NATIONAL LIBRARY OF MEDICINE Washington s£ .3 * 'A/L>- ^o n ~t#- * t>t TROY, NEW-YORK: '*•'• , r' h^ PRINTED BY O. PENNIMAN AND CO. TOR THEMSELVES; THOMAS AND ANDREWS, BOSTON; T. S. ARDEV, NEW-YORK; AND J. CONRAD AND CO. PHILADELPHIA. I8O4. CONTENTS. CHAPTER Vni. Fage Of BLOODLETTING, - I Sea. VII. Of Bloodletting in the ankles and feet, ib. Sea. VIII. Of Arteriotomy, - 3 Sea. IX. Of Topical Bloodletting, - 5 CHAPTER IX. Of aneurisms, - 11 Sea. I. General Remarks on Aneurifms, ib. Sea. II. Of the Treatment of Aneurifms, 32 CHAPTER X. Of affections of the brain from exter- nal VIOLENCE, - - 47 Sea. I. General Remarks on Affeflions of the Brain from External Violence, - ib. Sea. II. Anatomical Defcription of the Brain andfurrounding Parts, - - 50 Sea. III. Of Compreffion of the Brain from Ex- ternal Violence, - 58 § 1. Of Compreffion of the Brain from Frac- tures attended with Depreffion of the Skull, 60 § 2. Of Compreffion of the Brain from Ex- travafation, - - g$ Sed. IV. Of Concision or Commotion of the Brain, - .. 103 iv CONTENTS. Page Sed. V. Of Inflammation of the Membranes of the Brain from External Violence, no § i. Of Confufion of the Head, - 114 § 2. Of Fiffures, or fimple Fradures of the Skull, - - 129 Sea. VI, Conclufion, - - 137 CHAPTER XI. •Of the diseases of the eyes, - 142 Sea. I. Anatomical Defcription of the Eye, ib. Sea. II. Of Ophthalmia, or Inflammation of the Eye, - - 151 Sett. III. Of Wounds of the Eyelids, and Eyeball, 160 Sea. IV. Of Tumors of the Eyelids, 164 Sea. V. Of Inverfion of the Cilia, or Eye-la/hes, 169 Sea. VI. Of the Gaping or turning outwards of the Eyelids, - m \ja Sea. VII. OfConcretim of the EyeMs, 178 Sea. VIII. Of Flejhy Excrefcences in the Cor- nea, - - iyg Sea. IX. OfAbfceffes in the Globe of the Eye, 185 Sea. X. Of Drepfical Swellings of the Eyeball, -191 Sea. XL. Of Blood effufed in the Cavity if the Eyebail, - . Ig4 Sea. XII. Of Ulcers of the Globe of the Eye, 196 Sea XIII. Of Specks or Films upon the Eye, 204 Sea. XIV. Of Protrufiohs of the Globe of the Eye from the Socket, . 211 Sea. XV. Of Cancer of the Eye, and Extirpa- tion of the Eyeball, - . 2iy Sea. XVI. Of artificial Eyes, - 223 CONTENTS. v Page Sea. XVII. Of Catarads, - - 223 § 1. General Remarks on Catarads, ib. § 2. Of Couching or Depreffion of the Cata- rad, - - 229 § 3. Of extrading the Catarad, 243 § 4. Comparative View of the refpedive Ad- vantages and Difadvantages of the Opera- tions of Couching, and extrading the Cata- rad, - - -^55 Sea. XVIII. Of the Fiflula Lachrymalis, 261 1 Sea. XIX. Additional Remarks on Difeafes of the Eyes, - 286 CHAPTER XII. Of the diseases of the nose and fauces, 312 Sea. I. Anatomical Defcription of the Nofe and Fauces, - - ib. Sea. II. Of Hemorrhagies from the Nojlrils, 315 Sea. III. Of an Ozoena, - - 319 Sea. IV. Of Imperforated Nojlrils, 323 Sea. V. Of Polypi in the Nofe and Threat, 325 Sea. VI. Of Extirpation of the Tonfds, 346 Sea. VII. Of the Extirpation of the Uvula, 351 Sea. VIII. Of Scarifying and Fomenting the Throat, - - - 353 CHAPTER XIII. Of diseases of the lips, - 355 Sea. I. Of the Hare Lip, - ib. Sed II. Of the Extirpation of Cancerous Lips, 368 yt CONTENTS. CHAPTER XIV. Page Of the diseases of the mouth, 371 Sea. I. Anatomical Remarks, - ib. Sea. II. Of Dentition, - - 376 Sea. III. Of the Derangement of the Teeth, 379 Sea. IV. Of Gum Boils, - 382 Sea. V. Of Abfceffes in the Antrum Maxillare, 385 Sea. VI, Of Excrefcences on the Gums, 393 Sea. VII. OfLoofe Teeth, - 395 Sea. VIII. Of Cleaning the Teeth, 398 Sea. IX. Of Toothache, - 404 § 1. Of Toothache from the Nerve being laid bare, and of the various Methods of Ex- trading Teeth y - - 405 § 2. Of Toothache from Inflammation, 430 § 3. Of Toothache arifingfrom Affedions of dijtant Parts, - ~ 433 Sea. X. Of Tranfplanting Teeth, - 435 Sea. XL Of the Ranula, - 441 Sea. XII. Of Ulcers of the Mouth and Tongue, and Extirpation of the Tongue, - 444 Sea. XIII. Of the Divifion of the Franum Lin- gua, - - - 447 Sea. XIV. Of the Divifion of the Parotid Dud, 448 CHAPTER XV. Of the diseases of the ears, and the op-,. erations practised upon them, 451 Sea. I. OfDeafnefs, - - ib. § 1. Of an Imperforated Meatus Auditorius, 453 CONTENTS. vii Page § 2. Of Extraneous Bodies impaded in the Ear, - - 454 § 3. Of Excrefcences in the Meatus Audito- rius, - - - 455 § 4. Of Deafnefs from Wax colleded in the Ears, - - - 457 Sea. II. Of Perforating the Lobes of the Ears, 460 CHAPTER XVI. Of the wry neck, - - 462 CHAPTER XVII. Of bronchotomy, - 465 CHAPTER XVIII. Of oesophagotomy, - - 475 CHAPTER XIX. Of diseases of the nipples, - 481 CHAPTER XX. Of the amputation of cancerous mam- MM, - - 483 CHAPTER XXI. Of the paracentesis of the thorax, 494 Sea. I. General Remarks on the Operation, ib. Sea. II. Of Serum colleded in the Thorax, 495 Sea. III. Of Blood colleded in the Thorax, 504 viii CONTENTS. Page Sea. IV. Of an Empyema, or a Coilcfiion of Pu- rulent Matter in the Thorax, - 507 Sea. V. Of Air extravafated in the Thorax, 512 CHAPTER XXII. Of the paracentesis of the abdomen, 517 CHAPTER XXIII. OF HERNIiE, - 526 Sea. I. Of Hernia in General* - ib* * A SYSTEM OF SURGERY. CHAPTER VIII. OF BLOODLETTING. SECTION VIL Of Bloodletting in the Ankles and Feet.. WHAT has already been faid on the operation of bloodletting, renders it unneceffary in this place to be minute. When blood is to be taken from the veins of thefe parts, it will be readily under- ftood, that our firfl objea mould be to comprefs the Veins, fo as to produce an accumulation of their con- tents. The ligature being applied fufficiently tight a little above the ankle joint, all the branches of the vena faphaena, both in the infide and outfide of the foot, come at once into view; and as this vein is eve- ry where fuperfkial, being in general covered with (kin only, wherever it appears confpicuoufly, it mav with fafety be opened. Vol. II. B 2 Of Bloodletting. Chap, V1IL With a view to encourage the difcharge of blood, it has been a conflant praaice in opening thefe veins* to immerfe the feet in warm water immediately on the orifice being made. But this is a very inaccurate method, as the quantity of blood taken in this man- ner can never be afcertained, from being all mixed with the water : neither is the afliftance of warm wa» ter neceffary; for when all the veins are fufficiently compreffed, and the orifice of a proper fize, I never find more difficulty in obtaining a full difcharge of blood from thefe veins, than from thofe in other parts of the body. On removing the ligature, however, the blood flops eafily; fo that a piece of adhefive plafter applied over the orifice, anfwers all the pUrpofes of a bandage* Thefe are the feveral parts from whence blood is ufually taken by venefeclion ; but in fome inflances, where the contiguous parts have been particularly af> feaed, it has been judged advifable to open the veins of other parts, as thofe of the tongue, of the penis, the eye, and the external hemorrhoidal veins* When blood is to be difcharged in this manner from the pe- nis, the veins can be eafily brought into view by pref- fure with a ligature \ but, in the tongue, in the he- morrhoidal veins about the anus, and other parts where compreffion cannot be applied, all that can be done, is, to make an orifice of a proper fize in the mofl confpicuous part of the vein ; and if a fufficient difcharge cannot in this manner be obtained, it may be neceffary in fuch circumftances to put the parts in warm water; and, for fome time, to keep them im- merfed in it. Having thus confidered the various modes of dis- charging blood by venefeaion, we now proceed to arteriotomy. Sea. VIIL Of Bloodletting* SECTION VIIL Of Arter'wtomy. HATEVER advantages may in theory have been expeaed from arteriotomy, and howev- er keenly fome may in their clofets have given it their fupport, not only as being in many inflances prefera- ble to venefeaion, but as an operation perfeaiy fafe ; yet the mofl flrenuous friends to the praaice have fhrunk from attempting it on large arteries. Inflan- ces, indeed, have occurred of large arteries being open- ed, and no dangerous confequences taking place; but they are fo exceedingly rare, that no praaitioner of experience will be induced by them, deliberately, or from choice, to adopt the praaice. The fmaller branches of arteries may indeed be opened with fafety when not deeply covered, and efpecially when they Jie contiguous to bones ; for in thefe fituations, as foon as the quantity intended to be taken is difcharg- ed, all farther lofs of blood may be prevented by com- preffion ; but the opening of any of the larger arterie9 mud be always attended with fo much hazard, and the advantages to be expeaed from it in preference to venefeaion are apparently fo trifling, as mufl probably prevent it from ever becoming general* We know of few arteries, therefore, which with propriety can be opened: the different branches of the temporal are thofe indeed from whence blood in ordinary praaice is ever taken : but, if a fanciful prac- titioner fhould at any time incline to take blood in this manner from a different part, it may be done with fafety from one of the arteries running on each fide of the fingers. About the middle of the lafl phalanx, this artery is fufficiently large for discharging a con- fiderable quantity of blood j in mofl cafes it lies fu- B 2 w 4 Of Bloodletting. Chap. VIIL perficial, and in this fituation there can feldom be much difficulty in putting a flop to the difcharge : in performing this operation on any of the temporal , branches, if the artery is fuperficial, it may be done with one pufh of the lancet, in the fame manner as in venefeaion; but, when the artery is deeply covered, it fhould be previoufly brought into view, by cutting the fkin before making the orifice with the lancet: for when the fmaller arteries are cut entirely acrofs, they never bleed freely, from their being ap to retraa more or lefs within the furrounding parts. Some nicety is therefore neceffary in making the opening into the artery: it fhould neither be quite acrofs, nor direaiy longitudinal; for it never bleeds fo. freely, either in an artery or vein, when quite lon- gitudinal, as when fomewhat oblique. When the opening is properly made, and the artery of a moderate fize, it will at once difcharge freely, without being compreffed ; but the difcharge may be increafed at pleafure, by compreffing the artery imme- diately above the orifice, between it and the corre- fponding veins. The quantiy of blood being thus difcharged, a very flight compreffion on thefe fmaller arteries will fuffice for putting a flop to the evacua- tion : for the mofl part, any preffure that is neceffary may be applied here as in venefeaion, by means of a linen comprefs and roller: the orifice being firft en- tirely cleared of blood, and properly covered with ad- hefive plafler. If this fhould not prove fufficient, a comprefs of linen fhould be applied over it, and the whole fecured with a roller. In fome inflances even this does not fucceed, and the orifice continues to burfl out from time to time, fo as to produce much inconvenience and diflrefs. In this fituation we have different methods of put- ting a flop to the difcharge. i ft, If the artery is firftll, as all the branches of the temporal arteries commonly are, cutting it entirely acrofs, exaaiy at the orifice made with the lancet, by allowing it to retraa within Sea. IX. Of Bloodletting. 5 the furrounding parts, for the mofl part proves fuffi- cient. 2d, When the patient does not confent to this, we have it always in our power to fecure the bleeding veffel with a ligature, as would be done vyith an artery accidentally divided in any part of the body. And laflly, when the patient will not confent to either of thefe, we may, by regular continued preffure, ob- literate the cavity of the artery at the point where the opening was made, and thus produce an accretion of its fides. Different bandages have been contrived for compreffing the temporal artery ; but none of them anfwer the purpofe fo well as the one reprefented in Plate LXIV. fig. 3. As fome time, however, is required to obliterate the cavity of an artery, this method is accordingly more tedious: but with timid patients it proves more acceptable than either of the other two. Having thus confidered the various means employ- ed for evacuating blood from the larger arteries and veins, we now proceed to the confideration of topical bloodletting. SECTION IX. Of Topical Bloodletting* HEN, either from the feverity of local inflam- mation, or from any other caufe, we wifh to take blood direaiy from the veffels of the part affec- ted, the following are the different methods we employ for it. The application of leeches; fcarifications with a lancet, or fome other fharp inflrument; and, laftly, by means of an inflrument termed a fcarificator, con- taining from one to twenty lancets, or more : in this inflrument, Plate VII. fig. 1. the lancets are fixed in fuch a manner, that when applied to the part from w 6 'Of Bloodletting. Chap. VIIL whence we wifh to take blood, the whole number are driven fuddenly into it, by means of a fpring, and to a greater or leffer depth, at pleafure. This being done, as it is the fmaller blood veffels only that by this operation are ever meant to be cut, and as thefe fel- dom bleed freely, different means are employed for promoting the difcharge. Various methods have been propofed for this. Glaffes fitted to the form of the parts, with a fmall hole in the bottom of each, were long ago contrived j and thefe being placed upon the fcarified parts, a de- gree of fuaion was produced by a perfon's mouth, fufficient for nearly exhaufting the air contained in them.* This accordingly was a very certain method of increafing the evacuation of blood, but as it» was attended with a good deal of trouble, while it did not always prove fufficiently powerful, an exhaufting fy- ringe was at lafl adapted to the glafs, which ferved indeed to extraa the air contained in it, but being troublefome in the application, and praaitioners find- ing it difficult to preferve the fyringe always air tight, this part of the operation has for a confiderable time' been chiefly done by applying heat in fuch a manner to the glaffes, as to rarefy the air which they contain in a degree fufficient for producing a confiderable fuc-« tioii. And as the inflrument in this fimple form an- fwers the purpofe in view, the ufe of the fyringe will probably be laid altogether afide. The glaffes for this purpofe, it is evident, muft be entire ; for if the leaft communication is allowed between their cavities and the furrounding atmofphere, no effeft will refult from them. Different methods are employed for thus applying heat to the cavity of the glafs. By fupporting the mouth of it for a few feconds above the flame of a ta- per, the air may be fufficiently rarefied; but if the flame is not kept exactly in the middle, and is allow- * Celfus, lib. %. cap, ix. Sea. IX. Of Bloodletting. 7 ed to touch either the fides or bottom of the glafs, it is apt to crack and fly in pieces. A more certain, as well as an eafier method of applying the heat, is to dip a piece of foft bibulous paper in fpirit of wine, and having fet it on fire, to place it in the bottom of the glafs, and, on the flame being nearly extinguifhed, in- ftantly to apply the mouth of the inflrument upon the fcarified part. This degree of heat, which may be regulated by the fize of the paper, and which ought to be always in proportion to that of the glafs, if long enough applied, proves fufficient for rarefying the air, and at the fame time, if done with caution, never in- jures either the glafs or the patient. If the fcarifications have been properly made, they inftantly begin to difcharge freely on the glafs being applied: on being nearly full of blood, it fhould be taken away, by raifing one fide of it, or by undoing a fcrew fitted to a fmall opening in the bottom, fo as to give accefs to the external air. W;fcen -more blood is to be taken, the parts fhould be bathed with warm water; and, being made perfeftly dry, another glafs exaaiy of the fize of the firft, fhould be inftantly ap- plied in the fame manner ; and thus, if the fearifka- tor has been made to penetrate to a fufficient depth, fo as to have cut all the cutaneous veffels of the part, almoft any neceffary quantity of blood may be obtain- ed. It fometimes happens, however, that a fufficient quantity cannot be got at one place : in this cafe, we apply the Scarificator as near as poflible to the parts affeaed ; and this being done, the application of the glaffes muft alfo be renewed, as before. When we wifh to difcharge the quantity of blood quickly, two or more glaffes may be applied at once on contiguous parts previoufly fcarified; and the quan- tity of blood is more quickly obtained when the cup- ping glaffes are firft applied for a few feconds upon the parts to be afterwards fcarified. The fuaion thus produced by the glaffes, feems to have fome influence 8 Of Bloodletting. Chap. VIIL in bringing the more deep feated veffels into nearer contaa with the fkin, fo that more of them are cut by the fcarificator. A fufficient quantity of blood being procured, the wounds made by the lancets fhould be all cleared of blood ; and a bit of foft lint dipped in a little milk or cream, or fpread with wax ointment, applied over the whole, is the only drefling which they require : dry lint is fometimes applied, but it not only creates more uneafinefs, but renders the wounds more apt to fefter than when previoufly covered with an emollient. Although this operation is not difficult, yet a good deal of praaice is neceffary to perform it in a neat and fuccefsful manner ; but with proper attention, any operator may foon do it fo expertly as to be able in this way to difcharge any neceffary quantity of blood. In fome cafes of local pains, and in others with a view to promote fuppuration, an operation, termed dry cupping, has been propofed, and in fome inflan* ces praaifed with advantage: it confifts in the appli- cation of the cupping glaffes without the ufe of the fcarificator. In this manner, a tumor is produced upon the part; and, where any advantage is to be ob- tained from a determination of blood to a particular fpot, it will not fail to anfwer. In Plate V. is reprefented a fcarificator, together with different fize^s and figures of cupping glaffes, with which every operator fhould be amply fupplied, fo as to be able to adapt a glafs to every part from whence it may be proper to difcharge blood. When the part from which blood is to be difcharg- ed is fo fituated that a fcarificator and cupping glaffes can be applied, this method of taking it is preferable to every other ; but it fometimes happens, that parts are fo fituated as not to admit of their application; thus, in an inflamed ftate of the eye, of the nofe, and other parts of the face, the fcarificator cannot be ap- plied directly to any of thefe parts. In fuch inftances, Sea. IX. Of Blo:dlelting. 9 leeches are commonly employed, as they may with fafety be placed upon any fpot from which blood can be taken. In the application of leeches, the mofl effeaual me- thod of making them fix upon a particular fpot, is to confine them with a fmall wine glafs. Allowing them to creep upon a dry cloth, or on a dry board, for a few minutes before being applied, makes them fix more readily; and moiftening the parts on which we wifh them to fix, either with milk, cream, or blood, tends alfo to caufe them to adhere more fpeedily than they otherwife would do. As foon as the leeches have come away, the ordinary method of promoting the difcharge of blood, is to cover the parts with linen cloths wet with warm water, or even with dry warm cloths : in fome fituations, this is perhaps the beft method we can employ; but wherever the cupping glaffes can be applied over the wounds, they anfwer the purpofe more effeaually. When the fituation and figure of the part will therefore admit of their application, they ought always to be employed. Among other methods of performing local blood- letting, I mentioned fcarifications made with a lancet, or fome other fharp inflrument: this proves particu- larly ufeful in ophthalmia, and often gives immediate relief where general bloodletting has previoully been tried in vain. By fcarifying the turgid veffels of the eye$ fo as to difcharge perhaps only a few drops of blood, more advantage is often obtained than from the difcharge of a great quantity either from the jugular veins or temporal arteries: the mere divifion of the veffels has in.fuch cafes indeed been fuppofed to prove ufeful; but I have conftantly obferved, that the ad- vantage derived from this operation, has been nearly in proportion to the quantity of blood that has been taken. Different methods have been propofed for perform- ing it. It may be done with the fhoulder of a com- mon lancet, but more neatly and more eafily by in- io Of Bloodletting. Chap. VIIL ftruments that I fhall hereafter point out in chapter XL when fpeaking more particularly of difeafes of the eye. Among other methods that have been propofed for fcarifying the blood veffels of the eye, doing it with the beards of rough barley was at one period much extolled, and by fome the praaice is ftill continued. By drawing the beards over the furface of the eye, in a direaion contrary to the fharp fpiculse with which they are furnifhed, a confiderable difcharge of blood may be produced. But the pain attending it is ex- quifite ; and as k does not poffefs any fuperier advan- tage over the method of dividing the blood veflels with a lancet, it is now defervedly falling into difuf& I have thus flniflied the confideration of the various means employed in furgery for difcharging blood from the fyflem ; and as the difeafe termed aneurifm, is raoft frequently the effea of an unguarded manner of performing one of the operations that I have juft been defcribing, the farther confideration of the fubjea cannot, perhaps, be any where more properly intro- duced than in this place, where one of the principal caufes by which it is produced has been fo lately treated of. Sea. I. Of Aneurisms. i i CHAPTER IX. OF ANEURISMS. SECTION L General *Remarks on Aneurifms. BY the term aneurifm, was originally meant, a tu- mor formed by the dilatation of an artery ; but modern praaitioners make the term apply not only to tumors formed in this manner, but to fuch as pro- ceed from blood effufed from arteries into the conti- guous parts ; a circumftance which may take place either from the punaure or rupture of an artery. A tumor, produced by the dilatation of the coats of an artery, is denominated a true aneurifm ; and we term it a falfe aneurifm, where, by the punaure or rupture of an artery, blood is effufed into the fur- rounding parts. As the introduaion of new appellations frequently leads to confufion, neceffity alone can juflify the at- tempt in the prefent work, therefore it will feldom be done ; but as the treatment of aneurifm may be ren- dered more clear and diftina, by a change of terms applied to the different varieties of the difeafe, it would be culpable in an author not to propofe it. Where aneurifm is produced by the dilatation of an artery, as the tumor is circumfcribed, and contain- ed within coats peculiar to itfelf, it may with propri- ety be termed an encyfted aneurifm ; while the other, arifmg from blood fpreading among the neighbouring parts, may with equal propriety be termed the diffufed aneurifm. ' TV 12 Of Aneurisms. Chap. IX. As thefe two varieties of aneurifm are, in many cir- cumftances, different from each other, it will be pro- per to confider them feparately. In the true or encyfted aneurifm, the tumor, when firft obferved, is commonly fmall and circumfcribed ; the fkin retains its natural appearance ; when preffed with the. fingers, a pulfation correfponding with that of the artery below is diftinguifhed ; and by compref- fion, the contents of the fwelling, while they are yet foft and fluauating, may be eafily made to difappear. When means properly calculated for the removal of the difeafe, are not foon put in#praaice, the fwel- ling begins to increafe, it becomes more prominent, and proceeds in a gradual manner to acquire a larger fize. The fkin and teguments, for a confiderable time, retain their natural appearance ; the patient does not complain of pain ; the tumor continues of an equal foftnefs ; and its contents are ftill compreflible, yielding confiderably, and in fome inftances disappear- ing entirely, on the application of preffure. At laft, however, when it becomes large, the fkin lofes its or- dinary colour, becomes pale, and, in the more advan- ced ftages of the difeafe, even cedematous : the pulfa- tion ftill continues; but the tumor, although foft in fome parts, yet in others is firm, and cannot be made to yield much to preffure, part of the contained blood having in this flage of the difeafe become hard by coagulation. The fwelling continuing to increafe, at laft becomes painful; the fkin turns livid, apparently verging to a ftate of mortification ; an oozing of bloody ferum if- fues from the teguments ; and if gangrene does not take place, the fkin cracks in different parts ; and now the force of the artery not meeting with much refift- ance, if the veffel is large, a period is foon put to the patient's exiftence, by the blood burfting out with fuch violence as to produce almofl inftantaneous death ; at leaft in the larger arteries of the trunk of the body, this is the ordinary event of aneurifms. In the ex- Sea. I. Of Aneurisms. 13 tremities, however, the arteries are not fo large as by their rupture to be capable of producing effeas fo im- mediately fatal; and befides, we can here, by means of the tourniquet, effeaually guard againfl this fud- den termination of the difeafe. In aneurifms of the larger arteries, the effeas pro- duced upon the neighbouring parts, by the conflant pulfation and gradual augmentation of the tumor, are often furprifing. The fofter parts we might, a priori, expea to yield to a great extent ; but the hardeft parts of the body, probably from their not being ca- pable of yielding, evidently Suffer more from the ef- feas of this kind of preffure, than either membranes, mufcles, or ligaments. Even the bones frequently undergo a great degree of derangement by the pulfa- tion and diftenfion of contiguous aneurifms : fome- times they are feparated entirely from each other at the different joints : in fome inftances they are elevat- ed out of their natural Situations; and not unfrequent- ly we find them entirely diffolved. Thefe effeas of aneurifm, however, are not com- mon in any of the extremities : it is the ftrong pulfa- tion of the aorta only, or of fome of the larger arte- ries at no great diftance from the heart, that can ever produce fuch important confeqiiciiccs. Sometimes, however, Similar effeas of an aneurifm have been ob- ferved in the thigh, and upper part of the arm ; even the bones of thefe parts have been deflroyed by aneu- rifms of the neighbouring arteries. Thefe in general are the appearances and termina- tion of the encyfled aneurifm, to which, however, one exception occurs in a variety of the-difeafe, to be here- after dcfcribed. Various caufes may tend to produce encyfled aneu- riSms. 1. From daily observation we know, that par- tial debility frequently occurs in different parts of the fyflem : thus, there is nothing more frequent than cedematous Swellings of the extremities, even in con- flitutions otherwife healthy j and thefe Swellings we 14 Of Aneurisms* Chap. IX* juftly fuppofe molt frequently to depend on local weak- nefs of the parts in which they occur. Now, why may not debility of a fimilar kind fall upon part of the arterial fyftem ? and, if this mould happen, it is eafy to fee how in almoft every inftance it muft ter- minate in aneurifm : for the force of the heart con- tinuing the fame, if any particular part of an artery has loft its tone, as it is thereby rendered unable to refill the pulfations of the heart, dilatation of its coats, muft arthefe weakened parts neceffarily enfue j and as foon as a morbib enlargement of the cavity of an artery is thus commenced, as its power of refiftance will be proportionally lefs, while the vis a tergo con- tinues the fame, the farther increafe of the fwelling is a confequence that of courfe muft take place. This may be considered as the mofl frequent caufe of aneurifm not depending upon external violence* Aneurifms of the aorta, feem in almoft every inftance to arife from this Caufe ; as well as all others that do not obvioufly proceed from external injuries. 2. The external coats of an artery being deftroyed by a wound, a partial weaknefs of the part will thus be produced ; and this muft render it liable to be aa- ed upon by the heart and other parts of the arterial fyftem, in the fame manner as if previoufly debilitated by difeafe. In dilatations of an artery produced by this caufe, the progrefs of the tumor is fuch as I have defcribed ; the blood, from being ftill confined within the coats of the artery, continues to form a circumfcribed tu- mor. At firft the fwelling difappears upon preffure j but on advancing farther, part of its contents become fo firm by coagulation, as to render it impoflible by compreffion to difperfe it. This variety of aneurifm may fometimes arife from other caufes, but we meet with it mofl frequently from bloodletting in the arm; by the lancet, after paffing through the vein, going fo deep as to divide the external eoats of the artery with- out penetrating its cavity. Sea. I. Of Aneurisms. 15 3. This variety of aneurifm has alfo been produced by the matter of fores and abfceffes proving fo corro- sive as to deftroy the external coverings of the con- tiguous arteries : when this takes place, the fame train of Symptoms muft occur, as if the outer coats of the artery had been deftroyed by a fharp inflrument. 4. The bones, mufcles, and ligaments, give all fome degree of Support to the arteries which they furround; fo that the deftruaion of any of thefe parts muft evi- dently tend to the produaion of aneurifm ; indeed^, the firmnefs and {lability of parts naturally conneaed together, depends fo much upon a found Slate of the whole, that any one of them becoming weak and dif* eafed, generally terminates in a difeafed ftate of the others. In the thigh of a patient, where part of the mufcles and other foft parts were deftroyed by an ex- tenfive mortification^, different aneurifmal Swellings oc- curred in the courSe of the femoral artery which had thus loft part of its fupport; and no other caufe ap- peared to be concerned in their produaion. 5. I have already remarked, that in bloodletting at the ufual place in the arm, arteries are fometimes wounded, by the lancet paffing through the vein into the artery below) and when the artery lies in direa contaa with the vein, the blood difcharged from the orifice in the artery, paffing direaiy into the vein> fcrves to keep up a communication between them. A communication being in this manner produced between the artery and vein, and the coats of the vein not being able to refift the impulfe of the artery, a preternatural dilatation of the vein muft neceffarily en* fue : a tumor is accordingly foon produced, which at firft is Small and circumfcribed, but at laft it gradually extends both above and below the orifice; not only along the courfe of the vein originally wounded, but in fome inftances over all the contiguous veins. This variety of the difeafe was firft accurately de- Scribed by our celebrated countryman Dr. William Hunter ; and may with great propriety be termed the 16 Of Aneurisms. Chap. IX4 varicofe aneurifm. Since that period it has been fre- quently obferved by others j fo that its nature is now very generally understood. Although the coats of the artery are here complete- ly divided, yet, as the blood is contained within the cavity of the veins, this fpecies of the difeafe is obvi- oufly a variety of the encyfled aneuriSm ; and as the method of cure coincides, in fome circumftancas, with that of other encyfled aneurifms", the further consider- ation of the fubjea could not any where be more properly introduced. In the varicofe aneurifm, the fwelling is confined entirely to the veins. Soon after the injury is com- mitted, the vein communicating immediately with the artery begins to fwell: in a gradual manner, the tu- mor becomes more remarkable, and the anaftomofing branches of the contiguous veins alfo become enlarg- ed. This fwelling of the veins may, by preffure, be made to difappear, the blood contained in them being in part pufhed forward in its courfe towards the heart, while part of it is fometimes forced into the artery it- felf \ and, when the tumor is large, the blood, when thus forced out of it, is heard to make a Singular hif- fing kind of noife. This may be always considered as a very charaaeriftic Symptom of the difeafe; but as it is not met with in every cafe of varicofe aneurifm, it becomes neceffary to point out fuch circumftances as more certainly ferve as means of diftinaion. In the varicofe aneurifm there is a tremulous kind of motion difcovered in the dilated vein, attended with a particular kind of noife, as if air was paffing into it through a fmall aperture. If a ligature is applied upon the under part of the limb, immediately below the fwelling, and tied fo tight, as even to flop the pulfe in the under part of the limb, the fwelling in the veins, on being removed by pref- fure, returns inftantaneoufly on this being taken off, and does not appear to be affeacd by the ligature be- low ; which it undoubtedly would be, were it not for Se&. I. Of AneurisiMk 17 this direA communication between the trunk of the artery and correfponding vein* If the fwelling is removed, by preffing the blood forward to the heart, and a flight preffure is made with the point of the finger on the orifice in the arte- ry, the veins remain perfealy flaccid ; nor does any fwelling take place, till the preffure is removed from the orifice, when it inftantly becomes equally large as it was before ^ and this even happens, although the preffure on the artery is not fo firm as to flop the cir- culation in the under part of the limb. In like manner, if the trunk of the artery is com- preffed above the orifice, fo as to flop the circulation entirely, that tremulous motion and biffing noife in the tumor ceafes inftantly ; and, if the veins are now emptied by preffure, they will certainly remain flaccid till the compreffion upon the artery is removed. In fome inftances too, if two ligatures be applied* one an inch or two above, and the other as much below the fwelling, and are made fo tight, as to flop entirely the circulation of the blood in the tumor lying between them ; if the fwelling is now compreffedj all the blood Contained in it is made to paSs into the opening in the artery, from whence, however, it inftantly returns again, on the preffure being removed. This does not indeed always happen ; but its not doing fo, is no proof of the varicofe aneurifm not a&ually exifting; for if all or feveral of the other leading circumftances of the difeafe which I have enumerated, ever take place, the nature of the tumor is thereby rendered evident. In addition to other chara&eriftic Symptoms of the varicofe aneurifm, I may remark* that when the tu- mor has been of fuch duration as to excite much dila- tation of the veins, the trunk of the artery above the orifice generally becomes prctematurally large, while the branches below become proportionally fmall; and ©f confequence, the pulfe in the under part of the Vol. II. C 18 Of Aneurisms. Chap. IX. limb is always more feeble than in the found limb of the oppofite fide. Having thus enumerated the ordinary appearances of all the varieties of encyfled aneurifm, together with the various caufes by which they are produced, I Shall now proceed to defcribe the fymptoms and caufes of the diffufed aneurifm, and fhall conclude with consid- ering the method of cure. The diffufed, or what is commonly termed the falfe aneurifin, confifts in a wound or rupture of an artery, producing, by the blood thrown out from it, a diffufed fwelling in the contiguous parts. Some of the largeft internal arteries are occafionally ruptured by Severe bodily exertion ; particularly thofe of the lungs. This probably happens from the arte- ries in this organ being furrounded with foft contigu* ous parts, which do not afford them much fupport; for in the external parts of the body, where the artet ries are more firmly fupported, accidents of this kind are feldom met with. But it is chiefly in that variety of aneurifm, produced by wounds of the more fuper- ficial arteries, that furgery ever affords relief. Among other confequences of bloodletting in the veins of the arm, I,had occafion to mention wounds in the contiguous artery as one : in a few inftances, by the treatment which I then pointed out, the bad effeas which otherwise would reSult from it, do not take place by the wound in the artery being fpeedily cured. This happy termination, however, of thefe injuries, is fo rare, that it can never with certainty be looked for. When the pun/Shire of an artery does not heal fpeedily, it will neceffarily terminate in an aneurifmal tumor ; and the following is the ufual progrefs which it makes. A fmall tumor, about the fize of a horfe bean, gen- erally rifes juft at the orifice in the arterv, foon after the difcharge oS blood has been ftopt by compreffion : the tumor is at firft Soft, and has a ftrong pulfatiou. Sea. L Of Aneurisms. 19 It yields to preffure) but never in fuch a degree as that of an encyfled aneurifm: for, if it be not in the more advanced Stages of the latter^ the blood remains fluid, and can be eafily preffed from one part of the cyft to another; whereas, in the diffufed aneurifm, the blood forming the tumor is at once extravafated ; it foon coagulates, and thereafter becoms firm. In this flate of aneurifm, if the fwelling is not im- properly treated by the application of preffure, it gen- erally remains nearly of the fame fize for Several weeks : it then begins gradually to increafe; and if feated at the ufual place of bloodletting in the arm, it now proceeds farther up than the orifice, and extends rather more inwardly than towards the outer part of the arm, probably from the expanfion of the biceps mufcle not being in this place fo firm and compaa as in the external and under part of the arm. This en- largement of the tumor proceeds, too, more quickly in fome than in others, and in fome the fwelling is much more diffufed and extended than in others. Both thefe circumftances depend probably upon the fame caufe. If the blood poured out by an artery, is thrown into a very lax cellular fubftance, we can ea- fily SuppoSe, that its increaSe will not only be more rapid, but that the diffufion of the tumOr will for the fame reafon be much more confiderable, than when the artery is immediately enveloped with firm mem- branous or ligamentous parts, which do not So readily yield to the impulSe of the blood. From this circum- ftance alone, indeed, there is fuch a difference in the progrefs of aneurifm, that in Some inftances the tumor is many months, nay even years, in arriving at any confiderable fize ; while in others the blood is fo quickly poured out from the artery, as to be diffu cd over the whole limb in the Space of a Sew hours from the operation. An unufual degree of laxity in the cellular fubftance has undoubtedly much effea in promoting this rapid c 2 20 Of Aneurisms. Chap. IX* diffufion of the extravafated blood ; but the praaice of applying tight preffure in wounds of arteries has, 1 am convinced, in all fuch cafes, a very hurtful effea. In addition to what I judged it neceffary to fay upon this point in the chapter on bloodletting, I fhall here obferve, that if it was poffible to make moderate pref- Sure upon the orifice in the artery alone, Some advan- tage might perhaps be derived from it; but in apply- ing preffure to the artery of a limb, the corresponding vein muft be all So much compreffed, as to give much obftruaion to the return of blood from the artery. And whatever tends to obflrua the refluent blood, muft in the fame proportion diftend the wounded ar- tery, and thereby increaSe the quantity of blood that efcapes by the orifice. Many machines have indeed been contrived for compreffing the artery without af- feaing the reft of the limb : but however much thefe may have been extolled by their inventors, none have hitherto anfwered the purpoSe of compreffing the arte- ry alone, without at the Same time obftruaing the cir- culation in the veins; inSomuch that much harm has in different inftances been produced by all of them. Whoever may wifh to make ufe of thefe inftru- ments, will find various forms of them in Heifter's Syftem of Surgery, and in the works of Dionis and Platner. Mr. Dionis, an eminent French praaitioner, ak though he recommends the application of preffur^ to wounds in arteries, yet relates a cafe which happened to a furgeon of his acquaintance, in which the bad ef- feas produced by it were fo Strongly marked, as muft convince all who carefully perufe it, of the general impropriety of this remedy. A furgeon having in bloodletting opened an artery, the ufual method of applying tight compreffion was immediately employed. By this the external dif- charge of blood was foon flopped : but blood contin* uing to efcape from the orifice in the artery, it pafied up towards the fuperior part of the arm, which it fill- Sea. I. Of Aneurisms. 21 ed to fuch a degree, that on the operation for the aneurifm, which was foon found neceffary, being per- formed, upwards of four pounds of coagulated blood was discharged from it; and for this purpofe it became neceffary to lay the parts open along the whcfe courfe of the arm.*- • When, again, compreffion has not been applied, un- lefs an unufual degree of laxity prevails in the fur- rounding parts, the fwelling proceeds to increafe in a more gradual manner: in becoming larger, it does not, like the true aneurifm, become much more prom- inent ; but rather Spreads and diffuSes itfelf into the Surrounding parts : by degrees it acquires a firm con- fiftence ; and the puliation, which was at firft confid- erable, becomes always leSs in proportion to this dif- ference of confiftence, and to the increaSe which the tumor receives in fize ; inSomuch, that in large aneu- riSmal Swellings of this kind, the pulSation oS the ar- tery is Scarcely to be perceived. In the firft flages of aneurifm, if the blood thrown out from the artery lies deep, the fkin preferves its natural appearance, and does not change its colour till the tumor is much advanced. It frequently happens, however, that the blood is thrown out with fo much violence at firft, as to get into immediate contaa with the fkin ; in which cafe the parts become inftantly liv- id, as if tending to a State of mortification. A real fphacelus, indeed, has in fome inftances been induced where the extravafation of blood was confiderable, and where the means beft fuited for its removal have either failed or been omitted. It muft, however, be confidered as very culpable neglea, to allow a patient, from this caufe, to incur the rifk which always refults from mortification ; for the hazard arifing from operating for an aneurifm, is inconsiderable, when compared with the danger of an entenfive gangrene. * Vide Dionis's Courfe of Chirurgical Operations. 22 Of Aneurisms. Chap. IX. On the tumor becoming large, the patient, who at firft did not complain of it, is now much diftreffed not only with Severe pain, but with ftiftheSs, want of feeling, and immobility of the whole limb : and thefe Symptoms continuing to augment, if the tumor be not opened, the teguments at laft burft ; and if the artery is large, and effeaual means be not immediately em- ployed for preventing it, death will foon enfue, in con- fequence of the profufe hemorrhagy which neceffarily muft fucceed. I enumerated various caufes, as being frequently prpduaive, under certain circumftances, of the encyfl- ed aneuriSm : we alSo meet with Some variety in the cauSes of the diffufed aneurifm. I. Violent bodily exertion may be considered, as I have obServed above, as the mofl frequent eaufe of the rupture of arteries feated internally ; but as thefe do not properly belong to a work of furgery, I fhall not here confider them further. II. The corrofive matter of fores and abfceffes, by entirely deftroying the coats of contiguous arteries* may in this manner produce the diffufed aneurifm. III. The fharp fpiculae of a fraaured bone being; pufhed into a neighbouring artery, have in different inftances produced aneurifm. IV. Violent blows have been known to produce this kind of aneurifm. This, however, can fcarcely happen any where but on the head, where the arte- ries lie more expofed than in other parts to the effeas of this kind of injury, from their being here very thin- ly covered, and from a blow in this fituation falling on the artery lying almoft in clofe contaa with a firm hard body, the cranium. V« If the arterial covering of an encyfled aneurifm, fhould ever burft before the external teguments of the tumor, the blood contained in it would diffufe itfelf into the contiguous parts ; in which cafe, a real dif- fufed aneurifm would be formed. There is reafon, however, to think that this feldom happens: fo far as Sea. I. Of Aneurisms. 23 I have obferved, the internal coverings of aneurifmal Swellings never burft firft. The tumor proceeds to increafe in a gradual manner ; and the teguments at laft become So tenSe and overstretched, that they loSe their tone entirely ; the fkin becomes Soft and cede- matous ; in fome inftances it becomes gangrenous; and in others, although it retains its natural colour, yet its ufual powers are as evidently deftroyed as they ufually are in the laft Stage of mortification. In this ftate, it generally remains for a longer or fhorter pe- riod according to the ftrength of the arterial pulfation below. At laft, however, the fkin begins to crack, and a thin ferum oozes out; the edges of this fmall fiflure in the teguments gradually feparate ; and the contents of the tumor having loft a confiderable part of their fupport, the force with which they are im- pelled, by degrees becomes too powerful for the re- maining coverings, which accordingly foon burft, fo as to difcharge their contents externally, without any effafion into the neighbouring parts. I lhould therefore fufpea, that authors, in writing on this point, have been miftaken : the encyfled, or true aneurifin, as it is termed, has been commonly fuppofed in its laft ftages to burft internally, and thus to produce the diffufed or falfe aneurifm ; from what I have faid, however, there is caufe to prefume, that this is at leaft a rare occurrence. The progrefs and termination of the encyfled aneurifm, in every cafe that I have feen of it, has been nearly as I have juft defcribed it to be ; not by the arterial fac firft burft- ing, but by a rupture of the external teguments after being much overftretched ; the blood being foon there- after difcharged outwardly, and not eftufed into the furrounding parts. As it has been alleged, however, by very refpeaable authors, that the reverie of this has fometimes happened, I could not here avoid to confider it as one of the caufes of diffufed aneurifm. • VI. The mofl frequent caufe, however, of the dif- fufed aneurifm, are punaures with fharp instruments. $4 Of Aneurisms. Chap. IX, fuch as fwords, cutlaffes, and the lancet; which, laft may be confidered as the mofl frequent of any. Under one or other of thefe heads, almoft every circumftance may be comprehended, that can ever tend to produce aneurifmal tumors. It has unfortunately fometimes happened, that tu- mors of the aneurifmal kind have been miftaken for abfceffes and other colleaions of matter, and their contents of courfe have been laid open by incifion, The confequences of this may be more readily con- ceived than defcribed. With a view to prevent fuch a dreadful occurrence, it would be a point of the high. eft importance in praaice to have fuch a fet of diag* noftic Symptoms of aneurifm fet forth, as would with certainty determine the queftion. In the commence ment of the difeafe, it may, for the mofl part, be ea» fily afcertained : at this time, the pulfation in the tu- mor is commonly fo ftrong, and other concomitant cireumftances tend^ fo obvioufly to point out the na« ture of the difeafe, that little or no doubt refpeaing it can ever occur ; but, in the more advanced ftagess of aneurifm, when the tumor has become large, and has entirely loft its pulfation, nothing but a minute attention to the previous hiftory of the cafe can ena* hie us to judge of it with accuracy. 1'hofe Swellings, with which aneurifms are moft likely to be confounded, are, foft encyfted tumors, Scrofulous Swellings, and abfceffes containing either purulent or other matter, fituated either immediately above, or fo nearly in contaa with an artery, as to re- ceive the influence of its pulfation : when a tumor of this defcription is nearly conneaed with a large arte* ry, the pulfation which it receives from it is frequent* ly fo ftrong and diftina,, as to render it impoffible, from this circumftance alone, to form any juft idea of its contents. But there is one Symptom, which, when conne&ecj with a ftrong pulfation in the tumor, may always lead us to determine with certainty that the fwelling is. Sea. I. Of Aneurisms. 2 j aneurifmal, and it is this ; the contents of the tumor being made eafily to difappear upon preffure, at the fame time that they return inftantaneoufly on the pref- fure being removed. But although the presence of this circumftance, when conneaed with other charac- teriftic Symptoms of the difeafe, may lead us to con- clude, that a tumor is of the aneurifmal kind, yet the want of it ought not to convince us that it is not an aneurifm; for it frequently happens, particularly in the advanced ftages of aneurifm, that the contents of the tumor become fo firm and compaa, that no effea is produced upon them by preffure. Upon the whole, therefore, as in many inftances of aneurifm, no cer- tainty can be obtained of its real nature j in all fuch cafes, praaitioners fhould lay it down as an eftablifhed rule, to proceed as if the tumor was in reality of the aneurifmal kind. By adhereing to this, they may per- haps in a few inftances be deterred from opening tu- mors, which it may afterwards appear might have been laid open with fafety ; but any leffer inconve- nience which this may occafion, will be much more than compenfated, if, even in a Single inftance, a fur- geon is faved from thofe difagreeable feelings which he muft experience if he fhould ever have the misfor- tune to open an aneurifm inftead of a colleaion of matter. But it is in the trunk of the body only, it muft be obferved, or in the neck, axilla, upper part of the thigh or groin, that fo much caution in the treatment of tumors of this doubtful nature can ever be neceffa- ry. For in almoft every part of the extremities, and even in all acceffible parts of the head, when a tumor of this defcription has become large, the operation for the aneurifm fhould always be advifed ; for we are in all thefe parts poffeffed of a very certain method of preventing danger, namely, the application of the tour- niquet in the extremities, and of preffure with the fin- gers on the head, 26 Of Aneurisms. Chap. IX. In forming a prognofis in caSes of aneuriSm, three important circumftances chiefly require attention. The manner in which it appears to have been produced : the part of the body in which it is fituated : and, laft- ly, the age, and habit of body, of the patient. If an aneurifin has come forward in a gradual manner, without any apparent injury being done to the part, and without having fucceeded to any violent bodily exertion, there will then be reafon to fuppofe*. that the difeafe depends upon fome local debility of the artery in which it is feated, or perhaps of the whole arterial fyftem : in which laft cafe, little or no benefit can enfue from any attempt that can be made; as the operation for the aneurifm being performed near to the tumor, there would be reafon to fear, that the fame caufe by which it was produced here, ulti-. mately tended to produce fimilar dilatations in other parts of the artery : whereas, there is much caufe to hope, if the tumor has been produced by a bruife* punaure, or other external accident, that the opera- tion would not fail of fuccefs, provided the circulation of the part be not altogether deftroyed by the liga-' tures to be put upon the artery. In the varicoSe aneuriSm, we may in general ven- ture on a favourable prognofis. In different inftan- ces, it has been found, that the tumor does not in- creafe fo rapidly in the varicofe aneurifm, as in other varieties of the difeafe ; that as foon as it gets to a certain length, it does not afterwards acquire much additional bulk, and that any inconvenience produced • by it may be borne with cafe for a great number of years. It is in this alone, I may obferve, that we derive any advantage in the treatment of aneurifm from the difcovery of this variety of the difeafe: and a very important difcovery it is; for by means of it a patient may be faved, not only from a very painful operatiorr, but from the rifk which muft always attend the de- Sea. I. Of Aneurisms* 2 7 ftruaion of the principal artery of a limb. When a varicofe aneurifm becomes fo large as to excite much diftrefs, the operation fhould no doubt be advifed; but as long as the inconvenience arifing from it can be eafily borne, the hazard which very commonly at- tends the operation, and which nothing but neceffity ought to indicate, fhould certainly be avoided.* * In Volume II. Art. xxxvi. of the London Medical Obfervations, two cafes are related of the varicofe aneurifm, by Dr. Hunter. " One of them at that time was of fourteen years (landing, and the other had fubfiib.d for five years, and no operation had been found neceffary. And in Vol. III. of the fame work, Art. xiii. a fimilar cafe of five years duration is re- lated by Dr. Cleghorn. As it has been alleged by fome that no advantage is derived from the difcovery of this fpecies of aneurifm, from their fuppofing that the ufual operation is as neceffary in it as in any other variety of the difeafe; and as in different inftances the operation has been put in practice even in the incipient ftages of the varicofe auetirifm, where no real neceffity, I think, could occur for it; it therefore becomes a matter of fuch import- ance as to merit a very attentive inquiry: and it is with much fatisfac- tion that I communicate the following facts, as they tend to cftablifh witk certainty, that in the varicofe aneurifm, the ufual operation of obliterat- ing the cavity of the art«ry, is feldom, if ever, neceffary. In a letter which I received from Dr. Hunter, he fays, " The lady in whom I firft obferved the varicofe aneurifm, is now living at Bath in good health; and the arm is in no fenfe worfe, although it is now thirty-five years fiiice file received the injury." And the Doctor further obferves, that he never heard of the operation being performed for the varicofe aneurifm, that was known to be fuch. In a letter from Dr. William Cleghorn,.of Dublin, he fays, that the cafe of varicofe aneurifin above mentioned, da related in the third volume of the London Medical Obfcrvations, remains nearly in the fame ftate as at the time that account of it was made out, which was at leaft twenty years ago; only that the veins are rather more enlarged. The patient recover- ed, and the limb became nearly as ftrong and ferviccable as the other. The man has all along continued his bufinefs as {hoemakcr, and lias late- ly recovered from a fprain in the affected arm, which he received in lift- ing a heavy burden. In a letter from Mr. Pott, whofe opportunities for obfervation were great, he fays," that he has met with three different inftances of this fpe- cies of aneurifm, and that the operation never became neceffary in any of them." * Among other inftances of voricofe aneurifm which have appeared here, a young man from Pailley, who had the misfortune to meet with it fcve- ral years ago, was examined by different lurgeons of this place. The dif- eafe was clearly marked, and no operation was advifed. In a letter from Mr. William Hamilton, Profeffor of Anatomy in Glafgow, I am informed that this man was lately ferving in the navy, where he undergoes great fatigue without any inconvenience from the aneurifm, although it wa» fhen of thirteen years cpntinuance. 28 Of Aneurisms. Chap. IX. The fite of the tumor is the next point of import- ance requiring our attention. When an aneurifm is fb fituated that no ligature or effeaual compreffion can be applied for putting a ftop to the circulation, if the artery is large, there would be the utmoft hazard in laying it open; as the patient might probably lofe more blood than his flrength could bear, before it could be fecured. In aneurifms, therefore, that are fo fituated, particularly on any part of the trunk of the body, on the neck, axilla, or groin, there can never be a good foundation for a favourable progno- !>.$. In fuch Situations, indeed, the greateft danger is Always to be dreaded : for the force of the arterial £ .iiiation would at laft be apt to deftroy the coats .with which the tumor is Surrounded; and in Such an event, the mofl fatal confequences might enfue. The SucceSs oS this operation muft alSo prove doubt- ful in the Superior parts of the extremities: but in the inferior parts of the arms and legs, it may be per- formed with a very fair profpea of fuccefs, even on the principal arteries; for after the great artery of a limb has crept along the upper part of it, a number of final! branches are always Sent out, which by anaS- tomofing not only with fimilar branches below, but by their means with the under part of the large arte- ry itfelf, thefe, in the event of the common trunk from whence they fprung being deftroyed, come to dilate to fuch an extent as to carry on the circulation in the inferior part of the limb much more complete- ly than could a priori be expeaed. We would not naturally fuppofe, after the principal artery of a part has been obliterated, that the circulation would there be afterwards carried on with much force; and yet numberlefs inftances have occurred, of the large bra- chial artery being completely deftroyed by ligature, without being productive of much inconvenience to the parts below ; and the fame circumftance has alfo happened, where the operation for the aneurifm has &&. I. Of Aneurisms. *$ been performed on the trunk of the great femoral ar- tery.* From what has been faid, therefore, it muft appear, that when an aneuriSm is So fituated, that compreffion cannot be applied So as to Secure the patient from the lofs of much blood when the artery is laid open, the operation mould not be advifed; and in fuch cafes, the prognofis ought certainly to be very unfavoura- ble. But, whenever an aneuriSm, produced by ex- ternal violence, is Seated on any of the, extremities, where we are fure of commanding the circulation, the operation fhould always be advifed, as foon as there is caufe to fufpea, that the tumor, if left to itfelf, might burft, fo as to endanger the life of the patients^ The fuccefs of this operation, depending in a great degree upon the circulation afterwards going on in the under part of the member, our prognofis ought, cateris paribus, to be more or lefs favourable, accord- ing as the tumor is feated high or low on the limb. For the rifk of the circulation being hurt, is always * In one cafe, the operation for the aneurifm wag performed with th* Jnoft complete fuccefs, on the trunk of the femoral artery, about two hand breadths from the groin, by the late Mr. Thomas Hamilton, Profcffor of Anatomy in Glafgow. And what rendered this Cafe more remarkable^, was, that after the trunk of the large artery was fecured with ligatures, it was neceffary to perform the operation again upon a fmall branch of an artery which had been wounded, even farther up than the principal trunk. For fome time after the operation, the limb remained colder than the other, and it was upwards of a week before any pulfation could be felt in the artery at the ankle. In two months from the operation, the wound was completely healed, and the circulation and heat returned; and in a (hort time thereafter, the patient had fo far recovered the ufc of his limbs as to be able to take very violent exercife. Thefe particulars I thought it right to communicate, as the cafe of thw patient is one of a few well authenticated inftances, of this operation hav- ing been attempted on the femoral artery fo near to its origin; and the fuccefs attending it furcly points out the propriety of the meafure, in eve- ry aneurilm, even of thefe parts, not evidently ariftng from general debi- lity of the cr/ats of the artery. In Vol. III. Article rn.of the London Medical Obfervitions, another in- ftance is related of the operation for the aneurifm having been performed on the trunk of the femoral artery, by Mr. fcurchal, furgeon in Manchef- tcr: the patient recovered, and the limb became nearly as ftrong and as fervfceable as th; other. 30 Of Aneurisms. Chap. IT. in proportion to the height of the tumor : according as it is high or low, this rifk is always increafed or di* minifhed. But, laftly, whether an aneuriSm has been produc- ed by an external injury, or by internal diSeaSe, and whatever may be its fituation, the habit of body and age of the patient are circumftances meriting particu-1 lar attention in the prognofis to be formed of the pr6v bable event of an operation: in no operation, indeed, are the advantages derived from health and youth more confpicUous than in this ; for in the earlier pe- riods of life, all the fofter parts accommodate them- Selves much more readily to every important change,! ^than they ever do in the more advanced ftages of life: in old age, all the animal fibres have acquired fo much firmnefs and folidity, as to be rendered almoft incapable of diftention: this is particularly the cafe with the arterial fyftem, fome parts of which often proceed to a ftate of oflification: fo that at. this peri- od of life, we may readily fuppofe, that the fmaller arteries are rendered incapable of that degree of dif- tention neceffary for fupplying the want of the princi- pal artery of a part, which in the more early periods of life, they might with eafe have done. This operation having been performed with various fuccefs, even where the tumors were apparently fimi- lar, both in fituation and other circumftances, various reaSons have been Suggefted to account for it. With fome the operation has fucceeded, even under circum- ftances apparently more unfavourable, than with oth- ers where it failed. Thus it has proved fuccefsful, as I have lately remarked, in the trunk of the femoraf \ artery, while in others, it has failed when done in the ham : that is, in the former the circulation in the un- der part of the leg was ftill preferved, and the pa- tients recovered; while, in the latter, where fuccef* i might more readily have been looked for, the limbs I remained cold after the operation, no return of circu- S?#. L Of Aneurisms. $i lation took place, mortification at laft was induced, and the patients died. From this variety of fuccefs attending it, we find very contradiaory opinions held* forth refpeaing this operation. While one condemns it, as feldom prov- ing fuccefsfyi,/ if.it be not .in the very extreme parts of a member; others affert, that it may be done even in the largeft artery of a limb, and with great proba- bility of fuccefs. This contrariety of opinion, however, may, I think, be explained, by what I have faid concerning the age and habit of body of thofe on whom the operation is performed 5 for, to the different powers of distention with which the arterial Syftem is endowed at different periods of fife, the good or bad fuccefs with which it is attended, may, with fuflkient reafon, be often af- figned. So that, although it may fail in an old in- firm perfon, even in the under part of the leg or arm, we ought not to be thereby deterred from advifing it, even in much higher Situations, where the patient is young and healthy. It may alSo be proper to obServe, that in the ham the operation is Seldom done So well as in the thigh : the artery lies So deep in the ham, that it is taken up with more difficulty ; by which a confiderable quan- tity of blood is often loft ; the ftrength of the patient is in this manner exhaufted ; and hence he often Sick- ens and dies, when otherwise he might probably have recovered. Having thus confidered the ufual appearances and causes of aneurifm, together with the grounds upon which a juft prognofis is to be formed, we fhall now proceed to the method of cure. 32 Of Aneurisms. Chap. tX» SECTION IL Of the Treatment of Aneurifms* PRESSURE has been indifcriminately advifed in aneurifm, not only in the beginning of the dif- eafe, but in its more advanced ftages. In a former chapter, on bloodletting, as well as in fome parts of this, this fubjea has already been noticed : to thefe I muft now refer; and Shall at prefent advert to Such points only as were not before confidered. In the diffufed or falfe aneurifm, preffure has been advifed, not only with a view to difcufs the tumor j but in order to produce a reunion of the wound in the artery: I have already made it appear, however, as preffure in fuch cafes cannot be applied to the artery alone, without at the fame time affeaing the veins \ and as this, by increasing the refiftance to the arterial pulfations, muft force an additional quantity of blood to the orifice in the artery, that in this way it muft often do harm. But although preffure fhould never be advifed in any flage of the diffufed aneurifm, yet in fome peri* ods of the encyftecf aneuriSm, it may often be applied with advantage. In the early ftages of encyfled aneurifm, while thd blood can be yet preffed entirely out of the fac into the artery, a bandage of foft and fomewhat elaftic ma- terials, properly fitted to the part, will often prevent an increafe of the tumor ; and, in fome few inftances, by the continued fupport thus given to the weakened artery, complete cures have been obtained. In all fuch cafes, therefore, particularly in the varicofe aneu- rifm, which I have already endeavoured to fhew can feldom require the ufual operation, much advantage may be derived from moderate preffure. Sea. ft. Of Aneurisms. $$ But although preffure to a certain degree has fre- quently proved ufeful in encyfled aneurifm, it ought never to be carried far ; for tight bandages, by excit- ing reaaion in the parts to which they are applied, inftead of anfwering the purpofe for which they were intended, have often the contrary effea. Moderate preffure, therefore, is more eligible than a great de- gree of it; nor ought it ever to be employed but as an eafy Support to the weakened parts. While we thus, however, advife comprefiion, other means ought not to be omitted: the patient fhould be kept upon low diet; if the pulfe is full, blood fhould be taken; the bowels fhould be kept open ; and all violent exercife, particularly of the injured partj fhould be carefully guarded againft. In the lat- ter ftages of aneurifin, when much tgnfjon and pain are induced, opiates prove ufeful; and often indeed are the only remedies from which we obtain relief. This courfe of treatment applies to every aneurifin for which the operation is not to be performed; whe- ther this may proceed from the feat of the difeafe ren- dering it inadmiflible, or from any other caufe : in fuch circumftances, indeed, an eafy fupport by means of gentle compreffion ; a low diet in order to prevent a plethoric ftate of the vefiels ; repeated bloodlettings when plethora aaually exifts ; a total abstinence from exercife ; and the ufe of opiates when indicated by pain ; are the only remedies from which much bene- fit is ever likely to be derived. Having thus pointed out the different remedies to be employed where the operation is not to be per- formed, I Shall now proceed to defcribe the operation itfelf, a meafure that becomes neceffary when the means recommended for the previous treatment of the difeafe hive failed, or when die tumor has made much progrefs before proper afliftance is procured. Our firft Step in this operation-is, to obtain a full command of the circulation in .the under part of the limb, by means of the tourniquet applied above. Vol. II. D 34 Of Aneurisms. Chap. IX* This being done, the patient fhould be fo placed, that the difeafed limb, on being ftretched on a table, may be of a proper height for the furgeon, who ought to be feated during the whole courfe of the operation. The limb being in this fituation properly fecured by afliftants, an incifion is now to be made with a Scalpel through the fkin and cellular Subftance, along the whole courSe of the tumor ; and in order to enfure fufficient freedom for the remaining fleps of the ope- ration, this external incifion fhould be carried at leaft half an inch paft each end of the tumor. No mif- chief can enSue from the firft incifion being free and extenfive; and I have feen different inftances of the furgeon, being much embarraffed in the fubfequent fteps of the operation, by timidity or ill judged lenity in this part of it. This being done, the furgeon ufually proceeds in a flow cautious manner, differing away one layer of the membrane after another, till the artery itfelf is laid bare. In this manner the operation is always tedious, for the thicknefs of parts with which the artery is cov- ered, is often very confiderable, by one layer of a membranous fubftance having formed after another, from the coagulable lymph of the blood contained iii the tumor : but there is no real caufe for this degree of caution, as the operation may be equally well per- formed, in a fhorter fpace of time, and with much lefs pain to the patient. As foon, therefore, as the external incifion of the fkin and cellular fubftance is completed, a lancet fhould be pufhed into the Sac, So as to make an open- ing Sufficiently large for admitting one of the fingers: this being done, the forefinger of the left hand fhould be introduced at the opening, when the fac fhould be cut from one end to the other, by running a probe pointed biftoury along the finger from below upwards, and afterwards from above downwards, fo as to lay the whole cavity open. Sea. II. Of Aneurisms. 35 The cavity of the tumor being thus laid 6pen, all the coagulated blood is now to be taken out: for which purpofe, a variety of fcoops and other instru- ments have been invented, but no inflrument anSwers this intention So well, and with So much eaSe to the patient, as the fingers of the operator. The coagulated blood being removed, together with the membranous filaments ufually found in aneurif- mal tumors, the cavity of the fac muft now be dried with a Small Sponge, when the tourniquet fhould be made perSeaiy flack, in order to diScover not only the artery itSelS, but the opening into it Srom whence the blood colleaed in the tumor has all along iffued. This being done, we are next to employ proper means for preventing any farther effufion of blood in- to the fac. Various means have been propofed for this; but they are all comprehended in thofe that follow : I. Ligatures upon large arteries, having in fome in- ftances deftroyed the circulation in the under part of a limb, it was long ago propofed, on laying open the fac, to endeavour to finifh the cure, by applying a piece of agaric or dry fponge to the orifice in the ar- tery ; and in fome inftances, vitriol and other aftrin- gents, were uSed for the fame purpofe. II. Upon the fame principle with this, namely, that of ftill preServing the circulation in the whole courSe of the artery, it was fome time ago propofed by Mr. Lambert, an eminent furgeon of Newcaftle, to fecure the orifice in the artery with the twifted Suture.* A Small needle being pufhed through the edges of the wound, they are then to be drawn together by a thread properly twifted round the needle, in the manner I have advifed when treating of futures.! Thefe methods, however, are both liable to objec- tions : in the firft place, neither fponge, agaric, nor * Vide London Medical Observations, Vol. II. Article xsx A Vide $hap. VI. Sett. V. D 2 36 Of Aneurisms. Chap. IX. any aftringent with which we are acquainted, is pof- feffed of fuch powers as to deferve much confidence ; for, although in a few inftances, they have put a tem- porary ftop to hemorrhagies, they have Seldom pro- duced any permanent benefit. In almoft every in- ftance in which they have been uSed, the hemorrhagy has recurred from time to time, fo as to prove highly diftrefsful, not only to the patient, but to the praai- tioner ; fo that from this want of fuccefs, little or no attention is now given to remedies of this clafs. With regard to Mr. Lambert's method of Stitching the orifice in the artery, it is certainly an ingeniout propoSal, and would probably, in mofl inftances, put an effeaual ftop to all farther difcharge of blood ; but as it has hitherto been very feldom praaifed, far- ther experience of its effeas muft be obtained, before we can with propriety either receive or rejea it. But if, in a matter of fuch moment, reafoning may be ad- mitted, I would beg leave to obferve, that two mate- rial objeaions occur to it. One is, that in almoft every inftance of aneurifm, the artery lies at the back part of the tumor ; fo that when all the colleaed blood is removed, there is fuch a depth of wound, that it muft be always difficult, and in many inftances impoflible^ to perform this nice operation upon the artery, with that attention and accuracy, which, in order to inrure fuccefs, it certainly requires. It has fometimes, indeed, happened, that the artery has been found on the anterior part of the tumor, in which cafe the orifice would no doubt prove fufficiently acceffible. This, however, is a rare occurrence, as in almoft eve- ry inftance of diffufed aneurifm the artery lies at the bottom of the tumor, the blood being colleaed be- tween it and the common teguments ; and according- ly I have feen feveral inftances, in which, after the tu- mor was laid freely open, the artery was found to lie fo deep as to render it impoftible to perform this ope^ * ration. Sea. II. Of Aneurisms. 37 But there is another very important objeaion to this praaice recommended by Mr. Lambert. By in- troducing a needle through the fides of the orifice, and drawing thefe together with a ligature, the cavity of the artery muft undoubtedly be at that point much leffened. Mr. Lambert, indeed, in his account of the only cafe in which he performed this operation, ac- knowledges that the diameter of the artery was there- by diminifhexL Now, the paffage of the blood being thus contraaed at one point, the impulfe upon that particular part muft be very confiderable : fo that the very remedy employed for the cure of one variety of aneurifm, muft in all probability prove a powerful agent in inducing another; for the blood being thus oi> ftru&ed in its ufual courfe, there will he much haz- ard of a dilatation being produced immediately above the ftriaure from which an encyfled aneurifm is very likely to enfue. I muft fairly acknowledge, however, that all I have advanced, proceeds from reafoning alone, for, as yet, I cannot fpeak of it from experience. But, if farther trials of this operation Shall tend to Show that the ob- jeaions which I have ftated againft it are not well founded, no one will be more ready than 1 Shall he to adopt it ; for, if thefe obje&ions were removed, I fhould confider this operation as deferving to be rank- ed among the mofl important improvements which in modern times forgery has acquired. In the treatment of aneurifm by the common operation, if the princi- pal artery of a limb is concerned, fome rifk is always incurred, not only of injuring the parts below in a moft material manner, but even of destroying them entirely, by depriving them of the quantity of blood neceffary for their fupport. Now, by Mr. Lambert's improvement, an effectual flop is put to the farther evacuation of blood, while at the fame time the circu- lation in the difeafed artery is preferved ; fo that if farther experience of its effeas Shall evince, that the objeaions which I have ftated againft it are not well 38 Of Aneurisms. Chap. IX. founded, it will defervedly be admitted as an impor- tant improvement in the cure of aneurifm.* III. Neither of thefe methods being to be trufted, I fhall now proceed to deScribe the uSual method of per- forming this operation, and it confifts in obliterating the arterial cavity entirely with ligatures. The artery being laid bare in the manner I have di- reaed, and the coagulated blood carefully removed from the cavity of the tumor, on the tourniquet being made flack fo as to bring the orifice in the artery into view, a probe fhould be paffed into it, with a view to raife the artery from the Contiguous parts, fo that the furgeon may be enabled with certainty to pafs a liga- ture round it without comprehending the contiguous nerves, which in general run near to the large blood veffels of the limb, By this precaution, the nerves may be always avoided; by which much mifchief may be prevented, which otherwife would probably fuper- vene. In aneurifms feated in the ham, or in the ufual place of bloodletting in the arm, bending the joint of the knee or elbow, by relaxing the artery, renders this part of the operation more eafy, than when the limb is kept fully ftretched out. The artery being thus feparated from the contigu- ous parts, a firm waxed ligature muft be paffed round it, about the eighth part of an inch above the orifice, and another at the fame diftance below. More than this is commonly advifed, but much harm has arifen from the ligatures being pafled So far from the orifice as is commonly done ; for the rifk of lofing the ben- efit of anaftomofing branches muft always be in pro- portion to the extent of artery included between the ligatures. * Since the firft edition* of this work were printed, this operation has been once performed in the Infirmary here; but although done with fuf- ficient accuracy and attention, it did not fucceed; and before a cure could be ob^ined, it was judged neceflary to perform the operation in the ufu- al way. Sea. II. Of Aneurisms. 39 The eafieft method of introducing the ligatures, is by means of a blunt curved needle, of the form re- prefented in Plate V. fig. 2. A common fharp nee- dle is ufually employed ; but it does not anfwer the intention fo well. Being fharp in the point and fides, it is apt to injure the contiguous parts ; and when the common crooked needle is ufed with a fharp edge on its concave fide, there muft even be Some rifk of wounding the under part of the artery, as the needle in this fituation can fcarcely be introduced without be- ing in contaa with the coats of it. The blunt needle is not liable to either of thefe objeaions; and befides, when of the form reprefented in the plate, it is more eafily introduced than any of the needles commonly ufed in this operation. Of late a new inflrument has been propofed inftead of it: a curved Silver tube be- ing paffed beneath the artery, a probe, fitted to the tube, and previously armed with a ligature, is then pufhed through it, and the iigature drawn along with it: it proves to be, however, a much more complex method of anfwering the fame purpofe with the nee- dle, and will never therefore be employed by thofe who have ufed the other, The ligatures being both paffed, the upper one is now to be tied fufficiently firm for compreffing the fides of the artery. By fome, a fmall bolfter of linen is inferted between the artery and the knot, in order to prevent the artery from being cut. This, howev- er, can anfwer no good purpofe ; for if the whole ar- tery is not furrounded with the bolfter, it will be juft as liable to be cut by the ligature, as if this precaution had been omitted: and befides, as I have elfewhere had occafion to remark, the ligature on arteries need never be fo tight, as to incur the rifk of dividing them; much lefs preffure than is commonly applied being fufficient, b The upper ligature being thus finifhed, before the knot is paffed upon the other below the orifice, the tourniquet fhould be uutwifted, in order to See wheth- 40 Of Aneurisms. Chap. IX. er any blood is difcharged by the wound in the arte- ry or not. If blood flows freely, it will afford a pleaf- ant profpea of the fuccefs of the operation, as it will fhew, that the anaftomofing branches are fufficient for carrying on the circulation in the under part of the limb. But although blood fhould not be difcharged at this time by the orifice, we are not, from this cir- cumftance alone, to deSpair of fuccefs ; for it frequent- ly happens, that the operation fucceeds, although no blood is difcharged on the trial that I have advifed. But whether any blood fhould be difcharged by this trial or not, we fhould not reft fatisfied with one liga- ture ; for unlefs the ligature below the orifice is alfo tied, hemorrhagies may probably take place on the return of circulation to the under part of the artery : this precaution, therefore, fhould never be omitted; it is eafily done, and it renders the patient fecure againft all farther lofs of blood. After the knots are tied, the ligatures fhould be cut of fuch a length as to admit of their ends lying over the wound, fo that when neceffary they may be more eafily withdrawn. With a view to farther fecurity, it has been advifed to infert other two ligatures quite contiguous to thefe, and to leave them untied, fo that it either of the oth- ers fhould happen to fail, its place may be immediate- ly fupplied. There is not, however, any caufe for this precau- tion, for, if the firft ligatures are properly applied, they will not fail to anfwer the purpofe; and in the event of one or both of them giving way, they can be eafily renewed : we alfo have it in our power to ren- der the patient fafe againft any Sudden discharge of blood, by leaving the tourniquet loofe upon the upper part of the limb, which it ought always to be for Sev- eral days after the operation, fo that, in the event of blood burfting from the wound, it may at once be Secured. The ligatures being completed, the tourniquet fhould be made loofe ; and if no blood is flifcharged at the Sea* II. Of Aneurisms. 41 orifice in the artery, we may conclude that the opera- tion is properly performed. The wound fhould now be lightly covered with a pledget of any emollient ointment; and a comprefs of foft lint being applied over the dreffings, the whole fhould be fecured with two or three turns of a roller above, and as many below the centre of the wound. The patient being now laid in bed, the limb fhould be placed in a relaxed pofture upon a pillow, So as to create the leafl poffible uneafinefs Srom the pofture in which it is placed. As this operation is always tedious, and excites much pain and irritation, a full dofe of laudanum Should be given immediately after it is finished. With a view to diminifh fenfibility in chirurgical operations, I have in different inftances given opiates about an hour before: with fome, this has evidently proved ufeful, but with others it has appeared to do harm; particularly in weak irritable constitutions, in which with any doSes I ever ventured to give, the patients ap- peared to be rendered more SuSceptible of pain, than if no opiate had been taken. Immediately after every operation, of importance, however, an opiate fhould be given, and repeated occasionally, according to the degrees of pain and reftleflhefs which take place. In fome few cafes of aneurifm, it happens, that the pulfe in the under part of the limb is perceptible im- mediately after the operation. This, however, is not frequent; for aneurifin being more commonly met with at the joint of the elbow, as a confequence of bloodletting, than in any other fituation, and as it rarely happens that the brachial artery divides till it paffes an inch or more below the joint, the trunk of this artery is therefore mofl frequently wounded ; and, as the ligatures in this operation muft obftrua the paffage of almoft the whole blood going to the under part of the arm, there can be no reafon to expea any pulfation at the wrift, till the anaftomofing branches of the artery have gradually become fo much enlarg- 4« Of Aneurisms. Chap. IX. ed, as to tranfmit fuch a quantity of blood to the un- der part of the limb, as may be fufficient for aaing as a hamulus to the larger branches of the artery. Immediately after the operation, the patient com- plains of numbnefs or want of feeling in the whole member, and as it commonly becomes cold, it ought to be kept properly covered. In ten or twelve hours from the operation, although the numbnefs may con- tinue, the heat of the parts generally begins to return; and, in the courfe of a few hours more, all the under part of the hmb is even apt to become preternatural- ly warm. Although phyfiological dtfcuflions are not immedi- ately conneaed with our fubjea, and although I Shall not therefore enter on them often, yet I cannot here avoid to remark the clear proof which we derive from this operation, of the great dependence that one part of the human frame has upon another- The nerves we know to be the instruments of fenfe and motion; but on being deprived of their ufual fupport from the fanguiferous fyftem* their influence is inftantly lefk ened. Immediately after this operation, the want of feel. ing in the parts below the ligatures, is commonjy ' great j and in proportion as the circulation takes place *' in the under part of the limb, the feeling never fails to return. If we could fuppofe the nerves of the parts below to be always included in the ligature with the artery, that numbnefs which fucceeds to the operation might be eafily explained ; but I have known it hap- pen when nothing but the artery was fecured with the ligature: and befides, although the knot iipon the nerves would account for the immediate lofs of fenfw bility which fucceeds to the operation, it would not Serve to explain the return of feeling, on the circular '* tion being reftored; for the nerve being deftroyed by the ligature, if the want of feeling originated entirely from this, in what manner could the return of blood : to the part be fuppofed to aa in reftoring it ? Sea. II. Of Aneurisms. 43 In the mean time, the regimen and fituation of the patient are points which require particular attention: he fhould be allowed cordials and nourifhing diet when low and reduced, and confined to a low diet, if his constitution is plethoric: the limb fhould be kept in a relaxed pofture, and towards the end of the fourth or fifth day, if the operation is to fucceed, a weak feeble pulfe is difcovered in the under part of the limb; and as this becomes ftronger, the patient in the fame proportion recovers the ufe and feeling of the parts. As foon as matter has formed about the fore, which feldom happens till the fifth or Sixth day, an emolli- ent poultice fhould be applied over it, in order to Sof- ten the dreffings, which mould then be removed. At this time, top, the ligatures might be taken away; but as their continuance for a few days longer can do no harm, it is better to allow them to remain till the fecond or third dreffmg, when they either drop off of themfelves, or may be taken away with more fafety. The dreffings, which fhould always be of the fofteft materials, being renewed every fecond or third day, according to the quantity of matter, the fore for the mofl part heals eafily j and although the patient may Sor a confiderable time complain of numbnefs, and want of flrength in the difeafed limb, yet in mofl in- ftances a very free ufe of it is obtained at laft. . It will be readily fuppofed, that this termination is the mofl favourable that can poffibly happen. In fome inftances, our fuccefs is far from being fo com- plete : inftead of a return of circulation, and of the feeling and ufe of the parts, they remain cold and in- Senfible, and no marks of returning life are perceived. From a mere want of tjlood, therefore, mortification at laft takes place; and as nature is here deprived of one of her principal agents for the removal or fepara- tion of gangrenous parts, I mean the efforts of the fanguiferous fyftem, the difeafe for the moft part ter* rninates fatally* 44 Of Aneurisms. Chap. IX. Whenever mortification, therefore, enfues as a con- fequence of this operation, if the patient lurvives till a feparation takes place between the healthy and dif- eafed. parts, amputation of the limb is then our only refource. That this operation, when performed upon the principal artery of a limb, fometimes terminates in this manner, no praaitioner will deny; but its doing fo in fome inftances, does not warrant our rejecting it in all. The event of every capital operation is very uncertain ; and in this, as in every other of equal im- portance, as we cannot in any cafe fay with precifion how it will Succeed, fo we are never to advife it where means of a lefs hazardous nature will anfwer: while, on the contrary, when thefe are found to fail, and the patient's life appears to be in danger, ft ought with- out hesitation to be performed. Among the numerous improvement's which modern furgery has experienced, one of the mofl ingenious is a new method of operating for the cure of the pop. liteal aneurifm, firft propofed by the late Mr. John Hunter, of London. In operating for this variety of aneurifm in the ufu- al way, the depth of the artery renders it both diffi- cult and tedious ; befides which, from the artery be- ing frequently difeafed for a considerable way above the feat of the aneurifm, the operation is thereby apt to fail. With the view of avoiding thefe difficulties the femoral artery is Secured, in the new operation, about the middle of the thigh ; by which * when the operation fucceeds, the tumor in the ham foon difap* i pears, and in the courfe of a few weeks, the patient recovers the ufe of his limb. In performing the operation in this manner, the tourniquet ihouki be applied as near as poffible to the top of the thigh: but not drawn tight, in order to preferve the parts in their relative Situations ; an inci- fion, four inches in length, is then made through the Sea. II. Of Aneurisms. 45 Skin and cellular membrane, rather above the middle of the thigh, and crofiing the inner edge of the farto- rius mufcle in an oblique direaion from above down- wards. The fartorius being brought fully in view, the edge of it muft be raifed where the pulfation of the artery is perceived through the fafcia by which it is covered. This is next to be divided to the extent of two inches, when the artery muft be carefully fepa- nited from the nerve and vein with which it is ac- companied ; and a broad waxed ligature of filk being paffed round it, by means of a blunt edged hook, a firm knot muft now be tied on it; and the ligature being left out at the edges of the wound, they fhould then be laid together, and the whole covered with a pledget of Simple ointment. On the 'patient being put to bed, a tourniquet fhould be applied looSely on the upper part oS the thigh, with the view oS putting a Stop to any unex- pected hemorrhagy, and the limb fhould be placed on pillows, raifed to Such a height, that the thigh and leg may form an angle with the body, as well as with each other; in this manner, relaxing the mufcles, and particularly the fartorius, as much as poffible; care being alfo taken, during the firft eight or ten days, to retain the limb Steadily in this fituation. On the fourth or fifth day, the dreffings may be changed; but the ligature Should not be drawn till the fifteenth or fixteenth day, when in general it will come eafily away. Till the end of the third week, the patient fhould be kept in bed ; nor Should he be allowed to ufe his limb with freedom for the fpace of Several months after the operation. This is undoubtedly a very important improvement on the method of operating for the popliteal aneurifm, but further experience of the effeas of it alone c?ji Shew whether it will in general fucceed or not; and till this Shall be obtained, we muft remain uncertain, whether this operation, or that of amputating the limb 46 Of Aneurisms. Chap. IX* at the upper part of the thigh, will fall to be prefer- red ; for it is not that mode of conduaing a cure which carries the beft appearance, that ought to meet with our preference, but that which experience proves to be the beft, in confequence of its faving the great- eft number of lives. Sea. L Affections of the Bruin, fcfr. 47 CHAPTER X. Of Affedions of the Brain from External Violence* SECTION I. Ceneral Remarks on Affedions of the Braih from Ex~ ternal Violence. AFFECTIONS of the brain from external vio* lence, often induce a very complicated fet of Symptoms; are attended with imminent danger, and give much embarraffment to pracritioners : accord- ingly, both with refpea to the hazard with which they are attended, and the difficulty that we meet with in the cure, there is perhaps no clafs of difeafes to be compared with them. Wounds and bruifes of the head, which at firft exhibit no marks of danger, often induce a train of fymptoms which elude the (kill of the mofl experienced praaitioner; and, without ad- mitting of any mitigation, proceed to a fatal period, ending only with the death of the patient. The very intricate nature of thefe affeaions has ex- cited the attention of praaitioners from the time of Hippocrates downwards; but although this branch of praaice has received fome important improvements, from the induftry and obfervation of modern furgeons, yet it muft be admitted, that much ftill remains to be done in it. Authors of the laft and preceding centu- ries have propofed modes of treatment in affections of the head, which modern praaitioners do not admit; whilft in various points of importance, furgeons of our own times differ materially from one another. 48 Affedions of the Brain Chap. X, This uncertainty which prevails with refpea to the nature and treatment of thefe affeaions, proceeds from different caufes, the principal of which appear to be the following. I. The neceffity of a found and entire ftate of the brain for the purpofes of life and health, together with the peculiar delicacy of its ftruaure, makes injuries which in other parts of the body would induce no danger, when infliaed on this organ produaiveof the mofl alarming confequences. II. The Brain being furrounded with a firm cover- ing of bone, it is always difficult, and in many cafes impoffible, to obtain an exaa knowledge of the na- ture of the cafe, and of the parts more immediately injured : infomuch, that while the attending Symptoms often lead us to prefume that the brain has Suffered, if no external marks of injury appear, we are frequent- ly at a lofs to determine where the instruments necef- fary for the relief of the patient fhould be applied : for this reafon, we have not, perhaps in any inftance, fo much caufe to regret our very limited acquaintance with difeafes, as in affeaions of the brain ; in which, difcoveries are often made upon diffeaion after death, a knowledge of which, if obtained a day or two foon- er, might have put it in our powrer to fave our pa- tients. III. The mofl material impediment to our fuccefs- ful treatment of difeafes of this clafs, is the impofiibil- ity of obtaining an eafy and free accefs to the injured parts, even when we know with certainty where they are feated. For, the brain being on all fides furround- ed with bone, we can rarely accomplish fo extenfive an expofure of the injured parts as the proper treat- ment of them requires. IV. The manner in which difeafes of the head from external violence have been commonly defcribed, has had fome influence in rendering this part of praaice perplexed and intricate. Till of late ye:irs, authors have attended more to the confidcration of the caufes Sea. L from external Helena. 4f> which induce difeafes of the head, than to the real nature and treatment of the affeaions themfelves: oc- cupied almoft entirely in defcribing the one, they have very univerfally paffed over the other too remifsly.* Thus, the various contufions and wounds to which the head is expofed, have been particularly defcribed ; and every variety of fraaure which can happen has been mentioned with a minute accuracy. The mofl trifling differences that can > occur, have been diftin- guifhed by particular appellations, and much ingenu- ity has been exerciSed in deScribing the extent with reSpea to length and breadth, and every other cir- cumftance relative to the figure of a fraaure ; points of very little importance; and which, when fo much infifled upon, tend to perplex not only the younger, but even the more experienced part of the profeffion. Nothing, indeed, can fet the impropriety of fuch dif- tinaions in a Stronger point of view, than our obferv- ing daily that no advantage ever enfues from them. It is the effea which fractures of the fkull and other injuries produce upon the brain, which we ought to confider, and not their external appearances. If indeed the effeas produced upon the brain by a . fraaure of the Skull could be determined by the fize and figure of the fraaure, it ought to be minutely de- fcribed ; but every praaitioner knows that this is not the cafe. Fraaures of the fmalleft fize will in fome in- ftances produce the mofl dangerous Symptoms, whilft in others thoSe of the greateft extent excite no alarm- ing appearance. As long as it was imagined that the danger induced by fraaures of the fkull was in pro- portion to their extent and figure, we need not be furprifed at the attention with which thefe circumftan- * The French authors upon this fubjecl:, were the firft among t!ie mod- erns who wrote upon it with precition. And among thefe, that judicious practitioner, Monfieur Le Dran, ftands particularly eminent: I need fcarc •. ly obiervc too, that the public are much indebted to our countrytiun, the late Mr. Pott, for his valuable work upon this, fubjed. Vol. II. E 50 Affedions of the Brain Chap. X. ces were confidered ; but now, while we know that no advantage can be derived from diftinaions of this kind, I Shall not judge it neceffaVy to dwell particu- larly upon them. Thefe are the circumftances which render the man- agement of affeaions of the brain from external vio- lence uncertain. In the fubfequent part of this chap- ter I fhall endeavour to point out the means beft cal- culated to extricate this part of praaice from fuch uncertainty; but before proceeding to do fo, it will. not be confidered as improper our giving a concife anatomical defcription of the parts mofl apt to fuffer from injuries done to the head ; as by this the fubjea will be rendered more clear and intelligible. SECTION II. Anatomical Defcription of the Brain and fur rounding Parts. THE brain and cerebellum, with their membranes the dura and pia mater, have for their protec- tion a covering of bone, the cranium. The cranium confifts of eight bones, forming an oblong vault or box, flattened on the fides by the fu- perior firmnefs of the lower part of the temporal bones, and by the conflant aaion of the temporal mufcles : it is more capacious on the back part.than before, the lobes of the brain being here more extenfive. The bones of the cranium or fkull, are, the frontal bone, the two parietal bones, the two temporal, the occipital, the fphenoid, and ethmoid. The firft fix of thefe are faid to be proper to the fkull, the two laft bein^ confidered as common to it and the face. The os fr.mtis forms all the anterior or forepart of the cra- nium, the offa parietalia the middle and upper part, and the os occipitis the pofterior part of it: the offa Sea. II. from external Violence. 51 temporum form the lower part of the fides of the cranium ; and the fphenoid and ethmoid bones form the centre, or what is commonly termed the bafis of the fkull; but as thefe two laft mentioned bones lie So deep, as to be entirely out of the reach of any chi- rurgical operation, any injury to which they may be expofed, muft in almoft every inftance prove fatal. The other fix bones are conneaed together by joints or indentations, termed Sutures, which are five *in number, the coronal, Sagittal, lambdoid, and two fquamous. The coronal future extends over the head, from within a fhort fpace of the external canthus of one eye, to within an equal diftance oS the other on the oppofite fide of the head; and in its courfe, it ferves to unite the frontal bone to the anterior edge of the two parietal bones. The fagittal future unites the parietal bones on the fuperior part of the fkull, by running almoft in a direa line from the middle of the frontal bone to the middle of the os occipitis: in fome inftances this future proceeds along the whole extent of the os frontis, and terminates immediately above the nofe, by which that bone is divided into two equal parts j and inftances are mentioned oS the occipital bone being divided in a fimilar manner; but this is confeffedly a rare occurrence. The lambdoid future, fo called from its refemb- lance to the Greek letter a, begins where the fagittal future terminates, at the middle of the fuperior edge of the occipital bone; and its two crura or legs ftretching down to the bafis of the Skull, ferve to unite this bone to the pofterior edge of the two parie- tal and temporal bones. It is in the courfe of this future, namely, the lambdoid, that thefe fmall irregu- lar offifications, termed offa triquetra, are mofl com- monly met with. In fome inftances they penetrate the whole thicknefs of the bone ; but in others, they are chiefly confined to the external lamella of the fkull, being fcarcely perceptible inwardly. e 2 52 Affedions of the Brain Chap. X. The laft futures we have to notice, are the two fquamous, which ferve to unite the fuperior part of the temporal bones to the under and correfponding parts of the offa parietalia. In young people, thefe five futures are almoft uni- verfally met with,.and it is neceffary that praaition- ers fhould be well acquainted with their direaion j but it is proper to obferve, that in older fubjeas, fome of them are often wanting. Inftances are even re- corded, in which all the Sutures were completely cb-- literated; but this I believe to be a very rare occur- rence. The Sagittal and coronal Sutures, are thoSe that are mofl frequently wanting. Various advantages are derived from the formation of the fkull by feparate bones; but that which we have particularly to mention, is, that at the futures, a more direa communication, by means of blood vef- fels, takes place between the membranes of the brain and the teguments of the fkull, than otherwife could have been the cafe; and by means of thefe futures, too, there is reafon to fuppofe, that fraaures will not fpread fo extenfively *as if the whole cranium was formed of one bone only. Some advantage is in this manner accordingly de- rived from the fkull being formed of different bones \ for in the early ftages of life, while the bones are not firmly conneaed together, fraaures do not fo readily pafs acrofs the futures, as they afterwards do: but nature muft furely have had fome other intention in this mechanifm, otherwife the more perfoa adult would not probably be deprived of an advantage. which the earlieft period of childhood enjoys in great- er perfoaion : and although I have faid, that the fu- tures have evidently fome influence in young people, of flopping the progrefs of fraaures, their effea is evidently not confiderable ; for daily obfervation evin- ces, that fraaures pafs from one bone of the fkull to another, even while the futures remain in every ref- pea entire j a circumftance which every young prac- Sea. II. from external Violence. 53 titioner efpecially fhould be aware of; for, from ma- ny obfervations to be met with in fome of our older writers, we might be led to imagine, that fraaures rarely if ever traverfe the futures, which, however, we frequently find them do. The bones of the fkull are, for the mofl part, com- pofed of two lamellae or tables, feparated by a kind of bony network, or cancelli, commonly termed the diploe. The external table is every where consider- ably thicker than the internal, which is firm, com- pact, and more brittle than the other; which readily accounts for what we fometimes meet with, a fraaure and even a depreffion of the internal table of the fkull, while the external furface of the bone remains entire : but it unfortunately happens, that the difcov- ery of this is feldom or never made, till it is too late to prove ufeful; I mean not till after the death of the patient. In the direaions given by authors for applying the trepan, we are commonly defired to proceed with much caution in paffmg the inflrument through the inner table of the fkull, while we are told that no dan- ger can enfue from proceeding quickly in the firft part of the operation till the outer table and diploe are fairly penetrated. This however proceeds upon the fuppofirion of the -two tables of the fkull, with the in- termediate diploe, being at all times diftina and ob- vioufly marked. Now we know, that this is not the cafe; for the diploe becomes lefs with age, and in many inftances it has been fo completely obliterated as to take away entirely the appearance of two tables of the fkull over all the upper part of the head : and befides, in fome parts of the fkull, the diploe is natur- ally wanting, particularly in different parts of the 05 occipitis, owing perhaps to the preffure produced up- on this bone by the mufctes with which it is covered. It is alfo wanting at the under part of the os frontis, where the two lamellae of this bone feparate immedi- ately above the eyebrows, in order to form the two 54 Affedions cf the Brain Chap. X. cavities of the frontal finufes ; whilft in general it is more diftinaiy obferved over all the Superior part of the frontal bone, and through the whole extent of the offa parietalia, than in any other part of the fkull. The external furface of all the bones of the upper part of the cranium, is in general fmooth and equal, and this is alfo the cafe with the. internal furface of the fame parts of thefe bones, excepting the temporal bones and fome part of the offa parietalia, in which feveral deep furrows are formed by the pulfation of the arteries of the dura mater. But although the up- per part of the fkull is commonly fmooth, almoft the whole under part of it is rugged and unequal. This inequality on the outfide Seems to be calculated for the better attachment of the different mufcles which move the head ; and on the infide it ferves the pur- pofe of Supporting the different parts of the brain and cerebellum. Almoft the whole of the occipital bone is very un- equal both in its external and internal furfaces: this is likewiSe the caSe with all the inferior .part of the temporal bones, and with the under part of the os frontis ; So that none of thefe Situations are So proper for the application of the trepan, as the more fmooth and«equal parts of the fkull. The fkull is externally covered with the common teguments of the body, the fkin, and cellular fub- ftance ; with the frontal, occipital, and temporal muf- cles, and an aponeurotic expanfion formed by a com- bination of the tendinous fibres of them all ; and more immediately by the pericranium, a very ftrong membrane, which adheres firmly to every part of it, but particularly at the futures. It has by many been fuppofed, that the cavity form- ed by the bones of the fkull, is not naturally com- pletely filled. This, however, is now known to be an opinion void of foundation ; for every part of this cavity is occupied by the brain and cerebellum, with their investing membranes the dura and pia mater. Sea. II. from external Violence. $$ The dura mater which is a ftrong inelaftic mem- brane, adheres every where to the internal Surface of the Skull by an infinite number of fmall vafcular fila- ments, as is evident by thofe innumerable points of blood which appear over the furface of this mem- brane, and through the whole internal furface of the fkull, on the cranium and dura mater being forcibly feparated from each other. This adhefion, however, of the dura mater to the cranium, is much more firm at the futures than in any other part, owing to the blood veffels which paSs out here being not only more numerous, but of greater magnitude than in the reft oS the fkull. In other parts oS the head, any veffels which paSs Srom the dura mater to the fkull Seem to be chiefly intended to Supply the internal table, and the diploe, with blood; but at the Sutures an evident communication takes place, by means of blood veffels, between the external coverings of the fkull and the membranes of the brain, a circumftance which prac- titioners fhould be aware of, as it not only ferves to explain many of the phenomena attending injuries done to the head, but likewife points out the moft probable means of guarding againft them. By our knowledge of this part of the anatomy of the head, we learn, that the futures are not the moft eligible parts for the application of the trepan ; and, on the contrary, that this operation fhould never be perform- ed in the courfe of a future, if the fame intention can be anfwered by applying the instrument on any other part; and that, by the firm adhefion of the dura ma- ter to the fkull at the futures, matter or blood collea- ed on the furface of that membrane on one fide of a future, will not be difcharged by a perforation made on the oppofite fide of it. The dura mater, the firmnefs of which renders it particularly proper to fupport the brain by its differ- ent productions, is of too hard a texture to be imme- diately conneaed with that very delicate organ. It is therefore every where lined with another foft mem- $6 Affcdims of the Brain Chap. X. branous expanfion, the pia mater, which is immedi- ately applied over the whole furface of the brain and its convolutions. The great quantity of blood fent to the brain and its coverings, is fupplied by the carotid and vertebral arteries, and is again returned by the jugular veins ; but before reaching thefe veins, it is emptied into a number of finufes or refervoirs, formed by produc- tions or duplicatures of the dura mater : thefe finufes all communicate with each other : they are numerous on the back part of the head, but the moft material for furgeons to be acquainted with, are, the longitu- dinal, which runs along the middle and upper part of the head, direaiy in the courfe of, and firmly attach- ed to, the fagittal future ; and the two great lateral finufes, in which the longitudinal finus terminates at the middle and upper part of the cerebellum, at which part thefe two finufes commence, the one going to the right and the other to the left, and paffing down to the bafis of the fkull, they there terminate in the ju- gular veins. This general account of the anatomy of thefe parts, will ferve to render the consideration of the injuries to which they are expofed more clear and intelligible; while a more minute defcription of them would net only be incompatible with the nature of this work, but would not in any refpea be neceffary ; for the moft minute defcription that can be given of the dif- ferent parts of the brain would be of no advantage to praaitioners in the treatment of thofe affeaions to which it is liable. We may, in general, obferve up- on this point, that the brain is an organ effentially ne- ceffary for life ; and, that its parts cannot be derang- ed, either by wounds, contufions, or compreffion, but with the utmoft hazard: for although we fometimes meet with inftances of the brain being much injured, and even of parts of it being difcharged at wounds, without any important coniequences taking place ; yet thefe are rare occurrences, and are by no means fulfi- Sea. II. from external Violence. 