacks of congestive, but temporary dimness, and then acute inflammation of the globe, and it further shows the steady recovery of the recently-attacked organ when the extreme tension to which it had been subjected is effectually and permanently relieved by operation.

CASE 4.-This case was that of a lady, who had been many years a governess, and had recently resided in the "Home for Gentlewomen," in Queen's Square. She first came under my care at the hospital, about six years ago, suffering from deep-seated disease of the left globe, combined with cataract and partial staphyloma, which occasioned her severe pain. For this I removed the anterior part of the eye (an operation that was usually performed at that time in similar cases). The globe gradually diminished and healed, and an artificial eye was subsequently worn. Early in the spring of this year this lady had a slight attack of hemiplegia, from which she slowly recovered, and for which she was subjected to rather severe discipline; low diet, active medicines, and bleeding. In the autumn of this year she was suddenly attacked with severe pain in the right eye and dimness of vision. This continued to increase until on the fourth day she could not distinguish even large objects, and when I saw her six days after the attack, she could only distinguish light from dark. I found a widely dilated pupil, a dull state of the humors, and all the symptoms I have previously described. I performed immediately the same operation as in the other cases, and the result has been equally satisfactory-the pain almost immediately subsided, and the sight gradually but steadily improved. I saw her about a fortnight ago. The pupil was movable, and she read moderate-sized print to me with the aid of her usual glasses.

CASE 5. This, the last case that I would briefly notice, is one that seems to yield a sufficient amount of negative evidence in the same direction as those I have already related, to deserve notice. Early in November, I was requested by my friend, Mr. Boar, to see a lady suffering from severe inflammation of the right globe, of about a week's duration. The pain, which was somewhat mitigated when I saw her, had been most intense. The pupil was widely dilated, the humors were dull, and there were all the usual symptoms of deep-seated disease of the globe. The sight was much obscured. This state of things had existed about four days. I urged the operation that I had performed in the other cases with such signal success, but I could not succeed in obtaining the consent of the patient. The result has been that, although the pain has gradually subsided, the pupil has remained widely dilated, and the sight is permanently and seriously impaired.

The merit of the operation is, that it is easily and quickly performed, and that the wound speedily heals; and the disadvantage of it is, that it produces a permanently deformed pupil. This objection is in some measure obviated by an ingenious suggestion of Mr. Bowman: That the pupil should be drawn nearly directly upwards, so as to conceal the irregular portion beneath the upper lid. It would be foreign to the object of this paper to inquire how far this proceeding is applicable to other cases of a chronic character, as its original promoter believes.

On the Treatment of Lachrymal Obstructions. By Mr. BOWMAN, F. R. S., Surgeon to the Royal London Ophthalmic_Hospital. (“Ophthalmic Hospital Reports," No. 1, October, 1857; No. 2, January, 1858.)

As early as 1851, Mr. Bowman began to treat all cases of lachrymal obstructions by slitting up the punctum and by passing probes of suitable size through the upper or lower canaliculus. In this way he avoided the inconveniences of the opening in the skin required in the former objectionable treatment by the style; and from the very beginning he establishes a permanent opening, unseen, and attended by no inconvenience, through which the use of the treatment by probes can at any time be at once resumed in the event of relapse. In place of the old operation by the style-indeed, an operation in every respect clumsy and unsatisfactory-an operation is introduced which is both sightly and satisfactory.

In the course of his investigations on this subject, Mr. Bowman has kept

constantly in view the analogy of obstructions of the lachrymal ducts with those of the urinary passages. These obstructions are in many respects closely allied, and the history of urethral strictures may furnish some hints which are applicable to the treatment of lachrymal strictures.

Before the proposal to slit up the punctum, some anatomists may have been aware that the canaliculi were capacious ducts, large enough to admit an ordinary probe; but, certainly, surgeons took no account of that important fact. They have been syringed, and probes have been passed down them; but the instruments employed were only such minute ones as the puncta would admit, namely, of the size of a horse-hair. It may be even true that such probes may have been passed into the nose, but their effect, even then, can have been only such as would be produced on a urethral stricture if the surgeon were restricted to the use of the smallest urethral bougie. They may have passed the stricture, but can have done little to dilate or cure it.

When Mr. Bowman first began to slit up the puncta he became aware that the canaliculi were naturally capacious enough to admit a probe of one-twentieth of an inch in diameter or more; and finding, not unfrequently, that strictures existed in the canaliculi, sometimes about the middle, but oftener close to the sac, he had a series of probes constructed, reaching from a fine hair probe (No. 1) to one of one-twentieth of an inch diameter (No. 6). For convenience in use he has three probes, the six ends of which give the six sizes required, and the larger of which are so bent as to facilitate their passage through the nasal duct as hereafter to be noticed.

In the great majority of cases of sac-obstruction, a simple epiphora precedes, for a considerable period, the more inflammatory stages; there is regurgitation only of tears at first, afterwards of mucus, and of pus; the two latter being often rather sudden in their appearance, and often following immediately on a cold or catarrh, or some stomach derangement. The moment the secretions from the lining of the sac become too thick to escape easily, either through the canaliculi or nasal duct, they appear at once to aggravate the inflammation by mechanical distension; and the author was early led to assign much benefit to the opening of the punctum, merely on the ground of the greatly increased facility with which the discharge could then escape on to the eye, either spontaneously or on slight pressure. The punctum, too, having, no doubt, the attributes of a sphincter, is often highly sensitive, and its lips turgid and angry, when the passages are inflamed; and great immediate relief to the whole disease seems often to follow its division-much, perhaps, of the same kind as that which follows the division of the sphincter ani in irritable fissure of the

rectum.