57 cient to invalidate this general obfervation, that a found and entire ftate of this organ is highly neceffary for the purpofes of life. i fhall now proceed to treat more * particularly of the nature of thofe injuries to which the parts that have juft been defcribed are liable ; but inftead of enumerating in feparate feaions, as has commonly been done, the various caufes of affeaions of the head, and the fymptoms which each of thefe excite ; I mean to confider the general effeas which they produce up- on the brain, and to point out the manner in which they appear to operate, together with the means which Srom experience have been found to anfwer beft in their removal. All the fymptoms of affeaions of the brain from external violence feem evidently to originate from one of the following circumftances ; namely, from com- preffion of the brain ; from commotion or concuffion ; or from inflammation. Thefe I fhall proceed to con- fider in feparate feaions ; and as far as the intricate nature of the fubjea will admit, I fhall treat of them as diftinct and unconneaed with each other: for al- though we are not to expea that the fymptoms arifing from rhefe different caufes, are always diftina and pre- • cifely marked, and without conneaion with each oth- er ; yet it frequently happens that they are fo, and it is in their feparate uncombined ftate only that any de- scription can be given of them. Praaitioners of ex- perience muft indeed know, that cauSes frequently occur, by which all the affeaions of the brain that I have mentioned are induced at the fame time in.the fame patient ; and in fuch inftances, the fymptoms which they produce are no doubt fo very confufed as to be with difficulty diftinguifhed : thus, a ftroke up- on the head, attended with fymptoms of concuffion, is frequently accompanied with thofe which proceed from compreffion ; and thefe again are in fome in- ftances Succeeded by all the Symptoms of inflamma- tion. 58 Affedions of the Brain Chap. X. The appearances induced by the various combina- tions of thefe, can be learned only from praaice and obfervation ; but an accurate knowledge of them as they occur in a feparate and unconnected ftate, will prove highly ufeful in the cure, under whatever form they may occur. SECTION III. Of Compreffion of the Brain from external Violence. A GREAT variety of fymptoms are enumerated by authors, as indicating a compreffed ftate of the brain from external injuries; but the moft fre- quent, as well as the moft remarkable, are the follow- ing : giddinefs ; dimnefs of fight; flupefaaion ; lofs of voluntary motion -y vomiting ; an apopieaic ftertor in the breathing; convulsive tremors in different muC cles j a dilated ftate of the pupils, even when the eyes are expofed to a clear light; paralyfis of different parts, especially of the fide of the body oppofite to the injured part of the head ; involuntary evacuation of the urine and feces ; an oppreffed, and in many cafes an irregular pulfe ; and when the violence done to the head has been confiderable, it is commonly attended with a difcharge of blood from the nofe, eyes, and ears. Some of the milder of thefe fymptoms, fuch as ver- tigo, flupefaaion, and a temporary lofs of fenfibility, are Srequently induced by flight blows upon the head : and as they often appear to be more the confequence of a fhock or concuffion given to the brain, than of compreffion induced upon it; fo they commonly fooa difappear, either by the influence of reft alone, or of the other means to be hereafter pointed out. But when any of the other fymptoms take place, fuch as convulfive tremors j dilatation cf the pupils j in\ol- Sea. III. from external Violence. 59 untary paffage of the urine and faeces ; and efpecially when much blood is difcharged from the nofe, eyes, or ears, we may always conclude with a good deal of certainty, that much violence has been done to the brain, and that compreffion in one part or another is induced upon it. In the anatomical defcription of the cranium and brain, I had occafion to remark, that the cavity oS the Skull in a ftate of health, is completely filled -by the brain, no vacuity whatever being left between them : it therefore neceffarily follows, that compreffion of the brain will be produced by whatever tends to leffen the cavity of the fkull. # A diminution of the cavity of the fkull may happen in various ways ; by fraaures attended with depreffion of any part of the bones of which it is compofed ; by the forcible introduaion of any extraneous body through both tables of the bone ; and by the effufion of blood, ferum, pus, or any other matter. The fame effea may be likewife produced by the thickening of the bones of the head, as fometimes happens in lues venerea, and by water colleaed in the ventricles of the brain in cafes of hydrocephalus internus. Thefe two laft mentioned caufes, however, proceed from, and are conneaed with, difeafes which it is net our bufinefs in this place to confider. The effufion of pus or any other matter not evidently either blood or ferum, muft always be the confequence of inflam- mation, and will fall to be confidered in a different feaion ; and as the introduaion of extraneous bodies into the brain muft always be attended with a fraaure, and commonly with depreffion of fome part of the Skull, the consideration of the one is neceffarily con- neaed with that of the other. I fhall now therefore proceed to fpeak more particularly of fraaures attend- ed with depreffion, and fhall afterwards confider the other general caufe of coinrreffidn of the brain, effu- fion of blood or ferum. 60 Affedions of the Brain Chap. X. §1.0/" Compreffion of the Brain from Fraclurcs at- tended with Depreffion of the Skull. Fractures of the Skull, as I have already obferv- ed, have been diflinguifhed by a variety of appellations according to their figure, extent, and other circum- ftances of little importance; to retain thefe distinc- tions, could therefore anfwer no good purpofe ; and as it might embarrafs the younger part of the profef- fion, I do not mean to mention them. The only general distinction of fraaures neceffary for us to retain, is, thofe which are attended with de- preffion, and thofe which are not. All the variety of the latter I mean to comprehend under the denomina- tion of fiffures ; but the consideration of thefo will be more properly introduced in a different foaion. Fraaures of the fkull-may be produced in various ways : by falls from a height j by blows with fharp or blunt instruments; and by miilile weapons, fuch as Stones, and balls thrown from a diflance. Authors, who have entered minutely into this part of the fubjea, obferve, that in the treatment of frac- tures, much advantage may be derived, from a kowl- edge of thefe circumftances ; and that we may even afcertain with fome precision, the degree of violence that has been done to the brain, from being acquaint- ed with the caufe by which it was produced. But although it is proper to inquire into the nature of the caufe of every fraaure, yet we are not to imag- ine that any material advantage will be derived from it: we know, indeed, that a fraaure of the Skull, pro- duced by a blow with an obtufe or blunt inflrument, or by a fall from a confiderable height, is frequently attended with more ah.rming fymptoms than a frac- ture of the fame extent with a fharp inflrument. This* however, is not univeriatly the cafe ; and as it is im- poffible to ascertain the extent of any injury done to the brain by this circumftance alone, little or no de- pendence fhould ever be phced on iu Sea. III. from external Violence. 61 In the management of fraaures of the fkull attend- ed with depreffion, the indications are, i. To difcover as exaaiy as poffible the Site, the courfe, and the full extent of the fraaure. 2. To obviate the effeas of the injury done to the brain, by elevating or removing all the depreffed parts of the bone. 3. To endeavour to complete the cure by the ap- plication of proper dreffings, and attention to the after treatment. Thefe are the objeas which we ought to have in view. In many inftances, indeed, this is put out of our power by the nature of the fraaure ; but in oth- ers, when thefe indications can be accomplished, we are frequently able to afford more effeaual relief to patients, than it is ever in our power to do in the treatment of any other malady. In fraaures of the fkull, the teguments covering the injured part of it, are frequently cut, lacerated, or ev- en altogether torn away. In this cafe, the ftate of the bone is at once rendered evident; the fraaure is im- mediately difcovered, and the furgeon is left at liberty to employ the moft proper means for obviating the effeas of it: but when the fkin and other teguments are entire, it often happens, even when, from a con? currence of circumftances, we are tolerably certain of the existence of a fraaure, that we do not eafily as- certain it. When any outward mark of injury takes place, particularly when a tumor is perceived on any part of the head, accompanied with appearances of a recent contufion, the fymptoms are commonly found to orig- inate from a fraaure direaiy underneath ; and on the bone being laid bare, in the manner to be hereafter mentioned, the courfe of the fraaure is in general dif- covered. But every praaitioner knows, that injuries done to the head frequently produce affeaions of the brain, and even fraaures of the fkull, without leaving either 62 Affedions of the Brain Chap. X. tumor or any other external mark by which they can be difcovered. In this fituation, the whole head fhould be fhaved, When it will fometimes happen, that a particular fpot will appear red, which could not be obferved till the hair was removed, and will thus lead to a difcovery of the injured part. But when no tu- mor, inflammation, or riny other mark is difcovered, we may in fome inftances be direaed to the Seat of the injury, by preffing firmly over the whole head: and if we find, on repeated trials, that preffure excites more pain in a particular part than in others ; of which we may be convinced if the patient moans much on preffure being applied to it; and if he puts up his hand or draws away his head ; on this trial being re- peated, we may conclude with much probability that this is the feat of the injury. In circumftances, Such as we are now considering, fo fraught with danger to the patient, and fo perplex- ing as they frequently are to praaitioners, nothing that can throw light upon the nature of the cafe fhould be overlooked. If the patient raifes his hand, and applies it frequently upon or near to the fame part of the head, even this will merit attention; for in this manner I have in different inftances been led to the fite of a fraaure. When therefore the fymptoms of a compreffed brain are evidently marked, we ought, without hefitation, to proceed to examine the ftate of the cranium wher- ever appearances give caufe to fufpea that a fraaure has taken place. We do this by laying the bone bare by making an incifion with a fcalpel through all the external coverings of the fkull. In performing this operation, when the bone is pre- vioufly found to be much injured, which in fome in- ftances is the cafe even where the fkin directly above it is not lacerated, the incifion through the integuments fhould be made with caution ; otherwife the brain may be hurt, either by the knife preffing on Some de- tached portion of bone, or even by the point of it Sea. IIL from external Violence. 6$ paffing in between two of the feparated pieces. But when the bone upon which the incifion is made, is not either broken into different portions, or when the edges of the fraaured pieces have not receded from each other, and do not in any degree yield to preffure, the divifion of the fkin and other teguments rnav De then performed with freedom, by cutting through the whole of them down to the bone, with one ftroke of the fcalpel. The fole intention of this operation is to bring the injured parts of the bone into view ; but although the means of effeaing this fhould be fimple and eaSy, a very painSul and Severe method of doing it has been commonly praaifed. It has been in general fuppof- ed, that in fraaures of the fkull, the injured parts can- not be fufficiently expofed, either for the purpofe of tracing the courfe of the fraaure, or for applying the trepan, unlefs a portion of the fkin and other tegu- ments is altogether removed: with this view, fome have advifed a crucial incifion to be firft made, and the corners to be cut off. Others recommend an in- cifion of the form of the letter T : while by many we are advifed to remove a circular or oval piece of the teguments at once. Various objeaions, however, occur to all of thefe. They not only produce a painful wound, which is commonly difficult to heal; but by expofing a con- fiderable part of the Skull, tedious exfoliations Some- times take place, which might be prevented ; and the covering which nature afterwards provides for the de- nuded bone never anfwers the purpofe fo well as the teguments that were removed. Even all of thefe ob- jeaions, however, to the praaice that we are new considering, fhould be confidered as trifling, and ought not to be regarded, if we could not by more' fimple means difcover the extent of fraaures, and if we could not likewife by the fame means apply the trepan, or any other remedy. But as both of thefe objeas can 64 Affedions of the Brain Chap. X. perhaps in every inftance be accomplifhed in a more eafy manner, the other ought to be laid afide. On a fimple incifion being made in the manner I have direaed, the teguments always retract: fo much as to admit of the bone being freely examined ; and if a fraaure is difcovered, the courfe of it may be al- ways traced with as much certainty by extending this incifion along that part of the bone in which the frac- ture is found to run, as if a confiderable portion of the teguments was removed : and this retraaion of the divided parts alfo admits of the application of the trepan. On the teguments being in this manner divided, if the fkull is found to be fraaured and depreffed, the nature of the cafe at once becomes obvious; and the means to be hereafter pointed out for the treatment of fraaures attended with depreffion, fhould be imme- diately employed. But even where no outward ap- pearance of a fraaure is met with, and where no tu- mor, difcoloration, or other external mark of injury is difcovered, if the patient continues to labour under fymptoms of a compreffed brain ; if the pericranium has been feparated from the bone ; and efpecially if this membrane has loft its natural appearance, and has acquired a pale white or dufky yellow hue ; the trepan fhould be applied without hefitation at the place where thefe appearances mark the existence of an injury, for, in this manner alone, blood or ferum, which may have been effufed, and by which the com- preffion is induced, can be removed : it would, there- fore, in fuch circumftances, be highly improper to truft to the abSorption of the extravafated fluids, as by fome has been advifed ; the chance of a cure from this being very doubtful. Again, although no mark either of fraaure, or any other injury underneath, fhould appc?r on the exter- nal table of the bone, ftill it is poi-ible that the inter- nal table may be both fraaured and depreffed. This is not indeed a frequent occurrence, but yet various Sea. III. from external Violence. 6$ inftances of it are upon record : I have met with it in different cafes ; and other praaitioners, on whofe ac- counts we may place the moft perfea confidence, like- wife mention it. I formerly obferved that the internal table of the fkull k thinner and more brittle than the external: how far this will explain the faa we have juft been fpeaking of, I will not pretend to fay ; but this is cer- tain, that the injury done to the brain by the depref- fion of the internal table of the fkull, may be as great, and may prove as certainly dangerous, as if the whole thicknefs of the bone had been forced in. This is therefore another motive for the application of the trepan in all cafes, accompanied with fymptoms of compreffed brain, even where no external mark of depreffion is difcovered. It will often indeed happen, that no relief Will be obtained from the application of the trepan, even where the fymptoms are fuch as proceed from a com- preffed ftate of the brain, induced either by a depre{£. ed portion cf bonej or by extravafation of blood or ferum. This want of SucceSs Srom the operation, may proceed from a concurrence of caufes that we fhall afterwards have occafion to mention : but the moft fatal of all of them, is that which we term a contra- fiffure, and the French a contre-coup; in which the fkull is fraaured and fometimes depreffed, and blood or ferum perhaps effufed on the furface of the brain* at a part very diftant from that which received the blow, and where alone there is any apparent or exter- nal mark of mifchief. Many have doubted the reality of fuch an occur- rence ; for, as we cannot clearly Account for it, fo it is alleged, that it has rarely, or perhaps never happen- ed. As it is not the intention of this work, to enter upon minute theoretical difcuffions, I Shall not attempt to explain the manner in which contra-fiffures of the cranium may be produced ; I fhall juft fhortly ob- Vol. II. F 66" Affedions of the Brain Chap. X. ferve, that doubts concerning their exiftence, can have been entertained by fpeculative writers only ; for eve- ry praaitioner-of experience muft have met with op- portunities to afcertain the reality of the faa. I will not pretend to fay, that a blow received on one fide of the head, will neceffarily and certainly pro- duce a fraaure or other mark of injury on the oppo- fite fide ; neither does it appear that the part exactly oppofite to the place where the blow has been receiv- ed, will Suffer more readily than other parts of the head, at the distance of only two or three inches. All I wifh to eftablilh is, that the Skull may be fraaured in parts not immediately contiguous to thofe upon which blows are given j and that this fometimes hap- pens where no external mark can be difcovered upon the teguments correfponding to the fraaure, and while the bone remains perhaps entire on the part which more immediately received the injury. / We Shall therefore confider it as matter of faa, that the Skull may be fraaured in parts at fome diftance from thofe which have more direaiy received an in- jury ; and fome advantage I think may be derived from this being kept in view. In common praaice, if no benefit is reaped from the application of the tre- pan ; if no fraaure is difcovered of the internal table of the Skull, or no extravafation on that part of the brain newly denuded by a removal of a piece of the bone ; and if bloodletting, laxatives, and the other means ufually employed, do not remove the fymp- toms of compref.lon ; praaitioners very generally con- clude, that they depend either: on .concuffion of the brain, or on extravafation in fome of the internal parts of it, where the effeas of an operation cannot reach ; and accordingly, the patient is left to his fate, without any attempt being made for his relief. In this, however, I think, we are liable to much juft cenfure and blame : for although a patient in fuch circumftances is undoubtedly in great danger, and ah- though the chance of his recovering by any means Sea. IlL from external Violence* 6y we can employ, is inconfiderable, yet ftill he fhould receive this chance : in Such circumftances, no at- tempt that we can make will add to his hazard, So that nothing fhould be omitted from which there is the moft diftant chance of relief being derived* The head fhould be again examined with attention ; and by preffing firmly, Slowly, and deliberately, over every part of it, if even the fmalleft degree oS Senfibil- ity remains, the patient will complain, either by moan, or Signs with his hands, when preffure is applied to any part that is Sraaured. I have Seen different in- ftances of fraaures being difcovered in this manner, which, in the ordinary way of fearching for them, had been altogether overlooked. In whatever part of the head the patient complains on preffure being applied to it, the fkull fhould be laid bare by an incifion, in the manner I have mentioned. If both tables of the fkull are fraaured and depreffed, the caufe of the mifchief will thus be difcovered :• but even although no fuch depreffion or fraaure fhould appear in the external lamella of the bone ; as there is at leaft fome chance of mifchief being met with un- derneath, either from a fraaure of the internal table, or from extravafation, and as nothing can poffibly fave the patient but the removal of this, the trepan Should be immediately applied ; and wherever there is the leaft caufe to fufpea, either from pain being in- duced by preffure applied in the manner I have advif- ed, or from any other circumftance, that mifchief may be concealed, as long as relief is not obtained from what has previously been done, the operation fhould ftill be repeated, as the only means from whence any benefit can be derived. This, however, leads to a point that merits more extenfive difcuffion ; I mean, the effeas produced up- on the brain by the removal of a portion of the Skull with the trepan. F 2 68 Affedions of the Brain Chap. X. By many of our older writers on this fubjea, it is faid, that much hazard is at all times to be dreaded from this operation ; and in fupport of their opinion, they not only adduce a variety of faas, but employ much ingenious reafoning on the probable influence of the air finding acceis to the furface of the brain, an organ which nature has taken particular pains to pro- tect from it. Praaitioners of modern times, however, have adop- ted a very different opinion upon this point : they even affert, that no danger can ever accrue from the operation of the trepan confidered abftraaedly ; that it never proves hazardous of itfelf; and that it only apparently proves fo from being often employed for the removal of fymptoms for which this as well as every other remedy is altogether inadequate. In con- fequence of this, the trepan, in all injuries done to the head, is applied with freedom ; in moft inftances, pro- bably with much propriety ; but in others, I am con- vinced, with very dangerous confequences. My opinion on this important point is, that we Should endeavour to avoid both extremes. For, al- though! clearly think, that the trepan fhould be ap- plied with freedom wherever it is indicated by fyuip* toms of a compreffed brain, and where thefe fymptoms muft probably end in death, if the caufe which pro- duced them is not foon removed ; yet I am equally Satisfied, that it is the prefence of fuch fymptoms only which can warrant this operation ; and thati it fhould never be employed, as it too frequently has been, merely with a view to prevent them. In the one cafe, no additional rifle can be incurred by the trepan ; and as the patient will in all probabil- ity Suffer if it is not employed, we fhould not hefitateT to adviSe it: but, as I am perfeaiy convinced, from attentive obfervation of the effeas of this operation upon the brain, that it is by no means an innocent re- medy, and on the contrary indeed, that it is frequent- ly the caufe of dangerous fymptoms, which otherwife Sea. III. fiom external Violence. 69 would not have appeared, I would never think of ad- vifing it but for the removal of fymptoms already in- duced ; that are evidently of a dangerous tendency j and that cannot be obviated in any other manner. In a fubfequent part of this chapter, when treating of fiffures, I Shall again enter on the confideration of this fubjea. In the mean time, before defcribing the operation of the trepan, I thought it proper, in this manner, to mention the opinion I had formed of it. Having thus confidered the firft general indication to be kept in view in the treatment of fraaures at- tended with depreffion of the Skull, we now proceed to the confideration of the fecond, which comprehends the means beft adapted Sor the removal or elevation of a depreffed portion of bone. We have already had occafion to fee, that there is fome variety in fractures attended with depreffion; and the means employed for removing them, are likewife various. It often happens, that the corresponding teguments are either altogether removed by the cauSe which pro- duced the fracture, or fo much lacerated as to admit of the bone being freely examined ; but when they are either not divided in any part, or not in a fufficient degree, the firft objea of the furgeon, as I have already obferved, fhould be, to get the head fhaved, and then to divide the fkin and other teguments with a fcalpel through their whole extent, and direaiy upon the courfe of the injury. If a fraaure is difcovered, and is found to proceed in a ftraight line, the incifion fhould have the fame direaion : or if it takes an angular courfe, the incifion fhould likewiSe do So; for the fole objea of the one is to bring the other as completely as poflible into view. In making this incifion, one or more arteries are apt to be cut, and they fometimes continue for feveral hours to difcharge freely ; thefe, we are coremonly direaed, before proceeding further, to fecure with ligatures. 70 Affedions of the Brain Chap. X. If the patient is weak, or if a fufficient quantity of blood has been already difcharged, this ought no doubt to be done: but as the membranes of the brain are commonly much injured by the depreffed bone, and as nothing in fuch circumftances tends with fuch certainty to prevent inflammation, as a plentiful dif- charge of blood from the contiguous part; the arte- ries which have been cut by the incifion fhould be al- ways allowed to bleed in proportion to the ftrength of the patient, when they will commonly retraa, and give no further trouble. The hemorrhagy from the larger arteries being flopt, the remaining Steps of the operation are com- monly poftponed till the following day, in order to have all the oozing from the fmaller veffels removed alfo : but as foon as the difcharge from the principal arteries is over, that which takes place from the reft of the wound fhould not be regarded ; and as it may always be eafily flopped, by the edges of the cut being covered with dry lint, and moderately compreffed by an affiftant, and as the preffure on the brain fhould always be removed as quickly as poffible, the opera- tion ought therefore to be quickly completed. The extent of the fraaure being afcertained as far as it can be done, and the blood from the incifion flopped, we are next to endeavour to elevate the de- preffed portion of bone : the propriety of this, indeed, is fufficiently evident, and it has been admitted by praaitioners of every age, although they have differed much in the mode of effeaing it. Surgeons of the laft and preceding centuries were in general timid in every operation of importance, es- pecially in fuch as were performed upon the head : and being commonly averfe, as I have already remark- ed, to expofe any confiderable part of the brain, they endeavoured to elevate depreffions of the cranium, ei- ther without penetrating the bone at all, or by means pf very Small perforations only. Sea. III. from external Violence. Ji For the purpofe of perforating the fkull, a kind of circular faw, commonly termed a trepan, and of which I fhall give a delineation, was always employed ; but the opening formed by it was fo fmall, that it was ne- ceffary to apply it often, even in ordinary cafes, to ac- complifh the views of the operator: many inconven- iences enfued from this; to remedy which, various improvements upon this inflrument were fuggefted, and figure i. Plate VIIL reprefents the refult of all of them. Thus improved, it removes a much larger por- tion of bone at once ; and being entirely cylindrical, it penetrates the fkull more eafily than a conical faw, which, till of late was the only form in ufe. In one circumftance, however, modern furgeons have not made any improvement of this inflrument: they have rather indeed hurt it materially, by forming it fo as to render the operation of perforating the fkull with it both more difficult and more tedious than it otherwife might be. The inflrument delineated in Plate VIIL cuts the bone not only more quickly, but with equal fafety. The timidity of fome operators, however, has made them imagine, that it cannot be ufed of this form, but with the hazard of paffing too Suddenly through the bone at the end of the opera- tion, by which the brain would be unavoidably injur- ed : they have accordingly invented another* which divides the bone very Slowly, and which they therefore SuppoSe will perform the operation with more SaSety. This Instrument is termed a trephine, and is delineated in Plate VII. fig. i. This, however, is not poffeffed of any advantage over the other, not even that of be- ing more fafe for perforating the bone ; for, the fame degree of force muft be applied by the operator with each of them; and it has this very material defe£t, that it requires more than double the time to perform the fame operation that is neceflary with the trepan. It has long, however, been almoft the only instrument employed for this purpofe in many parts of Europe, efpecially in Britain j fo that prejudice may probably p Affedions of the Brain Chap. X. continue it in ufe: but whoever will attend to the principles on which the trepan and it are formed, will foon fee that the former fhould be preferred. When it was neceffary to perforate the skull, the trepan, in its then unimproved ftate, was formerly the inftrument chiefly employed. Others indeed were ufed for the purpofe of forming openings in the bones; but they were fo extremely rude and unmanageable, that it is not neceffary to defcribe them ; and this ef» pecially as delineations of all of them may be feen in the writings of almoft every chirurgical author of the laft and preceding centuries.* But, in many frac» tures and depreffions of the skull, it was formerly im- agined that the trepan was unneceffary, as it was then generally believed that the depreffed parts of it might be raifed by more fimple means: with this view, fome writers propofed to pafs a fcrew in a flow and gradual manner nearly through both tables of the depreffed bone, and then to raife it into the place that it form- erly occupied, by pulling the fcrew Slowly and firmly Upwards: and again in children, in whom the bones are more foft as well as more yielding, and in whom fiffures are fuppofed to occur frequently without frac* tures, we were advifed to cover all the teguments cor- refponding to the depreffed portion of bone, with leather Spread with adhefive plafter, and then by mean* of firings or cords fixed to the back part of the leather to elevate the depreffion. Whether a depreffion ever occurs, however, even In early periods of life, without a corresponding frac* ture of at leaft one of the tables of the skull, is much to be doubted, I rather think that it does not, at leaft I never met v. ith it: and I have feen different inftann ces which previoufly were Suppofed to be Such, but which, after death, were all except one found to' be attended with complete fraaures ; and in this the of- feous fibres of the internal table of the bone were * Vide tlic works of liildanus, Scultetue, and Dionis. Sea. III. from external Violence. 75 cracked or ruptured, while thofe of the outer table re- mained nearly entire. But whether this kind of de* preffion ever occurs, or not, is not material: the means to be prefently pointed out for elevating de* preffions of the skull will prove equally ufeful, whe* ther they are accompanied with fraaures or not; While I may freely venture to fay, that no dependence fhould in either cafe be placed on adhefive plafters, as they are evidently inadequate to the effea.- The powers of a fcrew in raifing depreffed portions of the skull would often be fufficient, but as it could neither remove any Sharp points of bone which might be beat in upon the brain, nor ferve to difcharge any diffufed blood which frequently accompanies fraaures attended with depreffion, this means of removing de- preffed portions of bone will never probably be adopt- ed. It has commonly, too, been objeaed to this in- ftrument, that it cannot be introduced but with the hazard of forcing the depreffed piece of bone upon which it is applied farther in upon the brain ; and therefore that much mifchief may thus be induced by it. In many inftances, however, the Screw might be employed without hurting the brain ; for the force neceffary to pafs forward a fcrew is ineonfiderable; fo that unlefs where a portion of bone is entirely detach- ed from the reft of the cranium, a fcrew might fre. quently be inferted into the depreffed piece with little or no hazard of forcing it in upon the brain. If therefore the other objections that I have adduced to it were not material, the latter would not be of much importance. And as fome praaitioners may incline to have it in their power in particular inftances to ufe it, I have thus thought it right to give an account of it. I fhall now proceed to defcribe the praaice of mod. em furgeons in fraaures attended with depreffion of the skull, together with fuch improvements as the praaice may appear to admit of. 74 Affedions of the Brain Chap. X. The fraaured part of the bone being brought into view by the divifion of the teguments in the manner I have advifed, and the flow of blood being likewife ftopped, the exaa fituation of the depreffed part of the bone next requires attention. In fome cafes we find it entirely feparated from the reft of the skull: in others, it adheres at one or two points: whilft in fome, a fiffure or rent is difcovered, with one fide of the bone beat down below the plane or level of the other. When a portion of the skull is broken into feveral pieces, as they would never probably unite, either with one another, or with the furrounding bones, we are in general defired to remove them : but when only one piece of bone is depreffed, and efpecially if this adheres at a point or two to the contiguous bones, praaition- ers often attempt to replace it, in order, as they fay, to avoid that expofure of the brain which the removal of a large portion of the skull muft always occafion ; and they allege as a reafon for this, that in fome in- ftances it fucceeds, by the fraaured and depreffed piece uniting firmly with the contiguous bone. It is not, however the unexpeaed fuccefs attending the particular treatment of a few cafes by which we are to aa : it is the refult of general obfervation only by which our praaice fhould be determined. What- ever may have happened with a few, in their attempts to preferve detached portions of the skull, praaition- ers of obfervation will allow, that more advantage is in general to be derived from removing them at once. It univerfally happens, when one or more pieces of the fkull are either entirely or nearly feparated from the reft, that blood in a greater or fmaller quantity is effufed upon the furface of the brain, or on the dura mater, through the whole extent of the injury ; fo that, when a loofe portion of bone is allowed to re- main, neither this extravafated blood, nor the matter which afterwards forms, can find a free vent; while the piece that has thus been detached and replaced fel- dom or never unites to the furrounding bone ; by the Sea. III. from external Violence. 75 early removal of the detached portions of bone, every inconvenience arifing from this is prevented; a free vent is thus given to any blood that may be prefently elfufed, or to the matter which may form in future ; the ftate of the dura mater, and even of the brain it- felf, may be freely examined ; while inflammation and gangrene alfo, to which thefe parts are liable from fraaures of the skull, are thus more effeaually guard- ed againft than they could be by any other means. When the depreffion is formed by different fmall portions of bone, the whole of them may for the moft part be eafily taken out with common forceps ; and by removing thofe portions firft, that appear to be moft detached, the reft will thus be loofened, and therefore more eafily taken away. But it fometimes happens, even when feveral portions of bone are beat in, and very commonly when the depreffion is formed either of one piece entirely feparated, or of a portion of the skull forced in upon the brain without any of it being altogether detached, that the depreffed pieces cannot be either removed, or even raifed into a level with the reft of the skull, in any other manner than by making one or more perforations in the contiguous found bone, for the purpofe of introducing an instru- ment termed a levator, with a view to elevate the de- preifion. It is for this purpofe chiefly that the trepan is em- ployed : hence it is evident, that this operation can never be neceffary, when the depreffed pieces of bone can be removed in the manner I have mentioned ; for the fole intention of it is thus accomplifhed in a more fimple manner. . But when the depreffed portions of bone are fo firmly attached to each other, that they cannot be elevated but with the rifk of wounding the brain or its membranes, which in fraaures of the skull is very commonly the cafe, the trepan fhould without hefitation be employed, and the following is the me- thod of doing it, 76 Affedions of the Brain Chap. X. In books of forgery, thofe parts of the s'kull are commonly pointed out on which this operation may with fafety be performed ; and much pains has been taken to afcertain thofe that we ought to avoid. In practice, however, thefe limitations are feidom in our power to adopt, as the operation muft always be per- formed near to the depreffed portion of bone. But, as it appears from the anatomical defcription that I have given of the different parts that may be concern- ed in this operation, that it may not only be perform- ed with more fafety in fome parts than in others, but with more profpea of advantage, praaitioners fhould be fo far direaed by this, as to avoid, as far as can be done confiftently with the advantage of the patient, all thoSe parts from whence much risk might enfue from a perforation being made in them. The parts which with this view we fhouid avoid, are, almoft all the under part of the temporal and parietal bones; all the under part of the occipital bone ; the inferior part of the frontal bone ; and the whole courfe of the longitudinal Sinus. The internal Surface of the greater part of the two firft oS theSe bones are furrowed with the large arteries of the dura mater ; a confiderable part of the occipital bone is not only very unequal, but various finufes lie immediately under it; the fron- tal finufes lie in the inferior part of the frontal bone ; and although we know that wounds of the longitudi- nal Sinus do not always prove fatal, yet as it tranfmits a large quantity of blood, we fhould at all times en- deavour to avoid it: but when the depreffed pieces of bone are fo fituated as to render it impoSfible to raife them without applying the trepan over theSe parts, as the patient would in all probability die if the depref- fion was not renv ved, the trepan fhould be employed without delay. We are not wantonly and unnecefla- rily to perforate the skull where parts are fituated which it might prove hazardous to wound ; but when the life of a patient depends upon this operation, no praaitioner, it i« hoped, will ever decline it, when if h poffible to perform it. Sea. III. from external Violence. 77 Of all fihe fituations I have mentioned, the moft in- convenient for the application of the trepan,, is, the back part of the head upon the occipital bone, and tlie frontal finufes immediately above the orbits. Be- neath the former, feveral large SinuSes are- diSperSed, and both the external and internal Surfaces of this bone are very unequal. And again, the two lamellae of the frontal bone are feparated fo far from each oth- er by the frontal finufes, and the internal furface of the bone at this part is fo very unequal, that no prac- titioner would make choice of it for the application! of the trepan. But cafes fometimes occur, in which it is neceffary to apply the trepan in both of thefe fituations., Wherever a fraaure or any other caufe of compreffed brain is. fo fituated that relief cannot be otherwife obtained, and where the patient muft oth- erwife die, no difficulty fhould deter us. The mufclesf of the occiput may be diffeaed off from the part where the trepan fhould be applied ; and with care and at- tention, a perforation may be made even through the frontal finufes. The instruments in common ufe for this operation are the following : a rafpatory for removing the peri- ofteu-m, reprefented in Plate VIIL fig. 3. A perfora- tor, Plate X.'fig. 5. The trephine itfelf, Plate VII. fig. 1. An inftrument termed a lenticular, Plate VIIL figure 2. Forceps, Plate VII. fig. 2 ; and an eleva- tor, reprefented in Plate XL figures 1, 2, 3, and 4. In proceeding to the operation, the patient Should be laid upon a table of a convenient height, with his head firmly Secured by affiftants : this being done, it is the common praaice to lay a confiderable part of the skull entirely bare round the part intended to be perforated. But this ought by no means to be done ; for although it is neceffary to remove as much of the pericranium as may admit of the head of the inftru- ment being applied as frequently as it can be needed, yet more Should never be removed : tedious exfoli- ations 0/ the denuded bone are apt to enfue from it; jS Affedions of the Brain Chap. X. by which the cure is not only retarded, but much more hazard induced. We are, therefore, either with a fcalpel, or the ras- patory, Plate VIIL fig. 3. t*> feparate and remove juft as much of the pericranium as will admit of the tre- pan being freely applied, and no more ; and the part at which this fhould be done, ought to be exaaiy at that point where the greateft refiftance Seems to be to the elevation of the depreffed piece of bone. With the view alfo of deriving every advantage from the perforation, it ought to be fo formed as to include not only the fraaure or fiffure, but if poffible a Small por- tion oS the depreffed piece. The weight and preifure of the inftrument during the operation, ought no doubt to reft chiefly on the found undepreffed bone, as much injury might be done' to the brain, by mak- ing it prefs much upon the depreffed portion of bone : but it very commonly happens, that a fmall fegment of the opening may be made with perfoa fafety upon the depreffed bone; and as the advantages that refult from this in the Subsequent Steps of the operation, are confiderable, it ought in every inftance to be done. The pericranium being removed, a Small hole fhould be made in the undepreffed bone, with the per- forator, Plate X. fig. 5, care being taken, as I have already obServed, to have it So near to the fraaure, that the head oS the trepan may include a portion of the depreffed piece. As foon as the hole is fufficient- ly large for receiving the point of the pin in the cen- tre of the circular faw, it ought to be inferted into it, by which the faw is firmly preServed in one place, till Several turns being made with it, an impreflion of a fufficient depth is formed in the bone for retaining it, when the pin fhould be removed: for by projecting paft the edge of the faw, it might injure the mem- branes of the brain before the perforation is finifhed ; and .as the folc purpofe of the pin is to fix the inflru- ment during the firft part of the operation, it becomes Sea. III. from external Violence. 79, unneceffary as foon as a cut is formed in the bone Sufficient for retaining it. The furgeon Should now proceed to finifh the per- foration by preffing on the^inftrument with moderate and equal firmneSs ; for if more preffure is applied to one fide than another, the divifion of the bone will be completed at unequal periods, which ought to be carefully guarded againft. If the trephine is employ- ed, all the force neceffary for turning it is applied by one hand of the operator 5 the faw is made to cut by forming only a half circle or Scarcely fo much ; and the perforation is finifhed by moving the faw back- ward and forward, till the whole thicknefs of the bone is divided: but in ufing the trepan, the Surgeon ap- plies the preffure upon the head of the inflrument with one hand, while he turns the handle with the other. Some operators indeed make the preffure with their Sorehead or chin; but it is both more eafily and more equally applied with one hand. With the tre- pan the Saw is made to move always in the Same di- reaion, by which it cuts more eafily, and performs the operation in a third part of the time required with the trephine. When one perforation is fufficient, this is not indeed an objea of much importance; but as feveral perforations are not unfrequently neceffary, and as the operation becomes thereby tedious, both to the operator and the patient, that method of operating ought certainly to be preferred, which renders the means of cure more eafy, provided it is equally fafe. Now, it is obvious that,the trepan is wrought with more eafe than the trephine; and whoever has feen the operation done with both instruments, will confefs that it likewife does it with equal fafety: for in the hands of thofe accuftomed to ufe it, there is no more risk of wounding the brain, by paffing too fuddenly in upon ir with this inftrument, than with the tre- phine. If the furgeon is cautious, there is no hazard of this with either of them; while, if not fufficiently attentive, the trephine will produce as much mifchief to Affedions of the Brain Chap. X. as the other. Befides, in ufing the trephme, the head of the patient is apt to be much jolted by the unequal motion of the inftrument, by which much uneafinefs is produced in the mean time, while it alSo Serves to promote that tendency to inflammation in the mem- kranes of the brain, that is apt in every inftance to occur from a portion of the Skull being forced in up-* on them. Some praaitioners, very fenfible of thefe advanta- ges of the trepan, but dreading the rifk of its paffing too fuddenly in upon the brain, commence the opera* tion with this inftrument, and finifh it with the tre-* phine :* this is far preferable to the ufual method of performing the operation entirely with the trephine; but thofe who have fully experienced the advantages* of the trepan, will employ it for the whole operation. But whichever of thefe inftruments are employed, the operator fhould proceed with great SlaadineSs, and with as equal a degree of preffure as poffible till the perforation is finifhed. For this purpofe, the inftru- ment mould be frequently taken out, and the depth of the cut examined by introducing the point of a probe or fharp pointed quill in the form of a tooth- pick : if the perforation has to go deeper in one part than in others, care fhould be taken to alter the pref- fure fo as to carry on the cut of an equal depth to the laft. At each removal of the inftrument, while the Sur* geon endeavours to diScover the depth of the cut, and to clear it of blood and particles of bone, an affiftant mould have the charge of cleanfing the Saw with a f fmall brufh; or, there may be two inftruments with ' the Saws exaaiy of the Same fize, So that while one is employed by the Surgeon, an affiftant may be clean- Big the other. * This', I believe, was firft fu£gefted by our prefent celebrated Profcflbf of-Anatomy, Dr. Monro, to whole ingenuity, fur^ay, in many poiuts of importance, i» much indebted; Sea. III. from external Violence. Bi When the inftrument has reached the diploe, atten- tion to the frequent cleanfing of the faw becomes more efpecially neceffary, as the blood difcharged from this part of the bone, and from the fpongy can- celli of which it is made, if not often removed, tends considerably to obftrua the operation : but we Should not expea always to meet with the diploe ; for it is wanting in fome parts of the skull, and becomes lefs in every inftance by age. The general direaion, therefore, given for performing the firft part oS this operation freely and Speedily till the diploe appears, cannot with Safety be admitted: every flep of it fhould be done, as I have faid, with fleadinefs ; but with fuch caution, as to prevent every chance of the brain or its membranes being injured by the inftrument being pufhed forcibly in upon them. But if caution is neceffary in the firft part of the operation, it afterwards becomes much more fo: fo that in proportion to the progrefs of the faw, it fhould be more frequently removed ; and as foon as the point of a probe, or fharp quill, can pafs entirely through at any part of the cut, the preffure fhould be removed from this point, and equally applied over the remain- ing uncut part of the bone. By proceeding in this cautious manner, the bone foon becomes loofe in dif- ferent points; and on this being difcovered, it mav either be taken out with the forceps reprefented in Plate VII. fig. 2, or the points of two levators being infinuated into the bottom of the cut formed by the faw, one on each fide of the piece to be removed, it may in this manner be eafily and fafely taken away. I here think it neceffary to remark, that praaition- ers are apt to be too anxious about the total fepara- tion of the piece of bone with the faw, before any at- tempt is made to remove it, from a fear of injuring the dura mater, if any fplinter is left: that this may be avoided, they proceed with the faw till the bone is entirely feparated ; and in order to bring it out with Vol. II. G 82 Affedions of the Brain Chap. X* the laft application of the inftrument, the head of the faw, till lately, has always been of a conical form, by which the piece of bone is very commonly taken out along with it. But, however plaufible thefe reafons may appear, the praaice ought not to be adopted ; for it rarely or never happens, that the piece of bone taken out by the trepan is of an equal thicknefs in every part; fo that if the faw is made to divide one fide of it long af- ter the other is cut, the dura mater immediately un- der the part that was firft divided would be hurt by the teeth of the inftrument, notwithstanding all the caution that could be employed: of this I have feen fuch a number of inftances, even in the hands of ex- pert furgeons, that I have no hesitation in advifing the practice to be avoided. In various caSes, indeed, where the operation has been SuppoSed to be very properly performed, the mark of the faw has, after death, been evidently difcovered on the dura mater over the whole circle of the perforation. Inftead of proceeding with the faw, therefore, till the piece of bone is entirely feparated, it is always fafer to force it out in the manner I have mentioned as foon as it is difcovered to be loofe at different points ; and even where fome fmall fragments or Splinters of bone are left, no difadvantage enfues, as they are eafily remov- ed with the common forceps, without hurting the dura mater.* * As the pra&ice of taking out the circular piece of the fkull entirely with the trepan, always appeared to me to be hazardous, I decidedly faid fo in the firft editions of this work. The fame remark has probably occur- red to others, and Dr. Monro, I find, has long taken notice of it in his clafs. With a view to prevent the brain from being injured, after the trepan has pafled through one part of the fkull, while the operator is employed in cutting the reft, it has been propofed by Dr. Douglas, a phyfician of eminence in Kelfo, to have one of the heads of the trepan exactly the fize of the others, but with teeth only on one fide, by which the operation may be finiflied with more fafety than in the manner in which it is usu- ally done. Sea. III. from external Violence. 83 In addition to what I have faid of the form of the faw, I may remark, that the cylindrical fhape is in every refpea preferable to the conical, which in fome parts of Europe is ftill retained. I have already ob- ferved, that it is not by the form of the inftrument that the dura mater and brain are to be avoided, but by proceeding through every Step of the operation with due caution; and while the conical faw is not neceffary for removing the piece of bone newly divid- ed, it does not penetrate the bone with the fame eafe as a cylindrical faw, neither is the piece which it takes out fo large, unlefs the fize of the inftrument is much larger than any that has yet been employed. This circumftance, of the fize of the opening made by the trepan, is an objea of much importance, and therefore merits particular attention. For, as the in<- tention of perforating the fkull, is to relieve the brain from a ftate of compreffion, produced either by de- preffion of the fkull, or extravafation of blood or fome other fluid; as this is much more effeaually done by a large than a fmall opening ; and as the pain and hazard of the operation are the fame in both, a large opening Should always be preferred. The perforation made by the trepan Should never in an adult be lefs than an inch in diameter. The piece of bone being removed, if any fplinters or points are found to remain, they may be taken out with forceps, or with the lenticular, but the latter is Seldom neceffary : this being done, we proceed to the main objea of the operation, and endeavour to raife the.depreffed portion of bone. If the elevation of the depreffed bone has been pre- vented, merely by being firmly wedged at one point; and if the trepan has been made to include this point, as it ought always to do, the whole piece, as it is thus entirely or nearly feparated from the reft of the Skull, may be now eafily removed with the forceps ; or if it ftill adheres firmly at other parts, the trepan muft be c 2 84 Affedions of the Brain Chap. X. again applied at each of thefe before any attempt is made to remove it. But when the depreffed portion of bone is not fo much feparated from the reft as to admit of being eafily taken out, our next objea is to raife it into a level with the reft of the fkull. "With this view, the point of a levator fhould be introduced at the opening newly made, and being pufhed in. be- low the edge of the depreffed bone, if it be not firmly wedged, in, it may be eafily raifed by moderate pref- fure on the other end of the levator. But when the depreffed piece is either of confiderable extent, or gives much refiftance at one or more points, before any attempt is made with the levator, the trepan fhould be applied again wherever, it may appear to be neceffary ; and by a proper ufe of the levator at thefe different openings, it will then be eafily raifed. The levator in common ufe, is not the inftrument that I wifh to recommend : for being made to reft on the oppofite fide of the perforation, all the preffure employed for elevating the depreffion falls on the con- tiguous parts of the fkull, by which much violence is often done to it; and as the fame intention may be accomplished in an eafier manner, the other fhould be avoided. By fixing the levator on a pin, fupported by a fmall frame upon two feet, and this frame being placed at a proper distance from the woundj the pref- fure which it makes, falls on a found part of the fkull, by which no harm can be done by it, while, from its fimplicity of conftruaion, it is eafily applied, and reat dily moved from one part of the head to another. The inftrument to which I allude is nearly the fame with the levator of the celebrated Mr. Petit of Paris, and it is reprefented in Plate XL fig. 3. As the great objea of this operation is to remove the depreffed portion of fkull, together with every other caufe of compreffion that is met with, I have taken different opportunities of pointing out the necef- fity of this being kept always in view. For if any portion of bone is overlooked, and fhould be allowed Sea. III. from external Violence. 85 to continue to prefs upon the brain, little or no bene- fit would enfue from the reft oS the operation ; the patient would continue in nearly the Same degree of hazard ; and after death, the operator would be high- ly mortified to find, that with further attention, the life of his patient might probably have been faved. At the fame time that care is thus taken to elevate the depreffed pieces of bone, the removal of any blood or ferum from the furface of the dura mater, is equal- ly neceffary ; and if any Sharp pointed inftrument, pieces of Stone, or other extraneous bodies, have been any where forced in upon the brain, I need fcarcely obferve, that thefe muft likewife be removed ; and this being done, the fore fhould be immediately dreffed, and the patient laid to reft. We meet with much variety in the direaions given both by ancient and modern praaitioners for the dreff- ing of fores after this operation. With a view to pre- serve the dura mater and brain from mortification, va- rious antifeptic applications have been recommended, and doffils or fyndons covered with ointments are de- fired to be introduced, not merely into the perSoration formed by the faw, but to be preffed as far as poffible in between the Skull and dura mater. The impropri- ety, however, of this, muft at once appear obvious from the flighteft attention to the effeas of it. The fole objea of the operation is to remove compreffion from the brain ; now the dreffings that I have men- tioned, namely, doffils of lint crammed into the dif- ferent perforations, muft evidently counteraa this, not only by the preffure which they produce, but by ferv- ing to prevent that free difcharge of matter after the operation, upon which the fafety of the patient in a great meafure depends. Inftead of this, the dreffings fhould be of the mildeft kind, and as loofely applied as poffible. Dry lint is commonly employed ; but it excites leSs irritation, and is more eafily removed, when thinly Spread with a fimple liniment of wax and oil; and no detriment enfues, as fome have imagined, $6 Affedions of the Brain Chap. X. from the application of unauous fubftances to the brain. No tent or doffil, as I have juft obServed, fhould be inferted into the perforation ; all that is ne- ceffary is to apply as lightly as poffible over the fore, a pledget of foft lint fpread with an ointment fuch as I have mentioned ; and this being covered with a thin cufhion of foft tow, the whole fhould be retained with a common nightcap, made fo as to tie below the chin, to be either pinned or tied of a proper tightnefs, on the fore or back part of the head. This fupports the dreffings with Sufficient SirmneSs; and it neither keeps the head too tight, nor prevents a Sree flow of matter from the fore, an inconvenience very apt to occur from the ufe of thofe bandages commonly employed after this operation. The patient, on being removed to bed, fhould have his head placed in fuch a manner as to prevent the fore from being hurt; while his pofition ought alfo to be fuch as will moft effeaually tend to difcharge any matter that the fore itfelf may afford, or any blood or ferum that may ooze from the furface of the dura mater. When the fymptoms under which the patient has laboured have arifen entirely from a depreffed portion of bone, and when this depreffion has been complete- ly removed, we commonly find that immediate relief is derived from the operation*. From being perfoaiy torpid, with a deep laborious breathing, and a confid- erable dilatation of the pupils, the patient becomes lefs ftupid and lethargic. He begins to tofs about in bed ; to raife his eyelids ; and to make fome feeble attempts to fpeak: his breathing becomes lefs oppreffed, and the pupils contraa when expofed to a ftrong light. But although all thefe favourable circumftances do not appear immediately after the operation, we are not to defpair of fuccefs ; for when the brain has been long compreffed, it does not always recover its func- tions immediately on the, caufe being removed by which the compreffion was produced: and, befides, Sea. III. from external Violence. 87 it often happens, that together with a fraaure and depreffion of the fkull, the brain has received a violent fhock or concuffion ; in which cafe, as the fymptoms do not depend entirely on the compreffed ftate of the brain, fo it is reafonable to fuppofe, that other means muft be neceffary for their removal, after every caufe is taken away by which compreffion could be produc- ed : with the aid of thefe, which hereafter we fhall have occafion to confider, the moft alarming Symp- toms are frequently removed at laft, which refift Sor a confiderable time the moft powerful remedies we can employ. ^ A furgeon ought not therefore to imagine that all his bufinefs is over when the operation is finifhed ; for this may be done in the moft complete manner, and yet the patient will certainly die unleSs other means are employed for his relief: when the Symp- toms Sor which the trepan was applied, become leSs violent on the depreffion of the fkull being removed, and if the patient in the courfe of a few hours becomes ftill more relieved, there will be much caufe to hope that he will recover without any other remedy being employed ; and that quietners, keeping an open belly, and avoiding every caufe of inflammation, will at laft prove fufficient for the cure : but when the reverfe of this takes place, when the fymptoms remain equally formidable after the operation as they were before, and efpecially if they do not become more moderate in the courfe of a few hours after the patient is laid to reft j remedies of a different kind become neceffary. As the fymptoms which in fuch circumftances are moft to be dreaded, originate from two different caufes, and as the choice of remedies to be employed for its removal fhould depend entirely on its' real nature, it ought in every inftance to be afcertained with as" much accuracy as poffible. The caufes to which 1 allude, are, inflammation of the membranes of the brain, and concuffion of the brain itfelf. 88 Affedions of the Brain Chap. X. In general, the fymptoms which prevail here, are all fufpeaed to proceed from the fame caufe; they are fuppofed to be entirely of the fame kind, and the fame fet of remedies are therefore commonly employ- ed in the cure. The impropriety of this, however, is obvious : for although it often happens, that the fymp- toms are of a mixed nature, and depend fo much on a concurrence of both the caufes I have mentioned, that they cannot be rightly diflinguifhed, yet in vari- ous inftances it is otherwife; and when an evident diftinaion is perceived, much advantage will accrue, from praaitioners direaing their attention towards it. After all the evident caufes of compreffion are re- moved, if the pulfe is flow and foft, if the patient re- mains torpid, and efpecially if the pupils do not con- traa on expofure to a ftrong light, there will be much caufe to fufpea that commotion or concuffion of the fubftance of the brain has taken place : for although all of thefe fymptoms are 'occasionally induced by a compreffed State of the brain, yet we know that they are likewife the frequent confequences of concuffion : So that, when all the depreffed bone and other obvious cauSes of compreffion are removed, we conclude with much probability, that any fymptoms which remain, when they are fuch as I have mentioned, depend more upon concuffion than on any other caufe. But when, inftead of thefe fymptoms, there is, along with fome return of fenfibility, as is indicated by the patient's becoming unmanageable, and often moving from one part of the bed to another ; if the pulfe is firm, full and quick; if the eye is found to be inflam- ed, and efpecially if the pupil is obferved to contraa more than ufual, and the patient to withdraw his head on the eye being expofed to much light; there will be much caufe to fufpea that inflammation of the membranes of the brain has taken place. Indeed the dura mater, like every other membrane, is fo fufcepti- ble of inflammation, that it is difficult to imagine how any part of the fkull can be beat in upon it, without Sea. III. from external Violence. 89 irritating and inflaming it in a remarkable degree; and if once inflammation is induced upon part of this membrane, we know from experience that it readily and quickly extends over the whole of it; a circum- ftance that eafily accounts for the high degree of in- flammation, which is often obferved in the eyes, as likewife for the contraaion of the pupils, and fevere degree of pain which expofure of the eyes in this fit- uation to much light never fails to produce. When the fymptoms proceed from inflammation alone, the pulfe, as I have obferved above, differs ma- terially from the pulfe of a perfon fuffering merely from concuffion of the brain. In a ftate of concuf- fion, the pulfe is full, flow, and foft; but when in- flammation takes place, the pulfe, although frequent- ly full, has a firmer ftroke, and is commonly quick and hard : and in this cafe the breathing, although not oppreffed and laborious as it frequently is when the brain is compreffed, is always more frequent than natural; a circumftance not commonly obferved in patients labouring under the effeas of concuffion. Although, Sor the reaSons that I have given, it may often be difficult or even impoffible to mark the ex- iftence of thefe different fets of fymptoms, yet an at- tentive obferver will frequently be able to distinguish them ; and whenever it can be done, much advantage may be derived from it. Praaitioners of every age have advifed in injuries done to the head, to difcharge a good deal of blood; and there is reafon to think that no general rule had ever a better foundation : but from attentive obferva- tion of the effeas of bloodletting, I have caufe to im- agine that furgeons of modern times frequently carry it too far. Where the membranes of the brain are re- ally inflamed, the propriety of discharging much blood is obvious, and will not be difputed ; but whenever there is reafon from the nature of the fymptoms to imagine that they proceed from concuflior, bloodlet- ting, if recommended at all, Should be pra&ifed with much caution. go Affedions of the Brain Chap. X. Although the general ftruaure of the brain with refpea to its figure, fize, and other circumftances, has long been well known ; yet it muft be confeffed, that our anatomical knowledge of this organ is ftill very deficient, nor have we the moft diftant idea of the manner in which it performs its various funaions. Indeed our knowledge of this part of anatomy is fo very lame, that we are frequently perfoaiy unable to difcover, by the moft minute diffeaion, any difference between the brain in its foundeft ftate, and that ftate of it in a peribn evidently killed by a fall or blow up- on the head, and in whom all the fymptoms induced by the accident were fuch as indicated an afteaion of the brain alone. This is particularly the eafe in thofe who die from what is termed concuflion or commotion of the brain. In fuch inftances the brain we fuppofe to be fomehow or other deranged ; but it moft fre- quently happens, that the moft accurate diffeaion can- not difcover the nature of this derangement, nor in what it confifts. From this it is obvious, that the effea of concuf- fion of the brain is not an excitement of inflammation ; for every flage of inflammation becomes obvious to diffeaion, and can Scarcely indeed efcape notice. Now, as it often happens in thofe whom we fuppofe to have died from concuflion, that no appearance of inflammation in any part of the brain is difcovered, it is not unfair to conclude, that the effe&s of thefe two caufes, inflammation and concuflion, are diftina, and perhaps very oppofite in their nature and effeas. From the circumftances I have mentioned of the effe£ts obferved upon diffeaion to arife from thefe caufes, and of the fymptoms induced by the one be- ing different from thofe which arife from the other, the conclufion I have formed with refpea to their dif- ference, mijrht even upon thefe grounds be fuppofed to be well founded : but it is not on Speculation alone, that I wifh to reft either this or any other opinion of praaical importance. The idea was firft Suggefted by Sea. III. from external Violence. 91 the different effeas which I had obferved to proceed from bloodletting in affeaions of the brain produced by external violence. In many, great advantages en- Sued from it, while no benefit was procured from any other remedy : but in others, inftead of benefit being derived from it, the patients became obvioufly worfe after every repetition of the operation. The pulfe, from being full, gradually became weaker; and the ftrength of the patient commonly finking in the fame proportion, he Seldom recovered from the effeas of bloodletting, whenever it was praaiSed to any confid- erable extent. From theSe circumftances I have been led to think, that concuffion of the brain operates upon the Syftem, in nearly the Same manner with Syncope induced by fear, inanition, or any fimilar caufe, in the treatment of which, bloodletting is known to prove hurtful. In what manner a blow upon the head or a fall from a height, in a full habit of body, and in a perfon oth- erwife in perfea health, who only a few minutes be- fore could have fupported the lofs of much blood, Should be able inftantly to induce fuch a ftate of the< fyftem as cannot admit of this evacuation, I will not pretend to fay : but that it frequently happens, I am now from repeated obfervations entirely convinced ; and whoever pays due attention to this branch of his profeffion, will find that it is fo. He will find, indeed, that all fuch fymptoms as arife from inflammation, are more effeaually relieved by bloodletting than any oth- er remedy : but he will for certain obferve, that all of thofe which do not depend upon this caufe, and which arife folely from concuffion, inftead of being relieved by this remedy, will be uniformly rendered more ob- ftinate and more alarming, in proportion to the quan- tity of blood that is taken away. So far, however, as my experience goes, the evacu- ation produced by purgatives never proves fo debilitat- ing as to render them improper : and as they have frequently an influence'in relieving the head, they 92 Affedions tf the Brain Chap. X. fhould never be omitted, and fhould always be pre- ferred in fuch doles, and thefe as frequently repeated, as the ftrength of the patient will permit; but they fhould never be carried fo far as to run any rifk of in- ducing debility and languor. In the following feaions, I fhall have occaGon to enter on a more particular confideration of the fymp- toms induced by inflammation of the membranes of the brain, and by concuflion of the brain itfelf; but thefe general remarks upon the fubjea, appeared to be neceffary here, with a view to explain the nature of our practice in the treatment of thofe fymptoms which proceed from either of thefe caufes, when con- neaed with a compreffed ftate of the brain, and when accordingly, the operation of the trepan is not found to afford fuch complete relief as it otherwife would do. Poftponing, therefore, a particular detail of the remedies to be ufed in cafes of inflammation and con- cuffion of the brain, I fhall now fhortly remark, that whenever the, operation of the trepan fails in relieving the fymptoms for which it is employed, as this gives reafon to believe that they proceed from one or other of thefe caufes, we ought in the moft particular man- ner to difcriminate between them. When inflamma- tion is found to have taken place, bloodletting, both general and local, becomes requifite,, together with fmart purgatives, mild fudorifics, and a Stria atten- tion to an antiphlogistic regimen : but when the Symp- toms appear to ariSe from concuffion, the only evacu- ation that can with propriety be advifed is gentle purging; for fn this cafe, as I have already remark- ed, and as I fhall afterwards endeavour irore particu- larly to fhew, bloodletting, inftead of proving ufeful, very constantly does harm. -gl In both fituations, as well as in every other requir- ing the trepan, the patient fhould be kept perfoaiy quiet ; little or no light fhould be admitted to his apartment •, any food he is able to take Should be of Sea. III. from external Violence. 93 the mildeft kind, and plenty of whey or any other diluent drink fhould be allowed. In the mean time, the ftate of the wound requires particular attention ;. for after the operation of the trepan, the membranes of the brain are not only liar ble to inflame, but to become gangrenous. In wounds of other parts of the body, we know that nothing fo certainly prevents inflammation and gangrene, as a free fuppuration being induced upon the injured parts ^ and whoever will profecute this practice in wounds of the head, will find, that although from the nature of the parts that have fuffered, it may not prove equally ufeful, that it will,, however, anfwer better than any other that has as yet been employed. With this view, warm emollient poultices and fo- mentations Should be applied over the dreffings, and renewed every two or three hours ; which foon tenda to promote a plentiful flow of matter from the perfo- rations in the Skull, by which the tenfion is foon re- moved, at the fame time that the other Symptoms are rendered leSs violent. At every dreffing, the matter refting in the perfo- rations Should be removed with a piece of foft fponge or lint, and thereafter the fore fhould be fpeedily cov- ered with a pledget of any mild; ointment. When the cure goes properly on, granulations foon? appear upon the dura mater as well as on the reft o£ the wound ; and thefe continuing to advance, the dif- ferent openings made by the trepan are at laft com- pletely filled up, and the whole being brought to a-. level with the reft of the teguments, a cicatrix is there- after obtained by the fame means that prove fuccefs- ful in other parts of the body, and of which I have „ already given a detail.* Thefe granulations however, which in general arife from the dura mater only, and not from the brain it- felf, as has commonly been fuppofed, inftead of mere- • Vide Chapter IV. 94 Affedions of the Brain Chap. X. ly filling up the openings in the bone, in fome cafes pufh out beyond the furface of the teguments, fo as to form diftina pendulous tumors. Thefe tumors or excrefcences, when they become large, prove fometimes troublefome, and various means have been propofed for their removal. Being com- monly confidered as produaions, of the brain itfelf, much caution has prevailed in remedies that have been employed for them. Compreffion is moft frequently advifed. In fome inftances they are kept down with efcharotics, and in others with ftrong cauftic. Some have propofed to remove them with ligatures, and others by excifion. Of all thefe modes of treatment, that by compref- fion is moft to be dreaded, and ought certainly to be exploded : for whether the tumors arife from the brain or dura mater, preffure cannot be applied to them without affeaing the brain; and we common- ly find, that even the flighteft degree of it induces headach, ficknefs, and in fome inftances convulfions. It ought not therefore in any cafe to be advifed. Thefe tumors are of various degrees of fenfibility. In Some, they are painSul, and cannot bear to be touched ; whilft in others they are almoft deftitute of fenfibility. In this laft cafe, the moft effeaual treat- ment is to touch them daily with lunar cauftic, or cal- cined alum, and when the tumor hangs by a fmall neck, it may with fafety be removed with a ligature. We feldom, however, find it neceffary to employ any of thefe means; for in general the tumors begin to diminifh as foon as the foft granulations in the per- forations of the fkull begin to acquire a firmer con- fiftence ; and by the time the offifying procefs of this fubftance is completed, they commonly drop off fole- ly by the preffure which this never fails to produce. We fhould not, therefore, in any cafe, proceed quick- ly to remove them ; but when they do not fall off on the different perforations being filled with bone, as the conneaion between, them and the brain is then in Sea. III. from external Violence. 95 a great meafure cut off, they may accordingly be re- moved with more Safety, either by excifion, cauftic, or ligatures. The cure being thus far complete, if the method that I advifed was adopted, of faving all the fkin and other teguments, a narrow cicatrix only will remain, and the parts will be nearly as firm as they were be- fore : but when much of the fkin and mufcles have been deftroyed, as theSe parts are never renewed, the bone will be leSt covered by a thin cuticle only, with perhaps a very Small proportion of intermediate cellu- lar fubftance; in which cafe a piece of tin or lead, lined with flannel, fhould be fitted to the part, with a view to protea it from the effeas of cold and exter- nal injuries. When the fymptoms arifing from injuries done to the head, proceed entirely from a depreffed portion of bone aaing as a caufe of compreffion upon the brain; if this can be removed, a due perfeverance in the plan of management that I have propofed, will in general anfwer. I muft, however, allow, that they do not end in this favourable way fo frequently as we could wiSh: for, along with the depreffion of the Skull, we often meet with fymptoms, as I have obferv- ed above, either arifing from concuffion, inflamma- tion, or gangrene ; circumftances at all times attend- ed with uncertainty, and commonly with much haz* ard. We now proceed to confider the other general caufe of compreffion of the brain, namely, extravafa- tion. 5 2. Of Compreffion of the Brain from Extravafation. By whatever caufe the brain may be compreffed, the fymptoms that enfue are nearly the fame ; and as thefe have already been minutely confidered, it will not be neceffary to enumerate them again. I Shall only obferve, that all the fymptoms arifing from a 96 Affedions of the Brain Chap. X. compreffed ftate of the brain, are induced with equal certainty, and attended with as much hazard, from effufions of blood, ferum, or pus, as from the moft- extenfive depreffions of bone. Thofe fymptoms in- deed that occur from extravafation are more to be dreaded than depreffions of great extent; for when a depreffed portion of bone is large, the feat of the in- jury is for the moft part eafily known, and by proper means may often be removed ; but where extravafa- tion takes place, our means of ascertaining the feat of the injury are more uncertain, fo that the effeas of our remedies are lefs to be trufted. When indeed the brain is compreffed by a complication of thefe two caufes, a depreffed portion of bone, and extravafation' of blood or ferum, the feat of the one is readily dif- covered by that of the other; but when compreffion is formed by extravafation alone, it is always difficult, and often impoffible, to difcover the feat of it. A complication of thefe two caufes is by no means uncommon ; for extravafation of blood or ferum is a frequent effea of fraaures or depreffion ; but we like- wife meet with inftances of both being effufed" on the furface of the brain, without any injury being done to the bone. In compreffion of the brain from extravafation, we have the fame objea in view, with that which a de- preffed portion of the fkull renders neceffary : having endeavoured to afcertain the feat of the injury, we are to make one or more perforations, in order to dif- charge the extravafated fluid, and this being done, we are to guard againft any effeas which the operation might produce upon the brain and its membranes. lit fometimes happens, that the part in which the colleaion is feated, is pointed out by the mark of a blow or bruife ; and on the bone being laid bare, a fiffure will in fome inftances t* found in it, while in others no other injury is difcovered, farther than a feparation of the pericranium from the furface of the bone. Sea. ill. from external Violence. 97 When any of thefe circumftances, however, take place, we fhould confider the Seat of the injury to be So far afcertained as to have no hefkation in fixing upon this Spot for applying the trepan; but, in fome cafes, no external mark of injury is difcovered : even after the whole head is fhaved, and minutely examin- ed, the Skin will in various inftances be found perfea- ly found, without any appearance either of tumor or difcoloration. Hitherto it has been held as an eftablifhed maxim, never to apply the trepan in coiripreffion of the brain from external violence where there is no external mark to point out the feat of the injury, the refult of the operation being in fuch cafes always uncertain: but as compreffion of the brain, if not removed, muft foon terminate in death, and as it cannot be removed in any other way than by perforating the fkull, in fuch circumftances, to leave any thing undone which would give even the Smalleft chance of faving the patient, fhews a degree of indifference not in any other in- ftance met with in the forgery of modern times. It is with truth indeed faid, when no external injury takes, place, that there is always much uncertainty of any perforation we can make being to fall upon the fpot where the caufe of compreffion takes place; that as the fymptoms induced by concuffion, are often highly fimilar to thofe arifing Srom compreffion, much dubiety muft occur from our not being able to fay with precifion, whether the fymptoms depend upon one cauSe or the other; and it muft be confeffed, i even where the fymptoms have previoufly been fup- poSed to ariSe Srom compreffion, that in- many inftan- ces no veftige has appeared on diffeaion, either of de- preffion of the fkull, or of effufion of blood or ferum. All this I fhall admit; but to what does it amount ? why, to no more than this: that where a patient is ■evidently in much danger, and is to die if means are not employed for his relief, wherever there is much Vol. IL H 98 Affedions of the Brain Chap. X. uncertainty in the effeas of thefe means, that it will be better not to advife them, but rather to leave the patient to his fate ! As long as the ftate of a perfon in this fituation affords caufe to hope that he may re- cover by other means, it would no doubt be improper to employ the trepan ; or if much additional rifk was to be incurred by the operation, no praaitioner of charaaer would advife it with fo little probability of any advantage being to arife from it. But as a patient labouring under the fympfoms I have defcribed, cannot be relieved by any other means, and in fuch defperate circumftances as no additional hazard can be incurred from an operation, we ought certainly, in juftice to the patient, to his friends, and to our own reputation, to advife it. The chance re- fulting from it, will not indeed be great; but being the only means from whence fafety can refult, by em- ploying it lives may be faved which otherwife would be loft ; and iS a prognofis Sufficiently guarded is giv- en, no juft blame could fall either upon the operator, or on the art. If the friends of the patient fhould be told of the hazard he is in; that he may, however, have fome fmall chance of recovering, if the trepan is applied ; even under this doubtful prognofis, they would in a great proportion of cafes wifh to have it done ; and however unfuccefsful it might prove, and although no extravafation, or other caufe of a com- preffed brain, fhould be met with, a prognofis of this kind would in every inftance fcreen the operator from blame: and having thus done all that could afford any chance of his recovering, the friends of the pa- tient, as well as the furgeon himfelf, would furely have more caufe to be fatisfied than if no attempt had been made for preferving him. I Shall therefore fuppofe that the trepan is to be ap- plied for the removal of fymptoms arifing from a com- preffed ftate of the brain; but where no external mark indicates the particular feat of the injury, it may be afked in what manner are we to proceed ? As the Sea. III. from external Violence. 99 caufe of compreffion may exift juft as readily in one part as another, it may Seem to be a matter oS little importance in what part of the head the firft perfora- tion is made. This, however, is far from being the cafe : for, as we are fuppofing the compreffion to be induced by blood or ferum, and as thefe, while in a fluid ftate, are always paffing as much towards the ba- fis oS the brain, as the intimate conneaion between the dura mater and the internal Surface of the fkull will permit; it will be proper to form the firft perfo- ration in the moft inSerior part oS the cranium in which it can with any propriety be made, and to proceed to perforate every acceffible part of the fkull, till the caufe of compreffion is difcovered. For this purpoSe there is no neceffity, as I have already obferved, to re- move any part of the integuments : wherever we mean to perforate the bone, if an incifion is made through the fkin, mufcles, and pericranium, they will retract fufficiently for admitting the inftrument; and this being all that is neceffary, more fhould not be done. If we are at laft fo fortunate as to meet either with blood or ferum, much care fhould be taken to difcharge it; for which purpofe, as blood, when co- agulated, frequently adheres to the dura mater, inftead of one perforation, two, three, or more fhould be ad- vifed, fo as to admit of all the extravafated blood be- ing removed. But in fuch circumftances the operator fhould like- wife recollea that the blood, inftead of being effufed on the furface of the dura mater, may be colleaed within the cavity of that membrane ; or it may even be contained within the pia mater, in immediate con- taa with the brain. For which reafon the ftate of the dura mater Should be examined with attention, after every perforation. If it is found to be of its natural colour, and not more tenfe than it ought to be, noth- ing farther Should be done ; but if very tenfe and elaf- tic, and efpecially if it has that dark or livid appear- Ii 2 too Affedions of the Brain Chap. X. ance which indicates the probability of blood being colleaed beneath, it ought undoubtedly to be opened, in order to difcharge it. The beft and eafteft mode of doing this, is to fcratch a fmall hole by repeated Strokes with a lancet: this being done, and the point of a pair of curved fciffars being introduced beneath the dura mater, the opening may thus be enlarged to the full extent of the perforation in the bone; or if one cut acrofs the perforation is not fufficient for dis- charging the blood beneath, a crucial incifion may be made, and, if neceffary, the corners thus produced may be cut oiL Although I would not recommend the divifion of the dura mater, where not neceffary for the fafety of the patient; yet, in every inftance where the opera- tion of the trepan is advifable, if, on perforating the bone, there is reafon to fufpea that a fluid is colleaed either between this membrane and the pia mater, or even below the pia mater itfelf, as the intention of the operation would not otherwife be fulfilled, the collec- tion, of whatever it may confift, ought immediately to be discharged : in Such circumftances, unleSs .we go this length, we in faa do nothing : for the dura ma- ter is fo thick and ftrong, that any blood or matter colleaed between it and the brain, would more readi- ly fpread inwards, than burft out through the differ- ent layers of this membrane. To this praaice it has been objeaed, that few have recovered where it has been carried into effea; that there is a rifk of fatal hemorrhagies being induced by it; and that the brain is apt to protrude at the perfo- ration inthe bone, after it has loft the fupport of its Surrounding membranes. That few have recovered by this means, I will al. low: but this does not proceed fo much from the opening made in the dura mater, or from this part of the operation being particularly hazardous of itfelf; but, from the caufe for which it is employed being productive of fuch danger as puts it out of the power Sea. III. from external Violence. 101 of art, either by this or any other means, to obviat© the fatal effeas of it. With refpea to hemorrhagies being apt to enfue from this praaice; although I have feen the dura ma- ter opened in feveral inftances by others, and have different times done it mySelf, I never knew an inftance of its doing harm, not even when any of the finufes have by accident been laid open; and although the brain will no doubt protrude more readily when the dura mater is divided, than it otherwife might do, yet this we know is a frequent occurrence in every wound where much of the cranium is removed, and that con- fiderable portions of the brain have been even dif- charged by wounds, without any material harm being done by it. The refult, therefore, of all that can be faid upon this point, is, that where the intention of the opera- tion is fully anfwered by perforating the cranium ; where any portion of bone that has been depreffed is thus completely removed; or where any preffure pro- duced upon the brain is found to proceed from blood or ferum on the furface of the dura mater ; as in any of thefe cafes the caufe of danger can be removed without penetrating this membrane, it ought not by any means to be done : but whenever the bad fymp- toms which have prevailed are not relieved by the perforation of the bone ; or by the removal of an ef- fufed fluid that may be met with on the dura mater ; and when from the appearance of this membrane there is caufe to fufpea that a fluid is colleaed beneath } it ought undoubtedly to be opened. Even although the inconveniencies refulting from it were greater than they have ever been, when the life of a patient ap- pears to depend on it, fomething ought to be hazard- ed : but we have feen the rifk attending this part of the operation is of little importance ; fo that I would confider any praaitioner as culpable who would ad- vife it to be omitted, when a patient in thefe circum- ftances has not been relieved by the previous fteps of the operation. 102 Affedions of the Brain Chap. X. In this fituation our views fhould be exaaiy fuch as ought to direa us in the treatment of abfceffes in other parts of the body. When a patient is fuftering with matter colleaed in a particular part, no furgeon of experience will be deterred from going to the full depth of the colleaion merely from finding that it is more thickly covered than he had reafon to expea before the fkin and cellular fubftance were divided. He will proceed more Slowly and with much caution; but he will at laft reach the feat of the matter with as much certainty as if it had been more fuperficially fituated. In like manner, when there is caufe to imagine, that matter is colleaed beneath the membranes of the brain, an incifion fhould for certain be made through them. No additional rifk can be incurred from it: fome few may be faved by it ; and at any rate, it muft always afford fatisfaaion, not only to the friends of the patient, but to the praaitioner himfelf, to know that nothing has been omitted from whence any ad- vantage could be derived. It will often indeed happen, that neither this, nor any other effort of art, will obviate the danger of the patient. But when the principles upon which an operation is founded are evidently juft, and when, on mature deliberation, it appears, that a patient may be faved by it, and that he cannot efcape by any other means, is is not the frequency of its fuccefs alone by which we are to be direaed : the danger induced by the caufe for which it is employed is the objea to be kept in view ; and every praaitioner who aas folely for the good of his patient, will at all times employ fuch means as- are beft calculated for the removal of this danger, without paying attention to any other confideration. If it were the objea of furgeons to operate only where certain fuccefs would enfue, many lives would be loft that otherwife are faved ; and in that cafe the praaice I thus wifh to inculcate, of ap- plying the trepan in injuries done to the brain, where Sea. IV. from external Violence. 103 no external mark of direaion exifts, would no doubt be inadmiffible: but as the SaSety of thofe intrufted to us ought to be our firft and great objea, and pro- feffional fame only a fecondary confideration, when- ever we are certain that death muft enSue, if not pre- vented by the timely application of a proper remedy, although there may be no great certainty of this re- medy proving fuccefsful, yet if it is the only means from whence there is a chance of fafety, it ought un- doubtedly to be employed. It is on this principle folely that I have advifed the praaice of perforating the fkull in different places, when, in a compreffed ftate of the brain, the part chiefly affeaed is not pointed out by fome external mark of injury : and al- though the opinion I have thus ventured to give is not agreeable to general praaice, yet as this praaice has ancient cuftom only for its Support, being in every other refpea apparently ill Sounded, the advantages which may accrue Srom a different mode of treatment will only require, as there is reafon to hope, to be thus fully pointed out, in order to procure it a favourable reception. Having fully adverted already to the after treat- ment of cafes in which the trepan has been applied for the removal of a depreffed portion of the fkull, it will not be neceffary to enter upon the fubjea again; for whatever the caufe may be for which the opera- tion is praaifed, the cure of the remaining fore ought to be conduaed in the fame manner* SECTION IV. Of Concuffion or Commotion of the Brain. EVERY affeaion of the head attended with flupe- faaion, when it appears as the immediate con- fequence oS external violence, and when no mark of 104 Affedions of the Brain Chap. X. injury is discovered, is in general fuppoSed to proceed from commotion or concuffion of the brain; by which is meant Such a derangement oS this organ as obftruas its natural and ufual funaions, without producing fuch obvious effeas on it, as to render it capable of having its real nature afcertained by diffeaion. Almoft all the fymptoms commonly produced by a compreffed ftate of the brain, as enumerated in the laft feaion, are in fome inftances met with from con- cuffion : but thofe which moft frequently arife from it are, flupefaaion; torpor to a greater or leffer de- gree ; a flow, Soft pulSe; and a dilated ftate of the pupils, even on the eyes being expofed to light. As it is not always eafy, however, to determine from the fymptoms, what particular affoaion of the head may have taken place, I fhall endeavour to mark, as far as can be done, a diftinaion between-concuffion and in- flammation, as well as between concuffion and com- preffion of the b*!Srrf ~Tt is an objea of much impor- tance, and therefore requires our moft Serious attention. It is Seldom difficult, as we have feen in the laft Sec- tion, to diftinguifh between the fymptoms which pro- ceed from inflammation, and thofe that arife from con- cuffion. Such as proceed from concuffion alone, commence immediately on the injury being done ; in violent degrees of them, the patient remains totally infenfible: the pupils are much dilated, and do not contraa even when the eyes are expoSed to the Strong- est light; and the pulSe, although Sometimes full, is not hard nor ftrong, and it always becomes weaker on blood being taken away. Thofe fymptoms again which originate from in- flammation, Seldom appear till Several days aSter the accident: by the description to be more particularly given of them in the following feaion, it will appear, that they are materially different from thofe which proceed either from a compreffed ftate of the brain or from concuffion. The pupils are not dilated ; nay the eyes, excepting in the mpre advanced ftages of Sect. IV. from external Violence. 105 the difeafe, are very fenfible to the impreffion of light; and the pulfe is firm and hard from the SirSt, and does not become weaker on moderate evacuations of blood. By thefe marks of diftinaion, as well as others, which an attentive praaitioner will commonly notice, little uncertainty can prevail in determining whether Symptoms proceed from concuffion or inflammation; fo that with refpea to this point we may foon deter- mine on the praaice to be purfued. And again, we can eafily distinguish between fymptoms arifing from flight degrees of concuflion, and thofe which proceed from compreffion. Thus, when a perion is knocked down by a blow upon the head, and quickly recovers from the more alarming effeas of it, but remains for a confiderable time giddy; with flight pains in differ- ent part? of his head ; with tinnitus aurium, weaknefs of fight; fome degree of imbecility, and lofs of me- mory ; if no other fymptoms occur, and efpecially if he is able to walk about, as frequently happens even in high degrees of thefe fymptoms ; we conclude from experience in fimilar cafes, that they all proceed from commotion or concuffion, and not from compreffion of the brain ; for the fymptoms which proceed from compreffion are of a more permanent nature, and uni- formly continue till the caufe which produced them is removed. But where the fymptoms are important from the beginning, and efpecially when the patient h altogeth- er infenfible,4f no external mark of injury takes plate, it is always difficult to determine whether they depend upon concuflion or depreffion. Indeed inftances often occur, in which Symptoms SuppoSed to originate from concuffion, have after death been found to proceed from extravafation, or perhaps from a fraaure attend- ed with depreffion of the fkull which had not been previously difcovered. And again, fymptoms have often been fufpeaed to arife from extravafanon, when on diiTiairn, no veftige either of this or any other morbid appearance could be traced. io6 Affedions of the Brain Chap. X. So far as my obfervation goes, the moft material difference between the fymptoms arifing from thefe two caufes, concufficn and compreffion of the brain, is met with in the pulfe and breathing. In a com- preffed ftate of the brain, the breathing is commonly deep and oppreffed, fimilar to what takes place in ap- oplexy ; whereas, in patients labouring under the ef- feas of concuffion, the breathing is in general free and eafy, and the patient lies as if he was in a found and natural Sleep. The pulfe is commonly foft and equal, and not irregular and flow, as it ufually is when the brain is compreffed. In a compreffed ftate oS the brain, although little or perhaps no relief may be ob- tained from bloodletting, yet no harm is obferved to enfue from it; fo that in moderate quantities, it does not reduce either the frequency or ftrength of the pulfe : whereas in concuffion of the brain, the pulfe, as I have already remarked, will frequently fink, and become much more feeble on the lofs of only eight or ten ounces of blood. In doubtful cafes, therefore, a quantity of blood fhould be immediately difcharged : if the pulfe, upon fix or eight ounces being taken away, is found to be ftronger and fuller than before ; if the blood is found to be fizy ; and efpecially if the patient becomes more fenfible ; we may conclude with much probability, that the Symptoms depend either upon extravafation ; upon Some part of the fkull being depreffed ; or upon Some degree of inflammation : and as long as the pulfe remains firm, and any advantages are gained by it, we may with fafety proceed to difcharge more blood. But when the pu fe, upon a few ounces of blood being taken, becomes feeble, efpecially if the patient becomes weak and languid, as almoft always is the cafe when the fymptoms proceed from concuffion, as the nature of the cafe is thus rendered in fome meafure certain, any farther difcharge fhould be immediately prevented. Sea. IV. from external Violence. 107 I have already endeavoured to fhow, that concuffion of the brain appears to operate by inducing debility of the whole fyftem ; our remedies, therefore, inftead of tending to increafe this, as bloodletting very certainly does, fhould be fuch as give additional vigour. With this intention, in fimilar circumftances arifing from other caufes, we would advife not only the inter- nal ufe of cordials, but the outward application of ftimulants ; and as fymptoms of debility in the cafe we are now considering, are as Strongly marked as in any diSeaSe whatever, I am clearly of opinion, that cor- dials, and even ftimulants, are equally neceffary in the method of cure. Many praaitioners have acknowledged, that al- though they have by general cuftom been induced to take blood freely in all injuries done to the head, that in various inftances no benefit has been derived Srom it, and in Some that it has even done harm. Having met with many inftances of this, in which all evacua- tions of blood funk the ftrength of the patient, in an alarming manner ; and finding indeed, unlefs where the fymptoms arofe clearly from inflammation, that few, if any, recovered, when the praaice of difcharg- ing much blood was carried far, I was induced in the firft place to fee what would refult from no evacuation of blood being advifed, and trufted chiefly to laxatives, and a gentle moifture being kept upon the fkin. On finding that no bad effeas enfued from it, and, even that more patients recovered than had commonly done from bloodletting, I was thereby induced to carry the praaice farther. Upon this principle, cordials were given internally : ftimulants, particularly blisters, were applied external- ly, in the fame manner as is ufually dene, in debility proceeding from any other caufe ; and hitherto the effeas that refult from it have been fuch as fufficient- ly warrant a continuance of the praaice. 111 every cafe, therefore, where concuffion of the brain appears to be the caufe of the fymptoms, the 108 Affedions of the Brain Chap. X. praaice I would recommend is, to exhibit in a grad- ual manner fuch quantities of warm wine as would ap- pear to be proper for the fame fymptoms of debility induced by any other caufe : as patients in fuch circum- ftances are apt to become cold, they fhould be kept warm by proper coverings : a blifter fhould be appli- ed over all that part of the head of which the fkin has not been injured ; finapifms fhould be applied to the feet; and although ftrong purgatives would be im- proper, by tending to reduce the ftrength of the pa- tient, yet gentle laxatives prove always ufeful, and fhould be regularly given, when the ftate of the bow- els requires them. As wine is a cordial upon which we can place more dependence than on any other with which we are ac- quainted, it ought in this, as in every cafe where cor- dials are required, to be preferred. But although with due pains, by opening the patient's mouth, and putting it in with a fpoon, it may in almoft every caSe ' be exhibited ; yet occasionally we meet with inftan- ces in which it cannot be Swallowed in Sufficient quan- tity : in this cafe the volatile alkali, ardent fpirits, and other cordials of a more aaive kind, fhould be given* In concuffions of the brain, Mr. Bromefield has recommended the ufe of opiates ; a circumftance which tends much to corroborate the opinion I have endeavoured to eftabliSh of the nature of this affec- tion ; for few medicines aa with more certainty as cordials than opium : when conjoined with antimoni- als, I have frequently found it prove ufeful; but al- though I have upon fuch refpeaable authority em- ployed opium by itfelf, I have not hitherto found it anlwer fo well as wine. This, however, may proceed, either from my not having puShed the ufe of it fo far as I ought to have done; or from the few cafes in which I have employed it having been fuch as would not have done well whatever remedy might have been ufed. I muft, therefore, have farther experience of Sea. IV. from external Violence. 109 its effeas before venturing to fpeak of it with more decision. Iffues are commonly advifed here; but as more ad- vantage I believe is to be derived from the ftimulat- ing powers of blifters, than from any difcharge which they produce, inftead of preferving a bliftered part open, with iffue ointment, as is ufually done, I would prefer a repeated and frequent renewal of blifters on different parts oS the head and neck. In this manner, any advantage to be derived from them as drains, will be equally certain as from iffues ; and by applying one blifter on another being nearly healed, almoft a conflant Stimulus will be kept up. In the progreSs of the cure, we fometimes derive advantage from a liberal ufe of bark and fteel mineral waters. Gentle emetics have Kkewife proved ufeful; and when much languor, inaaivity, and lofs of me- mory, have continued more permanent than ufual, ekaricity has been employed with advantage. It muft, however, be remembered, that, in recom- mending this praaice, it is exprefsly for the "removal of fymptoms that arife from concuflion, and that do not depend either upon a compreffed ftate of the brain or on inflammation; a circumftance which may in general be fo far afccrtained as to render it obvious whether fuch a courfe is proper or not, merely by the effeas that are obferved to refult from bloodletting. Attentive obfervation of other circumftances might in .fome inftances enable us to decide upon this point, without the neceffity of having recourfe to this means of diftinaion; but where there is fuch room for un- certainty as frequently prevails here, and where the life of a patient is to depend on the praaice to be purfued, nothing ought to be omitted that can tend to eftabliSh an accurate knowledge of his fituation. In fuch circumftances, therefore, there is no room to hefitate ; So that where much doubt and uncertainty take place, as much blood Should be difcharged as may tend to determine the nature of the cafe. no Affedions of the Brain Chap. X. This is the praaice I would always advife for the removal of fymptoms arifing Solely from concuffion : and accordingly, I have not thought it neceffary to mention the ufe of the trepan ; for although it is very univerfally advifed, yet unlefs where fymptoms take place of a compreffed ftate of the brain, no good rea- fon can be affigned Sor it. But in caSes of doubt and uncertainty, and efpecially where a patient remains comatofe and infenfible, the trepan ought by all means to be employed ; Sor as in theSe circumftances it could not add to the danger; and as it affords the only chance of fafety in fymptoms arifing from compref- fion, praaitioners would be highly blamable were they not to advife it; and as the hazard of the pa- tient muft here be imminent, perforations fhould be made in every acceffible part of the fkull as long as the caufe remains undifcovered. We now proceed to confider more particularly the effeas of inflammation upon the brain. SECTION V. Of Inflammation of the Membranes of the Brain from external Violence. INFLAMMATION in every part of the body de- mands particular attention, more efpecially in or- gans of importance; for its effeas being in general violent and rapid, if not quickly removed they com- monly end in more permanent diftrefs : if this is the cafe in parts of lefs importance, it is more particular- ly fo in inflammation of the membranes of the brain. Inflammation of the brain and of its membranes is apt to produce all the Symptoms that commonly oc- cur in inflammatory affeaions of other parts, while at the fame time it excites a fet of fymptoms in fome de- gree peculiar to itfelf. By whatever caufe infiamma- Sea. V. from external Violence. i11 tion of the brain or of its membranes may be induc- ed, the fymptoms do not appear immediately; feldom indeed till feveral days after the injury, and often not till two, three, or more weeks, have elapfed; a cir- cumftance, I muft again obferve, that Serves with more certainty than any other to diftinguifh inflam- mation of thefe parts from every other afteaion to which they are liable: for, while the fymptoms of in- flammation approach by flow degrees, the effeas of concuffion fucceed inftantly to the injury by which they are produced ; and this is alfo the cafe with thofe fymptoms that proceed from a depreffed portion of bone, or from extravafation of blood or ferum. At fome uncertain interval, of two or three days, in fome cafes of as many weeks, and in a few instan- ces of two or three months, from the date of the in- jury, the patient begins to feel an univerfal uneafineSs over his head, attended with liftleffneSs and Some de- gree of pain in the part that was hurt, but of which perhaps he has not till now had any caufe to com- plain. The liftleffnefs becomes more remarkable ; the pa- tient appearsdull and Stupid, and the pain becomes more Severe in the injured part; while in other parts of the head a SenSation of fulnefs takes place as if the brain. was girded or compreffed: the patient complains of giddinefs, naufea and retching. He finds himfelf hot and uneafy; his Sleep is disturbed, and he is not re- freshed either with what he enjoys naturally, or by what is procured with opiates. The pulfe is firm, or rather hard and quick, as it almoft always is indeed in inflammatory affeaions of membranous parts : the face is commonly flufhed; the eyes are from the be- ginning Somewhat inflamed, and expofure to light creates a good deal of pain. Where the fymptoms are accompanied with a wound of any part of the head, this flufhing of the face and inflammation of the eyes are apt to be attended with and feem to depend upon an eryfipelatous affcaioa 111 Affedions of the Brain Chap. X. proceeding from the fore : in which cafe the edges of the wound firft become hard and tumefied ; and the fwelling, which appears to originate in the aponeuro- tic expanfion of -the mufcles of the head, fpreads quickly over the whole of it, efpecially towards the eyelids, which often become Swelled to fuch a degree as to fhut the eyes .entirely. This fwelling is fome- what foft, and receives with eafe any preffure that is made on it: it is painful to the touch, and the Skin over the whole of it has an eryfipelatous degree of rednefs. This diffufed fwelling, however, although formida- ble in appearance to thofe who are not verfant in this branch of praaice, does not in general prove fo dan- gerous, as that puffy circumfcribed tumor to which the parts that received the blow are more efpecially liable; for this erysipelatous fwelling, which extends over almoft the whole head, proceeds moft frequent- ly not from any thing bad within the Skull, but mere- ly from the external wound in the tendons or muf- cles : in which cafe all the fymptoms that take place, very commonly vanifh by the effea of thofe means which ufually anfwer beft in eryfipelas in other parts. In a few inftances, however, this Symptom appears to arife from an affoaion of the dura mater; in which cafe its tendency is always of the moft dangerous nature, and therefore requires our moft ferious at- tention. Soon after thefe fymptoms have taken place, the part which received the blow begins to affume fome appearances of difeafe. If the bone has been laid bare, it is now obferved to lofe its natural healthv com- plexion : it becomes pale, white, and dry, either over its whole furface, or in particular fpot? which by.de- grees extend over the whole; and the edges of the fore, from the firft commencement of the fvmptoms, become hard, dry, Swelled, and painful : but when the bone has not been denuded, ar.cl when none of the Softer parts have been divided, but merely contuf- SeS:. V. from external Violence. "3 ed, they now begin to Swell, become puffy, Somewhat painful to the touch, and if the head is Shaved, the fkin is obferved to be of a more deep red than in the reft of the head : if, in thefe circumftances, the Swell- ed part is now laid open, the pericranium will in all probability be found detached from the fkull: a fmall quantity of a thin, bloody, and fomewhat fetid ichor will be found between this membrane and the bone; and the bone itfelf will he difcoloured in nearly the fame manner as if it had been laid bare from the be- ginning. With proper affiftance, all thefe Symptoms are for the moft part foon carried off; but when either neg- leaed from the beginning, or when not quickly re- moved, they very constantly become worSe. The pulSe ftill continues quick and hard; the patient becomes more and more reftleSs ; and in Some inftances, deli- rium takes place. His fkin is in general hot, but at times he is Seized with fhiverings, which gradually be- come not only more Severe, but more Srequent, and at laft they are commonly Succeeded by coma or Stu- por. About this period all theSe Symptoms either become fo much milder as not to be diflincTly obServed, or they are altogether loft in thoSe that enSue. Paralyfis oS one fide is not unfrequent; the pupils become di- lated, and are fcarcely affoaed by the impreffion of light; the urine and fasces are paffed involuntarily ; fubfultus tendinum and other convulsive Symptoms take place; and, iS the patient is not Speedily relieved, death very quickly enSues. TheSe are the moft Srequent Symptoms arifing from inflammation of the membranes of the brain. Others are met with in particular inftances ; but thofe that I have narrated are the moft frequent, and they ferve to mark the prefence of the difeafe with fufficient preci- sion. Vol. II. I 114 Affedions of the Brain Chap. X. In this enumeration, attentive obfervation will read- ily diftinguifh two Sets of fymptoms; each of which is conneaed with and clearly points out a particular ftate or flage of the difeafe. The one I would name the inflammatory ftate, and the other the Suppurative or purulent ftate. In the treatment of thefe fymptoms, it is of much importance to attend to this diftinaion. It ought to ferve indeed as the bafis of our praaice, in fo far as the remedies to be ufed in the one flage of them are improper or even inadmiffible in the other. During the prevalence of inflammation, we rely chiefly on the effeas of bloodletting ; but we ought to abftain from it, when the diSeaSe has advanced to Suppuration* In this ftate the operation of the trepan can alone give relief; while during the continuance of inflammation, it is not only uSeleSs, but might even do harm. I fhall hereafter, however, have occafion to Speak more particularly of this. External violence may induce inflammation of the brain and its membranes in three different ways; by depreffed portions of the Skull irritating the dura ma- ter ; by cohtufion ; and by fimple fiffures or Sraaures oS the fkull not attended with depreffion. The firft of thefe we have already confidered, and I fhall now pro- ceed to treat feparately of the other two. § i. 0/" Ccniuflon of the Head* It is not thofe flight contufions which affea the teguments of the head only that we are now to con- sider : it is fuch only as in their cortfequences prove formidable by communicating inflammation to the membranes of the brain that it is here neceffary to mention. A contufion oS the head may be produced in the Same manner with contufions of other parts ; by falls, blows, and by Stones or other iniffile weapons thrown from a diftance. It may be attended with wounds of Sea. V. from external Violence. 115 the Skin and other teguments; or the fkin, as moft frequently happens, may be left entire. The moft Srequent effea of thofe blows upon the head that afterwards end in danger, is inftantly to de»- pi ive the perfon of his fenfes, who complains, on his beginning to recover from this, of fome degree of gid- dinefs, which continues for a longer or fhorter period, according to the degree of violence which the brain 4ias fuffered. In a gradual manner, however, the pa- tient recovers fo as commonly to be nearly well after a night's fleep ; and unlefs a wound has been produce ed along with the contufion, he feldom or never com- plains of the part on which the injury fell, till feveral days after the accident. The time that intervenes between a blow being giv- en and the commencement of the after fymptoms is very uncertain : thefe fymptoms all originate from in- flammation, and this again makes a flow or rapid pro- grefs according to the violence of the caufe, and habit of body of the patient. Hence, in fome cafes, the in- flammatory fymptoms appear in the courfe of a day or two ; whilft, in others, the patient continues per- feaiy well for feveral weeks, and at laft is Seized with pain and inflammation of the part that was firft hurt, and from which alone all the train of bad Symptoms proceed that I have mentioned : nayj inftances have occurred of caSes of this kind ending fatally, in which no appearance of any thing morbid was obferved on the part that received the blow, till the eightieth, nine- tieth, or even till the hundredth day from the acci- dent. Hence* it is evident, that much danger may arife from injuries done to the head, which do not at firft exhibit any fufpicious appearance : a circumftance that points out the propriety of paying the moft accurate attention to every violence which it receives. In the treatment of contufions of the head, the in- dications to be kept in view are, 1 2. 116 Affedions of the Brain Chap. X. i. To employ the moft effeaual means for prevent- ing inflammation. 2. When thefe do not fucceed, we fhould endeav- our to keep the fymptoms moderate, and to prevent the formation of matter. 3. When this proves to be impraaicable, and when Suppuration takes place, a free' vent fhould be procur- ed for the matter : and, 4. When the injured parts are attacked with gan- grene, the moft effeaual means fhould be immediate- ly employed for putting a ftop to it. With refpea to the firft indication, I may remark, that in flight contufions of the head we feldom have it in our power to employ any prophylaaic or preven- tative means. Patients commonly recover fpeedily from the immediate effeas of contufions, and, till the after fymptoms commence, they feldom complain of any thing but a flight forenefs in the injured fpot. Praaitioners are not often informed therefore of the accident till it is too late ; and when they are, the pa- tient will feldom fubmit to any courfe that might prove ufeful. But when this can be done, the means we fhould advife are, bloodletting, both general and local, to a confiderable extent; the ufe of laxatives, to pre- ferve an open ftate of the bowels; the application of a ftrong Solution of ceruffa acetata to the part affea- ed ; a low diet, and total abstinence Srom every kind of fatigue. Saturnine and other cold applications are fometimes employed with advantage even where the brain and its membranes appear to be hurt, but they prove chief- ly ufeful, where the injury is confined to the external parts of the head. By thefe remedies, the effeas of many injuries done to the head might be prevented : but praaitioners, as I have remarked above, are feldom called till the bad fymptoms have commenced ; the particular treatment oS which we are now to confider. Sea. V. from external Violence. 117 In every inftance, we fhould endeavour, as quickly as poffible, to carry off the inflammation; the moft effeaual remedies for which are, bloodletting, purga- tives, mild fudorifics, and opiates, along with local ap- plications to the injured part. In common praaice, the blood is, in fuch circum- ftances, taken indiscriminately from any part of the body: but by many of our older writers, and even by fome of the moderns, we are told, that blood taken from the feet proves more effeaual than the fame quantity taken from any other part. This, however, is an idea built upon the erroneous doarine of derivation and revulfion, which is now very generally exploded. Inftead of which, we find, that in every cafe of inflammation, any blood that we difcharge proves moft ufeful when taken from the in- jured fpot. We tjarticularly obferve, in injuries done to the head, that much advantage enfues from the blood that is difcharged from veffels divided in the cq> eration of Scalping, or that of laying the fkull bare; a circumftance which Strongly indicates the propriety of local bloodletting in all affections of this land. On this principle, when a fufficient quantity of blood can be got by the application of leeches, or by cupping and fcarifying near to the injured part, this mode of difcharging it fhould be preferred: bwt when this cannot be done, we may always Succeed by fcarifying the parts with a lancet or fcalpel; a prac- tice from which I have in different inftances derived much advantage, and which 1 therefore wifh, in the ftrongeft manner, to recommend. When the fkull is already laid bare by the injury, or when the fcalp has been divided in order to difcharge any matter collea- ed beneath, there can be no neceffity for thefe Scarifi- cations ; hut when the teguments remain entire, or are only flightly hurt, and are attacked in a particular part with inflammation, fcarcely any remedy anfwers fo well as fcarifications, which, in order to prove ufe- ful, ought to be freely carried into the parts beneath, n8 Affedions of the Brain Chap. X." with a view to divide the largeft arteries that can be reached. In this manner, any neceffary quantity of blood may be taken, and it proves always more cer- tainly ufefiii than any other mode of difcharging it. When this operation however is not agreed to by the patient, or when general bloodletting may be judged more advifable, it anfwers beft to open the ju- gular vein or temporal artery. With reSpea to the quantity of blood to be difcharged, this muft always depend on the violence of the fymptoms and ftrength of the patient: but in circumftances fuch as we are confidering, as the patient's recovery or death is pro- bably to depend on what is done in a very fhort fpace of time, bloodletting, as being the remedy on which our hopes ought chiefly to be founded, fhould be pufhed immediately to as great a length as with fafety can be done. Inftead of taking eight or ten ounces, and repeating the operation, as is ufually done, I al- ways think it right, as I have juft obferved, to be de^ termined by the ftrength of the patient, and to draw blood as long as the pulfe continues firm. While this continues to be the cafe, no danger occurs from the evacuation; and in all cafes of violent inflamma- tion, it anfwers the purpofe with moft certainty, to take twenty or twenty-five ounces of blood at once, than to abftraa even a larger quantity by repeated operations. In the courfe of a few hours, again, if the Symptoms ftill continue Severe, and if the pulSe re- mains Sufficiently full, it may be proper to difcharge an additional quantity ; but this likewife fhould be determined by the effeas that refult from it. Together with a plentiful evacuation of blood, the bowels fhould be freely emptied, by brifk purgatives when thefe can be exhibited ; or when they cannot be taken in fufficient quantities, flimulating glyfters fliould be given inftead of them. In all affeaions of the head, it is an objea of importance to preferve an open ftate of the bowels, particularly where inflam- mation has attacked the brain : it is not, however, an sea. v. from external Violence. 119 open ftate of the bowels merely that proves ufeful. In order to receive much benefit from the praaice, a finart purging Should be kept up, with repeated dofes of calomel, jalap, fenna, or fome of the neutral falts. As it is found in every cafe of inflammation, that advantage is derived from the fkin being kept foft, it ought always to be advifed in an inflamed ftate of the brain. Perforation may, for the molt part, be indu-, ced by warm fomentations applied to the feet and legs, and laying the patient in blankets inftead of lin- en ; but when means of this more fimple kind do not anSwer the purpoSe, more powerful fudorifics muft be employed. In a great proportion of cafes, the common effer- vefeing draughts anfwer fufficiently well, particularly when a few drops of antimonial wine are added to each dofe : the calx antimonii nitrata, which appears to be the fame with Dr. James's celebrated powders, is fometimes ufed with advantage ; but nothing aas with fuch certainty as a combination of opium and antimony, or opium and ipecacuanha, as we have it in the form of Dovar's powder. This laft is recommended by a late celebrated prac- titioner of London, Mr. Bromfield ; * and I know from frequent experience, that the other proves often highly beneficial, and that it aas with entire fafety. In fevere degrees of pain, large dofes of opium be- come neceffary. A general prejudice has till of late indeed prevailed againft the uSe oS opiates in all caSes oS inflammation, particularly in inflammation of the brain ; but this feems to have arifen more from an erroneous idea of the proximate caufe of inflamma- tion, and of the modus operandi of opiates, than from aaual obfervation of the effeas which they produce. By exciting fome degree of heat, and in fome inftan- ces increasing the fulnefs of pulfe, it has been fuppof- * Vide Chirurgical Obfervations and Cafct, by William Brqmfield, p. 12, vol. i. 120 Affedions of the Brain Chap. X. ed that they muft always do harm in inflammation ; but I can from much experience of their effeas after t, that thefe fears are groundlefs, and even in inflamma- tion of the brain, that very important advantages of- ten refult from them. By leffening the pain, and re- moving that reftleSs ftate oS anxiety that commonly prevails, they frequently prove more uSeSul than any other remedy. TheSe are the means on which we chiefly rely; but fome attention is likewife neceffary to the local treat- ment of the injured parts, from which more advan- tage I think may be derived than is commonly ima- gined. Inftances often occur of inflammation in other parts of the body being relieved by drains or iffues ; and on the fame principle I have long been in the habit of advifing drains in inflammatory affeaions of the head. With a view to this, when the teguments are divid- ed, whatever the extent of the cut may be, as the lips of the fore are apt to become hard, dry, and painful, thofe applications fhould be advifed which anfwer beft in promoting the formation of matter: the fore fhould be covered with pledgets of lint fpread with any emol- lient ointment, and warm emollient poultices fhould be laid over the whole. In this manner, and particu- larly by a frequent renewal of poultices, a plentiful difcharge of matter is commonly induced ; which foon leffens the pain, and removes the hardnefs of the injured parts, by which all the other fymptoms foon become moderate. Where again the teguments are not divided, as foon as there is caufe to fufpea, from the parts that were injured becoming pained and Swelled at the diftance of Several days perhaps from the accident, that bad fymptoms may Supervene, the tumor fhould be imme- diately laid open, by dividing the fkin and teguments down to the pericranium; and if that membrane is found to be feparated and raifed from the bone, it ought alfo to be laid open : by this means any mat- Sea. V. from external Violence. 121 ter that is confined, and which otherwife might have done harm, will be difcharged ; and by inducing a Suppuration upon the Sore, in the manner I have men- tioned, all the Symptoms will be kept moderate. In the treatment oS theSe tumors, they are Seldom opened till a ffoauation is diftinaiy perceived in them. In this, however, I think we are wrong ; for the mat- ter that tumors of this kind contains is conftantly thin and acrid; fo that to confine it in contaa with the Skull, muft not only render the bone liable to become carious, but muft even incur fome hazard of making the inflammation fpread to the membranes of the brain : for, as an intimate conneaion takes place be- tween the veffels of the pericranium and dura mater ; and as it is evident in this kind of injury, where the external parts are firft hurt, that the dura mater be- comes inflamed only in conSequence oS its conneaion with theSe, I have long thought it probable* that the confinement of acrid matter beneath the pericranium, is to be confidered as the moft frequent caufe of the inflammation being communicated to the parts within the. Skull: I have accordingly been in the habit of difcharging it by a free incifion, as foon as the leaft tumefaction on the part affeaed is perceived > and evidently with much advantage* In all injuries indeed done to the head, in which the fymptoms do not commence till feveral days after the accident, as the inflammation does not originally at- tack either the brain or its membranes, for if it did fo, its effeas would be immediate, it is probable that it aas almoft folely by producing an effufion between the pericranium and Skull: and as we know that membranous parts feldom or never afford good pus, any effufion which takes place muft commonly be of a nature that will not readily become purulent, and will therefore be apt to acquire that kind of acrimony commonly met with in every extravafated fluid that cannot be converted into pus. 122 Affedions of the Brain Chap. X. Where the effufion is confiderable, an evident tu- mefaaion takes place from the beginning : but it of- ten happens, that it is fo fmall in quantity as Scarcely to produce any perceptible fwelling at firft ; in which cafe, as there is little or no tenfion, the patient feels little uneafinefs till the effufed fluid begins to turn acrid, which may happen fooner or later according to the violence of the injury, and habit of body of the patient, as well as other circumftances. But as foon as it becomes acrid, it excites pain, inflammation, and fwelling ; and as the pericranium and aponeurotic ex- pansions of the mufcles are very firm and ftrong, if this acrid matter be not foon difcharged by an inci- fion, it gradually insinuates between thofe parts of the pericranium and bone beneath that were not at firft affeaed: and as this extends the effeas of the injury, it not only tends to increafe the tumor of the integu- ments, but, by means of the vafcular conneaion that I have mentioned between the pericranium and dura mater, the inflammation is at laft conveyed to the parts within the fkull; and as foon as thefe inflame, but never till then, the bad fymptoms are fure to take place. It is therefore probable that the confinement of this acrid matter beneath the pericranium, muft have no Small effea in promoting the progrefs of the inflam- mation ; and hence, to difcharge it by an incifion is always advifable whenever there is caufe to fufpea, from the acceffion of pain and fome degree of tume- faaion as the confequences of external violence, that matter is colleaed even in the fmalleft quantity be- tween this membrane and the fkull. It muft be remarked, however, that I do not wifh to recommend this praaice in the treatment of tu- mors recently produced by external violence. It of- ten happens, that a tumor of a confiderable fize fuc- ceeds inftantly to a blow on any part of the head; but in general this foon difappears on the application of mild aftring'.-nts, fuch as Solutions of crude fal am- Sea. V. from external Violence. 123 moniac, white vitriol, or faccharum faturni: ardent fpirits make alfo a good application for thefe tumors, and they feldom fail to remove them. It would therefore be improper in all fuch cafes to lay the injured parts open ; a praaice, however, often adopted by thofe who are not verfant in this branch of bufinefs ; for, as this kind of tumor frequently af- fords, to manual examination, a fenfation fimilar to what is experienced from a depreffion of the Skull, young practitioners are very apt to be deceived with it, and to advife the fkull to be immediately laid bare. But no praaitioner of experience will ever be deceiv- ed with thefe appearances; nor will he ever proceed to lay the fkull bare, if more evident marks do not take place of its being injured, or of matter being ex- travafated beneath the Skull itfelf. But whenever a tumor attended with pain, appears at a diftant period upon the fpot on which a blow or a bruife was receiv- ed, as it feldom or never happens that fwellings of this kind are of a harmlefs nature, or that they can be difcuffed by external applications, they Should in every inftance be laid open as foon as they become perceptible. By doing fo, we can never do harm; while we always derive advantage from difcharging acrid matter, which in circumftances fuch as we are considering, is almoft always colleaed beneath the pe- ricranium. An incifion made for difcharging matter, muft ne- ceffarily go to the depth at which the matter is feated ; otherwife the purpofe for which it is meant will not be anfwered : and as in the circumftances now under confideration, it is almoft in every inftance colleaed beneath the pericranium, this membrane fhould always be Sreely divided. But in making Scarifications in the manner I have advifed above, for the purpofe of dif- charging blood, as they are fuppofed to be neceffary before any tumor has appeared, and not intended for the evacuation of matter, they need never be carried to fuch a depth. They fhould pafs indeed freely into 124 Affedions of the Brain Chap. X. the cellular membrane, otherwife the arteries of the part will not be fufficiently divided; but as no advan- tage could be derived in this ftate of the difeafe from dividing the pericranium, and as the bone might be hurt by it, it ought never to be advifed. The wound produced by the incifion, fhould be dreffed with any emollient ointment; and by the fre- quent renewal of warm poultices over the whole, a plentiful fuppuration will be induced, which, as I have already remarked, proves commonly very effeaual, not only for preventing, but removing all thofe bad fymptoms which inflammation of thefe parts is fore to induce. When, however, the inflammatory ftate of the brain does not yield to this treatment; when the fymptoms become more violent, and are fucceeded by paraiyfis, irregular convulsive motions, involuntary paffage of the faeces and urine, dilatation of the pupils, and in- fenfibility to the impreffion of light, along with a flow and full pulfe ; and more efpecially when thefe fymp- toms have been preceded by fits of rigor or Shivering; we conclude, that the fuppurative ftate of the difeafe has taken place; that matter is formed within the fkull, and operates by compreffing the brain. Shiv- ering fits take place on the formation of large abfceS- fes wherever they are Seated ; but in inflammatory af- feaions of the brain, they prove fo certainly charac- teristic of fuppuration, that no doubt can remain of matter having formed, whenever they are found to ac- company the other fymptoms that I have mentioned. The exiftence of matter within the cranium being afcertained, as we cannot depend on any other means for carrying it off, the trepan fhould be immediately advifed ; and as the fafety of the patient is to reft en- tirely on a free difcharge being given to the matter, it mould be applied with much freedom. In fuch cir- cumftances, indeed, it would be very culpable timidi- ty in any praaitioner to hefitate in forming as many perforations as are neceffary for J-iicharging the matter. Sea. V. from external Violence. 125 When, on perforating the fkull, no matter is met with, if the dura mater appears to be more tenfe than ufual, as this will give caufe to fufpea that the Symp- toms of fuppuration have arifen from matter colleaed between this membrane and the pia mater, or perhaps upon the brain itfelf, we ought not to' reft Satisfied with having merely perforated the bone: if in fuch circumftances we proceed no further, the matter will ftill remain confined ; the brain will be nearly as much compreffed as before; and of courfe no advantage will be derived from the operation. In this fituation, therefore, a praaitioner fhould not hefitate in dividing the membranes of the brain. But, for the method of effeaing this, as well as for fome further obfervations which relate to it, I muft refer to the fecond feaion of this chapter, where the fubjea has been fully confidered. When, again, it is found on perforating the fkull, that the dura mater has become floughy, with fome tendency to gangrene, the utmoft danger is to be dreaded : if mortification has commenced, death will foon probably terminate the fcene, although inftances have occasionally occurred of floughs forming upon the dura mater, and of cures being accomplifhed after thefe have feparated : all, however, that art fhould in fuch cafes attempt, is to preferve the fores clean ; to fee that any matter which may Sorm fhall be Sreely discharged ; to take care' that nothing but light eaSy dreffings Shall be employed ; and that Peruvian bark, conjoined with elixir of vitriol^ fhall be immediately given in as great quantities as the flomach will bear. If any tendency to inflammation ftill prevails, the diet fhould 'be low, with a plentiful allowance of whey and other diluents, and regular flools fhould be procured : but, when the fyftem is low and the pulfe feeble, wine fhould be exhibited as the moft effectual cordial. In other refpeas, the treatment fhould be fuch as proves moft beneficial in fimilar affections of other parts of the body; but as this has already been fully taken 126 Affedions of the Braid Chap. X. notice of in a preceding chapter, it is not neceffary to enter upon it again.* Before leaving the fubjea that we are now consid- ering, I think it right to notice a praaice that has pre- vailed in the treatment of this kind of injury* which ought in my opinion to be laid afide ; namely, the in- discriminate ufe of the trepan in the inflammatory as well as in the purulent or fuppurative ftage of thefe fymptoms. It has been common, in all cafes of this kind, in the firft place to prefcribe large evacuations j and if thefe do not procure relief* to apply the trepan immediately, whatever may be the ftage of" the difeafe. This praaice is chiefly founded on an idea that has prevailed with fome, of the operation of the trepan being an innocent remedy, and of no harm being ev- er produced by it. In Support of this opinion, exper- iments are related of the operation having been per- formed in found animals, with a view to determine the queftion, whether expofure of the brain to the air is detrimental or not ? And as it has happened in fev- eral inftances, that no bad effeas have enfued, a gen- eral conclusion has been drawn in favour of the oper- ation. But were we for a moment difpofed to admit the truth of this conclufion, yet one great objeaion to the application of the trepan in an inflamed ftate of the brain, would occur, that no benefit could be derived from it. The fole objea we fhould ever have in view from this operation, is to remove preffure from the brain : but in an inflamed ftate of this organ, as no preffure is fuppofed to exift, the remedy is of courfe unneceffary. If praaitioners would allow themfelves to be di- reaed by the effeas of thofe remedies that prove ufe- ful in fimilar affeaions of other parts of the body, in- flammation of the brain would never be treated in this manner : we need not furely expea to derive advan- * Vide Treatife on Ulcers. Sea. V. from external Violence. 127 tage from perforating the cheft in the firft ftage of an inflammatory affeaion of the pleura ; nor would any furgeon advife it till the formation of matter was ful- ly indicated. Befides this, however, I am decidedly of opinion* that the trepan cannot be applied in inflammation of the brain, but with manifest hazard : it tends always to increafe the fymptoms of inflammation ; and in al- moft every inftance in which I have known it em- ployed during this ftate oS the difeafe, the dura mater has been found, after death, either in a ftate of mor- tification, or covered with purulent matter. Thefe effeas we may fuppofe to be in fome meafure the con- fequence of admiflion of air to the brain ; and they may be partly owing to the violent feparation of a portion of the cranium from the inflamed dura mater, to which it adheres firmly in almoft every point. Neither is this the only ground on which I would objea to the praaice: contrary to the received opi- nion, I think that the operation of the trepan is in it- felf dangerous even when performed in a found ftate of the brain, where no inflammation takes place. Several years ago I made a variety of trials to deter- mine this point; and nearly one fourth of the animals that underwent the operation, appeared to die from the effeas of it. It is not, however, from the effeas of this opera- tion on other animals alone, that I wifh to draw any conclusion ; but when conSequences fimilar to what I have ftated, reSult from it when performed on the hu- man body, when no immediate injury has been done to the head, they will be allowed to have much weight in eftahlifhing the opinion I have advanced. I have accidentally met with three cafes much in point, in none of which there was any appearance of inflam- mation of the brain previous to the operation; and yet, two of the patients died in a few days after the perforation of the fkull, evidently from inflammation induced upon the dura mater. As cafes of this kind 128 Affedions of the Brain Chap. X. do nqt often occur, and as the refult of thefe tends to eftablifh the validity of the opinion I have advanced, I fhall here give a fhort account of them. In cafes of inveterate epilepfy, where every other means of relief have failed, it has been propofed, to admit the free preffure of the atmofphere to the fur- face of the brain, by one or more perforations made in the fkull with the trepan. Any advantage to be obtained from this, I muft acknowledge to be ex- tremely doubtful; and the effeas of it appear to me to be fo uncertain, and even hazardous, that I fhould never think of advifing it. But it has So happened, that I have known two inftances of its being done by others; and in a third, I had occafion to put it in praaice mySelS, in the caSe of a gentleman who had laboured under epilepfy for upwards of twenty years. But in this cafe, as the fits appeared to be the confe- quence of an injury received in childhood upon the forehead; as the external appearance of the part on which the injury was infliaed, gave caufe to fufpeft that a fmall portion of the fkull was depreffed at this place ; as there was fome reafon, therefore, to fuppofe, that the fits depended upon this caufe, and as they Were at this time become extremely violent, it was the opinion of feveral praaitioners of this place, as well as the earneft defire of the patient, that the trepan fhould be employed. This was accordingly done; the portion of the fkull which received the blow was taken out; and matters went on very favourably till the end of the fecond day from the operation, when Symptoms of inflammation occurred; and, notwith- standing all the remedies that were employed, he died in little more than forty-eight hours from this period. On opening the head, a great quantity of pus was found, not only on the dura mater, but on the pia mater, and even between this membrane and the brain ; and as there was not, till within twenty-four hours of his death, any fymptoms of a compreffed brain, there is much reafon to think that the matter was formed Sc&.V. from external twlence. 12^ merely in confequence of inflammation induced by the operation ; and therefore, that the means employ- ed for the patient's relief had evidently haftened htS death. One of the others on whom the operation was per- formed, recovered from the immediate effeas of it, but with no alteration or abatement of the fits for which it was employed. The other died on the fev* enth day from the operation: fymptoms of inflamma- tion appeared on the third; and thefe were at laft Suc- ceeded by evident marks of a compreffed brain: a confiderable quantity of matter was found between the dura and pia mater, and even beneath this mem- brane, not merely on the parts contiguous to the wound, but over the whole furface of the brain. We have here two cafes, very diftinaiy marked, of the hurtful effeas of this operation, even in a found ftate of the brain, at leaft where no previous inflam- mation appeared to exift in it. The fymptoms of in- flammation which Supervened in both instances, were evidently the effea of the perforations: fuppuration enfued in both ; and as both the patients died in the Space of a few days from this period, no doubt can be entertained of the caufe of it. I am therefore induced to confider the operation of the trepan as inexpedient* and even dangerous, in an inflamed ftate of the brain : but when fuppuration has taken place, and when matter formed within the fkull operates as a caufe of compreffion, as this operation affords the only chance of fafety, it fhould be employ- ed with freedom, and without hesitation. We proceed now to the confideration of fiffures, or fimple fraaures of the fkull. §2.0/* Fiffures or fimple Fradures of the Skull. The term fiffure is here meant to imply a mere di- vifion or fimple fraaure of the fkull not attended with Vol. II. K »3o Affedions of the Brain Chap. X< depreffion ; and it may either penetrate the whole thicknefs of the bone, or be confined to one lamella of it only : a fiffure may alfo be attended with a divi- fion or wound of the correfponding teguments, or thefe may be left entire. I have already had occafion to remark, that injuries done to the head, prove hazardous nearly in propor- tion to the violence which the brain receives from them : fo that fiffures, in fo far as they affea the Skull only, are not to be confidered as dangerous ; but be- ing frequently combined with affeaions of the brain from the beginning, and on other occafions produc- tive of confequences from which this organ is ulti- mately brought to fufter, they of courfe require our moft ferious attention. It often indeed happens, that very extenfive fiffures heal without any bad Symptom taking place; but as others which are apparently tri- vial, frequently terminate in the moft fatal manner, we cannot with propriety in any inftance treat them with neglea. Fiffures of the fkull may prove dangerous, either from being produaive of effufions of blood or ferum upon the brain, or by tending to excite inflammation of the dura and pia mater. When effufions take place, as this muft be attend- ed with fymptoms of compreffion, thofe means Should be advifed that are known to be beft fuited for its re- moval ; but as thefe' have been already fully treated of in the preceding feaions, it is not neceffary to en- ter into a further detail of them : I Shall juft fhortly obServe, that for the removal of thefe effufions, we have to truft entirely to a proper application of the trepan. The fiffures Should be traced through their whole extent; and a perforation being made in the moft depending part of each of them, if this does not prove fufficient, the operation fhould be repeated along the courfe of the fraaures, as long as any fymptoms continue of a compreffed ftate of the brain ; care be- ing always taken to include the fiffure in every perfo- ■*i Sea. V. from external Violence. 131 ration : for, as the caufe of the mifchief will in gen- eral be found contiguous to the fraaure, it would fel- dom anfwer any good purpofe to perforate the fkull in any other part. It is therefore fcarcely neceffary to obferve, that care fhould be taken to trace the courfe of the fiffures with much accuracy ; for which purpofe, as foon as we refolve on performing the operation, if the whole extent of the fraaure has not been previoufly difcov- ered, it fhould now be done by making an incifion through the fkin and other teguments down to the pe- ricranium : and by taking care to follow the direaion of the fiffures, they may thus be brought freely in view. When fiffures are of fuch magnitude as to produce an obvious feparation of the two fides of a fraaured bone, the nature of the cafe at once becomes obvious ; but it often happens, that they are fo fmall as to ren- der the operator doubtful and uncertain. A little at- tention, however, to the real ftate of the patient, will at all times prevent any hefitation refpeaing the means that we Should employ. The only appearances with which a fiffure is in danger of being confounded, are, thofe indentations formed on the external furface of fome parts of the fkull by the blood veffels which run upon it; and the different futures which ferve to unite the bones of the fkull together. In doubtful cafes of fiffure, we may frequently be determined by the degree of adhefion that takes place between the pericranium and Skull. The pericrani- um, as we have feen, naturally adheres firmly to eve- ry part of the fkull, and particularly at the futures ; and as one certain effea of a fiffure is to deftroy this conneaion entirely, when the pericranium adheres to the bone beneath, we may conclude without hefita- tion, that no fiffure exifts ; and, on the contrary, when this membrane is loofe and fomewhat feparated k 2 *32 Affedkns of the Brain Chap. X. from the bone, there will be much reafon to fuppofe that any rent or crack that appears in it, is produced by a fraaure. It often happens, however, that we are deprived of this means of deteaing fiffures, by the pericranium and other teguments being feparated from the bone for a confiderable fpace. In this fituation, various means have been propofed for obtaining a certainty of the nature of the cafe. By pouring ink over the furface of the denuded bone, the whole of it we are told, may be wiped off, if the bone is not fraaured ; but, wher- ever there is a crack or fiffure, that it will be impoffi- ble even with the afliftance of water to remove it. By making the patient keep a firm hold with his teeth of one end of a hair, or of a piece of catgut, while the other extremity is fecured at fuch a diftance as to render it tenfe, if it is now ftruck, the vibrations thus produced will create, we are told, a very fenfible degree of uneafinefs in the part affeaed, if it is frac- tured ; but will not otherwife have any effea. And again it is faid, if the patient is made to chew a bit of bread, or any other hard fubftance, that fome pain will occur from it if the bone is fraaured ; but other- wife, that the injured part will not fuffer. None of thefe tefts, however, are to be much de- pended on: neither of the two laft have any effea, unleSs the fiffure is extenfive, and the fides of the frac- tured bone considerably Separated Srom each other, 1 when this means of diftinaion can never be neceffary; and as ink penetrates the Sutures of the fkull, unleSs when they are firmly offified, it can feldom happen that any trial to be made with it will be produaive of any advantage. It commonly happens, in fiffures extending through the .whole fubftance of the fkull, and even in fuch as penetrate only to the diploe, that blood continues to ooze from them for a long time aft^er the accident, and it conftantly returns again almoft as Soon as it is wiped off: this is one of the moft charaaeriftic marks Sea. V. frm external Violence. 133 of a fiffure, and it points out with precifion the nature *< of the cafe. But there is no neceffity, I may remark, for fo much anxiety on this point as praaitioners com- * monly exprefs ; for, unlefs when fymptoms of an alarming nature take place, I fhall prefently endeav- our to Show that no operation fhould be advifed: and again, whenever the fymptoms indicate a compreffed ftate of the brain, if any appearances of a fiffure are dreaded in that part of the skull which has recently received a blow ; however equivocal they may be, yet as this is moft probably the feat of the injury, no doubt fhould be entertained of the propriety of perforating the skull at this place. If it fhould afterwards appear that the trepan has been applied upon a future, as the furgeon under fuch uncertainty would proceed with much caution, no harm could enfue from it; and if it fhould prove to be a fraaure, it would afford him much fatisfaaion to find that the perforation had been made where alone it could prove ufeful. But although I have in this place, as well as in oth- er parts of thefe observations, advifed the trepan as the only remedy to be trufted for the removal of Symptoms of a compreffed brain ; yet unlefs where fymptoms of this kind take place, even the prefence of a fiffure ought not to indicate the operation : but as this is a point upon which I happen to differ from many of the profeffion ; and as it is of much praai- cal importance to have it duly confidered ; I Shall ad- vert to it with more iriinuteneSs, than might be other- wise neceffary. Hitherto it has been a general rule, to confider the application of the trepan as neceffary in every fiffure, whether any fymptoms of a compreffed brain have occurred or not. But due attention to the real nature of a fiffure, and to the effeas moft likely to refult from perforating the Skull, will Show, that although fiffures may be frequently combined with fuch fymp- toms as require the trepan, yet that they are not al- ways or necefiarily fo ; and unlefs when fuch fymp- 134 Affedions of the Brain Chap. X. toms aaiially exift, that this operation, inftead of af- fording relief, muft frequently do harm : for it is by no means calculated for, or in any refpea adequate to, the prevention of thefe fymptoms : and I have al- ready endeavoured to ftiow, that laying the brain bare is never to be confidered as harmlefs ; and therefore that it fhould never be advifed but when it is probable that fome advantage may be derived from it. When a fiffure is attended with a compreffed ftate of the brain, there can be no hefitation, as I have ob- ferved already, in recommending an immediate appli- cation of the trepan : but in the cafe of a fiffure not accompanied with any Symptom of this kind, and while the patient complains of nothing but perhaps a flight degree of pain in the contuSed part, an occur- rence by no means unSrequent; what advantages are we to expea from perforating the fkull ? In this fitu- ation, we know, that no extravaSation takes place ; and that no part of the fkull is depreffed, otherwise fymptoms would occur of a compreffed ftate of the brain : for what purpoSe, therefore, fhould the trepan be applied ? No Sufficient reaSon, I believe, can be ad- duced for it. In the caSe of a fimple fiffure, not attended with any bad fymptoms, the moft alarming occurrence that we have to dread is the acceffion of inflammation ; for it frequently happens, that the membranes of the brain become afterwards inflamed, although the patient may have remained perfeaiy well for feveral days, nay, ev- en for weeks, after the injury producing the fracture was infliaed. Now, whoever attends to one of the immediate effeas of the trepan, namely, the violence done by it to the dura mater, together with the ad- miffion of air to the parts within the fkull, muft ac- knowledge, that this tendency to inflammation, the circumftance which, of all others, we have mofl caufe to dread, inftead of being leffened by this operation, muft, in all probability, be increafed ; fo that, as a preventative of- bad fymptoms, it ought never to be Sea. V. from external Violence. 135 advifed. It has, indeed, been keenly held forth by thofe who fupport a contrary opinion, that, in fiffures of the Skull, no additional rifk can be incurred by this operation ; for it is faid, that air being already admit- ted to the brain by the fraaure itfelf, the trepan will not give it a more free accefs, while at the fame time, they obferve, that it is attended with the very impor- tant advantage of forming and preferving a free vent for any matter that may form between the fkull and dura mater during the cure. This argument is fpecious, but it will not on exam- ination be found to merit attention. For, when .fif- fures are fo extenfive as to produce any obvious ''Sepa- ration between the fides of the fraaured bone, a more fufficient vent is thus procured for any matter that may form than could poffibly be obtained by an oper- ation : and again, in fiffures of leffer extent, as they do not always terminate in the formation of matter beneath the fkull, but, on the contrary, as they fre- quently do well without the occurrence of any bad Symptom, it cannot furely be confidered as prudent to advife a hazardous operation, merely for the chance of its becoming neceffary. And befides, inftances are often met with, in which fiffures penetrate no deeper than the external table of the Skull; a circumftance which cannot be previously known ; and for which even the warmeft Supporters of the praaice in queftion would never Surely recommend a perforation through the whole Subftance oS the bone. The idea that has hitherto very univerSally prevail- ed, of the harmlefs nature of this operation, has pro- bably been the chief caufe of the opinion reflecting the propriety of performing it in every cafe of fiffure : but, if the opinion that I have given is well founded, any utility probably to be derived from it, will be more than counterbalanced by the hazard with which we fuppofe it to be at all times attended. Whilft no bad fymptoms fupervene, a fiffure of the fkull fhould be treated, merely as a caufe that may 136 Affedions of the Brain Chap. X. give rile to inflammation. The patient fhould lofe blood once and again, in proportion to his ftrength ; his bowels fhould be kept open ; the fore fhould be treated with mild dreffings ; and as long as there is caufe to fufpea that inflammation may occur, violent exertion of every kind fhould be avoided : for al- though, in fuch circumftances, I would not, for the reafons that I have given, advife the common praaice of perforating the fkull in every cafe of fiffure, I am perfeaiy decided in this* that fiffures fhould always be treated with attention, and fhould have the moft effeaual means employed for obviating thofe effeas that arife from them when inflammation takes place. By the means that I have pointed out, a cure will frequently be obtained, without putting the patient to the hazard arifing from the operation of the trepan ; but when, from the violence of the injury, or from any other caufe, they are found to fail, and that the inflammation terminates in fuppuration, as in fuch cir-. cumftances nothing but a free difcharge to the matter can fave the patient, this operation will now with much propriety be employed : but, for the reafons I have already advanced, I muft again fay, that till this ftage of the difeafe takes place, the perforation of the skull ought never to be advifed. The arguments adduced in fupport of this opinion in different parts of this and the preceding feaions are perhaps of themfelves fatis- faaory ; but in a point of fuch importance, no perfon fhould fpeak decisively on any opinion not Supported by experience. When the reSult of experience, how- ever, is fupported by probability, we more readily give our affent to it than could ever be done to a mere praaical faa ; and as all the obfervation I have been able to make refpeaing the point we are fpeaking of, tends to Support the praaice that I have adviSed, it is without hefitation that I venture to propofe it. Sea. VI. from external Violence. l37 SECTION VI. Conclufion. THE importance of the fubjea that we have juft been considering, together with the intricacy in which it is involved, has led to a length of difcuffion which I did not at firft expea : if, however, in treat- ing of injuries done to the head, I have in any degree contributed to remove the perplexity that has hitherto obfcured the fubjea, arifing, as well from the compli- cated nature of the injuries themfelves, as from the manner in which authors have generally handled them; the time I have fpent, and the pains I have taken, will not be thought mifapplied. The length to which this chapter has extended, points out the propriety of bringing the more material parts of the Subject into one point of view : on this account, the following recapitulation is fubjoined : i. It appears, that in a ftate of health, the cavity formed by the bones of the skull is completely filled with the brain and its membranes. 2. That a direa communication takes place between the external coverings of the skull and the parts con- tained within it, by means of blood veffels paffing be- tween the dura mater and the pericranium, efpecially at the different futures. 3. From this mechanifm, we may perceive, how the fmalleft diminution of the cavity of the skull, how- ever it is produced, muft always occafion compreffion of the brain : and from it alfo we account for the ready communication of inflammation from the exter- nal teguments of the skull to the dura mater. 4. The various fymptoms arifing from injuries done to the head, may be referred to three general effeas ; compreffion, concuffion, and inflammation of the brain. 138 Affedions of the Brain Chap. X. 5. In a compreffed ftate of the brain, the fafety of the patient depends folely upon the removal of the caufe by which the compreffion is produced. When a portion of the bone is beat in, and is at the fame time fo loofe as to admit of its being taken out with the fingers of the operator, with common forceps, or perhaps a levator, thefe only Should be employed: but when the depreffed portion of bone is firmly fixed, or when the compreffion is produced by the effufion of blood, or formation of pus, a proper application of the trepan can alone afford relief; and we ought not to hefitate in employing it. In Such circumftances, the patient is \n a very haz- ardous fituation ; and perforating the fkull with the trepan as frequently as may be neceffary, may prove, as it often has done, a very effeaual remedy. 6. We are by no means, however, to imagine, as many have done, that a furgeon has accomplifhed all that may be proper for him to perform, on the oper- ation being finifhed. Indeed, little advantage will in general be derived from it, if other circumftances are not kept in view. As the cauSe producing the com- preffion, whatever it may be, muft injure the mem- branes of the brain, care fhould be taken, as far as it can be done, to obviate the effeas of it. No doffils, or fyndons as they are termed, fhould be crammed into the perforations made by the trepan, and every irritating application fhould be avoided. The whole furface of the fore fhould be lightly covered with foft lint fpread with any emollient ointment; and this, with a comprefs of foft linen, fhould be retained by a common night cap, as the eafieft and beft bandage that can be applied to the head. The patient fhould Iofe blood in proportion to his ftrength ; his bowels fhould be kept open ; his fkin fhould be preferved foft and perfpirable ; a low diet fhould be recommended ; and he fhould be kept free from noife and every kind of disturbance. Sea. VI. ^ from external Violence. 139 7. When Symptoms arifing from external violence done to the head, depend on concuffion or commotion of the brain ; as this feems to operate chiefly by induc- ing debility of the whole fyftem, the common praaice oS discharging much blood, and giving ftrong purga- tives, Should be avoided. Inftead oS this, a moderate uSe of wine, as well as other cordials, Should be advifed, together with a nour- ishing diet; whilft blifters and other ftimulants fhould be applied to the head itfelf. In long continued af- feaions proceeding from this caufe, fuch as lofs of memory and imbecility, ekaricity may be fafely em- ployed. I have known fome inftances where -it ap- peared to prove ufeful. 8. In the treatment of injuries done to the head, it fhould always be kept in view, that inflammation of the membranes of the brain very feldom takes place immediately, but is apt to fupervene at fome diftant period from the injury being received : in confequence of which, accidents which do not at firft appear to be of much importance, Srequently terminate fatally at laft. Where inflammation has taken place, we depend chiefly on general and local bloodletting, carried as far as the ftrength of the patient will permit. Strong purgatives Should be advifed : fudorifics prove fome- times ferviceable ; and when the patient is reftlefs, and diftreffed with violent pain, opiates frequently prove ufeful. When an inflamed ftate of the brain fucceeds to a contufed wound of the external teguments, warm emollient poultices are the beft applications we can make to the fore. By inducing a difcharge of matter from the neighbourhood of the inflamed parts, they prove often highly ferviceable ; and, when the fkin has not been divided by the contufion, it fhould be laid open upon the firft appearance of a tumor, with- out expeaing or waiting for a complete fuppuration. 140 Affedions of the Brain Chap. X. In recommending this treatment, I have departed from the common mode of praaice, which directs the immediate appfication of the trepan if bloodletting and other evacuations do not afford fpeedy relief; and I have done fo for two reafons. In the real inflammatory ftate of the membranes of the brain, compreffion of that organ does not take place: it is not indicated by the fymptoms which take place, nor is it met with on diffection in fuch patients as die in this ftage of the difeafe : perforating the fkull therefore in this fituation can do no good. And far- ther, the operation of the trepan in itfelf, is not, as is generally imagined, innocent and harmlefs. By ad- mitting a free accefs of air to the membranes of the brain, it tends evidently to excite and promote inflam- mation in the parts beneath. Applied therefore in this cafe, the trepan may aggravate, but cannot relieve, the complaint for which it is ufed. 9. When, notwithftanding all oux endeavours, the formation of pus takes place, either upon the furface of the dura mater, or within this membrane, it falls in every refpea to be treated as effufion induced in any other way. In this fituation, the operation of the tre- pan is indifpenfably neceffary; for by no other means can the matter be difcharged, or the fafety of the pa- tient infured. In performing this operation, inftead of removing a confiderable portion of the Skin and other teguments, as has commonly been done, a fimple incifion upon the part in which the inftrument is to be applied is all that is neceffary; and no more of the pericranium fhould be removed than is required for this purpoSe. 10. During the progreSs of the cure, after the ap- plication oS the trepan, fungous excreScences are apt to fhoot out from the different perforations in the bone. There is feldom, however, any reafon for our attempting to remove them, as is commonly done, by compreffion, cauftic, or ligature ; for in general they difappear foon after the offiSying proceSs is completed Sea. VI. from external Violence. 141 in the feveral openings. But when this does not hap- pen, and when they ftill continue to prove troublefome after the reft of the cure is accomplifhed, they may with fafety be taken away, either with cauftic or the Scalpel. In various points of importance treated of in this chapter, I have advanced opinions, and recommended modes of treatment, different from thofe which hith- erto have prevailed : but however diffident I am in firft diffehting Srom an eftablifhed doarine, if my own experience is found to juftify this diffent, the more re- fpeaable the authority by which the contrary opinion is fupported, the more investigation appears to me ta be neceffary. But in propofing modes of praaice different from what are fanaioned by long cuftom, I have never been confcious or being aauated by a fpirit of innovation, or a defire of appearing Singular: and whenever I have ventured to diffent from men of known abilities, I have always endeavoured, with fairnefs and candour, to ftate the reaSons of my doing fo, and the grounds upon which my opinions are formed: at leaft this has been my intention, and I hope it will appear to others that I have done fo. I4« Diseases of the Eyes. Chap. XL CHAPTER XL OF THE DISEASES OF THE EYES. SECTION I. Anatomical Defcription cf the Eye. THE objea of this chapter is the chirurgical treat- ment of the difeafes of the eye and parts with which it is conneaed : hence it v/ill comprehend the difeafes of the lachrymal paffages ; but, jn the firft place, it will be proper to give an anatomical descrip- tion of the parts in which thefe difeafes are feated. IVIinutenefs on this fubjea would lead to a greater length than the extent of this work will admit, nor does it appear to be neceffary : I Shall therefore give only fuch an account of thefe parts, as the nature of the difeafes, and the operations to be defcribed, feem to require. The eyes, and part of their appendages, are placed in two bony cavities, termed the orbits, formed by a conjunaion of the inferior part of the frontal bone with feveral other bones of the head and face; namely, with the offa maxillaria, offa malarum, offa unguis, os ethmoides, os fphenoides, and offa palati. All the up- per part of the orbits is formed by the orbitar proceff- es of the frontal bone ; and the fame proceffes Sorm a confiderable vacuity in each orbit towards the exter- nal canthus of the eye, in which the glandula lachry- malis is lodged. The inferior part of the orbits is formed by the offa maxillaria and offa malarum, which alfo form part of the fides or angles of each orbit; the former Stretching towards the internal canthus, and the latter towards the external angle of the eye. The Sed. L Diseases tf the Eyes. 143 bottom or back part of each orbit is formed by the ethmoid, fphenoid, and a fmall portion of the palate bones ; and a fmall part of the internal corner or an- gle of each orbit is filled up by the os unguis* As this laft mentioned bone, the os unguis, is fre- quently the fubjea of a nice operation, it is more par- ticularly neceffary for Surgeons to be well acquainted with its Slruaure and fituation. A confiderable part of it is fo thin and brittle, that a perforation may be made in it with very little force ; with lefs, indeed, than, is commonly imagined ; for not being thicker than fine paper, the point of a Sharp inftrument is ea- fily made to paSs through it. The internal Surface of the os unguis, which in part covers the cells oS the ethmoid bone, is Somewhat rough ; but its external furface is Smooth, and confifts of two depreffions or concavities divided by a ridge. This ridge forms the boundary of the orbit at the internal canthus of the eye, and one of thefe depreffions forms the very point or angle oS the orbit; while the other concavity, which lies between this ridge and the naSal proceSs of the maxillary bone, ferves to lodge in its upper part, where it is largeft, the lachrymal fac, and below it proteas the dua leading from this fac into the nofe, where it terminates immediately below the fuperior edge of the lower os fpongiofum. The nafal dua of the lachrymal fac admits a probe of the fize of a crow's quill; and it continues of this diameter till within a little of its termination in the membrane of the nofe; where, by running in an oblique direaion between the layers of this membrane, in a manner fimilar to the termination of the ureters in theAbladder, it is in general found contraaed to a very narrow point. The principal part of each orbit is filled by the ball or globe of the eye, a body compofed of feveral mem- branes or coats, inclofing fluids or liquors of different confiftences, improperly termed the humours of the eye. 144 Diseases of the Eyes. Chap. XL Anatomifts have confidered the coats of the eye as numerous, but three only can be diftinaiy traced ; namely, the fclerotic, the choroid, and the retina. The former has indeed been SuppoSed to confift of dif- ferent coats, to all of which names have been appro- priated, namely, the tunica albuginea, the cornea opa- ca, cornea lucida, &c. ; and even the choroid has been fuppofed to be formed of different tunics: but although a tedious maceration may feparate fome of thefe parts into different lamellse, the knife of the anatomift is not able to do fo ; and as diftinaions of this kind can tend to no ufeful purpofe, they ought not to be retained. The fat and different mufcles of the eye being fepa- rated from it, the fclerotic is the firft coat that pre- fents itfelf; and it is found to furround the whole globe of the eye, which is not the cafe with any of the others. In the anterior convex part of the eye, which in a healthy ftate is always tranfparent, this membrane is in general termed the cornea. The pofterior part of it is thick, ftrong, and perfeaiy opaque : it is this part of it that has commonly been termed the fclero- tic coat, or, as I have already obferved, the opaque cornea. But although the tranfparent cornea can be eafily feparated into different layers, which cannot be fo readilv done with the other; a circumftance which has led Some anatomifts to confider them as diftina coats ; yet as the one is evidently a continuation of the other, and as they are both fupplied with the fame blood veffels, there feems to be no good reafon, as I have juft remarked, for the diftinaion being retained. All the opaque part of the fclerotic coat is lined with the fecond coat of the eye, the choroides ; a dark or dufky red coloured membrane, which every where adheres to it with firmnefs, particularly at a fmall dif- tance behind the commencement of the tranfparent cornea, where a circular whitifh ring is formed by thk junaion of the choroides with the fclerotica, com- monly termed the ligamentum ciliare. From this Sea. I. Diseases pf the Eyes. 145 junaion of the choroid with the fclerotic coat, a per- forated kind of curtain or feptum is produced, which from the variety of its colours, is termed the iris. The perforation in the centre of this membrane is termed the pupil, and ferves to admit the rays of light to the bottom of the eye. Towards the middle of the iris, we perceive a num- ber of radiated lines running from the circumference to the centre: thefe are denominated the ciliary pro- ceffes, and on their aaion the contraaion and dilata- tion of the pupil appear to depend ; for it feems to be doubtful, whether any circular fibres exift in the iris or not. RuySch, as well as other anatomifts, have imagined that the tunica choroides confifts of two diftina coats, and the iris has been in general confidered as a con- tinuation of one of thefe ; but later difcoveries tend to fliew that the choroides in the human eye confifts of one fimple indivisible tunic, and that it is different in every refpea from the iris. The third and moft internal coat of the eye is the retina, which feems to be an expansion of the optic nerve. It does not line the whole cavity of the eye, but appears to terminate over the anterior edge of the fac or capfule of the vitreous humour to be hereafter defcribed. Vifion we fuppofe to be produced by the rays of light being applied in a certain manner to the retina : it is therefore obvious, that a found ftate of the optic nerve, by which this membrane is produced, is highly neceffary for the purpofes of vifion, and we conclude with much probability, that the nerve is found, when the ufual contraaion and dilatation of the pupil take place on light being applied to, or removed from, the eye : for in a healthy ftate of this organ, fuch a con- neaion fubfifts between the optic nerve and the iris, fhat the latter always contraas or dilates, juft in pro- portion to the quantity oS light thrown upon the other. Vol. II. L t^6 Diseases of the Eyes. Chap. XL Thefe are the only proper coats or coverings of the eye ; but there are two membranous expanfions which likewiSe cover a confiderable portion of the back part of the globe, which by many have been enumerated as part of its tunics ; namely, the albuginea, and tu- nica conjunaiva : the former, however, is formed en- tirely of the tendinous attachments of the mufcles of the eye ; and the latter is a continuation or refleaion of the membrane that lines the internal furface of the eyelids. The cavity formed by thefe coats or membranes, is filled with three kinds of fubftances, or humours as they are commonly termed ; namely, the vitreous, the crystalline, and the aqueous. All the posterior part or the eye is filled with the vitreous humour, which is perfeaiy tranfparent, and of a gelatinous confift- ence : this humour is completely furrounded by a ve- ry delicate membrane, which likewife appears to pafs through the fubftance of this gelatinous mafs, and to confine it in a kind of cellular texture or network. In the anterior furface of the vitreous humor, we find a depreffion exaaiy oppofite to the pupil, Sor the pur- poSe of receiving the cryftalline humour, a fubftance of a much firmer texture than itfelf, and of a rounded or lenticular fhape. This body, or the lens as it is commonly termed, is retained in its fituation by a ve- ry fine membrane or capfule, which appears to be formed by the capfule of the vitreous humour, fepa- rating or dividing at this part into two diftina laminae. It has indeed been fuppofed, that the cryftalline lens has a cyft or capfule peculiar to itfelf ; but I have never been able to diftinguifh it, nor has any fufficient evidence ever been given of this having been done. The whole anterior part of the eye, from the ter- mination of the .vitreous and cryftalline humours, to the internal furface of the tranfparent cornea, is filled with the aqueous humour, a thin tranfparent fluid. By the iris, already defcribed, this part of the eye is divided into two unequal departments : the fmalleft of Sea. L Diseases of the Eyes. 147 thefe, which is Scarcely a tenth of an inch in width, and lies between the iris and the capfule of the vitre- ous humour, is termed the posterior chamber; and the other, which is considerably larger, and occupies the whole fpace from the iris to the cornea, is called the anterior chamber of the eye. Although thefe two divifions of the eye, however, are perfeaiy diftina, it is obvious that they muft communicate at the pupil, the opening in the centre of the iris. The mufcles of the eye are fix in number; namely, the levator oculi, the depreffor, adduaor and abduc- tor, the obliquus fuperior and inferior. By thefe, all the motions of the eye are performed. The firft five arife from near the bottom of the orbit, at no great diftance from each other ; and the laft originates from the orbitar proceSs oS the maxillary bone, near to its junaion with the os unguis. They are all inSerted in- to the tunica Sclerotica, below the adnata or tunica conjunaiva. The conflant motion of the eye requiring it to be kept Soft and moift, it is for this purpofe plentifully fupplied by a fine tranfparent fluid, the tears. This fecretion is now known to depend in a great meafure upon a large glandular body, the .glandula lachryma- lis, feated immediately above the eye, in the depref- fion that I formerly mentioned in the os frontis, near to the external angle of the orbit. There is likewife in the internal or great angle of the eye, a fmall red coloured body, termed the car.uncula lachrymalis, which till of late was fuppofed to be the principal ori- gin of the tears. This, however, is not the cafe ; and there is even reafon to doubt whether this fubftance is of a glandular nature or not. But although the tears are chiefly fecreted by the glandula lachrymalis, there is much reafon to ima- gine that they are partly produced by exfudations from the whole furface of the eye, as well as from the membrane of the eyelids. But this being in fome L 2 t4$ Diseases of the Eyes. Chap. XI meafure foreign to our fubjea, I fhall not at prefent confider it further. The eye, and its appendages, that have juft been deScribed, are Supplied by Several arterial branches, either direaiy Srom the internal carotid, or from the maxillary arteries. None of thefe, however, are of any confiderable fize ; at leaft, before reaching the eye, they are in general found divided into branches of no great magnitude ; a circumftance of fome im- portance for praaitioners to recolfea : for, on the fup- pofition of thefe arteries being larger than they are, furgeons have commonly been deterred from operat* ing with that freedom on the eye which they Other- wife might do, particularly in the total removal or ex- traaion of the eyeball; an operation to be hereafter defcribed. The veins of the eye terminate partly in the external, and partly in the internal jugular veins. Vifion, as I have already obferved, depends in a great meafure on the optic nerve which paffes in from the brain at the bottom of the orbit ; but the eye does not depend entirely upon this nerve : it receive* branches from feveral others, particularly from the fourth, fifth, and fixth pairs. The globe of the eye and other parts contained in the orbit, are covered by two very moveable mem- branes, called palpebrce, or eyelids, formed chiefly of the Skin and a fmooth fine membrane already defcrib- ed, the tunica conjunaiva, with an intermediate thin cartilaginous body termed tarfus, on which the cilia or eyelafhes are placed. Both the upper and under eyelids are fupplied with this thin cartilage ; at the extreme border of which, towards the roots of the ci- lia, a number of fmall follicles are placed, named af- ter their difcoverer, the follicles or glands of Meibo- mius ; from whence is poured out a vifcid febaceous matter, commonly termed the gum of the eyes. The motion of the eyelids is performed entirely by two Tiiufeles, the orbicularis palpebrarum, and the le- vator palpebrse fuperioris. The forme:* is common to Sea. I. Diseases of the Eyes. ,149 both the eyelids: it originates by a fmall tendon at the inner angle of the eye, and by fine flefhy fibres from the orbitar procei's of the maxillary bone, and is inferted by a fmall round tendon into the nafal procefs of the fame bone. A few of the tendinous fibres of this mufcle are fpread upon, and feem to be inferted into, the anterior furface of the lachrymal fac. The ufe of this mufcle is to draw the eyelids together, and to comprefs the eyeball. The levator palpebral fuperioris originates from the bottom of the orbit, and is inferted into the membra- nous and cartilaginous parts of the upper eyelid : the fole ufe of this mufcle feems 'to be to raife this cover- ing of the eye. I have already defcribed the lachrymal fac and dua, by which the tears are conveyed to the nofe: we have now to attend to the manner in which they pafs from the eyes to the fac. After the tears have moiftened the eyes, they would at all times be falling over the cheeks, if not carried off in fome other manner: a very beautiful mechanifm, however, is employed by nature for this purpofe. Near to the internal angle of each eye, we perceive two fmall points or protuberances, one on the border or edge of the upper eyelid, and the other eaaiy op- posite to it on the under eyelid. In the centre of each oS theSe there is a Small hole or opening, termed the punaum lachrymale, which we find to bq the mouth of a fmall conduit leading to the lachrymal fac, and by which the tears are conveyed to it. Thefe ca- nals are of fuch a fize as to admit a probe fomewhat larger than a hog's briftle. They are each about four tenths of an inch in length ; and after running in an oblique direaion along the edge of the eyelids, they commcnly join into one common trunk immediately before they enter the lachrymal fac, fomewhat more than the tenth of an inch below the upper end of it. The protuberances on which thefe canals originate, are evidently irritable, as may readily be feen on their *"5° Diseases of the Eyes. Chap. XL being touched with a probe or any acrid matter. This renders it probable that they are endowed with the power of abforbing the tears ; and this fluid we find is at all times applied to the mouths of them, by a kind of membranous produaion of the tunica con- junaiva, of a femilunar form, lying in the internal an- gle of the eye. This membrane is by anatomifts term- ed valvula femilunaris. In order, however, to render the anatomy of thefe parts as intelligible as poffible, a circumftance oS much .importance in the treatment of the difeafes to which they are liable, I have given a delineation of the whole in Plate XII. fig. i. Being now prepared to enter on the confideration of the difeafes of thefe parts, I fhall proceed accord- ingly to this part of our fubjea. Inflammation of the eye frequently occurs, and is produaive of many other difeafes to which this organ is liable: I fhall therefore enter firft on the confidera- tion of this Symptom, and fhall afterwards treat of the following difeafes and operations peculiar to thefe parts: wounds of the eyelids and eyeballs ; tumors of the eyelids, fuch as abfceffes, melicerous and ftea- tomatous colleaions and warts; inverfion of the cilia or eyelafhes ; everfion of the eyelids; concretion of the eyelids ; flefliy excrefcences on the cornea; ab- fceffes in the globe of the eye ; dropfical fwellings of the eyeball; blood effufed in one or both chambers of the eye ; ulcers on the cornea ; fpecks or films on the tranfparent part of the eye; protrufion of the globe of the eye from the focket; cancerous affeaions of the eye, and extirpation of the eyeball; of artificial eyes ; of cataraas, and the means of removing them by depreffion and extraaion ; obliteration of the pu- pil, by concretion of its fides and adhefion of the iris to the capfule of the cryftalline and vitreous humours ; and, laftly, of the fiftula lachrymalis. Sea. II. Diseases of the Eyes. i$l SECTION II. Of Ophthalmia, or Inflammation of the Eyes. THE eyes and their appendages, like every organ- ifed part of the body, are liable to inflammation; and the fymptoms which it excites vary according to the particular feat of the difeafe. Thus the fymptoms arifing from inflammation of the retina and other deep feated parts, are different from thofe which proceed from inflammation of the external coverings of the eye; and thefe again are different from thofe which arife from an inflamed ftate of the eyelids. The moft frequent fymptoms attending inflammation of the eyeball, are, a preternatural rednefs of the ad- nata, owing to a turgefcent ftate of the blood veffels ; pain and heat over the whole furface of the eye, at- tended with a fenfation of motes or extraneous bodies rubbing upon the eyeball, and in moft. inftances a plentiful effufion of tears. All thefe fymptoms are increafed by motion of the eye or of its coverings, and likewife by expofure to light. We judge too of the depth of the inflammation by the degree of pain which expofure to light excites. When the pain induced by light is fevere, there is always caufe to fufpea that the parts at the bottom of the eye, are inflamed ; and again, when the pain is trifling ; we conclude that the inflammation is confined to the external parts of the eye. We alfo find, when the inflammation is fuper- ficial, that the fymptoms are in general local, and con- fined entirely to the eye ; but, when more deeply feat- ed, fevere fhooting pains are frequently felt through the head, and fever very commonly prevails. ^ During the whole courfe of the inflammation, there is for the moft part a plentiful flow of tears, which frequently become fo hot and acrid as to excoriate the neighbouring parts ; but it often happens that, to- 152 Diseases of the Eyes. Chap. XL gether with the tears, a confiderable quantity of yel- low purulent like matter is difcharged; and, when the inflammation has either fpread to the eyelids, or has been feated there from the beginning, as foon as the tarfi become inflamed, a difcharge takes place of a vifcid glutinous kind of matter, which adds greatly to the patient's diftrefs, as it tends to increafe the inflam- mation, by cementing the eyelids fo firmly together, as to render it difficult, particularly in the mornings, to open them. Thefe are the appearances of inflamed eyes in the firft ftages of the difeafe *; but when of long duration, it proceeds, like inflammation of other parts, to ter- minate either in fuppuration, or in the effufion of a fluid not convertible into pus. Inflammation of the eyes has alfo been known to terminate in mortifica- tion ; but this is a rare ocurrence ; and we even know that it does not readily end in fuppuration. Inflammation of the eyes is induced by various cauf- es : whatever tends to produce inflammation in other parts, will be attended with fimilar effeas, when ap- plied to the eye ; but the peculiar mechanifm of this organ renders it liable to be aaed on by caufes which may with impunity be applied to other parts of the body. Thus, much expofure to fmoke tends often to induce inflammation of the eyes: and it alfo happens from the application of much light; particularly from much expofure to the rays of the fun ; to the influence of a large fire ; or to the effeas of fnow : and the in- troduaion of lime, fand, or any other extraneous body, between the eyelids and the eye, is very univerfally attended with this effea. The confequences, however, of thefe caufes, are not in general permanent; for, in recent cafes, a removal of the caufe is, in moft inftances, attended with the cure of the difeafe. It is that variety of inflammation which originates from difeafe of the fyftem that proves moft obftinate, and which 'u, therefore, inoft to be dreaded, particularly that which occurs from fcrofula Sea. II. Diseases of the Eyes. 153 and lues venerea ; for we find by experience, that few fymptoms in either of thefe difeafes prove ever fo te- dious as thofe inflammatory affeaions of the eyes with which they are often attended. Whilft a venereal or fcrofulous afteaion fubfifts, it is in vain to expea a cure of any inflammation that may exift. Such rem- edies ought, therefore, to be employed as are known to prove moft powerful for the removal of the difeafe of the fyftem, at the fame time that we attend to the local treatment of the eyes. It is the management of this local afteaion that we are now to confider. In the treatment of inflamed eyes, the indications to be kept in view are, to remove any extraneous fuh» Stances that might tend to excite irritation ; to dimin- ish pain and irritability already induced; to remove the turgeScence of the blood velfels of the eyes; and to prevent a return of the difeafe. When inflammation is induced by fand, or any oth- er extraneous body aaing on the eye, nothing will prove materially ufeful, till the caufe of irritation is re- moved. With due pains, the eyelids may be fo far feparated with the fingers alone, as to admit of a clear view being obtained of a confiderable portion of the eyeball. But this will be more cffeaually done, if an affiftant, either with his fingers alone, or by means of a flat curved hook, fuch as is reprefented in Plate XIV. fig. 6. raifes the upper eyelid, while the furgeon himfelf depreffes the other. Any extraneous body difcovered in this manner, may be taken out with the end of a blunt probe, covered with a bit of foft linen or filk ; or, if any fharp pointed fubftance u fixed in the eye, it will be moft eafily removed with fmall for- ceps. It often happens, however, even when we are cer- tain, from the feelings of the patient, as well as from other circumftances, that the inflammation is kept up by fome caufe of this kind, that nothing is difcovered on infpeaion. In fuch circumftances, fome advantage is often derived from injeaing tepid water, or milk 154 Diseases of the Eyes. Chap. XL and water, between the eyelids and eyes, by which Sand and duft are often wafhed out, when they cannot be removed in any other manner : the eafielt and moft effeaual method of throwing in thefe liquids, is by means of a bag of elaftic gum; fitted with a fhort ivo- ry pipe. With this bag, a furgeon can eafily perforin all that is neceffary without affiitance, which with a common fyringe he cannot fo readily do. One of thefe bags, properly mounted, is reprefented in Plate XIV. fig. 3. In this manner, and by bathing the eyes frequently in warm water, they may, in general, be entirely clear- ed of all extraneous bodies: but, when the inflamma- tion has fubfifted for fome time, it often continues af- ter the caufe by which it was produced is removed ; in which event, other remedies muft be employed. When the pain is confiderable, and the pulfe quick, full, or hard, it becomes neceffary to take blood in proportion to the ftrength of the patient. The bow- els fhould be kept open with brifk purgatives ; a low diet fhould be continued for a length of time, propor- tioned to the violence of the difeafe ; the body fhould be kept cool; light fhould be" excluded from the eyes, and they fhould be conftantly covered either with foft linen foaked in a weak faturnine folution, or with ca- taplafms applied cold, compofed of this folution and crum of bread. In this manner, very fevere degrees of inflammation are often removed ; but cafes fre- quently occur, which refill thefe and all the remedies ufually employed. In fuch inftances, we find, that difcharging blood from the contiguous parts, or even from the blood veffels of the eye itfelf, proves fometimes ufeful, when all other means have failed. When a large quantity of blood is to be difcharged, it is done with moft ad- vantage from the jugular veins or temporal arteries; even the laft of which, as I have already endeavoured to fhow, may be opened with entire fafety.* In ad- » Vide Chapter VIII. Sect. 8. Sea. II. Diseases of the Eyes. 155 vifing local bloodletting, we do it either from the parts contiguous to the eyes, or from the veffels of the eyes themselves; and the means we employ for it are, cup- pi \ .\ and Scarifying the temples, leeches applied as near as poffible to the eyes, and fcarifying the blood veffels of the eyeball or eyelids. The operation of cupping and fcarifying, and likewife the method of applying leeches, have been already defcribed.f In a great proportion of cafes, an early and a plen- tiful diicharge of blood from the temporal artery or jugular vein proves fuccefsful; but, where ophthal- mia is either deep feated, or of long duration, I have commonly found, that little advantage is derived from our taking blood in this manner, and that no remedy anfwers fo well as a free diicharge of blood from the veffels of the inflamed eye. As this operation, how- ever, the divifion of the blood veffels of the eye, has always been confidered as nice and hazardous, it has feldom been praaifed; but any furgeon with a Stea- dy hand may perform it with fafety, and without in- juring the eye itfelf. Various methods have been propofed for dividing the veffels of inflamed eyes. It has been attempted with a brufh compofed of the beards of barley ; by drawing the Sharp fpiculee acrofs the part to be fcari- fied, a number of veffels are thus penetrated and di- vided. This was firft put in praaice by an EngliSh oculift, Mr. Woolhoufe, about the beginning of this century, and it was confidered as an improvement on the means which till then had been in ufe for the fame purpofe, from the days of Hippocrates and Cel- fus ; which were, rubbing the parts to be fcarified ei- ther with a piece of rough pumice Stone, or with the fpicula? oS thiftles, till the blood veffels were Sufficient- ly lacerated for discharging as much blood as was ne- ivilary. It has likewife been propofed to raife or ele- vate the veffels to be divided with the point of a nee- dle, and then, with fciffars or a Scalpel, to cut them acrofs. f Vide Chapter VIIL »5« Diseases of the Eyes. Chap. XL All'thefe modes, however, of fcarifying the eye, proceed from timidity ; they give much unneceffary pain, and they do not anfwer fo well as fcarifications made with a Sharp cutting instrument. Praaitioners have commonly been afraid of attempting this opera- tion with an inftrument of this kind; but any perfon accuftomed to chirurgical praaice, will find that it may be done both with eafe and fafety. In the hands of a Steady Surgeon, it may be done with the fhoulder of a common lancet; but, with a view to prevent the eyelids from being injured by one edge of the inftru- ment, while the eye is Scarified with the other, I have delineated a Small kniSe in Plate XII. fig. 4, and an- other in Plate XXIII. fig. 5, with either of which the operation may be done with fafety. In this operation, two afliftants are neceffary, one to Stand behind the patient, to fupport his head, and the other to fecure his hands. This being done, the furgeon, Handing or fitting before the patient, with the fore and middle finger of one hand fhould fepa- rate the eyelids, fo as to expofe as much of the eye- ball as poffible; whilft, with the inftrument I have mentioned in the other, all the turgid blood veffels fhould be divided. This is moft effeaually done by paffing the point of the inftrument below the enlarg- ed blood veffels, and thus cutting them from below upwards. In general, we wiSh to avoid the tranfpa- rent cornea in this operation, and to confine the fcar- ifications to the albuginea or cornea opaca ; but when the veffels of the tranfparent cornea are much diftend- ed, they may be divided with eafe and fafety. I have often found it neceffary, to divide the veffels of this part of the eye, and no inconvenience ever enfued from it. On the inflamed blood veffels being cut, we fhould endeavour to promote a difcharge of their contents; for which purpofe nothing anfwers fo well as bathing the eye in warm water, either by means of an eye- Sea. n. Diseases of the Eyes. *S7 cup, or with pieces of foft old linen, frequently im* merfed in the water. A plentiful difcharge of blood from the veffels of the eye often gives more relief in the pain arifing from ophthalmia, than any other remedy we employ. But when it either does not fucceed, or when not agreed to by the patient, opiates applied to the eye frequently anfwer. A few drops of a ftrong Solution oS opium in water being dropped into the eye, prove fometimes SucceSsful; but the common laudanum of the difpenfatories, particularly when wine is employed as the menftruum, proves often effeaual when the watery folution of opium has been ufed in vain. The pain arifing from ophthalmia, as well as every other fymptom which it excites, is frequently relieved by fhaving the head, and wafhing it from time to time in cold water. Blifters applied behind the ears, on the neck and temples, are in fome inftances ufed with advantage; alfo drains, formed either by pea iffues, or with a cord in the nape of the neck. In feme ftages of the difeafe, much diftrefs is expe* rienced from a thick vifcid fecretion, that glues the eyelids together. This takes place in fome degree in almoft every cafe of ophthalmia, particularly in the mornings, and when the tarfi or extreme borders of the eyelids are much inflamed. In this cafe, indeed, the inflammation foon terminates in a number of fmall ulcerations, which frequently may be diftinctly feen round the whole circumference of the cartilaginous border of the eyelids. From thefe this glutinous mat- ter, which in fome meafure is produced by the feba- ceous glands of thefe parts, is poured out in great quantities ; and unlefs fome means are employed for curing the ulcers, Scarcely any remedy will remove the inflammation of the eyes. A fmall portion of any emollient ointment, being from time to time inferted between the eyelids, proves often ufeful in preventing this vifcid matter from fix- ing them together; but the relief obtained in this 158 Diseases of the Eyes. Chap< XL manner proves only temporary. Some addition muft be made to the emollient for the purpofe of healing the ulcers from whence the matter is difcharged, oth- erwife no permanent advantage enfues from it; and when the difeafe is local, and not conneaed with Scro- fula, the cure of the ulcers will commonly be follow- ed by the cure of the inflammation by which they were produced. With this view the calx of zinc, or lapis calaminaris finely levigated, may be added to an equal quantity of an emollient ointment compofed of wax and oil; but no application proves fo generally ufeful as ointments of the mercurial kind ; and per- haps the beft of thefe is the unguentum citrinum of the Edinburgh Difpenfatory, mixed with an equal quantity of hog's lard, and made foft with oil ; or the blue mercurial ointment of different difpenfatories, prepared with quickfilver and lard. One ounce of quickfilver, triturated with Sour ounces oS lard, is, Sor this purpoSe, a very uSeful remedv. Every night and morning the ulceration on the eyelids fhould be cov- ered with a little of this, at the fame time that a fmall portion of the ointment fhould be inferted between the upper and under eyelids, while a weak faturnine or vitriolic folution fhould be employed once or twice daily, as a wafli. It is almoft unneceffary to remark, that no light fhould be admitted to the eyes, not merely while they continue inflamed, but as long as it excites pain : even when one eye only is inflamed, care fhould be taken to keep them both covered ; for we know from ob- fervation, that the expofure even of a found eye to light, while the other is inflamed, almoft conftantly proves hurtful to both. The eyes, however, fhould never be kept clofely tied down : by keeping them too warm, much harm is often done. They fhould be lightly covered with a loofe bandage either of filk or foft linen ; and when the patient is able to go abroad before his eyes can bear much light, the bandage in Plate XIV. figure 1, Sea. IL Diseases of the Eyes. 159 may be ufed with advantage: by means of it, the quantity of light admitted to the eyes is eafily regula- ted, whilft the eyes themfelves are neither compreffed nor kept too warm. By due perfeverance in this kind of coUrfe, local inflammation of the eyes is in moft inftances remov- ed ; but where it proceeds from, or is conneaed with fcrofula or lues venerea, no remedy will prove fuc- ceSsSul, till the diSeaSe of the fyftem is removed. With a view to prevent thofe frequent returns of ophthalmia to which many are liable, various reme- dies have been recommended, particularly aftringent lotions. They Seldom, however, anfwer any good purpoSe ; and when too ftrong, they are very apt to do harm. During the continuance of inflammation, we often derive advantage from bathing the eyes with weak folutions of fugar of lead, or white vitriol; but they have no effea in preventing a return of inflam- mation. For this purpofe, nothing that I have ever employed proves fo certainly ufeful as cold bathing. By keeping the head fhaved, and immerfing it daily in cold water, much may be done in preventing thofe frequent returns of inflamed eyes, to which many are liable. For the purpofe of applying local bathing to the eyes, different means are employed ; but the moft fim- ple and moft effeaual is by means of a cup, reprefent- ed in Plate XIV. fig. 2. This cup, which Should be of an oval form, and fomewhat larger than the eye, being filled with water, or any other liquid, and applied to the eye, if in this fituation the eyelids are opened and moved about, the whole furface of the eye will be thus elfeaually bathed. As a preventative of ophthal- mia, a liberal ufe of Jefuits' bark has alfo proved ufe- ful ; and we know from experience, that in periodi- cal returns of the difeafe, it is almoft the only remedy on which we have to depend. I need fearcely ob- ferve, too, when any caufe is difcovered by which in- flammation appears to be excited, or kept up, that it ought to be avoided ; for if this precaution is negfea- ed, no remedy will anfwer. l6o Diseases of the Eyes. Chap. XL SECTION III. Of Wounds of the Eyelids and Eyeball. AS the cure of wounds has already been treated of in Chapter II. it may be confidered as out of flace to enter upon any part of the fubjea again ; but judged it proper to referve for this place a more particular confideration of wounds of the eyelids and eyeball. In wounds of the eyelids, the parts may be divid- ed either in a longitudinal or tranfverfe direaion with refpea to the courfe of their mufcular fibres. If the fkin only is divided, or, if a wound penetrating the whole fubftance of the eyelid, is infliaed in fuch a manner as merely to feparate the fibres of the orbicu- laris mufcle from one another, all that we have to do is to draw the fkin and other divided parts exaaiy to- gether, and to retain them in this fituation with flips of adhefive plafter. As in fuch circumftances no re- traaion can take place of the divided parts, they are eafily retained ; and care fhould be taken that they are kept in this fituation till they unite. But when the orbicularis mufcle is cut tranfverfely, efpecially when a correfponding part of the tarfus or cartilaginous border of the eyelid is likewife cut, more care is requisite. If they are allowed to feparate much, fuch a want of tone in the eyelid is apt to take place, as ferves to interrupt its ufual motions : and again, if the divided parts are drawn too tightly together, they impede the motion of the eyeball. In tranfverfe wounds of the eyelids, it is fometimes " neceffary to employ futures. The interrupted future is ufually preferred; but the twifted future anfwers better. The method of performing thefe futures hav- ing been defcribed in Chap. VI. I have at prefent on- ly to remark, that m the praaice of either of them Sea. III. Diseases of the Eyes* 161 upon the eyelids, much nicety and delicacy is requir- ed, otherwife much harm may be done, not only to the eyelids, but to the eye itfelf. When the twifted future is employed, the pins fhould be fhort and fmall, fo as to run as little rifk as poffible of hurting the con- tiguous parts, and they fhould be made to pafs not on- ly through the fkin, but into the fibres of the orbicu- laris mufcle, otherwife little advantage will be gained by the operation : but they Should not be carried entirely through the inner membrane of the eyelid. This would irritate and inflame the eye ; and not be- ing neceffary, it ought to be avoided. If the fkin is properly retained in its fituation, with a few of the fibres of the mufcle underneath, a better cure will be obtained than if the needles were made to pafs through the whole fubftance of the eyelid ; for in this manner the aaion of the mufcle is preferved, whilft no rifk is incurred of the eyelid being too much contraaed ; a circumftance very apt to occur when the whole thick- nefs of the eyelid is penetrated by the futures. It is almoft unneceffary to obferve, that in order to enfure fuccefs from this operation, the motion of both eyes fhould be as much as poffible prevented, other- wife no union of the divided parts will be obtained; the eye will be irritated ; inflammation will occur; and this will render it neceffary to remove the futures before they have effeaed the purpofe for which they were employed. On the futures being finifhed, the eyelids fhould be clofed and covered with a pledget of lint or foft linen fpread with faturnine cerate, that the parts may be kept as eafy as poffible ; and a comprefs of lint being laid over it, and another over the found eye, the whole fhould be retained by a napkin over the head, tied in fuch a manner as to prefs equally and gently upon both eyes. Inflammation fhould be Strictly guarded againft ; or if it has already taken place, we muft en- deavour to remove it by the means pointed out in the Vol. II. M t62 Diseases of the Eyes. Chap. XL laft feaion ; and in the courSe of three days Srom the futures being inferted, they fhould all be removed ; for in this period, if the parts have been kept in con- taa, their union will be complete. We have hitherto been Suppofing, that the parts are only fimply divided ; and when replaced, that the eye is found to be as completely covered as beSore : but it Sometimes happens, that they are not only divided but deftroyed ; in which cafe, when fuch a portion of the eyelids is removed, as to prevent the parts that remain from being brought into contaa without im- peding the motion of the eye, it will be more prudent to leave them at fome diftance Srom each other ; and by treating them with light dreffings, to truft to na- ture for fupplying the deficiency, by a new produc- tion of cellular fubftance* The mechanifm of the eyelids is peculiarly adapted for the proteaion of the parts beneath from too free an admiffion of light, air, and duft; but no poffible ftruaure could prevent them from fuffering by inju- ries of a different kind : we accordingly find, that the eyeball is liable, like other parts of the body, to wounds, contufions, and other injuries. As the bones at the bottom of the orbit are in fome parts extremely thin, wounds of the eye which pene- trate deep prove dangerous from the near contiguity of the brain: but fuperficial wounds, that penetrate only the anterior part of the eye, although they may deftroy the beauty and utility of the organ, are not in other refpeas to be confidered as hazardous. Wounds of this part, however, of whatever kind they may be* require at all times the greateft care and attention ; not only with a view to,the prefervation of fight, but in order to prevent or obviate the effeas of inflamma- tion, a fymptom which they very commonly induce. Wounds of the tranfparent cornea, when direaiy oppofite to the pupil, moft frequently induce either a total or partial lofs of vifion ; for the cicatrix that fuc- ceeds very commonly remains opaque during life : Sea. III. Diseases of the Byes. j(>3 but although in this refpea wounds of the anterior part of the eye are always to be dreaded, they feldom inflame fo much as wounds of equal extent in the fclerotica or opaque cornea, which are always more painful, and produaive of more hazard. In other parts of the body, a fmall punaured wound is more to be dreaded than an extenfive cut; but in the eye, the rifk arifing from wounds is moft frequently in proportion to their extent; a circum- ftance which with furgeons ought to have influence in the preference which they give to the different opera- tions on the eyes : it is not the pain arifing from thefe operations to which I allude, and which frequently occurs in a greater degree from punaures than from very extenfive cuts; but it is the rifk induced by large wounds, of difcharging the humours xor contents of the eye, by which vifion, if not entirely deftroyed, fel- dom fails to be injured ; by which the eye is often fo much diminished, as to fink almoft to the bottom of the orbit: I Shall however, when treating oS cataraa, have occafion to confider this Subjea more Sully. In the treatment of wounds of the eyeball, to pre- vent or remove inflammation Should be confidered as our moft important objea. When a wound in the eye is large, it is fearcely poffible to prevent the hu- mours from being difcharged ; for the natural and ufual aaion of the mufcles neceffarily forces them out. In this cafe, no benefit is derived from the fkill of the praaitioner, and the ufe of the eye is immediately loft : but for one eye that is deftroyed in this manner, twenty are ruined by inflammation, either from its be- ing fo violent that no remedy can leffen or remove it, or from its being too eafily treated at firft, and allow- ed to proceed too Sar before the neceffary remedies are employed : in every wound, therefore, of this or- gan, all thofe means fhould be immediately advifed, which, by experience, we know to prove mcft effec- tual in the prevention of this fymptom ; but thefe M 2 164 Diseases of the Eyes. Chap. XL having already been fully mentioned in Seaion II. of this Chapter, it is not neceffary to enumerate them again. In wounds of the eyeball, the Struaure of the parts renders it impoffible to diminifh the extent of the opening: the parts in this fituation cannot, as in the eyelids* be placed in contaa, and retained with Su- tures : nothing of this kind being here admiffible, all that art can attempt, is, together with a ftria anti- phlogistic regimen, to keep the eye lightly covered with a pledget of any emollient ointment; to bathe it from time to time with a weak folution of leadj and when the pain becomes fevere, to give adequate dofes of opium. In extenfive wounds of the eye, attended with an entire difcharge of its contents, permanent blindneSs, with the uSual deformity induced by the finking of the eyeball, muft neceffarily fucceed ; but in wounds of leffer extent, we have it frequently in our power, by. due attention to the means that I have advifed, to remove fymptoms which otherwife might end in the greateft danger. SECTION IV. Of Tumors of the Eyelids. SMALL tumors occasionally form on the eyelids, which by impeding their motion, and rubbing on the globe of the eye, are apt to excite a great deal of diftrefs. ^ The contents of thefe tumors are various* and of different degrees of firmnefs. Towards the internal angle of the eye, and moft frequently on the under eyelid* near to the lachrymal punaum, fmall tumort are apt to form, chiefly of the inflammatory kind, and I Sea. IV. Diseases of the Eyes.' 165 in this country commonly termed the ftye.* They begin with a fenfation of fulnefs, fliffneSs, and uneafi- nefs in the internal canthus of the eye. At firft the fkin is Scarcely diScoloured; but if the tumor proceeds to fuppuration, it becomes firft of a pale red, and af- terwards yellow, when it commonly burfts and dis- charges a thick purulent matter. The ftye is a tumor altogether inflammatory, and fhould be confidered in- deed in no other light than a common boil or abfcefs. The only circumftances in which it differs from boils in other parts of the body, are, the colour of the fkin not being of fuch a deep red at firft, and its advancing more Slowly to fuppuration. This, however, proceeds evidently from the peculiarity of its fituation; for the matter being feated between the tarSus and internal membrane of the eyelid, the firmneSs of the cartilage prevents the fkin which covers it from being much diScoloured. TheSe are the tumors that prevail mofl frequently on the eyelids ; but they are alSo liable to others, in common with other parts of the body. The firft of thefe that I fhall mention is commonly of a round form, and fomewhat foft or compreffible: it feems to move or roll when preffed upon; the fkin retains its natural appearance ; and from the contents of it when laid open being of a fatty nature, we term it a fleatoma. The Soft white matter, of which thefe tumors are compofed, is always furrounded with a firm membranous cyft. Small tumors or excrefcences form occasionally on different parts of the eyelids, in fome inftances, with narrow pendulous necks; in others, with thin broad bafes. Some, being of a foft flefhy confiftence, are termed farcomatous tumors ; whilft others, being hard and firm, are denominated verrucas, or warts. In the treatment of the ftye or fmall boil, fo fre* quently met with near the internal angle of the eye. * This, is a variety of the Hordeolum of Sauvages and other nofologifts 166 Diseases of the Eyes. Chap. XL fome doubt has arifen of the propriety of bringing them to fuppuration; and by many it is even faid, that we fhould in perhaps every inftance, by means of vitriolic and other aftringent applications, attempt to remove them by refolution or difcuffion. Almoft the only reafon, however, that can be given for this is, the trouble of bringing them to fuppuration : but on con- fidering the advantage to be derived from it, and the hazard of injuring the eyelids, by frequently attempt- ing to repel what nature means to difcharge, we will not hefitate in the choice of our method of cure. By bringing thefe tumors to tuppuration, we incur indeed fome additional trouble ; but it is feldom confidera- ble : and as foon as matter is fully formed, if it does not burft and difcharge itfelf, opening the tumor with the point of a lancet procures complete relief, and the fore commonly heals quickly without further trouble, . As foon therefore as a Stye is clearly formed, we fhould endeavour, by a frequent renewal of warm emollient poultices, to bring the tumor to fuppurate, and then to difcharge the matter with a lancet, if it does not previoufly burft of itfelf. I know from ex- perience that the praaice is perfeaiy fafe; that the pain attending it is inconsiderable, and that it tends to prevent thefe tumors from ending in others of a more inveterate kind, which, in the ufual method of treating them, is apt to happen. After this kind of boil has Suppurated and difcharged its contents, bathing the parts with a weak faturnine or vitriolic folution proves ufeful; in the proportion of a grain of faccharum fa- turni, or vitriolum album, to each ounce of water: it tends to remove any uneafinefs that remains, and to reftore the parts to their ufual tone. All tumors of the eyelids of a firm confiftence, whether fteatomatous or warty, as they cannot be made to Suppurate, fhould be removed by excifion, as Soon as they impede in any degree the motion of the eye. As long as they remain Small, they are for the moft part inoffenfive, and are therefore overlooked; but Sea. IV. Diseases of the Eyes. 167 whenever they begin to increafe, they fhould immedi- ately be taken off. In all warty excrefcences of a fmall fize, as well as in thofe of the farcomatous kind, we are commonly advifed to remove them with cauftic ; or if the bafe is Small, to do it with a ligature. This, however, fhould never be done : no reafon indeed can be given for it but timidity either on the part of the patient or of the operator: whether we employ cauftic or ligatures, th« cure muft prove tedious ; they commonly excite in- flammation and irritability oS the eye, and they fre- quently give more pain than is ever done by the fcal- pel: in the removal therefore of thefe tumors, we fhould truft Solely to excifion, an operation neither at- tended with difficulty nor hazard. The patient being feated oppofite to a window, and his head fecured by an affiftant, if the tumor cannot be laid hold of with the fingers, a ligature fhould ek ther be paffed round it, or pufhed through it with a needle, in order to enable the operator to raife it by pulling it gently from the parts beneath ; and this be- ing done, if its bafe is narrow, it may be removed at once ; but when extensively attached to the neigh- bouring parts, it is better by flow diffeaion to enSure its total removal, than by proceeding quickly to incur the rifk oS allowing part of it to remain, or to require further trouble afterwards in removing it. On the operation being finifhed, a piece of foft lint fhould be applied to the fore, and retained with a flip of adhe- five plafter; by which the fore very commonly heals eafily, without further trouble. When, again, the tumor is of the fteatomatous or encyfled kind, inftead of diffeaing it off covered with the Skin that furrounds it, by which a troublefome un- Seemly cicatrix is always produced, it anSwers better merely to divide the Skin by a fimple incifion with a fmall fcalpel. This Should be done from one end of the tumor along the moft prominent part of it to the other; and a ftrong waxed thread being paffed through 168 Diseases of the Eyes* Chap. XL the centre of the cyft, this fhould be given to an af- fiftant, in order to Separate or raiSe it from the parts beneath, while the furgeon himSelf, with cautious dif- feaion, endeavours to feparate the fkin and cellular fubftance; and this being done, the tumor is eafily removed by the ligature. When, in the courSe of the operation, it has become neceffary to divide the internal membrane of the eye- lid, no dreffing fhould be applied to the fore, as the moft inoffenfive we could employ would irritate and inflame the globe of the eye. All that, in fuch cir- cumftances, Should be done, is, to lay the lips of the fore as nearly together as poffible ; and to remove as frequently as is neceffary, any Superfluous matter that may happen to form in it. But when it is found ne- ceffary to cut entirely through the eyelid, in order to render the cicatrix neat, the lips of the wound fhould be drawn together with the fingers,, and retained with flips of adhefive plafter till they unite. In the extirpation of theSe tumors, when the cyft is firm, and the contents of the Steatomatous kind, the bag fhould be preServed entire, as in this ftate it is more eafily and more effeaually removed by doing So than in any other manner : but whenever the cyft is thin, and eSpecially when the contents of it are fluid, it is commonly difficult, and in Some inftances impoS- fible, to Separate the teguments from it beneath, with- out laying it open. In this caSe, after dividing the fkin and cellular Subftance, by making an incifion along the moft prominent part of the tumor, it is bet- ter to open the cyft at once by a large punaure with the point of a lancet, in order to difcharge the matter contained in it, than to make any attempt, as is com- monly done, to preServe it entire ; by which, in Such circumftances, the operation is always rendered more tedious than it otherwise might be. Sea. V. Diseases of the Eyes. 169 SECTION V. Of Inverfion of the Cilia, or Eyelajhes.* THE eyelafhes are in fome inftances fo much in- verted, or turned inwards upon the eye, as to excite much pain, by rubbing or frejting the coats of it: in which cafe, it becomes neceffary to remove. them. This inverfion of the cilia is produced by different caufes : in fome cafes, it proceeds from a derangement of the hairs themfelves, which leaving their ufual di- reaion turn in towards the eyeball: but more fre- quently it is produced by a caufe of a more diftreSsSul nature, an inverfion of the tarfus or cartilaginous bor- der of the eyelid : this again is moft commonly in- duced either by an unequal fpafmodic afteaion of the orbicularis mufcle of the under eyelid; for it is not frequently met with in the upper palpebra : or it oc- curs as the effea of a cicatrix upon the fkin of this part, the confequence of fome previous injury: in fome inftances, it is produced by tumors, forcing the eye- lashes in upon the eye; and a relaxation of the exter- nal teguments of the eyelid has likewife been fuppofed to induce it. As the caufe of the difeafe is various, fo it is evident that the means of cure muft likewiSe be So. When it is found to originate Solely from a derange- ment of the cilia themSelves, without any inverfion of the eyelids, we are direaed by authors, in the firft place, to pull out the inverted hairs with Small pliers ; and to prevent them from growing again, we are de- fired to burn their roots either with lunar cauftic, or with the end oS a red hot wire. Nay, Some have pro- * The Trlehiafis and Entropium of authors. 170 Diseases of the Eyes. Chap. XL pofed that the whole cartilaginous edge of the eyeli4 in which the hairs are placed, fhould be entirely de- ftroyed with cauftic. The pain and inflammation of the eye, induced by an inverfion of the cilia, is in fome inftances indeed fo diftreSsful, and it is fo difficult to prevent them from rubbing upon the eye, that none who have feen how obftinate they often are, will be furprifed at the atten- tion with which by many authors they have been coni fidered : but it fortunately happens, that none of the painful remedies that I have mentioned are neceffary ; for the fame intention may in almoft every inftance be accomplifhed by means of a more fimple nature. When the eyelafhes have remained long in a de- ranged ftate, and have acquired their full ftrength and elasticity, it is altogether impoffible to bring them again into a proper direaion. In fuch circumftances, therefore, they fhould all be pulled out by the roots ; for to cut them over, as is fometimes done, tends on- ly to make them ftronger and fharper than they were before. This being cautioufly done* with fmall forceps or pliers, relief is thus commonly obtained immediate- ly : but unlefs we can prevent the new hairs from taking a fimilar direaion, they very fpeedily advance fo far as to induce a return of the difeafe. Nothing* however, can be done for this, till the new hairs have acquired fome length ; but as foon as they are about half their ufual length, and whilft they are yet more foft and pliable than they afterwards become, by turn- ing them down upon the eyelid with the end of a blunt probe, and retaining them in this fituation for two or three weeks, either by covering them with narrow flips of adhefive plafter, or with ftrong mucilage or glue by means of a fmall pencil, a complete cure may thus be commonly obtained. Much attention is neceffary, indeed, in order to enfure fuccefs ; more, it muft be acknowledged, than the difeafe commonly meets with : but due perfeverance in the means I have mentioned, will in almoft every inftance anfwer; and being an Sea. V. Diseases of the Eyes. 171 eafy method of obtaining relief in a very painful affec- tion, nothing fhould be omitted that can tend to ren- der the praaice of it frequent and more certain. When, again, the difeafe appears to originate from an unequal fpafmodic exertion of the orbicularis muf- cle of the eyelid, no danger can enfue from making a flight incifion on the internal furface of the under pal- pebra, of fuch a depth as to divide thofe fibres of the mufcle that appear to be contraaed, and by which the inversion of the cilia is produced. The only incon- venience that this can produce, is fome degree of ftiff- nefs or. immobility in the under eyelid, but which could not, even in the worft degree of it, be of much importance : and as no other remedy could in this va- riety of the difeafe prove ufeful, we fhould not hefitate to advife it. If, then, thofe fibres of the mufcle that appear to be preternaturally contraaed are freely di- vided, a cure of the difea e will be obtained, and the incifion will readily heal, without any dreffings being applied. In this fituation, indeed, no dreffing can with propriety be employed; but experience Shews that it is not neceffary; for a cut in this part com- monly heals eafily. When the cilia are found to be pulhed in upon the eye, either by a tumor or cicatrix of fome old fore, no cure can be obtained till the caufe is removed. When produced by a tumor, this muft be extirpated in the manner pointed out in the laft feaion ; and when an old cicatrix falls to be removed, we do it by making an incifion with a fcalpel fo as to furround the whole of it, and afterwards in a Slow cautious manner diffect it off. When the preffure produced by the cicatrix has been the fole caufe of the cartilage being turned inwards, the removal of the cicatrix will in general re- move the difeafe ; and in this caSe the Sore may be healed in the uSual manner with eaSy dreffings. But when it is found that the direaion of the cilia is not immediately altered upon the cicatrix being removed, the lips of the fore Should be drawn together, fo as to 172 Diseases of the Eyes. Chap. XL bring the edges of the divided fkin into contaa ; and in this ftate they fhould be Secured either with flips of adhefive plafter; or when this does not anSwer, it may be done either by the twifted or interrupted fu- tures : by which means the points of the eyelafhes may be turned entirely outwards, fo as to accomplifh in the moft complete manner the intention of the oper- ation. It has alfo been fuppofed, as I have already remark- ed, that this difeafe may be produced by the external fkin of the eyelid being too much relaxed. This, however, is what I never met with; and as we cannot fuppofe that thefe parts are retained in their fituation by any exertion of the fkin alone, it is not probable that any relaxation to which it is liable can have much influence in giving them a wrrong direaion; but if the contrary fhould ever be the cafe, the remedy to be employed is obvious: if the difeafe is of fhort du- ration, and the relaxation and lofs of tone in the fkin not confiderable, bathing the parts frequently with a ftrong folution of alum in an infufion of oak bark, or with any other aftringent, may leffen or remove it; but when this does not anSwer, our only reSource is to remove all the relaxed fkin with a Scalpel: this being done, we draw the edges of the cut together, and re- tain them till they unite, either with adhefive plafters, or futures* in the manner already pointed out. An inverfion of the cilia conftantly excites, as I have already obferved, inflammation of the eyeball: this fymptom, however, commonly Subsides on the hairs being removed; but when this does not happen* thoSe means muft be employed which uSually anfwer beft for the removal of inflammation of the eyes, by whatever caufe it may be induced. Thefe having been enumerated in Seaion II. of this Chapter* it is not neceffary to fpeak of them here. I have already obferved, that the inverfion of the cilia occurs moft frequently in the under eyelid. In fome inftances, however, we meet with it in the up- Sea. V. Diseases of the Eyes. "73 per palpebrae; and in Such caSes it is Scarcely neceffa- ry to remark, that the diSeaSe being exaaiy fimilar both in its cauSes and effeas, the means employed for removing it Should be the fame. In the upper eye- lid, a fwelling occafionally occurs over the whole of it, by which the ufual and natural exertion of its muf- cles is either much impeded, or perhaps entirely inter- rupted, and by which, too, the eyelaShes may be fo far inverted, as to produce this difeafe. In fuch ca- fes, as the fwelling of the eyelid is commonly of the dropfical kind, it is more readily removed by two or three Small punaures with the point of a lancet than by any other means: but when this does not prove fufficient, if it appears to be perfeaiy local, and not conneaed with an anafarcous fwelling over the reft of the body, rather than allow vifion to be much in- terrupted by a continuance of the fwelling, it has been propofed to cut out a fegment of the moft prominent part of the Skin, to difcharge any water that may be contained in it, and to reunite the divided edges of the fore with futures. Nay, much time and ingenui- ty has been employed in the invention of inftruments for effeaing this operation neatly, and without much lofs of blood; an occurrence, which in former times was always much dreaded. This fhould, indeed, be guarded againft as far as is neceffary ; but in the ope- ration of which we are fpeaking, it can never require much attention, for none of the blood veffels in thofe parts are of a fize that can render it dangerous to di- vide them. The inftrument to which I allude aaed folely by preffure: all the fkin meant to be removed being in- cluded between two thin plates of brafs or fteel, a de- gree of preffure fufficint to deftroy the circulation in the contained parts was applied and continued by means of a fcrew till the whole dropped off; but as the operation may be both more neatly and more fpeedily done with a Scalpel, it ought in every inftance to be preferred. In whatever way it is done, as much 174 Diseases of the Eyes. Chap. XL of the Skin Should be removed as appears to be fuper* fluous. If the edges of the fore, on being brought to- gether, can be retained with adhefive plafter, it ought to be done ; but when plafters do not anSwer, we have recourfe to the interrupted Suture. SECTION VL Of the Gaping or turning Outwards of the Eyelids. THIS deformity is produced by the internal fur- face of one or both of the eyelids being turned outwards fo as to fold over fome part of the cilia and contiguous fkin: by nofologifts it is in general term- ed earopium ; and lagophthalmus when in the upper eyelid only, Srom the reSemblance which it is SuppoS- ed to bear to the eye of a hare. Every degree of" this affeaion occasions deformi- ty ; fo that even in this view it merits attention: but in its more advanced ftages it frequently gives much diftrefs, by leaving a confiderable part of the eye un- covered. The internal membrane of the eyelids may be turn- ed outwards by various caufes: tumors of whatever nature they may be when feated within the orbit, fome- times produce it: it is alfo induced by dropfical effu- fions in the cellular fubftance that covers it; and like- wife by inflammation of the fame part. Relaxation, induced either by an inflamed ftate of this part, by a previous dropfical fwelling, or merely .as a confe- quence of old age, excites the moft obftinate kind of it: and laftly, we find it often induced by the cica- trix of a wound or abfcefs, when fo fituated as to cor- rugate or contraa the fkin of either of the eyelids. In the method of cure it is evident, that due attention becomes neceffary to the particular caufe by which it is produced. Sea. VL Diseases of the Eyes. 175^ When tumors are difcovered to be the Caufe, they muft be removed in the manner pointed out in Sea. IV. of this Chapter. When they appear to be drop-. fical, conneaed with general anafarca, if the difeafe of the fyftem is carried off, this particular fymptom will mofl frequently vanifh alfo ; but when it appears to be local, as in fome inftances is the cafe, no depen- dence is to be placed on medicines : in this cafe, the effufed tfuid fhould be difcharged either by punaures or fcarifications, not made through the external cov- erings of the eyelids, but direaiy into that part of the internal membrane that is protruded by the water colleaed within it. Small punaures fhould be firft advifed with the point of a lancet; and if thefe fail, fcarifications fhould be made with one or other of the inftruments delineated in Plate XII.