The punctum is most conveniently slit up as follows: The patient sits in a chair and leans the head against the chest of the surgeon, who stands behind and bends over. For dividing, e. g., the left lower punctum, the ring finger of the left hand is placed on the skin over the lower edge of the orbit, and fixes it there, while tightening or relaxing the lower canal by a sliding movement of the skin upon the bone-the punctum being at the same time everted. The right hand now inserts the No. 1 probe while the canal is relaxed, and then places the probe between the index finger and thumb of the left hand, which holds it in the canal, and further everts the punctum by turning the probe downwards on the cheek, while the ring finger stretches and fixes the canal by a sliding movement of the skin outwards, toward the malar bone. A fine, sharp-pointed knife, held in the right hand, now slits up the canal on the everted conjunctival aspect, from the punctum, as far as the caruncle, and the probe is raised on its point out of the canal, to make sure that the edge of the punctum has not escaped division. Care should be taken not to slope this little incision obliquely through the tissues it severs, as there is then a broader surface exposed, and greater chance of union by the first intention. To avoid this, it is in all cases desirable to pass a probe across the line of incision, on each of the few ensuing days, to break through adhesions if they form, and to secure patency. If the punctum is slit when already inflamed and discharg ing pus, there is much less disposition to this primary union than when it is done for simple epiphora.

Having slit up one or both puncta, as may seem desirable, the canals are at once probed to ascertain whether they are of full size. Where the fluids of the sac regurgitate towards the eye there is usually no contraction that may not be at once overcome by a full sized probe (No. 6); but it is well to have noted beforehand, whether regurgitation occurs from both puncta, and in the first instance to be content, in ordinary cases, with slitting up the lower punctum, inasmuch as this usually suffices for the cure, and it is through this that the passages can be most conveniently probed in their whole extent down to the nose.

In examining the canal for stricture some experience and tact are requisite to avoid errors, just as in the examination of urethral strictures. The instrument should be handled very delicately, and the canal held by the surgeon in the same way as when the puncta have to be slit, and he should, of course, have in his mind's eye at the moment, the anatomy of the parts with which he is dealing-no force should be used. If No. 6 will not pass, No. 4 or No. 2 may be tried; and if these fail, it is better to postpone further proceedings till a few days have elapsed, and the slit in the canal is permanently established. Speaking loosely of the general result of a great number of cases, Mr. Bowman says that he has not found any stricture in the canals in more than onefourth, and that the common situation of the stricture has been close to the sac -less frequently about the middle part of the canal. The stricture of the middle parts is commonly in old cases, where there is rigid thickening of the coats, and probing by instruments successively larger suffices to dilate it. The canal should be stretched lengthwise as the probe reaches it, as its passage is thereby facilitated-for it is easy to fold the canal before the point of the probe. The greatest care is to be taken to proceed gently and not too rapidly-as, if a false passage be formed and the wall of the canal torn, the injured part is liable to become more rigidly occluded.

If the exploratory probe is arrested at the point where the canals coalesce and join the sac, the fact may be known by noticing the skin near the tendo oculi is moved when the probe is moved, and an elastic resistance is experienced; whereas, if the probe has entered the sac, it hits against the inner bony wall, and the skin is motionless. Where the sac is not distended, attention to this point is particularly necessary, and it is also requisite that the canal should be held on the stretch by the finger on the cheek, otherwise the outer wall of the sack may be pressed against the inner and give a wrong indication, for the opposite walls are very near each other. Care must also be taken, when an obstacle is encountered, to turn the point of the probe in different directions, urging it gently forwards in each, for otherwise it may merely be caught in a fold of membrane at the orifice to the sac. If there is decided obstruction still, the probe may be forced here, and if it does not then at once pass into the sac (and particularly if, the sac being distended, there is no regurgitation by the canal), Mr. Bowman has recourse to the canula lancet, described in the "Annales d'Oculistique" of 1855-6, and, after piercing the obstruction, immediately passes the largest-sized probe (No. 6).

Such strictures of the canals, when once they admit a No. 6 probe, are treated by its repeated use at suitable intervals, in conjunction with the treatment of the passages below, and therefore they need not be further separately dwelt upon.

With regard to the subsequent steps of the treatment, Mr. Bowman prefers to explore the nasal duct by pushing down the No. 6 probe into the nostril. When the sac discharges pus or mucus, this always has to be done again and again, in order thoroughly to open the duct, and even where the sac is not inflamed, it is satisfactory to have passed the probe once.

The passage of a probe or style in the old method, through an orifice in the skin, is not always an easy task. There is frequently a firm closure of the nasal duct, requiring the use of considerable force to overcome it, and a surgeon without experience is apt to be timid or to make pressure in a false direction. In fact, with the old style or probe, which was always straight, it was often impossible to find the lower orifice of the sac, and the rude force exerted was apt to make the end of the style scrape the surface of the bone,