- fig. 4* or in Plate XXIII. fig. 5, all along the courfe of the fwelling ; and being carried to a fufficient depth, they will not only difcharge the effufed water, but the inflamma- tion which they excite will tend to prevent it from colfeaing again : after the water is difcharged* and any inflammation induced by the operation is gone, the. parts fhould be frequently bathed with a weak fo- lution of white vitriol, or any other aftringent colly- rium. In cafes of earopium induced by inflammation, our means of cure fhould be chiefly direaed to the re- moval of this fymptom ; and, for the moft part, when not long negfeaed, or not particularly obfti- nate, the protrufion will Subfide on the inflammation being removed. But when the inflammation has fub- fifted long, the protrufion often continues fixed and permanent long after the caufe that gave rife to it is gone : whenever the difeafe therefore depends upon this caufe, we fhould endeavour by the moft active remedies to have it fpeedily carried off. In Seaion II. of this Chapter, thefe have been fully enumerated : I have now therefore only to remark, in addition to the means that were there pointed out, that deep fca- 176 Diseases of the Eyes. Chap. XL rifications into the inflamed membrane itfelf prove here particularly ufeful. The veffels of the protruded membrane are in this ftate of the difeafe commonly fo turgid as to give it a confiderable degree of preternat- ural thicknefs : if this increafe of bulk be not remov- ed, no cure can take place ; and nothing tends with fuch certainty to accomplifh this, as unloading the in- flamed veffels of their contents ; which we do in the moft effeaual manner by deep fcarifications. When again, the difeafe occurs from relaxation, as is often the cafe in advanced ftages of life, no chirur* gical operation fhould be advifed. In this fituation we truft altogether to palliatives. The patient fhould be defired to bathe his eyes daily in cold water, or in water mixed with a fmall proportion of brandy ; or he may ufe a weak aftringent collyrium of vitriolum album and faccharum faturni diffolved in water. In this manner, he may prevent the difeafe from advanc- ing farther, and in fome inftances may even be able to "remove it. But whether this fhould be the cafe or not, when it is evidently the effea of old age, nothing very fevere in its operation Should ever be advifed. The moft diftrefsful, and perhaps the moft frequent caufe of earopium, is the cicatrices of fores, abfceffes, and the confluent fmall pox, when fo fituated as to contraa the fkin of either of the eyelids. A cicatrix may be fo fituated, as we have feen in the laft feaion, as to produce an inverfion of the cilia. Of this I have met with different inftances, but it more fre- quently happens, that the difeafe we are now consid- ering is induced by it. As the diSeaSe is here evidently induced by a pre- ternatural contraaion of the fkin conneaed with the eyelid, nothing can accomplifh a cure but the divifion of fuch parts of the fkin as are thus morbidly drawn together. For this purpofe, the operator, by an at- tentive examination of the parts affeaed, fhould ren- der himfelf perfeaiy certain of the full extent of the difeafe; and this being done, an incifion fhould be / SecV VI. Diseases of the Eyes* tff made direaiy acrofs that part of the fkin which ap- pears to be contraaed, and carried freely into the cel- lular fubftance by which the fkin is conneaed to the parts beneath. When the contraaion takes place at one point only, a free divifion of the fkin at this part will be fufficient; but it commonly happens, that the Skin is fixed to the parts beneath over the whole courfe of the cicatrix; in which event, a fmall inci- fion, in the manner I have mentioned, and with which operators in general reft Satisfied, will have little or no effea in removing the difeafe. In this cafe, after making an incifion through the teguments from one end of the cicatrix to the other, the edge of the divided fkin fhould be raifed with the affiftance of diffeaing forceps, and the whole of it fhould be feparated and removed with the Scalpel from the parts to which it adheres. If this is proper- ly done, that part of the eyelid that was turned out- wards, will either return of itfelf to its natural fitua- tion, or it may be eafily replaced by the operator; and this being done, the reft of the cure muft confift in fuch an application of a bandage, or of flips of ad- hefive plafter, as will retain the fkin, till by the for- mation of granulations at the bottom of the fore, any farther contraaion may be prevented. To give di- reaions for the application of bandages is unneceffary, as it muft always depend on the ingenuity of the operator. In general, however, I may remark, that when flips of adhefive plafter can be made to anSwer the purpofe of bandages, they ought to be preferred for parts contiguous to the eyes, where bandages can never be applied with fuch tightnefs as to retain the dreffings, without injuring the parts beneath. Vol. IL N- 178 Diseases of the Eyes. Chap. XL ^ SECTION VII. Of Concretion of the Eyelids. IT has long been known, that any two parts of an animal body being kept in contaa when inflamed, very readily unite together ; a faa that accounts for many phenomena, and among others for thofe adhe- fions of the eyelids that fometimes fucceed to an in- flamed ftate of thefe parts. Inflammation of the eye- lids, when of long duration, frequently forms partial adhefions, not only of the eyelids to each other, but to different parts of the eye itfelf: to flight degrees of this, a patient will commonly rather fubmit, than un- dergo the pain and terror of an operation ; but when the adhefions are fo confiderable as to impede the motion of the eyelids, and thus to obftrua vifion, it becomes neceffary to employ the moft effeaual means for relief. It fometimes happens, too, that the eye- lids adhere together at birth, of which I have met with different inftances. When the adhefion is flight, and not of long dura- tion, it may in general be removed by Separating thoSe parts of the eyelids that adhere, with the end of a blunt probe paffed behind them * but when they ad- here either firmly to each other, or to the eyeball, a cure can be effeaed by diffeaion only. In perform- ing this operation, the patient's head ihould be firmly fecured by an affiftant, who fhould likewife endeav- our to fupport or elevate the upper eyelid, whilft the Surgeon, with fmall forceps in one hand, fhould raife or feparate the under palpebra, and at the fame time fhould proceed to divide with a fcalpel in the other, every fibre by which the adhefion is produced. In every part of the operation, much fteadinefs is requir- ed ; particularly where any part of the palpebne ad- heres to the eveball. Sea. VIIL Diseases -of the Eyes. 179 When the caufe of adhefion is thus completely re- moved, as the dreffings ufually applied to fores can- not with propriety be ufed here, all that we Should attempt, is to cover the eye with foft lint fpread with Goulard's cerate, or any other emollient ointment; and after the firft dreffing, a fmall portion of the fame ointment, perhaps the fize of a pea, may be daily in- finuated between the eyelids : by this means the fore is kept foft and eafy, at the fame time that the ufual motion of the eyelids prevents every rifk of new ad- hefions between the parts newly divided. In this, however, as well as in every operation upon the eye, the ftruaure of which is fo delicate as to render it very fufceptible of inflammation, much attention is neceffary to prevent this fymptom, and to remove it when it has aaually taken place. SECTION VIIL Of Fleffy Excrefcences on the Cornea. EYES that have been liable to repeated attacks of inflammation, are apt to have a membranous fubftance form on fome part of the opaque cornea : this, in fome inftances, continues of a fmall fize, and does not produce much inconvenience, while in oth- ers it extends fo as to form a ring round the whole tunica conjunaiva, and even fpreads to fuch an ex- tent as to cover not only all the opaque cornea, but even the tranfparent part of the eye. Being fuppofed to refemble a fowl's wing, it has by fome been termed pterygium, and by others onyx, from its refemblance to the nail of a finger : it begins moft frequently near the internal angle of the eye ; but in fome we firft perceive it on the moft prominent part of the tunica albuginea. N 2 I So Diseases of the Eyes. Chap. XI. In fome inftances of fevere inflammation, a tough yellow coloured membranous fubftance forms and fpreads over the whole eyeball: this, however, is per- feaiy inorganic, and is evidently of the fame nature with thofe crufts or exfudations fo frequently met with in parts recently inflamed : but the difeafe we are now considering confifts of an organic membranous fubftance, that is equally irritable with other parts of the body, and which, when wounded, difcharges blood freely. It is indeed fo clearly vafcular, as to render it probable that it confifts entirely of a congeries of fmall blood veffels, which being once forced out from any point of the ball of the eye, either as a confe- quence of external violence or of inflammation from any^other caufe, we can eafily fuppofe that every frefh attack of inflammation will caufe them to pullulate or fhoot out in a degree fomewhat proportioned to the violence of the caiife by which it is produced. In fome inftances, this produaion does not appear till the violence of the inflammation is over: in which cafe, it is not accompanied with pain, unlefs when fome caufe of irritation is applied to it; but in others it takes place during the continuance of inflammation, when the pain attending it is always fevere. During this inflammatory ftate of the difeafe, this membrane is in general of a deep red colour ; but when the in- flammation fubfides, it becomes pale and fomewhat yellow. As long as this kind of excrefcence continues of a moderate fize, and does not impede the motion of the eyelids, nor obftrua vifion, all we ought to do is, by means of gentle aftringents, to endeavour to pre- vent its increafe. In Seaion II. of this Chapter, 1 have faid all that appears to be neceffary on the fub- jea of inflammation. I fhall now therefore fuppofe that the inflammatory fymptoms are, by the means which were then pointed out, either removed or much mitigated, and that our attention is now to be direaed to the removal of this preternatural membranons pro- Sea. VIIL Diseases of the Eyes. 181 duaion. In this ftate of the difeafe, aftringent appli- cations, as I have obferved above, ought to be alone depended on as long as the fize of the excrefcence is inconfiderable. A weak folution of corrofive Subli- mate, in the proportion of a grain to four ounces of water, has fometimes proved ufeful; but in general, nothing anfwers either with fuch certainty or fafety as white vitriol, or alum, diffolved in water, care being taken to have the folution of fuch a ftrength as the eye can eafily bear. A feruple of white vitriol, or half a drachm of alum, to four ounces of water, will in general prove fufficiently ftrong : but in every cafe, the Strength of the remedy ought to depend on the feelings of the patient; for with fome it may be em- ployed of double the ftrength which others can bear. A proper uSe oS eScharotic powders has alSo proved uSeSul here ; but in this form, efcharotics require to be ufed with much caution. Calcined alum in fine powder, a fmall proportion of white vitriol, or of verde- gris, mixed with a fufficient quantity of white fugar, or any other powder of a mild nature, may all be ufed for this purpofe. A fmall quantity of any of thefe may be fprinkled upon the difeafed part once or twice daily, and repeated as long as any benefit is de- rived from them ; or the ufe of the powders may be alternated with that of the wafh in the manner I have mentioned. A due perSeverance in the ufe of thefe remedies will very commonly retard, as I have obferved above, the progrefs of the excrefcence ; but when it proves oth- erwife, and when it proceeds fo far as to cover any part of the tranfparent cornea, as this might foon be attended with a total lofs of fight, other means fhould be employed. As our objea here is to remove the excrefcence en. tirely, the fcalpel alone is to be trufted. Authors, who have written on this fubjea, defcribe an operation for the purpofe of removing membranes of this kind by diffeaion. When the excrefcence is loofe througli 182 Diseases of the Eyes. Chap. XL a confiderable part of its extent, and attached to the eye by a fmall pedicle only, it may be removed with fafety and expedition with a Scalpel; and in fuch caf- es, this method Should be preferred to every other. But whenever it adheres to the eye over its whole fur- face, to remove it by diffeaion is both difficult and hazardous ; and as the fame intention may be carried into effea by more gentle means, thefe ought to be adopted. This excrefcence is very commonly feated, as I have already obferved, upon fome part of the tunica con- junaiva, and approaches in a gradual manner towards the centre of the eye : we have likewife feen that it confifts almoft entirely of an extenfion or elongation of a number of fmall blood veffels: hence we may conclude, that nothing will tend with more certainty to remove it, than the deftruaion or divifion of thofe veffels by which it is produced: and accordingly I have in various inftances been able to complete the cure of fuch affeaions by thefe means alone ; and as the operation for this purpofe, with thofe accuftomed to perform it, is neither attended with difficulty nor danger, it ought always to be done as foon as the dif- eafe is found to refift the means ufually employed for it. The method of performing it is this : the patient being placed upon a pillow on the floor, the furgecn, fitting behind on a chair, fhould caufe him to incline his head backwards upon his knees, with his face raif- ed in fuch a manner that a fufficient degree of light may fall direaiy upon his eyes. This being done, and the patient's hands properly fecured, the under eyelid fhould be drawn down by an affiftant, while the upper palpebra is fupported in fuch a manner by the left hand of the furgeon, as to expofe to view the full extent of the difeafe on the eyeball. With the knife, fig.*^. Plate XII. he is now to make fcarifications through the full thicknefs of the excrefcence, near to, and entirely round, its external circumference, fo as to. cut off all communication between the roots and Sea. VIIL Diseases of the Eyes. 183 extremities of thofe veffels of which it is formed. This may either be done by one continued ftroke oS the Scalpel, or with repeated Smaller Scarifications ; and in order to render the Succefs of the operation more cer- tain, by a free divifion being made of every blood vef- fel conneaed with the excrefcence, after the difcharge of blood induced by the firft incifions is abated, one, two, or more circular fcarifications may be made with- in one another, in fuch a manner as that the laft may be contiguous to the centre of the excrefcence. In making thefe fcarifications, it is neceffary to avoid the eyeball; for which reafon, it is better to do the incifions by repeated Strokes, than to go to the full depth of the excrefcence at once; but it may be done with much more eafe in the manner I have mention- ed, than by lifting the excrefcence with a needle and ligature before dividing it; for we may juft as readily injure the coats of the eye with the needle as with a fcalpel. This method of elevating the parts to be di- vided by means of a ligature, is much recommended by fome praaitioners ; but I know from experience, that the operation may be performed with more eafe in the manner I have pointed .out. After as many incifions have been made as appear to be neceffary, the parts may be allowed to bleed freely, and may be afterwards bathed two or three times daily with a weak folution of faccharum faturni. The incifions may alfo be repeated in a fimilar man- ner, if, in the courfe of a few days, the excrefcence does not begin to diminifh; and the fame operation may be renewed with fafety from time to time, as long as any part of the difeafe is found to remain. When, again, any portion of the excrefcence is ob- ferved to become more looSe in its conneaion with the eye, either in conSequence oS the number of inci- fions made in it, or of the fuppuration which com- monly enfues from this operation, it ought immedi- ately to be removed with the fcalpel: but when this does not happen, and when every part of it continues 184 Diseases of the Eyes. Chap. XL ftill to adhere firmly to the eye, no attempt fhould be made to remove it. When a cure can be effeaed by any means hither. to known, the plan that I have mentioned will more readily anfwer than any other; and being attende4 with no hazard to the eye, it ought to be preferred. But it is neceffary to remark, that although this oper, ation very commonly fucceeds, yet inftances Sometimes occur, in which no advantage is derived Srom it, an4 in which Scarifications made in the excrefcence, or any pther operation performed on it, inftead oS proving ufeful, is regularly attended with an increafe oS the clifeafe. This being the caSe, the operation I have de- Scribed fhould not be perfifted in. In fuch circum- ftances, a palliative courfe ought alone to be kept in view. No remedy with which we are acquainted, will in this ftate rejnove the difeafe, but it may commonly be prevented from acquiring any additional increafe; and the fymptoms induced by it may be kept moder- ate, by the eye being frequently bathed with a weak faturnine folution, and by keeping it covered with pledgets of Goulard's cerate, or any other fimilar ap^ plication. When it is found, however, that the difeafe does not yield to any of the remedies I have mentioned, and if the excrefcence ftill proceeds to acquire an ad- ditional bulk ; So as entirely to deftroy vifion, and to excite Severe pain, as this will give much cauSe to SuS- pe6t that it may degenerate into cancer, it ought at once to be removed by extirpating the eyeball. The remedy is no doubt Severe : but in circumftances Such as we are deScribing, as the uSe oS the eye is Suppofe4 to be irrecoverably loft ; and as the patient's life might be endangered by the contiguous found parts being allowed to remain long in contaa with thofe that ar« difeafed ; no doubt fhould be entertained of the pror priety of removing them. The method of performing this operation will be the fubjea of one of the follow- ing feaions. Sea. IX. Diseases of the Eyes. 185 SECTION IX. Of Abfceffes in the Globe of the Eye. INFLAMMATION of the eyes is by experience known to terminate moft frequently by refolution ; that is^ the pain and tenfion abate, and the redneSs and fulneft of the veffels are difcuffed, without any marks being left of their having ever exifted. Inftan- ce, however, occur of inflammation of the eye end- ing in the formation of matter ; in fome cafes, from thofe means being omitted at firft which moft certainly tend to remove inflammation ; and in others, from the patient being of a fcrofulous habit or otherwife dif- eafed. When the internal furface of the coat of the eye has been long inflamed, it fometimes yields a purulent like matter, which being poured into one or other of the chambers of the eye, is foon diffufed over all the aqueous humour ; by which the ball of the eye not o:.ly becomes enlarged, but vifion is either in a great meafure or perhaps entirely deftroyed ; the appearance of the eye is much changed ; and neither the iris, pu- pil or cryftalline, can be distinguished. In Some inftances again, the iris is pufhed forward, and is obServed to lie in cloSe contact with the inter- nal Surface of the tranfparent cornea : the coats of the eye being weaker here than in other parts, a protru- fion commonly takes place, which, if not foon open- ed, at laft burfls of itfelf, and discharges either fome part or perhaps the whole contents of the eye ; and at this opening, the iris, in a thickened difeafed ftate, is very generally pufhed out. It is this difeafe which, from its fuppofed refemblance to a grape, is denomi- nated Staphyloma ; different varieties of which are de- fcribed by authors under different names : but, as thefe are all of a fimilar nature, and require the fame meth- 186 Diseases of the Eyes. Chap. XL od of treatment, any difference or form from whence thefe denominations have been taken, is not of fuch importance as to deferve notice ; and as the distinc- tions they hold forth, anfwer no good purpofe, I do not mean to enumerate them. Under the general term of ftaphyloma, a word I fhall retain merely from its having been long employ- ed, may be comprehended all colleaions, fuch as I have defcribed, that take place within the cavity of the eye. In moft inftances, as I have already obferv- ed, the tranfparent cornea is protruded from its being the weakeft part of the eye; but in others, partial fwellings or protrufions' occur in the Sclerotica, or opaque cornea. During the formation of this difeafe, the patient fuffers not only lofs of fight, but fevere pains in the eye, that Shoot backwards through the head, attended with want of reft, heat, and other fymptoms of fever ; and thefe very commonly remain either till the eye burfts of itfelf, or till its contents are difcharged by an opening made for the purpofe. In moft inftances, the pain is fevere, but I have met with cafes in which no other inconvenience was expe- rienced but deformity and lofs of fight; but in theSe, any matter that forms in the fwelling is in fmall quan- tity, and the principal part of the tumor appears to be produced by ferum ; and in fome inftances perhaps by an increafed fecretion of the aqueous humour of the eye; but, whether it contains a greater or fmaller proportion of pus, the external appearances are the fame, and the method of treatment is likewife fimilar. Befides the colleaions I have defcribed, in which the matter is lodged within the coats of the eye, this organ, we find, is liable to abfceffes of a different na- ture, in which the matter is feated in the fubftance of one or other of its tunics. In the fmall pox, it fome- times happens, that a puflule is feated on the eyeball, when the variolous matter being formed between two of its coats, gives all the appearances of a fmall abfeefs: Sea. IX. Diseases of the Eyes. 187 but colleaions of pus alfo occur here from external injuries ; and from inflammation, by whatever caufe it may be induced ; although by no means fo frequent- ly, as I have already remarked, as in other parts of the body. This difeafe has, in general been termed hypopion. ' It ought not, however, to be diflinguifhed by any par- ticular appellation ; for, it is precifely an abfcefs in the coats of the eye, and exhibits exaaiy the fame appear- ances here, and requires to be treated in the fame man- ner, as colleaions of matter in any other part. The matter in this difeafe is met with in various parts of the eye ; in fome inftances in the Sclerotica ; but moft frequently in the tranfparent cornea, when it very commonly deftroys vifion entirely. The hypopion is distinguished from the Staphyloma by the matter being colleaed in a particular bag or cyft ; at leaft it is always confined to one part of the eye, which is obferved to be elevated into the form of an ordinary abfcefs, whilft the reft of the eye retains its ufual form : but in the other, although the matter always at laft forces out fome protuberance ; moft fre- quently, as I have already obferved, in the tranfparent cornea; yet an enlargement may be commonly ob- ferved over the whole fubftance of the eyeball: in both, the motion of the eyelids is much impeded ; but, in the Staphyloma, this is always more confiderable and more diftrefsful than in the other, and in it alfo a fenfe of tightnefs is felt over the whole globe of the eye ; whereas, in the hypopion, this uneafinefs occurs at a particular point only. In the latter, the pain is feldom fo fevere as when the matter is colleaed with- in the ball of the eye. Any uneafinefs produced by it, affeas the furface of the eye only, and does not fpread back towards the head as it commonly does in the Staphyloma. In-the treatment of the ftaphyloma, as it rarely happens that the ufe of the eye can be preferved, our great objea fiiould be to abate the violence of the i88 Diseases of the Eyes. Chap. XL pain, and remove that deformity which an enlarge- ment of the eye is always fore to produce. With a view to abate the pain, bloodletting, blifters, cooling applications to the eye, and opiates, are to be chiefly depended on at firft : in this ftage of the difeafe, in- deed, the pain is to be confidered entirely as the ef- fea of inflammation, and to be accordingly treated in the manner I have pointed out in Seaion II. of this Chapter. But when thefe and the other means employed for abating inflammation do not fucceed ; if fuppuration takes place ; and if the pain ftill continues fevere, as this very commonly occurs from the coats of the eye being diftended ; nothing will fo certainly give relief, as difcharging the matter by making an incifion into the ball of the eye. This will commonly indeed eva- cuate all the humours of the eye, particularly the aqueous humour ; but in circumftances fuch as we are defcribing, this is not to be regarded, as vifion is already totally deftroyed by the difeafe. We are therefore to ufe the moft effeaual means for remov- ing pain, and for obviating the deformity induced by the enlargement of the eye, without any regard to the humours which it contains. For this purpofe, an opening fhould be made in the eye fufficiently large for difcharging all the thinner part of its contents, the beft fituation for which is the moft depending part of the tumor. The patient's head being fecured by an affiftant, and the operator Handing before him, the eyelids may be fufficiently feparated with the fingers of one hand, while the point of the knife, figure 4, Plate XII. being introduced with the other into the part to be opened, it may be eafily carried forward in a horizontal direaion, till an opening is made of a fize fufficient for the purpofe. Authors who have written upon this fubjea, in- ftead of a Simple incifion into the tumor, direct all the prominent part of the eye to be cut off either with a fcalpel or (cif.ars: whilft others, from an apprehen- Sea. IX. Diseases of the Eyes. 189 fion of hemorrhagies from an extenfive wound, have advifed the tumor to be removed with a ligature; by which they imagine that the eye may be fufficiently diminifhed, at the fame time that the deformity pro- duced by the fwelling will be effeaually removed. There is no neceffity, however, for our adopting eith- er of thefe methods ; which are both of them more painful, and neither of them in any refpea more ufe- ful than the mode I have advifed, of difcharging the contents of the tumor by a fimple incifion. The dif- eafe, as I have already obferved, is in reality an ab- fcefs, or a colleaion of matter within the coats of the eyes ; and ought to be treated exaaiy in a fimilar manner with abfceffes in other parts of the body; not by removing any part of the tumor, but merely by laying it open. There is indeed a variety of the fla- phyloma fometimes met with, in which, either from a long continuance of the difeafe, or from fome caufe with which we are not acquainted, the different hu- mours of the eye are totally abforbed, or as it were annihilated, and in which all the external appearances of the difeafe that have juft been defcribed, are dif- tinaiy obferved; but in which the tumor is formed by a thickening of the different coats of the eye, and particularly of the iris. In this fituation, no benefit could enfue from this operation; nor from any other means, but the extirpation of all the prominent part of the eye ; which is beft done with a fcalpel. It rarely happens, however, except in the very advanced ftages of the difeafe, that this variety of ftaphyloma is met with. After the contents of the eye have been difcharged, the parts fhould be flightly covered with a foft com- prefs, moiftened with a weak faturnine folution ; the patient fhould be kept upon low diet; and every part of an antiphlogiftic regimen fhould be purfued, either till the wound in the eye is completely cured, or till there appears to be no rilk of inflammation. 190 Diseases of the Eyes. Chap. X\* With refpea to the cure of hypopion, namely, that Species of the difeafe in which matter is colleaed eith- er in the fubftance of one of the coats, or between two of the coats of the eye, it fhould be nearly the fame with what I have advifed for ftaphyloma. In general, the pain is moderate, or is eafily kept fo with Small dofes of opiates; and as foon as the matter is freely and clearly formed, it fhould be difcharged by an incifion made in the manner I have mentioned, in the moft depending part of the abfcefs. The general praaice on this point ought not how- ever to be followed. We commonly obferve that praaitioners decline to operate, till they are in fome meafure forced to it, either by the deformity being confiderable, or by the abfcefs becoming fo large as to impede the motion of the eyelids. But delays fhould be always avoided when it is obvious that fup- puration has taken place; for as the matter of the abfcefs may juft as readily burft inwardly, and mix with the humours of the eye, as outwardly by an ex- ternal opening ; and as this very constantly terminates in a total lofs of vifion, it ought in every inftance to be guarded againft, by difcharging the matter as foon as it is certain that fuppuration has taken place. The after treatment of the parts Should be the fame here as in cafes of ftaphyloma. In both thefe difeafes, fungous excrefcences are apt to form where the opening has been made ; but this we may commonly prevent or remove by the applica- tion of calcined alum in fine powder, or touching the parts from time to time with lunar cauftic, a praaice from which I have never known any hazard enfue. Sea. X. Diseases of the Eyes. 191 SECTION X. Of dropfical Swellings of the Eyeball. IN dropfical Swellings of the eye, the patient com- plains of a fenfe of fulnefs in the eyeball, long be- fore any increafe is perceived in it by others : at laft the motion of the eyelids begins to be impeded ; and although the power of vifion ftill in Some degree con- tinues, yet it gradually becomes more imperfea, till at laft the patient can Scarcely distinguish light from darknefs. In this period of the difeafe, fome part of the eye, moft frequently the tranfparent cornea, gener- ally begins to protrude, fo as to form a Small tumor, and if the contents of the eye are not now difcharged by an operation, the fwelling in this ftate commonly proceeds to increaSe quickly, and Soon burfts of itfelf. When the difeafe has been of long duration, it is apt to be mistaken for ftaphyloma, to which indeed it bears a refemblance; but, in the real dropfical fwell- ing, the patient is always fenfible to the effects of light; and if the pupil can be diflinguifhed, a clear light will commonly make it contract. Whereas, in the other, excepting in its very firft ftages, the patient is never fenfible to light, nor can any kind of contraaion be difcovered in the pupil. When thefe difeafes, howev- er, are far advanced, our being able to diftinguifh them could be of little importance, as in this fituation the ufe of the eye is in general fo much deftroyed as not to be recoverable : but in the commencement of this afteaion, we may very commonly diftinguifh it from the other; and when we are able to do fo, it ought not to be negfeaed. Staphyloma is evidently an inflammatory difeafe: it begins with all the fymptoms of inflammation, and terminates in the formation of pus. By this circum- ftance alone it is very cLftinctiy marked; fo that, in 192 Diseases of the Eyes* Chap. XL the early period of the difeafe, it is eafily distinguish- ed from a mere dropfy of the eye ; in which no Symp- toms of inflammation take place, and in which the only marks of difeafe at firft are, a fenfation of fulnefs in the eye, which by degrees terminates in an enlarge- ment of the eyeball, and in a confufed ftate of vifion. When, by a long continuance of the difeafe, vifion is deftroyed, all that we have in our power to do, is to remove the deformity arifing from the enlargement of the eyeball; which is moft efteaually done by an incifion made in the moft prominent part of the tu- mor, in the manner that I have mentioned in the laft feaion. But in the earlier ftages of this tumor, an objea of greater importance prefents itfelf, I mean the poflibility of faving the ufe of the eye; which, from the refult of fome cafes that I have met with, there is reafon, I think, to imagine might in many inftances be done. When water or any other fluid colfeas in the eye in fuch quantities as to enlarge it much beyond its natural fize, vifion is thus frequently deftroyed mere- ly by diftention, when no other morbid affeaion is perceived. In fuch circumftances, when the nature of the difeafe is obvious, and as foon as the eye begins to lofe its ufual powers, inftead of allowing the fwell- ing to increafe, as is commonly done, till it arrives at a great bulk, and till the power of vifion is loft ; would it not be better to difcharge the fluid by which the fwelling is produced ? No danger could refult from it, for the operation may be done with fafety; and it would at leaft prevent the eye from fufferjng by over diftention, and might thus give fome chance of a cure being obtained, either as an effort of nature, or by the application of proper remedies. The eafieft and beft method of performing this op- eration, is by making a fmall opening in the under and moft depending part of the tranfparent'cornea. By paffing the point of the knife, fig. 4. Plate XII. into this part of the cornea, and making an incifion Sect. X. Diseases of the Eyes. 193 of three-tenths of an inch or thereby in length, all the aqueous humour is at once difcharged, and as the wound feldom heals immediately, the water or ferum is thus allowed to drain oft* almoft as quickly as it is fecreted. But in the event of the difeafe returning af- ter the wound in the cornea is healed, as a repetition of the operation in this part might induce a cicatrix of fuch a fize as would injure vifion, I fhould think it better to make an opening into the posterior chamber of the eye, direaiy behind the iris, either with the point of the knife above mentioned* or with a very fmall trocar. This inftrument, if not thicker than a crow's quill, and made of a flat or lancet point form, will pe- netrate the coats of the eye with almoft as much eafe as a round couching needle; and an opening made with it will difcharge the aqueous humour of the eye with more certainty than an opening of an equal fize made in any other manner. The patient's head being properly fupported by an affiftant, the eyelids may be fufficiently feparated by the operator himfelf, with the fingers of one hand, whilft, with the other, the trocar is pufhed into the moft depending part of the eye: the point of the in- ftrument fhould enter at a tenth part of an inch be- hind-the iris, and be carried to fuch a depth, that the end of the canula may be completely covered by the coats of the eye, when the ftilette fhould be with- drawn ; and as much of the aqueous humour being allowed to run off, as is judged proper, the canula may be taken out, when the opening will require no further attention. With a view, however, toilrength- en the eye, and, if poffible, to prevent a return of the difeafe, the parts may be frequently bathed with an aftringent wafli; fuch as cold water with a proportion of brandy, a folution of alum, or a decoaion of oak bark. In this manner a complete removal of the d:f- eafe may in fome inftances be obtained ; and as it gives at leaft fome chance of pre ferving the eye,. I do Vol. II. O 194 Diseases of the Eyes* Chap. Xf. hot hefitate to recommend it in preference to the ufu* al praaice of allowing the tumor to become fo large before being opened, as to produce in almoft every inftance an entire loSs of the organ* When the tumor has become So large as to deftroy vifion entirely, it has been propofed to difcharge the contents of it, by paffing a fmall feton or cord through the eye : but in an organ of fuch delicate mechanifm* whofe parts are all extremely irritable, there is reafon to imagine that more pain and inflammation would in general enfue from this, than from a free incifion made with a knife, or with a lancet; and as the full intention of the operation may be obtained by this means, it fhould therefore, I think, be preferred. SECTION XL Of Blood effufed in the Cavity of the Eyeball. A FREE paffage of the rays of light to the optic nerve, fo neceffary for a perfect ftate of vifion, requires a clear and tranfparent ftate of the different humours of the eye. We find accordingly, that vifion is always greatly impaired, in many inftances even de- ftroyed, by any of the humours becoming opaque, and nothing tends more certainly to induce opacity of the aqueous humour than blood being effufed in it. Blood may be effufed in the aqueous humour of the eye, by various caufes. In fome inftances it has been the effea of putrid difeafes, either producing a diffolv- ed ftate of the blood ; or arifing more probably from a relaxed ftate of the folids, by which the red glo- bules of the blood are admitted into veffels and parts which do not naturally receive them, and by which all the Secretions are in thefe difeafes frequently ting- ed with blood; Blood is fometimes poured into the ftye, too, as the effea of an inflamed ftate of this or- Sea. XI. Diseases of the Eyes. 195 gan; but we meet with it more frequently, as the confequence of a ruptured blood veffel from external violence, than from any other caufe. It frequently enfues from blows on the eye, and from wounds that penetrate the poflerior chamber. In fome inftances, too, wrounds that penetrate the anterior chamber only are Succeeded by effufions of blood ; but this is not frequent, as the veffels of this part of the eye are in general fo fmall that they do not admit red blood. In whatever manner blood may be effufed in the eye, if it mixes with the aqueous humour, fo as to render it opaque, and is not foon abforbed, it ought to be difcharged by an operation. In a few cafes, we obferve. that a fmall quantity of blood is effufed in the eye, without exciting any inconvenience, by its fink- ing immediately below the axis of vifion, and remain- ing in this fituation without mixing with the aqueous humour* In this cafe, no attempt fhould be made for removing it; for, as long as it continues at the bottom of the eye, no harm is done by it; and we have it always in our power to remove it, if, at any period in future, it is found to diffolve in fuch a man- ner in the aqueous humour as to render it opaque, or materially to injure vifion. The method of perform- ing this operation Should be the fame with that which I have pointed out in the laft fection, for the removal of dropfy of the eye. The opening fhould be about three-tenths of an inch in length, and be made as near to the moft de- pending part of the tranfparent cornea as the junaion of the iris to the coats of the eye will permit: in or- der to promote the difcharge of the blood, the patient fhould be defired to turn his face downwards, and the fides of the divided cornea may be fomewhat feparat- ed by the end of a blunt probe. As the aqueous hu- mour will be difcharged along with the blood, the eye will appear to be much diminiffied by the anterior part of it collapfing. This, however, is a matter of o 2 196 Diseases of the Eyes. Chap. XL little importance * for the wound in the cornea com- monly heals foon, and the aqueous humour is in gen- eral quickly renewed. The only application required after the operation, is a comprefs of foft lint moiften- ed in a weak folution of faccharum faturni. SECTION XII. Of Ulcers on the Globe of the Eye. IN Chapter IV. the theory and management of ul- cers were fully confidered ; fo that I fhall refer to what I there endeavoured to eftablifh : but ulcers on the eye merit particular attention ; for we have here not only the cure of the ulcers to keep in view, but means muft be employed to prevent or remove thofe marks or fpots which they almoft univerfally produce, and which very commonly terminate either in a total or partial lofs of fight. In other parts of the body, the cicatrix induced by an ulcer is feldom produaivc of much inconvenience ; but in the eye, the cicatrix of even the fmalleft fore does much harm. It is evi- dent, however, that this effea of ulcers muft depend much on the part of the eye on which they are feat- ed. Thus, we obferve, that even large ulcers form on the tunica conjunaiva without vifion being injur- ed ; whilft they commonly deftroy it entirely when feated on the tranfparent cornea : our prognofis there- fore, muft in general, in a great meafure, depend on their fituation; for fores, which in one part of the eye might be of little importance, will in others ren- der the organ ufelefs. The danger arifing from ulcers on the eye, depends in fome meafure, too, upon their form, which we find to be equally various here as in other parts of the body; but the ftruaure of the eye renders the form of any fore that occurs in it of more importance Sea. XII. Diseases of the Eyes. 197 than it can poffibly be in any other fituation. In fome inftances, ulcers upon the eye are very Superficial, be- ing no deeper than the tunica adnata; whilft in others they are Small, narrow, and penetrate to a confider- able depth. ThoSe which Spread upon the Surface of the eye may deftroy vifion by the cicatrix which they produce ; but the deep feated ulcers are not only at- tended with this effea, but very commonly terminate in an evacuation of the aqueous humour, either from their penetrating immediately through all the coats of the eye, or from their leaving fuch a weaknefs in fome particular part, as admits of the aqueous and other humours forcing a paffage for themfelves. In other cafes again, inftead oS a loSs of fubftance being produced by ulcers, the parts become foft and fungous, and excreScences or granulations (hoot out, is we frequently find to be the cafe in fores of other parts of the body. Ulcers of the eye may arife from various caufes ; fuch as wounds, contufions, and burns. And they may be induced by a general diSeaSe of the constitu- tion ; fuch as lues venerea, and Scrofula. But in moft inftances they may be traced as the effea of inflam- mation terminating in fuppuration; for abfceffes in the eye are often met with ; and every abfcefs termi- nates in an ulcer, excepting in a very few inftances; in which they either continue during life, or in which the matter, inftead of being difcharged by an opening) is abforbed into the fyftem. Ulcers of the eye are not only often induced by in- flammation, but it commonly happens, that inflamma- tion is the moft troublefome fymptom with which they are attended : indeed the pain arifing from an inflamed ftate of an ulcer on the eye, proves in fome inftances fo very diftrefsful, as to induce reftlefsnefs, heat, quick* nefs of pulfe, and every other fymptom of fever : fo that in the treatment of thefe ulcers, this fymptom of inflammation requires aur moft Serious attention. 198 Diseases of the Eyes. Chap. XL When they are found therefore to be in an inflam- ed ftate, bloodletting, both general and local, fhould be employed ; together with blifters, laxatives, and cooling applications to the eye, in the manner pointed out in Seaion II. of this Chapter, for the cure of oph- thalmia : for till the violence of this fymptom abates, no remedy we can employ for the cure of the ulcers will anfwer the purpofe : m other Ciifes of ophthalmia, along with general evacuations, I have urged, in a particular manner, the propriety of local bloodletting, by fcarifying the turgid veffels of the eye. In ulcers of the eye, too, where enlarged veffels are obferved to pafs from the fores over a confiderable part of the eye^ ball, it often proves ufeful- to cut thefe veffels com- pletely acrofs ; not only for the removal of inflamma- tion, but for the cure of the ulcers. From obferving the effeas indeed that refult from this, I think it pro! bable, that the difcharge arifing from ulcers of the eye is commonly fupplied by the turgid veffefe that run into them ; for it often happens, that the fores are cured by this remedy alone, when every other means have failed. The operation, however, requires to be very neatly and fleadily performed ; for when deep and extenfive fcarifications are made in the neighbour- hood of an ulcer, they are apt to degenerate into te- dious fores of a fimilar nature. This, however, is not the fault of the remedy, but of the method of putting it in praaice : for it is an effea I have never obferved to refult from it, when the turgid veffels only have been divided ; which may be eafily done in the man- ner I have mentioned in Seaion II. of this Chapter. Some have objeaed to this praaice, that by divid- ing the lymphatics, which proceed from the fores along with the turgid blood veffels, the healing of the fores will be rendered more tedious than it otherwife would be; for thefe, by abforbing the matter fecreted or dif- charged into ulcers, they conclude muft have a con- fiderable influence on the cure •' and therefore, it is faid, that we mould not run the rifk of dividing them, Sea. XII. Diseases of the Eyes. 199 by fcarifying the large veffels of the eye, which they very commonly accompany. The idea is ingenious ; but fo far as I have obferved, it is not Supported by experience, Scarifications, when improperly perform- ed, may in fome inftances, as I have obferved above, do harm ; but in many caSes of ulcers of the eye, I have known them prove very ufeful. Befides, we might, from reafoning alone, conclude, that Scarifica- tion, when properly performed, ought not to do harm j and that the doubts which have been entertained with refpea to it, cannot be well founded: for although fome proportion of the matter afforded by ulcers is no doubt carried off by abforption, yet daily experi- ence Shows, that we are never to depend upon this for effeaing a cure ; and, on the contrary, that fores are more frequently cured by applications, that feem to laa by destroying the power of the abforbents, as well as of the other veffels with which ulcers are fupplied, than by any other means ; namely, by drying aftrin- gent remedies, and by external preffure, applied with fuch firmnefs as muft frequently annihilate the fmaller veffels of fores, by keeping them for a confiderablje time clofely compreffed together. After the inflammatory ftate of an ulcer on the eye has been removed in the manner I have mentioned, our views fhould be exaaiy the fame as in the treat- ment of fores in other parts of the body; and the means employed for effecting them, muft, for the moft part, be likewife fimilar. When it appears to he con- neaed with any general difeafe of the fyftem, this muft be correaed before any permanent cure can take place. In fome inftances, fores on the eye are combined with lues venerea r in which cafe a well direaed mercurial courfe is alone to be trufted to : but they are much more frequently combined with Scrofula; a diSeaSe which often affeas the eyes more than any other part of the. body ; and hitherto we have not been fo fortu- nate as to difcover any certain remedy for its removal. Cold bathing, however, with, the ufe of muriated ba- 200 Diseases of the Eyes* Chap. XL rytes, fteel mineral waters, bark and other tonics, and living in a dry atmoSphere, frequently prove uSeful; and for the Symptom that we are now considering, namely, ulcers on the eyes, iflues, when duly perfifted in, are to be more depended on than any remedy with which we are acquainted. In the local treatment of fores upon the eye, the remedies to be employed muft depend entirely on the appearances which take place. Before any attempt is made to induce the formation of a cicatrix, any fun- gous excrefcences which occur muft be deftroyed; and if the matter difcharged is thin, and the bottom of the ulcer foul, thefe circumftances muft be correa- ed. With this view, detergent ointments and wafhes* as they are called, fhould be applied ; and for the re- moval of excreScences, the fcalpel and efcharotics are alone to be depended on. A general prejudice prevails againft the uSe of Stim- ulating applications to the eye ; and in many of the difeafes to which this organ is liable, they certainly cannot be employed with propriety; but in others, efpecially in ulcers, they may not only be applied with fafety, but with much advantage: in many inftances a cure cannot be otherwife obtained, and much mif- chief is daily done by the contrary praaice of a long continued ufe of emollients. In cafes of ophthalmia, accompanied with much pain and tenfion, a proper ufe of emollients, particularly of warm fomentations and cataplafms, proves in fome inftances extremely ufeful; but in ulcers of the eye, after the inflammation is removed, inftead of being produaive of any advan- tage, I have constantly obferved them do harm. They not only Seem to promote that tendency to relaxation and SpongineSs which uSually occurs in theSe Sores, but in different inftances they have appeared to be the Sole cauSe of thoSe excreScences very frequently met with in ulcers of the eye, and which always prove extreme- ly troubleSome. When I firft engaged in praaice, I entered into a free ufe. of remedies of this clafs, in ul- Sea. XII. Diseases of the Eyes. 201 cers as well as in other affeaions of the eyes ; but I now think it fair to acknowledge, from repeated in- ftances of their proving hurtful, that I am convinced that they fhould be employed with caution. "When the ulcers are hollow, with foul edges, and difcharge thin and perhaps fetid matter, a liniment of wax and oil, with a fmall proportion of red precipitate, commonly anfwers the purpofe of cleanfing them ; or the fame intention may be obtained from a remedy of the fame nature, prepared with white vitriol, or w,ith a fmall proportion of verdigris; care being taken to have the liniment of fuch a thin confiftence, that with a fmall brufh or pencil a little of it may be eafily ap- plied at any time over the furface of the fores. By adding a fmall proportion, too, of camphire to thefe ointments, their effeas in cleanfing ulcers of the eye are frequently improved; and the fame remedy proves fometimes ufeful in a diffolved ftate, when employed as a walh to the fores. The moft effeaual waih, how- ever, for this purpofe, is either a weak folution of ver- digris or white vitriol in water; and I have in fome iiftances employed, with advantage, a weak folution of corrofive Sublimate, One grain of corrofive mer- cury in four ounces of water, makes a folution of a fufficient ftrength for this purpofe, Praaitioners not accuftomed to the application of irritating fubftances to the eye, may be furpriied to find red precipitate, verdigris, and even corrofive fub- limate, recommended; but daily experience Shews, that in many difeafes of this organ, they may be em- ployed both with freedom and utility. When by a due continuation of thefe means, or of remedies of a fimilar nature, an ulcer on the eye is properly cleanfed, and a good fuppuration induced, granulations will foon be obferved to form ; any de- ficiency of p?rts which may have been induced by the fore will be filled up ; and, if no interruption occurs to the cure, a cicatrix will foon be obtained. &02 Diseases of the Eyes* Chap. XL It often happens, however, in this ftate of the ulcer, that a cure is difficult to accomplifh. The furface of the fore remains Soft, and becomes fomewhat elevated above the reft of the eye, by which a cicatrix is pre- vented. In this fituation, drying aftringent applica- tions prove moft ufefuL The parts affected fhould be covered once or twice daily with lapis calaminarig finely levigated; with prepared chalk, or crabs eyes j and they may be bathed morning and evening with a ftrong folution of alum ; with brandy properly dilu- ted ; or with a ftrong infufion of galls or oak bark : by thefe means, when the conftitution is otherwife healthy, a cure will in general be obtained. When, again, the fore, inftead of being hollow and attended with a deftruaion of fome of the parts in which it is feated, is found to be covered with a fun- gous produaion, this excrefcence muft be removed before any permanent cure can be obtained; and the. fame means muft be employed for the purpofe here, that prove moft effeaual for the removal of excreS- cences in other parts of the body. In fome inftances, theSe produaions arrive at a con- fiderable fize, and, after Separating the eyelids, Sail down upon the upper part of the cheek. Of this, different caSes are recorded by authors ; Some of which were on diffeaion found to be conneaed with the more interior parts of the eye* and in which extirpation of the eye might have faved the patient: but it fome- times happens, that tumors of this kind adhere to the furface of the opaque cornea only, when they may commonly be removed without any material injury be- ing done to the eye. In general, we are direaed to remove thefe excreScences with ligatures ; but as this commonly proves painful, tedious, and uncertain, the fcalpel or lunar cauftic ought in every inftance to be preferred. For the removal of a large excrefcence, excifion by the fcalpel fhould alone be trufted ; and when done with caution, no danger enfues from it. The parent Sea. XII. Diseases of the Eyes. 203 being firmly feated oppofite to a clear light, and the furgeon fitting beSore him, his head fhould be Support- ed by an affiftant behind, who at the Same time Should Separate the eyelids, by elevating the one and drawing down the other; which may be eafily done by the fingers of each hand properly placed on them. This being done, a needle armed with a firm waxed ligature fhould be paffed through the centre of the excreScence, for the purpofe of fixing it and raifing it as much as poffible from the Surface of the eye : with one hand the operator fhould now lay hold of this ligature, while with a fcalpel in the other he flowly and fteadily re- moves the excrefcence. The only dreffing that fiiould be applied, is a piece of foft lint foaked in a weak fo- lution of faccharum faturni, laid over the eyelid ; and if the fore produced by the operation does not heal eafily, fome of thofe aftringent applications fhould be employed that I have juft had occafion to mention. But in the treatment of excrefcences of the eye which are neither pendulous nor much elevated, there is no neceffity for the ufe of the fcalpel, as they may almoft always be removed by a proper application of cauftic. By touching the furface of the part intended to be deftroyed with a piece of lunar cauftic, either daily or once in two days, the protuberance will foon be removed ; and the fore being in this manner reduced to the level of the reft of the eye, a cure may be obtained by the means I have already mentioned. It is neceffary, however, to remark, that in the ap- plication of cauftic to the eye, much SteadineSs and nicety is required; but with due attention it may be done with perfea fafety, and often with much advan- tage. In order to prevent the reft of the eye from fuffering by coming in contaa with the cauftic, the eye fhould be previously fixed with a fpeculum ; and after the excrefcence is rubbed over with cauftic, be- fore removing the fpeculum it fhould be entirely wafh- ed off with a fmall brufh or pencil foaked in warm water; or in warm milk, which proves commonly more 204 Diseases of the Eyes. Chap. XL effeaual than any other liquid for destroying the ac- tivity of cauftic In this manner, all the advantages may be obtained from the ufe of lunar cauftic that we daily derive from it in the removal of excreScences in other parts of the body ; and when applied with cau- tion, it may be done without rifk. I have already remarked, that when the constitution is Sound, ulcers of the eye will commonly heal by the means that I have mentioned ; but it happens in fome inftances that they ftill continue obftinate, and even daily become more virulent, notwithstanding the uSe of «thefe and all the other remedies that are employed: in which event, whenever the diSeafe has advanced fo far as to deftroy vifion, and when it is ftill proceeding to increaSe, as nothing but extirpation of the morbid parts will afford any chance of preventing it from fpreading to the contiguous found parts, this ought certainly to be advifed. The method of extirpating a difeafed eye will be the fubjea of a different fection. SECTION XIII. Of Specks or Films upon thi Eyes. VISION is frequently deftroyed or impaired by opaque fpots or films forming upon the eye; a difeaSe commonly termed leucoma, albugo, or nu- becula. TheSe Spots are met with occafionally on the Scle- rotica or white part of the eye ; but, as the inconve- nience that enfoes from them in this fituation is Sel- dom of much importance, they do not oSten become the objea of forgery : but in the tranfparent part of the eye, they require very ferious attention ; for in this fituation, even the leaft degree of opacity is apt to terminate in the entire lofs of vifion : and although we cannot in every inftance remove them entirely, yet Sea. XHI. Diseases of the Eyes. 205 we can often do fo, and, by proper treatment, we have it frequently in our power to preferve eyes which oth- erwife would in all probability be loft. I have already given a defcription of various affec- tions that may tend to obftrua vifion, by inducing an opaque ftate of the tranfparent cornea and humours of the eye. Thus, every high degree of inflamma- tion, the ftaphyloma, hypopion, and ulcers on the tranfparent part of the eye, are all attended with this effea: but as each of thefe forms a diftina difeafe* requiring a method of treatment peculiar to itfelf, I have judged it proper to allot a feparate feaion for each of them; and, what 1 now mean to confider, are thofe white opaque fpots frequently met with on the cornea, which occur moft commonly as the confe- quence of inflammation. Affeaions of this kind are for the moft part, in- deed, fo evidently induced by inflammation* that it may be doubted if they ever occur from any other caufe ; for all thofe fpecks which fucceed to wounds of the cornea, as likewife thofe which arife from fmall pox and meafles, are always preceded by an inflamed State of the eye : I therefore conclude, that they de- pend, perhaps entirely, on inflammation, by whatever caufe this may at firft be excited. In attending to the nature of thefe opaque fpots on the cornea, it appears fufficiently obvious, that in moft inftances they are the effea of that effufion, which in- flammation, when in a high degree, always excites. In fome cafes, when it terminates in complete fuppu- ration, a fmall abfcefs is produced; which, either on burfting, or on being opened in the manner direa- ed in a preceding fection, very commonly leaves an opaque Spot, attended with fome degree of prominen- cy or elevation of the parts in which it is feated : but in others, when the effufion, inftead of being near to the Surface of the cornea, is diffuSed among the dif- ferent lamellae of which this coat of the eye is com- pofed ; or when the degree of inflammation which 2©6 Diseases of the Eyes. Chap. XL takes place is not fufficient for carrying it on to fup- puration, the opacity induced by it does not, as in the cafe of an abfceSs, Sorm a protuberance ; but appears rather to constitute a part of the fubftance of the cor- nea itfelf. In the one, the different lamellae of the cornea are evidently feparated from each other; and on the matter contained between them being difcharg- ed, the fpeck which remains appears in the form of an adventitious body, adhereing to, but not intimately conneaed with, that part of the eye on which it is feated: whereas in the other, that is, when a fmall effufion only has taken place, and when no tendency to fuppuration occurs, although a very confiderable degree of opacity may be produced by it, yet the niceft examination will not difcover the cornea to be at this part either elevated or increafed in thicknefs, In this cafe, the difeafe appears to form a part of the eye itfelf, and cannot be feparated from it but with the deftruaion of the organ ; whereas, in the other, the appearances which it exhibits are fuch as would lead one to confider it as a preternatural formation ; and in many inftances it may be removed without much injury being done to the eye. Thefe fpots upon the eye are met with in various forms and in different degrees of magnitude ; but the inconvenience which they induce is always in propor- tion to their extent, to their degrees of opacity, or to their fituation with refpea to the pupil; for as they prove hurtful merely by preventing the rays of light from paffing to the bottom of the eye, it is evident that it is by one or other of thefe circumftances that this muft be determined. When a fpot upon the eye, therefore, is either fo fmall, fo flightly opaque, or fo far removed from the pupil, as not to injure vifion, it ought not to be confidered as an objea of forgery ; for till the ufe of the eye is impaired by it, as it is never attended with pain, unlefs when the parts are inflamed, no other confideration can render it proper to meddle with it: for every praaitioner knows, that Sea. XIII. Diseases of the Eyes. 207 this organ is fo very delicate, as often to fuffer more by the means employed for removing difeafes, than it previously did by the difeafes themfelves. But when- ever vifion is materially impaired, we are then author- ized to endeavour to remove the caufe by thofe means which experience has Shewn to prove moft fit for the purpofe. I have endeavoured to Shew that inflammation is to be confidered as the principal and perhaps the only caufe of fpecks upon the eye: this fhould therefore be a powerful argument, in every inftance of inflam- mation of the eye, for lofing no time in the applica- tion of the moft efficacious remedies ; for, whenever it has gone fo far, as to induce even the fmalleft de- gree of effufion, we can never with certainty prevent either a partial, or perhaps a total lofs of fight. The means beft adapted for the removal of inflammation having been already detailed in Seaion II. of this Chapter, it is not neceffary to repeat them; fo that I fhall now mention thofe remedies only on which we fhould chiefly depend for the cure of fpecks that are already formed. In the management of fpecks upon the eye, it is a matter of much importance to attend to the particular nature of each of them; for the two varieties I have mentioned are fo different from each other, that fuch remedies as prove ufeful in the one, are fcarcely, if at all, admiffible in the other: and hence we find, that the fame applications being indiscriminately employed in every cafe, much injury is done which ought not to happen; and remedies fall into discredit, which when properly applied, prove highly ufeful. Thus, we find by experience, that efcharotics of a moderate ftrength may with Safety be applied to the eye; and as fpecks upon the cornea are often remov- ed by them, it has long been a common praaice to apply them with equal freedom in every cafe. By at- tentive obfervation, however, to this branch of prac- tice, I am convinced, that it is in one variety of the 2o8 Diseases of the Eyes. Chap. XL difeafe only that remedies of this clafs ever prove ufe- ful ; namely, in that which is attended with an evi- dent prominency or elevation of the difeafed part. In fuch inftances, when the cornea beneath is found, the removal of this elevated opaque fpot will leave it tranfparent, and fit for the purpofes of vifion ; and in fuch cafes, mild efcharotics may with much propriety be employed: but in the other variety of the difeafe, where the effufed matter feems to fpread through the whole fubftance of that part of the cornea in which it is feated, without railing or elevating any part of it, no advantage is ever obtained from efcharotics. In this caSe* the diSeaSed part of the cornea, as I have for- merly mentioned, does not Seem to be thicker than the other parts of it; and it is impoffible to deftroy the effuSed matter without deftroying the cornea itfelf* In fuch circumftances, the employment of efcharotics can never be proper; and I have no hefitation in fay- ing, that in this ftate of the difeafe, they can never be ufed but with much rifk of doing harm. It fometimes happens, however, even in this varie- ty of the difeafe, that the patient recovers either a par, tial or even a complete ufe of his eye, by the opacity in the cornea being gradually carried off, probably by abforption taking place of the effufed matter. As this has in fome inftances happened by a natural exertion of the fyftem, praaitioners fhould endeavour to affift this operation of nature, by employing Such remedies as are known to prove moft powerful in promoting abforption: with this view, there is nothing perhaps to be more depended on than a gentle courfe of mer- cury. In fimilar effufions in other parts of the body, mercury often proves ufeful; and it is the only inter- nal medicine, which, fo far as I have yet feen, fhould ever be employed in nlms or fpecks on the eye : iffues have in fome inftances, too, appeared to prove ufeful; and as a cord in the neck in general discharges free- ly, it commonly anfwers the purpofe in the moft ef- feaual manner. Sea. XIII. Diseases of the Eyes. 209 With the fame view, too, a brifk purgative given from time to time, proves fometimes ufeful ; but it muft be acknowledged, that the effea of our praaice in this difeafe is always uncertain: for, although in a few cafes, fome advantage has apparently been deriv- ed from thefe remedies, it has not happened fo fre- quently as to admit of our placing much dependence on any of them. But although we feldom derive advantage in this variety of the difeafe, either from internal medicines or external applications, it often happens in the other, that a due attention to the diflerent circumftances of the cafe proves highly ufeful. As in this cafe we fup- pofe the difeafe to be produced by a thin lamella of the cornea being elevated and feparated from the reft of the tunic beneath, by an effufion of fome kind of matter, and as this feparated portion is in general opaque, our chance of effeaing a cure is to remove it entirely. Even this will not always leave the eye perfeaiy clear and tranfparent; for it fometimes hap- pens, either from the effufed matter having been of a Sharp corrofive nature, or from its having been long confined, that a roughnefs, attended with fome degree of opacity, is left upon that part of the cornea which remains. This, however, is not univerfally the cafe ; and, at any rate, although a complete cure may not in every cafe be obtained by the removal of the ele- vated part of the cornea, yet in almoft every inftance fome benefit will enfue from its being thus made to admit a greater quantity of light to pafs to the retina. Spots of this kind may be removed either with the knife or with efcharotics; but, in general, the knife fhould be preferred. The head being fecured by an affiftant ftanding behind, and the eye properly fixed with a fpeculum, Plate XIII. fig. 1, the furgeon Should feat himfelf in a convenient height between the patient and the clear light of a window ; when, with repeat- ed fmall Strokes of the knife, Plate XII. figure jl, he Vol. II. P 210 Diseases of the Eyes. Chap. XL fhould endeavour to cut away and remove all that por- tion of the' cornea that he finds to be in any degree feparated from the reft ; for no part of it that is loofe will ever adhere again, and the cure will not be com- plete if any portion of it is allowed to remain. The natural delicacy and irritability of the eye would appear to render this operation difficult; but it may be done with eafe by furgeons of fleadinefs and obfervation. The fpeculum I have mentioned fixes the eye completely; and on the head being properly fecured, the operation may be done with entire fafety. The knife I have mentioned is in moft cafes the beft; but in a few inftances a knife with two edges I have thought has anfwered better. A representation of a knife of this kind may be feen in Plate XVI. fig. i. Patients, however, will not always fubmit to this operation: in which cafe we are obliged to employ efcharotics; by a continued ufe of which we have it often in our power to remove blemifhes of much firm- nefs and of confiderable extent: and although ftrong applications of this kind are not admiffible, and have frequently done harm, by creating inflammation and pain, yet I think it right to remark, that there is no caufe for fo much caution on this point as in general we are led to believe ; for daily experience ferves to evince, that a good deal of freedom may be ufed in the application of remedies of this clafs to the eye. It has been alleged, that, befides exciting pain and a temporary ftate of inflammation, efcharotics muft do harm by corroding and inducing ulceration on the found part of the eye, juft as readily as they will de- ftroy the fpot intended to be removed. This reafon- ing is fpecious, but not fupported by experience ; for every praaitioner muft have obServed, and it is par- ticularly well known to itinerants, who commonly uSe no delicacy in matters of this kind, that fpecks upon the cornea are frequently removed by efcharotics, without any kind of harm being done to the reft of the eye; and the faa, I think, may be explained. So Sea. XIII. Diseases of the Eyes. 211 far as I have been able to obferve, thofe fpecks in which efcharotics are employed with moft advantage, confift of a fubftance in which there is little or per- haps no animal life ; at leaft they are perfeaiy white, are deftitute of the circulation of red blood, and are fo far infenfible, that little or no pain is experienced from their being cut or even bruiSed with much free- dom. Now we know, that in other inftances, efcha- rotic or corrofive applications of a moderate Strength will deftroy a part of a dead animal, which did not in any degree aa on it during the life of the animal. This is particularly remarkable in a procefs that fome- times occurs in the ftomach after death ; a curious faa, firft taken notice of by the late ingenious prac- titioner Mr. John Hunter. The ftomach has fre- quently been found on diffeaion to have holes corrod- ed in it, even where no pain or other fymptom of difeafe of this organ had previously existed ; from whence we may fairly conclude, that the liquor gaf- tricus, or that fluid which nature has provided for the purpofes of digeftion, although during the life of the animal it may aa only as a moderate flimulus to the vifcera, yet after death, the ftomach being now de- prived of the power of refifting the corrofive property of this liquor, comes at laft to be deftroyed by it. In the Same manner we may SuppoSe, that a dead liSeleSs Spot may be removed by corrofive applications, the ftrength of which is not fufficient to affea the living part of the eye. We may thus perhaps account for the caufe of this phenomenon ; but whether this reafoning fhall appear to be well founded or not, the faa, as I have faid, is certain, that corrofive applications may be made to the eye fufficiently ftrong for removing many of thofe fpots to which it is liable, without doing any injury to the reft of the organ. For a confiderable time I was afraid to apply ftrong efcharotics to the eye: further experience, however, p 2 212 Diseases of the Eyes. Chap. XL has convinced me, that they may be ufed with more fafety than is commonly imagined. Remedies of this kind may be ufed in different forms; but they are moft conveniently employed in the form of a powder, an ointment, or a waSh. When powders are ufed, they fhould be very finely levigat- ed ; otherwife, by their fpicuta, they are apt to irri- tate and inflame the eye : and, for the fame reafon, when conjoined with ointments, they fhould be very finely prepared. Articles of this kind that are foluble in water, are perhaps preferable to any; for, in the form of folution, they can never prove hurtful if their ftrength is duly regulated, as in this manner none of their fharp fpiculae can come in contaa with the eye. In the form of a powder, various articles have been employed; but the moft effeaual perhaps of any is red precipitate, or verdigris finely levigated, mixed with three or four parts of fine fugar. Calcined alum, too, white vitriol, and levigated glafs, likewife mixed with a proportion of fugar, or with egg Shells in fine powder, have frequently proved ufeful. Ointments for the fame purpofe are prepared, by adding to fine hogs lard, or any emollient ointment of the fame confiftence, Such a proportion oS any of the powders I have mentioned as the patient is able to bear; and wafhes are made by diffolving a due proportion of the fubftance to be employed, in water. For this purpofe, verdigris or white vitriol are em- ployed with advantage; and in fome inftances I have known good effeas refult from a weak folution of corrofive fublimate. The following is a form of oint- ment much employed by Mr. Pellier, both for the re- moval of fpecks and inflammation. &. Mercur. pre- rip', rub. Lapid. Calam. pp. aa 3ifs. Lythargyr. pp. 5i. Tutiae pp. ^fs. Cinnab. nativ. $i. F. pulv. tenuif- fim.: mifee cum axungise porcinae Jii. et adde bal- fam. Peruvian., gutt. xv. Of this, a little is introduced on the end of a blunt probe, between the eyelids, evening and morning, at Sea. XIV. Diseases of the Eyes. 213 the fame time that a weak faturnine folution is employ- ed as a wafh. It is impoffible, in cafes of fpeas upon the eye, to confine any application to the difeafed part: all we can do is to infert the powder, ointment, or wafh, within the eyelid ; by the motion of which it is very quickly conveyed over the whole furface of the eye. In order, however to have every poffible advantage from remedies of this clafs, their ufe fhould be long continued, and two or even more of them fhould be employed at the fame time. Thus, a fmall quantity of any of the powders or ointments I have mentioned, may be inferted within the eye evening and morning, and a weak folution of corrofive fublimate, of verdi- gris, or white vitriol, may be employed two or three times a day for wafhing the eye. It cannot be alleged, that thefe or any other reme- dies will in every inftance prove effeaual ; but I can with confidence fay, that a prudent and long continu- ed ufe of them has often removed fpots upon the eyes, which otherwife would probably have terminated in an entire lofs of vifion. SECTION XIV. Of Protrufions of the Globe of the Eye from the Socket. I~? VERY praaitioner muft have met with inftances _j of the eye being pnShed more or lefs from its natural fituation in the focket, and various caufes are recorded of it by authors. 1. A partial protrufion of the eyeball takes place in fome of the difeafes of which we have treated in the preceding feaions ; particularly in the hypopion, ftaphyloma, and dropfical Swellings of the eye. 2. The eye may be displaced or pulhed from its focket by external violence. And, 214 Diseases of the Eyes. Chap. XL 3. It may be raifed or elevated by tumors forming beneath it. Even the flighteft diftortion or displacement of the eye affords a very difagreeable appearance ; and to thofe not accuftomed to meet with it, gives much caufe to fufpea that vifion will be completely deftroy- ed by it. All fuch affeaions have therefore been in general confidered as incurable : little or nothing has accordingly been done for removing them ; fo that patients labouring under them have for the moft part been allowed to finifh a miferable exiftence without any means being employed for their relief. But al- though vifion cannot in every afteaion of this kind be preferved, yet in moft inftances it may be done ; and wherever there is any chance of this being in our power, the attempt fhould undoubtedly be made. As the means of cure muft depend upon the caufe by which the difeafe is induced, it is a point of the firft importance to have it afcertained. When the ball of the eye is enlarged from any of the caufes I have mentioned ; namely, from water, pus, or any other fluid colleaed in any part of it, if a portion of it is by this caufe pufhed forward, all that art can do is to diminifh the fize of the eye in the manner I have mentioned in different parts of the pre- ceding feaions, either by punaure, incifion, or per- haps, by removing a part of it. In moft cafes of this kind, vifion will be irrecoverably loft ; but by the means I have mentioned, the deformity produced by the difeafe may be commonly removed. When, again, the eyeball is pufhed from its focket by external violence, as the optic nerve muft in this caSe be Suddenly Stretched, we might a priori conclude, that vifion would be deftroyed by it. This will moft frequently be the cafe; but it does not always hap- pen : for, inftances have occurred of the eye being pufhed fuddenly and entirely out of the focket, and on being replaced, of vifion being as perfea as it was before. Sea. XIV. Diseases of the Eyes. 215 Several years ago I met with an inftance of this, in which the eye was almoft entirely turned out of the focket by a Sharp pointed piece of iron puffied in be- neath it. The iron paffed through a portion of the focket, and remained very firmly fixed for the fpace of a quarter of an hour ; during which period the pa- tient fuffered exquifite pain ; he was quite blind in the affeaed eye ; and the eyeball being pufhed fo far out as to give reafon to fufpea that the optic nerve was ruptured, it was doubted whether it would anfwer any purpofe to replace it or not. As no harm, however, could arife from a trial being made of it, I refolved to make the attempt; and with much pleafure and af- toniffiment I found, on removing the wedge of iron, which being driven to the head was done with difficul- ty, that the power of vifion inftantly returned even beSore the eye was replaced. The eye was now put eafily into the Socket; and the effeas of inflammation being guarded againft, the patient enjoyed very perfea vifion. A cafe of a fimilar nature to this is recorded by a very ingenious praaitioner, Mr. White of Manchef- ter : in which the eye was ftill more completely dif- placed than in the one I have mentioned, and in which the power of vifion was Scarcely affeaed.* As in thefe cafes the attempt to fave the eye proved fuccefsful, where the eyeball remains entire, and is not altogether Separated from the contiguous parts, we ought not to defpair* however fevere the injury in oth- er refpeas may have been: nay, we here have evi- dence of no material inconvenience having enfued ev- en from a fodden extenfion of the optic nerve. No fuch cafe therefore fhould be confidered as incurable, till it has aaually proved to be fo by the power of vifion being entirely loft after every endeavour for preventing it has failed. All extraneous bodies being removed, the eye Should be cautioufly replaced ; and • Vide Cafes in Surgery, &c. by Charles White, F. R. S. &c. 2l6 Diseases of the Eyes. Chap. XL with a view to prevent or render moderate the inflam- mation, which otherwife might probably run high, bloodletting, both general and local, fhould be adviled, together with a ftria antiphlogiftic regimen. At the fame time, light fhould be excluded from the eye, and it ought to be kept covered with a foft comprefs moift- ened in a weak faturnine folution. When the eye is pufhed out by a tumor fituated beneath it, the cure muft depend on a removal of the cauSe. When an abfceSs or a colleaion of any kind of fluid is attended with this effea, a cure may be ob- tained merely by laying the cyft or abfcefs fufficiently open: but when the tumor is firm, it muft be entire- ly removed. Here I think it neceffary to remark, that praaition- ers are in general too timid in operating on tumors of this kind, owing to their near contiguity to the eye; infomuch, that when a tumor is fituated entirely with- in the orbit, a patient is commonly advifed rather to allow it to remain than to fubmit to an operation. As long as no material inconvenience enfues from fuch tumors; when they are not likely to degenerate into a worfe nature; and when they appear to remain Sta- tionary without receiving any additional increafe ; it would furely be improper to advife a patient to under- go the pain and terror of an operation : but whenever they begin to acquire an additional bulk ; when there is any reafon to fear that they may ever become can- cerous ; and efpecially when they begin to impede the motion of the eye, and to pufh it out of the focket; no further delay fhould be admitted. In fuch circum- ftances, the SaSety of the patient requires the tumor to be removed, and it ought to be done without delay. Even where thefe tumors have acquired a confider- able bulk, they are more eafily removed than is com- monly imagined. By proceeding cautioufly, they may often be taken out without hurting the eye, even where they pafs deep into the focket. But where the eye has already been pufhed from its fituation, as Sea. XV. Diseases of the Eyes. 217 nothing but the removal of the tumor can in any de- gree prove ufeful, it ought in every inftance to be done, even although there fhould be fome rifk of the eye being hurt by it: for, befides the injury which fuch tumors do to the eye, when they increafe to any confiderable bulk, by preffing on the contiguous bones, they very commonly bring thefe likewife into a ftate of difeafe. In fome inftances, the bones become cari- ous, and produce tedious ulcers ; but moft frequently they Swell, become Soft, and on being laid open, in- ftead of the ufual appearances of bone, they are found to confift of a clear gelatinous matter. In this ftate of the difeafe, no advantage can be derived from ex- tirpating the tumor, fo. that it ought not to be advif- ed 5 but this diftrefsful fituation may very commonly be guarded againft, by the operation being done more earlv. It fometimes happens, that the eye is pufhed from its focket by an enlargement of the glandula lachry- malis. This forms a kind of tumor, of more difficult management than any other to which thefe parts are liable: we ought not, however, even in this cale, to defpair of effeaing a cure; for even this gland, in a State of enlargement, has been entirely removed, with- out injuring the eyeball; and there will feldom be much difficulty in replacing the eye, on the caufe be- ing; removed by which it was puShed out. SECTION XV. Of Cancer of the Eye, and Extirpat'wn of the Eyeball. THE eye, like every part of the body, is liable to cancer, a difeafe that cannot be cured by any remedy with which we are acquainted, and which therefore renders the removal of the difeafed part ne- ceffary in order to prevent it from extending farther. 2l8 Diseases of the Eyes. Chap. XL Cancer of the eye is apt to fucceed to ftaphyloma: the ball of the eye, after becoming enlarged, at laft protrudes beyond the boundaries of the focket: it ac- quires a firm, and even a hard confiftence : vifion is at laft deftroyed, and the tumor commonly acquires a red or flefhy appearance. In fome inftances, a yellow glutinous matter, but moft frequently a thin acrid ic- hor, is difcharged from the furface of the tumor. For a confiderable time the patient complains only of heat, or a fenfation of burning in the fubftance of the fwell- ing ; but at laft he becomes diftreffed with fevere pains, fhooting through the whole of it, and acrofs the brain to the oppofite fide of the head. In this fituation, bloodletting, opiates, and the ex- ternal uSe of emollients, are commonly advifed, with a view to render the pain moderate ; but although in fome inftances this may be done by large dofes of opi- ates, yet no remedy will prevent the difeafe from fpreading ; and as it is always a point of importance to remove cancerous tumors early, the operation ought always to be advifed as foon as the difeafe appears to be evidently formed. In Chapter IV. Seaion VIIL we entered fully into the confideration of cancer. I there made it appear, that extirpation of the difeafed part is the only remedy on which we ought to depend; that it often fucceeds when employed early in the difeafe ; that it muft ne- ceffarily frequently fail, when the operation is long delayed ; and that praaitioners have till of late years been often blamable, in having an ill founded averfion to this operation, by which their patients have in many inftances been prevented from fubmitting to it fo early as they ought to have done. For a more particular ' difcuffion of this point, I muft refer to the feaion I have mentioned ; but it is here neceffary to remark, that this general averfion to operate in cafes of cancer, has been carried ftill further, when the difeafe is feat- ed in the eye, than in any other part of the body. Sea. XV. Diseases of the Eyes. 219 This general objeaion prevails againft the extirpa- tion of cancer wherever it is feated, that the difeafe is fo apt to return, that the advantage to be derived from it is feldom equal to the pain, trouble, and confine- ment that arife from it. This, I have elfewhere fhewn, is by no means the cafe : but when the difeafe is feat- ed in the eye, another objeaion has been raifed to it; namely, the hazardous nature of the operation ; for, as it is impoffible, from the depth of the orbit, to fe- cure any arteries with ligatures that lie at the under part of it, it has been fuppofed that much danger muft occur from this circumftance alone : and accordingly, although we find the method of extirpating the eye has long been defcribed in books, excepting by a few praaitioners, the operation has been very feldom per- formed. There is no caufe, however, for this timidity : for although a good deal of blood is fent to the eye by different branches both of the internal and external carotid arteries ; yet, at the place where thefe are di- vided in extirpating the eye, they are commonly fo much ramified, that no hazard, fo far as I know, has ever occurred from this operation; and I have not only done it frequently, but in various cafes I have feen it performed by others. It is not the extirpation of a portion of the eye,, namely, that part of it which protrudes beyond the orbit, that we are now consider- ing, but the total removal of the whole eye, when it is altogether difeafed. A partial extirpation of the eye is often indeed recommended, chiefly for the reafon I have mentioned, the danger that is fuppofed to occur from a deep divifion of the ocular artery : but when- ever the tve is in a cancerous State, as all the difeafed parts muft be removed in order to render the patient Safe ; as 1 have endeavoured to fhew that the eye may be altogether cut out without hazard ; and as no ad- vantage can be derived from a portion of it being al- lowed to remain ; we fiiould never hefitate in remov- 22o Diseases of the Eyes. Chap. XL ing the whole. The method of performing the oper- ation is this. The patient fhould either be firmly feated in a pro- per light, with his head fupported by an affiftant; or, what anfwers better in every tedious operation, he fiiould be laid upon a table, with his head upon a pil- low ; the moft convenient pofture not only for him- felf but for the operator. When the eyelids are dif- eafed, they fiiould be removed along with the eye it- felf; but whatever part of them is found, fliould be allowed to remain as a proteaion to the orbit. In the courfe of the operation, it is a point of im- portance to have the palpebral kept completely fepa- rate ; for the moft part this may be done by the hands of affiftants, but in fome cafes where the ball of the eye is much enlarged, the palpebral are more eafily feparated by means of two flat hooks, one of which is reprefented in Plate XIV. fig. 6. When the eyeball has become fo large as fo pro- trude beyond the orbit, the operator will in general be able to lay hold of it with his fingers; but when this cannot be done, a broad flat ligature fhould be palled through the centre of the tumor, in order to fix it dur- ing the operation. While this is done with one hand, the furgeon, with a common fcalpel in the other, muft endeavour to feparate the whole ball of the eye from the different parts to which it is conneaed. All the difeafed parts Should be removed ; but care fhould be taken not to injure the bones ; for as in fome parts of the body they are extremely thin, much harm might enfue from their being hurt. On the eye being taken out, the attention of the op- erator is firft direaed to the hemorrhagy : but although in fome inftances this may take place to a confiderable degree, yet it does not often happen ; for in general, the diicharge of blood in this operation is fo inconfid- erable as Scarcely to require the aid of compreffion to put a ftop to it. But whenever it proceeds too far, it may be eafily ftopped by preffure; or, a piece of dry Sea. XV. Diseases of the Eyes. 221 fponge being applied to the mouths of the bleeding veffels, preffure may alfo be employed, by fluffing the reft of the orbit with foft lint and applying a napkin over the whole, fo as to make it prefs with fome firm- nefs on the fponge beneath. When fponge, however, is employed, fome attention is neceffary in applying it; for when fponge is appli- ed to the mouth of a bleeding artery, it is apt to ad- here fo firmly as to require a good deal of force, as well as fome management, to remove it. Before in- ferting the fponge, therefore, a piece of ftrong waxed pack thread fliould be tied to it; by which it may be pulled out when the hemorrhage is fuppreffed. As foon as a free fuppuration takes place, the band- age and lint will be eafily removed ; and the only ne- ceffary dreffing is a pledget of emollient ointment, to be continued as long as any difcharge of matter takes place from the orbit. In performing this operation, I have advifed the common fcalpel to be employed ; and I have no hefi- tation in faying, that it is preferable in every refpea to any inftrument that has yet been propofed. Different forms of Scalpels have been invente'd for this operation, particularly one with a confiderable degree of curva- ture. As this has been in fome inftances employed, I have given a view of it in Plate XXI. fig. 1. But it does not anfwer the purpofe fo well as the Straight Scalpel; and in ufing it, we are more apt to injure the bones of the orbit. The operation I have defcribed, namely, the extir- pation of an eye, is attended with much pain to the patient, and appears to be of a cruel and dangerous nature to byftanders ; fo that few furgeons have re- folution to perform it. It ought in no inftance to be advifed where a cure can be accomplifhed by more gentle means ; but when this cannot be done, and when a patient will for certain die jn mifery if the eye be not removed, it ought furely to be advifed as the moft certain means of affording at leaft fome chance 222 Diseases of the Eyes. Chap. XL of fafety : for although it will not always anfwer, yet we know from experience, that in fome inftances lives have been faved by it, which otherwife would proba- bly have been loft. We ought, however, to remem- ber, that in every cafe of cancer, extirpation proves, caeteris paribus, moft SucceSsful when praaifed early; fo that it Should always be adviSed in cancer of the eye, as foon as it is evident that the difeafe is com- pletely formed. SECTION XVI. Of Artificial Eyes. AS the lofs of an eye is always produaive of much deformity, our being in fome meafure able to obviate this, is not unfrequently a deiirable ob- jea ; and by the ingenuity of modern tradefmen, it is eafily done. A thin concave plate of glafs, filver, or gold being fitted to the orbit, muft be coloured fo as to match the other eye as nearly as poffible; and if care is tak- en to render it perfeaiy fmooth, it may be introduced beneath the palpebral, and ufed without exciting pain. Of all thefe fubftances, however, glafs is the moft pro- per ; for it not only can be made to refemble the nat- ural eye more exactly than the others, but it is much more cleanly. It has been objeaed to the ufe of glafs indeed, that it is apt to break by blows and other ac- cidents : of many, however, who I have known ufe this artificial eye, I do not remember an inftance of any who ever were hurt by it. An artificial eye may be fitted to any orbit, where the eye has either been funk by the evacuation of part of its contents, or where a portion of the eyeball has been removed : but it feldom happens that any advan- tage is derived from this invention where the globe of Sea. XVII. Diseases of the Eyes. 223 the eye has been entirely taken away; for when not fupported beneath, the artificial eye finks too deep in- to the orbit, and can never be made to fit properly. It is chiefly, therefore, in cafes of hydrophthalmia and ftaphyloma in which it has been found neceffary to evacuate a portion of the contents of the eye, or per- haps to remove fome part of it, that artificial eyes prove ufeful. SECTION XVII. Of Catarads. § 1. General Remarks on Catarads* VARIOUS definitions have been given of the term cataraa ; fome of which are fufficiently accurate, but others have rather tended to convey an improper idea of the nature of the difeafe. Blindnefs, induced by an opaque body immediately behind the iris, forms the difeafe we name cataraa ; and as we find from diffeaion that this opacity is in every inftance feated in the cryftalline lens, or in its investing membrane, a cataraa may with propriety be defined, to be a deprivation of fight induced by an opaque ftate of the lens or of its capfule. The real feat of cataraa being a late difcovery, we need not be furprifed at finding very perplexed and contradiaory accounts of it in all our ancient chirur- gical authors. By fome it was confidered as an affec- tion of the internal furface of the cornea ; others im- agined that it was feated in the vitreous humour; whilft by many it was fuppofed to be produced by a new formation of a membranous fubftance within the cavity of the eye- By fome this new produaion was fuppofed to be attached to the coats of the eye * while 224 Diseases of the Eyes. Chap. XL others alleged that it ufually continued loofe, and floated in the aqueous humour. Some writers of emi- nence, too, appear to have confounded the gutta fere- na with this difeafe, the former being often mention- ed and defcribed under the name of the black cataraa. The faa, however, is now afcertained, that cata- raa, in a pure unmixed form, depends entirely on a difeafed ftate of the lens or of its capfule ; and its ap- pearance indeed is fo diftinaiy marked, that no prac- titioner of experience can ever miftake it : but for the advantage of beginners, and of others not accuftomed to this branch of bufinefs, I fhall, in the firft place, give a fhort hiftory of the rife and progrefs of the dif- eafe and fhall afterwards endeavour to point out fuch cicumftances as diftinguifh it more particularly from fome other affeaions of the eye. Inftances fometimes occur, in which cataraas form fuddenly, and a total lofs of fight, with complete opa- city in the lens, takes place at once without any pre- vious affeaion. This, however, is rare ; and it com- monly happens, that the difeafe approaches in a very gradual manner, from a flight degree of dimncfs, with which it commences, to an entire lofs of vifion. The firft fymptom that ufually occurs in cataraa is what the patient terms a weaknefs of fight, and which commonly takes place long before any alteration is perceived in the State of the lens. By degrees this weaknefs, or rather dfmnefs of fight, becomes more confiderable ; and the patient being from his feelings led to fuppofe that it is in fome meafure produced by duft or motes floating in the air, or by fome opaque matter upon the external furface of the cornea, is of- ten employed in rubbing his eyes ; and is furprifed to find that his fight never becomes clearer from his do- ing fo. If in this ftate of the difeafe the eye is examined, the lens will be obferved to have acquired a duSky hue ; and inftead of being clear and diaphanous, which it naturally is, it will be found to be flightly Sea. XVII. Diseases of the Eyes. 225 opaque. By degrees the dimnefs of fight becomes more diftrefsful, till at laft it terminates either in total blindnefs, or perhaps the patient may be able to dif- tinguifh light from darknefs ; but in the advanced ftages of the difeafe, he can feldom diftinguifh colours, excepting thofe of the brighter kinds, nor can he find his way in roads where he is not perfeaiy acquainted. In proportion to the degree of blindnefs that takes place, the lens is obferved to become more and more opaque, till at laft it is found to be either entirely white, or of a light gray or pearl colour. In a few inftances this whitenefs is confined to a fmall portion of the lens, and forms a fmall opaque fpot in fome particular part of it; but in general, the whole body of the lens is equally difeafed. During the whole courfe of the difeafe, the pupil contraas and dilates according to the degree of light in which it is placed ; at leaft this will be always ob- ferved when the eye is not otherwife difeafed, Cata- raas, however, are often combined with gutta ferena ; in which cafe the pupil is not affeaed by any degree of light we apply to it: this, indeed, does not proceed from the ftate of the lens, but from the difeafed ftate of the optic nerve. Cataraas are not commonly attended with pain ; but in fome inftances it is otherwife, when every ex- pofure to light creates much uneafinefs. This, how- ever, is always to be confidered as an accidental cir- cumftance, depending probably on Some degree of in- flammation at the bottom of the eye, and not as a ne- ceffary fymptom of cataraa. I have already obferved, that cataraa has been con- founded with other difeafes. This however, can only happen from inattention ; for there is Scarcely any other difeafe to which it bears much refemblance. But in books, we find it has been miftaken for the gutta ferena; for the hypopion and ftaphvloma ; and it has Vol. II. Q 226 Diseases of the Eyes. Chap. XL been confounded with white opaque fpots on the cor- nea. It is eafily diflinguifhed, however, from all of thefe. In cataraa, the pupil contraas when expoSed to much light, and an opaque body is obServed behind the iris: whereas in an unmixed caSe of gutta ferena, the pupil remains in a ftate of dilatation whatever degree of light is applied to it, and no opacity is obferved at the bottom of the eye: it is diflinguifhed from the hypo- pion, ftaphyloma, and white fpots upon the cornea, by the evident marks of difeafe which in all of thefe take place in the anterior part of the eye, the cornea itfelf; which in all of them is opaque, and which in the hypopion and ftaphyloma is .commonly elevated into a fmall tumor or protuberance : whereas in cata- raa, the only fymptom that occurs, is, blindnefs to a greater or lefs degree, attended with a white opaque fpot behind the iris, the cornea and every other part of the eye remaining perfeaiy found. I have already obferved, that this opacity is found by diffeaion to de- pend upon a morbid ftate of the lens. For the moft part it is the body of the lens only that is difeafed ; fo that the opacity is removed, and the eye appears perfeaiy clear on this being taken out: but in a few inftances, the membrane or capfule that Surrounds the lens is the Seat of the difeafe; fo that the fame degree of opacity ftill continues even after the fens is remov- ed. This, however, is not a frequent occurrence; but it is fometimes met with, and is with fufficient propri- ety termed the membranous cataraa. It is difficult, or perhaps impoffible, to aScertain the proximate cauSe oS cataraa; but I think it probable, that it confifts in Some degree of obftru£tion of the veffels of the lens, in fome inftances induced by exter- nal violence, but moft frequently by fome internal caufe, for which we cannot properly account. The exiftence of veffels in the cryftalline is doubted indeed by many, who imagine that nourishment is conveyed to it by the fmall quantity of fluid that we Sea. XVII. Diseases of the Eyes* 227 meet with in the capfule of the lens. But the faa I confider as eftablifhed, that the lens is fupplied with veffels from its capfule, injeaions having been made to pafs from one to the other, not only in different ani- mals, but in fome inftances in the human eye. But whether this could have been demonftrated or not, the exiftence of veffels in the lens, is rendered, I think, fufficiently probable, by a circumftance I took notice of in the hiftory of the difeafe, namely, the hidden formation of cataraas, which in a few cafes has been obferved. I have now met with feveral inftances of this ; in fome of which the moft complete degree of opacity took place in the cryftalline in the courSe of a few hours from the firft fenfation of dimneSs ; a faa that cannot be So readily explained on any other Sup- pofition. It may be alleged, where the cataraa is So Speedily formed, that the opacity may ariSe from difeafe in the veffels of the capfule, and not of the lens itfelf. In fome inftances this may be the cafe; but in more than one of thofe to which I allude, the difeafe appeared to be fixed in the body of the cryftalline, and the cap- fule remained perfeaiy found ; for on the lens being extraaed, the opacity was entirely removed. In confirmation, too, of this opinion, of cataraas being probably produced by fome degree of obstruc- tion in the veffels of the lens, I may remark, that they occur more frequently in women about the ceffation of the menfes than at any other period ; and we know that this period is particularly produaive of obstruc- tions in other parts of the body. As long as the opinion prevailed of there being dif- ferent fpecies of cataraas, a variety of means were ad- vifed in the method of cure ; but now that the real nature of the difeafe is known, our Sole objea is to re- move the opacity of the lens; or when this cannot be done, we remove the lens itfelf from the axis of vifion. Q 4 228 Diseases of the Eyes. Chap. XL In confirmed cataraas of long duration, no advan- tage is ever derived from any internal medicine; but fo the incipient ftate of the difeafe, before the opacity of the lens is complete, mercury has in fome cafes proved ufeful. When inflammation takes place, blood- letting both general and local; the application of blif- ters to the temples, together with a ftria antiphlogif- tic regimen, fhould be advifed ; and I have in a few cafes derived advantage from the operation of brifk purgatives ; but nothing I have ever tried has anfwer- ed So well as Small doSes of calomel often repeated. £xtraaum hyofcyami, flammula jovis, and other ve- getable produaions, have likewife been celebrated for their efficacy in cataraa ; but no trials that I have giv- en them, and I have ufed them all in different inftan- ces, can juftify the recommendation. When mercury, and the other remedies we may employ, are found to fail, our next objea, as I have already obferved, is to remove the difeafed lens from the axis of vifion : this we accomplifh by one or oth- er of two chirurgical operations, namely, by preffing the fens from its natural fituation in the centre down to the bottom of the eye, an operation commonly termed couching the cataraa ; and that operation which we denominate extraaion of the lens, by which the difeafed body is taken entirely out of the eye. Each of thefe operations has been much employed ; fo that the merits of both ought long ago to have been .ascertained: but although the fubjea is of the higheft importance, it ftill remains in a ftate of uncertainty. By fome praaitioners, couching is preferred ; whilft others confider extraaion of the lens as the only rem- edy on which we fhould place any dependence. The uncertainty in which we ftill remain upon this point, proceeds, I believe, from this branch of prac* tice having hitherto been for the moft part in the hands of itinerants: and as praaitioners of this de- nomination, have uniformly from their firft outfet in life, adopted one method of operating only, they have Sea. XVII. Diseases of the Eyes. 229 very univerfally condemned the Other ; which they themfelves neither praaife, nor perhaps understand : fo that regular praaitioners, not being able to deter- mine from their own experience, they have in general remained upon this point very undecided. &tk the public appearing now to be convinced of the propri- ety of intruftlng this, as well as every other operation of importance, to eftablifhed Surgeons of reputation-* opportunities will thus be afforded of determining the point in queftion by experiment; the only means by which any degree of certainty can be obtained. In profecuting the confideration of this fubjea, 1 fhall endeavour to point out as clearly as poffible the refult of my own obfervations upon it, together with that of fome of our beft employed Surgeons. With this view, I fhall firft deScribe the operation of couch- ing ; and after considering the. different fteps of th€ operation of extraaing the cataraa, I fhall attempt to draw a juft comparifon of the merits of the two. § 2. Of Couching, cr Depreffion of the Catardd. I have already obferved, that the operation of douching confifts in preffing the cataraa or difeafed fens from its natural fituation in the centre down to the bottom of the eye. By this means the opacity producing the difeafe is removed from the axis of vi- fion ; and although the fight is never fo perfea as Be- fore the lens became opaque, when the eye is other- wife found it proves quite fufficient for the common purpofes of life. In the anatomical description of the eye, which makes the fubjea of the firft part of this chapter, we have feen, that the leils is placed behind the pupil, where it is lodged in a flight depreffion of the vitreous humour, to which it is attached by a capfule, formed by a portion or lamella of the tunic which includes- thc vitreous humour itfelf. In couching, the lens is feparated from its capfule ; and being preffed down 230 Diseases of the Eyes. Chap. XL behind the iris, if the operation fucceeds, it either re- mains there during life, or is diffolved in the aqueous humour in which it is lodged. Before we proceed to this operation, fome circum- ftances in a particular manner require attention ; the moft material of which are, the degree of opacity in the lens, and the ftate of the eye with refpea to other difeafes. It is a faa well know to praaitioners, that no oper- ation can be performed on the eye, but with the rifk of inducing inflammation ; a fymptom that proves te- dious, or otherwife, according to the conftitution of the patient, and other circumftances of the cafe. This points out the propriety of proceeding with caution, and of attempting no operation on this organ, not ab- folutely neceffary for the welfare or comfort of the patient, Where a patient is rendered fo blind by ca- taraas in both eyes, that he cannot condua himfelf in the common occurrences of life, we fhould not he-. fitate in advifing an operation Sor his relieS. In Such circumftances, any rifk oS his Suffering Srom inflam- mation is more than counterbalanced by the advan- tages he may derive from the operation.. But when one eye only is loft, and the patient enjoys a perfea ufe of the other ; or where even both eyes are difeaf- ed, if the opacity of the cryftallines is not So confid- erable as to prevent the patient from managing his ordinary bufineSs ; or if it does not deprive him of his fight in any confiderable degree; in any of theSe circumftances, a prudent praaitioner will rather avoid an operation, and will adviSe it to be delayed as long as vifion remains tolerably perfea. The ingenious Dr. Richter of Gottingen, is indeed of opinion, that the exiftence oS cataraa in one eye is particularly apt to produce a fimilar affeaion in the other, and therefore he advifes the cryftalline to be re- moved as foon as it becomes entirely opaque, whether it is difeafed in the other eye or not. The propriety, however, of this advice .can be only determined by J5ea. XVII. Diseases of the Eyes. 231 further obfervation ; but it often happens, that to- gether with an opaque ftate of the cryftalline, the eye is in other refpeas fo much difeafed, as to afford no hopes of vifion being reftored by the cataraa being removed ; in which cafe, as no advantage could be derived from an operation, it ought not to be advifed. This is particularly the cafe in the hypopion, in the gutta ferena, and in every affeaion of the eye attend- ed with an opaque ftate of the cornea. Writers on this fubjea mention another reafon, by which they think that praaitioners fhould be deter- mined, when the operation in cafes of cataraa fhould be advifed. It has very univerfally been fuppofed, that a cataraa ought to be in a particular ftate, in or- der to enfure fuccefs from an operation; infomuch that we are advifed never to operate unlefs this ftate of the difeafe is found to prevail. The ftate to which I allude, is a fuppofed ftate of maturity, which it is believed every cataraa will fooner or later arrive at, and which is faid to be clearly and evidently pointed out by certain appearances of the opaque cryftalline. It is true, that both in the operation of couching and extraaing the cataraa, the lens is fometimes found to be partly foft and in part very firm, and in a few cafes it is even perfeaiy fluid ; a circumftance com- monly confidered as unfavourable : but although this may have firft fuggefted the idea of the unripe ftate of a cataraa, as it is termed, yet no advantage has hith- erto been derived from the diftinaion; for notwith- ftanding a variety of figns have been mentioned, by which the real ftate of a cataraa is faid to be evident- ly marked, yet it does not appear to be fupported by experience : on the contrary, we often find that a ca- taraa is of a firm texture, that was previously fufpea- ed to be foft; and vice verfa. Nothing, indeed, can render it more obvious, that this idea of the mature ftate of a cataraa is ill found- ed, than the variety of opinions that prevail refpeaing it: for while by Some it is faid that this ftate of the 232 Diseases of the Eyes. Chap. XL difeafe is indicated by a pure white or milky appear- ance, others affert, that a light gray or pearl colour is the moft certain mark of it. Now, the faa is, that the real ftate of a cataraa can never be known from its colour ; and the beft informed praaitioners will allow, that no advantage is to be derived from this means of diftinaion. The idea of a cataraa being more ripe at one peri- od of the difeafe than at another, originated, as I have obferved above, from the cryftalline being in fome in- ftances found to be fluid, which gave caufe to fufpea that the firft effea of a cataraa is to induce a foftnefs of the lens, and that this foft or fluid ftate of it is gra- dually altered by the progrefs or continuance of the difeafe, by which it is fuppofed to acquire a firm con- fiftence, when it is conceived to be thoroughly ripe. This opinion, however, of this being neceffarily the firft effect of a cataraa upon the lens, is equally ill founded with the idea I have mentioned, of the real ftate of the difeafe being to be diflinguifhed by its ex- ternal appearance ; for we know from experience, that cataraas are often of a firm texture from the be- ginning. From my own obfervation, indeed, I would fay, that the moft frequent effea of cataraa upon the lens is-to produce a preternatural degree of hardnefs through the whole of it; as, for the moft part, an ex- traaed opaque cryftalline is of a firmer texture than it is ever found to be when healthy and tranfparent. We are, therefore, to conclude, with refpea to this circumftance of the ripe or unripe ftate of a cataraa* that in the treatment of the difeafe no advantage is to be derived from any thing we yet know concerning it. In the common acceptation of the term, indeed, the word ripenefs has in this refpea no determined meaning affixed to it: I would therefore propofe, that inftead of being employed to fignify the appearances of a cataraa, it fhould be applied only to exprefs the effeds that arife from it. In this manner, the term might ftill be retained with propriety; for we might Sea. XVII. Diseases of the Eyes. 233 very properly fay that a cataraa is ripe when the pa- tient is rendered entirely blind by it, and when there- fore it is ready for an operation ; and, on the contra- ry, that the difeafe is ftill in an unripe ftate, as long as vifion is not much impaired by it. As the ftate or confiftence of a cataraa, is much infifted upon by almoft all who have wrote on it, I here judged it right to enter on this inquiry ; and, on the whole, this conclufion I- think may be drawn from what has been faid, that in determining upon the pro- priety of operating, we are never to place any depend- ence on the appearance of the lens; that we are to be folely direaed by the effeas which cataraas produce* and by the ftate of the eyes with refpea to other dif- eafes. As long as vifion remains tolerably perfea, whether in both or only in one eye, for the reafons I have given, a prudent praaitioner would rather avoid the operation: but, when the fight becomes much impaired, if the cornea is found to be tranfparent, and if the pupil dilates and contraas freely, according to the degree of light to which it is expofed, we fhould not hefitate in advifing an operation as the only effec- tual means of relief. And when the operation of couching is agreed on, the following is the method of doing it. As it is of importance in this as well as every oper- ation upon the eye, to guard againft inflammation, nothing fhould be omitted that can in any way tend to prevent it: the patient Should be confined, Sor Sev- eral days before the operation, to a low regimen: he Should loSe ten or twelve ounces of blood, and even more if his ftrength admits of it, and two or three purgatives fhould be given at proper intervals. In performing this operation, and likewife in ex- traaing the cataraa, a large quantity of light is necef- fary ; but no funfhine fhould be admitted ; for by the irritation which it excites, the eye is prevented from being kept fo fleady, even with a fpeculum, as it oth- 234 Diseases of the Eyes. Chap. XL erwife may be. A north expofure fhould therefore be preferred. The only apparatus to be provided for this opera- tion, is a fpeculum of a proper conftruaion, and of a fize adapted to that of the eye; and an inftrument termed a needle, for the purpofe of depreffing the cat- araa. Different forms of the needle are reprefented in Plate XV.; and in Plate XIII. are delineated differ- ent views of the moft uSeful fpeculum that has yet been invented. As it is of much importance to have the eye pro- perly fixed during the whole courfe of the operation, and as this is beft done with a fpeculum exactly fitted to the eye, every operator fhould be provided with feveral Sizes of this inftrument. The beft needle for this operation is that of a flat form, reprefented in Plate XV. fig. i. The patient fhould be placed upon a low feat with his face towards the window, and the furgeon, upon a chair considerably higher, fhould be Seated direaiy beSore him : an affiftant ftanding behind muft be di- reaed to Support the patient's head, which is moft ef- feaually done by placing one hand under the chin, and the other on the forehead; and in order to pre- vent interruption, the hands of the patient fhould be firmly fecured by an affiftant on each fide. During the operation, it is of much importance for the furgeon to have his hand and arm firmly fecured: for this purpofe, nothing anfwers fo well as a proper reft for the elbow, which ought therefore to be placed either upon a table, or on the knee of the operator raifed to fuch a height that it may be nearly on a line , with the eye of the patient. Practitioners ufually truft to the hand being fecured by the ring and little ringers refting on the cheek or temple of the patient: but this feldom proves fufficient for the perfea SteadineSs which operations on the eyes require; and whoever will make trial of the mode I have mentioned of fixing the elbow, will find it preferable. It is proper, indeed, Sea. XVII. Diseases of the Eyes. *3S that any advantage to be derived from refting thefe two fingers upon the cheek fhould be likewife laid hold of; but this alone fhould not be relied on. An ingenious author, who has lately written on the cataraa, has communicated fome valuable praaical observations to the public* His method of giving fupport and Sleadinefs to his hand during the opera- tion of extraaing the cataraa, and the fame obferva- tions, I may remark, apply with equal propriety to that of couching, is to prefs the upper part of the arm and elbow of that hand with which he performs the operation, Strongly againft his own breaft and ribs, and to reft his little finger about an inch Srom the out- fide of the eye, on the cheek bone of the patient, at the fame time that he retains his breath, and remains as much as poffible in that fituation, till the incifion of the cornea is finished. He has alfo invented a chair, for the purpofe of fixing the head of the patient, which he has ufed for many years with much advan- tage. He very properly obferves, that in the ufual method of fixing the head, by preffing it againft the breaft of an affiftant, that the leaft motion, even that which occurs from the affiftant drawing breath, muft occafion a corresponding motion of the head of the patient. The chair that he has invented, is reprefent- ed in Plate XXIX. and it appears to be well calcula- ted for the purpofe for which it is meant. Whether the patient is feated on this chair, or in the manner I have advifed above, the affiftant is now to raife the upper eyelid with the fingers of his left hand ; and the furgeon applying the groove in the upper part of the fpeculum, Plate XIII. fig. i. in fuch a manner that it may receive the edge of the eyelid, the opening or circle formed by the brim of the fpe- culum is to be preffed upon the ball of the eye, till the tranfparent cornea, and nearly about an eighth * Vide a Treatife on the extra&ion of the Cataract, by Frederick Bif- choflf, F. M. S. Oculift to hi* Majefty in the Electorate of Hanover, and t« her Majefty in England. 236 Diseases of the Eyes. Chap. XL •part of an inch of the Sclerotica, is protruded; by ■which means, if a Steady and equal preffure is contin- ued upon the eye, it will be kept firmly fixed without any injury being done to it, at the Same time that a fufficient quantity of the ball will be left uncovered by the fpeculum for the purpofe of the operation. I am at prefent fuppofing that the operation is to be performed upon the. left eye. For this purpofe, the patient being fecured in the manner I have advif. ed, the fpeculum being applied and fecured by the furgeon's left hand, and the furgeon himfelf being feated, with the elbow of his right arm fixed at a pro- per height, he muft take the couching needle in his right hand, and having fixed it, as we do a pen in writing, between the thumb and fore and middle fin- gers, while the ring and little fingers are made to reft upon the cheek or temple of the patient, the point of the inftrument muft now be made to pafs the external canthus of the eye ;. and being brought nearly in con- taa with the Sclerotica, it fhould now be quickly plung- ed through this coat, Somewhat below the centre of the eye, and about one-tenth oS an inch behind the iris. In Plate XVII. fig. 1. is delineated a needle paff- ed into the eye in this manner, by which a better idea is given of the operation than can be done by any de- scription. In order to avoid the iris, the inftrument Should be introduced with its flat furface towards this membrane, and fhould be carried forward in a ftraight direaion till the point of it is difcovered behind the pupil, as is reprefented in the figure I have mentioned. By de- preffing the handle of the needle, the point of it will be raifed, and the fiat furface of it being turned down- wards, it muft now be pufhed into the upper part of the cryftalline, when the operator, by elevating tl^ handle, muft endeavour to carry the lens upon the point of the inftrument down to the bottom of the eve ; which will be inftantly difcovered, on the fur- geon obfcrving through the pupil tlii.it the cataraa dif- Sea. XVII. Diseases of the Eyes. ly? appears, and by the patient becoming fenfible to the impreffion of light. Were we fore of the lens continuing at the bottom of the eye, the needle might now be withdrawn, and the operation would be finifhed : but as we know from the anatomy of the eye, that there is a portion of the aqueous humour lodged between the vitreous humour and the iris ; as it is into this part of the aqueous hu- mour that the cryftalline is depreffed ; and as this hu- mour is of a confiftence too thin for preventing the aaion of the muScles of the eye from raifing the lens again on the preffure of the inftrument being with- drawn ; we need not be Surprised at the operation be- ing frequently found to fail on being finifhed in this manner. Inftead of this, on the cryftalline being preffed to the bottom of the pofterior chamber, it fhould be flow- ly carried on the point of the inftrument towards the outer and back part of the eye ; a movement which is beft accomplifhed, by the operator raifing his hand fo as to elevate the handle of the needle, at the fame time that he makes it pafs fomewhat outward over the cheek. In this manner, the cryftalline is to be partly lodged below the vitreous humour; which being of a firm confiftence, very commonly prevents it from rif. ing again; and being brought towards the external canthus of the eye, if it fhould afterwards be forced up by the aaion of the mufcles, not being oppofite to the pupil the paffage of light to the retina will ftill re- main clear, and vifion will accordingly be no more affeaed than if the cataraa had remained at the bot- tom of the eye. As foon, therefore, as this movement is finifhed, the needle fhould be withdrawn ; and there being now no further ufe for the fpeculum, it fhould likewife be tak- en off: but as it is of importance to have the eye pro- perly fixed during the whole courfe of the operation, the fpeculum fhould not be removed till the whole is finifhed. 238 Diseases of the Eyes. Chap. XL On the inftrument being taken away, praaitioners commonly try what effea is likely to refult from the operation, by prefenting different objeas to the pa- tient : but although no harm enfues from flight trials of this kind, they fhould never be carried far; for they may do harm by tending to promote inflamma- tion, while no real advantage can ever arife from them. After the operation, a comprefs of foft lint, foaked in a weak faturnine folution, fhould be lightly applied over the eye; and this being retained by the band- age, Plate XXX. fig. 3, the patient fhould be confin- ed in a dark apartment, and kept on low diet as long as there is any rifk of inflammation taking place: with the view, too, of preventing this, a dofe or two of a brifk purgative fhould be exhibited ; and, when neceffary, blood fhould be taken from the temporal artery, from the jugular vein, or from the neighbour- hood of the eye, with leeches. The eye fhould be looked at daily, that the real ftate of it may be known; but the patient, for a con- fiderable time, fhould be kept in an obfcure light, with his eyes fufficiently covered. For the moft part, we difcover in the courfe of a few days whether the operation is to fucceed or not, but in fome inftances the patient remains for a con- fiderable time perhaps equally blind as before, and yet gradually reeovers the power of vifion afterwards, fo as to diftinguifh objeas equally well as if the opera- tion had proved fuccefsful from the firft. This I fup- poSe to happen from fome degree of inflammation be- ing produced in the capfule of the lens, by the vio- lence done to it by the couching needle, and till this is entirely removed, that the effea of the operation cannot be afcertained. On removing the coverings from the eye, if the cataraa is not difcovered, the objea of the furgeon is completed; but if the lens has again got into its ufual fituation, after a further delay for the purpofe of al- Sea. xvn. Diseases of the Eyes. *39 lowing the inflammation induced by the firft opera- tion to Subfide, another attempt ffiould be adviSed ; and a Second or third I have Srequently known to Suc- ceed, when the firft had entirely failed : this, in a great meafure arifes from the circumftance to which I have already adverted, the needle being withdrawn immediately on the lens being preffed to the bottom of the eye; for this being done, it is in general fup- pofed that the operation is finifhed. I have endeav- oured however to fhow, that this is by no means the cafe; and that the cataraa will feldom rife again if it be preffed towards the external canthus of the eye, and gently pufhed beneath the vitreous humour. Thofe who have not operated in this manner, will perhaps objea to it, that by forcing the lens into the vitreous humour, an unneceffary violence is thus done to this part of the eye, by which it muft be fo much injured, as to have Some influence on the fuccefs of the operation. This, however, does not on experi- ence appear to be the cafe ; for I have often done the operation in this manner, and I never obferved any harm enfue from it. We fhould not wantonly hurt the vitreous humour; but we know that it is often much more materially hurt in extraaing the cataraa, and with little apparent detriment to the eye, than it can ever be in the operation of couching. Thus it often happens, in extraaing the lens, that a confider- able portion, or even the whole of the vitreous hu- mour, is difcharged, and yet the operation fucceeds equally well as if no fuch occurrence had taken place. This, indeed, every operator would rather wifh to avoid ; but it fliows clearly, that no injury of impor- tance can be done to vifion by the practice I have advifed, of lodging the cataraa in the operation of couching, partly beneath, or even entirely in, the fub- ftance of the vitreous humour. The operation I have defcribed is fuppofed to be done, as I have already obferved, upon the left eye ; for which purpofe the right hand of the operator 240 Diseases of the Eyes* Chap. XL muft be employed : but in operating upon the right eye, if the needle is to be entered in the ufual way, from the outer or external canthus of the eye, it muft either be done with the left hand of the furgeon, or, if he wifhes to ufe his right hand, he muft either fit or ftand behind the patient, when, by fupporting the head upon his breaft or upon his knee, he may in this manner accomplifh his purpofe. This mode of oper- ating upon the right eye has been frequently praaifed even by furgeons of eminence, but it is extremely awkward; and befides, the operator can never have fuch a full command of the eye when he fits or Stands behind, as when placed beSore the patient. Few Sur- geons, however, are So alert in ufing their left hand, as to be able to perform with it this very nice opera- tion ; fo that with the ufual inftruments there is no other alternative than that of doing it from behind. But in Plate XV. fig. 4. and 5. there is delineated a form of needle, by which the operation may be done with eafe and fafety on the right eye with the right- hand of the furgeon, whilft he is feated before and oppofite to the patient. Only in this caSe, inftead of entering the inftrument at the uSual place, by puffiing it inwards from the external canthus of the eye, it muft be entered at the internal angle, and pufhed out- wards, as is reprefented in Plate XVIII. figure 1. In every other refpea the operation is to be conduaed as I have already direaed ; only, the cataraa, inftead of being carried to the external canthus of the eye, muft in this caSe be drawn by the point oS the needle to- wards the noSe. In this manner the operation may be done upon the right eye by any Surgeon who can perform it upon the left; an improvement that many will judge to be important. As the operation of couching is very univerfally performed without the affiftance of a fpeculum, it may be confidered as an affeaation of Singularity to re- commend one. In anfwer to this I muft obferve, that although the cataraa may be depreffed without the Sea. XVII. Diseases of the Eyes. 241 ufe of a fpeculum, it may be done more perfeaiy, and with more eafe both to the patient and furgeon, When a fpeculum is employed, than when it is not. By means of the fpeculum, delineated in Plate XIII. as well as with that in Plate XXII. fig. 5. the eye may be very firmly fixed, which allows the operator to manage the needle with more eafe than can otherwife be done. It has been commonly objeaed to the ufe of the fpeculum, that it does not fecure the eye fufficiently; and that it always proves detrimental, by exciting in- flammation over the eyeball. This obfervation, I be- lieve, is well founded with refpea to the inftrument in ordinary ufe, of which a delineation is given in fig. 3. Plate XII. But it does not apply to either of the others ; which, when properly fitted to the fize of the eye, fecure it exaaiy ; and when finely polifhed, nev- er do harm. Some praaitioners, fenfible of the impoffibility of fixing the eye properly in the manner commonly at- tempted with the fingers alone, and finding the com- mon fpeculum insufficient, have propoSed another in- ftrument for this purpoSe : it confifts of a Sharp fpear or prong, fixed in a handle, with a croSs flat bar near the point, as is delineated in Plate XII. fig. 2. This inftrument has long been employed in Some parts of the Continent: it is uSed by pufhing the point of it through the Sclerotic coat on the fide of the eye oppofite to where the needle is to be entered ; and it is prevented from penetrating far, by the croSs bar with which it is furnifhed : in this fituation, it is Se- cured by an affiftant on one fide of the patient; and the eyelids being Separated by the Surgeon himSelf, affifted by the perfon behind who fupports the head, the eye may in this manner be fixed in fome degree, but never with fo much eafe and certainty as with either of the fpeculums I have mentioned. Vol. II, R 242 Diseases 6f the Eyes. Chap. XL Needles of various forms and Sizes have been uSed in this operation ; but the flat needle, figure i. Plate XV. anfwers the purpofe better than any that I have tried. It ought not to be broader than this, otherwife it makes too large a cut in the coats of the eye ; and if much narrower, it does not fo readily carry the lens along with it. The round needle, fig. 2. of the fame Plate, has been much employed by many itinerants ; but I have not found, upon trial, that it anfwers fo well as the other. After piercing the cataraa, it parts with it too eafily : and befides, it enters the coats of the eye with more difficulty, and it cannot be fo eafi- ly moved when introduced as the other ; which being broad in the cutting part of it near the point, the opening formed by it in the tunica fclerotica is fome- what larger than the diameter of the reft of the in- strument, which admits of its being afterwards eafily moved in every direaion. It has been objeaed to the flat needle, that by its breadth it is more apt than the round one to hurt the iris ; but with the precaution I have mentioned, of in- troducing it with the flat furface towards this mem- brane, there can never be any hazard of this. The flat part of the needle may indeed be made too broad, and this I believe is very commonly done; by which the opening made with it is too large ; more irritation is thus excited; and when broad near the point, it does not fo readily penetrate the lens as a narrow needle would do. The needle delineated in Plate XV. fig. 1, is in every refpea of a proper fize. Fig. 3, reprefents a needle with a fmall degree of curvature, by which I have fometimes thought that the cataraa may be more eafily depreffed than with a ftraight nee- dle ; but I have not yet ufed it fo frequently as to be able to fpeak of it with decision : in piercing the eye with it, the convex fide of the curve fhould be to- wards the iris, as this membrane would be apt to be injured, were it introduced in any other manner. Sea. XVII. Diseases of the Eyes. 243 In defcribing the operation, I defired that the nee- dle might be entered at one fide of the eye, by paffing it through the fclerotic coat at the diftance of one- tenth of an inch from the iris. And I likewife ob- ferved, that it anfwers the purpofe better by introduc- ing it fomewhat below the centre of the eye, than if entered, as is ufually done, in a line with the centre of the pupil. It ought not, however, to be far below this point. The twelfth part of an inch is fully fuffi- cient ; for when the needle is introduced near the bottom of the eye, the cataraa is not fo eafily depreff- ed with it. It has been faid by fome, that the operation may be performed, not only with more eafe, but with more fafety, by introducing the needle through the tranfpa- rent cornea, and after paffing it through the pupil, to pufh down the cataraa with the point of it to the bot- tom of the eye. It is not, however, probable, that this propofal can ever be generally admitted, for it is not poffible in this manner to deprefs the lens fo eafi- ly as when the needle is entered in the manner I have adviSed, while it can Scarcely be done without hurting the iris. § 3. Of Extrading the Catarad. The operation of couching, or depreffing the cata- raa, had been long praaiSed, and was confidered as the only means by which an opaque cryftalline could be removed, till the year 1737, when an eminent ocu- lift of Paris, Mr. Daviel, firft propoSed and praaiSed the method of removing it by extraaion. It is true, that Several years previous to this period, Mr. Petit propoSed to make an opening through the transparent cornea, Sor the purpoSe oS removing the fens when Sorced into the anterior chamber oS the eye, either by accidental violence, or when pufhed through the pupil in the operation oS couching, an occurrence r 2 244 Diseases of the Eyes. Chap. XL which fometimes happens: but, being confidered as extremely hazardous, it was rarely pradifed ; nor was it ever SuppoSed to be proper in any other ftate of the difeafe, till Mr. Daviel, about the time I have men- tioned, put it frequently in praaice, in preference to the operation of couching. 3yc fome, the merit of this operation has been attributed to our countryman Taylor, a famous itinerant of thefe times ; but this will not be admitted by any who have paid attention to the hiftory of it, given by thofe who had the beft opportunities of being able to judge of it. This operation confifts in an opening being made through the tranfparent cornea, of a fufficient fize for admitting the paffage of the lens after it has paffed through the pupil into the anterior chamber of the eye. The operation itfelf was nearly, if not exaaiy, the fame when praaifed at firil by Mr. Daviel, as it is at prefent; but the method of doing it then was more difficult and tedious, by a greater number of inftru- ments being ufed in it than are now found to be ne- ceffary. At that period knives of different forms were employed ; as alfo, fciffars, forceps, a lancet conceal- ed in a canula for opening the capfule of the cryftal- line, as well as many others. In the prefent improv- ed ftate of this operation, the only inftruments we em- ploy are, a fpeculum for fixing the eye ; one or other of the knives, Plates XVI. XXII. and XXX. a fmall fcoop, Plate XVI. fig. 4. and a flat blunt crooked probe, Plate XVIII. fig. 5. In proceeding to this operation, the patient fhould be placed in the fame kind of light, and fecured in the fame manner as I have advifed for the operation of couching. The furgeon fhould likewife be feated in the fame manner before the patient, and ought to reft his elbow either upon a table, or upon his knee raifed to Such a height as to bring his hand nearly on a line with the pupil. This being done, if the operation is to be perform- ed on the left eye, the fpeculum muft be applied in Sea. XVII. Diseases of the Eyes. 245 the manner I have adviSed in the operation of couch- ing, and muft be preffed upon the eye with the left hand of the operator with as much firmnefs as is ne- ceffary for fecuring the eye ; but more than this Should be avoided, as it not only gives more pain,, but is apt to prefs the cornea into too near contaa with the iris ; by which the latter is in great rifk of being injured in the fubfequent fteps of the operation. The furgeon is now to take the knife between the thumb and fore and middle fingers of his right hand, allowing nearly an inch to projea paft the extremity of his middle finger; and the point of it being brought in contaa with the lucid cornea, it muft be made to penetrate this coat at the diftance of the fixteenth part of an inch or thereby from the.iris, in a line running from the external canthus of the eye direaiy acrofs the centre of the pupil, as is reprefented in Plate XVII. fig. 2. The convex furface of the knife being ftill kept next to the iris, it muft be carried fiowly forward in this direaion, till the point of it reaches the other fide of the eye direaiy oppofite to where it entered ; and muft here be pufhed out till nearly a quarter of an inch of it is freely through the cornea. The op- erator is now, in a gradual manner, to form a femilu- nar cut in the under part of the cornea, by moving the knife downwards in fuch a manner, that all that portion of the cornea lying between the point at v. hich it entered and that at which it paffed out, may be di- vided at an equal distance from the iris ; as is repre- fented in Plate XVII. fig. 4. In this manner an opening will be formed fufficiently large for the paffage of the cataract. While this Semilunar cut is forming in the cornea, the preffure of the fpeculum upon the eyeball fliould be gradually leflened, otherwise the vitreous humour will be forced out on the incision being finished. We are advifed indeed by fome to remove the fpeculum aliogether on the knife being paffed out at the oppo- 246 Diseases of the Eyes. Chap. XL fite fide of the eye ; for which purpofe they leave an opening on one fide oS the inftrument, to admit of its being taken off,- as is reprefented in fig. 3. Plate XIII. But with an operator accuftomed to the ufe of the fpeculum, there it no neceffity for this precaution ; for a degree of preffure may be made with it fufficient for fixing the eye, without any rifk of forcing out the vit- reous humour; and by keeping the eye fixed to the laft, we are enabled to form the incifion with more accuracy than can poffibly be done when the fpeculum is removed early in the operation. I have feen it in- deed often done in this manner ; but as foon as the eye has loft the Support of the fpeculum, the preffure of the knife is apt to draw the eyeball too much down on the under edge of the focket, by which a fmaller fegment of a circle is commonly formed than is fuffi- cient for the paffage of the lens ; for by the eye being drawn fuddenly down on the fpeculum being remov- ed, the under part of the incifion is almoft always formed at too great a diftance from the iris, and is thus made too fmall for the purpofe. When the eyeball has been too forcibly compreffed by the fpeculum, the cataraa, together with all the aqueous humour, and a confiderable portion of the vitreous, are very commonly preffed fuddenly out; but when this part of the operation is properly done, nothing but the aqueous humour paffes out. As foon as the incifion is finifhed, the operator muft lay afide the knife ; and having lifted the flap formed in the cornea with the flat crooked probe, Plate XVIII. fig. 5. the point of it fhould be paffed through the pupil, in order to fcratch an opening in the capfule of the lens; or this may be done with the inftrument reprefented in Plate XXIV. fig. 2. and 3. This being accomplifhed, the cataraa will either pafs out at the cut in the cornea, by the aaion of the mufcles of the eye ; or when this does not happen, it muft be forc- ed eafily out by very moderate preffure, applied over the globe of the eye with the finger. Sc<^. XVII. Diseases of the Eyes. 247 It happens indeed in fome inftances, that a good deal of preffure is required to force the cataraa out: but this always proceeds from fome fault in the pre- vious fteps of the operation ; almoft univerfally indeed from the cut in the cornea being too fmall, by which the lens is with difficulty forced through the pupil; or if it is made to enter the anterior chamber of the eye, it does not pafs through the opening in the cor- nea with fuch eafe as it ought to do. In this fituation, it is the common praaice to force out the lens by repeated applications of preffure. This, however, ought never to be done; for nothing proves more deftruaive to the eye than violence ap- plied to it in this manner : for befides the lofs of the vitreous humour with which it is commonly attended, the iris is often materially hurt, and much inflamma- tion induced by it. When the lens cannot be eafily removed from the anterior chamber of the eye by means of a fcoop, and in every inftance where it is with difficulty forced through the pupil, the operator, inftead of perfifting to employ much preffure, Should rather enlarge the opening in the cornea, ufing for this purpofe {mail probe pointed fciffars ; and this being done, the oper- ation falls to be finished in the manner I have already advifed. With a view to render the paffage of the lens as ea- fy as poffible, the pupil Should at this part of the op- eration be in the ftate of the moft perfea dilatation ; for which purpofe, after the incifion of the cornea, and the opening of the capfule of the cryftalline are completed, a dark cloth or curtain may be placed be- tween the eye and the light, to be removed on the lens paffing out; or the patient may be placed with his back to the window. In a few inftances of cataraa, the caufe of opacity is not found in the lens itfelf, but ia its capfule: in this cafe, the extraaion of the lens anfwers no good purpofe, as the opacity is equally ftrong after the op- 248 Diseases of the Eyes. Chap. XL eration as if was before. Some authors have there- fore in fuch circumftances advifed the opaque capfule to be removed with forceps and other inftruments paffed through the pupil; but this can never be done but with much rifk of deftroying the iris, and doing much injury to other parts of the eye : it ought never therefore in my opinion to be attempted : we fhould rather truft to time, and an antiphlogiftic regimen, for the removal of the opacity ; from which no harm can enfue, and I have known inftances of cures being performed by it: whereas the forcible extraaion of the opaque capfule, fo far as I have yet heard, has nev- er in any cafe effeaed a cure ; and it has frequently deftroyed the eye entirely. When, again, the operation is to be performed up- on the right eye, if the furgeon wifhes to do it in the ufual way with the knife commonly employed, he muft ufe his left hand ; but as few praaitioners are able to perform this nice operation with the left hand with fufficient fteadinefs, I have delineated a knife, fig. 2. Plate XVI. by which it may be eafily done with the right hand, while the patient and furgeon are fit- ting oppofite to each other in the manner I have men- tioned : only, in this caSe, the point oS the knife, muft be entered at the internal canthus of the eye, and muft then be pufhed out to the oppofite fide, inftead oS be- ing introduced at the external angle, and carried to- wards the noSe. The operation being finifhed, the eye fhould be im- mediately covered with a comprefs of foft lint, or old linen, foaked in a weak faturnine folution, to be re- tained by the bandage, fig. 3. Plate XXX. or any oth* er that does not comprefs the head much, or keep it too warm. For feveral days ,after the operation* no light fhould be admitted to the patient's" apartment. A very low diet fliould be advifed : and the eye being very apt to inflame, repeated bloodlettings are fre- quently reqaifite Srom the jugular vein or temporal artery. Sea. XVII. Diseases of the Eyes. 249 As this operation indeed is more apt to fail by the fubfequent inflammation of the eye than from any oth- er caufe, it requires our utmoft attention to guard againft it: and as the healing of the incifion depends in a great meafure on the eye being kept at reft, every caufe of irritation fhould be avoided. When the op- eration fucceeds, the incifion is in general cured in fourteen or fifteen days ; but in fome inftances it con- tinues open for feveral weeks. In defcribing the operation, I have noticed an oc- currence that is apt to happen, when every part of it is not done with caution, and which commonly proves very alarming ; namely, the lofs of a confiderable part, or perhaps the whole, of the vitreous humour. By this the eye becomes flat, and inftantly finks within the orbit: but although it ought to be guarded,againft with the niceft attention, it does not always prevent the SucceSs oS the operation. I have known indeed Some inftances oS the eye remaining Sunk and uSeleSs aSter this accident, but moft frequently the globe be- gins foon to fill again, and in the courfe of two or three weeks it has commonly acquired its ufual bulk. Whether this takes place from a regeneration of the vitreous humour, or merely from the ball of the eye being all filled with an aqueous fecretion, I will not pretend to fay. The latter is the common opin- ion ; but why may not the vitreous humour be re- newed as readily as the other ? I am inclined to think that a renewal of the one happens as readily as that of the other, from having often obferved as perfea a ftate of vifion after this operation, where all the vitre- ous humour had been loft, as if none of it had been difcharged ; of which a remarkable inftance occurred in a woman who fome time ago had the operation performed upon both eyes. The eyes were otherwife both apparently found : in one, the whole of the vit- reous humour was forced out along with the cataraa, and the eye funk entirely to the bottom of the orbit; in the other, the operation was performed with much 250 Diseases of the Eyes. Chap. XL accuracy; the cataraa was extraaed, and none of the vitreous humour efcaped. In the courfe of three or four weeks, however, from the operation, both eyes were of the fame bulk ; their appearance was perfea- iy fimilar, and the patient difcovered objeas equally well with each of them. This does not indeed deter- mine the point with certainty, as it may be alleged, that the figure of the eye being preferved by the aque- ous humour, the effea produced upon vifion by the lofs of the vitreous humour cannot probably be great; but we can Scarcely fuppofe that any part of fuch an important organ has been formed in vain. I fhall now offer a few obfervations on the inftru- ments employed in this operation. Knives of various forms have been propofed for it; but thofe delineated in Plate XVI. have been moft generally ufed ; and of thefe fig. 1. and 3. are the beft : the firft I have ufed fuccefsfully in various inftances ; and the latter, which I now believe to be the beft that has yet been propof- ed, is the knife of the ingenious Dr. Richter of Got- tingen. The Shape oS the firft is nearly that of a fpear pointed lancet; only the back of it is blunt, except- ing a fourth part of an inch or thereby near the point, which fhould be fharp on both edges ; and that fide of the knife which paffes next the iris fhould be fome- what round, while the other is nearly or altogether flat. By this we prevent, as much as poffible, any rifk of hurting the iris, which is apt to happen with a knife that is flat on both fides, and with both edges fharp through its whole length. The operation has frequently indeed been performed with this kind of knife, but it is done with more fafety with the one I have mentioned. We ought however to take care, that while a knife for this purpofe fhould be extreme. ly fharp and finely polifhed, it ought likewife to be firm; for the cornea being both thick and firm, it is more difficult to pierce than thofe who are not accuf- tomed to this operation are apt to imagine, and whft Sea. XVII. Diseases of the Eyes. 251 are therefore difappointed at finding the inftrument in ordinary ufe too fine. It fhould be at leaft as firm as a common lancet. For the purpofe of opening the capfule of the lens, nothing anfwers better than the flat curved probe de- lineated in Plate XVIII. fig. 5. The inftrument com- monly ufed for this is reprefented in Plate XXIV. fig. 2. but we incur with it a greater hazard of hurting the iris. But whatever inftrument is employed, it fhould be paffed through the pupil with much fleadi- neSs, otherwise the iris may be readily injured, of what- ever form it may be. I have thus defcribed all the fteps of the operation as it is now praaifed, with fuch improvements as it appears to admit of: but as it is an operation of much importance, and liable to different objeaions, even in its prefent improved ftate, I have been led to confider it with more than ordinary attention, and to make ex- periments upon different animals with a view to obvi- ate thefe ; the refult of which I fhall now fhortly re- late, although I did not think it proper either to place; any weight on them, or even to mention them in the defcription of the operation ; for, till confirmed by experience upon the human body, no conjeaure, how- ever well founded it may appear to be from experi- ments on other animals, fhould be allowed to have much influence on our opinion. The moft material objeaions that occur to this op- eration are thefe : the vitreous humour is apt to pafs fuddenly oft* along with the cataraa ; by which the eye is in fome inftances funk fo much as never to re- cover its form again : the incifion being made in the tranfparent part of the eye, the cicatrix which enfues is frequently fo extenfive a*_ to obftrua the rays of light in their paffage to the retina ; by which vifion is often as effeaualy obfcured, as if the cataraa had not been extraaed : and laftlv, the lens being often too large for paffing through the pupil, the iris is frequcnt- 4- 252 Diseases of the Eyes. Chap. XL ly much injured by this part of the operation, when in every other refpea it is perhaps very properly per- formed. In regard to the firft of thefe, it may be alleged, that it does not occur when the operation is properly done ; and that it cannot with propriety be ftated as an objeaion, merely becauSe it frequently happens from awkwardnefs or inattention in the operator. It is, however, fo frequent, that whatever can tend to prevent it, muft be confidered as a very material im- provement. This, I think, may be in fome meafure done, by the incifion being made in a different part of the cor- nea. When the opening in the cornea is made, as in the ufual way of performing this operation, in the moft depending part of it, all the aqueous humour is inftantly difcharged, by which the vitreous humour is deprived of fupport at its anterior furface; fo that any preffure made upon the ball of the eye by the fpecu- lum, or even by the natural aaion of the mufcles of the eye, is very apt to force it out. Inftead of this, by making the cut in the upper part of the cornea, the lens may be extraaed with equal eafe, while a confiderable part of the aqueous humour being ftill retained by the inferior half of the cornea remaining entire, the vitreous humour is neither fo fuddenly nor fo entirely deprived of the fupport which it affords, and does not efcape fo readily as in the ordinary meth- od of performing the operation. At leaft, this I have found to happen in other animals ; and there is realbn to imagine that it will likewife be the cafe when the operation is done on the human eye. It is alfo probable, that another advantage may be derived from the incifion being made in the upper part of the cornea. One material objection to this opera- tion, when done in the ufual wav, arifes, as I have al- ready obferved, from the cicatrix induced by the in- cifion on the come:-. The fame extent of the cornea will no doubt be cut, when the operation is perform- Sea. XVII. Diseases of the Eyes. *S$ ed in the manner I have mentioned ; but the cicatrix being in the upper part of the eye, it will not proba- bly prove fo hurtful, as it is of moft importance for objeas to be feen diftinaiy that lie beneath the eye. We frequently find that patients who have undergone this operation, fee every objea more diftinaiy, when placed above the eye, than when viewed beneath it; a circumftance that cannot in any other manner be fo well explained. The upper part of the cornea is cut with the fame eafe as the under part of it; the fame inftruments be- ing employed, and the Surgeon, patient, and affiftants, being placed in the Same manner: only in this caSe the knife muft be introduced with the cutting edge of it towards the upper part oS the eye, the incifion be- ing to be extended in this direaion : and as the un- der half of the cornea remains undivided, the lens, on paffing through the pupil, being apt to be retained by the flap, muft be cautioufly removed, either with the fcoop, Plate XVI. fig. 4; with a fmall fharp hook, Plate XVIII. fig. 2, or with the fmall forceps, fig. 4, which were made for this purpofe when I was engag- ed in the experiments that I have mentioned. In this manner the two firft objeaions to this ope- ration are in fome meafure removed ; and from all the obfervations that I was able to make of it in the courfe of the experiments to which I allude, I think it probable that it will anfwer in every refpea better than any other that has yet been propofed; but as I have never put it in praaice in the human eye, I cannot fpeak of it with decision ; and I propofe it only as a Iiint for future obfervation. But although we may by this means prevent the efcape of the vitreous humour, and may in fome mea- fure avoid the bad effeas that ufually refult from the cicatrix after this operation, yet the third objection remains in equal force againft it ; the cataraa muft neceffarily pafs through the pupil, and in doing fo the iris is often irreparably hurt. 254 Diseases of the Eyes. Chap. XL As this renders the operation much more hazard- ous than it otherwife would be, it has always appear- ed to me that it would be a very important improve- ment of this operation, to extraa the cataraa in any other manner that would not expofe the iris to this hazard. This we may do by opening the eye behind the iris, inftead of making the incifion in the ufual place in the lucid cornea ; and it would be attended with this advantage, that no inconvenience would en- fue from the cicatrix. In this manner I have fre- quently performed the operation on other animals; but it has never* fo far as I know, been put in prac- tice on the human eye. The objeaions which occur to it are, that the opening being made in the fcleroti- ca, the inflammation induced by it muft probably be great ; and this coat of the eye being thicker than the tranfparent cornea, wounds made in it are commonly fuppofed to be more difficult to heal. In fome expe- riments, however, which I made upon rabbits, with a view to determine this point, no reafon appeared for this conclusion.. The inflammation induced by an opening made in the Sclerotica was not more confid- erable ; nor was the cure in any reSpea more diffi- cult than when the operation was done in the uSual manner. If the operation is ever performed in this manner, the opening Should be made in the upper part of the eye, by entering the point of the knife about the tenth part of an inch or thereby behind the tranfpa- rent cornea ; and the incifion being made of a fuffi- cient fize for allowing the cataraa to pafs, the Sharp hook, fig. 2. Plate XVIII. fliould be introduced, with a view to extraa it. As the point of the inftrument is extremely Sharp and fine, it penetrates the lens with eaSe, and in this manner it may be removed without making any preffure on the eye. Having thus finished the confideration of the two operations of couching and extraaing the cataraa, be- fore concluding the fubjea, I Shall oifer a few obfer- Sea. XVII. Diseases of the Eyes. 255 vations on the comparative advantages that refult from them ; and Shall at the fame time, mention thofe rea- sons by which I have been induced to preSer the one to the other. § 4. Comparative View of the refpedive Advantages and Difadvantages of the Operations of Couching, and extrading the. Catarad. The operation of couching, or depreffing the lens, was the firft that was praaifed for the cure of the ca- taraa. The extraaion of the lens was afterwards pro- pofed, as a more certain means of removing the difeafe. Both methods have had their abettors, and much has been faid in favour of each. To appreciate therefore the merits of thefe operations, and to afcertain that by which our intention may be accomplished in the faf- eft and eafieft manner, are objeas meriting particular attention. It has been objeaed to the operation of couching, 1. That it frequently fails from the cataraa rifing again into its uSual fituation. 2. That it muft always fail when the lens is in a foft or liquid ftate, by the fluid contained in the capSuIe diSperfing through the eye when the capSule is opened by the couching nee- dle. And, laftly, when the opacity lies in the cap- Sule, and not in the lens, that it cannot be cured by couching. With regard to the firft of thefe, it muft be ac- knowledged, that the cataraa frequently rifes again af- ter having been depreffed to the bottom of the eye: but when the lens, inftead of being pufhed down im- mediately behind the iris, is carried, as I have direa- ed, by the point of the needle towards one angle of the eye, and lodged partly beneath the vitreous hu- mour, it never rifes again ; and even where the oper- ation fails through the fault of the furgeon, or from any other caufe, the pain attending it is fo inconfider- able, that few patients will refufe to have it repeated 256* Diseases of the Eyes. Chap. XL once or oftner; and I have feldom known it fail, where this has been done. The fecond objeaion may appear of more impor- tance to thofe who are not accuftomed to this opera- tion, but it is not So in reality. A cataraa in a fluid ftate, and Spreading over the eye immediately on the capSule being pierced with the needle, is not a com- mon occurrence ; from my own obfervation I would fay, that Jj^ites not happen more than once in twenty times : but were we even to meet with it more fre- quently, So far from Stating it as an objeaion to the operation, we fhould rather confider it as an advan- tage. In this caSe the violence done to the eye is not fo great as when the operation of couching becomes neceffary in all its parts Srom the cataraa being of a firm confiftence ; a repetition of the operation can never be requisite ; and the milky whiteneSs commu- nicated to the aqueous humour by the diSperfion of the liquid cryftalline through it, commonly disappears in a fhort time after the operation. At leaft that it commonly does So, is confiftent with my own experi- ence ; and the obfervation is confirmed by the tefti- mony of others, particularly by that of the late Mr. Pott, on whofe authority we may rely with confidence. Nay, further, even when the cataraa is firm and entire, if completely feparated from its capfule by the couching needle, it almoft always diffolves in the aque- ous humour, without leaving any veftige of opacity; an obfervation much in favour of the operation of couching, as it obviates the objeaion founded on the rifing of the cataraa after it has been depreffed: it ' Shews, at the fame time, that there is little or perhaps no reafon for ever putting in praaice the propofal of Mr. Petit, for removing a cataraa which in couching may have been accidentally pufhed into the anterior chamber of the eye, as time will, in moft inftances, accomplifh without pain or hazard what cannot be done by Mr. Perk's method but at the expence of both. Sea. XVII. Diseases of the Eyes* 257 The lens appears to diffolve in the aqueous hu- mour fooner or later, according as it is more or lefs firm when feparated from its capfule. The opacity produced by the difperfion of a fluid lens in the aque- ous humour, commonly difappears foon after the ope- ration : cataraas of a firmer confiftence are feldom altogether diffolved in lefs than feveral weeks ; in ma- ny a fmall portion of a depreffed cataraa is obferved in an undiffolved ftate a good many months after the operation, and in a few after feveral years have elapf- ed ; but this is a rare occurrence. The third objeaion, of which I took notice, the al- leged impoffibility of removing the difeafe by couch- ing when the caufe of the opacity lies in the capfule, and not in the lens, feems a priori to be the moft con- clufive againft this operation; but it will not on ex- amination be found to be fo. In the firft place, this variety of cataraa is rarely met with : it occurs occa- sionally, but by no means fo frequently as to lead us to prefer one mode of operating to another for this reafon alone. Secondly, I have already obferved, that this variety of cataraa cannot be cured even by extraaion. The opaque capfule may indeed be forcibly torn away with inftruments paffed through the pupil, but not without doing fuch violence to the eye, as muft in a great pro- portion of cafes, probably in every inftance, be pro- duaive of certain blindnefs. I may therefore, with- out hesitation predia, that although this operation may be performed from time to time by thofe who are fond of innovation, and who wifh to Shew their dexterity at the expence of thofe intrufted to their care, that it will never be generally praftifed. I have feen it done by fome of our moft expert oculifts, but in every inftance the eye was completely deftroyed by it, while the inflammation which it ferved to excite never failed to prove uncommonly fevere. Vol. U. S 258 Diseases of the Eyes. Chap. XL Befides, although I will not fay that this variety of cataraa can in every inftance be removed by couch- ing, yet an attempt towards it may be made with per- fea fafety, by endeavouring to feparate and depreSs the capSule with the point of the needle. If this can be done, the operation will prove as fuccefsful as if no fuch caufe of difeafe had fubfifted : and when it hap- pens to fail, provided the trial is made with caution, no detriment will enfue. Befides thefe objeaions, it has been faid, in opposi- tion to the operation of couching, that the pain and inflammation that attend it, are frequently greater than what arife from extraaion ; and that the .vitreous hu- mour is more apt to be deranged by the needle in couching, than by the other method of operating. But neither of thefe affertions will be admitted by thofe who have had fufficient opportunities of putting both operations in praaice. They know, that in gen- eral the fymptoms of pain and inflammation arifing from the extraaion of the cataraa are more confider- able than thofe that proceed'from couching ; and it muft be acknowledged by all who fpeak impartially, that the operation of extraaion is frequently attended with the lofs of fome part, or perhaps of the whole of the vitreous humour, whilft that of couching can pro- duce no material derangement. We have thus feen, that the feveral objeaions ftat- ed to the operation of couching are not well founded: that the cataraa can be removed by it as efteaually as by the operation of extraaion : that it is attended with lefs pain, and lefs fubfequent inflammation; while at the fame time, it never can occafion thoSe deformi- ties that arife from a large cicatrix on the cornea, or from the finking of the eyeball, which fometimes oc- curs from the lofs of the vitreous humour. But thefe circumftances alone fliould not be allow- ed to decide a queftion of fuch importance: the ulti- mate and permanent effeas of the two operations ought alone to have weight on our opinion. Now, Sea. XVII. Diseases of the Eyes. 259 from much obfervation, it appears clearly to me, that the operation of couching proves upon the whole more fuccefsful than the other ; that is, vifion is as perfea- iy reftored by couching, and caeteris paribus, a great- er proportion of thofe who fubmit to it receive benefit from it, than of thofe who undergo the operation of extraaion. With thofe who have not had frequent opportuni- ties of obferving the confequences of extraction, it proves always a very deceiving operation. The re- moval of the cataraa is in moft inftances attended with an immediate return of vifion, much to the fatif- faaion of both the patient and operator ; but, in a great proportion of cafes, even of thofe which at firft have every appearance oS proving SucceSsful, although vifion may be tolerably perfea for fome time, perhaps for feveral weeks, or even for months ; yet it gener- ally grows more indiftina, till at laft the patients be- come altogether blind. This is the refult of my ob- fervation ; and it correfponds with the event of the operation when performed by various good operators. The late Dr. Young of this place, who praaifed forgery for a confiderable time with much reputation, had at one period a very high opinion of this opera- tion. In the fecond volume of the Edinburgh Phy- sical Effays, he gave an account of his fuccefs in fix caSes in which he had operated a Sew months before, and which, at the time of writing the paper, appeared to be remarkably great: but in a converfation with the Doaor on this fubjea a good many years after- wards, I found his opinion much changed. The Doaor's obfervations on the confequences of extrac- tion were exactly fimilar to thofe that I had made on it. In the greater number of patients upon whom he had operated, vifion was reftored immediately on the removal of the cataraa ; but in nearly the whole of them the fight began to be impaired in a few months from the operation, and became gradually worfe, till total blindnefs at laft was produced. s 2 260 Diseases of the Eyes. Chap. XI. The progrefs of the lofs of that degree of vifion which is reftored by the extraaion of the cataraa, is marked by the following appearances. Some degree of immobility is at firft obferved in the pupil: it re- mains inaaive when the eye is expofed to light: it gradually becomes fmaller ; and at laft it is found to be fo much contraaed, as fcarcely to appear capable of admitting a crow's quill: it now remains immove- able to whatever light it may be expofed, and the pa- tient is often reduced to a worfe ftate than he was in before the operation, being even incapable of diftin- guifhing light from darknefs. This unfavourable event appears to proceed from the violence, which, in the courfe of the operation, is done to the iris; which is well known to be a mem- brane of the moft delicate texture ; and as the pupil through which the dataraa is forced is never fuffi- ciently large for admitting the lens to pafs with eafe, it accordingly is feldom extraaed but with injury to this very nice and ufeful part of the eye. It may be Said, that the violence thus done to the iris fhould produce an'immediate effea ; and that vi- fion, if not hurt by it at firft, fhould hot afterwards be affeaed. In various cafes, the iris is torn in differ- ent places, and appears to be irregular in its contrac- tion and dilatation from the time of the operation be- ing performed : but although in thefe, as well as in other inftances where the pupil is only overftretched, blindnefs does not take place immediately ; yet it is almoft as certainly to follow, as if it had been inftant- ly produced. The reafon of this it is perhaps impof- fible to explain ; but in the courfe of my obfervation, the faa has been exaaiy what I have mentioned. Proceeding upon the idea of the failure of this ope- ration depending in a great meafure upon the injury done to the iris by the paffage of the cataraa, and being anxious to improve an operation for which at one time I had a great partiality, I have offered a pro- pofal for' this purpofe. By making the opening in Sea. XVIII. Diseases of the Eyes. 201 the eye behind the iris, in the manner I have propof- ed, this inconvenience may be avoided ; but whether this mode of operating will be found to fucceed or , not, future experience alone muft determine. In the mean time, till the operation oS extraaion is So far improved as to obviate the bad effeas that I have pointed out, the method of cure by depreffion I fhall continue to prefer, as being more eafily perform- ed ; lefs apt to injure the other parts of the eye ; and in moft inftances produaive oS more real advantage. SECTION XVIII. Of the Fiftula Lachrymalis. A SINUOUS ulcer, with hard or callous edges, is in general termed a fiftula ; but authors, in treating of difeafes of the lachrymal paffages, have af- fixed a different meaning to this term : every obstruc- tion to the paffage of the tears from the eye to the nofe, is commonly, though improperly, denominated a fiftula lachrymalis. A Sinus in theSe parts, attend- ed with callofity, ought alone to receive this appella- tion ; but as fome confufion might arife from any in- novation that could be propofed, I fhall avoid, as I have hitherto done, any attempt towards it; and fliall endeavour to defcribe, as clearly as poffible, the vari- ous appearances which the difeafe in its different ftag- es is known to affume, under the general denomina- tion of fiftula lachrymails. An anatomical defcription of the eye having already been given in the fecond Seaion of this Chapter, I fhall now refer to what was then faid of the parts con- cerned in the difeafe that we are now to confider. An accurate delineation is likewife given of thefe parts in Plate XII. fig. 1.; b reprefents the punaa of the two lachrymal duas, by which the tears are carried from 262 Diseases of the Eyes. Chap. XL the eye to the fac e ; from whence they are tranSmit- ted by a canal which paffes in an oblique direaion through the os unguis into the nofe, where it termi- nates below the os lpongiofum inferius. , I formerly remarked, that the os unguis is divided longitudinally by a kind of ridge, which at this part forms the boun- dary of the orbit; and it is neceffary to obferve, that the groove in this bone, through which the nafal dua of the lachrymal fac runs, lies altogether exterior to the orbit, being feparated from it by this ridge of the os unguis. This Short recapitulation of the anatomy of the lach- rymaUpaffages, will render the defcription now to be given of the difeafes to which they are liable more in- telligible. The fiftula lachrymalis arifes, as I have already ob- ferved, from obftruaion to the paffage of the tears in- to the nofe; but the difeafe affumes a variety of ap- pearances, according to the feat of the obftruaion, and to the effeas which it excites on the neighbouring parts. Thus we may readily fuppofe, that the fymp- toms produced by obftruaion in the punaa lachry- malia, or in the duas leading from thefe to the fac, will be widely different from thofe which arife from obftruaion in the lachrymal fac itfelf, or in the dua leading from this fac to the nofe. And again, we might a priori, conclude, that the appearances induc- ed by a recent obftruaion of any of thefe paffages, muft probably be very different from thofe which take place after a long continuation of the difeafe. The lachrymal punaa and duas are apt to be ob- ftruaed by burns, wounds, or whatever excites inflam- mation in any part of them, and when the tears are thus prevented from paffing into .the nofe, they necef- farily fall over the cheek, and where they do not be- come acrid, fo as to excoriate or fret the neighbour- ing parts, this difcharge of tears is almoft the only fymptom which this variety of the diSeaSe ever excites: a dryneSs indeed takes place in the correfponding 110S- Sea. XVIII. Diseases of the Eyes. 263 tril, by the want of this fecretion which ufed to be poured into it; but this inconvenience is never of much importance. It is this variety of the difeafe only which ought to be termed epiphora, or a watery or weeping eye; for when the obftruaion is feated in any other part of the lachrymal paffages, the difeafe that enfues is attended with very different fymptoms. When the lachrymal punaa and duas remain op- en, if obftruaion takes place either in the under part of the lachrymal fac, or in the dua that leads from it to the nofe, the firft warning that the patient receives of it is a fmall tumor that forms in the internal can- thus of the eye, that difappears on being compreffed, by a plentiful flow of tears paffing into the eye, and from thence over the cheek. In this incipient^ ftate of the difeafe, fome portion of the tears frequently paffes into the nofe on the fac being compreffed ; a circumftance always to be confidered as favourable, as it Shows that the obftruaion is not altogether com- plete. If the tears are regularly preffed out before the tu- mor becomes large, and before they have remained In the fac fo long as to. become acrid, they are ufually clear, and of a natural appearance when forced out from the punaa; and, from the refemblance which this fluid bears to the contents of hydropic colleaions in other parts of the body, this ftage of the difeafe has been termed a dropfy of the lachrymal fac ; a diftinc- tion, however, of no real importance. When in this ftate of.lhe obftruaion the patient is attentive to a proper and. frequent application of pref- Sure, and does not allow;the lachrymal Sac to be over diftended, a complete, cure may either be obtained, or the difeafe prevented from giving much uneafinefs ; at leaft this is alw ays the. cafe fo long as the tears re- tain their natural appearance, and while a confiderable proportion of the contents of the tumor can be preff- ed into the nofe. S64 Diseases of the Eyes. Chap. XL It moft frequently happens, however, from the pa- tient being inattentive to the ftate of the fac, and al- lowing it to be over diftended, that this moft fimple ftate oS the diSeaSe proceeds in a gradual manner to turn worSe : the paffage into the nofe becomes com- pletely obftruaed : the fwelling in the corner of the eye acquires a greater bulk, but ftill retains the natur- al appearance of the fkin : the tears are now with dif- ficulty preffed out, and are obServed not to be trans- parent, but mixed with a proportion oS a thick, opaque, whey coloured mucus, Somewhat fimilar to, but when minutely examined found to differ confiderably from, purulent matter. Even in this ftage of the difeafe the patient feldom Suffers much pain, or any farther inconvenience than that which refults from the flowing of the tears and mucus over the cheek: at laft, however, the tumor begins to inflame, to become tenfe, red, and painful to the touch ; and the matter preffed out from it has now a more purulent appearance. At this period the tumor is exaaiy fimilar to a com- mon boil or abfcefs ; and by thofe not verfant in this branch of praaice, it is frequently confidered as fuch. It becomes gradually more inflamed and more tenfe, till the teguments at laft burft, and form an opening in the moft prominent part of it, at which the tears and matter contained in it are now altogether dif- charged. When the opening thus formed is fmall, it com- monly heals in the courfe of a few days ; but it burfts again as foon as any confiderable quantity of tears and mucus is colleaed ; and continues thus to colfea and burft alternately, till the opening becomes fufficiently large to prevent any farther colleaion from taking place. This ftate of the difeafe exhibits exaaiy the appear- ances of a Sinuous ulcer, with callous, and fometimes with retorted, edges, conftituting what is properly termed the fiftula lachrymalis. Tears, mucus, ancl Sea. XVIII. Diseases of the Eyes. 265 purulent matter, are now abundantly difcharged from the fore. When the bone beneath is found, this dif- charge is feldom either acrid or offenfive to the fmell; for the opening being in general in the under part of the tumor, the matter is difcharged almoft as fpeedily as it is formed ; but when any of the contiguous bones are carious, they are not only found to be fo by the introduaion of a probe, but by the appearance, fmell, and effeas of the matter upon the neighbouring parts. In this cafe, it is thin, fetid, and commonly fo acrid as to fret and corrode the teguments mofl contiguous to the ulcer: and when the difeafe is conneaed either with Scrofula or lues venerea, an occurrence by no means unfrequent, the difcharge and appearances of the fore are different according as it happens to be combined with one or other of thefe difeafes. I have thus defcribed the different fymptoms of this difeafe, and the progrefs which it ufually makes from the firft formation of obftrudtion in the lachrymal paf- Sages, to its laft or ultimate ftage ; and it is highly ne- ceifary that praaitioners Should be acquainted with the different appearances which the various Slates of it af- ford ; for the method of cure beft fuited to one peri- od of the difeaSe, is frequently unfit for, and indeed altogether inadmiffible in others. From the hiftory that I have given oS the rife and progrefs of this difeafe, it is evident, that in every in- ftance it originates from obftruaion in fome part of the lachrymal paffages: the cure muft therefore de- pend upon the removal of this obftruaion ; but the means of effeaing this will vary according to the na- ture of the caufe by which it is produced, and to the particular ftage of the affeaion, as well as of the part in which it is feated : our prognofis muft likewife be direaed by attention to theSe points ; for we may readily conceive, that a cure will be more eafily and more certainly obtained in the cafe of a recent obstruc- tion, where the bones are yet perfeaiy found, and where there is no fufpicion either of Scrofula or lues 266 Diseases of the Eyes. Chap. XL venerea, than in oppofite circumftances. When the obftruaion is induced by the venereal diSeaSe or by Scrofula, and eSpecially when the os unguis and other contiguous bones have become carious, nothing will anSwer the purpofe till the general taint oS the confti- tution is removed; and even then a weeping eye or a frequent flow of tears over the cheek very common- ly enfues, and can never in future be removed. But when the fiftula lachrymalis arifes, as it moft frequent- ly does, from inflammation of the lachrymal paffages, induced either by cold, by the meafles, or any inflam- matory affeaion to which the eyes are liable, if it has not continued fo long as to hurt the bones beneath, we may in general give a favourable prognofis: for in fuch circumftances, a due perfeverance in the means to be now pointed out, though not always, is yet very commonly attended with an entire removal oS the difeafe. Again, when obftruaions are induced in the Iach- rymal canals by tumors in the contiguous parts, which they Sometimes are, particularly in caSes oS polypi in the noSe, where the tumor by preffing upon the infe- rior extremity of the nafal dua is apt to produce a ftoppage to the flow of tears, the prognofis muft in a great meaSure depend on the praaicability oS remov- ing the excreScence ; Sor till this is accomplifhed, nothing effeaual can be done in the treatment of the fiftula lachrymalis. The lachrymal fac and duas are lined with a mu- cous membrane, fimilar to the membrane that lines the nofe; with which it is conneaed, and of which indeed it appears to be a continuation. In a healthy ftate of thefe parts, the nafal dua of the lachrymal fac will eafily admit a crow's quill ; a Size perfeaiy fufficient for allowing a free paffage of the tears into t':e nofe : but when this membrane that lines the dua becomes ir, flamed, as the fulnefs which this ex- cites muft dimlniiL ilic diameter of the canal, obftruc- Sea. XVIII. Diseases of the Eyes. q6j tion proportioned to the violence of the inflammation muft neceffarily enSue. I particularly mention the naSal dua, as it is in this dua that the obftruaion producing the moft Srequent variety of the difeafe is feated, owing to its near con- tiguity to the nofe; by which, in cafes of catarrh, in- flammation is apt to be communicated to it from the membrane of the nofe: but obftruaion to the flow of tears into the nofe will juft as certainly take place from inflammation feated in the duas leading from the eye to the lachrymal fac ; and the principles up- on which the method of cure proceeds muft be near- ly the fame in both. When the difeafe proceeds from inflammation, we fhould depend chiefly on fuch remedies as prove moft effeaual in inflammatory affeaions of other parts of the body. General and local bloodletting ffiould be prefcribed in quantities proportioned to the ftrength of the patient, together with laxatives and a low diet; and a faturnine folution fhould be applied to the part affeaed, either in the form of a poultice, or with compreffes of foft linen. In this manner, when the means are timoufly employed, and duly purfued, ob- ftruaions arifing from this caufe are frequently re- moved ; but when the parts have been long in an in- flamed ftate before any remedies were ufed, it often happens that a cure cannot afterwards be accomplifh- ed even by the moft complete removal of the inflam- mation : for, as inflamed parts, when kept long in contaa, are every where apt to adhere, fo the fides oS the lachrymal pidTages, when much inflamed, very readily unite together; by which a very obftinate va- riety of the difeafe is produced ; and which fhews, in a ftrong point of view, the propriety of treating every « affeaion of this kind with the utmoft attention from the begin rung: by which we frequently have it in our power to prevent the formation of this obstruc- tion, and which nothing but a painful operation can, afterwards remove. 268 Diseases of the Eyes. Chap. XL When the obftruaion is feated in the punaa lach- rymalia, or in the duas leading from thefe to the fac, and when it is found to continue after the inflamma- tion which gave rife to it is removed, we fometimes fucceed in removing it by inferting a fmall probe into each punaum, fo as to pafs it along the courfe of the duas into the lachrymal fac. In this manner the opening may be rendered pervious, and be afterwards preferved by injeaing, twice or thrice daily with a fmall fyringe, a weak folution of alum, faccharum fa- turni, or white vitriol; and by keeping at other times fmall Silver or leaden probes constantly inSerted, till the fides of the duas become callous, the tears will thus find a free paffage to the fac, by which a cure will be obtained. This is no doubt a very nice operation; but who- ever is verfant in the anatomy of thefe parts, and ac- curately acquainted with the courfe of the lachrymal duas, may, in the courSe oS a few trials, be eafily able to perform it. The probes reprefented in Plate XXI. figs. 5. and4 6. and the fyringe and fmall tubes in Plate XX. figs. 1. 5. and 7. are the inftruments to be em- ployed for it. In obftruaions of thefe duas, it has been likewife propofed to pafs a fmall cord or feton from the punaa through the lachrymal fac into the nofe, and to allow it to remain till the paffage becomes callous. But, befides the difficulty of effeaing this, there is much reafon to think that it would do more harm than good, as the fmalleft cord that we could pafs would create much inflammation and pain. The obftruaion, however, is moft Srequently Seated in the dua leading from the fac to the nofe, forming a variety of the difeafe that requires a more complex method of treatment. When Induced by inflamma- tion, a Stria antiphlogiftic courfe, fuch as I have men- tioned, will frequently remove it; but when this hap- pens to fail, either from the difeafe having been im- properly treated from the firft, or from any other Sea. XVIII. Diseases of the Eyes. 269 caufe, other means fliould be employed. I Shall there- fore fuppofe, that all fymptoms of inflammation are removed; but that the nafal dua ftill remains ob- ftruaed ; that it is attended with a flight tumefaaion in the internal canthus of the eye, along with a fre- quent flow or difcharge of tears over the cheek; and that the Skin covering the tumor ftill retains its natur- al appearance. This is the moft fimple ftage of the diSeaSe. It is neither attended with pain nor with much deformity or inconvenience; and with a moderate Share of atten- tion on the part of the patient, the aid of a furgicai operation may be rendered unneceffary : by compreff- ing the lachrymal fac from time to time with the fin- ger, the contents of it are difcharged before they be- come acrid ; and although this does not accomplifh a cure, it in general renders the difeafe very fupportable; fo that in this ftage of it, fo far as I can determine from my own experience, nothing further fhould be attempted. Various means have indeed been propofed for effeaing a complete cure of this ftage of the dif. eafe, but being all tedious and painful, and not by any means certain, as long as a watery or weeping eye is the only inconvenience that occurs from it, a pru- dent praaitioner will rather advife a patient to fubmit to this, than undergo the pain, confinement, and un- certainty, of a nice operation. As a frefh attack of inflammation would be apt to render the difeafe worfe, he will advife him to avoid expofure to cold, and whatever might tend to induce an inflamed ftate of the eye and neighbouring parts ; and, in the mean time, he will defire him to truft to gentle preffure alone for obviating any effeas that might enfue from the obftruaion. For the purpofe of applying preffure to the lachry- mal Sac, various machines have been invented ; the moft convenient form of which is reprefented in Plate XIX f;g. 1. by which any neceffary degree of compref- fion may be continued with eafe and without interrup- 270 Diseases of the Eyes. Chap. XL tion. But, as we are now fuppofing that the nafal dua of the lachrymal fac is completely obftruaed, and that no part of the tears can be forced into the nofe, no benefit can be derived from a continued courfe of preffure ; and as any advantage to be obtained from the praaice is found to accrue with equal certainty from the finger being applied from time to time on the courfe of the fac, I have always, in this ftage of the difeafe, been accuftomed to depend upon this alone. The other means that have been recommended Sor the cure of this'ftage of the fiftula lachrymalis, are, the introduaion of a probe into the nafal dua of the lachrymal fac, with a view to remove the obftruaion : the injeaing of water, or any other mild liquid, for the fame purpofe : and, laftly, it has been propoSed to introduce a quantity oS quickfilver into the Sac, through the lachrymal punaa, the weight and fluidity of which being fuppofed well fitted for making it pafs through any ordinary degree of obftruaion. Mr. Anel, a French praaitioner, was the firft who brought to perfeaion the method of introducing a probe, or the point of a fyringe, into the lachrymal fac: but although an accurate knowledge of the ana- tomy of thefe parts may enable any one to perform it in a found or pervious ftate of the lachrymal paffages, yet in an obftruaed ftate of the nafal dua it can Scarcely be done ; and, even when affeaed, it is not found that fo much benefit is derived from it as at firft there might be rea'fon to expea. Two. modes are propofed for effeaing this opera- tion : in the one, a fmall probe, or tube of a fyringe, is inferted at one of the lachrymal punaa ; and being insinuated along the courfe of the correfponding dua, it is in this manner paffed into the fac, and from thence we are direaed to carry it through the nafal dua into the nofe: or, when this cannot be fully ac- complished, we are delired to force an opening through this dua by an injeaion thrown in with a fyringe in- Sea. XVIII. Diseases of the Eyes, 271 ferted at one of the punaa. The fyringe above men- tioned, with the fmall correfponding tubes, as deline- ated in Plate XX. is the inftrument recommended for this purpofe. By the other mode of doing the opera- tion, a curved probe, or tube, of a larger fize, fuch .as is delineated in fig. 4, of the fame Plate, is to be insinuated into the noftril of the difeafed fide; and the point of it being paffed beneath the edge of the os fpongiofum inferius, it is there to be eafily moved about till it meets with the termination of the nafal dua of the lachrymal fac, from whence it is cautiouf- ly carried forward till it paffes into the fac itfelf. Different objeaions, however, occur to thefe opera- tions. The punaa lachrymalia are fo very fmall, that no probe or fyringe can be paffed through them of a fufficient fize Sor removing any obftruaion in the naSal dua. And although a Syringe oS a larger fize may in a ftate of health be introduced through the noftril direaiy into the naSal dua itSelf, in a difeafed ftate of thefe parts, it can feldom or never be done. In obftruaions of this dua, as they very commonly arife from inflammation communicated from the membrane of the noftrils, the difeafe often commen- ces in the extremity or termination of the canal; fo that it is always difficult and often impoffible to intro- duce a probe or fyringe into it; and if the operator is even fo fortunate as to accomplish this, it always requires fome violence to force it into the lachrymal fac. Hence a good deal of pain is excited, by which the dua and fac are both apt to become inflamed : fo that, inftead of any advantage being derived from the praaice, much mifchief is apt to enfue from it. The propofal of curing this difeafe by injeaions, is very ingenious; but, for the reafons I have given, it will feldom, I imagine, be of much real utility. We a»*e indeed told, that it will often anfwer in cafes of flight obftruaion ; and tnat all the pain and uncertain- ty of the ordinary means of cure may thus be avoid- ed. But when th> olftruaion is completely formed, 272 Diseases of the Eyes* Chap. XL it is altogether inadmiffible, from the impoffibility of introducing a probe; and whenever the ftoppage of tears is only partial, there will be much rifk of doing more harm than good, by the irritation, pain, and confequent mflammation, which the operation never fails to produce. In fuch circumftances, the patient fliould rather fubmit to any inconvenience arifing from the difeafe, than to uncertain trials of this kind. For the fame reafons that the paffing of a probe, and of injeaions, into the lachrymal paffages, can fel- dom if ever prove ufeful, the introduaon of quickfil- ver into the lachrymal fac will likewife probably fail: where obftruaion is already formed, it will not be able to remove it; and unlefs obftruaion takes place, no attempt of this kind is indicated. The praaice, however, is ingenious; and as it may be done with more eafe, fo it is lefs exceptionable than the ufe of probes or injeaions. In the early ftages of the obftruaion, I have fre- quently paffed injeaions from the punaa lachrymalia into the nofe; but although this proved always fatif- faaory at the time, it has not been attended with any real advantage ; for although I have now done it in upwards of fifty inftances, and in many of thefe li- quids were daily palfed along the lachrymal paffages for feveral weeks together, yet in none has the difeafe been removed by it. The liquids that I employ, are warm water, rofe water, and weak folutions of faccha- rum faturni. I have thus defcribed the modes of treatment to be advifed in the moft fimple ftage of the difeafe ; but I muft again obferve, that as long as a watery or weeping eye, with perhaps a flight occafional tume- faaion in the internal canthus, is the only inconveni- ence that it excites, nothing Should be adviled but the application of moderate preffure from time to time with the finger. But whenever the difeafe arrives at fuch a height as to produce either much pain or deformity, a different Sea. XVIII. Diseases of the Eyes* 273 treatment is required. When the tumor in the an- gle of the eye becomes large, inflamed, and painful, as the colleaed matter foon turns Sharp and acrid, the contiguous bones are apt to be injured, if the mat- ter is not quickly difcharged. In fuch circumftances, a perfon not acquainted with the anatomy of the difeafed parts, and with the caufe of the tumor, would be induced to trull entirely to an opening being made in it fufficient for difcharging the matter: for in this ftate of the difeafe, it affumes ex- aaiy the appearance of a common boil or abfcefs; and therefore this method of treatment might be con- fidered as fufficient. But although fome temporary advantage might thus be derived from the difcharge of the matter, as the caufe of the tumor would not be removed, a permanent cure it is evident would not enfue. We are here fuppofing that the difeafe origi- nates from obftruaion in the nafal dua leading from the lachrymal fac. It is clear, therefore, that the fac only being laid open, will be attended with no further benefit than that of producing an immediate difcharge of its contents ; for while the tears are conveyed into it by the punaa and lachrymal duas, if they do not find a free paffage into the nofe, they muft neceffarily be either difcharged by the opening newly formed, or, if this is allowed to heal, they will again colfea and produce a tumor fimilar to the firft. In this fituation, therefore, our views muft be, to difcharge the contents of the fwelling; to procure a free exit in future for the tears from the lachrymal fac into the nofe, and to prevent the dua from being again obliterated. And this being accompliffied, the external opening muft be healed. While the tumor continues firm, it ought not to be opened, as this would not only excite more pain, but the parts beneath could not be So Sreely examined as they otherwise might be. As long, therefore, as the tumor is hard, a warm emollient poultice fhould be Vol. II. T 274 Diseases of the Eyes. Chap. XL kept applied to it; and as foon as it becomes foft and compreflible, it may be opened with freedom. On account of the contiguity of the eye, and of the in- fertion of the orbicularis mufcle, to make an incifion into the lachrymal fac has in general been confidered as a nice and hazardous operation, and particular di- reaions have been given, not only for the figure and fize of the incifion, but for difcovering the exaa fite of the fac. There is no caufe, however, for anxiety upon this point; for the fituation of the fac is always ascertain- ed with precision by the tumor itSelf; which is form- ed, as I have already obferved, by tears and mucus col- leaed in the fac ; fo that any incifion that difeharges this colleaion muft for certain reach the fac. Neither does the form of the opening make much difference in the hazard attending the operation. A femilunar cut has commonly been recommended ; not only with a view to render the opening larger, but in order, as it is faid, to avoid with certainty the tendon of the or- bicularis mufcle. There is no rifk, however, of this tendon being injured if the incifion is made where it ought to be, namely, in the moft prominent and moft depending part of the tumor; and it is eafier done with a common lancet than with any other inftru- ment. The point of the lancet fhould be entered at the upper part of the tumor, pufhed freely into the fac, and carried downwards in a Straight direaion to the moft depending part of it. A few fibres of the orbicularis muScle which are inSerted into and Spread over the lachrymal Sac, will indeed be divided by thd incifion; but no inconvenience is found to reSult from this ; and a Straight cut, Such as I have direaed, admits of a very free examination of the parts be- neath, at the Same time that it Serves to evacuate more effeaually than any other, the tears and mucus which the tumor is found to contain. An opening being thus formed, the contents of the tumor fhould be forced out with moderate preffure; Sea. XVIII. Diseases of the Eyes* 275 a Small doffil of foft lint fpread with emollient oint- ment fhould be inferted between the lips of the fore, and a flip of moderately adhefive plafter employed to retain it. As a plentiful difcharge commonly takes place, it is neceffary to renew the dreffings daily; and with a view to preferve the opening of a fize Sufficient for admitting of a free examination of the parts be- neath, inftead of a doffil of lint, a fmall piece of pre- pared fponge may be inferted into the fore every fe- cond or third day ; but as the fwelling of the fponge, by the moifture applied to it, tends to irritate and in- flame the contiguous parts, it fliould previoufly be covered with a Single ply of oiled foft linen, which does not hinder it to fwell, at the fame time that it al- lows it to be more eafily withdrawn; for the purpofe, however, of removing it more readily, a piece of ftrong waxed thread fhould be attached to it. In former times it was the common praaice, after opening the tumor, to endeavour to deftroy the hard edges of the fore, either with the aaual or potential cautery, or with ointments impregnated with red pre- cipitate, and other efcharotics. By this the patient was made to fuffer much unneceffary pain, and more deformity was produced; while the chance of a cure was much lefs than when milder dreffings are em- ployed. Indeed the only way in which a cure can be effeaed with this treatment, is the total oblitera- tion of the lachrymal fac and duas with which it is conneaed. Thefe being either deftroyed, or made to inflame, their internal Surfaces might in fome in- ftances adhere together, on preffure being applied to them. This, however, could not frequently happen ; for while the punaa lachrymalia and duas connea- ed with them remained open, the tears ftill finding ac- cefs to the parts beneath, would neceffarily produce frequent returns of the difeafe; and when, by the vi- olence of the inflammation, thefe duas happened to be obliterated, ftill the patient would be liable to a t 2 276 Diseases of the Eyes. Chap. XL conftant trickling of the tears over the cheek. This idea, therefore, ought never to be kept in view. In- ftead of efcharotics, the mildeft dreSfings only fliould be employed ; nor fliould the doffils oS lint or Sponge that I have adviSed, be of fuch magnitude as to pro- duce much pain; all that they are expeaed to per- form, being to dilate the lachrymal fac, by which we may be enabled to fearch with freedom for the com- mencement of the dua leading from the fac to the nofe. In this manner any hardnefs in the edges of the cut will foon be removed ; and the fore being fufficiently cleared of a tough vifcid kind of mucus, fomewhat re- fembling Sloughs, with which, for a few days after the operation, it is always covered, we are now to proceed to the moft important part of the cure, the fearching for and forming a free paffage for the tears from the lachrymal fac to the nofe. This part of the operation is effeaed in different ways: by clearing the natural dua leading - from the lachrymal fac through the groove in the os unguis in- to the nofe; or when this is found to be impraaica- ble, we form an artificial opening into the nofe direa- iy through the fubftance of this bone from the under and back part of the lachrymal fac. As unneceffary violence Should always be avoided, we Should firft endeavour, by the eafieft method, to diScover the natural conduit of the tears, and to re- move the obftruaion formed in it. For this purpofe* a firm round pointed probe, or the curved inftrument* Plate XXV. fig. 2. fhould be inferted, by the incifion* into the bottom of the lachrymal fac ; and if the point of it can be paffed into the commencement of the na- fal dua, fome hope may be entertained of the paffage being made pervious : fome degree of force may in- deed be neceffary for effeaing this ; but whenever it can be done, which frequently is the cafe, by the probe being pufhed in a proper direaion with moderate pref- Sea. XVIII. Diseases of the Eyes. 277 fore, it ought always to be preferred to every other method of treatment. The paffing of the probe into the nofe is the moft difficult as well as the moft uncertain part of this op- eration; for when this is accompliffied, we have it generally in our power to preferve the opening, by keeping a piece of bougie, catgut, or lead wire con- flantly in it, till the paffage of the dua is rendere4 fufficiently clear. But it fometimes happens, that alj our trials for the difcovery of the nafal dua prove in- effectual. Much force, however, Should never be em- ployed ; for, as the point of the inftrument will more readily be pufhed againft the bone than into the dua, it would be more apt to do harm than good. When it enters the Superior part of the canal with eafe, it may with fafety, and with fome probability of fuccefs, be pufhed forward in the manner I have mentioned ; bujt when the dua is obliterated through its whole courfe, by the fides of it adhering together, an occurrence, however, which I now believe to be lefs frequent than I once fuppofed it to be, it would be highly improper, for the reafon I have given, to ufe much force in our endeavours to detedl it. When, therefore, all our trials for discovering the natural paffage between the lachrymal fac and the nofe prove unfuccefsful, as we know that a cure will' not be obtained if the tears be not conveyed to the nofe, our views muft now be folely directed to the forma- tion of an eafy and free artificial opening for this pur- pofe. In the anatomical defcription that Lpremifed of thefe parts, we have feen that the pofterior part of the la- chrymal fac is lodged in and attached to a groove in the os unguis j and as the fac is feparated from the cavity of the corresponding noftril by this bone only, it is evident that an opening made from the back part of the fac muft Serve to convey the contents of it into the nofe. It is this part of the operation that we are now to confider. 278 Diseases of the Eyes. Chap. XL I have already obferved, that the aaual cautery was formerly employed for deftroying the hard edges of the fore, and as it was a prevailing opinion with almoft all the praaitioners of the laft and preceding centuries* that the fiftula lachrymalis was almoft always connec- ted with a carious ftate of the correfponding bones, the cautery was likewife ufed for aflifting in the exfo- liation of the difeafed parts. In confequence of this, a cure was fometimes accomplished by a remedy that was employed only for the removal of what they con- fidered as an accidental occurrence, and not as a caufe of the difeafe : for the os unguis being extremely thin, a hot iron can Scarcely be applied to it without deftroy- ing it entirely; and as this would in Some inftances happen, a cure would be Sometimes obtained even where the praaitioners who employed the remedy were totally ignorant of the manner in which it aaed ; for as they were unacquainted with the real caufe of the difeafe, from their ignorance of the anatomy of the parts concerned in it, any cures that they performed muft have been more the effea of accident than of defign. It is not, however, without furprife, that we find, even in later times, when the caufe of the difeafe is well known, and when the principles of the operation are founded on an exaa knowledge of the difeafed parts, that the fame method of treatment has been continued. Till of late, the aaual cautery was very commonly employed by the beft furgeons of this coun- try, for perforating the os unguis. Even the celebra- ted Chefelden patronifed this method ; and it is ftill praaifed in feveral parts of the Continent, With all the caution, however, that can be employ- ed, of covering the hot iron with a canula, or wet cloths, it is an uncertain and dangerous praaice ; for parts muft be deftroyed by it, or at leaft much injur- ed, which ought not to be hurt, as it is impoffible to convey a red hot iron to the os unguis, and to deftroy Sea. XVIII. Diseases of the Eyes. 279 part of this bone, which alone ought to be perforated, without doing mifchief to the contiguous parts. The cautery ought therefore to be laid afide; and this the more readily, as the fame intention can be accompliffied with equal certainty, and with more eafe and fafety, in a different manner, merely by forcing a firm fharp inftrument, of the form and Size oS the common trocar, from the back part of the fac through the os unguis. A curved inftrument of this kind has commonly been employed, fuch as is reprefented in Plate XIX. fig.. 5.; but the Straight trocar, delineated in the fame Plate, fig. 2. anfwers better. With this inftrument, the opening through the bone may be made, either by twirling it round between the fingers ; by moving it forward and backwards with the fingers or palm of the hand; or by pufhing it ftraight for- ward ; and the furrounding parts may be proteaed, at the fame time that the inftrument is more Steadily fixed than it otherwise can be, by paffing it through a canula, Such • as is delineated in the Same Plate, figure 4. In proceeding to this part of the operation, the pa- tient's head fhould be fupported by an affiftant; and the furgeon, fitting or ftanding between him and the window, fhould introduce the canula of the trocar in- to the opening made in the tumor ; and the end of it being carried to the under and back part of the fac, it fhould be kep firm in this fituation with one hand, while the ftilette is inferted into it with the other: the point of the ftilette muft now be pufhed firmly but flowly forward in a proper direaion into the noftril, and we know that it has entered that cavity as foon as a difcharge of blood is perceived to take place from it. In making the perforation, a proper direaion to the courfe of the ftilette is a point of the firft importance, and therefore merits the greateft attention. IS turned in any degree outward, or inclining towards the eye, it would penetrate the orbit; pofteriorly, it would pafs 286 Diseases of the Eyes. Chap. X L into the ethmoid bone ; and if puffied in a horizontal direaion towards"the nofe, the os fpongiofum fuperius would be injured, while the intention of the operation, that of affording a free paffage for the tears into the nofe, would be entirely fruftrated. In order to avoid thefe inconveniencies, the instrument Should be puffied on towards the nofe in an oblique direaion downwards and inward from the inferior part of the lachrymal fac. Care fhould be taken, however, not to endeav- our to follow the courfe of the natural paffage of the tears, as by fome has been advifed ; foiun this man- ner we would not only injure the maxillary bone, but the opening here could not be made fo free and large as in that part of the os unguis where the lachrymal fac terminates, and where the commencement of the nafal dua takes place. On the instrument having reached the noftril, it fliould be moved with fome freedom ; not by carrying it farther in, as this might injure the parts within the nofe; but by giving it a free rotatory motion, fo as to render the opening made with it fufficiently pervious : this being done, the ftilette fhould be withdrawn, when a lead probe, fully equal to the fize of the canula* fhould be introduced, and then the canula fhould be taken out. One end of the lead fhould pafs freely through the opening in the os unguis, and the other muft projea about the eighth part of an inch or there- by paft the level of the external fore. With a view to prevent the lead from Slipping altogether into the nofe, this projeaing part of it Should be fomewhat curved after the canula is withdrawn. The fore fliould now be covered with a fmall pledget of lint fpread with emollient ointment, and the whole may be retain- ed with a flip oS adhefive plafter ; for no bandage can be kept on thefe parts but with much inconvenience and diftreSs. In this manner the operation is completed; but much attention is neceffary on the part of the furccon to preferve the opening, and to prevent it from-filling Sea. XVIII. Diseases of the Eyes. 281 up in future. With this view, the lead probe muft be continued for a confiderable time, in order to ren- der the paffage as callous as poffible ; care being tak- en to withdraw it every day or two, for the purpoSe oS clearing it and the Sore from any impurities; and at each dreffing a quantity of infufion of oak bark, a folution of alum, or any other aftringent, fhould be in- jeaed with a Small Syringe from the external opening into the nofe. The fyringe, fig. 1. Plate XX. anfwers this purpofe properly. No certain period can be fixed, at which we can fay the paffage will be fufficiently callous, and at which the lead probe may be withdrawn ; for this will in fome meafure depend on the conftitution of the pa- tient, as well as on the particular ftate of the parts themfelves. In fome inftances, it may poffibly be done with fafety in a fhorter period; but I have nev- er ventured on taking it away till the eighth or ninth week has elapfed, commonly not fo foon. The in- convenience attending it is inconfiderable ; and we are to remember, that the Succefsful iffue of the operation is to depend greatly on due attention to this part of it; for if obftruaion ffiould afterwards occur, either from the opening in the bone filling up with callus, or from the fofter parts adhering together, the patient will foon be in the fame difeafed ftate as before any attempt was made towards a cure. On withdrawing the lead, the external opening fhould be cleared from any mucus with which it may be fluffed ; and as by this time it will be reduced to a very fmall fize, it will foon heal merely by laving the fides of it together, and covering it with a pfece of adhefive plafter : or, when this does not Succeed in a few davs, touching the edges of the fore wkh cauftic will in general complete the cure quickly. In the mean time, moderate preffure fliould be applied on the courfe of the lachrymal fac, either with the finger of the patient frequently placed en it, or by means of the machine, Plate XIX. il^. 1. And this 282 Diseases of the Eyes. Chap. XL fliould be continued, till there is reaSon to SuppoSe that the Sac and contiguous parts have again recovered the tone oS which they were deprived by the long conti- nuance of the difeafe, as well as by the operation. What I have faid with refpea to the propriety of continuing the lead probe for a confiderable time, and of applying preffure afterwards on the courfe of the fac, is equally applicable when the natural paffage of the tears has been difcovered, as when an artificial opening is formed in the manner I have advifed. In- deed more attention is neceffary to this point in the one cafe than in the other; for we find by experi- ence, that the difeafe is more apt to return when the operation is finifhed by the tears being carried through the nafal dua, than when an artificial opening is made for them ; owing, as I imagine, to a wider and more free paffage being commonly formed by this laft me- thod of conduaing the operation. Inftead of a probe of lead, fome praaitioners em- ploy a piece of catgut or common bougie; but nei- ther of thefe anfwers the purpofe fo well. They are more difficult to introduce ; they retain the mucus of the part, and therefore are not fo cleanly; they are apt to be entangled by the newly divided bone ; and they do not anfwer fo well for rendering the paffage callous as the other. I have thus defcribed the different fteps of the op- eration ; and the praaice I have advifed is fuch as ex- perience has proved to be the moft fuccefsful. It muft indeed be acknowledged, that it does not in ev- ery inftance fucceed ; for cafes frequently occur which render fruitlefs every attempt that can he made for curing them. After performing the operation in the moft fatisfaaory manner ; when the paffage for the tears has been rendered completely pervious ; and ev- en where external preffure has afterwards been con- tinued in the mofl attentive manner ; the difeaSe is Sometimes found to recur. In fuch inftances, howev- er, we conclude, that Scrofula, or fome other diSeaSe Sea. XVIII. Diseases of the Eyes. 283 of the conftitution, takes place ; by which alone, or by the contiguous bones being carious, this operation, when properly performed, can be rendered abortive. It may fometimes indeed fail by too fmall an opening being formed in the os unguis ; but this is the fault of the operator, and not of the operation. There is no caufe for timidity on this point: for although it has been alleged that mifchief may enfue from break- ing this bone with the trocar, yet daily experience tends to prove the contrary ; for even where it has been broken with much freedom, I never knew any inconvenience arife from it. In order to prevent the bad confequences which thofe not accuftomed to this operation have SuppoSed would occur from the fplintering of this bone with a trocar, it has been propofed to take out a piece of it entirely with a fharp cutting inftrument, Such as is de- lineated in Plate XVIII. fig. 3. By applying this inftrument to the os unguis, in the manner that I have mentioned Sor the uSe of the trocar, a portion of the bone may be eafily cut out; but there is no neceffity for this precaution. The op- eration is more effeaually done with the trocar; and as no danger is found to enfue from it, it ought to be preferred. In the treatment of this difeafe, when it is unfortu- nately found to return even after the operation has been properly performed, if it appears to arife from a carious ftate of any part of the contiguous bones, a cure may yet be accomplished by laying the tumor again open ; by endeavouring to accomplish an exfo- liation of the difeafed bone ; and by afterwards form- ing another opening in the cs unguis in the manner I have direaed, if the opening made by the feparation of the exfoliated pieces of bone be not fufiicient. But when a relapfe takes place, without fome obvious caufe of this kind, as any opening we might form in the bone would probably be obliterated by a continuance of the fame difeafe of the fyftem by which the firft at- 284 Diseases of the Eyes. Chap. XL tempt was rendered fruitlefs, it could anfwer no pur- pofe to repeat it, were it not with a view to make tri- al of a different mode of operating. A confiderable time ago it was propofed by differ- ent praaitioners, to obviate the uncertainty attending this operation, by introducing a fmall canula of gold or filver, either through the natural paffage of the os unguis, or through an opening made with a trocar; and by leaving the canula, and healing the fkin over it, thus to form a paffage on which no difeafe of the conftitution could have any effea. By thofe who confider the ufual operation for the fiftula lachryma- lis as very uncertain, it has been propofed to employ a canula of this kind in every cafe ; but as this oper- ation, when properly performed, proves frequently very fuccefsful, and as patients ufually confider it as a fevere meafure to have an extraneous body left in a wound with a view to remain, it may be proper not to advife it in any cafe, till on trial we have found that the other will not fucceed. In every cafe, however, where the ufual operation has failed, the method of cure by a canula ought to be tried; and when pro- perly performed, it will very commonly fucceed, Tubes for this purpofe ffiould all be of gold, as being lefs apt to be injured by the fluids of the part in which they are left than any other metal; and much care fhould be taken to have the canula well polifhed, and as exaaiy fitted as poffible to the parts in which it Is placed. When properly fitted, it gives little pain, even from the time of being introduced, and at laft it frequently fits with perfea eafe. In Plates XX. XXV. and XXVII. different forms are delineated of thefe tubes, but of thefe fig. 5. and 6. Plate XXV. as re- commended by Mr. Pellier, are the beft. They are of a length that experience has Shewn to anfwer in the moft part of aduks; and their diameter fliould be as large as the opening in the bone can admit, with a view to prevent, with as much certainty as poffible, Sea. XVIII. Diseases of the Eyes. 285 the tears and mucus that may pafs into them from flopping them up. The proper length of the tube is obvioufly a point of the firft importance in this operation. For, if too ftiort, it will fail, by the under part of it being apt to be plugged up with the lining membrane of the nofe, and if too long, by the end of the tube being preffed againft the feptum nafi on the oppofite fide of the nof- tril. This laft objeaion appears to apply to the tubes oS Mr. Wathen, which, in one caSe in which they were tried here by my friend Dr. Wardrop and me, prov- ed unfuccefsful, chiefly from this caufe; and as Mr. Pellier's tubes, which are considerably fhorter than Mr. Wathen's, have anfwered in every caSe in which I have known them uSed, I conclude that in this re- Spea, as I believe in every other, they are preferable to thoSe of Mr. Wathen. As the direaions given for the ufe of Mr. Pellier's tubes in the next feaion, are fufficiently full, I fhall now refer to them ; and direc- tions for thofe of Mr. Wathen will be feen in the ex- planation of Plate XXVII. in which the tubes that he recommends are delineated. In defcribing the progrefs of the difeafe, I had oc- casion to obferve that the tumor in the corner of the eye, when it inflames and fuppurates, proceeds at laft to a ftate of ulceration. This circumftance, however, does not point out any difference in the method of cure; only in this cafe, inftead of ufing a lancet for laying the fac more freely open, a cut ffiould be made with a fcalpel upon a direaor introduced at the ulcer. In every other point, the cure is to be managed as I have already advifed, by rendering the natural paffage of the tears pervious when this is found to be practi- cable ; and, when this cannot be done, by making an artificial opening through the os unguis. When, again, the os unguis and other contiguous bones are found to be carious, the fores Should be preferved open till the difeafed parts are all removed; when, if a large enough opening is not formed for the 286 Diseases of the Eyes. Chap. XL paffage of the tears, by the pieces of bone which have been taken away, it may now be made, and all the other fteps of the operation completed in the manner I have already pointed out. In local affeaions of thefe bones, a cure may thus be in fome inftances ac- complished.; but where the caries depends upon a ve- nereal taint, as is not unfrequently the cafe, although a well conduaed courfe of mercury may cure the general difeafe of the conftitution, it is feldom able to prevent very extenfive exfoliations of the difeafed bones; by which, the natural paffage of the tears be- ing deftroyed, and the bones through which they fhould be conveyed being perhaps altogether remov- ed, they muft in future pafs entirely over the cheek; for in fuch circumftances art can afford no relief. SECTION XIX. Additional Remarks on Difeafes of the Eyes. IN the preceding feaions of this chapter, the difeafes of the eyes were fo fully treated of, that it was not my intention to fay any thing further upon them: but a foreign oculiSt, M. Jean Francois Pellier, having appeared in this country, where he defervedly acquir- ed much reputation, I judged it proper in the former editions of this work, to communicate fuch parts of Mr. Pellier's praaice as appeared to be of importance. Poffeffing the advantages of a liberal education, a found judgment, and much experience, Mr. Pellier has been enabled to fuggeft improvements in the treatment of almoft every difeafe to which the eyes are liable; and an uncommon degree of fteadinefs, conjoined to a quick eyefight, give him a command of himfelf, and a facility of operating, not often at- tained. I think it proper likewife to remark, that Mr. Pellier communicated to me his knowledge of the dif- Sea. XIX. Diseases of the Eyes. 287 eafes of the eyes in the moft candid manner; which puts it in my power to lay his observations beSore the public, he having given me permilfion to do So. While, by giving an early account of material improvements, I thus acquit myfelf of an obligation to the public, I at the fame time embrace, with much fatisfaaion, the opportunity which it affords of an- nouncing the merit of an operator, who, although a Stranger, and as yet not much known in this country, is perhaps one of the beft oculifts now in Europe. In the firft place, I fhall mention what I have learn- ed of Mr. Pellier's praaice; and fhall then offer fuch remarks as occur to me upon it. On the fubjea of the cataraa his obfervations are particularly valuable. By attentive examination, he can in many inftances Say whether a cataraa is hard, Somewhat Soft, or altogether fluid ; and as his method oS operating varies according to theSe circumftances, it is oS importance to be able to determine a priori with regard to them. He can alSo aScertain, whether a cataraa is of a large or fmall fize; by which he is often direaed in the different fteps of the operation. I know that thefe are circumftances which praai- tioners in general confider it as impoffible to judge of with precifion, particularly with refpea to the con- fiftence of cataraas; and I muft acknowledge, that I was clearly of this opinion, till of late that I was con- vinced of the contrary, not by Mr. Pellier's affertions alone, but by different proofs of the faa. I affifted Mr. Pellier in different cafes where the cataraa was extraaed: in all of them he previoufly foretold the confiftence and fize of the cataraa with perfea con- fidence ; and in every inftance his prognofis was pre- cife and accurate. I am credibly informed, too, that this happened with other praaitioners in whofe pre- fence he operated in different parts of this country. He distinguishes feveral varieties of cataraa, which in praaice ought to be kept in view. 288 Diseases of the Eyes. Chap. XL The three principal varieties that he mentions are, what he terms the true or curable cataraa $ the mix- ed or doubtful kind ; and the falfe or incurable. i. What he terms the curable or true cataraa, is known by the pupil retaining its natural power of contraaing and dilating in full perfoaion, while the patient is at the fame time able to diftinguifh the light of a candle, or of any other luminous body, and even certain bright colours, fuch as red, green, &c. 2. The mixed or doubtful cataraa, is attended with a weak feeble contraaion and dilatation of the pupil, and the patient can Scarcely diftinguifh light from darknefs. Along with an opaque ftate of the lens, this is fuppofed to be attended with a difeafe of the retina, or of fome other part of the eye. 3. In what he terms the falfe or incurable cataraa, along with an opaque ftate of the lens, there is evi- dently a difeafed Slate of the pupil, which remains immoveable to whatever degree of light it may be ex- pofed, at the fame time that the patient does not dif- tinguifh between the moft brilliant light and perfea darknefs. Cataraas may be either fimple or compound, or they may be complicated with other affeaions. 1. A fimple cataraa is a mere opacity of the cryf- talline lens, all the other parts of the eye remaining perfeaiy found. 2. A cataraa is faid to be of a compound nature, when blindnefs is produced by an opaque ftate of the body of the lens, of the liquor which furrounds it, and of the capfule. 3. The difeafe he considers as complex, when it is conjoined with other affeaions of the internal parts of the eye ; the moft frequent of which is amaurofis. Cataraas are not unfrequently attended with a dif- folution of the vitreous humour, and Sometimes with an opaque ftate of it. This variety of the difeafe is for the moft part produced by vluient inflammation. It is eafily distinguished by thofe accuftomed to an at- Sea. XIX. Diseases of the Eyes* 289- tentive examination of the eye ; and it is particularly neceffary for operators to be well acquainted with it; for no operation, either extraaion or depreffion, fhould be ever advifed for it. The operation has never in any inftance of this kind of cataraa been known to fucceed ; and for the moft part, Mr. Pel- lier obferves, it is produaive of very dreadful pain, and the mofl violent degree of inflammation that he ever met with. In general, too, the pain and inflam- mation induced in this manner remain fixed and per- manent, without yielding in any degree to the ufual remedies. Cataraas are fometimes accompanied with an im- perforated iris ; in which cafe, as no light can pa*s to the bottom of the eye, no degree of vifion takes place; and at other times they are complicated with adhe- fions, either to the iris, or to the capfule of the vitre- ous humour. Preternatural adhefions of the lens to the capfule of the vitreous humour can Scarcely be distinguished by the eye ; but they take place very commonly where cataraas have been originally pro- duced by, or attended with, much inflammation ; and they always render the operations of extraaion and couching difficult. It is this kind of adhefion, Mr. Pellier imagines, which prevents the operation of couching from Succeeding fo frequently as it other- wife might do ; for when it takes place in any de- gree, the cataraa, he fuppofes, will always rife again on the needle being removed from it. In forming an opinion of cataraas from the real feat of the difeafe, different circumftances require at- tention. 1. It often happens, as I have already remarked, that the lens only is opaque. This variety of the dif- eafe is moft frequent, Mr. Pellier obferves, in adults, and efpecially in old age. 2. When the opacity is feated in the capfule of the lens, if the anterior part of it onlv is difeafed, it ap- Vol. II. U 290 Diseases of the Eyes. Chap. XL pears to be remarkably white, and to be placed very contiguous to the iris ; while, on the contrary, if the pofterior part of it only is opaque, it is commonly of a grey colour, and the opacity appears to be deep feated. It fometimes happens, both after the operation of extraaion and couching, that in the courfe of ten or twelve days, the capfule of the lens, which at firft was perfeaiy found, becomes quite opaque. This variety of the difeafe Mr. Pellier terms the cataraae fecon- daire. 3. When the body of the lens and its capfule are both opaque, the cataraa is commonly foft or even altogether fluid. In this cafe, much care is required in the operatian to prevent the capfule from burfting: a degree of nicety, Mr. Pellier obferves, at which thofe not much accuftomed to this branch of praaice can feldom arrive, but which is very praaicable with ope- rators of experience. 4. In fome inftances, cataraas appear to proceed from a partial affeaion of the lens, fmall opaque fpots being obferved in it, while the reft of it remains found. In this cafe, vifion is always moft perSea in an obScure light, when the pupil is moft dilated. In forming an opinion of the confiftence of cata- raas, three circumftances particularly require atten- tion. 1. When a cataraa is of a firm confiftence, it is in almoft every inftance Somewhat brown ; it appears in general direaiy behind the iris ; not So deep as the lens is uSually placed ; and the pupil dilates and con- traas very flowly. 2. A fluid or Soft cataraa is not commonly white* but rather of a cream colour, fomewhat refembling purulent matter ; and for the moft part in this vari- ety of the diSeaSe, the globe oS the eye appears full, and fomewhat more prominent than it uSually is. 3. It Sometimes happens, PVlr. Pellier obServes, that along with this fluid ftate of a cataraa, the capSule is Sea. XIX. Diseases of the Eyes. 291 much thickened. To this he gives the appellation of the cyftic cataraa. The colour of a cataraa is another point of im- portance. 1. I have juft obServed, that a Soft or fluid cataraa is for the moft part of a cream colour; but in that variety of the difeafe fometimes met with in children at birth, although it is always fluid, the colour is al- moft always a milk white. In general, however, at other periods of life, a white cataraa is of a cheefy confiftence. 2. When a cataraa is yellow, a fmall portion of the lens often remains hard, the reft of it being dif- folved into a thin tranfparent fluid, forming that vari- ety of the difeafe ufually termed the hydatid cataraa. 3. Although a black cataraa is not a frequent oc- currence, Mr. Pellier fays he has met with it in differ- ent inftances. The only difeafe for which it may be miftaken is the gutta ferena ; but with due attention, the one may be diflinguifhed from the other. In the gutta ferena the difeafe for the moft part comes on fuddenly, the pupil is of a deep black, it remains im- moveable'in every degree of light, and the patient cannot distinguish colours, or the cleareft light from perfea darknefs ; whereas in the black cataraa, the acceffion of blindnefs is commonly flow and gradual; the pupil, to a certain degree, contraas and dilates on being expofed to light. The bottom of the eye is of a dark colour, but not of fuch a deep black as in the gutta ferena; and the patient can diftinguiffi light and vivid colours. In Short, the fymptoms of this variety of the difeafe are exaaiy the fame with thofe of the common cataraa ; only, inftead of being white, the opacity is black. Mr. Pellier prefers the method of cure by extrac-' tion, excepting in a few cafes where the pupil is un- commonly fmall, when he operates by depreffion. He always prepares his patients for the operation, bv con- u 2 292 Diseases of the Eyes* Chap. XL fining them to a low diet for five or fix days ; by giving two or three dofes of Saks and fenna ; and when plethora prevails, he takes away ten or twelve ounces of blood. In extraaing the cataraa, he makes the incifion of the cornea in the ordinary place, and of the ufual fize ; but he has fome peculiarities in his method of doing it. Inftead of placing the patient with his face oppofite to a clear light, he feats him with his fide towards it. If he is to operate upon the left eye, he ufes his right hand, and the right fide of the patient is placed to- wards the window. He always ufes his left hand in operating upon the right eye ; and in this cafe the pa- tient is made to fit with his left fide towards the light. The patient being feated, with the other eye tied down with a bandage, an affiftant Supports his head behind, while, at the Same time, he fixes the eye on which the operation is to be performed, with the fpe- culum, fig. 5. Plate XXII. The figure reprefents the mflrument of the full fize. It is made of wire j and may either be of gold, filver, or any other metal. The head being fixed by preffing it againft the breaft with one hand under the chin, the affiftant takes the fpeculum in the other; and placing the round curva- ture of one of the ends of it upon the upper eyelid immediately behind the cartilaginous border, he muft by gentle gradual preffure upon the eyeball, fix it above, while the operator with the fore and .middle fingers of his left hand, when the operation is to be done upon the left eye, muft fix it below, at the Same time that he draws down the under eyelid. In ufing this Speculum, the upper eyelid is forced almoft en- tirely into the orbit behind the eyeball, but it imme- diately returns to its natural fituation on the inftru- ment being removed. The eye being thus fixed, the knife, figure 1. Plate XXII. fixed in its handle, muft be put into the opera- tor's right hand, who now divides the cornea in the Sea. XIX. Diseases of the Eyes. 2?3 ufual manner : but when the point of it comes oppo- fite to the pupil, if the capfule of the lens is to be di- vided, Mr. Pellier has arrived at fuch dexterity in this operation, that he plunges the point of the knife through the pupil into the lens ; and withdrawing it gently, he carries the point of it forward to the oppo- fite fide of the eye, and finiffies the operation in the ufual way. But in making the latter part of the in- cifion, he is very attentive to the preffure made by the fpeculum, which he defires the affiftant to remove en- tirely before completing the incifion, in order to pre- vent the vitreous humour from efcaping. This being done, the eyelids are immediately fhut; and while they are in this ftate, a flow, gradual pref- fure is made upon the eyeball, with the flat end of the inftrument, which he terms a curette, fig. i. Plate XXV. which for this purpofe is placed immediately above the tarfus of the upper eyelid, As the accefs of light to the eye is thus prevented, the pupil re- mains in a ftate of dilatation, by which the lens is more eafily preffed out than it otherwife could be ; and if the preffure is cautioufly applied, no part of the vitreous humour is ever forced out. When the cataraa does not come out entire, which is fometimes the. cafe, or when it is found to adhere to the contiguous parts, the end of the curette is in- troduced through the pupil, and any adhefions that take place are gradually feparated ; at the fame time that any detached pieces of the lens are turned out through the cut in the cornea : or, inftead of the cu- rette, the ciftatome, fig. 3. Plate XXIV. is fometimes employed for feparating the adhefions. In the courfe of this operation, it fometimes hap- pens that the iris is forced too much forward into the anterior chamber of the eye, or even altogether through the cut in the cornea. With a view to pre- vent tirf bad effeas that might refult from this, Mr. Pellier infinuates the flat fide of the curette into the • 294 Diseases of the Eyes. Chap. XL wound in the cornea, and by means of it endeavours to put the iris into its natural fituation. This is the ufual method in which Mr. Pellier per- forms this operation; but circumftances fometimes occur that require fome peculiarity of management. The moft material of which are thefe: when he has reafon to think that the cataraa is in a fluid ftate without any opacity of the capfule, inftead of making an opening in the cornea of the ufual fize, he inSerts a fharp pointed knife, Somewhat convex on the back, into the inferior part of the tranfparent cornea, at a fmall diftance from the iris; and having made an in- cifion of about the tenth part of an inch in length, he pufhes the point of the inftrument upwards till it comes oppofite to the pupil, when he carries it cau- tioufly on till it reaches the lens ; and having now made an opening in the capfule fufficiently large for difcharging the fluid contained in it, he withdraws the inftrument with the fame caution with which it was introduced, and in this manner the operation is finifh- ed : the cataraa being in a ftate of fluidity, the whole of it paffes eafily off without any preffure. When, again, along with a foft or fluid cataraa, there is reafon to fuppofe that any part of the capfule is opaque, or even where the capfule alone is fuppof- ed to be difeafed, he carefully avoids opening it or burfting it in the courfe of the operation : in either of thefe events, he fays it would be with difficulty ex- traaed. He therefore by flow gradual preffure with the curette, in the manner I have mentioned, forces out the lens, contained, as he imagines, in its capfule or cyft; and he does it, he Says, in every inftance without forcing out any part of the vitreous humour. In fome cafes, however, he finds it neceffary to intro- duce the end of the curette through the pupil, and to feparate the capfule of the lens from the contiguous parts; but even this, he fays, does no harm to any part of the eye. The importance of our being able to judge from the appearances of a cataract, of the Sea. XIX. Diseases of the Eyes* 295 real ftate oS the diSeaSe, is therefore fufficiently obvi- ous, from the difference which this variety of it re- quires in the method of conduaing the operation. In extraaing the cataraa, it is a matter of the firft importance to avoid the iris with the knife; but as this is extremely difficult in eyes that are not pro- minent, Mr. Pellier often employs a knife with that fide of it convex which paffes next to the iris. One of thefe inftruments is reprefented in Plate XXII. fig. 2. In every other refpea this knife is the fame with that which he ufes in ordinary cafes, reprefented in fig. 1. of the fame plate. In the courfe of this operation, it fometimes hap- pens that the aqueous humor efcapes in too great quantity before the point of the knife is carried acroSs the eye So as to penetrate the oppofite fide of the cor- nea : when this takes place, which it often does when the hand of the operator is not perfeaiy fteady, as the iris is apt to pafs in before the point of the inftru- ment, Mr. PeUier advifes the fharp pointed knife to be withdrawn, and another with a probe point, fig. 3, to be introduced at the opening ; and the point being Slowly carried over to the oppofite fide of the eye, an incifion is there to be made, either with the other fharp pointed knife or with a common lancet, fuffi- ciently large for letting out the blunt point of the other; when the operation is to be finifhed, by pufli- ing it forward, and making a femicircular incifion in the ufual way in the under part of the cornea. As foon as the cataraa is extraaed, it is the com- mon praaice to prefent a watch or fome other objea to the patient, with a view to difcover the fuccels of the operation. In fome inftances Mr. Pellier has been forced to confent to this ; but he does not approve of it. Inftead of this, he immediately clofes the eyelids, and covers each eye with a fmall bag of foft old linen or cotton about half filled with foft fine wool. Thefe bags are applied dry, and are fixed with pins to a cir- cular bandage of old linen paffed round the forehead, 296 Diseases of the Eyes. Chap. XL which again is kept firm in its fituation by a flip of the fame linen made to pafs beneath the chin and over the upper part of the head ; care being taken to fix them both with pins to the night cap below. The patient is now to be undreffed, and with as lit- tle exertion as poffible fhould be laid in a bed, upon his back, with his head low: in this fituation he is de- fired to remain with as little variation as poffible dur- ing the firft fix or eight days, as it tends more than any other in which he can be placed to a Speedy cure of the wound in the cornea. If the patient is not low and emaciated, Mr. Pellier always adviSes eight or ten ounces of blood to be taken in the courfe of a few hours after the operation. He keeps him on a low diet, and gives Small doSes of opiates from time to time, which anfwer better than a large dofe at once, which often excites ficknefs and vomiting, fymptoms that ought to be guarded againft ; for nothing fo readily, hurts the eye after this operation as the exertion of vomiting, coughing, and fneezing. For which reafon he does not admit of fnuff or tobacco in any form be- ing ufed for the firft eight or ten days. An eafy flool is procured daily, and on the fourth or fifth day the dreffings are removed; when after clearing the eye of any mucus or matter that has form- ed on it, and the eyelid being cautioufly lifted, the fame kind of bandage is applied again. From this time forward, the dreffing is renewed every fecond day, and in ten or twelve days from the operation, the eye fhould be bathed before the new bandage is applied, with a weak faturnine folution; but till this period, warm milk and water is confidered as preferable. About the end of the third week, the bags of wool, after having been gradually leflened, are taken away, and a piece of green filk put over the eyes inftead of them. If no unufual interruption occurs to the cure, the diet is now made gradually better ; and when the operation has been performed on one eye only, Mr, Pellier commonly allows the patient to go abroad at sea. XIX. Diseases of the Eyes. 297 the end of the fourth week, but never fooner; and even then the eyes are kept well covered: but when both eyes have been cut, he advifes a confinement of at leaft fix weeks. This is the plan of treatment which Mr. Pellier pur- Sues in ordinary caSes ; and he attributes much of the fuccefs of his operations to a rigid obfervation of thefe regulations. But where there is a particular tenden- cy in the fyftem to inflammation, remedies of a differ- ent kind are neceffary. The eye becomes in fome cafes fo much inflamed even in the courfe of a few hours from the operation, that one bloodletting is not fufficient. In this cafe he advifes leeches to be applied to the temple and con- tiguous parts; and if a fecond or third general eva- cuation is neceffary, he direas the blood to be taken from the foot, as by experience he finds this to anfwer better than taking it from the arm or neck. The pa- tient is defired to drink plentifully of Arabic emulfion, with a large proportion of nitre. The pediluvium frequently repeated, he finds proves ufeful. And, for the removal of that violent pain which inflammation fupervening to this operation commonly excites, noth- ing that has yet been tried, he thinks, anfwers fo well as a liniment c^.rurol'cd of the white of an egg and powdered alurn beat for a confiderable time together : a little of which fhould be applied to the eye every two hours between two plies of foft old linen. Befides affording relief from pain, it tends more effeaually than any other remedy to ftop the progrefs of inflam- mation ; infomuch, that Mr. Pellier emplovs it in ev- ery cafe as foon as the eye begins to inflame. Inftead of alum, he fometimes adds to the white of an egg three grains of white vitriol, and the fame quantity of faccharum faturni diffolved in a fpoonfol of rofe water ; and the whole being well beat togeth- er till it puts on the appearance of white froth, a little of this is inferted between the eyelids with a fmall pen- cil three or four times a day, at the fame time that the 298 Diseases of the Eyes. Chap. XL eyelids are covered with a fmall bag of thin linen in which fome of it is contained. When the heat and pain attending the inflammation begin to abate, he advifes a poultice compofed of a ripe apple, well boil- ed, with the water preffed out of it, to which he adds; a fmall quantity of camphor and powdered Saffron. By perfevering duly in thefe means the inflamma- tion is commonly at iaft removed. In fome inftances, however, this does not happen, and notwithstanding the utmoit attention, all the Symptoms become worSe ; the veffels oS the tunica conjunctiva become turgid ; the eyehds Swell to a confiderable fize ; and the pain, which before was fevere, becomes infupportable. In this fituation, nothing tends to ftop the inflammation but local bloodletting carried to a confiderable extent by incifions made in the affeaed parts. For this pur- pofe the mere divifion of the turgid veffels with a lan- cet or fmall fcalpel fometimes anfwers ; but in gener- al it fucceeds better by taking away fmall portions from different parts of the internal furface of the eyelids with fmall convex fciffars, Such as is repreSented in Plate XXII. fig. 4. This, Mr. Pellier obferves, Sel- dom Sails of giving immediate relief; he has never found that it does harm afterwards, and the ftate of the eye being very critical, no remedy fhould be omit- ted that affords any chance of obviating the danger ; for if this is not quickly done, fuppuration will foon take place, either in the coats of the eye, or in one or both of the chambers, by which the power of vifion is very commonlv deftroyed. When matter is evidently formed, a frequent ufe of warm emollient Steam, applied to the eye by means of a funnel of pafteboard, or of any other fubftance, will Sometimes produce a flow difcharge oS it at the cut in the cornea: but when this does not Succeed in the fpace of a day or two, no more time Should be loft; the matter ffiould be difcharged by an incifion, made in the moft depending part of the abfcefs, when feat- ed in the fubftance of the cornea; or, by opening the Sea. XIX. Diseases of the Eyes. 299 lips of the incifion made for extraaing the cataraa, when the colleaion is in either of the chambers of the eye. By this means the patient will be immediately relieved from pain, while, at the fame time, it will give him the only chance of preferving the ufe of his eye. During the firft two or three weeks after this oper- ation, a kind of herniary fwelling is apt to form in the eye, by the iris or fome other part being forced out at the opening in the cornea, either by violent cough- ing, fneezing, or fome other effort; and in fome in- ftances, by expofing the eye too Soon and too frequent- ly before the cicatrix is fufficiently firm for refilling the preffure thus produced on it. When the tumor is fmall, it may commonly be removed by touching it frequently with a fmall pencil dipped in Goulard's ex- tract of lead, concentrated by evaporation, or in any mild antimonial efcharotic ; an attempt, Mr. Pellier obServes, that may be made with SaSety, iS care be tak- en to prevent the cauftic Srom hurting the reft oS the eye, by touching the diSeaSed part only, and immerf- ing the eye immediately in warm milk, or in Some warm emollient decoaion. But when the diSeaSe is farther advanced, and the tumor firm and folid, it an- fwers better to remove it entirely either with the fcal- pel or fciffars ; or if it appears to be any part of the aqueous humour contained in a thin membranous pro- duaion, as is fometimes the cafe, all that is neceifary is, to make an opening into it with a lancet of a fize Sufficient to difcharge what it contains. It is Scarcely neceffary to obServe, that after either of thefe opera- tions, the parts muft be treated with much attention, otherwife much harm would arife from it. A Stria antiphlogiftic regimen muft be obServed. The eye fhould be lightly covered, either with a Small bag, Such as I have mentioned above, filled with Soft wool, or with a comprefs of old linen foaked in a weak fo- lution of faccharum faturni. Mr. Pellier's method of extraaing the cataraa, which I have thus endeavoured to defcribe, with his 500 Diseases of the Eyes. Chap. XL treatment of the confequences that fometimes enfue from it, Is the refult of much experience, and ufually answers better than any other with which we are ac- quainted. Much of Mr. Pellier's fuccefs undoubtedly proceeds from his fuperior dexterity in performing the operation ; but much of it alfo depends upon the mi- nute attention that he gives to every cafe for a confid- erable time after the operation. In ordinary praaice, and efpecially with the moft part of itinerants, it is commonly fuppofed, if the operation is properly per- formed, and if the cataraa, comes away eafily, that little more is required of the operator ; but it is much otherwife with Mr. Pellier, who confiders the after treatment as fo effential, that he commonly declines to operate where he cannot have the fubfequent man- agement of the cafe for two or three weeks: and by conftant and aSfiduous attention, he is often able to obviate fymptoms that would otherwife prove alarm- ing ; and which often might render operations alto- gether abortive, which might otherwife be attended with complete fuccefs. This I had various opportuni- ties of observing. In the preceding feaion, I entered into a full dif- cuffion of the refpeaive merits of the two operations of couching and extraaing the cataraa; and I then endeavoured to eftablilh the preference of the former : but if experience Shall Shew, that Mr. Pellier's method of operating is attended with more permanent advan- tages, I fhall be very ready to retraa my opinion ; for which purpofe, I fhall carefully attend to the confe- quences of thofe operations that he has performed In this country ; and as the public will probably be in- terested in them, I fhall at fome future period perhaps communicate the event of them. There are two points of importance in this opera- tion, with refpea to which I differ in opinion from Mr. Pellier. When he confiders it as proper to di- vide the capfule of the lens, he frequently does it, as I have already obferved, by insinuating through the Sea. XIX. Diseases of the Eyes. 301 pupil the point of the fame knife with which he makes the cut in the cornea, even before the incifion is com- pleted. This may poffibly be done with fafety by fuch a very dexterous operator as Mr. Pellier: but as moft praaitioners, by imitating him, would run the rifk of hurting the iris, the praaice ffiould not be encourag- ed ; for when the capfule of the lens is to be divided, it is furely better to do it after the incifion of the cor- nea is finiffied, by lifting up the flap, and paffing in the end of the blunt probe reprefented in Plate XVIII. fig. 5. or of the ciftatome, Plate XXIV. fig. 3. The other point to which I allude, refpects the prac- ticability of extraaing the capfule of the lens, without doing any material injury to the eye. When the cataraa appears to be of a firm confift- ence, and when the difeafe is fuppofed to be confined entirely to the lens itfelf, Mr. Pellier frequently opens the capfule in the manner I have juft defcribed, with a view to allow of a more eafy extraaion of the lens ; and in this cafe he admits that the capfule remains in the eye : but when he finds, after an operation, that the capfule of the lens becomes opaque, or if he ob- ferves that any part of it has been previoufly in a ftate of opacity, he advifes it to be cautioufly extraaed with Small forceps: and again, in every cafe where he fuf- peas the cataraa to be fluid, forming what he calls the cyftic or hydatid cataraa, he avoids the divifion of the capfule, and advifes the lens to be taken out in- cluded in it; which he fays may be done in the man- ner I have mentioned, by making an equal and grad- ual preffure upon the ball of the eye immediately after the divifion of the cornea ; or by Separating any adhe- fions that take place between the capfule of the lens and the contiguous parts, with the curette, Plate XXV. fig. 1. paffed through the pupil. I have not indeed feen Mr. Pellier extraa the cap- fule of the lens, after removing the lens itfelf; for no cafes requiring it occurred during his refidence here : 302 Diseases of the Eyes. Chap. XL I received, however, full information of his method of doing it, by introducing fmall forceps at the pupil. But as I cannot imagine how this can be done with- out injuring the eye materially, I muft ftill retain the opinion I advanced of it in a preceding feaion, till I have evident proofs of its being praaifed with advan- tage. And whenever thefe are offered, I Shall receive them with much fatisfaaion, as it would in many in- ftances be a material improvement of this operation. We have n6w to confider the poflibility of extraa- ing the capfule entire along with the lens: feveral praaitioners in this country had opportunities of fee- ing Mr. Pellier extraa cataraas, as they fuppofed, in this fituation. I faw him operate in two inftances of this kind, where he, as well as feveral others, imagin- ed that the real capfule was taken out along with the lens ; but as I entertain a different opinion on this point, it is proper to ftate the reafons which have led to it. i. The capSule of the vitreous humour, and that which contains the lens, are fo intimately conneaed together, that it is difficult, or perhaps impoffible, for the beft anatomift to determine whether they are Sep- arate produaions or not: at leaft they are So intimate- ly conneaed, that they appear to be formed oS the Same Subftance, the cryftalline lens being furrounded with a coat which feems to be a thin lamella of that which forms the capfule of the vitreous humour. The contrary, I know, has been alleged ; but whoever will make the experiment, will find that the capfule of the lens has exaaiy the appearance that I have mention- ed. It appears to be a produaion of the other ; and they cannot be feparated without tearing or deftroying fome part of one or both of them : now, if this is the cafe when the contents of the eye are all laid open, and when all the affiftance can be got that nice diflec- tion affords, it appears to me impoffible that they fhould be feparated in the operation of extraaing the Sea. XIX. Diseases of the Eyes. 303 cataraa, without injuring the reft of the eye, and par- ticularly the vitreous humour, very materially. 2. In performing this part of the operation, viz. in attempting to extraa the capfule of the lens entire, Mr. Pellier does it by means which do not appear ad- equate to the intended effea. He does it in moft in- ftances, by making a gradual equal preffure over the ball of the eye, and not by the introduaion of forceps. Now, it is difficult to conceive in what manner pref- fure applied to the eye can feparate that intimate con- neaion which certainly takes place between the cap- fule of the vitreous humour and that of the cryftalline lens: by preffure they are frequently both forced out; but no operator would wiffi to meet with this, and no perfon guards with more anxiety againft it than Mr. Pellier, infomuch, that the efcape of the vitreous hu- mour, or even of any part of it, is an occurrence he rarely meets with. In fome cafes, indeed, Mr. Pellier infinuates his curette, as I have already remarked, through the pupil, with a view to detach the capfule of the lens from the contiguous parts : he allows, however, that this is not always neceffary ; and be- fides, there is much caufe to fufpea, that the eye would often be hurt by it. 3. When it is found, however, as I have already obferved, either during the operation or afterwards, that the capfule of the lens is opaque, even Mr. Pellier himfelf does not attempt to extract it by preffure. In this cafe he does it with forceps paffed through the pupil. Now, if preffure anfwers in one variety oS the diSeaSe, it ought probaby to do So in others, So that the uSe oS forceps fhouid not be neceffary; but it is only in the hydatid or foft cataraa which Mr. Pellier allows that this praaice by preffure fucceeds. 4. But as feveral praaitioners, both here and elfe- where, have feen Mr. Pellier extraa the cataraa, fur- rounded, as they imagined, with its proper capfule ; and as he afferts with confidence, that it may be done merely by preffure ; it will be aiked, in what manner 3°4 Diseases of the Eyes. Chap. XL is this apparent contradiaion to be explained ? I can account for it only on the. fuppofition of there being in all fuch cafes, where this praaice of extraaing the capfule entire is confidered as admiffible, a preternat- ural formation of a new membrane within the capfule of the lens ; which being of a firmer nature than the. capfule itfelf, and probably very little, if at all, attach- ed to the contiguous parts, we can eafily fee how it may be forced out entire, even by moderate preffure, and how eafily byftanders may be deceived with it. When I firft faw it done by Mr. Pellier, as he previ- oufly faid that he would extraa the whole capfule along with the lens ; as I had heard from very refpec- table authority that he had done it in different instan- ces in Glafgow; and as I certainly faw the cryftalline pufhed out, furrounded with a membranous bag, I muft own that I was nearly converted to Mr. Pellier's opinion: but on further confideration, the reafons I have mentioned againft it appeared too conclufive, even for this weight of evidence, to remove; and Since that period, a circumftance has occurred, which with me puts the matter beyond a doubt. A cataraa of a foft nature was extraaed by Mr. Pellier, fur- rounded with this membrane or bag quite entire. From the firft I doubted much of its being the proper capfule of the lens, as it was faid to be ; for this tunic is well known to be exceedingly fine and delicate; whereas this membrane was firm, and required fome degree of force to tear it. The patient, however, dis- tinguished objeas immediately after the operation; and what was then advanced concerning it could not be well refuted : but by fome caufe or other, poflibly from the eye becoming inflamed, an opacity foon be- gan to form in the old fite of the cryftalline, direaiy behind the pupil, forming to all appearance a real ca- taraa ; and it now continues, even after the inflam- mation is removed. Whatever explanation may be given of this by thofe who are inclined to fupport the contrary opinion, it proves to me a convincing proof Sea. XIX. Diseases of the Eyes. 305 that fome deception takes place where the' capfule is fuppofed to be extraaed entire along with the lens; for in this cafe, where the capfule was imagined to be taken entirely out, the opacity which fucceeded, and which ftill exifts, appears evidently to be feated in the capfule, and no where elfe. I therefore conclude, where praaitioners have imagined the capfule was ex- traaed entire, that they have been deceived by the lens being enveloped with a preternatural bag or cyft, formed perhaps by an inflammatory exfudation from the internal furface of the capfule : that this produc- tion, however, is certainly formed in this manner, I will not poffitively affert; but in my opinion it is the moft probable way by which we can account for it. Thefe are the remarks that I have to offer on Mr. Pellier's theory and praaice in the treatment of cata- raa. If further obfervation fhall convince me that I am wrong, I will readily acknowledge my miftake ; but, in the mean time, the reaSons I have adduced, appear to evince the impropriety of extraaing the capfule piecemeal, by means of forceps paffed through the pupil, as well as the impoflibility of making it pafs entire along with the lens. It fometimes happens in fmallpox, as well as in fe- vere inflammation of the eye from whatever caufe it may proceed, that the centre of the cornea is left in a ftate of opacity, by matter forming between the coats of it. When not carried off by the remedies ufually employed, if the iris, retina, and other parts of the eye appear to be found, Mr. Pellier advifes an opera- tion, from which he has in different inftances derived much advantage. The centre of the cornea being opaque, the rays of light are thus prevented from paff- ing to the bottom of the eye through the pupil; but when the fides or external border of the tranfparent cornea ftill remain clear and found, light may be al- lowed to pafs to the retina, by enlarging the pupil; which, Mr. Pellier fays, may be done with fafety by Vol. II. W 306 Diseases of the Eyes. Chap* XL making an incifion from one fide of the iris to the other. And his method of doing it is this: he firft makes an opening in the prominent part of the cornea, in the fame manner as for extraaing the ca- taraa : he then inferts a fmall grooved direaor be- neath the flap of the cornea through the pupil; and having paffed it in a horizontal direaion, immediate- ly behind the iris, towards the outer angle of the eye, he now takes a pair of fmall curved fciffars, and paff- ing one of their blades along the groove of the direa- or, he at once divides this part of the iris, when he withdraws the inftruments, and makes a fimilar cut on the oppofite fide of the eye. In this manner, when the opacity is confined to the centre of the cornea, which it often is, the rays of light which pafs through the fides of it get accefs to the bottom of the eye, by the pupil being extended from one fide of the iris to the other; and thus a degree of vifion is produced which could not otherwise be obtained. It will rea- dily be imagined, that perSea vifion is not to be ob- tained in this ftate of the eye : various reafons indeed concur againft it: but it is a matter of importance for a perfon already totally blind to be rendered capable of finding his way, and of conduaing himfelf from one place to another, which, by this operation, Mr. Pellier has done in different inftances : and, So far as I know, the public are indebted to him alone for pro- pofing it. After the operation, the eye muft be tied up, and treated in the fame manner and with the fame atten- tion as is done after extraaing the cataraa ; for where fo much violence is done to the eye, if inflammation be not guarded againft, much mifchief may enfue from it. 1 In defcribing the method of dividing the iris, I have faid that it fhould be done with fciffars; for this membrane being loofe and unfupported, it would yield before the edge of the fharpeft knife. In the introduc- tion of the direaor and fciffars, care fliould be taken, in Sea. XIX. Diseases of the Eyes. 307 paffing them between the iris and lens, not to injure either the lens or its capfule; that is, when the dif- eaSe is not complicated with cataraa; Sor when the cryftalline is opaque, it fhould be extraaed. In the treatment of the fiftula lachrymalis, Mr. Pel- lier has much merit; for, with moft operators, it of- ten happens that no permanent advantage is obtained from any of the remedies that they employ, and even thofe who prove moft fuccefsful very frequently fail. Mr. Pellier does not fay that he always fucceeds; but he does fo in moft inftances ; and I know that his method has often proved fuccefsful where others have failed. In a confirmed fiftula lachrymalis, the curative in- tention is, to form an opening between the lachrymal fac and the correfponding noftril. In Seaion XVIII. of this chapter, I have Shewn that this is accomplished in different methods ; by fearching with a blunt probe to difcover the natural paffage: if this fails, by mak- ing an artificial opening through the os unguis ; and when neither of thefe fucceed, by leaving a tube or canula, either in the natural or artificial opening, for * the purpofe of conduaing the tears to the nofe. As we know from experience, that the operation fails frequently from the paffage becoming again im- pervious, and this whether it may have been done by opening the natural paffage or by forming another, it would be the idea perhaps of moft praaitioners to leave a tube in the opening, were it not liable to one very important objeaion, namely, the uncertainty of its continuing fixed in its fituation ; for hitherto we have not been poffeffed of any certain method of pre- venting the canula either from rifing and forcing its way out at the corner of the eye, or from paffing down and coming out at the nofe. In Plate XX. I have delineated various forms of tubes that have been ufed for this purpofe ; and of thefe, figs. 3. and 10. will frequently be found to anfwer : for when w 2 308 Diseases of the Eyes* Chap. XL preffed Sufficiently into the opening through the os Unguis, the bulge or prominence with which they are furnifhed above, for the moft part prevents them from rifing, while their conical fhape prevents them Srom paffing into the nofe. I muft however acknowledge, that they Sometimes fail ; and that an invention of Mr. Pellier's anfwers better. Mr. Pellier afferts, that when properly introduced, it never fails ; and from any experience that I have had of it, I am clearly of the fame opinion. In a patient of mine, on whom the operation was performed upwards of fifteen years ago, and in others where it was done nine or ten years ago, the tubes are ftill firm and immoveable, and an- fwer the purpofe of giving a free paffage to the tears. Two reprefentations of thefe tubes are given, in Plate XXV. figs. 5. and 6. They may be made either of gold or lead. Mr. Pellier commonly employs lead : but when of gold, the tube is lefs bulky ; and as this metal receives a finer polifh, by which the opening through it is not fo readily filled up with the tears, it ought, I think, to be preferred. Tfie peculiarity of form of Mr. Pellier's tubes con- fifts in their having two projeaing edges ; one at the top forming a kind of brim, correfponding as nearly as poffible to the fize of the lachrymal fac ; and the other near to the middle between this and the other end of the inftrument; by which means, when pro- perly fixed in the paffage where it is to remain, it is kept firm in its fituation by the granulations that fhoot out from the contiguous parts ; and which, by grafping as it were that part of the tube which lies be- tween the two projeaing edges, effeaually prevent it from paffing either up or down ; and hence that ma- terial inconvenience is avoided, of which praaitioners, who employ cylindrical tubes, always complain. It is neceffary, however, to obferve, that the utmoft nicety is required in the ufe of thefe as well as of eve- ry variety of tube ; not merely in accurately adapting them to the fize of the openings through which they Sea. XIX. Diseases of the Eyes. 309 are to pafs ; but afterwards in ascertaining the depth to which they fhould be preffed into the nofe : for if a tube be either too fmall or too large for the open- ing through the os unguis, we may readily imagine that it will not anfwer; and if it is preffed even in a trifling degree too far into the noftril, it will neceffa- rily irritate the lining membrane of that cavity, fo as to create much pain and inconvenience. The tubes reprefented in Plate XXV. are of a fize both in length and thicknefs that anfwers for the moft part of adults, but praaitioners ffiould be provided with various Sizes. The method of ufing them is this. After laying the lachrymal fac freely open in the ufual way, the natural conduit of the tears is fearched for, either with a firm probe, or with the conduaor, Plate XXV. fig. 2. ; and Mr. Pellier afferts, that he never fails in finding it. As foon as this is difcovered, the tube muft be put upon the conduaor, previoufly furniffied with the compreffor, fig. 3. as in fig. 4.; and the tube fliould be of Such a fize that the conduaor may fit it exaaiy in point of thicknefs, while the end of this part of the inftrument is fo much longer as to pafs through the tube about the tenth part of an inch. The point of the conduaor is now to be insinuated into the lachrymal dua ; and being pufhed in till it reach- es the noftril, which may be known either by paffing a probe up the noftril, or by a few drops of blood being obferved to fall from the nofe, the conduaor being no longer neceffary, muft be withdrawn, taking care to leave the compreffor upon the upper brim or edge of the canula ; which mult be firmly preffed down with it in the left hand, while the conduaor is removed with the other. If this precaution be not taken, the canula would be brought out along with the conduaor ; but this inconvenience is thus very effeaually guarded againft, while the fame inftru- ment ferves more eafily than any other to prefs the canula to a fufficient depth in the lachrymal dua ; a 310 Diseases of the Eyes. Chap. XI. point of the firft importance in this operation ; for if the canula be not firmly fixed at the firft attempt, it will not afterwards be fo eafily done. This being accompliflied, the compreffor muft be taken out ; and, with a view to difcover whether the canula is at a proper depth or not, a little milk and water Should be injeaed through it with the fyringe, Plate XX. fig. i. If the injeaion paffes eafily into the noftril, there will be no reaSon to doubt of the ca- nula being properly placed; but, if any obftruaion occurs, there will be reaSon to fear that it is already pufhed too far, and that it preffes againft the os Spon- giosum inferius; in which cafe the canula fliould be withdrawn, with a view to fhorten it, when it muft be again introduced in the manner I have mentioned. As the wound recently made in the fac will yield a large quantity of matter, it ought to be kept open for eight or ten days with a bit of foft lint fpread with any emollient ointment, taking care to cover the whole with a comprefs of foft old linen, fecured with a pro- per bandage. An injeaion of milk and water fhould be daily paffed through the canula; and at the end of this time, or whenever the fuppuration is much di- miniffied, and the fore looking clean and in a healing ftate, the doffil of lint fhould be removed ; and a piece of court plafter being laid over the Sore, it may in this ftate be leSt to heal, care being taken to renew the plafter occafionally, if any matter appears to form be- neath it. By this mode of treatment, cafes of fiftula lachry- malis that do not depend on difeafe of the contiguous bones, or on any latent difeafe of the conftitution, will for the moft part, as Mr. Pellier obferves, be com- pletely cured in three weeks, nay fometimes in a fort- night, which by the ufual praaice might require three, four, or five months. In Plate XXVII. I have delineated the form of tube as well as all the other parts of the apparatus employ- ed for this operation, by Mr. Wathen ; but although Sea. XIX. Diseases of the Eyes. 311 the invention is ingenious, and may anfwer in a great proportion of cafes, as Mr. Pellier's tubes appear to me to be better adapted to the form of the lachrymal paffages, while his mode of introducing them is more fimple, I think it probable that they will meet with a preference. As I have been witnefs of the moft complete fuc- ceSs of Mr. Pellier's praaice in this difeafe, I have confidered it as a point of juftice, not only to Mr. Pellier, but to the public, to give this full detail of it. If I had not indeed been convinced of the fuperior utility of Mr. Pellier's praaice, and of the unreferved manner in which he communicated his knowledge of the difeafes of the eyes, 1 fhould have deemed it im- pertinent to have given the preceding account of eith- er to the public. Since the firft edition of this was publifhed, the opinion which I then fuggefted, of the impoffibility of extraaing the capfule of the lens entire, has been the fubjea of much investigation : and as it now appears that it cannot be done, I ftill conclude that Mr. Pellier and others who fupported a diflerent opinion, have been deceived, 312 Diseases of the Chap. XII. CHAPTER XII. OF THE DISEASES OF THE NOSE AND FAUCES. SECTION I. Anatomical Defcription of the Nofe and Fauces. A MINUTE defcription of thefe parts is not necef- fary for our purpofe; but a few remarks on their general form and ftruaure will ferve to elucidate the nature of the difeafes to which they are liable. The external prominent part of the nofe is chiefly compofed of bones and cartilages, which ferve to pro- tea the more deep feated parts of the organ of fmell, and to form a kind of vaulted paffage for the air to the throat. This paffage, divided by the feptum nafi, forms the noftrils, which extend almoft in a horizontal direction from the fuperior part of the upper lip backwards to the pharynx, where they terminate above the velum pendulum palati. The fuperior and lateral parts of the arch of the nofe, are formed by the nafal procefs of the os fron- tis; by the two offa nafi ; by the offa unguis ; and by an extenfive proceSs from each of the offa maxilla- ria, to which the cartilaginous alae of the nofe^cover: ed by the common teguments, are immediately at- tached. The feptum narium is formed by the nafal procefs of the ethmoid bone ; the vomer; middle cartilage of the nofe ; and fpinous proceffes of the palate and max- illary bones. The under part of the cavity of the nofe is anteri- orly bounded by a horizontal procefs of the offa max- Sea. I. Nose and Fauces. 313 illaria, and backwards by a pnfcefs of a fimilar form,- from each of the offa palati. The fphenoid and eth- moid bones form the boundaries of the pofterior part pf the nares. Towards the upper part of the nofe we meet with a very beautiful contrivance of nature for enlarging the organ of fmell. In the fuperior part of each noftril, oppofite to the Septum, we find a fpongy, cellular pro- duaion of bone, proceeding from the os ethmoides, which, from their form, texture, and fituation, are termed conchae, offa fpongiofa, or offa turbinata fupe- riora : and beneath thefe, on the fame fide of the nof- trils, are two bodies of a fimilar texture, which have likewife been fuppofed to be produaions of the eth- moid bone, but of which there is no evidence; which, from their fituation, are termed offa fpongiofa inferio- ra. In fome inftances, two, and even three, Small bones of this kind are met with in each noftril; but this is not a frequent occurrence. Thefe bodies being prominent and irregular on their furfaces, give the noftrils a winding, or even a crook- ed appearance : but every praaitioner will know, that they are fo in appearance only ; infomuch that a probe may be paffed almoft in a Straight line from the exter- nal nares to the throat. We meet with feveral openings which terminate in the noftrils, with fome of which it is material for fur- geons to be acquainted, namely, the duaus inciforii, which commence at the under and back part of the noftrils, and terminate behind the dentes incifivi of the ujjper jaw ; the finufes of the fphenoid and fron- tal bones, which both open into the upper part of the nares ; the Sinus oS each maxillary bone, commonly termed the antrum maxillare. or highmorianum, which opens into the noSe between the upper and under offa SpongioSa of the fame fide ; and laftly, the duas of the lachrymal facs, which in the preceding chapter I have had occafion to defcribe, and which terminate on 3*4 Diseases of the Chap. XII. each fide immediately beneath the os fpongiofum in- ferius. All the cavity of the noftrils ; the different finufes I have mentioned, as well as the paflages which lead to them; the whole furfaces of the offa SpongioSa, and even the fauces, are covered or lined with a thick foft membrane, which, from its affording a plentiful Secre- tion of mucus, is commonly termed membrana pitui- taria, or membrana Schneideri, from Schneider, the firft anatomift who gave an accurate account oS it. This membrane appears to be a continuation oS the cuticle. Towards the external nares, near to its con- neaion with the epidermis, it is exceedingly thin ; but as it proceeds backward upon the Septum nafi and of- fa fpongiofa, it acquires a confiderable degree of thick- nefs ; and again becomes thin as it proceeds to line the different finufes. The cavity of the nofe, as I have already remarked, is feparated from the mouth by a plate of bone, form- ed by a procefs from each of the offa maxillaria, and by the offa palati. To the pofterior edge of the laft mentioned bone there is a firm membrane conneaed, termed the velum or valvula palati, formed by a junc- tion of the common membrane of the mouth, with a continuation of the membrana Schneideri, together with feveral mufcular fafciculi, intended for the mo- tion of this and the contiguous parts. This mem- brane, as it Stretches back from the palate, falls down and terminates in the uvula immediately above the root of the tongue ; by which it is not only well fitted for preventing the food, during maftication and degluti- tion, from paffing up to the nofe, but for conveying back to the pharynx all fuch parts of the mucus fur- niffied by the membrane of the nofe, and contiguous finufes, as are not difcharged by the external nares. On each fide of the throat, at the termination of the velum pendulum palati, there is fituated a promi- nent glandular fubftance, commonly termed the amyg- dalae or almonds of the ear. They are naturally of a Sea. II. Nose and Fauces. 315 foft, yielding texture ; and in general they have exca- vations of different degrees of deepnefs on various parts of them, which, by thofe not acquainted with the ufu- al appearances of thefe parts, are often miftaken for ulcerations. On looking farther into the throat, along the courfe of the tongue, a thin, elaftic, cartilaginous body is obferved, termed epiglottis, which is fo placed as to prevent the food from falling into the trachea in its paffage from the mouth to the pharynx, a wide ca- pacious bag, which terminates in the cefophagus, and occupies all that part of the throat that is feen on look- ing into the mouth. From this defcription it is evident, that the pharynx is furniffied with feveral openings or outlets. Below, it terminates in the cefophagus ; anteriorly, it commu- nicates direaiy with the mouth ; and from the fupe- rior part of the bag it has a free direa communication with the pofterior openings of the noftrils. I Shall now proceed to confider the diSeaSes oS thefe parts, and the operations that are praaifed for them. The fubjeas are, hemorrhagies from, the noftrils ; ozaena; imperforated noftrils ; polypous excreScences in the nofe and throat; extirpation of the amygdalae and uvula ; Scarifying and fomenting the throat. SECTION II, Of Hemorrhagies from the Noftrils. THE internal parts of the nofe are fupplied almoft entirely with blood from the internal maxillary artery : in general, the branches of this artery that go to the/nofe are fo fmall, as to render a divifion or rup- ture-of them an objea of little importance; but, in fome inftances, it Is otherwife, and hemorrhagies oc- cafionally occur from thefe parts that give much anx- iety and diftrefs to praaitioners, and prove very haz- 316 Diseases of the Chap. XII. ardous to patients. They have fometimes even baf- fled every attempt that could be made to reftrain them ; fo that, however inconfiderable this evacuation may in a great proportion of inftances be, it ought, in every cafe, to be treated with attention. In a great proportion of cafes, a proper application of cold puts a temporary ftop to the difcharge ; and in general, any future returns of it may be prevented by bloodletting, a moderate ufe of cooling laxatives, and a low regimen. In order to obtain all the advantages that may be derived from cold, it muft be employed in various ways, and to a confiderable extent. The patient fhould be placed in a large apartment, with a current of cold air paffing through it: his food and drink ought all to be cold: his face fhould be frequently bathed, and even immerfed, in cold water, or in cold water with a proportion of vinegar : the mouth fhould be kept filled from time to time with a cold folution of alum, or any other aftringent: compreffes, wet in any liquid oS this kind, fhould be applied over the noSe: when in bed, the patient fhould be lightly cov- ered ; and he fhould Sleep with his head as high as poffible. By theSe means being duly continued, naSal hemor- rhagies may in general be removed ; but in Some in- ftances no benefit is derived from them, the flow of blood not being in any degree diminiflied by whatever care and affiduity they happen to be applied. In fuch cafes, compreffion of the ruptured blood veffei is alone to be depended on; but when deeply Seated in the noftril, the application of prefnire is both difficult and uncertain. It fometimes happens that a doffil of lint paffed into the bleeding noftril will put an immediate ftop to the difcharge. This, however, is rare; for the extent and diameter of the paffage through which the doffil is puffied being very une- qual, the effea produced by it muft likewife be fo: Sea. II. Nose and Fauces* 317 hence we cannot place much dependence on this me- thod of applying preffure. In former editions of this work, when treating of the difcharge of blood from the anus in cafes of piles, I advifed the application of preffure by the introduc- tion of a piece of gut, tied at one end, into the reaum, and by filling it at the oppofite extremity with any cold liquid, to increafe the preffure by forcing up the liquid, and fecuring it with a ligature. The fame remedy may be employed in hemorrhagies from the nofe. It has already been fuccefsfully ufed in a few inftances ; and may frequently, I think, be employed with advantage. A piece of hog's gut, previoufly dri- ed and moiftened again, anfwers beft. One end of it firmly tied with a bit pf fmall packthread, fhould, by means of a probe or direaor, be pufhed along the whole courfe of the noftril from which the blood is difcharged, to the upper end of the pharynx. The gut fhould now be filled with cold vinegar, water, or any other cold liquid, by means of a fyringe inferted at the end hanging out at the noftril; and as much being injeaed as the gut will admit, the whole fhould be preffed as far up as poffible, and fecured in this fit- uation with a ligature. In this manner a very confiderable degree of pref- fure may be applied ; and fome advantage may be de- rived from the application of cold direaiy to the vef- fel from whence the blood is difcharged. In fome in- ftances, however, even this may fail, owing to the rup- tured artery being fo fituated that preffure cannot in this manner be diraely applied to it. In Such circum- ftances, other means muft be employed, and the fol- lowing very commonly anfwer. Let the curved inftrument, fig. 4. Plate XXVI. be inferted at one of the noftrils with a piece of catgut or firm waxed thread contained in it; and being con- veyed into the throat, the ligature muft be laid hold of with forceps or the fingers, and taken out at the mouth ; when the inftrument is to be withdrawn, and 318 Diseases of the Chap. xir. again introduced at the other noftril with a ligature of the Same kind, to be likewiSe taken out at the mouth. A bolfter of SoSt lint, of a Sufficient fize for ftuffing or filling the pofterior nares, is now to be firmly tied to the two ends of the ligatures hanging out at the mouth, when the oppofite ends of them muft be pulled for- ward at the noftrils till the cufhion of lint is firmly ap- plied to and fixed in the upper part of the pharynx; when a comprefs of linen muft be applied to each nof- tril, and fixed in this fituation by tying the ligatures over it. The patient Should now be laid to reft. If the bolsters of lint have been properly applied, no blood will efcape either from the pofterior or anterior nares; any blood that is effufed into the noftrils will foon coagulate, and thus a ftop will be put to the he- morrhagy. It is evident, however, that in order to infure fuccefs, the bolsters of lint fhould not only be accurately applied, but continued for a length of time fufficient for admitting of the healing or reunion of the ruptured blood veffels. In fixing the bolfter of lint in the back part of the mouth, I have advifed two ligatures to be employed ; one to be paffed through each noftril. In this man- ner it may be applied not only more firmly, but more equally, than by the ufual method of paffing only one ligature through that noftril from whence the blood is difcharged. I alfo think it right to remark, that a ligature fhould be attached to the bolfter of lint in the pharynx, oS a Sufficient length to hang" out at the mouth, by which the bolfter may be withdrawn on the hemorrhagy being ftopped : otherwise, when the bolfter is firmly fixed behind the velum pendulum pa- lati, it cannot be removed but with much trouble, both to the furgeon and patient, of which I have met with different inftances : in one of thefe, after various at- tempts had been made for taking the bolfter away, it was allowed to remain for three or four weeks, till it fell into the throat during fleep, when it nearly fuftb- cated the patient before being got out. Sea. III. Nose and Fauces. 319 SECTION III. Of an Ozana. THE term ozaena has in general been applied to fuch ulcers of the nofe as are foul; that dif- charge a fetid matter, and are attended with a carious ftate of one or more of the bones; whilft by fome the fame general denomination of ozaena is applied to every ulcer in the noftrils, whether attended with ca- ries or not. At prefent I fhall adhere to this laft ac- ceptation of the term. Every catarrh affeaing the lining membrane of the nofe, ferves in a greater or lefs degree to excite an inflamed ftate of the parts in which it is feated. But this in general terminates eafily, and the inflammation is removed by a plentiful difcharge either of mucus or thick yellow matter. In fome inftances, however, even after every other catarrhal fymptom is removed, this difcharge of matter continues obftinate, either from ulceration alone, or perhaps from ulceration conjoined with fulnefs and fwelling of the fining mem- brane of the nofe. Expofure to cold is to be confidered as the moft frequent caufe of this ftate of the difeafe; but exter- nal violence of every kind that terminates in an in- flamed ftate of the membrane of the nofe, fuch as the application of acrid irritating fubftances, blows and bruiSes, may HkewiSe tend to produce it. When the Syftem is not otherwiSe diSeaSed, this Is the moft fimple variety of an ozaena; and as in this ftate we fuppofe it to be perfeaiy local, local reme- dies ought alone to be employed. In this ftate of the difeafe, we truft chiefly to the uSe of drying and aftringent applications. Of thefe, decoaions of walnut-tree leaves, or of Peruvian or oak bark, mixed with a folution of alum, Solutions of 320 Diseases of the Chap. Xlt. white vitriol, and ftrong faturnine Solutions, are per- haps equal if not preferable to any. Brandy or any other ardent fpirits diluted with water, and lime wa- ter, may likewife be employed with advantage. Doffils of Soft lint Soaked in any oS theSe Should be introduced into the noftril three or four times daily, and pufhed up fo as to be brought in contaa with the difeafed parts ; and every night at bedtime an oint- ment fhould be applied, prepared with a large pro- portion of calcined zinc or lapis calaminaris. By a due continuation of thefe means, almoft eve- ry local difeafe, depending on ulceration of the mem- brane of the nofe, will at laft be removed. But in- ftances have occurred of other difeafes being miftaken for fores in the nofe, and of the running produced by them continuing to refill every effort that could be made for removing it. This is particularly the cafe with colleaions of matter in the antrum maxillare. In the anatomical defcription I have given of thefe parts, we have feen, that there is naturally a paffage or opening from the antrum maxillare into the nofe immediately below and covered by the os fpongiofum inferius of the fame fide. In colleaions of matter in this cavity, when large in quantity, it is occafionally difcharged by this outlet into the nofe in eveiy pof- ture of the body, and almoft always when the patient lies on the Sound or oppofite fide, if the paffage be not obftruaed. The method of treatment beft fuited for the removal of colleaions in the antrum maxil- lare, will be the fubjea of a feaion in the next chap- ter : at prefent I have only to fay, that in difeafes at- tended with a difcharge of matter from the nofe, prac- titioners fliould be on their guard, left, by mistaking one difeafe for another, mifchief may be done; not only by a mifapplication of remedies, but by thofe means being omitted from whence alone any real ad- vantage could be derived. When, again, the matter difcharged from an ulcer in the nofe is thin, Setid, and of a brown or fomewhat Sea. III. Nose and Faucis* 321 black colour, as this gives caufe to fufpea that the contiguous bones are carious, it would be in vain to expea a cure till thefe are removed. We may in general know that caries exifts, by the peculiar fetor of the matter which the fores afford : but when any doubt remains of this point, we have it commonly in our power to have it afcertained by the introduaion of a probe. As a carious Slate of the bones of the nofe occurs more frequently from lues venerea, than from any other caufe, this fhould be kept in view in every fymp- tom of this kind: and whether we may be able to trace it with certainty as a fymptonr of this diSeaSe or not, whenever there is the leaft caufl Sor SuSpicion, the patient fiiould without hesitation be put on a long continued courSe of mercury. From whatever caufe the difeafe may have arifen, mercury will not proba- bly do harm ; and as I have feen it prove ufeful even where no venereal taint has existed, I now in general, in all Such caSes, adviSe it immediately. In the mean time, the local treatment of the fores fhould not be negfeaed. The parts fhould be bathed from time to time with one or other of the decoaions I have mentioned; and as the foft fpongy bones of the nofe are apt, when carious, to produce trouble- fome fungous excreScences, ointments, impregnated with corrofive applications, fhould be employed occa- fionally ; and of thefe there are none I have ever em- ployed that anfwer fo well as prepared verdegris, ca- lomel, or red precipitate. A general prejudice indeed prevails againft the ufe of remedies of this kind in difeafes of the internal parts of the nofe, from a fear of their doing harm, by irritating the very fenfible membrane to which they are applied. There is no good caufe, however, for this timidity ; and I can fay from experience, that ointments, fuch as I have men- tioned, of a ftrength Sufficient for keeping down fun- gous excreScences, may be employed with much fafe- Vol. II. X 322 Diseases of the Chap. XIL ty, and without any rifk of hurting the contiguous parts. It is fcarcely neceffary to remark, that in the uSe of remedies of this kind, fome caution is neceffa- ry, in adapting the ftrength of the article to the parts to which it is to be applied. The internal furface of the nofe will not bear the fame degree of irritation that may with fafety be applied to fome other parts of the body ; but it will bear the application of corrofive ointments more ftrongly impregnated than is com- monly imagined. A liniment compofed of wax and oil, with an eighth or ninth part of red precipitate* may be employed with fafety, and the corrofive pow- ers of it can be occafionally increafed or diminifhed ; calomel may be ufed in a larger proportion, and twenty grains of verdegris may be added to an ounce of liniment. The growth of fungous excreScences being thus prevented, and the fores kept clean by the frequent ufe of an aftringent antifeptic wafh, the paf- fage of the noftril will be preServed pervious, the dif- eafe will not fpread fo readily, and the carious bone will be more quickly feparated and thrown off than when thefe circumftances are overlooked* Till the caries is removed, no permanent cure will take place. The treatment therefore that I have juft pointed out fhould be continued till this is fully ac- compliffied. Indeed, after a fufficient quantity of mercury is exhibited for the removal of any latent ve- nereal taint that might exift in the fyftem, all that we can expea further from art, is to affift in the manner I have advifed, in effeaing a feparation of fuch bones as are difeafed. This being done, the fores will af- fume a milder afpea, and will in general heal by a continuance of the aftringent applications alone. This is the praaice which by experience I have found to anfwer beft in cafes of ozaena. It muft, however, be acknowledged, that no remedies with which we are acquainted will at all times fucceed. This kind of ulcer proves always tedious, not only from the difficulty of reaching the fore with proper Sea. IV» Nose and Fauces. 323 dreffings, but from the offa fpongiofa, when they be- come carious, being always flow in exfoliating. When however, the fyftem is not otherwise diSeaSed, the means that I have mentioned will very commonly Suc- ceed at laft. SECTION IV. Of Imperforated Noftrils. CHILDREN are not unfrequently born with the vagina or anus in an imperforated ftate; and although we know of no reafon why the noftril fhould not in like manner be often imperforated at birth, we are certain that it is a rare occurrence. Every prac- titioner, however, muft have met with Some inftances of preternatural adhefions of the noftrils, the confe- quence of confluent fmallpox, of burns, or venereal fores. Adhefions of this kind are in various degrees. In fome cafes the noftrils are only flightly contraaed, without producing any material impediment to refpi- ration : in others, they are So much drawn together, as hardly to admit a common probe or a Small quill: and in a Sew, the paffage is entirely obliterated. In caSes oS this kind, it is the objea of forgery to remove the caufe of obftruaion as completely as it can be done, and when an opening is left, however fmall it may be, much aid may be derived from it in effeaing our intention. A fmall grooved direaor be- ing pafied into the opening, it may be eafily enlarged to its natural fize, by running a fmall biftoury or fcal- pel into the groove, and thus dividing the parts which adhere : but when there is no paffage whatever, whe- ther the effea oS natural conformation, or of any oth- er caufe, we fliould, in the firft place, by flow diffec- x 2 «24 Diseases of the Chap. XII. tion with a fmall fcalpel, endeavour to difcover one of the noftrils, taking care, with as much caution as pof- fible* to keep the opening in a proper direaion, be- tween the feptum nafi and the contiguous external cartilage : and the paffage being once difcovered, it muft be enlarged to the natural fize in the manner I have mentioned, by the introduaion of a direaor and biftoury. This being done in one noftril, we endeav- our, by the Same cautious diffeaion, to diScover the other. A clear opening being thus formed in each noftril, our next objea is to preServe it of a full fize, and to prevent the parts from adhering again; which by ex- perience we know they would do, and which much attention alone can prevent. The introduaion of doffils of lint of an adequate fize, or of any other Soft fubftance, retaining them till there is no rifk of future adhefions, and taking care to withdraw them daily, in order to cleanfe or renew them, might anfwer the purpofe : but metallic tubes, adapted to the fize of the openings, while they admit of free refpiration through the noftrils, ferve to dif- tend the parts with more equality, and are more eafi- ly retained in their fituation. Before being introdu- ced, they fhould be covered with foft leather fpread with any emollient ointment; by which they fit with more eafe, and are more readily withdrawn at the dif- ferent dreffings. Various forms of tubes have been recommended for this purpofe. Thofe reprefented in fig. 2. Plate XXVI. are of a form that anfwer perfeaiy well; and they are eafily retained either with a bandage round the head, or with adhefive plafters for attaching them to the contiguous parts. They fhould be continued as long as any degree of forenefs or excoriation re- mains in the courfe of the incifions ; for if withdrawn before the fores are healed, new adhefions or contrac- tions would very commonly enfue. Sea. V. Nose and Fauces. 325 It fometimes happens from burns, as well as from the confluent fmallpox, that along with a contraaion, or perhaps a total obliteration, of one or both noftrils, an adhefion is produced between the nofe and fkin of the upper lip. In this cafe, the adhefion oS the lip to the nofe fhould, in the firft place, be removed with a fcalpel; and the fore thus produced fhould be firmly cicatrifed before we attempt to open the noftrils. It is fcarcely neceffary to remark, that* during the cure* the fore ffiould not only be kept properly covered, but with a view to remove any improper contraaion which the lip may have acquired, it ought at each dreffing to be tied down with feveral turns of a dou- ble headed roller paffed round and over the head. SECTION V, Of Polypi in the Nofe and Throat. THE lining membrane of the nofe is liable to ex- crefcences, which, from their fuppofed refem- blance to infeas of. that name, have commonly been termed polypi. Every part of the nafal cavity, and of the back part of the throat, is liable to thefe excrefcen* ces; but moft Srequently they ariSe from that part of the membrane of the nofe that lines or covers the of- fa fpongiofa. For the moft part they are confined to one fide of the nofe, and they do not commonly ap- pear So far back as the throat; but in fome inftances they occupy both noftrils, and in others they are fo large, as to be diftinaiy perceived on looking into the pharynx. In fome cafes, indeed, they are found to arife in the pharynx. The firft warning that a patient commonly receives of this difeafe, is a partial lofs of fmell, attended with a fenfation of fulnefs or obftruaion in fome particular part of the nofe, very fimilar to what is experienced 326 Diseases of the Chap. XII. from the ftuffing of the noftrils in a common cold or catarrh. This continues to increaSe, till a Small tumor or excrefcence is perceived in one, and Sometimes in both noftrils ; which in Some inftances never deScends farther than to be merely perceptible on looking into the noftril; while in others it falls down upon the up- per lip, and at the fame time perhaps pufhes back into the throat. In fome, this elongation of the tumor continues Steady and permanent, while in others it retraas alto- gether within the noftrils in dry weather, and protrudes only in rain, or in thick hazy weather. Indeed, the influence of weather on the fize of thefe excreScences is often aftonifhing. I have known fome patients who in clear dry weather were not known to labour under the difeafe, in whom the tumors protruded to a con- fiderable length on the leaft tendency to moift weather, TheSe tumors are of various degrees of firmnefs. In a great proportion of cafes they are foft and com- preffible, but in others fo firm as to be equally hard with cartilage: all kinds of them are apt to bleed on being fretted or roughly handled ; but it is the foft fpongy kind only that are fo remarkably affeaed by changes of weather. The colour of thefe tumors is likewife variable : for the moft part they are fomewhat pale and tranfparent, but in fome inftances they are of a deep red ; and, fo far as I have yet had opportunities of obferving, I would fay, that there is fome conneaion between their colour and texture. The experience of others may lead to a different conclusion ; but in the courSe of my obfervation it has uniformly happened, that the foft compreffible polypus has been of a pale complex- ion, while thofe of a firmer texture have always been pf a deep red. In the commencement of polypus, the pain is always inconfiderable; and in the fofter kinds of it there is feldom much pain, even in its moft advanced ftages. But polypi of a harder nature become painful as they Sea. V. Nose and Fauces. 327 increafe in fize, particularly on any caufe of irritation being applied to them. In fome inftances they become unequal and ulcerated over their whole extent. In this ftate, confiderable quantities of a thin fetid mat- ter are difcharged ; and if a cure be not obtained by extirpation, they are now very apt to degenerate into cancer. It is proper, however, to obferve, that it is the firm flefhy kind of polypi only that are apt to be- come cancerous, and that this change rarely or never happens with thofe of a foft texture. But although the fofter kinds of polypi feldom end in cancer, and are rarely produaive of much incon- venience in their early ftages, or as long as they are confined to either of the nafal cavities ; yet when more advanced, they are often attended with much diftrefs. Befides the trouble arifing from their falling down up- on the lip, they fometimes pafs fo far back into the fauces, as not only to impede deglutition, but to ob- ftrua refpiration ; and in fome inftances they become fo large, as not only to diftend the fofter parts of the noftrils, but to elevate and even to feparate and diffolve the firm bones of the nofe. This, indeed, is not a common occurrence; but every praaitioner muft have met with it, as I have done in different inftances. Various opinions are met with in authors of the caufe of polypi. By fome they are faid to arife moft frequently from feroSula ; while others imagine, that they proceed moft frequently from lues venerea. I will not fay that polypi do not occafionally occur along with the venereal diSeaSe and Scrofula. They may even be met with as fymptoms of thefe difeafes. But in fuch inftances I would confider the general dif- eafe of the fyftem in no other light than as an occa- fional or exciting cauSe of the local affeaion, for in almoft every cafe of polypus a local injury may be traced as the caufe of it; and from every circumftance relating to the difeafe, I conclude, that it is always lo- cal and circumfcribed. For even where a polypus originates from lues venerea, this particular fymptom 328 Diseases of the Chap. XII. is fo. far of a local nature, that it remains fixed and permanent after the general taint of the fyftem is re- moved. Nor is it aaed upon by any quantity of mer- cury that is given. All the harder kinds of polypi may probably origi- nate from the fame caufes which produce tumors of a fimilar texture in other parts of the body ; but in moft inftances they appear to be conneaed with, and even to proceed from, a caries of the bone beneath ; and it is this chiefly which renders them more hazardous, and of more difficult cure than thofe that are foft, which, in general, I conceive to be produced by a mere diftention or relaxation of the membrana Schnei- deriana. When any portion of this membrane be- comes inflamed, either bv the effeas of cold or from external violence, if in this ftate any part of its furface is ruptured or eroded, as frequently happens from picking or blowing the nofe too forcibly, a degree of weaknefs or relaxation is produced,, that is apt to ter- minate in a fulnefs or prominency of the injured parts; and this being increafed by every fucceeding cold, the difeafe we are now confidering comes in this manner to take place. The further progrefs of the difeafe may depend on various caufes; but in general it will advance quickly or flowly, according as the parts affeaed are more or lefs liable to inflame. Thus I have known various inftances of polypi remaining Small and ftationary for a great number of years, when the patients have not been much expofed to the open air; while in poor people, who are expofed to every inclemency of weath- er, and who are therefore more liable to frequent re- turns of catarrh, they advance with more rapidity. In the treatment of every difeafe, it is a point of importance to be able to form a juft prognofis, not on- ly of the manner in which the fymptoms may proba- bly terminate, but of the effeas which may refult from the remedies that are to be employed for them ; and Sea. V. Nose and Fauces. 329 in no inftance is this more defirable than in polypous excreScences of the nofe. By fome we are led to conclude, that polypi are al- ways doubtful with refpea to their termination ; that for the moft part they are even of a dangerous nature ; and therefore that we fhould confider every perfon in whom they occur as in a ftate oS hazard : whilft oth- ers affert, that although they may occafionally excite fome inconvenience, yet they are feldom or never at- tended with riSk. Some, again, are fo timid in the treatment of poly- pi, as to fuppofe that they ought never to be touched ; and allege, that there is more chance of rendering them worfe than better, by any operation we can ad- vife for removing them ; whilft by others we are told, that they may be taken away with fafety. This difference of opinion in regard to the nature of polypi, and of the effeas of the remedies employed for them, has arifen in a great meafure from authors not having diflinguifhed the different kinds of thefe excreScences with fuch precifion as they ought to have done: for while in one variety of the difeafe there is little rifk to be dreaded, and no great caufe to doubt of our being able to remove it; in others, there is un- doubtedly much hazard, and great reafon to fear that no remedies whatever will prevent a return of it. I have already obferved, that polypi are of various degrees of firmnefs ; and all the obfervation that I have been enabled to make of them, has led me to conclude, that in general the rifk with which they are attended, is nearly in proportion to their firmnefs. The foft compreflible polypi are not only lefs painful than the others, but may at any time be removed with more faSety. They are not uSually indeed attended with pain ; and it Seldom happens that any material inconvenience occurs from their extirpation : but the firm flefliy kind of polypi are in general not only pain- ful, but more apt to return after being extirpated. In forming an opinion, therefore, of the probable event 33° Diseases of the Chap. XII. of polypi, this circumftance of texture deferves partic- ular confideration. In a foft compreflible polypus, if the patient is healthy, we may in every inftance give a favourable prognofis; for as long as the tumor is of moderate fize, it feldom proves troublefome, and therefore ought not to be meddled with ; and again, when, by acquiring additional bulk, its removal be- comes neceffary, it may always be advifed with pro- bable hopes of fuccefs. But, on the contrary, in po- lypi that are fleffiy, and efpecially when of a firmer texture than this, the patient or his friends ought al- ways to be informed of the rifk being confiderable : for it frequently happens that they cannot be entirely removed; and even when this is eafily and complete- ly praaicable, they are apt to regenerate, and in fome inftances, as I already obServed, to end in cancer. In all Such cafes, therefore, a guarded prognofis fhould be given; otherwife, if the difeafe fhould afterwards return, the operator would be jtiftly blamed, while the operation itfelf would fall into difcredit. Indeed fome praaitioners are fo averfe to this oper- ation in all cafes of firm or hard polypi, that they al- ways decline to advife it. As long as they remain ftationary, and do not give pain, if they do not ob- ftrua breathing or deglutition, they ought not to be touched : but whenever they become painful, efpecial- ly when they have acquired fuch a bulk as to obftrua either the paffage to the ftomach or lungs, we ought certainly to endeavour to extraa them, if this be not already impraaicable by their adhering through the whole of their extent to the bones of the nofe, and by thefe being rendered carious; which, in the late ftages of the difeafe, is very frequently the cafe. All the fofter kinds of polypi, which are liable, as I have already defcribed, to be affeaed by the ftate of the weather, may frequently be prevented from be- coming large by the uSe oS aftringent and eScharotie applications, particularly by a ftrong folution of alum or white vitriol, the powder of calcined alum, a decoc- Sea. v. Nose and Fauces. 331 tion of oak bark, or the application of vinegar or ar- dent fpirits. By one or other of thefe being applied from time to time over the furface of the tumors, I have known different inftances of their increafe being checked for a great length of time ; and, in fome caf- es, where the remedy has been freely employed, they have at laft fhrivelled and become lefs. It muft be acknowledged, however, that efcharotics feldom or never accomplifh a cure; but it is a matter of no fmall importance, our being able, by gentle means, to ren- der any painful operation unneceffary. On the firft appearance, therefore, of a polypus, we ought, by a free ufe of Some aftringent or eScharotic application, to endeavour to prevent its farther in- creafe ; but when this does not fucceed, we are to confider by what mode the tumor may be moft effec- tually removed. Various methods have been propoSed for the remo- val of polypi: namely, the ufe of cauftic or corroding applications; the aaual cautery; the paffing of a fe- lon or cord through the difeafed noftril; excifion with a fcalpel or fciffars; the application of a ligature round the neck of the tumor; and evulfion, or extraaion by a proper application of forceps. An ignorance of the circulation of the blood, and of the eafy method with wrhich we are now acquaint- ed of putting a ftop to hemorrhagies, led in earlier times to the praaice of removing tumors wherever they were feated, by corrofive applications, and even by the ufe of the actual cautery. If this praaice was confidered as neceffary in other parts of the body, it is not Surprising to find it propofed for the removal cf polypi in the nofe, where the effea of hemorrhagies was more dreaded. Cauterifing irons were therefore invented for this purpofe, together with metallic tubes for conduaing them. But even with the utmoft at- tention the difeafed parts cannot be deftroyed without injuring the Sound. Remedies of this kind are there- fore very apt to do harm, fo that they are now very 332 Diseases of the Chap. XII. generally laid afide; as are likewife all kinds of ftrong corrofive applications, which are equally liable to un- certainty, by their being apt to fpread to the contigu- ous found parts of the nofe and throat. As fome have imagined that polypi may be remov- ed, by inducing fuppuration over their furfaces, it has been propofed to infert a cord of filk or cotton into the difeafed noftril, and one end of it being taken out at the mouth, by daily drawing it, and covering that part of it that remains in contaa with the tumor, with a flightly irritating ointment, thus to create Some de- gree of inflammation and confequent fuppuration over it. I will readily allow, that in this manner a plentiful flow of matter may be excited ; but it is not probable that this would have much influence on the fize of the tumor. Till of late indeed, it was imagined, that the formation of pus is neceffarily attended with a dif- Solution of the Solid parts in which it occurs. Upon this principle Mr. Daran and others endeavoured to explain the operation of bougies in obftruaions of the urethra ; and a Similar idea fuggefted the remedy of which we are now fpeaking, in polypous excreScences of the nofe. But it is now known, as I have elfe- where fully Shewn,* that the diffolution of Solid parts is by no means neceffary for the formation of pus. It is alfo known, that in difeafes of the urethra, bou- gies prove effeaual only by their form, and by the preffure which they produce; and I have no difficul- ty in faying, that it is in this manner only, by which a cord, if it ever proves ufeful, can have any effea on polypi of the nofe. As the paffage of the noftrils is very unequal, being wider in one part than another, and as the roots of polypi are frequently fo fituated that no preffure can be applied to them, 1 am not of opinion that they can ever be removed by the aaion of a feton paffed through the nofe, as many have ipi- 4 Vide Chapters I. and III. Seft. V. Nose and Eauces* 333 agined. But after the extirpation of polypi in the manner I Shall hereafter point out, if their roots^ are not entirely removed, fome advantage may be derived from our endeavouring in this manner to clear the paffage more completely. It was for this purpofe folely, I may remark, that the praaice we are now considering was firft propoSed by that judicious ob- server M. Le Dran. But although it might, in this manner, Sometimes prove uSeSul, yet from being trou- blefome in the application, it has feldom been employ- ed. We fhall have occafion, however, in a fubfequent part of this feaion, to fpeak of it again. In other parts of the body, the removal of tumors by excifion is univerfally preferred to every other me- thod ; and it would likewife be fo in polypi of the nofe, were it not for their inacceffible fituation. We feldom indeed find them fituated fo as to render this mode of treatment praaicable ; for although Scalpels and fciffars of various forms have been invented for this purpofe, the roots of polypi are in general feated fo high in the noftrils, and the paffage is for the mofl part fo completely filled by the tumor itfelf, as to ren- der it always difficult, and often impoffible, to remove them by excifion. But when it is found that the tumor rifes in the under part of the noftril, and when the point of a fcalpel can eafily reach the root of it, we ought, with- out hefitation, to employ this method of taking it away, even in preference to that by ligature : for in this manner the whole of the tumor may be more ef- feaualiy removed ; and in this fituation, there is no reafon to be afraid of hemorrhagies, as compreffion can be readily applied to any blood veffel that may be cut in the under part of the noftrils. We rarely find, however, as I have obServed already, that a polypus is Seated So Sar down in the noftrils as to render this me- thod of treatment praaicable. It therefore appears, that all the means we have yet confidered for the removal of polypi in the nofe, are 334 Diseases of the Chap. XIL either inadequate to the effea, or altogether inadmif- fible ; and hence we are obliged to employ either the method by ligature, or that by extraction with the forceps. As the removal of polypi by tearing or twilling them off, is attended with much more pain than the application of ligatures round their necks, the latter would always have been preferred, if it had been con- fidered as equally praaicable. And as we now know that it can be done in a very fafe and eafy manner, it will probably in future be very generally employed. The method to which I allude, is that which Mon- fieur Levrette, of Paris, firft recommended, for the removal of polypi in the vagina, and which we now find may be ufed with equal propriety in polypi of the nofe and throat. The following is the method of ap- plying it in the throat. Fig. i, Plate XXXI. reprefents a piece of pliable filver wire paffed through a double canula ; the wire being fufficiently long when double to admit of its paffing through the nofe in the pharynx. Let the wire be taken from the canula, and the doubling at the end of it be Slowly and gently insinuated through one of the noftrils : as foon as it appears in the throat, the operator, with his fingers inferted into the mouth, muft open the double Sufficiently for paffing it over the pendulous extremity of the tumor ; and having preffed it down to the neck or root of it, the two ends of the ligature hanging out at the noftril muft be again paffed through the canula; which is now to be puffi- ed back along the courfe of the wire, till it comes in contaa with the root of the polypus. The fingers fhould ftill be continued in the throat, to retain the ligature at the root of the tumor; and the canula be- ing placed in the manner I have advifed, the wire muft be drawn tight; and the ends of it being fixed on the wings or handle of the canula, as in Plate XXXII. fig. i, it muft be left in this fituation till the following day, when being again drawn fomewhat Sea. V. Nose and Fauces. 335 tighter, and this being daily repeated, the tumor, will fall off fooner or later, according to its fize. When fmall, it fometimes drops off in the courfe of the fec- ond day ; and tumors even of a large Size often come away on the third or fourth. It is better, however, to make the compreffion more gradual; for, when the wire is drawn with much force, inftead of aaing as a ligature, and removing the tumor by compreffion* it removes it too quickly, by cutting it acrofs, and may thus be equally produaive of hemorrhagies, as if the operation had been done with a fcalpel. In this manner, all thofe polypi may be removed, which either originate in the throat, or that proceed back from the noftrils into the fauces; and the prac- tice may be extended even to thofe that are deeply feated in the pharynx, if the ligature can be properly applied over them, either with the fingers, with the affiftance of forceps, or with an inflrument, fuch as is delineated in Plate XXXIII. fig. 3. Some inftances, indeed, have occurred, of excrefcences feated too deep in the cefophagus, for admitting of ligatures be- ing ufed in this manner; nor is it admiffible even where the upper part of the tumor is acceffible, if the bafe or neck of it be fo low down as to prevent the ligature from being applied to it. In the third vol- ume of the Phyfical and Literary Effays of Edingurgh, there is a cafe related, in which a very ingenious me- thod was put in praaice by the late Mr. Dallas, for Surrounding deep feated polypi with ligatures ; and although inftances of fuch excrefcences are rare, yet, as they are fometimes met with, I think it right to give a delineation of the inftrument which in this in- ftance was fuccefsfully employed. In this cafe both breathing and deglutition were impeded by a large fleffiy excrefcence in the cefopha- gus, a confiderable portion oS which was thrown into the mouth, by every exertion to vomit; but it Soon retraaed and remained concealed within the pharynx till vomiting or retching was again excited. This 336 Diseases of the Chap. XIL portion of the tumor, which occafionally protruded, was removed by the method to which I allude, and which I have more particularly defcribed in the ex- planation to Plate XXXIV. The patient was in this manner relieved from much inconvenience and dif- trefs ; but another branch of the tumor that extend- ed towards the ftomach, becoming afterwards very large, he died of the effeas of it in about two years from the operation. I think it right to remark, that this patient might probably have been faved by the ufe of the ligature and double canula, fuch as I have defcribed, and that in fimilar cafes it is to be confidered as perhaps the beft means of relief. When a polypus is fuSpected to have formed in the cefophagus, if no part of it is ob- ferved to protrude into the pharynx, there will be much caufe to imagine that it proceeds down towards the ftomach; fo that, if the double of a piece of flex- ible wire be pufhed down the cefophagus, the pendu- lous part of the tumor may be laid hold of in with- drawing it; or, if one attempt fhould fail, other trials may Safely be made with it: and as foon as the dou- ble of the ligature is found to be firmly fixed, all that portion of the tumor which it furrounds may be eafily removed by the application of the double canula, in the manner I have advifed. It is proper, however, to obferve, that the ligature and canula fhould both be carried through one of the noftrils into the cefopha- gus ; for in this manner they will not prove fo trou- blefome as when paffed through the mouth, and they may be applied with equal eafe and advantage. For this purpofe the canula muft have a flight degree of curvature, as is reprefented in Plate XXXI. fig. 2. In a great proportion of cafes, ligatures may be ap- plied round polypi of the back part of the nofe and throat, in the manner I have advifed, and without in- terrupting refpiration ; but when deeply feated in the cefophagus, and on all occafions when the application of the ligature is difficult and tedious, it is proper to SeA. V. Nose and Fauces. 337 fecure an eafy and free refpiration during the Qpera* tion, by previoufly advifing bronchotomy. By tihis no additional rifk is incurred, for it may with eafe and fafety be accompliffied ; and it puts it in our power to finiffi the operation more perfeaiy than we other- wife could do<. It is likewife proper to remark, that although the operation may often be done without any affiStance from a fpeculum oris, yet, whenever it proves tedious, and when the ligature cannot be eafily appli- ed, this inftrument ffiould be employed^ I have now to mention the method of applying a ligature to a polypus feated in the anterior part of the nofe, and which, inftead of paffing back into the pha- rynx, proceeds down one of the noftrils towards the upper lip. Let the double of the ligature be paffed over the moft depending part of the polypus, and be flowly pufhed up to the root of it with the flit probe, Plate XXXIII. fig. 2. The probe being given to an affiftant to preServe the ligature in this fituation, the two ends of it muft be paffed through a double canu- la ; which being inferted into the noftril on the oppo- fite fide of the polypus, and being pufhed eafily along till it reaches the root of it, the ligature muft now be drawn So tight as to make Some impreffion on the root of the tumor, when the ends of it muft be tied to the wings of the inftrument, and daily pulled fomewhat tighter, till the tumor drops oft*. In this manner almoft every polypus in any part of the nofe may be extirpated. Thofe who have not feen it put in praaice, may be apt to doubt of this affer- tion : but a few trials will Shew that it is not only the moft effeaual method, but the fafeft and eafieft that has yet been propoSed for removing polypi of every kind : it alfo has the advantage over every other meth- od of applying ligatures upon polypi in the nofe, of anfwering equally well in the large as in the Smaller kinds of them ; and it may even be applied where the tumor is fo large as to diftend the noftril to a confid« Vov. II. Y 338 Diseases of the Chap. X1L erable fize. In plate XXXIII. fig. i. there is delinea* ted a remarkable form of a polypus extirpated in this manner* under the direaion of Dr. Monro, who was the firft, I muft obferve* who put in praaice this meth- od of removing polypi from the nofe and fauces. This polypus filled the noftril completely; to fuch a de- gree* indeed, that it could not have been removed in any other manner; not even with forceps, for the blades of the inftrument could not have been inferted. Befides this, another method has been propofed of applying ligatures round polypi in the noftrils: by in- troducing a ligature through the noftril in which the tumor is feated, pufhing it back to the throat, and paffing it in fuch a manner, that the doubling may in-l elude the root of the polypus, if the oppofite ends of it be taken out at the mouth, they may be fufficiently twifted, it is alleged, for removing the tumor. In a few caSes this might poffibly anSwer, but it would often fail: I think it right, however, to men- tion it, from its being recommended by a very judi- cious praaitioner, Mr. Chefelden. Figure 2. Plate XXXII. exhibits a reprefentation of a polypus fur- rounded with a ligature in this manner. Various forms of forceps have been invented for the purpoSe of removing polypi. ThoSe that anSwer the intention beft, and now moft generally uSed, are re- presented in Plate XXXV. ThoSe of a Straight form are intended for extraaing polypi by the anterior nares, and the crooked forceps are employed by Some for the removal of thofe excrefcences which pafs into the throat behind the uvula. I have fhewn indeed that polypi of this kind may be more eafily removed with ligatures, but I think it right to delineate fuch forms of forceps as are ufed by thofe who prefer a dif- ferent method. In proceeding to extraa a polypus with forceps,' the patient ought to be firmly feated, with his head leaning back, and fupported by an affiftant behind ; and as it is of much importance, our being able to dif- Sett. V. Nose and Fauces. 539 cover, as nearly as poffible, the origin of the excref- cence, fome advantage may be obtained from the face being placed in fuch a manner that the light of a clear fun may fall into the noftril. In the ordinary method of performing this opera- tion, the furgeon now takes the forceps, fig. 2. Plate XXXV. and inferting one of the blades on each fide of the polypus, he carries them eafily along till he brings their points as near as poffible to the neck of it, when he lays hold of it firmly, and endeavours to ex- traa it entire, either by pulling direaiy downwards, or by moving the forceps from one fide of the noftril to another; or, as Some more properly advife, by turn- ing or twilling the polypus round, till it is completely Separated. By this laft method I think it probable, that the root or attachment of the excrefcence will be more readily loofened than in any other way, at the fame time that that part of the lining membrane of the nofe will not be fo much injured as when the tumor is torn away by being pulled either laterally or in a perpendicular direaion downwards. When a polypus is of a firm texture, if the opera- tion is properly conduaed, we may frequently be able to bring it all away at once : but when Soft and yield- ing, it commonly requires repeated applications of the forceps; and we fhould never defift, as long a$ anv portion of it remains that can with propriety be re- moved. It is proper, however, in this place, to obferve,- that the firft^ application of the forceps is commonly attend- ed with the difcharge of fo much blood, that begin- ners are apt to defift before the operation is nearly fin- ifhed, from their being afraid of fatal confequences from the hemorrhagy ; but this ought not in general to be regarded, as long as, by a farther ufe of the for- ceps, we can extraa any more of the polypus. And even when the operation is finifhed, if the patient ism any degree plethoric, fome advantage may enfue from y 2 $4* Diseases of the Chap. XII. a farther difcharge, by which inffammation may be prevented, which otherwife might produce very trou- blefome confequences. Profofe hemorrhagies from this operation feldom happens; by no means fo fre- quently as thofe are apt to imagine who have not of- ten had occafion to praaife it. I will not pretend to fay that inftances may not occur of more blood being loft by it than is proper; but I can Safely affert, that k is not a common occurrence. When it is found, however, that the hemorrhagy is proceeding too far, we fhould immediately employ thofe means that we know from experience are mofl effeaual in putting a ftop to k; but thefe having already been folly confid- ered in Section III. of this Chapter it is not neceflary to enter upon-them at prefent. As it fometimes happens that part of the roots of polypi are not extraaed by the forceps, we are defired by Some praaitioners to deftroy them, by inferting cauftic or corrofive applications into the noftrils imme- diately after the operation. Unlefs, however, we can evidently obferve the fpot on which the cauftic fhould be applied, I am clearly of opinion that this practice fhould not be adopted ; otherwife we muft work en- tirely at random, and will more probably do harm than good. But when, by expofing the noftril to a clear light, we can bring the Seat of the exe*efce«cg into view, we may with propriety-touch any parts of it that remain with lunar cauftic, properly covered with; a canula, in order to protea the contiguous found parts. An inftrument for this purpofe is reprefented in fig. i. Plate XXXIV. This, however, mould not be attempted on the day of the operation, as is com- monly advifed; for while any difcharge'of blood con- tinues, a clear view of the parts cannot be obtained r but it may with propriety be done on the following day ; and the cauftic fhould be repeated every Second or third day, as long as any remains of the excreScencc are. obServed. Sect. V. Nose and Faucis* 343 When, again, the root of a polypus lies fo deep ■that it cannot be difcovered, if we find, either by the introduaion of a probe, or by the breathing through the noftril not being free, that the excrefcence is not entirely removed by the forceps, although, for the reafons I have mentioned, cauftic fhould not in this fituation be employed, it may be highly proper to de- Uroy it by means of a more harmtefs nature. In this cafe, the praaice I have defcribed, of paffing a feton through the noftril- into the throat, might Sometimess anfwer, but the frequent application of large bougies fucceeds with greater certainty. In one of the follow- ing chapters I fhall have occafion to remark, that in the removal of obftruaions in the urethra, bougies feem to operate chiefly by mechanical preffure ; and there is caufe to imagine, that upon the fame principle they may be employed with advantage for the remov- al of thofe parts of polypus excrefcences in the nof- trils that cannot be taken away with the forceps. Nay more, were we confulted early in the difeafe, before the excrefcences have become large, they might, I think, be fuccefsfully employed in preventing their further increafe; and if duly continued, they might, in fome inftances, in this incipient ftate of the difeafe, remove them entirely. Praaitioners, however, are feldom advifed with, till the difeafe has gone too far fo admit of this. I have only had one opportunity of trying it; but in this cafe, the efteas of it were fuch as to juftify our putting it to the teft of future expe- dience. This was the opinion that I publifhed of this reme- dy feveral years ago, and Since the firft editions of this work were printed, I have had many opportunities of putting it to trial. In all it give9 great relief, by en* abling the patient to breathe more eafily through the nofe, and in fome it has entirely removed the difeafe. It is not, however, the common bougie that I employ, but a piece of bougie plafter rolled up into a flat form, nearly of the breadth and thicknefs of the forefinger of 343 Diseases of the Chap. XII, an adult; and of a length to pafs into the pharynx, while half an inch or thereby remains out of the nof- tril. The plafter fhould be of a firm confiftence ; the bougie perfeaiy Smooth ; and if well covered with oil it may be eafily paffed, even where the excrefcence is So large as to fill a confiderable part of the noftril: the patient is foon able to infert it himfelf, and by do- ing it every night at bedtime, and withdrawing it in the morning, it gives him little trouble in the applica-, tion, while it commonly foon affords relief to the ftate of his breathing. The perfon in whom this mode of treatment was firft employed, had for feveral weeks complained of a kind of ftuffing, and interruption to breathing in one of his, noftrils. On looking into it, I clearly faw and touched with the probe, a fmall, pale coloured, foft polypus, at 3 confiderable depth. As it did not yet produce much inconvenience, I did not think of advif- ing it to be extraaed ; but considering it as a fit cafe for trying the effeas of compreffion, a roll of bougie plafter was paffed into the noftril; and being gradu- ally increafed in fize, the paffage at laft became clear and pervious ; and in the courfe of feven or eight weeks, the excrefcence difappeared almoft entirely ; but the patient was at this time obliged to go abroad, and I hay£ not Since that period heard of him. In the fatter part of the treatment of this cafe, a fil- ver tube covered with plafter was employed; by which the breathing went freely on ; and being of fuch a length as to pafs into the pharynx, it was eafily kept inferted, and was prevented from falling out, or from paffing back to the throat, by a piece of adhefive plaf- ter, connected with it hy means of a ftrong thread being applied acrofs the upper lip. In defcribing the operation of extraaing polypi, I have fuppofed that the forceps in common ufe are to be employed ; and when the excrefcence is fmall, they anfwer the purpofe as well as any other : but when the polypus is So large, as nearly to fill the nof- Sea. v. Nose and Fauces. 343 tril, they cannot be either eafily or properly applied; for the two blades of the forceps being both introdu- ced at once, they cannot but with much difficulty be pufhed deep into the noftril already much obftructed; and the more they are preffed forward upon the ex- crefcence, and the nearer the end of it is brought to the axis of the inftrument, the more widely the blades of it are neceffarily opened at their extremities; by which the tumor cannot be fo equally compreffed, nor is there fuch a chance of extirpating the root of it by means of them, as if they were So conftruaed as to apply preffure equally through their whole length. To remedy theSe inconveniencies, Several improve- ments have been propoSed ; but the beft that I have met with is one by the very ingenious Dr. Richter of Gottingen. A reprefentation of it is given in Plate XXX v. fig. 3. This inftrument may be ufed in the ordinary way, by introducing both blades at once, when the polypus is Small; but when the tumor is large, it anfwers better to introduce the blades Sepa- rately, as is done with midwifery forceps. One of the blades being carried Slowly and cautioufly forward along the courfe of the polypus, the other muft in like manner be introduced at the oppofite fide of it, So that they may now be firmly locked together at the joint. The blades are accordingly made to feparate eafily, and to fix in fuch a manner, as to admit of their being employed in the way that I have men- tioned. Thefe, and every other variety of forceps employed for this operation, ought to be as thin and flender in that part of them which is inferted into the nofe, as the nature of the difeafe will admit; for I muft again obferve, that the ftraitnefs of the part in which the in- ftrument muft move, is one of the principal difficul- ties we have to encounter. But when the forceps are made of well tempered fteel, they need never be fo thick and bulky as they are commonly made. 344 Diseases of the Chap. XII, When, however, polypi have acquired a large fize, the obftruaion they produce in tihe noftril is in fome inftances to fuch a degree, that no forceps can be in- ferted : in fuch circumftances, as a confiderable (pace may be gained by laying t-he Boftril open, it may in fome inftances be proper to divide die cartilaginojus part of it by a longitudinal cut; and, after extraaing the tumor, to reunite the divided parts either by a£ hefive plafters, or with one or more futures. In mentioning this, however, I think it right to ob- ferve, that it is a meafure which ought not in any in- ftance to be haftily adopted ; but I alSo think, thfct it fiiould net be univerSally condemned, as we find it to be by Some practitioners. I do not imagine that it would in every caSe prove fucceirful: but when a po- lypus has already become So large as entirely to fill the noftril; when, therefore, no forceps ca>n be infert- ed for removing it; when the tumor is ftill continu- ing to increafe.; and when of courfe there is much reafon to fufpect, that it may terminate fataUy if it be not extraaed ; it will furely be better to give the pa- tient any fmall chance that may be derived from the praaice I have propofed, than to leave him to die i» mifery, which in all probability he would do were no attempt made for his relef. If, on laying the noftril open, it is found that the tumor can be with fafety removed with forceps, a complete recovery may poffir bly be obtained ; and thus the pain that the patient has Suffered, and the trouble of the operator, will be amply rewarded, whilft no material injury will be done, nor any kind of rifii incurred, if, on laying the parts open, it is unfortunately found that no part of the tumor can with propriety be taken away. In the firm flefiiy kind of polypi, which in Some in- ftanqes degenerate into cancer, whei\ it is found that the tumor is already in a ftate oS ulceration, and that the contiguous cartilages and bones of the noSe are diSeafed, it would no doubt be. imprudent to advife |he treatment I have mentioned, Sor no advantage Bed. V, Nose and Fauces. 345 would probably accrue from it; the patient would be made to fuffer a great deal of unneceffary pain ; and the operation itfelf would be brought into difrepute : but in the fofter kinds of the difeafe, which rarely or never become cancerous, and when the more external bones and cartilages Of the nofe are not affeaed, we ought without hefitation to adopt it, when the tumor, as is here fuppofed to be the cafe, is meant to be re- moved with the forceps, and when this cannot be done in any other manner. In the cafe of a firm fleffiy excrefcence, which fill- ed the noftril fo completely that the forceps could not be introduced for removing it, a method was put in praaice by Dr. Richter for reducing the Size of it ; which to a certain degree anfwered the purpofe* and afforded confiderable relief. A hole or opening was made through the centre of the excrefcence by puffi- ing a common trocar through the whole length of it, after -being made red hot and covered with a canula, By this means a paffage was formed through which the patient breathed eafily, and the tumor was much leflened ; but the Doaor was unfortunately prevent- ed from attempting to complete the cure, either by extraaion or otherwife, by the patient leaving the place. This cafe, however, affords an ufeful praai- cal hint, and points out a mode of treatment, which in tumors of this particular kind, may in fome inftan, ces be Successfully employed.* . I have thus defcribed the method oS extraaing po- lypi of the nofe with forceps ; but I muft again re- mark, that they may be removed both with more eafe and SaSety with ligatures; and as this mode of opera- ting is admiffible in a great proportion of cafes, it feems only to require to be more generally known, to be very univerfally preferred. * For a more particular account of this cafe, and of the forceps nen- tioncd above, vide Augufti Gottlieb Richteri Obfervationum Chirurgica- run faft-iculum fccuaduxjj, Gottingae, 17 "6. 346 Diseases *of the Chap. XII. SECTION VL Of Extirpation of the Tonfils. I^HE amygdalae or tonfils are frequently, even in a natural ftate, fo large as almoft to fill up the paffage from the mouth to the throat. As long, how- ever, as they remain Sound, and are not attacked with mflammation, any inconvenience that they produce is feldom of much importance '• but tonfils of this en- larged fize are very apt to inflame on the patient be- ing much expofed to cold ; and frequent returns of inflammation are often attended with fuch an addition of bulk, as to produce nearly a total obftruaion to the paffage of food, drink, and air. It is this enlarged ftate of the amygdalae that in general is termed a fchirrous ftate of the tonfils; but I think it right to obferve, that the term fchirrous ap- pears here to be very improperly applied; for, excep- ting the circumftance of a firm tumor, every other charaaeriltic of fichirrus is here very commonly want- ing. A real fchirrus is attended with frequent (hoot- ing pains, and it very commonly terminates in cancer: now we know, that pain very feldom occurs in cafes of enlarged tonfils, except from inflammation: while in an inflamed ftate, they are frequently indeed very painful; but as foon as the inflammation fubfides, no more pain is experienced, and they remain perfeaiy eafy and indolent till the patient is again expofed to cold. This, however, is'never the cafe with Swellings of the real fchirrous kind ; for whenever they become painful, they uniformly proceed to turn worfe : and, again, enlarged tonfils are feldom or never known to terminate in cancer. I never knew an inftance of their doing fo; and few praaitioners, I imagine, have met with it. Sed. VL Nose and'•Fauces. 347 Mr. Sharpe, when treating of this fubjea, recom- mends a more frequent extirpation of enlarged, or what he terms fchirrous tonfils, than what has hither- to commonly prevailed ; and he is induced to do, fo, from having obferved that the difeafe never returns, as it too frequently does after the extirpation of fchir- rous tumors in other parts. His words being much in point, I Shall tranfcribe them, ?' AH other tumors of the fchirrous kind, whether of a Scrofulous or can- cerous nature, are fubjea to a relapfe ; the poifon ei- ther remaining in the neighbourhood of the extirpa- ted gland, or at leaft falling on fome other gland of the body. In this cafe, I have never met with one fuch inftance ; and the patient has always been reftor- ed to perfea and fafting health."* Mr. Sharpe has here communicated a very interest- ing faa ; the more valuable, by coming from a man of high reputation, and whofe praaice was very ex- tenfive. By many* however, the truth of his affertion has been doubted, from its being univerfally known that fchirrous tumors frequently return in other parts of the body after being extirpated. It would indeed be furprifing to find the extirpation of fchirrous tonfils prove always fuccefsful when the fame operation often fails when praaifed for fimilar affeaions in other parts. But the explanation I have given, fets it in a more dif- tina point of view. Thefe tumors of the amygdalae,' commonly termed fchirrous tonfils, are not of the true fchirrous nature ; and hence it is, that they never de- generate into cancer, nor return after extirpation ; and this is accordingly a very weighty argument for re- moving them as Soon as they become fo large as to impede either deglutition or refpiration. Till this:, howeyer, takes place to a confiderable degree, no prac- titioner ought to advife this operation ; for, as it is at- tended with a good deal of pain, It ffiould be avoided as long as the fafety of the patient does not require it; * Vide Critical Inquiry, &c. by Samuel Sharpe. Fourth Edition, Sec- tion VII. .34* Discasts of the Chap. X1T. but whenever the tumor becomes fo large as to pro- duce much interruption to the paffage of food and air, we fhould not hefitate to advife it. Different methods have been propofed for removing enlarged tonfils. Some have advifed the repeated ap- plication of the aaual or potential cautery: others recommend excifion with the fcalpel or crooked fcif- fars : and, laftly, it has been propofed to do the oper- ation with ligatures.. Cauftic, however, fhould here be confidered as in- applicable, from the impoffibility of ufing it wkhout injury to the neighbouring parts ; and we are debarr- ed from the ufe of the knife and fciffars by the profufe hemorrhagies that fometimes occur from excifion. Neceffity, therefore, obliges us to employ the ligature ; and with due attention, almoft every tumor may be removed by means of it with which the amygdalae are attacked. In the laft feaion I have given a detail of the beft method of applying ligatures to polypous excrefcences in the throat, and it likewife appears to be the eafieft and beft method oS forming figatures upon tumors of the amygdalae. It ought to be done with pliable fil- ver wire, but catgut of a proper ftrength will likewife anfwer ; and although the double canula to be paffed through the nofe might be of a ftraight form, it will anfwer better if fomewhat crooked,, as in figv 2. Plate £XXI. The double of a ligature, formed of pliable filver wire or catgut, being inferted into one of the noftrils, iHiuft be puffied back till it reaches the throat, when ithe operator, introducing his fingers at the mouth, inufl open the ligature ; and having paffed it over the tumor, it muft now be preffed clofely down to the root oS it. In this fituation, he muft continue to pre- ferve it with his fingers ; while an affiftant having in- ferted the two ends of the ligature into the canula, muft pufh it eafily into the noftril, till the farther end of it is cither feen or fek in the throat; and' the wire $ea. vr. Hue and Fauces. 34$ being now pulled fo tight as to fix it in the fubftance of the tumor, the ends of it hanging out at the other end of the canula muft be tied in the manner pointed out in the laft feaion, to the wings or handle of the inftrument; and the ligature being made tighter from time to time, the fwelling will foon fall off. The more pendulous the tumor is, the more eafily will the ligature be fixed. But however broad the bafe of it may be, it may with little difficulty be done ; for the fwelling is always prominent: fo that when the double of the wire is fairly paffed over, it may ea- fily be puffied down to the bafe with the fingers ; and being preferved in this fituation till pulled fufficiently tight, it will not afterwards be in danger of moving. I have advifed the ligature to be firft carried through the nofe before being put over the tumor. It might be inferted by the mouth ; but in this manner more inconvenience would enfue from the ligature and ca- nula hanging out at the mouth during the cure. This - method, however, may be tried when any difficulty occurs in applying the ligature by paffing it through the nofe. For the moft part we find both tonfils nearly equal- ly enlarged, and in fome cafes the removal of one of them forms a fufficient opening for the paffage of the food ; but when it becomes neceffary to extirpate both, it anfwers better to allow the inflammation and tenfiori induced by the removal of the firft, to fubfide entirely fcefore attempting to remove the other. This mode of applying ligatures upon thefe tumors, is in my opinion the beft; but it may often be done in a different manner. Let a ligature fufficiently ftrong be formed of waxed thread, and carried round the tu- mor either with the fingers or a Split probe, Such as is represented in Plate XXXIII. fig. 2. A noofe is now to be made on it, by which a knot of any degree of tightnefs may be tied, by fixing one end of the thread at the fide of the tumor in the throat, with the inftru- ment, fig. 2. Plate XXXVIII. while the other is firm- 550 Diseases of the Chap. XIL ly drawn with the other hand of the furgeon out of the mouth. This method was firft put in praaice by Mr. Che- felden ; and fince that period by Mr. Sharpe and oth- ers. Where the tumor has a broad bafe, in order to fix the .ligature, a needle with an eye near the point, fuch as is reprefented in Plate XXX VIIL fig. 3, was likewife propofed by Mr. Chefelden. A double liga- ture being put into the eye of the needle, the inftru- ment is pufhed through the centre of the tumor near to its bafe, and the threads being difengaged with a pair of forceps, the needfe is withdrawn. In this manner two ligatures are to be formed, each of them being made to comprehend one half of the tumor by one of the threads being tied above, and the other be- low. The inftrument, fig. 2, of the fame Plate, is likewife neceffary here. Although it is proper to mention* this method of fixing ligatures upon tumors of the tonfils with broad baSes, it will not probably be often employed. The double canula renders it unneceffary, as we can apply, by means of it, fuch a degree of force as will at once fix the ligature in the fubflance of the fwelling : even when the operation was done in a manner that did not admit of the ligature being fo firmly fixed as may be done with the double canula, Mr. Sharpe was of opinion, that Mr. CheSelden's method of performing the operation was unneceffary. His obfervation on this point is, " That he had never in one inftance found it neceffary to employ the double ligature re- commended by Mr. Chefelden."* By whatever method, however, the operation is performed, the tumor will not in every inftance fall off by the firft ligature; in which caSe, another muft be applied, and continued till a cure be obtained. * Vide Mr. Sharpe's Treatlfe on the Operations of Surgery, Chap. xxxiL SeS. VII. Nose and Fauces.' 351 SECTION vn. Of the Extirpation of the Uvula.' THB1 uvula, by frequent attacks of inflammation, as likewiSe from other caufes, becomes in many inftances fo relaxed and elongated, as to excite much diftreSs, not only by impeding deglutition, but by ir- ritating the throat So as to induce cough and retching. Slight degrees of enlargement of this part may in general be removed by the frequent ufe of aftringent gargles, compofed of ftrong infufions of red rofe leaves, Peruvian bark, or oak bark, with a proportion of alum or vitriolic acid; and as long as remedies of this kind anSwer the purpoSe, no others fhould be ad- viSed. But when theSe fail, and when the uvula be- comes fo large as to create much diftrefs, we depend on extirpation alone for a cure. The uvula may be extirpated either with a ligature or by excifion. By the laft, the parts affeaed are quickly removed, and the patient obtains immediate relief; whereas the other is not only flow in its ope- ration, but is applied with difficulty. But by excifion, troublefome hemorrhagies Sometimes occur, while no rifle whatever enfues from ligatures. Some praai- tioners indeed allege that no danger can enfue from any hemorrhagy that takes place from the removal of the uvula by excifion ; but although this may fre- quently happen, yet I know from experience that in- ftances of the contrary fometimes occur, and that large quantities of blood have been loft by this opera- tion. This will moft readily happen where the uvula . is much enlarged, and where of confequence the vef- fels with which it is fupplied are in an enlarged ftate. Where the uvula is merely elongated, there will fel- dom, I imagine, be much rifk in removing it by exci- fion. In this ftate, therefore, of the difeafe, excifion 352 Diseases of the • Chap. Xlf« fhould be preferred ; but when the parts to be re- moved are much increafed in bulk, it anfwers better to do it with ligatures. Different inftruments have been invented for cut- ting oft* the uvula. The one that has been moft fre- quently ufed is reprefented in Plate XXXIX. fig. i, But neither this, nor any other of a Similar form, irk- fwers the purpofe fo well as a curved probe pointed biftoury, fuch as is delineated in figure 3. of the fame Plate. Or the operation may be very eafily done with fciffars of the common form, or with a curve, fuch as is reprefented in Plate XXXVI. fig. 2. When any of thefe inftruments are employed, the mouth being firft fecured with a fpeculum, fuch as is reprefented in Plate XLI. fig* 1, the uvula fhould be laid hold of with fmall forceps, or with a fharp hook, by which it will be more eafily cut" off than if left loofe in its natural pendulous ftate. After the operas tion, if much blood is difcharged, it may be restrain- ed by the ufe of an aftringent gargle ; by the applica- tion of ardent fpirits ; or even by touching the bleed- ing veffel with lunar cauftic. It will Seldom happen, however, that any precaution of this kind is neceffa- ry ; for a moderate flow of blood will never do harm, and more than this will rarely occur where the parts are not much enlarged. When, again, a ligature is to be employed, the mode of fixing it defcribed in the laft feaion may be adopted: it may be done by the double canula paffed through one of the noftrils; or the canula may be introduced at the mouth; or it may be done by the method employed by Mr.-Che-' felden, for applying ligatures upon the tonfils, alfo defcribed in the laft feaion. After paffing the liga- ture round the tumor, which in general will be eafi- eft done with the fingers, a knot may be tied on it in the manner I have there direaed', with the inftrument, fig. 2. Plate XXXVIII. I have likewife thought it right to reprefent another inftrument, hitherto almoft the only one employed Sea. VHL Nose and Fauces. 353 ibr fixing a ligature upon the uvula, Plate XXXI. fig. 3. From the name of the inventor, it has commonly been termed the Ring of Hildanus. The invention is very ingenious; and by means of it a ligature may be firmly applied upon the uvula: but the fame in- tention may be accomplished in a more fimple man- ner, by either of the other methods defcribed above j fo that this will probably be laid afide. section vm. fif Scarifying and Fomenting the Throat. IT frequently happens in inflammation of the amyg- dalae and contiguous parts, that fcarifications be- come neceffary; in the firft place, for leffening the degree of inflammation by inducing a topical difcharge of blood; and afterwards for the difcharge of matter contained in abfceffes, when fuppuration has not been prevented by the means ufually employed for this purpofe. In Plate XL. figs. 1. and 3. I have delineated dif-# ferent forms of inftruments for this purpofe : the wings with which figure 1. is furnifhed, are meant to comprefs the tongue, while the fcarificator is employ- ed in the back part of the mouth. With either of thefe, fcarifications may be made, or abfceffes opened, in any part of the mouth or throat with entire fafety. In the treatment of inflammatory affeaions of thefe parts, we often find it neceffary to recommend fomen- tations ; a remedy which proves alfo ufeful in catar- rhal affeaions of the trachea and lungs. Various methods are propofed for conveying fleams to thefe parts ; but the beft that has yet appeared, and it is likewife the neateft and moft fimple in its conftruc-. Vol. II. Z 354 Diseases of the Nose, &c. Chap. XII. tion, is the inftrument delineated in Plate XL. fig. 2. the invention of Mr. Mudge of Plymouth. By means of it, the throat, trachea, and lungs, may be very ef- effeaually fomented by drawing warm fteams into them, and without any difficulty or inconvenience to the patient, who may lie in bed during the whole operation. This inftrument I confider as fo highly ufeful In the treatment of every cafe of catarrh, that I think every family fhould have it. . Sea. I. Diseases of the Lips. 355 CHAPTER XIII. OF DISEASES OF THE LIPS; SECTION I. Of the Hare Lip. NATURAL deficiencies are not fo frequent in any part of the body as in the lips. Children are often born with fiffures in one of the lips, particu- larly in the upper lip. In fome inftances this is at- tended with a want or real deficiency oS parts ; in others we only meet with a fimple fiffure or divifion; whilft in fome again, there is a double fiffure with an mtermediate portion of the lip between them. Every degree of this affeaion is termed a hare lip, from a refemblance which it is fuppofed to bear to the lip of a hare. For the moft part this fiffure or opening is confin- ed to the lip itfelf: but it often extends back along the whole courfe of the palate, through the velum pendulum and uvula into the throat; and in fome in- ftances the bones of the palate are either altogether or in part wanting, while in others they are only divid- ed or feparated from each other. Every degree of the hare lip gives much deformity, and it fometimes prevents a child from fucking: it is always produaive of fome degree of impediment of fpeech ; and when the divifion extends along the bones of the palate, the patient is much incommoded both in chewing and Swallowing, by the food paffing readily up to the nofe. When in the under lip, which is not often however the cafe, it commonly pre- vents the faliva from being retained. z 2 356 Diseases of the Lips. Chap. XIII. Thefe are all very urgent reafons for an early re- moval of the hare lip being attempted : where it in- terrupts, indeed, the fuckling of the child, the opera- tion muft either be done immediately, or the child muft be fed with a fpoon ; but by praaitioners in general, we are defired at all events to delay the ope- ration to the third, fourth, or fifth year ; left the cry- ing of the child fhould render the means employed for obtaining a cure altogether abortive. This reafon, however, does not appear to be of im- portance ; for till the child arrives at his twelfth or fourteenth year, when we may fuppofe him to be pof- feffed of fufficient fortitude for fubmitting eafily to the operation, the Same objeaion holds equally ftrong : nay, a child of fix or eight years of age is in every refpea more difficult to manage than one of fix, eight or twelve months. I am therefore clearly of opinion, that in a healthy child the operation fhould never be long delayed ; for the more early it is performed, the fooner will all the inconveniencies produced by the difeafe be removed ; and now, after various trials, I find that it may be done even in very early periods of infancy, perhaps in the third or fourth month, with the fame profpea of fuccefs as in any period of fife. I have done it in the third month with very complete fuccefs, but the twelfth or thirteenth anfwers better. Praaitioners all agree in regard to the intention of this operation, which is to cut off the fides of the fif- fure fo as to reduce the whole of it to the ftate of a recent wound, and then to draw them together, and retain them in contaa till they unite. But although the principles on which this praaice refts are univer- sally admitted, authors are of very oppofite opinions in regard to the beft method of carrying it into effea. By fome we are advifed to employ the interrupted fu- ture for retaining the fides of the fiffure: others pre- fer the twifted future : whilft by many. Sutures of eve- ry kind are faid to be improper; and that a cure may be always obtained with adhefive plafters, or banda- Sea. I. Diseases of the Lips. 35? ges; by which means a great deal of pain would no doubt be avoided, which futures are always fore to excite. This is a point of much importance, and therefore merits particular difcuffion ; more efpecially as it has been warmly contefted even by Surgeons of reputa- tion. In the treatment of every diSeafe, our principal ob- jea is to obtain an effeaual cure; but every praai- tioner will allow, that the eafieft mode of effeaing this fhould be preferred. On this principle, much pains have been taken to fhew, that futures are fel- dom neceffary in wounds of any kind, efpecially in the cure of the hare lip ; and in fupport of this opi- nion, various cafes are recited of cures being perform- ed with bandages alone: nay, fome have gone fo far as to affert, that in every inftance of hare lip a cure may be obtained with more certainty with a bandage than by futures; for they allege, that the irritation produced by futures ferves in a great meafure to coun? teraa the very purpofe for which they are employed. After the edges of the fiffures are cut off or rendered raw, the contraaion of the adjoining mufcles is the only difficulty that we have to encounter; and this, we are told, inftead of being removed by futures, is always increafed; while the fame Intention, it is faid, may be accompliffied with no inconvenience whatev- er, by a bandage applied in fuch a manner as to keep the edges of the fore in clofe contaa, which it does by fupporting the contiguous parts fo as to prevent the reaction of the mufcles with which they are conr neaed. That a hare lip may be completely cured with the uniting bandage, or even with ahhefive plafters alone, there is no reafon to doubt; and being attended with lefs pain than the method of cure by Sutures, it ought in every caSe to be preferred, if with equal certainty it could be relied on: but although with much pain and attention, we might in fome inftances be able to 358 Diseases of the Lips. Chap. XIII. accomplifh a cure, with plafters and bandages; yet, from the nature of the remedy, there is caufe to ima- gine that it would frequently fail; for in the cure of the hare lip, if every point of the parts meant to be united be not kept in contaa till complete adhefions take place, our intention is always fruftrated, and nothing afterwards anfwers the purpofe, but a repeti- tion of the operation in all its parts. The edges of the fore muft be again rendered raw, and the patient muft Submit, either to another application of the band- age, or to the ufe of futures; which, if employed at firft, might have faved much trouble both to himfelf and the operator: for it is proper to obferve, that in cafes where the operation is applicable, the method of cure by futures, when rightly conduaed, never fails; at leaft I have never known an inftance of its doing fo. It fometimes happens, indeed, that the deficiency of parts is fo great, as to render it impoffible by any means to keep them in contaa; and if futures are employed in cafes of this kind, they will no doubt fail. This, however, is not the fault of the remedy, but of the operator, in ufing it in an incurable varie- ty of the difeafe. As I have had often occafion to put this operation in praaice, and being at firft prepoffeffed in favour of the method of cure by bandages and plafters, I gave them both a fair trial; and the refult was exaaiy what I have mentioned. I found, that by a proper application of bandages and plafters, a complete cure might in fome inftances be obtained, but that the greateft care and attention could not enfure fuccefs; and finding that difappointments never occur from the ufe of futures, I have now laid every other meth- od afide ; and hitherto I have had no cauSe to regret my having done So. I fhall therefore proceed to de- scribe the operation as it ought to be performed with futures ; and as none of the methods by bandages or futures will ever probably be received into general ufe, it would be confidered as fuperfluous to give an Sea. I. Diseases of the Lips. 359 account of them: and befides, our doing fo here is unneceffary, as the fubjea has already been fully treat- ed of by various authors of reputation, particularly by Monfieur Louis, of Paris, who has given a paper in the 4th Volume of the Memoirs of the Royal Acade- my of Surgery, that contains every argument that has been fuggefted in favour of this method of curing the hare lip with bandages. In proceeding to the operation, the patient, if an adult, fliould be feated oppofite to the light, with his head properly fupported by an affiftant; but if a child, he will be more firmly fecured if laid upon a table, and kept in a proper pofture by an affiftant on each fide. The upper lip fhould now be completely Separated from the gums beneath, by dividing the frenum that conjoins them. This admits of the lip being more equally Stretched ; and when one of the fore-teeth is found oppofite to and projeas into the fiffure, as fome- times happens, it ought to be taken out, otherwife it will irritate and ftretch the parts if allowed to remain. In fome inftances, too, efpecially when the fiffure runs through the bones of the palate, a fmall portion or corner of bone is found to projea from one or both of the angles. This fhould likewife be removed ; and it may be eafily done with pliers or forceps, which fhould be both firm and fharp, as is reprefented Plate XLIIL fig. 2. Thefe preparatory fteps being adjufted, the Surgeon, ftanding on one fide of the patient, muft take one fide of the lip between the thumb and forefinger of his left hand ; and defiling an affiftant to do the fame with the oppofite fide, and to ftretch it fomewhat tight- ly, he ffiould with a fcalpel make an incifion from the under border of the lip up to the fuperior part of it ; in which he muft take care to include, not only all the parts immediately concerned in the fiffure, but ev- en a fmall portion of the contiguous Ibund fivin and parts beneath : and this being done on one fide, a fim- 360 Diseases of the Lips. Chap. XIIL ilar incifion muft be made on the oppofite fide; which ought to be of the Same length with the other, termi- nating in the Same point in the upper part of the lip. By this means, if the operation is rightly done, a piece, including the fiffure completely, will be cut out, of the form of the letter V inverted; and the deficien- cy will in every part of it have the appearance of a re- cent wound. With a view to prevent inflammation, the divided arteries fhould be allowed to difcharge freely; efpe- cially if the patient is plethoric ; and this being done, the furgeon fhould proceed to unite the fides of the fiffure. In this he will be much affifted by defiring the cheeks to be pufhed forward fo as to bring tjie edges of the wound nearly into contaa, although not altogether fo dole as to prevent him from feeing free- ly from one fide of it to the other; the affiftant be- hind being deSIred to Support the parts in this Situation during the remaining fteps of the operation. The furgeon is now to fee that the two fides of the cut correfpond exaaiy with each other; and this be- ing done, the pins intended to fupport them muft be introduced in the manner I have mentioned in defcrib- ing the twifted future, Chap. V. Sea. V. The firft pin ffiould be near to the under edge of the lip: if poffible, indeed, it fhould be placed entirely within the red part of the lip, leaving no more fpace beneath than is merely neceffary to fupport it. In adults, another pin fhould be inferted in the centre of the cut, and a third within a very little of the fuperior angle. By fome we are advifed to ufe a greater number of pins; but even in adults three are always fufficient, and in infants two will very commonly anfwer. In paffing them, they fhould be made to enter nearly half an inch from the edge of the fore ; and being carried nearly through the whole fubftance of the lip, which will be feen by retaining the wound open in the manner I have advifed, they muft be again paifed outward, in a Sea. I. Diseases of the Lips. 361 fimilar direaion, and to an equal diftance on the op- pofite fide of the fiffure. The affiftant fliould now puffi forward the cheeks, and having brought the edges of the fore clofe togeth- er, a firm waxed ligature fhould be applied over the pins in the manner I have formerly mentioned for the twifted future, as will perhaps be better underftood by fig. 3. Plate XLIV. The ligature fhould firft be ap- plied to the under pin, and being made to pafs two or three times round it, fo as to defcribe the figure of 8, it fliould then be carried to the contiguous pin ; and being in a fimilar manner carried round this pin, the operation is finifhed by carrying it to the other ; care being taken in the whole courfe of applying it, to draw it of fuch a tightnefs as may retain the parts in con- taa ; but not fo ftrait as to irritate or inflame them, as is too frequently done. By fome we are defired to uSe a Separate thread Sor every pin, in order, as they Say, to admit oS one pin being removed, if it fhould become neceffary, without difturbing the others. This, however, I have never found to be the cafe ; fo that the precaution is unne- ceffary, while it deprives us of the advantage of paff- ing the ligature diagonally from one pin to another, by which we have it in our power more effeaually to prevent the fides oS the fiffure between the pins from rifing into unequal heights than otherwife could be done. A piece of lint covered with mucilage to retain it, fliould now be put over the cut, with a view to protea it more effeaually from the air; and it ffiould likewife be made to cover the ends of the pins, to prevent them from being entangled with the bedclothes, or other- wife ; and this is all the dreffing or bandage that in general we ought to apply. We are defired indeed by many, after the pins are all fecured with ligatures, to apply the uniting bandage, in order to fupport the mufcles of the cheek, fo as to prevent the pins from cutting or irritating the parts through which they pafs, 362 Diseases of the Lips. Chap. XHI. which they are apt to do, when the deficiency of parts is confiderable. In the courfe of my experience, however, no bene- fit has enfued from this, while in fome inftances it does harm, for a bandage cannot be applied with fuch tightnefs as to give fupport to the mufcles of the cheek without exciting pain in the parts newly divided ; and it alfo proves hurtful, as I have elfewhere obferved, by preffing upon the ends of the pins over which it muft pafs; for even although a flit is made in that part of the bandage which correfponds to the lip, as fome have advifed, preffure upon the pins can fcarcely be avoided : and befides, although a bandage may be ap- plied fufficiently tight at firft, the motion of the jaw commonly loofens it foon, fo as to prevent it from hav- ing any farther effea. When, however, the deficien- cy of parts is great, and the e.dges of the fore are with difficulty brought together, fome advantage may be derived from a proper ufe of adhefive plafters. An oblong piece of leather, fpread either with common glue, or with ftrong mucilage, fuch as is employed in making court plafter, being applied over each cheek, and of a fize fufficient for reaching from the angle of each jaw, to within an inch or thereby of the pins, and each piece of leather having three firm ligatures fixed to that end of it next the pins, one at each cor- ner and another in the middle, the cheeks fiiould now be fupported by an affiftant, when the ligatures ffiould be tied fo as to retain the parts in this fituation; and if care is taken to make the ligatures pafs between the pins, and not immediately over them, little harm will be done them. It mrely happens, however, that this kind of affiftance is needed ; for I have, in almoft ev- ery inftance, found that the pins alone anfwer the purpofe. It is fcarcely neceffary to obferve, that while the pins are in the lip, the patient fhould be fed upon Spoon meat, and be prevented from laughing, crying, and Stretching his mouth in any manner oS way. Sea. I. Diseases of the Lips. 363 The pins having remained in the lip for five or fix days at fartheft, they fliould then be taken out; for I have found by experience, that the parts are by that time united ; and by remaining longer, they are apt to leave marks which do not fo readily dilappear as when they are removed fooner. I have reafon indeed to think, that three days would frequently prove fuf- ficient ; but as I know from experience that the pins may, without detriment, be allowed to remain for five or fix, I think it better not to remove them Sooner. In order to illuftrate what I have Said, Some figures are delineated in Plate XLIV. representing the appear- ance of a hare lip before the operation ; the parts which ought to be removed; the application of the pins ; and the appearance which the parts fhould have when the operation is finifhed. But for a more particular account of thefe, I. muft refer to the explanation of the Plate. What I have hitherto faid relates to the difeafe in Its moft ordinary form. In the cafe of a double hare lip, the operation requires to be performed twice in all its parts; firft in one fiffure, and then in the other; although by fome we are advifed to do them both at the fame time : but this ffiould never be attempted ; for by doing So, we incur the riff: of lofing all the ad- vantages to be derived from the intermediate found parts, and of which I once met with a very diftrefsful inftance. The found part of the lip lying between the two fiffures, was by no means inconfiderable, but being much Stretched with a great number of pins paffed through it, it began to inflame immediately af- ter the operation ; and the inflammation and pain in- creasing, the whole pins were obliged to be removed, and the patient would not afterwards Submit to any Sarther trial. We ought., therefore, firft to complete the cure of one fiffure ; and this being done, we may in the fpace of a few weeks venture with much fafety on the other. 364 Diseases of the Lips. Chap. XIII. In defcribing this operation, I have defired, that al- though the fiffure may not extend the-whole breadth of the lip, yet that the cut fhould pafs up to the up- per part of it; and any perfon accuftomed to this op- eration, will know that the parts may be united much more neatly in this manner, than when the lip is only cut through part of its breadth. By one method of treatment, the parts, when drawn together, are fmooth and equal; but by the other, they are apt to be un- even, and much puckered. Lhave alfo defired that the furgeon fhould take par- ticular care to make the two fides of the cut exaaiy of an equal length ; a point of much importance in this operation, and requiring more attention than it commonly meets with: for it is obvious, if one fide of the wound is longer than the other, that the cica- trix will not be fmooth and even, as it ought to be : by inferting the firft pin at the edge of the lip, this part of it will indeed be properly united, but the reft of it muft be uneven. The moil effeaual preventa- tive of this, is to mark with fmall dots of ink, not on- ly the length of the cut on each fide, but the direaion that it ought to take, by which every chance of going wrong is guarded againft. It is of much importance to have the lip equally and tightly ftretched in making the incifion, otherwife the edges of the fore will be ragged and uneven: this, with proper attention, may be always done ; but with a view to guard againft it as much as poffible, curved forceps may be emploved for laying hold of the lip. Different forms of thefe are delineated in Plate XLII. fig. 2. and 3. They fhould be made fo as to comprefs the lip equally ; and being applied in the direaion in- tended for the incifion, the fcalpel is carried along the fide of them, by which the cut may be made very ex- aa and even. Other forms of this inftrument have been propofed; but thofe that I have delineated are more fimple, and anfwer the purpofe better than any that I have met with. Sea. I. Diseases of the Lips. Z^S By fome we are defired not to employ any inflru- ment of this kind, under an apprehenfion of its irri- tating and bruifing the lip. This fufpicion, however, can have occurred only to thofe by whom it has never been ufed; for when the blades are fmooth and equal, a degree of compreffion may be made with it perfectly fufficient for fixing the lip without creating pain, which I can affert from much experience of its utility. Inftead of making the incifion in this manner, fome defire it to be done by fitting a piece of pafteboard, lead, or tin, to the gums beneath ; and the lip being placed on it, it is divided by cutting down on it with a fcalpel to the fopporting fubftance: the operation may no doubt be done in this manner, but the cut is more eafily made in the manner I have advifed. Till of late, the incifion in this operation was com- monly made with fciffars ; and although they are now very generally laid afide on the fuppofition of their bruifing the lip, yet 1 know that the operation may be very properly done with them. Sciffars fhould not be employed to cut a part of much thicknefs, but the lip is Seldom fo thick as to render it improper to ufe them in this operation. They have of late been ufed in this place by different praaitioners ; and as the point can be determined by experience only, I have likewife employed them. In order to afcertain which of the two modes of operating, that with the fcalpel or fciffars, Should be preferred, I have in different ca- fes made the incifion on one fide with a fcalpel, and on the other with fciffars. The patients commonly fay that the fciffars give leaft pain, probably from their making the cut in lefs time than can be done with the knife ; and, during the cure, that fide of the lip on which the cut is made with fciffars, neither Swells nor inflames more than the other. I do not from this, however, mean to fay, that Sciffars are preferable to the fcalpel; I mention it only to Shew that the com- mon idea entertained of the effea of fciffars is ill founded, and that the operation may be equally well $66 Diseases of the Lips. Chap. XIII. done with both inftruments. Sciffars for this purpofe fhould be very ftrong, and particularly firm at the joint. They fhould alfo be highly polifhed. The fize and form of them reprefented in Plate XLIII. fig, i. has been frequently ufed, and is found to anfwer. When defcribing the twifted Suture in Chapter VI. I gave the preference to gold pins ; and I am clearly of opinion that they are the beft. When of a proper form, fuch as are reprefented in Plate IV. figs. 2. 3. and 4. they pierce the lip with much eafe, without any affiftance from a porteaiguille : but thofe who think that a Sharper and firmer point than can be giv- en to gold will anfwer better, may have fteel points added, as is reprefented in figures 6. 7. and 8. of the fame Plate ; and the fteel points being moveable, they may be removed after the pins are paffed, by which every rifk is avoided of wounding the contiguous parts. By fome praaitioners, flexible needles are employed for this operation ; but they do not anfwer So well as thoSe that are firm, and give fufficient refiftance to the ligatures. In paffing the needles, I have faid that they fhould go nearly through to the oppofite fide of the lip: this merits particular attention, otherwife a fiffure is apt to remain in the inner part of the lip, from which a good deal of trouble may be experienced. And befides, although the difcharge oS blood that Succeeds to this operation is always Stopt immediately on the parts be- ing drawn together by the ligatures if the pins have been properly introduced, yet when not paffed to a fufficient depth, the blood will continue to get out be- hind, and may afterwards be produaive of much dif- treSs. I have Seen an inftance of this, where a very troublefome oozing of blood continued for feveral days after the operation; and an inftance is recorded even of death having enfued from it. In order to prevent the lip from being Stretched by the patient in fpitting, it is the ufual praaice to defire him to Swallow his Sa- liva with the blood that may be discharged Srom the Sea. I. Diseases of the Lips. %6*j fore. In this cafe the patient complied implicitly with the direaions given him; and he having died from the caufe I have mentioned, namely, a great lofs of blood, his ftomach and bowels were found filled with blood that he had fwallowed.* I have thus defcribed all the fteps of the operation for the hare lip ; and it is proper to obferve, that they are equally applicable in the treatment of a fiffure in the lip by whatever caufe it may be formed ; only, in a recent cut, as the edges of it are already raw, all that the furgeon has to do is to infert the pins and ap- ply the ligatures. In wounds where fuppuration has already commenced, there is ufually fome degree of inflammation upon their edges. While this continues ■, it would be improper to draw them together by liga- tures ; but as foon as the inflammation fubfides, we may with fufficient propriety infert the pins and finifli the operation in the manner I have advifed. We are told indeed by many, that this praaice will fucceed only in recent wounds, and that it fliould not be re- commended where matter is already formed : I have often, however, aaed otherwife, and where the edges of a fore have not become callous, they have never failed to unite with equal eafe when covered with pus, as when perfeaiy recent, and covered with blood. In cafes of hare lip accompanied with fiffure in the bones of the palate, after uniting the foft parts in the manner I have pointed out, fome advantage may be derived from a thin plate of gold or filver exaaiy fit- ted to the arch of the palate, being fixed by a piece of fponge Stitched to the convex fide of it, and infert- ed into the fiffure. If the fponge is properly fitted and inferted dry, the moifture which it imbibes from the contiguous parts will for the moft part make it remain fufficiently firm, by which both fpeech and deglutition will be rendered more eafy. In fome ca- fes, however, the form of the fiffure is fuch as to pre- *" Vide Memoires de 1'Academic Royale de Chirurgie, Tom. iv. p. 427. 368 Diseases of the Lips* Chap. XIII. vent the fponge from having any effea. This always happens when the opening is wideft outwardly. For fuch cafes other means have been propofed, efpecially thin plates with gold fprings, made fo as to fix upon the contiguous parts; but no invention of this kind has yet been found to fucceed. SECTION II. Of the Extirpation of Cancerous Lips. THE under lip is more frequently attacked with cancer than any other part of the body ; and as we know of no internal remedy by which the difeafe can be cured, the only means we employ for it is the removal of the difeafed parts. When treating of can- cerous ulcers, in the fifth Chapter of this work, I en- deavoured to fhew, that little dependence can be plac- ed on arfenic or any other of the cauftic applications, that have been So much recommended for this pur- pofe ; and that we are to truft to the fcalpel alone for relief. When a cancerous fore has fpread over any confid- erable part of the lip, and efpecially when the lip is al- together difeafed, all that a furgeon can do is to re- remove the difeafed parts ; to fecure the divided arte- ries with ligatures, when this is found neceffary; and to drefs the fore as a recent wound. In this manner a cancer may be effeaually taken away ; but it gives a very difagreeable appearance, from the under teeth and gums being left uncovered; while the patient can neither retain his faliva, nor Swallow liquids eafi- ly. There is here, however, no alternative; for where the whole lip is taken away, thefe inconvenien- cies muft neceffarily enfue, as there is no pcffibility of drawing the divided parts together. Sea. IL Diseases of the Lips. 369 But when the difeafe has not attacked any confid- erable part of the lip, we may always have it in our power to draw the edges of the cut together, fo as to make them unite with the twifted future in the man- ner defcribed in the laft feaion ; by which we not only prevent deformity, but the patient is equally ca- pable as before the operation, of Swallowing liquids and retaining his Saliva : and befides, this method of treatment, as I have elfewhere remarked, by leaving a fmall extent of cicatrix, feems to have fome effea in preventing a return of the difeafe; at. leaft this has been evidently the cafe with thofe that have fallen un- der my obfervation. . Where the operation has been performed in the ufual way, without drawing the di- vided parts together and uniting them with ligatures, the difeafe has in feveral inftances returned : but, ex- cepting in a very Sew unfavourable cafes, it has never returned where the hare lip method of treatment has been employed. Nay more, this will Sometimes fuc- ceed where the other has failed. A man appeared at our Infirmary here, with a cancer on the under lip. It had been twice removed by extirpation in the ufual way ; but the difeafe returned after each operation al- moft as foon as the fore was healed: the lip being fufficiently full, the hare lip -method of treatment was next put in praaice ; the cure was accompliffied ; and I had an opportunity of knowing, eight years after the operation, that the man remained in good health., without any return of his difeafe. Nor ffiould we be deterred from doing the operation in this manner, by the difeafe being extenfive, if we find that the parts that have been divided can be drawn together and re- tained by the twifted future : and this, I may remark, may be always done where the difeafe does not ren- der It neceffary to remove almoft the whole lip. The parts, forming the lip, ftretch fo considerably, that in general this method of treatment may be advifed, al- though only a third part of the lip may remain. Vol. II. A a 37° Diseases of the Lips. Chap. XIIL With refpea to the method of doing the operation, I muft refer to the laft feaion. In addition to which, I have to obferve, that all the cancerous parts ought in the firft place to be removed, taking care to form the cut in fuch a manner as will moft readily admit of the divided parts being eafily and neatly drawn to- gether. When the difeafe is feated in the lip only, the parts will have nearly the fame appearance after this operation, as after that for the hare lip. But when the cancer extends to the cheek, as is Sometimes the cafe, a longitudinal divifion of the lip will not on- ly be needed, but alfo a tranfverfe cut into the cheek; both to be united by pins and ligatures : an operation which, in different inftances, I have put in praaice with very complete fuccefs. Sea. L Diseases of the Mouth. 37* CHAPTER XIV. Of the diseases of the mouth; SECTION I. Anatomical Remarks. BEFORE proceeding to confider the diSeaSes that are the objea of the prefent chapter, it may be proper to premife a ffiort anatomical defcription of the teeth, gums, and jaws, the parts in which thefe difeafes are chiefly feated. On examining a tooth, we find it divided into three parts; that part of it which lies above the gums, termed the body or corona of the tooth ; the roots or fangs, which the gums, in a ftate of health, cover en- tirely ; and a kind of depreffion between the body and fangs, juft where the gums commonly terminate, which we term the neck of the tooth. The root, as well as the interior part of the corona, is compofed of offeous matter; but it appears to dif- fer from bone by our not being able to throw injec- tions into it: for although we are told that this may be done, there is much reafon to imagine that the opinion is ill founded, from the beft anatomifts hav- ing failed in it.* This offeous part of the teeth being of a foft texture, would foon fuffer and wear away by maftigation: but nature has amply provided againft this inconvenience ; for we find all that part of them lying above the • Vide the Natural Hiftory of the Hunan Teeth, by John Hunter, 277 every fymptom, by making an incifion through the gums direaiy upon the approaching tooth or teeth ; an operation ufually termed Scarification of the gums. A common prejudice prevails againft this operation, from an idea of its doing harm in the event of-a cica- trix being left upon the gums ; which fometimes hap- pens when the tooth is not juft at hand ; for it is fup- pofed that the cicatrix will afterwards be worfe to penetrate than if the gum had not been touched. For this reafon, the operation is feldom or never advifed till the tooth is obferved to have elevated the gum : but in this we are wrong ; for when delayed fo long, almoft all the advantages that might be derived from it are IJ\. I have commonly obferved, that the very worft fymptoms of dentition take place, before the teeth have come this length ; and that they ufually abate on the teeth approaching towards the Surface of the gums, probably from their being rendered more infcnfible by the long continued preffure of the teeth beneath. Whenever there is caufe, therefore, from the fymp- toms, to fufpea that they are owing to this caufe, we Should without hefiration make a free incifion through that part of the gums where the tooth appears to ap- proach ; and if this incifion ffiould afterwards heal, and if the fymptoms fiiould again fupervene, no rifk could occur from the operation being repeated. I have frequently found it neceffary to cut two or three times upon the fame tooth ; but with a view to pre- vent the neceffity of this, I commonly make a crucial incifion down to the depth of the tooth, and I have never found it to do harm. We need never be afraid of hemorrhagy. Indeed the cut feldom bleeds above a few drops, and it commonly heals eafily. The operation may be done with a common lan- cet ; or with a biftoury or fcalpel; the inftruments ufually employed for it: but it cannot be neatly done with any of thefe; and befides, we are in danger, either with a lancet or fcalpel, of hurting the conti- 37§ Diseases cf the Mouth. Chap. XIV. guous parts. The inftrument represented in Plate XXXVI. fig. 4. is not liable to any oS theSe objec- tions ; and being oS a Small fize, it may beentirely concealed in the palm of the hand. The child being fecured by the nurSe, the Surgeon with the fingers of one hand fliould open the mouth; and conduaing the edge of the inftrument with the forefinger of the other, the incifions fliould be finifhed before it is with- drawn, care being taken to make a crucial cut over every tooth that appears to be approaching. The in- cifion, as I have already advifed, ffiould always be carried to the depth of the tooth, fo as to lay it en- tirely bare; and when this is freely done, the efteas that refult from it are often remarkable. I have feen inftances of children being inftantly relieved by it, who previoufly appeared to be in the moft imminent danger. It Sometimes happens, too, as I have already obfervr ed, that difagreeable fymptoms take place from the approach of the fecond fet of teeth. I have known pain produced over the whole jaw, attended with fwelling and inflammation of the gums, cheeks, and contiguous parts, from a Single tooth not getting free- ly out. This happens moft frequently with the den- tes Sapiential; in Some inftances, from the irritation that they produce upon the gums, which in the back part of the jaws are very thick; but in others from their not being room in the jaw to admit them. In the firft cafe, we have it commonly in our power to remove all the fymptoms, by making a free incifion direaiy upon the tooth; but in the other this does hot always prove fufficient, and nothing will frequent- ly anfwer but extraaion of the tooth. When the fymptoms are found to proceed from this caufe, we fhould not hefitate in removing the tooth : for it fel- dom happens that any advantage is gained from de- laying it, while the inflammation induced upon the gums often fpreads to the throat and contiguous parts ; and is thus produaive of much diftrefs, which might Sea. III. Diseases of the Mouth. 379 be eafily prevented. When the throat inflames and Swells, no other remedy will anSwer, while the moft violent degree of inflammation will be removed in the courfe of a ffiort time, by the removal of the tooth. This I have known where the fymptoms had obfti- nately refifted every other means for a great length of time. SECTION III. Of the Derangement of the Teeth. THE fecond fet of teeth frequently appear in a ve- ry irregular manner: fome of them will be ve- ry properly placed, while fome are farther out, and others farther in, than they ought to be. When the derangement is not very remarkable, it feldom meets with much attention; but it often happens, that the deformity is fo confiderable, that artifts are applied to for removing it. It happens moft frequently with the incifores and canine teeth, feldom with any of the molares. Derangements of the teeth may take place from different caufes: from a deficiency of fpace in the jaw, by which they cannot be all admitted in the fame line; from a natural mal-conformation; or from fome of the firft fet remaining firm after the fecond fet have appeared. We often find, that teeth that are out of the line will fall into it without any force being applied to them, on fpace being given them by one or more of thofe in the line being pulled. When it appears, therefore, that the derangement proceeds from any of the firft Set not having dropped, they ought to be re- moved ; for the longer this is delayed, there will be the lefs chance of the irregular teeth falling into their fituation: but when it even proceeds from thofe of 380 Diseases of the Mouth. Chap. XIV. the fecond fet being too large for the fpace they are to fill, we fhould not hefitate in removing fome of them, for no other method will anfwer. When the teeth which occupy the natural circle of the jaw are regular, and have a good appearance, the tooth or teeth that are out of the circle ought to be pulled ; but when either of the contiguous teeth do not fill the place fo properly as thefe would do, or when they- are rough, or otherwife of a disagreeable appearance, it is Sometimes advifable to remove one of thefe that are in the circle, while at the fame time we endeavour to bring the others into it. If this is done before the teeth have been long fixed, and if they are not far dif- tant, they will Sometimes in a gradual manner, as I have already obferved, fall into the vacancy without any afiiftance ; but when this does not happen Soon by an effort of nature alone, we may frequently em- ploy means for promoting it. No attempt, however, of this kind can be made till the body of the derang- ed tooth has paffed freely out from the gums, as till then we cannot with eafe lay hold of it. The ufual method of moving teeth that are out of the range, is to apply a ligature round them, and pull- ing it tighter from time to time, to fix each end of it firmly to the contiguous teeth : or a plate of gold or filver is fitted to the contiguous teeth, and made to fur- round the deranged teeth in fuch a manner, that when firmly preffed down by the oppofite jaw, it aas witlr confiderable force in bringing the teeth nearer together. This laft method, however, proves troublefome to the patient; and the other, while it in Some degree moves the deranged teeth towards the circle, ferves nearly in the fame degree to draw the others out of it : but we 1 v.zy in a different manner apply a ligature for this purpofe with Safety, and it is the beft that I have Seen for the purpofe. Let a thin plate of gold v't a length fufficient to pafs over four of the contiguous teeth, be exactly ntted to the outfide of the two teeth on each fide of the vacancy into which the deranged tooth Sea. III. Diseases of the Mouth. 381 is to be moved. The plate fliould be perforated with feveral fmall holes : on being applied to the teeth, and fixed to them with a bit of waxed thread, let a piece of flexible wire be paffed through two of the holes ; and the doubling of the ligature being carried over the tooth to be moved, the two ends of it fliould be firmly drawn through the holes, and fixed with pliers. Every two or three days the ligature ffiould be made tighter ; and this being continued, almoft every tooth in this fituation may at laft be brought into the circle. It fometimes happens that much deformity is pro- duced by an opening in the anterior part of the jaw, formed either by one or more teeth being accidental- ly driven out, or from there being a natural want of them. When a furgeon is called immediately on a tooth being driven out, he Should inftantly replace it; or if the tooth is broken, or otherwife much injured, he may confult the inclination of the patient with re- fpea to the transplanting of a found one from the mouth of another perfon. But patients feldom com- plain till the injured parts have become inflamed and tumefied, when it is too late to put this method of treatment in praaice. In this fituation we muft wait till the pain and fwelling are removed ; when, if more than one tooth is wanting, the deficiency muft be fupplied with artificial teeth fixed to thofe which remain firm ; but when one tooth only is wanting, we may frequently, in young people, be able to remove the deformity, by paffing a ligature round the two contiguous teeth, fo as by degrees to draw them near- er together. Nature will frequently accompliffi this, in fome degree, of herfelf: but the operation is com- monly flow; and befides, it is feldom done fo com- pletely as when ligatures are employed. By jhis means the bodies of the teeth are equally drawn together;; but when ligatures are not ufed, although the teeth, from want of fupport, will fall nearly together at their points, the opening will commonly remain nearly the fame at their roots. 382 Diseases of the Mouth. Chap. XIV. SECTION IV. Of Gum Boils. THE gums, like all the foft parts of the body, are liable to abfceffes ; but they are more frequent here than in other parts, from the gums being more expofed to caufes that tend to produce them. Ab-. fceffes may in this fituation proceed from cold and from external violence, as well as from every caufe that tends to produce inflammation in other parts ; but for the moft part we may trace them as the con- fequences of toothache : and they arife not only from carious teeth, but from inflammation at the roots of teeth, when perhaps in every other refpea the teeth are perfeaiy found. A gum boil commonly appears after a fit of tooth- ache has continued for fome time. It begins with fome degree of pain, attended with a fmall tumor on the part affeaed. By degrees the cheek Swells ; and this Swelling frequently fpreads over the whole face,- fo as to produce much deformity. On fuppuration taking place, the fmall tumor, which is commonly feated on the outfide of the gums, exaaiy oppofite? to the difeafed tooth, begins to point; and if it be not opened, it generally burfts either through an opening in the fide of the gum, or between the gum and the tooth. A quantity of matter is now commonly dif- charged, by which the patient is in general complete- ly relieved. But as the caufe ftill remains, the dif-v charge likewife continues ; for the difeafe being moft frequently induced by fome affeaion of a tooth, or by a portion of the jaw becoming carious, a difcharge of matter ufually continues, either till the tooth is re- moved, or till the carious part of the jaw has exfoli- ated : or, if the opening happens to cloie, the difeafe is quickly renewed ; the Swelling returns, and again Sea. IV. Diseases of the Mouth. 3^3 goes through all the ftages of inflammation and fup- puration in the manner 1 have juft defcribed. When indeed, the difeafe proceeds merely from inflamma- tion at the root of a tooth, and when the root hap pens not to be denuded of its periofteum, after the matter of the abfcefs is difcharged, the fides of it may collapfe and adhere, and a cure will in this manner take place: but when it arifes either from a carious tooth, or from a carious portion of the jaw, or even when it proceeds from inflammation alone, if the root is laid bare by the matter, the difeafe will recur from time to time, till the tooth or carious part of the jaw is removed ; for thefe will continue to irritate the contiguous parts in the fame manner with extraneous bodies of any other kind. In the cafe of .a Spoiled tooth, we fliould advife it to be immediately removed y but when the difeafe proceeds altogether from inffam- mation at the root of a tooth, before pulling it every method of a more fimple nature fhould be tried ; and the fame means that we employ for the cure of ab- fceffes in other parts, fhould be put in praaice here. When a free opening is formed by the burfting of the abfcefs, we may fometimes be able to dry up the run- ning, by injeaing from time to time lime water, ar- dent fpirits, tinaure of myrrh, or tinaure of Peruvi- an bark properly diluted. But although trials of this kind may be advifable with timid patients, who will not fubmit to other means, we can feldom place much dependence upon them : our fureft praaice is to lay the abfcefs open by an incifion from one end to the other, and to endeavour to heal it from the bottom, by inferting a fmall doffil of lint between the edges of the cut, with a view to open them, till a fufficiency of granulations form beneath. This is the fureft meth- od of obliterating the impofthume ; and when any part of the focket is carious, it will in this manner more readily exfoliate than it would do were it ftill covered with the gums. 3 S4 Diseases of the Mouth. Chap. XIV. I have hitherto been Suppofing that the matter has been colleaed in the Subftance of the gums, or between the gums and the tooth, or perhaps that it Surrounds the Socket of the tooth; but abfceffes in thefe parts are often more deeply feated, when they not only cre- ate more immediate pain and diftrefs, but more fubfe- quent rifk : for when the more folid parts of the j?.w become carious, which they commonly do when the matter of impofthumes gets into contaa with them,, the cure not only proves tedious, but external marks of a difagreeable kind are apt to enfue from them. With a view to obviate this, the ufual praaice of ap- plying warm poultices fhould be avoided ; we fliould rather, by warm fomentations taken into the mouth, and by the application of any warm Stimulating Sub- ftance, Such as a roafted onion, to that part of the gum which appears to be moft affeaed, endeavour to pro- mote the formation of any abfcefs that may point in- to the mouth ; and as foon as matter appears to be formed in it, it ought to be opened without waiting till complete fuppuration has taken place. In the after treatment of the abfcefs, all that we can do is to preferve a free depending orifice for the dif- charge of the matter, by which any farther mifchief Will be prevented, and by which alone we can reason- ably expea a cure ; for even where the difeafe is con- nected with a carious ftate of the jaw, giving a free vent to the matter is perhaps all that art ought to at- tempt. If the conftitution is otherwife found, this,' together with the removal of any of the contiguous teeth that are difeafed, and of fuch parts of the jaw as are carious-, and feparate from the reft, will ultimately effea a cure, if this by any means can be done. But in difeafed habits of body, efpecially in Scrofulous con-' flitutions, this kind of tumor is always of difficult man- agement, and can feldom- indeed be healed till the general difeafe of the-fyftem is removed. Sea. V. Diseases of the Mouth. 3^5 SECTION V. Of Abfceffes in the Antrum Maxillare. MATTER may colfea in the antrum maxillare from various caufes : whatever tends to induce , inflammation on the lining membrane of this cavity may produce them. Hence they may be induced by blows and other injuries done to the cheeks. Inflam- matory affeaions of the membrane of the nofe, and even long continued inflammation of the eyes, by fpreading to the contiguous membrane of the antrum, have often an influence in producing colleaions of this kind ; and much expofure to cold has frequently been traced as the caufe of them. . But their moft fre- quent origin is pain and irritation excited in the jaw- by repeated and violent returns of toothache. From this account of the caufe, the nature of the Symptoms will be readily understood. Indeed, if We make allowance for the nature of the parts in which thefe colleaions are feated, the fymptoms will be found to be nearly fuch as take place from inflammation and abfceffes in other parts of the body. At firft fome degree of pain is felt over the cheek, and this com- monly continues for a confiderable time before any external fwelling is perceived. On a farther contin- uance of the difeafe this pain becomes more fevere, and in fome inftances fpreads to the neighbouring parts, fo as to create uneafinefs in the eye, nofe, and ear; and at laft an extenfive hard Swelling appears over the whole cheek, which Sooner or later points at a particular place, moft Srequently in the centre of the cheek, a litrfe above the roots of the pofterior molares. In fome inftances, indeed, the matter burfts out be- tween the roots oS theSe teeth and the gums, by which the external tumor upon the cheek is prevented from Vol. II. B b 386 Diseases of the Mouth. Chap. XIV; pointing. This, however, does not commonly hap- pen ; and it only takes place, I imagine, when the roots of the teeth penetrate the antrum, by paffing through the palate at the bottom of the focket. For the moft part, too, as Soon as matter is fully formed in the antrum, we find fome of it difcharged by the correfponding noftril when the patient lies upon the oppofite fide with his head low ; and if this frequent- ly happens, it prevents the external fwelling for a con- siderable time from pointing at any particular place, and confequently from burfting, which it would al- ways do if the matter was not difcharged in Some oth- er manner. This difcharge of matter by the dua leading from the antrum to the nofe, does not, indeed, take place in every inftance ; but as I have met with it in feveral cafes, I am not inclined with Mr. Hunter to confider the obliteration of this dua as a frequent caufe of thefe colleaions :* indeed I doubt if it is ever the caufe of them. For the moft part, they may be traced as the effea of one or other of the caufes that I have men- tioned ; particularly of toothache, or of inflammation excited by cold, or in fome other manner. When obftruaions, therefore, happen in this dua, they are rather to be confidered as a confequence of the dif- eafe : more frequently, perhaps, as the effea of the adhefive ftage of inflammation, than as the caufe of the colleaion. A difcharge of matter from one of the noftrils, when it fucceeds to pain and inflammation of the cheek, will for the moft part be found to proceed from an abfcefs in the correfponding antrum maxillare; but we ought to remember that matter may be difcharged from the noftrils from other caufes ; particularly from an in- flamed ftate of the membrana Schneideriar»a ; from an ozeng,^ from affeaions of the frontal finufes ; and * See a^ractical. Treatife on the Difeafes of the Teeth, &c. by John Hunter, F. R.S. &c. p. 44. Sea. V. Diseases of the Mouth. 387 from abfceffes in the lachrymal Sac. In forming our opinion, therefore, every circumftance conneaed with the difcharge, ffiould be taken into confideration, oth- erwife much difappointment may enfue from our treat- ing one difeafe for another. In the treatment of abfceffes of the antrum maxil- lare, nothing will accomplish a cure but our giving a free difcharge to the matter : colleaions of matter, indeed, in this fituation, ffiould be confidered in the Same light with affeaions of a fimilar nature in what- ever part of the body they may be : wherever matter is difcovered, it ought to be difcharged.; and in no inftance is attention to this more neceffary than in ab- fceffes of the antrum maxillare : for if the matter be not difcharged, it will diftend and elevate the bones of the cheek, and at laft render them carious. With a view to prevent this diftreSsful occurrence, an opening ffiould be made into the antrum as foon as we are convinced, from the nature of the Symp- toms, that it contains matter. It may be perforated in two different parts. In that part of it which pro- jeas outwardly over the two great molares ; or one of thefe teeth may be taken out, and an opening made into the antrum, by perforating direaiy upwards in the courfe of one of the fangs. As moft people wifh to avoid the pulling of teeth when not entirely necef- fary, the perforation is commonly made above the roots of the teeth. This lenity, however, proves often hurtful; for in this manner the perforation muft be made in the fide of the antrum, by which a depend- ing opening cannot be given to the matter ; nor can it be obtained in any other way than by making a per- foration in the manner I have mentioned in the direc- tion of one of the roots of the teeth. I have already obferved, that either of the two large molares mav be draw in order to admit of this perfo- ration. When either of them is Spoiled, the diSeaSed tooth fhould be taken out ;• Sor being carious, there BBS 388 Diseases of the Mouth. Chap. XIV. Will be caufe to fufpea that it may have Some fhare in the formation of the difeafe : but when this is not the cafe, we fhould remove the fecond great molaris, or that tooth which lies next to the dens fapientiae; for although the tooth immediately anterior to this is fomewhat more acceffible, the difference in this refpea is inconfiderable ; and the plate of bone that Separates the antrum from the roots of the teeth being thinner in the back part of the jaw than in the anterior part of it, the perforation is accordingly more eafily made in it. On removing one of thefe teeth, matter in Some in- ftances is immediately difcharged from the antrum; owing either to the roots of the teeth having been fi> long as to pafs into this cavity; or, to the matter having corroded the bone that Separates the roots of the teeth from the antrum : in this cafe, if the open- ing is fufficient for giving, a free vent to the matter, the operation will thus be finifhed ; but as it is eafily enlarged; it ought always to be done where there is caufe to doubt that the matter will not be difcharged With freedom ; andywhen no difcharge of matter takes place on pulling the tooth, an opening muft be made into the antrum in the manner I have already advifed,. by pufhing a fharp inftrument into it in the direaion of one of the fangs. A' common trocar is ufually employed for this, and in general the operation may be fufficiently well done with it; but the curved in- ftrument reprefented in Plate XXV. fig. 2. anfwers better. In making the perforation, the patient fliould be feated on the floor oppofite to a clear light, with his head laid back upon the knee of the operator, who may either Stand or fit behind him. The inftrument fhould be withdrawn as foon as it has entered the an- trum, which is eafily known by tlie refiftance being removed from the point of it. The matter will now flow out freely ; and as foon as it is all difcharged, a: fmall wooden plug, exaaiy the fize of the trocar, fhould be introduced into the opening, with a view to 5ea. V. Diseases of the Mouth. 389 prevent, not only the air, but the food in maftication, from getting into the antrum ; and when the plug is properly fitted to the opening, it will remain fufficient- ly firm, while at the fame time there is no rifk of its flipping in, if formed with a knob or head fomewhat iarger than the opening. This plug fhould be removed from time to time, perhaps twice or thrice in the courfe of a day; by which all the matter will be quickly difcharged ; and no more being allowed to colfea, the difpofition to form it will in general be foon removed, and a cure obtained. But in fome inftances, either from much relaxation of the lining membrane of the antrum, or from a tendency in that membrane to inflame, the difcharge of matter does not diminiffi, but continues nearly the fame both in quantity and confiftence long after the operation. In this cafe we may often for- ward the cure by throwing liquids of a moderate de- gree of aftringency Srom time to time into the antrum. A decoaion of bark is commonly employed for this purpofe ; but nothing fhould be ufed that contains the leaft particle of Solid matter, as there is always fome riSk, when liquids not properly filtered are in- jeaed, of depofitions being left in the antrum ; and in different inftances I have feen mifchief enfue from this. I commonly employ a folution of alum, or fac- charum faturni, brandy properly diluted, or lime water. When the. contiguous bones are found, a cure will at laft be accomplished by a continuation of thefe means ; but when any of thefe bones are carious, it will be in vain to expea a cure till the difeafed por- tion either exfoliates, or diffolves and comes away in the matter. By the introduaion of a probe, we may always know whether the bones of the antrum are ca- rious or not; but in general we may reft our judg- ment on this point on the Smell and appearance of the difcharge. When the bones are carious, the matter 390 Diseases of the Mouth. Chap. XIV. is always thin and fetid, and it becomes thicker and lefs offensive as this ftate of the bone diminishes. I have hitherto been fuppofing that the antrum is perforated for the purpofe of giving a difcharge to matter; but the fame operation becomes neceffary for the removal of other caufes. I once met with an in- ftance of a violent blow on the cheek ending in a large colleaion of blood in this cavity ; and worms that form in it can only be removed by this operation. In what manner worms are produced in this Situation, is difficult to determine ; but whenever their prefence is indicated, by fevere pains in the region of the an- trum, not induced by toothache or any other obvious caufe, there can be no rifk in making an opening for extraaing them ; but in this cafe there is no neceffity Sor removing any of the teeth. A perforation made into the antrum* immediately above the roots of the large molares, will anfwer the purpofe fufficiently. We fliould not, however, reft Satisfied merely with extraaing fuch worms as appear at the opening: we fliould injea from time to time fuch liquids into the antrum as will moft probably deftroy any that may remain ; particularly oil, a filtrated Solution of afafce- tida, and perhaps a weak infufion of tobacco : and the perforation fhould be kept open Sor a confidera- ble time, to prevent as much as poffible the rifk of any worms being left. I have mentioned the only two parts in which I think the antrum can with propriety be opened; namely, in the direaion of the roots of the two large molares of the upper jaw ; and immediately above the roots of thofe teeth on the outfide of the jaw. I think it right, however, to obferve, that it has been faid that a perforation may alfo be made into the antrum from the noftril. None will doubt of this being prac- ticable; but we might with perhaps equal propriety, fay, that an opening may be made into it by entering the in- ftrument from the roof of the mouth. Jt is evident, however, that it would not be fo proper to perforate Sea. V. Diseases of the Mcuth* 391 the antrum in either of thefe parts as in thofe that I have mentioned; and therefore I would not have judged it neceffary to notice them here, were it not with a view to give my opinion of this method of making an opening from the noftril; which being propoSed by very refpeaable authority, I think it right that the younger part of the profeffion, for whom this is chiefly intended, ffiould know that there is much caufe to doubt of the propriety of the advice.* By purfuing the means that I have pointed out, all fuch fymptoms as arife from colleaions in the antrum maxillare may be removed : but the antrum is liable to fwellings of a more hazardous nature, and which frequently, do not terminate but in the death of the patient. The tumors to which I allude feem to pro- ceed from an enlargement of the bones of the cheek. No matter is found, in the antrum ; and therefore no advantage is derived from our making an opening in- to it. I have in different inftances, indeed, obferved much mifchief enfue from it: for thofe who are not accuftomed with this branch of praaice, are apt to be milled by the ftate and appearance of the fwellings ; and fufpeaing that they contain matter, they very commonly make perforations into them, which fre- quently aggravate all the fymptoms by occafioning a more rapid increafe of the difeafe. We ffiould there- fore attentively diftinguifh between fwellings oS this kind and real colleaions of matter in the antrum. In the latter, the cheek feldom fwells to any great ex- tent ; and when the difeafe is of long duration, if the matter does not find an opening into the noftril, or along the roots of the teeth, it commonly points to- wards the moft prominent part of the cheek. But when no matter is colleaed, and the difeafe proceeds from a carious ftate of the bones, the fwelling by de- grees arrives at a confiderable fize, but it fpreads * Vide the Natural Hiftory of the Human Teeth, Part II. p. 46, fjrft edition. By John Hunter, F. R. S. &c. 392 Diseases of the Mouth. Chap. XIV. equally over the whole cheek, without pointing at any particular part, excepting in its more advanced ftages, when the Surrounding foft parts become difeafed, mat- ter fometimes forms in them. Till the fkin becomes inflamed, which does not happen till the difeafe has been of long continuance, the Swelling remains per- feaiy colourlefs ; but the moft charaaereftic mark of it is a remarkable degree of elafticity which it ac- quires. The bones yield to preffure ; but they in- ftantly return to their Situation on the finger being re- moved ; and if in this ftate an incifion is made into them, which in different inftances I have known done, they are found to be reduced to a Soft cartilaginous ftate, and in the advanced Plages of the difeafe to a confiftence fomewhat gelatinous. This kind of fwelling is of a nature fo very obfti- nate, that hitherto I have fcarcely known any benefit derived from any remedy that has been employed for it. In a few cafes where it appeared to arife from carious teeth, the removal of the teeth has put a tem- porary ftop to its progrefs. But even this has never produced any permanent benefit; I mean in the dif- eafed ftate of the bones that we are now considering; for the cheek is, like other parts of the body, liable to fwellings of a more harmleSs nature, which yield to the remedies commonly employed for them. But in this no material benefit is derived either from medi- cines or external applications. A long continued gentle courfe of mercury, along with decoaion of mezereon, I have Sometimes know prove ufeful; but neither thefe, nor any other remedy that I have ufed, have ever produced a permanent cure. Sea. VI, Diseases of the Mouth* 393 SECTION VI. Of Excrefcences on the Gums. EXcrescences of different degrees of firmnefs occafionally form on the gums : they are all of a red colour, nearly the fame with the gums them- felves ; but Some of them are foft and fungous, while others are firm, and even of a hard warty nature. In fome, they are painful; but for the -moft part they create no further inconvenience than an impediment in fpeech and maftication. We meet with them in both jaws, but moft frequently in the under jaw, and in the infide of the teeth. In fome inftances they are conneaed to the gums by a fmall neck, but in genr eral they adhere firmly through their whole extent. This kind of excrefcence frequently originates from carious teeth, and in a few inftances from a carious 'ftate of the alveoli; in which cafe the removal of the fpoiled teeth, and the fubfequent exfoliation of the ca- rious part of the jaw, will often accomplifh a cure. Like fungous excrefcences in other parts of the body .arifing from a carious bone beneath, as foon as the difeafed part of the bone is removed, the excrefcence ufually begins to fhrivel, and at laft disappears entire- ly : but when this does not happen, it fhould be re- moved as Soon as it gives pain; and this fhould be the more readily done, as the operation is attended with little or no rifk. An averfion, indeed, generally prevails againft meddling with this kind of tumor, either from an idea of its being cancerous, and that it will probably be rendered more inveterate by an ope- ration ; or from a dread of the hemorrhagy that the operation will induce. I know, however, from expe- rience, that there is no caufe to be afraid of this. I have extirpated many tumors of this kind ; and I ne- 394 Diseases of the Mouth. Chap. XIV. ver knew an inftance of cancer having followed, or of any hemorrhagy of much importance. When the excrefcence is attached to the gums by a narrow neck, it fliould be removed by paffing a lig- ature round it Sufficiently tight for making it fall oft; but when conneaed to the contiguous parts by a broad bafe, we are under the neceffity of taking it away with the fealpeL The aaual and potential cau- tery uSed to be employed, for this ; but as this prac- tice is now laid afide, and never likely to be revived, I do not think it neceffary to Speak of it further. In proceeding to the extirpation of the tumor, the patient fhould be firmly feated oppofite to a clear light, with his head fupported by an affiftant ftanding behind. If he is poffeffed of fufficient refolution, no inftruments will be needed for keeping the mouth open ;' but where we cannot with certainty truft to this, which with children is always the cafe, a fpecu- lum oris becomes requifite. Of this inftrument, we have various forms. Thofe in common ufe are repre- sented in Plate XLI. fig. 2. and 3.; but they occupy too much Space in the mouth to admit of the free ap- plication of other inftruments. To obviate this, 1 fome time ago propofed the one delineated in the fame Plate, fig. 1.; and by experience it is found to an- fwer. A common fcalpel will for the moft part anfwer for diffeaing the tumor away 5 but an operator ffiould always be provided with others, particularly with a curv- ed knife, fuch as is reprefented in Plate XXI. fig. 1. and likewife with crooked fciffars, fuch as are delineated in Plate XXXVI. fig. 1. and 2. ; for in Some cafes the roots of the excrefcence are more eafily feparated with a curved fcalpel and fciffars, than v/ith thofe of a ftraight form. But whatever inftrument is employ- ed, much advantage may be derived from raifing the tumor as much as poffible from the parts beneath with a diffeaing hook ; and for this purpofe a hook Should be ufed with two fangs, fuch as is reprefented in Plate Sea. VII. Diseases cf the Mouth. 395 XXXVII. fig. 3. In the courfe of the operation, care ffiould be taken to remove the difeafe entirely, at the fame time that the incifion fhould not be carried fo deep as to injure the parts beneath, unlefs the tumor is firmly and clofely attached to them; in which cafe, it may not only be proper to remove a portion of the gums, but even to go to the depth of the focket: but as this will incur the rifk of injuring the contiguous teeth by laying their roots bare, it fhould never be done when with any propriety it can be avoided. After the operation, the blood veffels that have been divided ffiould be encouraged to difcharge freely : but when the hemorrhagy proceeds too far, it ffiould be restrained, by the patient being made to take from time to time a mouthful of fpirit of wine or tinaure of myrrh ; or if this does not prove fufficient, the ap- plication of lunar cauftic to the bleeding arteries will commonly fucceed. The fituation of the fore renders the application of dreffings inadmiffible: Sor Some days, however, aSter the operation, the mouth Should be frequently waffl- ed with a warm emollient decoaion ; and afterwards, if a cicatrix does not readily form, the cure may be promoted by the application of lime water, port wine, ^tinaure of rofes, and other astringents. SECTION VII. Of Loofe Teeth. THE teeth ought naturally to continue firm till they become loofe by the ordinary effeas of old age : but they are liable to difeafes which render them loofe, and which even make them drop out at early periods of life ; and as this is often the caufe of much diftrefs and deformity, it becomes frequently an im- portant objea with praaitioners. 39§ Diseases of the Mouth. Chap. XIV. As the teeth may become loofe from various cauf- es, all of which require a different method of treat- ment, I fhall enumerate the moft material, and at the fame time fhall point out thofe means of cure which feem to be beft adapted for each of them. The teeth are frequently loofened by external vio? fence ; by falls and blows; and often by an impro- per ufe of inftruments in pulling the contiguous teeth. Teeth loofened in this manner, can be made fall only by being kept for Some time firmly in their Situ- ation ; which may be done by preffing them as far in- to the focket as they will go, and fixing them with ligatures of Indian weed, catgut, or waxed filk, to the contiguous teeth, and feeding the patient upon fpoon meat till they become firm. In youth, when teeth are loofened by external vior fence, as the Sockets Lt this age are complete, they readily become firm again when kept a due time in their fituation with ligatures : nay, even when force4 entirely out of the Sockets, they will foon become firm, if they are immediately replaced and retained in their fituation. I have in feveral inftances put this method of treatment fuccefsfully in praaice, and no harm can refult from the trial. But in old age, what- ever may be the caufe of teeth becoming loofe, the chance of their ever becoming firm is exceedingly fmall; fo that in advanced periods of life, it ought never perhaps to be advifed. The teeth fometimes become loofe from thick lay- ers of tartar forming over them and paffing between their roots and the gums, and in Some cafes even be- tween their roots and the Sockets. In this cafe, the removal of the caufe, if it has not fubfifled long, will commonly remove the effea. That the operation, however, may prove effeaual, the tartar fhould be completely Scaled off, and it ought to be done early ; for the longer theeth remain loofe, the lefs chance there is of their ever again becoming firm. Sea. VII. Diseases of the Mouth; 391 In Some inftances, they become looSe from the gums having acquired a fpongy foftnefs, and Separat- ing not only at their necks, but often a confiderable way down, from the roots. This is fometimes the effea of a long, continued courfe of mercury ; but it is commonly, although often improperly, fuppofed to proceed from Scurvy : we no doubt meet with it as a fymptom of real Sea Scurvy : but this is a very uncom- mon difeafe at land; while the other, namely, a foft fpongy ftate of the gums, is frequently met with. When, however, it proceeds from a general Scor- butic ftate of the fyftem, nothing but the removal of this will accomplish a cure; but when entirely localy topical remedies are alone to be trufted.. When teeth have remained long loofe, we can never with certain- ty fay that any means we can ufe will render them firm ; but the moft effeaual remedy that hitherto has: been employed, is a frequent Scarification of the gums: both in the outfide and infide of the loofe teeth. The incifions Should be carried deeply into the fubftance of the gums: they fliould be allowed to difcharge freely, and repeated from time to time, as long as any of the teeth remain loofe. \ In this manner, that fpon- gy Slate of the gums that I have defcribed, is often removed, and a difpofition produced in them to ad- here to the inverting membrane of the teeth, by which they often become firm and healthy. With a view to remove this fpongy ftate of the gums, aftringents are commonly prefcribed; but I have feldom known any advantage enfue from them: on the contrary, a frequent ufe of them feems to do' harm, by inducing a difpofition in the gums, that de- prives them for ever of the' power of adhering to the parts beneath : at leaft, I have met with different in- ftances where this was evidently the cafe; in which by a long continued ufe of aftringents, the gums be- came fo hard and firm, that the fcarifications after- wards employed had no eftea in fixing them. They mould not therefore be ufed till adhefion takes place 393 Diseases of the Mouth. Chap. XIV. between the gums and teeth, either by means of fcar- ifications, or in fome other manner; and this being accompliffied, they may be employed with freedom, and even with advantage. The remedies of this clafs that are moft to be trufted, are, tinaures of Peruvian bark, and oak bark, tinaure of myrrh, and a ftrong folution of alum. The mouth fliould be frequently wafhed with cold water, ltrongly impregnated with any of thefe, at the fame time that the patient fhould be defired not to ufe the loofe teeth, till they have for Some time been perfeaiy firm. The teeth Sometimes become loofe by abfceffes forming between their roots and the alveoli; efpecial- ly when the alveoliy from being thus immerfed in matter, at laft become carious: but this having alrea- dy been minutely treated of in the fourth Section of this chapter, when fpeaking of gum boils, I muft now refer to what was then Said upon it. It is Scarcely neceffary to mention the looSening of the teeth that occurs in old age ; for this takes place from a caufe for v/hich there is no remedy : not from the roots of the teeth decaying, or from their being pufhed out of their Sockets, but from a real annihila- tion of the Sockets ; probably in confequence of the offeous matter of which they are compofed being ab- sorbed, while nature having now no ufe for teeth,- does not continue to fupply it. SECTION VIIL Of Cleaning the Teeth. THE teeth are apt to become foul from different caufes, and frequently require the affiftance of a dentift to render them clean. i. They Sometimes lofe their natural healthy colour, and acquire a dufky yellow hue : or they become to Sea. VIIL Diseases of the Mouth. 399 a certain degree black, without any adventitious mat- ter being perceptible on any part of them. 2. At other times they become foul, and give a dif- agreeable putrid taint to the breath, merely from a too long remora of the natural mucus of the mouth. 3. But the moft frequent caufe of foul teeth is a calcareous matter that forms on them, commonly termed the tartar of the teeth, which feems to be a deposition from the faliva, as calculi in the bladder are from the urine. Few people are entirely exempt- ed from this; but Some are much more liable to it than others, infomuch, that I have known different inftances, of the teeth becoming thickly incruftated with it in the courfe of a few weeks after having been completely freed from it. Tartar firft appears in the fore-teeth, and in thofe parts of them that are leaft liable to be rubbed by the tongue or lips. Hence it is firft perceived on the out- fide, in the angles between two of the teeth, near to the junaion of the gums. The ordinary effeas of maftication prevents it in general from fpreading to- wards the points of the teeth : but the difpofition to form it is in Some constitutions fo great, that I have known it proceed from the gums upwards even over the flat furfaces of the grinders ; and in fuch inftan- ces, when not removed, it is apt to fpread over the whole teeth, and to give the appearance of a continu- ed incruftation from one end of the jaw to the other. In fome cafes again, inftead of paffing over the whole, it feems to fix more particularly on one or two of the teeth ; and in fuch inftances, the depofition of this matter goes on fo quickly as to give caufe to fufpea that the whole calcareous matter of the mouth is by fome caufe or other attraaed to this particular point. I have known one or two teeth completely covered with it in the fpace of a few weeks, while none of it formed in any other part of the mouth. In fome thefe partial incruftations are fo large as to disfigure the external appearance of the cheek ; and, by thofe 400 Diseases of the Mouth. Chap. XIV. not accuftomed to this branch of praaice, they are fometimes miftaken for difeafes of a worfe nature : they have even been treated as exoftofes arifing from the jaw bone. While the tartar confifts of a thin Scale only, and as long as it is confined to the external furface of the teeth, and does not prove hurtful to the gums, it fel- dom meets with much attention : but when it forms in any confiderable quantity, it very commonly hurts the gums, by producing flight ulcerations upon thofe parts to which it lies contiguous ; or, it infinuates be- tween the gums and the alveoli, fo as to feparate them to a confiderable depth from each other. In either of thefe events, thofe means Should be employed by which we know that it will be moft effeaually re- moved. . . When the teeth have remained long covered with any kind of extraneous matter, if it has acquired any degree of firmnefs, it cannot be removed but with the help of inftruments. Even a flight diScolouring, al- though not attended with any perceptible covering of an adventitious matter, when of long continuance, can feldom be removed in any other way.; But when Once the teeth are thoroughly Scaled with inftruments,: they may in general be preferved in this ftate by mo* derate friaion with a bruSh. Frequent wafhing with' cold water ; and rubbing every fecond or third morn- ing with burnt bread ; Peruvian bark ; cream of tar- tar ; chalk or any other mild, fubftance in fine pow-' der, will for the moft part keep them clean and white: but this we muft obServe is not univerfally the caSe; for the tendency I have mentioned to foulnefs of the teeth, efpecially to a deposition of tartar, is in Some in- stances fo great, that the* greateft pains and attention does not prevent the renewal of it. This, howevery is not frequent; for it is well known, that due atten- tion to cleanlinefs will very generally prevent every formation of this kind. Sea. VIIL ' Diseases of the Mouth* 4°* I have faid, that when once the teeth have become foul, they cannot be cleaned but with the help of in- ftruments. This is art leaft the beft, as it is the Safeft and fureft method. Rubbing the teeth with acids of a certain ftrength, will indeed render them white ; Sor the tartar and other kinds of matter that adheres to them being Soluble in acids, a frequent ufe of them removes it completely ; and we accordingly find, that acids of one kind or another form the bafis of almoft every wafh that has been advertifed for the teeth. The public, however, fhould be much on their guard againft the ufe of thefe applications; for the teeth themfelves are very apt to be hurt by acids, infomuch that it is perhaps impoffible to employ acids of a fuf- ficient ftrength for diffolving any extraneous matter upon them, that will not at the fame time prove inju- rious to the enamel. Every one knows, that even the mildeft vegetable acid will render the teeth'rough, and fet them on edge: we may therefore fuppofe, that thofe of a ftrong nature, the mineral acids, very com- monly ufed by itinerants for this purpofe, muft prove much more hurtful; and in faa many have loft their teeth entirely by the ufe of them. It is indeed faid by many, that in cleaning the teeth with inftruments, harm is apt to be done, by hurting the enamel. This I believe has in fome inftances hap- pened : but it fliould not be confidered as the fault of the remedy, but of the manner of ufing it. A fharp inftrument may no doubt be fo improperly applied, as to remove the enamel; but this muft always be the fault of the operator : Sor every incruftation to which the teeth are liable may be taken off with Safety, and without hurting the teeth. In Plate LX2HI. inftruments of various forms are reprefented for this operation. Figs. 2. 3. and 4. are the beft, and will anfwer for moft purpofes ; but the others are fometimes neceffary for the removal of fuch parts of the incruftation as form between the teeth. Von. II. C c 402 Diseases of the Mouth. Chap. XIV. They fliould all be moderately fharp, otherwife the operation is done with difficulty; but the edge of none of them fliould be fine, otherwife it will be apt to turn, and even to break, with the force neceffary for fcaling off the tartar. In performing this operation, the patient fhould be placed upon a low feat, with his face oppofite to a clear light, and his head fupported by an affiftant. The furgeon himfelf fhould be feated upon a chair fomewhat higher. It is commonly indeed done while the operator is ftanding ; but I have in different parts of this Work had occafion to remark, that furgeons ought to fit at every operation when it can with pro- priety be done. The furgeon fhould now wrap the forefinger of his left hand in a wet cloth, with which he fhould prefs firmly upon the point of the tooth intended to be firft cleaned, while the back part of the fcaling inftrument will form a point of refiftance for the thumb of the fame hand. In this manner the tooth may be firmly fupported, fo as to prevent every rifk of its being loof- ened by the inftrument. This in every cafe is a ne- ceffary precaution ; more efpecially when any of the teeth are loofe. The fharp edge of the inftrument is now to be in- sinuated beneath the under part of the incruftation, care being taken to avoid the neck of the tooth, oth- erwife, if pufhed down this length, and if much force is employed, the tooth will either be loofened, or per- haps turned entirely out. On being certain that the instrument is properly placed, it muft be puffied with firmnefs from below upwards to the top of the tooth, and repeatedly applied in this direaion till all the in- cruftation is removed ; and one tooth being cleaned, [ill the reft that require it muft be treated in the fame manner. This being done, the teeth fliould all be well rubbed over with a bit of fponge in the form of a brufh, covered with a fine powder prepared of equal parts of cream of tartar and Peruvian bark ; and this Sea. VIIL Diseases of the Mouth. 403 being continued from time to time, further affiftance wHl feldom be required : but if, notwithftanding of this, the teeth fhall again become foul, any new In- cruftation muft be Scaled off in the manner I have mentioned. This is the beft and moft effeaual method of clean- ing the teeth when they .become foul from extraneous matter having formed on them ; but they Sometimes lofe their colour, as I have already obferved, and ac- quire a kind of foulnefs, when no fncruftation is per- ceived on them: even in this caSe, as long as the Sur- face of the teeth remains fmooth and found, moderate friaion with the edge of a fcaling inftrument will fre- quently prove uSeful ; and if the operation is done with caution, no rifk will accrue from it. But when the teeth become black from this caufe, we fometimes find the enamel corroded, or perforated as it were with an infinite number of fmall holes ; and this, I muft obferve, is the worft kind of foulnefs to which they are liable : for it is difficult to remove, and when re- moved, it in general Soon returns, nor does it com- monly ftop till all the teeth which it attacks are de- ftroyed. As this kind of foulnefs cannot always be removed with inftruments, we endeavour to diffolve it with fome chemical preparation. All the mineral acids will do it in the moft effeaual manner ; but for the rea- fons I have given, they ought never to be ufed. I have commonly employed faponaceous, or even pure alka- line applications; by which the teeth may be often rendered perfeaiy clean without any injury being done to them. A ftrong lather of common foap will often anfwer ; and a folution of fait of tartar applied over the teeth with a fmall pencil or brufli, proves in fome inftances equally fuccefsful. When in this maimer the foulnefs is removed, the moft effeaual means for preventing a return of it, is to wafh the teeth frequently with cold water, and to c c 2 404 Diseases of the Mouth. Chap. XIV. rub them from time to time wilh one of the pow-< ders that I have mentioned. I have fometimes, too, thought, that repeated applications of tinaure of Pe- ruvian bark have ferved to prevent it. As this vari- ety, indeed, of foul teeth feems to depend upon fome degree of putrefceney ; for it is evidently attended with a caries or mortified ftate of the difeafed teeth y there is caufe to imagine that antifeptics of every kind would prove ufeful in the method of cure. For the purpofe of applying powders and other ap- plications to the teeth, bruffies of different forms, and various kinds of roots properly prepared, are daily ufed. Lucerne and alkanet roots dried and beat at One end into the form of a brufh, are much employed for it, and they may be ufed both with fafety and ad- vantage for cleaning the interftices between the teeth: but neither thefe, nor any kind of brufh fhould be employed for rubbing the roots of the teeth and up- per parts of trie gum ; for as their points pafs between the gum's and the Sockets,, they are apt to feparate the one from the other, from which much mifchief is apt to enfue. For this reafon, I always employ a piece of fponge fixed in a fmall handle, which may be ufed with entire fafety. SECTION IX. Of Toothache. TOOTHACHE appears to be more unfopporta- ble than any other kind of pain. It renders all who labour under it very unhappy ; and being one of the moft frequent difeafes to which the human body is liable, ft neceffarily becomes a frequent objea of attention. The pain induced by toothache, even when confin- ed to a Single tooth, is often produaive of fevere dif- Sea. IX. Diseases of the Mouth. 405 trefs ; but this is trifling when compared with the confequences that fometimes enfue from it. Inftan- ces, indeed, often occur of the moft robuft conftitu- rjons being, ruined by frequent returns of it. Befides the ufual fymptoms of pain in one or more of the teeth, and of fwelling in the contiguous gums, the cheek frequently fwells to a large fize ; the eye, and even the ear of the affeaed fide, are often attacked with pain and inflammation; and to thefe, feyer, with all its confequences, is apt to fucceed. Thefe fymptoms may be induced by different cauf- es, and by affeaions of the teeth feemingly of oppo- fite natures. 1. They may proceed from the nerve and other parts within the cavity of a tooth being denuded, ei- ther by external violence, or by the enamel falling off as the effea of other difeafes. 2. They may proceed from inflammation, either of the parts within the tooth, or of the membrane that Surrounds the root of it. And, 3. The teeth and contiguous parts of the jaws are often attacked with pain in confequence of what is ufually termed Sympathy ; that is, they often become pained from affeaions of diftant parts, very fevere fits of toothache being fometimes induced by difeafes of the eye, of the ear, and ftomach. I fhall proceed to treat feparately of thefe caufes in the order they are here mentioned. % 1. Of Toothache from the Nerve being laid bare, and of the various Methods of extrading Teeth. Ik whatever manner $ie cavity of a tooth be expof- ed, we find from (daily obfervation, that for the moft part it excites much pain ; and the reaSon is obvious. Nature, as we have already obServed, has provided the teeth with nerves, but at the Same time fne has given them a very complete covering of bone: when this proteaion, therefore, is deftroyed, either by accident 406 Diseases of the Mouth. Chap. XIV. or difeafe, it might a priori be imagined, that thefe parts which were not formed for being expofed, would fuffer various injuries, not merely from the action of food and drink in paffing over them, but from the external air being at all times freely applied to them. But it is not the mere expofure of a nerve, or the violence employed in laying it bare, that produces pain ; it is the confequence of this expofure, the ef- feas that refult from it, from which all the enfuing diftreSs originates : of this every praaitioner muft have met with frequent inftances. Thus I have often known the cavity of a tooth laid open by the enamel being broken by a fall or a blow, and no inconveni- ence enfue but a flight degree of pain ; and it fre- quently happens, that the enamel breaks off, and the reit of the teeth moulder away without any pain be- ing produced : it is therefore evident, that expofure of the nerve alone is not the ultimate caufe of tooth- ache. It is a certain degree of irritability induced by this expofure that appears to be the caufe of it; and to this our views fliould be direaed in the method of cure. This irritable ftate of the nerve may be induced by various caufes, and more efpecially by faccharine, acid, and other Stimulating fubftances contained in food, being frequently applied to it ; by the too fre- quent ufe of toothpicks, which may often be traced as the origin of toothache ; and by much expofure to a flream of cold air. Expofure to cold, particularly in a damp ftate of the air, often terminates in toothache by inducing inflammation ; but it frequently excites very fevere degrees of pain in teeth already deprived of part of their enamel, when no other fymptom of inflammation is difcovered. Thefe are the moft common caufes of toothache when the nerve of a tooth has previoufly been laid bare ; and in fuch circumftances their mode of ope- rating may be eafily explained ; but we cannot So ea- fily fuggeft a reaSon Sor this ftate of a tooth being Such Sea. IX. Diseases of the Mouth. 40 7 a frequent occurrence, nor does k appear in what manner it is for the moft part produced. The enam- el is fometimes broken by falls and blows, and it fre- quently Suffers by attempts to break nuts and other hard Subftances with the teeth : in Such caSes the cauSe is obvious; Sor we know by daily observation, that the offeous part of a tooth very Soon becomes carious, and waftes away on the enamel being deftroyed. But how do we account for the mofl frequent of all cauf- es of toothache, the decay or wafting of the enamel by rottennefs, when no evident external violence has been done to it ? It has been alleged, that we may of- ten trace it to a too free ufe of acids, and by^fome it is faid that it depends moft frequently upon a want of cleanlinefs in not wafhing or otherwife clearing the mouth of putrefcent particles after meals. Particles of food in a ftate of putrefcency, by refting upon the teeth, are SuppoSed" to be capable of communicating fome degree of their own nature to the enamel; and putrefcency being produced even in a Single point, the contiguous parts, it is SuppoSed, will become difeafed, from the fame caufe that mortification fpreads in oth- er parts of the body. I will readily admit that a frequent application of acids, even of the mildeft kind, will prove hurtful to the enamel; and therefore that they fhould be avoid- ed ; while it is equally clear, that the mouth fhould be regularly wafhed after meals, not only for prevent- ing that kind of incruftation upon the teeth that we have already confidered, but for preferving a fweetnefs of breath : it does not, however, appear, that the dif- eafe we are now considering, fpoiled or carious teeth, depends upon either of thefe caufes. Were it to orig- inate from the too free ufe of acids, it ought to affect all the teeth equally, whereas it begins almoft in eve- ry inftance in a fmall point, or fpot, which, in gener- al, extends much more flowly than it probably would do if the difeafe was produced in this manner. And again, with refpea to the effea of any putrefcent par? 408 Diseases of the Mouth. Chap. XIV. tides lodging upon the teeth, it is not hkely that this difeafe can be ever induced by them. A piece of meat remaining in the mouth from one meal to anoth- er, may acquire fome degree of fetor ; but it cannot probably in that ffiort period become fo highly putrid as to deftroy the living principle in thofe parts, with which it comes in contaa. It is a point, however, which may be eafily determined by experiment ; and from the refult of Some trials that I made for this pur- pofe, there is reafon to fuppofe that the common opin- ion with refpea to it is ill founded. A tooth newly pulled was put into the centre of a piece of putrid beef, and after remaining in it for eight days, it-was as free from putrefaaion, as when firft put into it, neither the enamel nor internal parts of the tooth being in any degree injured ; and the experiment being repeated with teeth that had been pulled for a considerable time, the reSult was exaaiy fimilar. Now, if this hap- pens with teeth entirely dead, even when totally im- merfed in highly putrid matter, we may fairly con- clude, that a partial application of putrefcent particles to teeth ftill enjoying life and conneaed with the reft of the body, will not be apt to hurt them : for we know, that in other parts of the body, the vital prin- ciple has a confiderable effea in refifting putrefaaion; and there is no reafon to doubt of the teeth being en- dowed with the fame power of felf-prefervation. But, befides this general argument in fupport of the opin- ion, I may remark, that if the common idea on this point was well founded, thofe parts of the teeth ffiould be moft liable to corruption where particles of food are molt apt to lodge ; while, on the contrary, thofe parts of them that are not expofed to this, fhould fel- dom fuffer. Now, every praaitioner knows that this is by no means the cafe ; for it muft be acknowledged, that one part of a tooth is juft as apt to become cari- ous as another. The moft likely part for food to reft in is between two teeth ; and we allow that the teeth fometimes fpoil in thefe parts, but by no means ni°re Sea. IX. Diseases of the 'Mouth. 4°9 frequently than in other parts not fo much expofed to tfcis inconvenience. It does not appear, therefore, that the caufes which have been ufually imagined to be moft produaive of carious teeth have much effea, nor do we know cf any incidental occurrence from which, in particular, they can be fuppofed to proceed : from all the obfer- vation that I have been able to make, they feem rath- er to proceed from fome general conftitutional caufe ; from fome tendency in the fyftem to produce a waft- ing or decay of this particular part. The caufe of this again I fhall not pretend to explain; but I think it perhaps equally probable, that this mortification of the teeth depends upon fome general afteaion of the SyS- tem, as that pain in gout originates Srom general cauSe or diSpofition: inftances no doubt occur, of teeth be- coming carious evidently from fome particular occa- sional caufe, and efpecially Srom. the enamel being in- jured by external violence : this, however, is not Sre- quent : it is rarely indeed met with when compared with the Srequency of carious teeth ; a diSeaSe which in moft inftances begins without any evident caufe, and which in general has Subfifted for fome time be- fore being noticed. But allowing that the opinion I have offered upon this point were admitted, it may be afked, to what purpofe will it tend ? Will it fuggeft any difference in the treatment of the difeafe ? I think it will. As the pain in toothache creates much impatience, and is with difficulty fupported, if the pained tooth is carious, it is in general not only .the defire of the patient, but the earneft advice of praaitioners, to have it extraaed, as being the moft certain means of obtaining relief. In violent degrees of toothache, when the other remedies ufually employed do not fucceed, extraaion of the dif- eafed toot 11 ought certainly to be advifed ; and in fuch circumftances no perfon can be more clearly of this opinion than I am ; but I am equally clear, that, in cemmon praaice, this is carried too far, and that teeth 4io Diseases of the Mouth. Chap. XIV. are daily pulled which ought not to .be touched. , In moft inftances, the pain is no doubt removed immedi- ately on the diSeaSed tooth being removed; but it. commonly happens, that relief obtained in this man- ner proves only temporary, and that the caries foon fixes upon Some other tooth, which foon becomes as much difeafed as the firft ; and this being likewife re- moved, the difeafe is apt to proceed from one to anoth- er, till fcarcely any are left. Of this I have met with many inftances, where almoft the whole teeth have been fucceffively taken out, one becoming carious foon after another was removed. Nor is there eyen at laft any advantage gained by the praaice; for, after all the teeth are taken out, the pain often remains equally Severe in the jaw itfelf. The frequent occurrence of this tends much to ef- tablifli the opinion of carious teeth being often a con- stitutional difeafe ; and it likewife fuggefts the propri- ety of extraaing teeth lefs frequently than is common- ly advifed. As we can never at firft be certain wheth- er toothache depends on a general caufe or not, it is perhaps right in every cafe to extraa the firft, and ev- en the fecond tooth that becomes difeafed, as foon as the fits become frequent and fevere: but whenever the difpofition is fo ftrongiy fixed in the fyftem, that a third or a fourth foon become difeafed, the patient fhould be advifed rather to fubmit to a good deal of diftrefs than to extraa any more ; and it often hap- pens, when he has reSolution to Submit to one fit of the toothache, and to wait till it is completely over, that he never afterwards, in this tooth at leaft, feels any return of it. Cafes no doubt occur in which this does not happen ; but it happens often enough to warrant the propriety of giving it a fair trial in perhaps every inftance : even where it fails, no harm is done by the trial; and when it fucceeds, the advantage gained by it is great. For a confiderable time I adop- ted the common praaice on this point in its full ex- tent : every carious tooth attended with pain I advifed Scft. IX. Diseases of the Mouth. 411 to be pulled ; but finding in general that no advantage was derived from it, the refult being for the moft part nearly as I have already deScribed, I was hence induc- ed to depart from it; and now, after a patient has had a tooth or two extraaed, if the difeafe ftill continues to return, I never advife the praaice to be pufhed farther, unlefs when the pain is fo fevere as to be un- Supportable, which, however, is not often the caSe. By avoiding expoSure to cold during the fit, and by exhibiting doSes oS laudanum proportioned to the de- gree oS pain, the diftreSs produced by it is at laft in general removed; and by due attention to cleanlineSs, particularly by frequently wafhing the mouth with cold water, and, when praaicable, by ftuffing the opening in the carious tooth fo as to prevent the ac- cefs of air, many have been faved, not only from the pain and diftrefs of pulling teeth that became firft af- feaed, but of lofing others, which probably would have become carious if the common praaice had been followed of extraaing all difeafed teeth as foon as they become painful,. Having thus endeavoured to ffiow that carious teeth are moft frequently produced by fome general confti- tutional caufe, I ihall now proceed to confider more particularly the means to be employed, not only for preventing, but for removing toothache depending upon this caufe, In cafes of carious teeth, it is the prevailing prac- tice to remove the black or mortified fpot with a file, in order to prevent k from fpreading ; but, fo far as my obfervation goes, the practice ought not to be fol- lowed ; for the difeafed part of a tooth can never be removed without expofing thofe parts that remain to a more free accefs of air than that to which they were previoufly liable; and therefore inftead oS proving uSeful, I have almoft univerfally feen it do harm. In many, I have known it induce pain where none exist- ed before ; and inftead of preferring teeth, it frequent- ly feems to have the effect of rendering the remain? 4<2 Diseases of the Mouth. Chap. XIV. ing found parts of teeth fooner carious than they might have become if they had not been touched. I therefore do not hefitate to fay, that this praaice of filing fhould be exploded ; and whoever confiders the neceffary effea of it, will probably be of the fame opi- nion. It is evident that the part of a- tooth already carious cannot be fenfible of pain. For what purpofe, therefore, fhould it be removed ? while it remains, it ferves in fome degree to cover and protea the found parts beneath; while by taking it off, they are left perfeaiy bare, and apt to be hurt by whatever is tak- en into the mouth. When, again, as much of the enamel is removed, dther by caries or external violence, as to form a ca- vity in a tooth, we have it frequently in our power tq prevent the acceffion of toothache, by ftuffing or flopping up the opening, fo as to prevent the air and particles of food from getting accefs to the nerve., Different fob fiances are employed for this : fuch as gum lac, maftich, olibanum, beeswax, fealingwax, tin, lead, and gold. When the opening made by the dif. eaSe is large, and eSpecially when narrow at the bot- tom, and wider outwardly, maftich and gum lac, or even beeswax, will Sometimes anSwer, when none of the harder fubftances will remain in the cavity: but all of thefe being foft or friable, they are quickly rub- bed down in maftication, and require to be Srequently renewed; fo that Some of the metals are preferable when the form of the opening admits of their being employed, which is always the cafe when the tooth is much Scooped out inwardly, with a fmall hole leading into it. Gold leaf is fometimes ufed; but nothing anfwers fo well as common tinfoil. As much of it fhould be cut off as will probably be needed; and one end of it being pufhed into the hollow of the tooth with the inftr. orients, fig. 6. 7. or 8. Plate XLV. the reft of it fhould be gradually preffed in till the ca- vity is filled ; and this being done, any portion oS the tin that remains fhould be cut off, and the Surface of Sea. IX- Diseases of the Mouth. 413 the whole made fmooth by frequent rubbing, with the burniffier, fig. 9. of the fame Plate. But before any attempt is made for flopping a tooth, the nerve fhould be rendered quite infenfible ; Sor till this is done, the patient will not be able to bear the preffure which fixing the tin requires. In general the nerve becomes Sufficiently callous, merely by delay : but when this does not anSwer, we may oSten effea our intention by inSerting daily into the cavity of the tooth a few drops of oil of origanum, thyme, or any other effential oil; by which any flight degree of irritability in the nerve is often removed, So as to admit of preffure being ap- plied to it v/ith freedom. I have already obferved, that neither tin, lead, fior any hard fubftance, will remain in the hollow of a' tooth unlefs the opening into it is narrow. It has however been propofed, when the opening is of a dif- ferent form, and when the ftuffing cannot be fixed in any other manner, to do it by drilling a fmall hole through the fides of the tooth ; fo that when the lead is preffed down, it may be retained by paffing a peg of filver, gold or any other metal, from one fide of the tooth to the other. In a few cafes this mav Sue- ceed ; but it will not anSwer either where the opening is wide outwardly, or where the fides of the tooth are not firm, as in Such circumftances is often the cafe ; for where the external opening is wide, even a peg paffed through the centre of the ftuffing will not keep it fufficiently firm to prevent fome parts of the *food from finding accefs to the parts beneath ; and, when the remaining part of the tooth is thin and brittle, it will be apt to break in making the hole. When, however, by any of the means that I have mentioned, the hollow of a tooth can be properly ftopped, it will not only prove the moft effeaual me- thod of preventing frequent returns of toothache, but will liave fome influence in preferring the remaining part of the tooth. I have known various inftances-of this where carious teeth have been preferved for a 414 Diseases of the Mouth. Chap.'XIV, great number of years, without being produaive eith- er of pain or any other inconvenience; but this re- quires the cavity to be completely ftopped, So as to prevent either food, drink, or even air, from finding* accefs. When a perfon with carious teeth has been liable to frequent fits of toothache, befides ftuffing the hol- low teeth in the manner I have mentioned, he fliould attentively avoid expoSure to cold * his head fhould be kept warm with flannel' coverings through the night; and he fliould live in a dry fituation. Indeed, a moift atmoSphere proves So deftruaive to the teeth, that people living in wet fituations find it exceedingly difficult to preferve them ; and I have known various inftances of frequent returns of toothache being pre- vented entirely, by the removal of the patient from a' damp to a dry fituation: nay this will fometimes fuc- ceed when every other means have failed. By due attention to thefe means, much may be done in preventing people with carious teeth from fuf- fering fo much as they otherwife would do : but, not- withstanding of all our endeavours, teeth in this fitua- tion are* very apt to become painful, and are often produaive of much miSery; So that the moft effeau- al method of leffening or removing this is often a ve- ry important objea. Some varieties of toothache may be removed by* remedies applied to other parts of the body. Thus when pain occurs in a tooth, as k fometimes does, from inflammation firft beginning in the ear, it may be more effeaually removed by applying a blifter be- hind the ear than by anv other means : or when a foulnefs of the ftomach is the caufe of it, an emetic proves the moft effeaual remedy. This I Shall after- wards confider more particularly; but when tooth- ache proceeds from the nerve of a tooth being laid bare, If will feldom happen that any remedy will an- fwer that is not applied direaiy to the part itfelf. Bark, efearicity, and a variety of noftrums, are fre- Sea. IX. Diseases of the Mouth. 415 quently employed; but in this variety of toothache, the only remedies that I have ever known prove ufe- ful, are, anodynes, corrofive applications, and extrac- tion of the tooth. In flight degrees of toothache, the pain is Some- times relieved, or even altogether removed, by apply- ing either opium or laudanum direaiy to the bare nerve : I have known camphor too prove ufeful, both by itfelf and when conjoined with opium ; and it fome- times anfwers in a liquid form, diffolved in fpirit of wine, when it does not fucceed in any other way : aether may be likewife mentioned as a remedy in toothache; but as thefe and other applications of a milder nature do not commonly fucceed, we are for the moft part obliged to employ others of a more ac- tive kind, with a view to deftroy the nerve entirely. A long continued ufe of any of the ftrong effential oils will in Some caSes, as I have already obServed, render the nerve callous or Somewhat inSenfible, but they never deftroy it So entirely, as to prevent the rifk of future returns of toothache. This, however, mav be done by remedies of a diflerent kind ; by fpirit of vitriol or any other concentrated mineral acid ; by in- ferting a bit of lunar cauftic into the cavity of the tooth ; or by burning the nerve with the aaual cau- tery. But, in ufing either the lunar cauftic or any of the ftrong acids, much attention is neceffary to pre- vent the contiguous parts from being hurt; for if not inferted with much caution, they are apt to fpread and do much harm : the actual cautery may, how- ever, be employed without rifk : but that it may prove effeaual, the hot iron muft be puffied farther into the hollow of the tooth than patients in general will al- low ; for if the nerve be not deftroyed to the very extremity of the root, no advantage will be gained ; and this being both tedious and painful, we meet with few that agree to it; but when properly applied, we have it in in our power entirely to deftroy the nerve : It may be done with a piece of fmall wire made Sharp 416 Diseases of the Mouth. Chap. XIV. at the point, or with tlie inftrument reprefented in Plate XLV. fig. 8. It often happens, however, that none of thefe rem- edies anfwer, either from their not being duly applied, or from praaitioners not puffiing them fo far as they ought to do. In this cafe, when the pain continues violent, we are under the neceffity of destroying the nerve in a different manner, namely, by the extrac- tion of the tooth ; and this being done, if the tooth is not much fpoiled, and if it be not broken in the operation, after the focket is cleared of blood, it may be replaced in the manner I Shall afterwards mention when treating of the method of tranfplanting teeth. This will not always fucceed, efpecially in the molares ; but in the back part of the mouth it is not fo neceffa- ry as when the incifores or canine teeth are taken out, when it often anfwers. And when a tooth thus re- placed becomes firm, it proves equally ufeful as be- fore ; while, from the total destruction of the nerve, it is not afterwards apt to produce pain. I fhall now proceed to confider the method of extraaing teeth. r The pulling of teeth being a frequent operation, much pains has been taken to perform it with as much Cafe as poffible ; and although it ftill neceffarily gives pain, it is now done both with more eafe and fafety than it could poffibly be in former times, while the instruments employed for it were rude and imperfea. It is evident that a tooth may be pulled in different direaions : it may either be pulled in a perpendicular direaion with refpea to its roots ; or it may be made to turn upon its axis, by depreffing the corona or up- per part of it, by which the point of the root will be proportionally raifed; or a fufficient degree of force may be applied for pufliing it out of the focket in a lateral direaion. If thefe methods of operating were all equally prac- ticable, we would not hefitate to fix the preference : in raifing a tooth perpendicularly, much lefs violence muft be done to the contiguous narts than by forcing Sea. IX. Diseases of the Mouth. 417 it out in a lateral direaion: for as the roots of the teeth are all firmly fixed in bone, they cannot poffibly be preffed out laterally, but with fuch a force as is fufficient Sor breaking or burfting open that part of the alveolar procefs of the jaw bone with which they are furrounded; and as this muft produce both lace- ration and contufion of the gums, it is neceffarily pro- duaive of much pain: but as all the fpace we can obtain, even by the greateft wideneSs of the mouth, will not admit proper inftruments for moving the teeth in the back part of the mouth in a perpendicu- lar direaion, we are for the moft part under the ne- ceffity of ufing fuch as move them laterally. All the incifores and canine teeth may indeed be taken out in a perpendicular direaion, and even Some of the molares, when they are loofe ; but when the molares are firmly fixed, no inftruments with which we are acquainted will pull them in this manner. Various propoSals have been made for this purpofe; but al* though hitherto every attempt has failed, fome farther trials may perhaps render our inftruments fufficiently perfea for effeaing it. The only inftruments of which praaitioners in for- mer times were poffeffed for the extraaion of teeth, were different kinds of forceps or tenets, named ac- cording to their form, hawks bills, cranes bills, &c. and different kinds of levers, both ftraight and crook- ed. Thefe, however, were rudely conftruaed, and it was with much difficulty that teeth firmly fixed were moved by them. In procefs of time, therefore, vari- ous improvements were propofed on them; but few of thefe being of much importance, it is not neceffary either to defcribe them, or to give delineations of them ; efpecially as they may be feen in the works of Garengeot, Scultetus, Hildanus, and other writers of the 17th and preceding centuries. All that I mean to do, is to delineate thofe inftruments that are approved of by modern praaitioners of reputation ; to propofe Vol. II. I) d 4i8 Diseases of the Mouth. Chap. XIV; fuch improvements upon thefe as by experience have been found to prove ufeful; and to give a detail of ' the method of ufing them. For a long time paft, an inftrument termed a key has been almoft the only one employed in Britain Sor extraaing firm teeth, and it is now very generally uf- ed in different parts of the continent. Different forms of it are delineated in Plates XLVI. and LV. In operating with this inftrument, if the tooth to be taken out is in the under jaw, the patient fhould be feated in a chair, while his head fhould be fupport- ed by an affiftant behind; but if in the upper jaw, he fliould be feated upon a pillow, with his head turned back, and fupported upon the knees of the operator, who in this eafe muft ftand or fit behind him, wheth- er the tooth be in the right or left fide of the jaw: but when a tooth is to be extraaed from the under jaw, if it is on the right fide, the operator fhould be placed Somewhat to the leSt; and, vice versa when the tooth is on the leSt fide, the Surgeon fhould place him- felf fomewhat to the oppofite fide. That the instru- ment may be applied with as much freedom as pofli- be, as well as to prevent the gums from being lacera- ted, all the foft parts adhering to the teeth fhould be feparated, by insinuating between them the point of the fcarificator, fig. i. Plate XXXVII.; and this being done, the operator muft proceed to the application and uSe of the key. The patient having cleared his mouth of blood pro- duced by feparating the gums from the tooth, the point of the claw, Plate XLVI. fig. i. muft be preffed as far down between the gum and root of the tooth as poffible; and in this fituation it muft be firmly fixed and retainedwith the forefinger of the left hand, while the fulcrum C, being placed as far down as it will go upon the gums on the oppofite fide of the tooth, the operator muft now with his right hand apply fuch force as may be fufficient to move it; and by turning the handle firmly round, almoft any tooth may be taken Sea* IX. Diseases of the Mouth.' 41$ out at one pull without raifing the inftrument: but whenever a tooth proves to be firmly fixed, and efpe- cially if it is one of the large molares whofe roots di- verge confiderably, it is better, after it is freely loofen- ed, to remove the inftrument; and having turned the claw to the oppofite fide, to apply it fo as to turn the tooth to the other fide of the jaw, by which it will be made fo completely loofe as to be eafily taken out with common teeth forceps, Plate XLVIII. fig. 3. In ufing the key, when the tooth to be taken out is firmly fixed, efpecially when there is no vacant fpace between it and the contiguous teeth, fome care is ne- ceffary to prevent thefe laft from being loofened. When it cannot, be done. in any. other manner, the edges of the tooth to be removed, fhould be filed down with a thin file, and it may be done without hurting the neighbouring teeth, by ufing a file that is fmooth or polifhed on one fide. This I believe to be the beft method hitherto known of extraaing firm teeth from the back part of .either of the jaws ; and the incifores and canine teeth may likewife be pulled in the fame manner : but thefe, namely, all the fore-teeth, as well as loofe teeth in ev- ery part of the jaw, may be pulled in a different man- ner, which I ffiall afterwards deferibe.. Although there is fome difference of ftrength, as I have already ohferved, between the outer and inner plates of the alveoli of the teeth, the difference is fo trifling, that in pulling a tooth it merits little confider- ation. Neither does the direaion of the roots of teeth deferve attention in this operation : for although it is alleged by Some, that they may be turned with moft eafe towards the infide of the mouth, from their roots being fuppofed to fpread towards the outfide of the jaw ; yet this is by no means the cafe. For the moft part, the roots of the large molares. diverge equally towards both fides of the jaw ; fo that in this refpea they may be pulled with the fame propriety to the one d d 2 420 Diseases of the Mouth. Chap. XIVy fide as to the other. But the two laft molares of the lower jaw afford an exception to this ; for they are fo fituated, that in every inftance where the common key is employed, they fhould be turned inwards. The ba- fis or origin of the coronoid procefs forms a ftrong fharp ridge on the outfide of the jaw, exaaiy oppofite to the roots of thefe teeth ; fo that, when turned out- wards, as the heel of the inftrument muft reft upon this ridge, the gums which cover it are neceffarily much bruifed. When a tooth is much Spoiled on one fide, it is almoft the univerfal praaice in pulling it, to fix the point of the claw on the found fide ; and this being confidered as neceffary, may be given as a rea- fon for our being obliged in fome inftances to turn even one of thefe teeth towards the outfide of the jaw.- This, however, is not on experience found to be the cafe ; for, in general, it is fuppofed to anfwer belt to fix the claw of the inftrument on the foundeft fide of a tooth, and to turn it to the oppofite fide ; yet with due pains and attention, we might perhaps in every inftance follow the very reverfe of this with equal fuc- cefs : for with a proper application of the fcarificator, we may almoft always feparate the gums, fo as to be able to prefs the point of the claw far enough down upon the root, and in this manner to turn it with eafe to the oppofite fide. The key inftrument, however, may be made fo as to turn even the two farthest molares outward, \\ ith- out doing any injury to the gums lying above the pro- ceSs that I have mentioned. A form of it for this purpofe is delineated in Plate XLVI. fig. 3. which I propofed feveral years ago, and which I have often ufed. By the heel of the inftrument refting upon the gums beneath the firft great molares, while the claw is bent in Such a manner as to apply to either of the two pofterior teeth, they may in this manner be turn- ed out with Safety. The heel fliould be made long, So as to paSs Sar down upon the gum ; otherwiSe, for this particular purpofe, it will not anfwer fo well. In- Sea. IX. Diseases rf the Mouth. 421 deed the heel of the key inftrument fhould be always longer than it is ufually made ; for when ffiort, it a&s with much lefs power, and is more apt to break the tooth, than when made of a greater length. The con- trary of this I know has been much inculcated ; but after giving a fair trial to both methods, I am now convinced that the key with a long heel is much pre- ferable to the other. The chief objeaion to the ufe of a long heel is, that it muft bruife the gum more than a ffiort one. This, however, is not the cafe, as will be readily allowed by all who attentively think of it; for even the fhorteft heel muft preSs upon Some part oS the gum; otherwise, if applied upon the tooth itfelf direaiy oppofite to the point of the claw, as fome have advifed, it will aa in nearly the fame manner, and with no farther power than common forceps : while, again, a long heel does not, as is commonly imagined, injure the gums in proportion to its length ; for although the flat fide of it is applied to the gums at firft, as foon as it begins to aa, the fartheft point of it only will be found to touch them ; and accord- ingly this part of the heel, as well as all the reft of it, fliould be made as fmooth as poffible ; fo that in turn- ing upon the gum, it will do lefs harm than when of a rough furface according to the ufual form. I have already obferved, that in pulling teeth, the fide to which they are turned need not be much re- garded, from any difference of ftrength between the outer and inner plates of the alveoli or Sockets; for in this refpea they are nearly fimilar. But even al- though the difference was more than it really is, it would not merit attention ; for, in pulling teeth in the manner I have defcribed, namely, in an oblique or lateral direaion, it is evident that the Sockets muft be broken on both fides $ at leaft this muft be always the caSe where the roots oS a tooth are of the ufual length, and not Shortened, as they fometimes are by difeafe ; for while the corona of a tooth is forced down upon one fide of the focket, the point of the 422 Diseases of the Mouth. Chap. XIV. root muft neceffarily be turned in nearly the Same pro- portion upon the other. The Softer parts will not in- deed Suffer So much, as they will not be bruiSed by the heel of the inftrument; but the Socket muft ob- vioufly be much hurt by it; So that in every point of view, little or no confideration is due in this operation to any SuppoSed difference between the ftrength of the two plates of which the Sockets of the teeth are formed. But as it is of much importance to fave both fides of the alveoli as far as poffible, nothing fhould be omitted that can with propriety be done for their pro- teaion. For this purpofe, a form of the key inftru- ment has been propofed, for fupporting the gums and alveoli, while the tooth is raifed and feparated from them by turning the inftrument in the ufual manner. But if the focket is fupported, and not allowed to yield on the tooth being preffed towards it, there is much reafon to fear that the tooth itfelf would break; and if the inftrument be not applied in Such a manner as to have this effea, it will anSwer no other puipoSe than the key in common uSe; while, being more com- plex, It is managed with more difficulty. The pro- poSal however is ingenious, and may lead to improve? ment in the operation oS tooth-drawing.* In pulling a tooth with the key inftrument, it is the common praaice to force it out at once. But al- though this may Sometimes fucceed, it ought not to be tried ; for when the roots of teeth diverge much, or when any portion of the fang is enlarged, as is Sometimes the cafe, we run much rifk, by this me- thod, of breaking them, at the fame time that the foc- ket muft be much more injured than when the tooth is loofened in the manner I have advifed, by turning it firft to One fide and then to the other with the key inftrument, So as to be able afterwards to take it out * This inftrument is the invention of Dr. John ^\itken. For a more particular account of it, fee Eflays on feveral important Subjects in Sur- gery. '■'■ - §ea. IX. Diseases of the Mouth. 423 with common forceps. And if this is done flowly, with a gradual equal preffure, and if the heel of the key has been property covered with feveral plies of foft linen, fcarcely any harm can be done by it: but mftead of this, when the inftrument is applied direa- iy to the gum, without the intervention of any Soft fubftance, and the tooth turned out, as is frequently done, by a hidden jerk, the gums are not only great- ly bruifed and lacerated, but the focket is more Se- verely injured, at the fame time that the tooth itfelf is under a greater rifk of being broken than when pulled in a more gradual manner. It is natural for patients, ignorant of the rifk attending it, to wifh for the ope- ration to be quickly done ; but it is unpardonable in praaitioners to indulge them in this, when a mo- ment's reffeaion muft convince them, that a tooth cannot be quickly pulled but with much rifk, either oS the jaw or it being broken. Even when the operation is done in the moft cau- tious manner, troubleSome accidents Sometimes enSue from it: and thefe particularly are, contufions oS the gums ; Splinters of bone being feparated from the jaw ; and alarming hemorrhagies. Laceration and contufion of the gum being a very painful part of the operation, we ought, as far as pof- fible, to guard againft it; not merely by covering the heel of the inftrument in the manner I have advifed, , but by declining to ufe it while the gums are much inflamed ; for while much inflammation continues, the operation neceffarily gives much more pain than it otherwife would do. For obviating the effeas of laceration, when any portion of gum is much fepara- ted from the reft, it Should be cut off with fciffars ; the mouth Should be fomented from time to time with warm milk, or any emollient decoaion; and when there is caufe to imagine that fuppuration will take place, it ffiould be encouraged by the application of roafted figs or onions, by way of cataplafm. In this manner, if an abfcefs occurs, it will be Soon brought 424 Diseases of the Mouth. Chap. XIV. to maturation ; when, if it does not burft quickly, it ought to be opened : and again, in flighter contufions, nothing alleviates the pain induced by them fo effec- tually as the applications I have mentioned. When the focket only has Suffered, little or no harm enSues from it; fo that it is feldom neceffary tp mention it even to the patient. But when the fplin- ter extends to the more Solid part of the jaw, which in children efpecially is apt to happen if the operation is not done with the utmoft attention, as the fore thaj: enfues proves commonly tedious, and does not readi- ly heal as long as any loofe pieces of bone remain in it, any of thefe that are perfeaiy detached fhould im- mediately be taken away ; but as they are feldom fo completely feparated as to come eafily away at firft, no force fhould be ufed in it, as they afterwards either fall cut of themfelves, or may be eafily taken away on a free formation of matter taking place. After this, if the matter is prevented from lodging, and if the conftitution is in other reSpeas Sound, the Sore uSually heals with eafe, Hemorrhagies of importance are not frequently pro- duced by tooth-drawing ; for the blood veffels of the teeth being fmall, it is fcarcely poffible that they can difcharge much blood. But when the roots of teeth are deeply fixed in the jaw, and when much force has been ufed in the operation, we can eafily fuppofe that in this manner fome of the larger arteries of the con- tiguous parts may be divided ; and it is thus I ima- gine that any troublefome hemorrhagy is ever produ- ced by this operation. At firft we advife the patient to take frequent mouthfuls of cold water, red wine, brandy, vinegar, or even alcohol; and for the moft part one or other of thefe prove fuccefsful; but when they happen to fail, other means muft be employed, and the moft powerful of thefe is compreffion. A doffil of foft lint, fitted to the opening, muft be puffir ed into it; and the patient being defired to comprefs it by keeping his mouth fhut, if this is properly done, Sea. IX, Diseases of the Mouth. 425 it does not commonly fail. I have met with inftances however, even of this proving unfuccefsful, and of fainting and other diftrefsful fymptoms being produ- ced by the hemorrhagy. In this fituation the aaual cautery is alone to be trufted ; and it muft be applied with freedom, otherwife no advantage enfues from it. A fmall bit of lunar cauftic inferted into the opening might anfwer; but it does not aa with fuch certain- ty as the other, while there is more rifk of its doing harm, from its being apt to fpread fo as to injure the contiguous parts. The key inftrument is perhaps the beft hitherto in- vented for the pulling of teeth in an oblique or lateral direaion ; but we have feveral others that aa nearly on the fame principles : thefe, however, being lefs perfea, I fhall not delineate them all here ; but with a view to convey fome idea of them to fuch as may not have other opportunities of feeing them, I have given a representation of two of them in Plate XLVII. figures 2. and 3, But even thefe, although the beft with which I have met, are far inferior to the key : for they aa with much lefs power ; and they have this material defea, that they can never be employed for pulling teeth towards the infide of the mouth. I have thus defcribed the method of extraaing firm teeth from the back part of the mouth. Any of the fore-teeth may likewife be pulled, as I have already pbferved, with the fame inftruments ; for they may be turned either inwards or outwards, by a proper ap- plication of the key : but they may alfo be pulled in a different method ; and as this may be done with in- ftruments that do net bruiSe the gums, they fliould perhaps in every inftance be pulled in this manner. The incifores and canine teeth, and even the two fmall molares have only one root; fo that they are never fo firmly fixed in the jaw as the large grinders ; and they may be extraaed with more eafe. For the moft part this may be done with the common teeth forceps reprefented in Plate XLViil. figs. 1. 3. or 4. 4i6 Diseases of the Mouth. Chap. XIV, In ufing this inftrument, it fhould be preffed as far down upon the tooth as poffible, otherwife it is apt to break off the corona or upper part of it, and to leave the root; and the tooth fhould not be pulled direaiy upwards, but twifted alternately from one fide to the other till it becomes loofe, when it may be taken out without further trouble. In fome cafes, however, even the fore-teeth are too firmly fixed to admit of being pulled with this inftru- - ment: I have therefore given a representation of for- ceps that aa with more power ; a very ingenious in- vention firft made public in the Britifn Magazine, in the year 1762. It is delineated in Plate XLIX. figs. 1. and 2. Fig. 1. repreSents a common ftrong Sor- -ceps with moveable claws. The axis of the claws is fliown at A. Fig. 2. is a fulcrum. B, C, is the han- dle going off obliquely from B, by which it is more eafily applied. B, F, D, is a plate of iron covered underneath with a piece of foft buff; and E is the other fide of the fame plate made round, fmooth, and uncovered. The tooth intended to be pulled is laid fall hold of with the forceps, fig. 1.; then the ful- crum B, F, D, is placed upon the neighbouring teeth, when the forceps being placed upon the round part of the plate E, by a proper motion of the lever G, H, I, K, the tooth is in this manner extraaed. In the pulling of loofe teeth, this inftrument may be ufed fo as to draw them nearly ftraight up ; and this we are told may even be done where the teeth are firm, pro- vided their roots do not diverge much, and that there are no offeous adhefions between them and the fockr ets: but with a view to prevent any bad confequen- ces that might enfue from the application of much force, we are defired by the anonymous author of the inftrument, inftead of attempting to pull firm teeth direaiy upwards, to twill them outwards, which I00S- ens them So much, that they may then be pulled in a perpendicular direction with much eaSe. Sea. IX. Diseases of the Mouth. 427 The advantage fuppofed to be derived from forceps with moveable claws is this: when common forceps is ufed with immoveable claws, if the tooth is firm, it muft either be forced out obliquely, or the firft hold muft be loft, and the inftrument fixed again : but when the claws are moveable, the inftrument retains its hold, fo that the tooth may be pulled nearly in a perpendi- cular direaion; for the claws, by turning upon cen- tres, will always fall into the way of the tooth ; and will therefore raife it nearly in a ftraight line.^ I have taken different opportunities of obferving, that the moft painful part of tooth drawing arifes from the ■bruifing and laceration of the gums and Sockets ; a circumftance that cannot be altogether avoided when the key instrument is employed. The great objea of the forceps that I have juft defcribed being to pull in a ftraight direaion, by which the gums and Sockets are almoft entirely faved, would render it the moft complete inftrument that hitherto has appeared, were it not liable to fome very important objeaions, The ingenious author of this forceps thinks it may be em- ployed for the extraaion of any teeth ; even of the large molares ; but as the mouth cannot be fo widely opened as to admit of our applying it properly, this attempt fhould not be made with it: it muft therefore be confined, as I have obferved already, to the pulling of teeth in the forepart of the mouth. But befides this, as the fulcrum is placed upon the contiguous teeth, when the tooth to be pulled is firmly fixed, it is fcarcely poffible to prevent theSe from being hurt: for they will be very apt to fuffer even when the pref- fure is made as nearly as poffible in the direaion of their roots ; and when this is not done with accuracy, they are apt to be broken, or even forced entirely from their Sockets. In the pulling of loofe teeth, however, and whenever the fore-teeth are not fo firmly fixed as to require much force to move them, this inftrument mav be employed with advantage. When, again, it is difcovered upon trial, that an unufual degree of 428 Diseases of the Mouth. Chap. XIV, force is neceffary, a prudent praaitioner will rather lay the forceps afide, and finifh the operation with fome other inftrument. The common key, as I have already obferved, may be ufed ; or either of the in- ftruments, fig. i. and 2. Plate XLVII. may be em- ployed for loofening the tooth; after which it may be taken out either with thefe or with common forceps. I have hitherto been fuppofing that the tooth to be pulled is only carious in a particular part, and that a confiderable part of the corona is ftill remaining. When a tooth becomes fo much difeafed that the up- per part of it falls entirely off, fo as to leave little or nothing above the gums, the remaining part of it is thus reduced to what is commonly termed a flump. In this ftage of the difeafe, the conneaion between the roots that remain and the Sockets, undergoes a very important change. By the corona being removr ed, the roots, whatever number there may be, are all feparated from each other ; for being united folely through the intervention of the corona, their connec- tion muft evidently be deftroyed on this being taken away. In this manner their conneaion with the Sock- ets becomes leSs firm, than when diverging roots, tied together above, tend all to fupport each other; but they become ftill more loofe by a diffolving or wafting procefs, to which teeth in this fituation are always li- able. A confiderable part: of the corona of a tooth may become carious, and fall away, without the roots being affeaed ; but I have fcarcely known an inftance of the corona being completely removed for any length of time, where the roots did not fuffer a remarkable diminution. Nay, in fome cafes, the roots, even of the largeft molares, have been almoft completely an- nihilated ; and inftead of the long fangs with which thefe teeth in a ftate of health are furnifhed, only a fmall point or two of fpoiled bone has been met with. In confequence of this they become loofe ; and their conneaion with the jaw being now very fuperficial, they may be forced out much more eafily than a large Sea. IX. Diseases of the Mouth. 429 tooth. I know that praaitioners in general are not of this opinion, the pulling of a flump being for the moft part confidered as more difficult, as well as a more painSul operation, than the extraaion of a large tooth. This, however, can proceed only from want of experience in this branch of praaice ; for thofe who are more verfant in it know, that there is much more pain, hazard, and difficulty, in the pulling of a com- plete tooth when firmly fixed, than in the taking out of feveral flumps. When the point of the claw can be forced fo far down upon a Stump as to get a firm hold, it may be pulled with the key inftrument in the manner I have advifed for the extraaion of large teeth; but this fhould not in general be done, as we may commonly employ a fuffident force with inftruments that do not injure the gums, and by which a very painful part of the operation may be avoided. When the flump can be laid hold of, either with common forceps, or with thofe with moveable points, this, as the eafieft meth- od, fhould be preSerred : but when So much Spoiled, as to be nearly, or perhaps entirely, covered with the gums, the points oS forceps cannot be preffed Sufficient- ly down upon it; in which caSe, we are under the neceffity of forcing it out with a fimple fever. This inftrument is commonly termed a punch; of which different forms are reprefented in Plate L. figs. 1. 2. and 3. In ufing it, the gums muft be freely feparat- ed from the flump with a Scarificator ; and the point of it being preffed down upon the root, a degree of for- tinue to difcharge faliva for life, may be eafily healed, with fcarcely any mark of their having ever exifted ; of which I have now had feveral inftances, in all of which complete cures were obtained. A common feton or cord of cotton has been recom- mended for this operation inftead of lead ; and a bit of catgut has been ufed inftead of it: but nothing ren- ders the parts fo quickly callous as lead ; and befides, it is more cleanly than a cord or tent of any fofter fubftance. Sea. I. Diseases of the Ears. 4P CHAPTER XV. OF THE DISEASES OF THE EARS, AND OPERATIONS PRACTISED UPON THEM. SECTION I. Of Deafnefs. DEAFNESS may proceed from various caufes; for, as a free paffage of found to the tympanum or drum of the ear, together with a found ftate of this membrarte and of the parts conneaed with it, are re- quisite for the fenfe of hearings fo whatever tends to obftrua the one, or to induce diSeafes Of the other, will neceffarily excite deafnefs. Two paffages are appropriated for the purpofe of conveying found to the ear; one of them termed the meatus externus, terminating in the external ear; and the other the tuba euftachiana, ending in the throat. It is true, that the firft of thefe is of more importance than the other, for it is larger, and more convenient- ly placed for colleaing found ; but it is certain, that the latter or internal paffage is a very neceffary part of the organ of hearing; for when by any means it is ftopped, deafnefs, to a greater or lefs degree, almoft constantly enfues. Thus we obferve, that any preter- natural fulnefs or enlargement of the amygdalae, efpe- cially when they are attacked with inflammation, is always attended with fome degree of dcafnefs. In this way, too, we account for that deafnefs to which pa- tients are liable who have fuffered much from vene- real ulcers in the throat: and polypous excrefcences that extend back from the nofe and fauces, by com- F F 2 45* Diseases of the Ears* Chap. XV. preffing the eustachian tube, are frequently produaive of fimilar confequences. In that variety of deafnefs which originates from this caufe, a removal of the polypus, or Swelled amyg- dalae, will frequently accomplifh a cure, while no oth- er remedy can be of any avail. But when it is in- duced either by an ulcerated ftate of thefe parts, or by much inflammation, as the extremity of the dua will probably be obliterated, it would be in vain to employ any means of cure. It has indeed been pro- pofed in this variety of obftruaion, to endeavour to open the dua, by inferting the end of a curved blunt probe into it, or even to injea milk and water, or any other mild fluid, into it, with a curved fyringe. But although a perfon well acquainted with the anatomy of the parts1, may, by much praaice, arrive at fuch perfoaion as to be able to do this with little difficulty upon a dead body, there is no reafon to imagine that in praaice any advantage will ever be derived from it: for even in a healthy ftate of thefe parts, the irri- tation which the end of a probe or of a fyringe ferves to excite on being made to touch them, muft be fo confiderable as to render every attempt for inferting them very uncertain; and the difficulty muft neceffa- rily be increafed where the extremity of the dua is. obftruaed by difeafe. But if we have not much in our power in the treatment of deafnefs arifing from this caufe, we are in many inftances able to afford much relief, and even to reftore the moft perfea hearing where it has been entirely wanting, when the difeafe arlfes from obftruaion in the external paffage of the ear. The meatus externus may be obftruaed in various ways. It may be in an imperforated ftate at birth ; it may be more or leSs filled with extraneous bodies forced into it; tumors or excrefcences may form in it; and it maybe too much fluffed with wax, the na- tural Secretion of the part. As. each of thefe caufes Sea. I. Diseases of the Ears. 453 requires a method of treatment peculiar to itfelf, I fhall confider them under feparate heads. § 1. Of an Imperforated Meatus Auditorius. Among other natural deficiencies to which the hu- man body is liable, none occurs more frequently than an imperforated ftate of fome of the paffages. This does not fo frequently happen in the meatus audito- rius as in others, owing perhaps to the lining mem- brane of this paffage being every where attached to bone, by which it is prevented from collapfing. Not- withftanding, however, of this, different inftances have occurred of it, and Some variety is difcovered in the nature of it. In fome cafes the obftruaion is formed by a thin membrane fpread over the extremity of the paffage ; while in others a confiderable part of the conduit is entirely filled with a firm fleffiy kind of fubftance. In the treatment of this variety of deafnefs, nothing can prove ufeful but the removal of the caufe by an operation. When this is to be done, the patient's head fhould be fecured in a proper light, and at a con- venient height, by an affiftant; when the operator, with a Small fharp pointed biftoury, fliould make an incifion of a proper length exaaiy on the Spot where the external paffage of the ear fhould terminate. When covered by a membrane only, the operation will foon be finiffied ; but when impervious to any great depth, the incifion muft be continued, by paff- ing the biftoury in a gradual manner farther in, eith- er till the refiftance is removed, or till there is reafon to fear that the tympanum would be hurt, if it were carried deeper; in which cafe the inftrument fhould be withdrawn ; and in order to prevent the parts from adhering together, a bit of bougie properly oiled fhould be introduced, and retained till the cure is fin- ifhed ; care being taken to remove it daily for the purpofe of cleaning it, and for wiping off any matter that may have colleaed in the ear. 454 Diseases of the Ears. Chap. XV. In this manner deafnefs depending upon this caufe may often be removed when the obftruaion lies be- tween the tympanum and the farther extremity of the meatus externus; and it fhould be always attempted about the time when the child fhould be beginning to fpeak. At a more early period, the child would not be fo able to bear it; and when delayed much later, it would impede his Speech ; for we know that dumb- nefs depends more frequently on a want of hearing than on any other caufe. § 2. Of Extraneous Bodies impaded in the Ear. Although the vifcid nature of the wax of the ears is well calculated for preventing duft and other foreign matters from paffing into them, yet we know that much diftreSs is in Some inftances induced by this cauSe. Children often pufh fmall peas, cherry-ftones, lead drops, and other fuch articles into their ears, and flies and other infeas frequently creep into them. When thefe lie near to the end of the paffages, flies and other things that can be laid hold of fhould be extraaed with fmall forceps, fuch as are delineated in Plate XL VIIL fig. 2. But peas and other round bo- dies are more eafily removed, by turning them out with the end of a curved probe, or paffing the end of the inftrument Plate XXV. fig. 1. behind them; and their extraaion is facilitated by a little oil being pre- vioufly dropped into the paffage. When inSeas have got So far into the ear that they cannot be taken out with forceps, the beft method of removing them is to wafh them out, by throwing in quantities of warm water, or any other mild liquid, with a fyringe; but as they adhere while living with confiderable firmneSs to the neighbouring parts, we fhould firft endeavour to kill them, by filling the ear with oil, or any other liquid that proves poifonous to them without injuring the tympanum. Lime water, fpirit of wine, and other liquids, might be employed Sea. I. Diseases of the Ears. 455 for this purpofe: but nothing proves fo harmlefs as oil; and although it does not kill every fpecies of in- fea inftantaneoufly, yet few of them live if immerfed in it for any length of time. The patient fhould there- fore be defired to reft his head on the oppofite fide; and Some tepid oil being poured into the ear, it may thus be eafily kept in it as long as is neceffary. Peas and other Soft bodies that Swell with moifture, are apt to become So large when they remain long in the ear, that they cannot but with much difficulty be extraaed entire. In this caSe we fhould endeavour to break them, either with the points of Small forceps, or with a fharp fmall hook cautioufly introduced along the paffage ; and as foon as they are Sufficiently divid* ed, they muft either be taken out piece-meal with for- ceps, or walhed out with a fyringe. § 3. Of Excrefcences in the Meatus Auditorius. I have already treated of polypi in the nofe and throat; and I may now remark, that the external paf- fage of the ear is equally expofed to them. It is not indeed common for this kind of excrefcence in the ear to arrive at fuch a bulk as they do in the nofe ; but whoever has paid attention to this branch of prac- tice, will acknowledge, that they are by no means un- frequent, and they often appear to be the caufe of very obftinate deafnefs. On looking into the meatus auditorius, we Some- times find it filled with a polypous excrefcence hang- ing loofe by one pedicle; while at other times the paffage appears to be obftruaed merely by a thicknefs or fulnefs of the lining membrane of the ear, when no particular part of it is more difeafed than another. As polypi of this part are ufually of a firmer tex- ture than polypi in the nofe, and as the membrane of the ear is firm, and does not readily yield, they can- not eafily be extraaed with forceps; but they may Joe taken out either with the knife, or with a ligature, 456 Diseases of the Ears. Chap. XV. When they lie near to the entrance of the external paffage of the ear, and can be laid hold of either with fmall forceps, or with the diffeaing hook, Plate XXXVIII. fig. 3. they may be cut out with the probe pointed biftoury, reprefented in Plate XXXIX. fig. 3. and as they do not appear to be fo vafcular, as fimi- lar excrefcences in the nofe, they may in this manner be removed with fafety ; for they feldom difcharge much blood. But when they lie deep, it is better tp remove them with ligatures; for as the paffage is ftrait, a knife is in this fituation introduced with diffi- culty, and ufed with uncertainty. Various methods have been propofed for applying ligatures to excrefcences in this fituation; but the method of removing polypi of the nofe, defcribed in the explanation of Plate XXXIII. appears to be the beft. With the forked probe, fig. 2. the doubling of a ligature may be pufhed up at one fide of the po- lypus till it reaches the root of it; and the two ends of the thread being carried round the excrefcence, and inferted into a ffiort double canula, fuch as is deline- ated in Plate XXXI. fig. 1. the canula fhould then be pufhed to the root of the polypus on the oppofite fide ; when the two ends of the ligature being drawn fufficiently tight, and fixed upon the knobs at the end of the tube, the probe may be withdrawn, and the po- lypus will drop off in a day or two. But it often happens, that thefe excrefcences can- not be removed in this manner; for inftead of bdng pendulous by a fmall neck, they frequently extend to a considerable depth along the lining" membrane of the ear. In this cafe efcharotics have been recomr mended: but as they cannot be employed but with much rifk of hurting the tympanum, they fhould nev-» er be ufed ; and this efpecially, as the difeafe may in general be removed by means of a more fimple na- ture. This affeaion of the membrane of the ear I confider to be exaaiy fimilar to that variety of ob- ftruaion in the urethra in which tjpugies prove parti- Sea. I. Diseases of the Ears. 457 cularly ufeful; and the fame remedy, when duly per, filled in, proves equally ferviceable in the one difeafe as in the other. In the introduaion of the bougie, care muft be taken not to pafs it to the depth of the tympanum, otherwife it may do more harm than good; and the fize of it muft from time to time be enlarged till the paffage becomes fufficiently open. When bougies are firft paffed into the ear, they al- ways create fome degree of uneafinefs, by irritating the parts to which they are applied; but this foon fubfides when they are ufed with caution, and proper- ly oiled before being introduced. § 4. Of Deafnefs from Wax colleded in the Ears. Whether it is from the lining membrane of the ear being poffeffed of fome degree of a contraaile power, or from the outward extremity of the paffage being fomewhat lower than the other, that the ceru- men or wax does not ufually lodge in it, is perhaps difficult to determine ; but it is certain, that in a heal- thy ftate of thefe parts they are ufually very thinly covered with this fecretion : deafneis in a certain de- gree is very commonly induced by the paffage of the ear being fluffed with wax; for in this ftate it very effeaually obftruas the paffage of found to the tym- panum. It commonnly happens too when wax re- mains long colleaed in the ear, that it becomes thick, and even hard, infomuch that in fome inftances it be- comes almoft as firm as a bit of timber. The treatment of deafnefs arifing from this caufe is obvious. By an attentive examination of the ear, we can distinguish with certainty whether there is a fuper- abundance of wax or not: for by placing the ear in a clear funffiine, we can fee even to the tympanum ; and whenever the paffage is much obftruaed with wax, we ffiould not hefitate in advifing it to be removed. Different methods have been propofed for clearing the ears of wax ; but the fafeft and eafieft is to waSh 45 8 Diseases of the Ears. Chap. XV. or fyringe them with warm water or any other mild liquid. Milk and water, or foap and water, anfwer the purpofe : but before the operation a few drops of oil Should be poured into the ear, not with a view to diffolve the wax, for more powerful Solvents of this fubftance might be mentioned ; but for the purpofe of lubricating the paffage, by which the wax is more eafily forced out. By a proper ufe of the fyringe, which experience alone can teach, the ears may be en- tirely cleared of every obftruaion produced by wax. Although obftruaion of the external paffage of the ear is the moft frequent caufe of deafnefs ; yet in fome inftances it is produced in a different manner. It may occur from a morbid ftate of the tympanum, and of the parts contained within it. To a certain degree it will take place, if either by accident or difeafe the ex- ternal parts of the ear are deftroyed ; and it fometimes occurs from a deficiency of wax. The fmall bones of the ears fometimes become diS- eaSed in Scrofula,'and the deafnefs that enfues from this is never in any inftance removed. In fuch cafes all that art can do, is to preferve the parts clean and free from fmell, which is moft effectually done by wafhing out evening and morning any matter that happens to colfea in the paffage, by throwing in warm milk and water with a fyringe : for if this be not done, the matter difcharged from the carious bones foon be- comes offensive ; and it continues to be So, either till the diSeaSed parts of the bones are entirely diffolved and difcharged, or perhaps during the life of the pa- tient. We ought not, however, to confound this difeafe with a difcharge that frequently takes place from the ears, of a milder nature. In fome cafes this appears to be the confequence of a boil "or abfcefs in the mea- tus externus; while in others it takes place without any previous impofthume, and feems to be induced by fome flight inflammation of the lining membrane of the ear, or perhaps of the tympanum itfelf. Sea. I. Diseases of the Ears. 459 This is a common occurrence, and for the moft part I think it is not properly treated. In general, it is fuppofed to proceed from morbid humours in the fyf- tem ; fo that fome rifk is fuppofed to attend any at- tempt that may be made for putting a ftop to it. This, however, is wrong. In moft inftances the difcharge may be traced to the cauSe I have mention- ed, inflammation of the membrane of the ear ; which being of a local nature, no rifk can enfue from check- ing it. And accordingly, in cafes of this kind, I com- monly advife injeaions, fuch as prove moft ufeful in gonorrhoea. A weak folution of alum, or of faccha- rum faturni, frequently anfwers, or French brandy Somewhat diluted. In fome cafes, pouring a few drops of any of thefe into the ears, morning and evening, proves fufficient; but when this fails, they fliould be gently thrown in with a fyringe. It is proper here to remark, that the more early in the difeafe this praaice is employed, the more effec- tual it ufually proves; fo that it Should never be long delayed. And befides, when the difcharge has been of long duration, it not only does harm by relaxing or even destroying the tympanum, but fome rifk may * thereafter arife from a Hidden ftop being put to an evacuation to which the fyftem has for Some time been accuftomed. The danger, however, may be obviated by the previous introduaion oS an iffue Somewhat ad- equate to the diScharge Srom the ear, either in the head, neck, or any other part; but in recent cafes there is no neceffity for putting the patient to the in- convenience of an iffue ; for here the difcharge may with fafety be ftopped immediately. When deaSneSs takes place, either from relaxation of the tympanum, or from any deficiency in the ex- ternal parts of the ear, fome affiftance may be derived from our endeavouring to colfea or concentrate found fo as to make a ftronger inipreffion on the organ of hearing. Various inftruments have been invented for this; but none of them anfwers fo well as one nearly 460 Diseases tf the Ears. Chap. XVf of the form of a common horn, fuch as is reprefented in Plate LII. fig. 2. Figure 1. is a convoluted tube employed for the fame purpofe ; and fig. 3. reprefent? an inftrument intended to be concealed beneath the hair or wig, and to be fixed to the head by the two firings conneaed with it. When, again, a deficiency of wax is fufpeaed to be the caufe of deafnefs, dropping a little pil of al- monds, or any other mild oil into the ear, once or twice daily, proves fometimes ufeful. In fome cafes I have known benefit derived from a little foft foap be- ing inferted into the paffage ; which not only keeps it moift, but by aaing as a Stimulus to the lining mem- brane of the ear, it tends thus to induce a return of the Secretion of wax. With the fame view too, I have fometimes employed Strained galbanum made into a proper confiftence with oil, along with a finall proporr tion of the juice of an onion. SECTION II. Of Perforating the Lobes of the Ears. BY medical writers of the 17th and preceding cenr turies, piercing the lobes of the ears is recom? mended as an operation that may prove ufeful in dif- ferent difeafes, particularly in affeaions of the head. In thofe times a fmall feton was drawn through the opening, with a view to induce a difcharge of matter, which in fome cafes might prove ufeful. At prefent this operation is never employed but for the purpofe of ornament. This is perhaps the moft fimple of all operations ; but as it is fuppofed to be of fome importance by thofe on whom it is praaiSed, it is neceffary to defcribe it. As heavy ear rings are apt to tear the parts, the open- ing fhould be made as high on the lobe as with pro- Sea. II. Diseases of the Ears. 46* priety it can be done ; and the fpot fhould be previ- oufly marked with ink. The patient being feated, and the head fecured by an affiftant, the lobe of the ear fhould be ftretched upon a piece of cork placed beneath it. The furgeon is now to pierce it with the inftrument, fig. 6. Plate LII. and having puffied it fo far through that the tubular part of it is freely per- ceived on the oppofite fide, the cork muft be with- drawn with the perforator ftuck into it. A fmall piece of lead wire is now to be inferted in the tube remaining in the ear ; and on being drawn into the perforation, the lead muft be left in it. By moving it daily, which may be done with little or no pain if it is previoufly rubbed with oil, the paffage will foon be- come callous, and thus the operation is finifhed. Before concluding the chapter on the difeafes and operations on the ears, it may be expeaed that I ffiould defcribe the method of cauterifing or burning behind the ears for the toothache. At one period this oper- ation was much employed, and different inftruments were propofed for doing it. It is unneceffary, how- ever, to delineate any of them ; for the praaice is now, I prefume, very generally laid afide ; and at any rate it may be done with a red hot probe of any kind equally well as with the neateft inftrument. It was fuppofed to prove ufeful by burning or destroying the nerve producing the pain ; but it would rather appear to aa by inducing terror or SurpriSe ; and if this is the cafe, it is probable that the fame operation would anfwer if practifed in any other part. But as the pain attending it would by moft people be confidered as more Severe even than the pulling of a tooth, it is not probable that it will ever be revived. 462 Of the Wry Neck. Chap. XVI. CHAPTER XVI. OF THE WRY NECK. THE neck is fometimes considerably bent to one fide : when this takes place to Such a degree as to produce much deformity, the affiftance of Surgery becomes neceffary. The wry neck may be produced in various ways. It may depend upon an original mal-conSormation of the bones of the neck : on a preternatural degree of contraaion in the muScles of one fide of the neck, par- ticularly of the fterno maftoideus mufcle : or, it may be induced merely by a contraaion of the fkin, in con- fequence of extenfive fores and burns. When the vertebrae of the neck are distorted, it would be in vain to attempt any means of relief; but either of the other caufes I have.mentioned feems to admit of almoft a certain removal. In books of forgery the operation for the wry neck is very commonly defcribed; and as this deformity has in general been imagined to proceed folely from a contraaed ftate of the flerno maftoid muScle, a divi- fion of this mufcle is ufually propofed as the only means to be trufted. Even Mr. Sharpe was of this opinion ; and he delineates an inftrument termed a probe razor for performing the operation.* But were we even to admit that the divifion of this mufcle was a neceffary meafure, the method of doing it by introducing the probe razor beneath it and di- viding it afterwards, appears to be exceptionable, as being attended with much rifk of«wounding the con- tiguous blood veffels : it would furely be better to di- * Vide Sharpe's Surgery, Chap. xixv. Chap. XVI. Of the Wry Neck. 463 vide the mufcle, by repeated ftrokes of a fcalpel, and to continue the^ncifion in a gradual manner to Such a depth as may be neceffary ; by which even the large veins of the neik might be avoided. But although we allow that A wry neck may be fometimes produced by a contraaion of this mufcle, yet it appears to be a rare occurrence : I have now met with many inftances of this deformity, and in all of them the contraaion feemed to be in the fkin alone. When the fkin only is affeaed, the parts are more eafily divided and with leSs rifk than when the deep feated muScles are to be cut; but even this fhould be flowly done, So as to avoid the external jugular veins ; for although no great harm might enSue Srom their being cut, they ffiould never be wounded unneceffari- ly. But whether the caufe of contraaion is feated in the flerno maftoid mufcles, or in the fkin, the incifion fhould be carried fo deep as to remove it entirely, otherwife little or no benefit will enfue from the ope- ration. We ought not, however, to conclude, that our ob- jea is accompliffied on the contraaed parts being di- vided ; for unlefs fome method is employed to fupport the head during the cure of the fore, it will Still be apt to incline more to this fide than to the other, by which the parts newly divided will readily unite, fo that no advantage will be derived from the incifion. By Mr. Sharpe and others, we are indeed adviSed to Stuff the fore with lint, fo as to prevent this inconven- ience with as much certainty as poffible ; but I know from experience that this does not fucceed, and that nothing will anfwer but a firm fupport being given to the head. For this purpofe the inftrument reprefent- ed in Plate LIV. fig. 1. anfwers well: it was made for a cafe of this kind, in which it was ufed for feve- ral weeks, and with complete fuccefs. It fhould al- ways be worn, not only till the fore is healed, but for fome time thereafter; and if properly fitted to the 464 Of the Wry Neck. Chap. XVI. parts upon which it refts, it is ufed wkh no uneafi- nefs. . The fkin beneath the chin is fometimes fo much contraaed in confequence of burns and other caufes, as to draw the head confiderably down upon the breaft; the fame method of cure muft be praaifed for it that I have juft recommended for the wry neck. The con- traaed fkin muft be freely divided with a Scalpel, and the head properly fupported from behind till the fore is cicatrifed. Chap. XVII. Of Bronchotomy* 46$ CHAPTER XVII. OF BRONCHOTOMY. HEN refpiration becomes much obftruaed and endangers the life of the patient, and when this appears to proceed from a local affeaion of the fuperior part of the windpipe, an operation com- monly termed bronchotomy is employed for relief. But as this confifts in ah opening made into the tra- chea, and not into the bronchiae, it ought more pro- perly to be named tracheotomy. This operation has in general been SuppoSed to be of a more dangerous nature than it really is; and this has prevented praaitioners from advifing it So frequent- ly as they otherwife would have done. By many, it is faid to be feldom neceffary; and even fome authors of eminence have afferted, " that it is ufeful only in that fpecies of angina, where the throat is exceedingly enlarged by the fwelling of the thyroid gland and parts adjacent." Thefe are the words of Mr. Sharpe in his treatife on this fubjea.* But it is evident that in this inftance Mr. Sharpe has written without full confideration ; for, although a fwelling of the thyroid gland may become fo large as entirely to comprefs the trachea, and may thus render bronchotomy neceffary, yet this is furely a rare occurrence ; few praaitioners have probably met with it; and there are not many, I prefume, who have not performed the operation on other accounts. The danger that once was fuppofed \ to attend it is not now dreaded, and accordingly it is more frequently advifed ; but ftill there js.jeafon to think, that it fhould be oftener praaifedvftian it has hitherto been. • Operations in Surgery, Chap. xx*i. Vol. II. G g CJ w 466 Of Bronchotomy. Chap. XVII. The caufes that may render bronchotomy neceffiv ry are : i. Spafmodic affeaions of the mufcles of the la- rynx, when they became fo fevere as to threaten fuf- focation: in Some cafes of catarrh, the mucus of thefe parts become fo acrid, as to irritate the glottis in a moft difagreeable manner. Even from this kind of irritation, it is evident from the fenfe of fuffocation, which fometimes occurs, that much contraaion is pro* duced in the glottis : but this takes place in a more alarming degree, from hard fubftances of any kind paffing below the epiglottis into the larynx ; infomuch that from this caufe alone, fuffocation has in various inftances happened. Among others that might be re- cited, a remarkable hiftory is recorded by Bonetus, of a child having died from a piece of bone paffing into the trachea arteria; and it has often happened, that children., and even older people, have been fuffocated by nutfhells, crufts of bread, and other fubftances paffing into the trachea. It has been alleged, that no alarming degree of con- traaion in the glottis can ever take place ; and it has even been faid, that the mufcles with which it is fur- nifhed are not adequate to this effea. This opinion, however, originates from the very relaxed ftate in which thefe mufcles are found after death ; which is not by any means a fair method of judging ; for we know well, that all the mufcles in' the body are after death found in a ftate of relaxation, however feverely they may previoufly have been contraaed. 2. A piece of bone, flefh, or any other firm fub- ftance, being lodged in the pharynx, or in the upper part of ther cefophagus, and too large to pafs down to the ftomach, may by its bulk comprefs the pofterior and membranous part of the trachea in foch a man- ner as to produce a total obftruaion to the paffage of air into the lungs. Different inftances have occurred in this place of fuffocation being induced by a piece of flefh lodging in the fuperior part of the pharynx ; Chap. XVII. Of Bronchotomy. 4&7 for in fuch inftances, it commonly happens that pa- tients are irrecoverably dead before any affiftance can be procured. I have mySelf met with feveral inftan- ces of this, in all+ of which the utnioft certainty was obtained of refpiratioh having been obftruaed for a few minutes only ; and yet none of the people recov- ered, although all the means uSually employed in Such caSes were immediately put in praaice. But in all there was reaSon to think that bronchotomy would have proved effeaual, had it been poffible to procure more fpeedy affiftance. The event of thefe cafes, as well as of fome others of drowned perfons, in whom refpiration had been obftruaed for a very ffiort period only, and in whom every method now known was put in praaice for their recovery, makes me conclude, that few, if any, have ever recovered in whom refpiration has been totally obftruaed for more than a few minutes. After all the attention that I have been able to give to cafes of this kind, I would fay, that complete in- terruption to breathing, for the fpace of five minutes only, muft, in perhaps every inftance, prove fatal. We have heard, indeed, of the recovery of many drowned people after they had been half an hour, nay even hours, under water; but thefe accounts of the time which bodies have remained immerfed are fel- dom accurately obtained, from the general inclination in byftanders to exaggerate, as well as from other caufes; fo that little or no credit is in general due to them. 3. Polypous excrefcences in the nofe have been known to fall So far into the pharynx as to endanger fuffocation ; and \t very commonly happens, that thefe tumors, which originate either faom the uvula or from the fuperior part of the pharynx, are attended with this effea ; in all of thefe, when extirparion with a ligature is to be attempted, if the tumor is large, it is \vith much difficulty that the neceffary apparatus is g g 2 46*8 Of Bronc/wtomy. Chap. XVIl. applied. This, however, may be much facilitated by a previous opening of the trachea, which admits of eafy refpiration while the ligature is forming roun4 the bafe of the tumor. 4. Tumors that are firm, particularly thofe pf the fchirrous ana) fleffiy kinds, even when feated external- ly, have been known to comprefs the trachea fo much as almoft entirely to obftrua refpiration : when fo fit* uate4 as to cover all the acceffible part of the trachea, which in the latter ftages of the tumor termed bron- chocele, is too frequently the cafe, this operation is inadmiflible; but much benefit may be derived from k whenever it can with fafety be performed. 5. An inftance is mentioned by Dr. Richter, of an inflammation of the tongue arriving at fuch a height as entirely to obftrua the paffage to the fauces ; and different inftances have occurred of mercurial Saliva- tions, when carried too far, indudng fuch a tumefiecfc ftate of the glands in the mouth and threat, as to be attended wkh the fame effea. In one cafe that I met with feveral years ago, and in which the glands of the' throat were naturally large, fuch complete obftruaion, was produced to the paffage of the air, as required the aid of this operation to fave the patient. In this in- ftance, fuch a quantity of mercury had been quickly thrown in, that the fwdling of thefe glands arrived at an alarming height in the fpace of a few hours from its commencement ; and although all the remedies ufually employed in fuch cafes were put in praaice, none of them had any effea : the operation was, con- trary to my opinion, delayed till the patient was al- moft completely Suffocated ; but he revived inftantly on the perforation being made. .6. Swellings of the amygdalae and contiguous parts,* which do not terminate Speedily in Suppuration, when they become large are apt to induce an obftruaed reSr piration ; and may thus render bronchotomy neceffar r.y. It is not fuch tumors, however, as originate en- tirely from inflammation that moft frequently come Chap. XVII. Of Bronchotomy. 469 this length: hard fwellings of the amygdala?, wherir attacked with inflammation, are Sometimes known to produce Such tumors in the fauces as entirely fhut up the paffage, which none of the ufual remedies will re- move ; and which, therefore, require the aid of this operation. But in real inflammatory tumors of thefe parts, constituting the angina inflammatoria of authors, unlefs the glands have been morbidly enlarged before the commencement of inflammation, the fwelling will feldom or perhaps never, proceed to fuch a height as to require it. When fwellings of this kind arrive at a large fize, we almoft conftantly find, that they do fo from their having gone into a ftate of fuppuration, when relief may be obtained by means of a more fim- ple nature than bronchotomy, namely, by difcharging the matter contained in the tumor by an incifion or a punaure. A common fcalpel or biftoury, wrapped up with a piece of linen near to the point, is general- ly ufed for punauring the amygdalae and other parts of the fauces ; but no precaution whatever will render this a fafe instrument for thefe purpofes. In Plates XL. and IX. are reprefented different forms of canu- las containing concealed lancets, which every furgeon ought to have, as by means of them any part of the ^throat may be Scarified with fafety, 7. Among the means employed for reftoring the circulation in people who have been long under water, or where refpiration has been obftruaed in any other manner, blowing air into the lungs, and repeatedly difcharging it, is, perhaps, more to be trailed than any other ; for, the aaion which is thus given to the lungs is readily communicated to the heart itfelf. The ufual method of throwing air into the lungs in fuch cafes, is by blowing forcibly into the mouth while the rioftrils are compreffed ; or by means of a curved tube inferted at one of the noftrils, fo as to make its ex- tremity terminate immediately above the glottis. But, although one or other of thefe methods may, in Some inftances, anfwer the purpofe of filling the 470 Of Bronchotomy. Chap. XVII. lungs with air, yet I know from experience, that it will not commonly fucceed. In different inftances of people who had been a few minutes under water, fev- eral attempts of this kind were made for throwing air into the cheft; but, either from fome contraaion of the epiglottis, or of the fuperior part of the larynx, none of them were found to fucceed ; and, as bron- chotomy was in both cafes obliged to be performed for effeaing it, I am therefore warranted in mention- ing this as one caufe that may render it neceffary. When, Srom any oStheSe cauSes, refpiration becomes So much obftruaed as to endanger the patient's exis- tence, bronchotomy fhould be immediately adviSed ; and the method of performing it is this. Whenever it is neceffary to have a patient firmly fecured during an operation, he fhould always be plac- ed upon a table ; and as this is a matter of much im- portance in bronchotomy, a table fhould be preferred tp a chair. The patient being laid upon a table, with his head drawn back and limbs fecured by affiftants, a longitudinal incifion fhould be made with a Scalpel, through the fkin and cellular Subftance on the middle and inferior part of the trachea, beginning at the infe- rior part of the thyroid cartilage, and proceeding downwards for the fpace of an inch. The flerno thy- roidei mufcles are thus brought into view ; and being Separated Srom one another, a confiderable portion of the thyroid gland is in this manner laid bare. As this gland is plentifully fupplied wkh blood veffels, and as the divifion of any of thefe proves always troublefome, and in fome inftances even dangerous, it fhould wkh much attention be guarded againft. This may com- monly be eafily done, by avoiding the inferior portion of the gland, where the two lobes of which it is com-, pofed unite, and finifhing the operation at the upper part of it where they feparate. In order, too, to guard as much as poffible againft the inconvenience arifing from the divifion of the arteries of this gland, the in- cifion fhould be flowly made ; and, as the arteries are Chap. XVII. , Of Bronchotomy. 471 of fuch magnitude as to be perceptible to the naked eye, they may, with due care, be avoided. The cellular fubftance lying between thefe portions of the gland being cautioufly removed, the trachea is thus laid bare ; and if no large blood veffel has been divided, the operation may be immediately finiffied, by making an opening between any two of the cartil- ages ; but if any large artery has been cut, it muft be fecured with a ligature beSore going Surther. Authors differ much in their opinion oS the beft manner oS fin- ifhing this part of the operation. By Some we are de- fired to make an opening with a Scalpel, while others preSer the point of a lancet; and by all, the perfora- tion is advifed to be of fuch a fize as to receive a tube or canula of filver, through which a quantity of air may be tranfmitted fully fufficient for the purpofe of refpiration ; but, as much mifchief enfues from blood getting into the trachea, by the convulfive cough which it induces ; and as this can fcarcely be prevented in the ufual manner of performing the operation, it has been propofed to employ a cutting inftrument adapted to a canula of a proper fize for being left in the open- ing. Descriptions of inftruments for this purpofe may be met with in the works of the ingenious Dr. Rich- ter of Gottingen,* to which I have already referred, and alfo in the fourth volume of the Memoirs of the Royal Academy of Surgery of Paris, by Mr. Bauchot. An inftrument which I confider as an improvement upon theSe, with which I have twice performed this operation, is delineated in Plate XXIII. fig. 3. It is nearly of the form of a flat trocar, but not quite fo long. The patient's head being ftill fupported and fomewhat drawn back, the point of the ftilette muft be made to penetrate the membrane between two of the cartilages ; and the extremity of the canula being pufhed fairly into the trachea, the ftilette is to be with- • Vide AuguAi Gottlieb Richteri D. Medicinse Profeflbris Gottingenfiq, Ohferv. chirurg. Fafcicul. fecund, can. iii. Gottingas, 1776. Of Bronchotomy. Chap. XVIL drawn, and the canula afterwards fecured, by a piece of tape conneaed with it being tied on the back of the neck. The inftrument is here reprefented without, encum- brances from the dreffings; but before bdng intro- duced, it Shoud be paSfed through the centre of three or four thin compreffes of linen : thefe not only ferve to cover the pledget of emollient ointment with which the wound fhould be proteaed after the ftilette is withdrawn, but by withdrawing one or more of them, which may be eafily done without moving the inftru- ment, merely by cutting up their fides with a pair of fciffars, the length of the canula may thus be aug- mented at pleafure; and which, in the event of the parts about the wound becoming Swelled, is found to be a very Important precaution ; for, when negfeaed, a very flight tumefaction on the fides of the fore will throw the canula out, The canula fhould, therefore, be always of fuch a length as may obviate the incon- venience that might enfue from this acceffion of fwell- ing. For this purpofe, it fhould never be lefs than two inches'long : when firft introduced, juft as much of its extremity fhould be left uncovered by the com-. preffes as. admits of its paffing eafily into the trachea. If ,iny fwelling takes place, one, two, or more plies of the linen being cut off, will ftill admit of the canula penetrating to the fame depth ; and, on the contrary, when it happens that the parts are Swelled at the time of the operation, as the quantity of tube lodged in the trachea might be too much increafed on the fwelling being removed, the inconvenience that would other- wife enfue may be eafily prevented, by Some addition- al plies of linen being inferted between any two of the compreffes. On experience we find, that a double canula an- fwers beft in this operation. When one tube only is ufed, it is apt to fill with mucus ; and as it muft fre- quently be taken out for the removal of this, refpira- tion is in the mean time apt to be impeded : but when Chap. XVII. Of Bronchotomy. 473 a double tube is employed, the inner canula can be eafily removed, cleaned, and replaced, white every in- convenience that would otherwife refult from iwis pre- vented by' the other being left in the opening. When, therefore, the outer canula of the tube is properly fix- ed, the other having been previoufly adapted to it, and the opening in the canula covered with a piece of crape or fine muffin, to prevent the admiffion of duft, the operation is in this manner completed. As the intention of this operation is to obviate the inconveniencies arifing from an obftruaed refpiraticm, it is evident that the canula fhould be continued in the wound as long as the cauSe that firft gave rife to it ex- ists. If a piece of bone or any other, fubftance has paffed into the trachea, and if this cannot be extraa- ed at the opening newly made, a curved probe Should be introduced at it, in order to afcertain the fituation of the extraneous body ; and this being done, anoth- er perforation muft be made direaiy above it. In this manner, this caufe of the difeafe may, in fome inftan- ces, be removed, and when obftruaions of a different kind are found to take place, the means beft adapted for their removal ffiould be immediately employed. But till the breathing becomes perfeaiy eafy, the ca- nula muft be continued ; and when at laft it is judged proper to withdraw it, the Skin fhould be immediately drawn over the orifice, and retained there with a piece of adhefive plafter, by which means a cure of the fore will foon be obtained. Dr. Richter, among other improvements which he propofes upon this operation, advifes the canula to be curved ; but, in the different inftances in which I have had occafion to perform it, none of the inconvenien- cies occurred which the Doaor fuppofes may proceed from employing a ftraight one : I have found indeed that the ftraight canula anfwers -every purpoSe ; and as a curved tube cannot have another exaaiy fitted- to it to be occafionally inferted and withdrawn, this I Of Bronchotomy. Chap. XVII, think is a fufficient reafon for not adopting the curved canula of Dr. Richter. To fuch as have not had opportunities of perform- ing this operation, the attention that I have advifed, to a proper regulation of the length of the canula, may appear to be unneceffary. This, however, is far from being the cafe; and much embarraffment would enfue from the negfea of it. The means that I have recommended for this purpofe are fimple, are at all times eafily procured, and upon trial, I have found that they anfwer the purpoSe: but a very neat and in- genious contrivance for the fame intention has long been exhibited by Dr. Monro in his courSe of Surge- ry ; and of which he has been fo obliging as to ad- mit of a delineation being here given. It is reprefent- ed in Plate XCII. fig. i. Chap. XVIII. Of Oesophagotomy. 475 CHAPTER XVIII. OF OESOPHAGOTOMY. SUBSTANCES are frequently taken into the pha- rynx, which, in paffing into the cefophagus, are too bulky to be forced down to the ftomach by the mufcular exertion of the parts at which they ftop. When any part of fubftances in this fituation can be obferved on looking into the pharynx, they are in general eafily removed with common forceps ; but when they have paffed entirely out of the pharynx, and are lodged deep in the cefophagus, this cannot be done ; and in fuch circumftances we are obliged either to allow the fubftance to remain where it is fix- ed ; to pufh it into the ftomach; or to extraa it by laying the cefophagus open. When the fubftance refting in the cefophagus is of a foft texiure, fuch as bread, cheefe, or even flefh, the eafieft and beft method of getting free of it is, to pufh it into the ftomach wkh an inftrument termed a pro- bang, Plate IX. fig. i. and %. This is much fafer and eafier than to attempt to bring it up, as is frequently advifed, by a ftrong emetic ; for when this does not fucceed, the exertion of vomiting in this obftruaed ftate of the cefophagus is very apt to do harm. But when a pin, a piece of fharp bone, or any oth- er firm fubftance, is fixed in the paffage, we fhould by no means attempt to pufh it down ; for, by doing fo, if it does not go into the ftomach, any point or roughnefs with which it is furnifhed, might be puffied direaiy into the fubftance of the cefophagus, as in feveral inftances I know has happened. 476 Of Oescphagotomy. Chap. XVIII. I think it neceffary to obferve, that this is a point of importance, and ought therefore to meet with at- tention. In every cafe of obftruaion of the cefopha- gus, arifing from a foreign body being fixed in it, it is almoft the univerfal praaice to endeavour to pufh it into the ftomach. When the obftruaing fubftance is of a foft yielding nature, fuch as bread, or a piece of flefh, this may commonly be done with fafety ; but for the reafon that I have given, it will very frequent- ly do mifchief when it is hard. In every cafe, there- fore, where the pain is not great; if the breathing id not much affeaed; and the paffage ftill fo pervious as to permit the food to get down to the ftomach, no attempt fhould be made for removing it; for we know irv.iii experience, that in moft inftances every thing of this kind is at laft carried down, either by the aaion of the cefophagus itfelf, by fome degree of diffolution taking place in the fubftance lodged in it, or by fome partial fuppuration forming in the cefophagus, by which that part of the extraneous body that was fix- ed in it becomes loofe. But where the obftruaion is So complete as to pre- vent the paffage of nourishment to the ftomach, or when the breathing is much interrupted, if the caufe of obftruaion cannot be removed by other means, it comes to be a queftion whether any attempt fhould be made for taking it out by incifion. As the cefo- phagus lies deep, being covered with the trachea, and as different blood veffels and nerves of magnitude and importance lie near it, it has always been very juftly confidered as dangerous to make an incifion into it; and in general it has been laid down as an eftablifhed maxim never to attempt it. But although no praaitioner would think it advif- able to perform this operation without fome reafon of importance, yet in fuch inftances as thofe to which I allude, where much danger muft enfue from any ma- terial interruption being formed, either to the paffage of food to the ftomach, or of air into the lun^s, it Chap. XVIII, Of Oesophagotomy. 477 would furely be preferable to give the patient a chance even from this doubtful remedy, than to allow him to meet a certain and miferable death. Notwithftanding a very general prejudice that pre- vails againft this operation, I think we are Sufficiently warranted in recommending it in thoSe cauSes oS ob- ftruaions in the ceSophagus that cannot be otherwife removed ; and the opinion is founded on the follow- ing circumftances : wounds in the ceSophagus, whe- ther infliaed by accident or defign, have been fre- quently cured, different inftances of which have fallen within my own knowledge, the moft remarkable of which was the cafe of a man, who, in an attempt to deftroy himfelf, cut the trachea on the right fide com- pletely through, and likewife penetrated the cefopha- gus ; and among other inftances recorded by authors of wounds in the cefophagus being cured, one is men- tioned by Bohnius ; in which, from the food paffing freely out at the wound, it was evident, that the cefo- phagus was injured, and yet a cure was eafily accom- pliffied. By various experiments, this operation is found to be fafely praaicable on dogs and other animals, in which the ftruaure oS the parts concerned is nearly the Same as in the human body : it has been repeat- edly done on the dead Subjea, without any injury to the contiguous large blood veffels or nerves ; and, laftly, there are at leaft two inftances upon record, of its having been performed with Safety and fuccefs on living fubjeas.* I have therefore no hefitation in fay- ing, that cafes may occur in which it may be proper to cut into the cefophagus. Befides thofe obftruaions arifing from the caufes that I have mentioned, inftances fometimes occur of the cefophagus being fo completely ftopped by con- ftriaions and tumors, that all communication between the mouth and the ftomach is cut off. • Vide Mcmoires de I'Academic Royale de Chirurgie, torn. iii. p. 14. Paris, 17J6. 478 Of Ocsophagotomy. Chap. XVIII. When the ftriaure is Seated in the fuperior part of the oeSophagus, making an opening into it may, in Some inftances, be Sometimes advifable, with a view to the conveyance of nourishment into the ftomach : any advantage* however, to be obtained in Such caSes from the operation, will in general prove only temporary, as diSeaSes of this kind have hitherto refifted every at- tempt that has been made Sor removing them. By many anatomifts the ceSophagus is reprefented as lying evidently to the left fide ; if it ftretches how- ever to the left, it is iri a very inconfiderable degree ^ but this confideration may render it proper to prefer the left fide for this operation; the method of per- forming which is this: the patient being fecured in the manner I have defired for bronchotomy, and his head drawn back and kept firm by an affiftant, an in- cifion fhould be made with a Scalpel, at leaft two in- ches in length, direaiy through the fkin and cellular Subftance, keeping cloSe by the fide of (he trachea, and commencing about half an inch above the feat of the obftruaing Subftance when this can be done ; and where this is impraaicable, by the obftruaion being within the cavity of the cheft, the incifion fliould commence about an inch and a half above the breaft bone. The cellular fubftance being freely divided, the fler- no thyroidaei and flerno hyoidaei mufcles, together with a portion of the thyroid gland, will be brought into view : with a flat blunt hook, one affiftant fhould pull the muScles gently to the left fide, while another by the fame means is employed in pulling the trachea fomewhat to the right, fo as to admit of the cefopha- gus being brought into view. If any large blood vef- fel is thus unavoidably divided, it fhould now be fe- cured with a ligature; and this being done, the oper- ator is to proceed to open the cefophagus. When the piece of bone or other fubftance fixed in the paffage is difcovered by the finger, the perforation fhould be made direaiy upon it, and the cut, which fhould al- Chap. XVIII. Of Ocsophagotonvj. 479 ways be longitudinal, being made of a fufiicient fize for extraaing it, this fhould be immediately done with fmall forceps. But when the caufe of obftruaion is found to lie within the cavity of the cheft, which muft add greatly to the hazard of the operation, the ceSo- phagus ought in this caSe to be opened immediately above its entrance into the cheft ; care being taken, in order to give fufficient room for what is to follow, that the opening in the cefophagus be extended up- wards to the full height of the external incifion. This being done, a large firm probe fhould be introducedj in order to determine the feat of the obftruaion, when by means of long fmall forceps, the fubftance produce ing the mifchief fhould be cautioufly laid hold of, and flowly extraaed. The operation being in this manner finifhed, all our attention is to be given to the treatment of the fore, and nourishment of the patient. When the op- eration is performed for Some difeafe in the fuperior part of the cefophagus, till this is either removed by medicines, or by an operation, which in cafes of com- preffion from tumors may fometimes be done, our principal objea is the conveyance of nourishment to the ftomach : in Such inftances, there is a neceffity for preferving the opening in the cefophagus. But when the operation has been performed for the purpofe of removing a foreign fubftance fixed in the paffage, as foon as this is accompliffied, nothing ffiould be omit- ted that can tend to promote an immediate reunion of the divided parts. If, in fuch circumftances, the pa- tient is allowed either to eat or drink much, the open- ing in the ceSophagus will be found difficult to heal, and may become fistulous. It will therefore be more prudent to recommend total abftinence from Solid food for feveral days, and to convey nourishment, in the form of ftrong Soups, by the anus, and allowing very fmall quantities of milk or Soup to be Swallowed from time to time : by preventing the patient from moving his neck, and treating the wound in the fame manner 4Sa Of Oesophagotomy* Chap. XVIII. with Similar affeaions in other parts, we know from experience, that a cure may at laft be obtained; and, at any rate, if this Should not happen, and if the wound fliould remain fistulous, or even if death fhould fuc- ceed, ftill the operator will have the confolation of having attempted every probable means for the fafety of his patient. In addition to what I have already obferved of the propriety of this operation in particu- lar cafes, I may remark, that the hazard attending it is not fo great as is commonly imagined. If the in- cifion is made in the manner I have direaed, clofe by the fide of the trachea, no injury can be done to any of the larger arteries or veins: the only blood veffels we have to be aware of, are thofe branches of the la- ryngeal artery that fupply the thyroid gland. With proper caution, the principal arteries of the gland may in general be avoided ; but if any of them fhould be divided,they may commonly be fecured with ligatures, efpecially if the external incifion is fufficiently free : in proceeding with caution too, that branch of the eighth pair of nerves, which from its inverted direc- tion has been termed the recurrent nerve, and which runs clofe by the fide of the cefophagus, may in gen- eral be avoided ; and even in the event of fome branches of this nerve bdng divided, the only bad confequences that probably would enSue, would be fome degree of weaknefs in the voice ; for the muf- cles of the larynx, in which they are chiefly fpent, do not depend entirely upon them. Chap. XIX. Diseases of the Nipples. 481 CHAPTER XIX. OF DISEASES OF THE NIPPLES. THE nipples are in fome cafes fo deeply funk in the breaft, that a child in attempting to fuck, finds it difficult or even impoffible to lay hold of them. To remedy this inconvenience, different means are employed. If the prominent part of the breaft can be preffed fo far back as to uncover even a fmall part only of the nipple, it may commonly be drawn out by getting a flout child of fix or eight months old to fuck it: but as this cannot be always done, glaffes of different kinds are employed for the purpofe. In Plate LIII. figs. 1. and 3. are reprefented two forms 6f glaffes with which the breaft may either be fucked by the patient herfelf or by an affiftant; and fig. 2. is a glafs cup mounted with a bag of elaftic gum. In ufing this, the air muft be preffed entirely out of the bag, when the cup being placed upon the breaft fo as to include the nipple, fuch a degree of foaion is pro- duced as very commonly draws it out. The bag, however, fliould be much larger than ufual, otherwife it does not aa with fufficient force. But whichever of thefe means is employed, it ffiould be continued till the nipple is drawn fully out; and always repeat- ed before the child attempts to fuck. The nipples, like every other part of the body, are liable to ulcerations; but from their peculiar delica- cy, any fores with which they are attacked, are al- ways produaive of much diftreSs, while the Sucking of the child tends not only to render them worfe, but of much longer duration than they otherwife would be. Cracks or chops in the nipples have not a for- midable appearance, but they are commonly much Vol. II. II h * 482 Diseases of the Nipples. Chap. XIX. more painful than ulcers of the greateft extent in oth- er parts of the body. Various remedies are employed for thefe affeaions, but emollients are moft frequently ufed: I have not found, however, that they ever give permanent relief 5 for although they may procure temporary eafe, it fel- dom or never proves of long duration. Mild aftrin- gents and drying applications prove more ufeful. As a wafh, lime water, weak faturnine Solutions, and So- lutions of allum, prove ferviceable; and port wine and water, or brandy fufficiently diluted, may be em- ployed for the fame purpofe. After bathing the parts with one or other of thefe, the nipple fhould be cov^ ered with foft lint, fpread with ungentum nutrkum, or Goulard's cerate ; but of thefe the firft is the beft : I have often ufed it with advantage, and I know of nothing that anfwers fo well in chops or cracks wher- ever they are fituated. It is proper, however, to ob- ferve, that the nipple fhould be entirely cleared of this application always before the child is allowed to fuck; for as lead forms the moft important part of it, mif- chief might enfue from much of it being carried into the ftomach. Till the nipple is completely healed, the child fhould not be allowed to fuck oftner than is quite ne- ceffary ; and when one of the nipples only is fore, this may be eafily managed, as the child may be kept at the found breaft, while the other is drawn from time to time with a glafs which does not injure the nipple. In Plate LIV. fig. 2. 3. and 4. fmall cups are delineated for proteaing the nipples during the cure. When properly fitted to the parts, they not only protea them from the friaion of the clothes, but allow the milk to run off as quickly as it falls from the breaft. Chap. XX. Of the Ampulation, &c. 483 CHAPTER XX. OF THE AMPUTATION OF CANCEROUS MAMMjE. CANCER has been known to attack almoft every part of the body; but we meet with it more frequently in the breafts of women than in almoft any Other part. In Chapter II. Seaion VIIL I entered fully into the confideration of cancer: I have now, therefore, to re- fer to that part of the work for the defcription and diagnofis as well as for the medical treatment of the diSeaSe; and in this chapter, I fhall chiefly adhere to the removal of cancerous tumors of the mammae by amputation. A real cancer is perhaps the moft formidable dif- eafe to which the human body is liable: wherever it is feated, its confequences are to be dreaded; but more eSpecially when fixed on one or both of the mammae. Various caufes have been affigned for can- cer proving more malignant in this fituation than in others; but the obvious reaSon of it is, that cancers being very commonly feated in glands, and the breaft being entirely glandular, cancer is neceffarily more apt to form in it than in parts not fo extenfive. In Chapter II. Seaion VIIL I endeavoured to fliew, that cancer, on its firft appearance, is perhaps, in ev- ery inftance, a local diSeaSe ; that the cancerous diathe- fis is produced, not by any original diSeaSe in the con- ftitution, but by abSorption, from a local ulcer ; and hence I obServed, that cancerous Sores fhould be re- moved by immediate amputation, wherever this can be done. This, I think, fhould be an eftabiifhed maxim in the treatment of cancer wherever it is fituated ; but 11 h 2 484 Of the Amputation Chap. XX. from its being more apt to infea the conftitution, when feated on the mammae than on other parts of the body, this is an additional reafon for early amputation in cancer of the breaft. As every fchirrous gland in the mammae is apt to degenerate into cancer, and as indurations of the mam- mae have hitherto refifted the efteas of every other remedy, early amputation fhould in every inftance be advifed : this, I know, is a point with refpea to which praaitioners are not agreed; fome having alleged, that, as fchirrous glands in the mammae have been known to remain in an indolent, inoffenfive ftate for a great length of time, their removal fhould never be advifed till they have aaually gone into a ftate of ul- ceration. But this opinion, which is evidently founded in1 timidity, has been the caufe of much unneceffary dif- trefs to a great proportion of all by whom it has been followed ; while it has ferved to bring the operation of amputating cancerous breafts into a degree of gen- eral difcredk, which it does not merit. There is no faa of which I am more convinced, than that many more would recover by means of the operation, were it employed in a more early period of the difeafe, par- ticularly while the glands are ftill in a fchirrous ftate, and before any matter-is formed in them : and as in- ftances of their remaining long in an indolent ftate are exceedingly rare, no dependence fhould ever be plac- ed on their doing fo. It is not a fingle inftance or two, in matters of fuch importance, on which an opin- ion ought to be formed : it is the refult of general ob- fervation that ought to direa us ; and every unbiaffed praaitioner muft confefs, that what I have here affert- ed refpeaing this matter is, at leaft in general, well founded. The propriety of amputating fchirrous breafts early being admitted, and the praaice eftablifhed, it may poffibly happen in a few inftances, that fchirrous tu- mors of this part may be removed, which might have Chap. XX. of Cancerous Mamma. 485 remained in an indolent ftate for fome time longer. But as this would not frequently be the cafe; as we have no means by which we can judge with certainty, between fuch cafes as might remain for fome time in this indolent ftate, and thofe which might proceed more rapidly ; and eSpecially, as the advantages derived Srom early amputation are unqueftionably great; no hefi- tation fhould occur in putting it univerfally in praaice. When praaitioners, therefore, have an opportunity of amputating cancerous or fchirrous breafts early, they ought always to embrace it. It often happens, however, from an improper delicacy in patients, as well as from other caufes, that praaitioners are not eonfulted till the difeafe is far advanced. But, al- though the advantages to be derived from the opera- tion will, in general, be in proportion to the previous duration of the difeafe; yet on all occafions, even in very advanced ftages of cancer, it is right to advife it, provided the parts affeaed can be completely remov- ed. When this cannot be accomplifhed, from the cancerous parts lying jtoo deep, or being immediately conneaed with organs effentially neceffary to life, by which amputation of the one cannot be performed without much injury being done to the other; in fuch circumftances, as the operation would not be of any real utility, it Should not be advifed ; for, as all the difeafed parts could not with propriety be removed, and as the cancerous virus is of a very affimilating na- ture, it would anfwer no beneficial purpoSe to ampu- tate only a portion. But in every inftance where the diSeaSed parts can be Safely feparated from the found, as nothing but their removal can afford any chance of fafety, I muft again fay, that we fhould not hefitate to advife the operation. I fhall now proceed to defcribe the method of performing it. In every chirurgical operation it fhould be an estab- lished maxim to Save as much Sound Skin as poffible, Such portions of the common teguments as are dif- eafed, or that adhere firmly to the parts below, ought 486 Of the Amputation Chap. XX. certainly to be taken away ; but it can never be pro- per to remove more than this : for it is now univer- fally known, that the cutis vera is never regenerated; and when deftroyed, that the parts underneath are af- terwards covered with thin fcarf-fkin only. This, however, is not the only objeaion to an extenfive re- moval of fkin : in every operation where much of it is deftroyed, the wound that remains is neceffarily much more extenfive, and the cure therefore more tedious, than when little, or perhaps no fkin has been taken away. Indeed, this is fo much the cafe, that in operations where no flan has been removed, cures will be fometimes accomplished in a few days, which, by the removal of much fkin in the ufual way of per- forming the fame operation, Would be protraaed to many weeks or months. This praaice of removing much fkin in the ampu- tation of tumors, feems to have originated from an idea that has long and very univerfally prevailed, of the fkin being by much diftention apt to lofe its tone fo entirely as not to be able to recover it again ; and therefore, that in every fuch inftance, a confiderable part of it fhould be taken away. This, however, is by no means the cafe ; and whoever will adopt a dif- ferent praaice, will find, that tumors rarely or never become fo extenfive as to deftroy the elafticity of the fkin that furrounds them. Inflammatory tumors, in- deed, proceed frequently with fuch rapidity to a large fore, as to diftend the Skin more quickly than it can properly bear, and at laft burft it entirely when fup- puration takes place: but in almoft every other vari- ety of tumor, the progrefs of the fwelling is fo flow knd gradual, that the natural contraaile power of the fkin is feldom or never fo far deftroyed by it, as to prevent it from recovering its tone on the caufe pro- ducing the diilention being removed : and in caSes of fchirrous breafts, this contraaile power of the fkin is commonly So remarkable, that even when the breaft is much enlarged, and all the glandular part pf it re- Chap. XX. of Cancerous Mamma. 487 moved, the fkin, if it has been preferved, almoft con- ftantly contraas to the fize of the remaining fore; fo that in all fuch cafes, none of the fkin fhould be re- moved that is not either aaually difeafed, or adhering fo firmly to the parts below, that it cannot be eafily feparated. In proceeding to the operation, the patient muft be either firmly feated in an arm-chair, her head being fupported with a pillow by an affiftant behind, whilft her arms are properly fecured by an affiftant on each fide ; or fhe may be placed upon a table, which an- fwers better than any other pofition :*in this manner She is more eafily fecured ; faintings are leSs apt to occur ; and the Surgeon proceeds with more eaSe through every part of the operation, than when the patient is Seated in a chair. But in whatever pofition foe may be placed, the Surgeon fhould for certain be feated : Surgeons indeed, perform this operation mofl frequently while ftanding beSore the patient; but no operator will ever attempt it in this manner, who has once experienced the advantages that reSult from do- ing it in the manner I have adviSed. In the firft place, I fhall SuppoSe the operation to be performed for a Schirrus of the mamma, while the fkin is ftill found, and without adhering to the parts beneath. In theSe circumftances, an incifion fhould be made with a Scalpel through the fkin and cellular Subftance, Srom one extremity of the tumor to the other ; taking care to direa the fcalpel So that it may avoid the nipple, by carrying it an inch or So to one fide of it. When the diSeaSe has extended, as it flome^ times does, beyond the mamma towards the Sternum, as this commonly throws the longeft diameter oS the tumor acroSs the body, this external incifion fhould run in a direaion corresponding to the length oS the tumor, by making it to commence at one fide of the mamma, and terminate at the other ; but when the mamma alone is diSeaSed, the external incifion fliould run in a perpendicular direaion, commencing at the 488 Of the Amputation Chap. XX. upper part of the tumor, and finifhing at the moft de- pending point of it. By this means, any matter that may form during the cure is freely difcharged ; which does not happen when the incifion runs in a tranSverSe direaion, unlefs the inferior portion of the teguments is afterwards divided from above downwards; which in fuch cafes, fhould always be done : for although, in Some inftances, a cure is eafily obtained, even where this precaution is not kept in view, yet in gen- eral, fome inconvenience would eufue from the ne- gfea of it. The fkin and cellular fubftance being thus freely ( divided, are now to be feparated from the difeafed ' parts below by a flow and fteady diffeaion ; and this being accomplished, the teguments fhould be kept -afunder by affiftants, till all the glandular part of the breaft is diffeaed from the peaoral mufcle and other parts with which they are conneaed. With a view to preferve the peaoral muScle as much as poffible from being cut by the fcalpel, the arm of the affeaed fide Should be kept extended Somewhat above a hori- zontal direaion; by which means all the fibres of this muScle are preServed in a ftate of extenfion, and are thus leSs liable to be injured during the operation than when they are kept relaxed. It often happens, indeed, that the difeafed parts ad- here to the pectoral mufcle ; and, in fome inftances, even to the periofteum of the ribs. In fuch cafes, as all the difeafed parts muft be removed, we fhould not hefitate to ufe every neceffary freedom with the pec- toral mufcle, as well as with every other part to which the mamma adheres ; but whenever the removal of the difeafe can be accomplifhed without injuring thefe parts, it ought undoubtedly to be done. On the mamma being removed, the operator fliould examine with much accuracy, not only the furface of the fore, but the parts beneath the edges of the divid- ed fkin ; and if any indurated glands are difcovered, they fhould all be removed. In this part of the ope- Chap. XX. of Cancerous Mamma. 489 ration, much care and attention is requisite ; for un- leSs all the diSeaSed glands are removed, no advantage will be derived from it. I have defired that the whole glandular part of the mamma fhould be removed. Even where a Small portion of it only is diSeaSed, the whole ffiould in gen- eral be taken away ; for no good purpoSe can be an- fwered by a portion of it being left; and in many in- ftances where this had been done, mifchief enfues from the difeafe making its appearance again in fome part of the glands which remain. When indeed it is found that a Single loofe gland only is difeafed, it may be taken out without injuring the reft of the breaft ; but whenever the diSeaSe is extenfive, the whole mamma fhould be removed. The next flep in the operation is to Secure the di- vided arteries, and it fhould always be done with the tenaculum. As the arteries of the mamma are fre- quently fmall and numerous^ much attention is ne- ceffary to difcover them. All the coagulated blood fhould be effeaually cleared away with a fponge and warm water ; and if the patient is faint, a glafs of wine or fome other cordial fliould be exhibited ; by which means fmall branches of arteries are often dif- covered which otherwife w-ould efcape notice, and which if negleaed might induce much hazard and diftrefs. The blood veffels being thus fecured, and the Sur- face of the fore cleared of blood, the divided tegu- ments Should be brought together; and, in order to fecure them with accuracy in their fituation, ligatures fliould be introduced at thofe points where they are •moft likely to anfwer the purpofe. I have fometimes employed flips of adhefive plafter inftead of ligatures, but they do not retain the parts fo exaaiy in their fituation; and the pain which ligatures excite is too trifling to be mentioned. In fecuring the teguments In this manner, care muft be taken to leave all the ligatures of the arteries hang- 493 Of the Amputation Chap. XX, ing an inch or two out from the wound, fo that they may be withdrawn in a few days ; which in general may be eafily and fafely done when they have been applied with the tenaculum, In order to promote the adhefion of the teguments to the parts beneath, moderate preffure fhould be ap- plied over the whole by means of the napkin and fica- pulary bandage ; but before applying it, the parts fliould be all covered with a piece of Soft lint Spread with any emollient ointment, and over this there fhould be a thick comprefs either of lint, tow, or Soft old linen. In this manner, when no portion of the teguments has been removed, as the whole Sore will be covered with fkin, a cure will be obtained by a proceSs which furgeons in general have termed the firft intention ; that is, without the formation of matter. But it does not often happen that the operation is advifed whilft this mode of praaifing it is admiffible. In general, before a praaitioner recommends amputar tion of a breaft, and ftill more frequently before a pa- tient confents to it, a confiderable portion of the ex- ternal teguments are fo much difeafed, as to render it neceffary to remove them along with the glandular part of the mamma; pr, if the fkin is not aaually dif- eafed, it commonly adheres fo much to the moft prom- inent part of the breaft, that it cannot be feparated from it. In either of thefe circumftances, fome por- tion of the fkin muft be removed along with the mam- ma ; and the eafieft method of doing it is this: a lon- gitudinal incifion fhould be made, in the manner I have advifed, through fuch parts of the teguments as are perfeaiy found, whilft that portion of the fkin that is difeafed, or which adheres firmly to the glandular part of the breaft, fhould be Separated from the Sound fkin, by a circular or oblong incifion, with which the longitudinal cut ought to communicate; and this be- ing done, the operation is to be finifhed by diffeaing oft* every part that is indurated, along with that por- .Chap. XX. of Cancerous Mamma. 49? tion of the fkin which in this manner has been fur- rounded with an incifion Such as I have mentioned. In the after ftate of the fore, a material difference takes place between the operation that I have now de- fcribed, and that in which there is no neceffity for re- moving any portion of fkin. Where none of the fkin is removed, the divided teguments on being drawn to- gether cover the fore completely; an adhefion com- monly takes place over the whole ; and the cicatrix that enfues is inconfiderable : but when any portion of fkin is removed, a fore is always left, which not only renders the cure tedious in proportion to the quantity of fkin that is taken away, but the cicatrix is neceffarily of the fame fize ; by which much tender- xiefs and irritability is left in the fite of the difeafe, which I am convinced has often fome influence in making It return. The fore that remains after the operation, fliould be treated with the mildeft dreffings. When any he- morrhagy takes place Srom the Surface of the fore, and is not removed on the larger arteries being Secured with ligatures, dry lint fhould be applied for the firft dreffing ; but for all the after dreffings, lint covered with any emollient ointment fhould be preferred. Mild emollients never give pain, which dry lint is very apt to excite ; and they certainly admit of a more quick formation of granulations than any dreffings that give irritation. I have hitherto been Suppofing that the diSeaSe oc- cupies the mamma only ; but the lymphatics leading from the breaft to the armpit are alfo often indurated, and likewife the glands in the armpit itfelf. In fome inftances, too, a number of difeafed glands are found to run from the breaft to the clavicle, and to fpread in confiderable clufters along both the upper and un- der edges of that bone. In fuch circumftances, the amputation of the mam- ma itfelf muft be managed in the manner I have al- ready advifed ; bu: befides this, an incifion fliould be 492 Of the Amputation Chap. XX. made through the fkin and cellular fubftance from the further extremity of every duller of hardened glands, and made to terminate in the principal cut produced by the removal of the mamma. Thus, when the glands in the armpit are enlarged, although they might frequently be pulled out either feparately or connea- ed together, by a hook infinuated below the Sound fkin at the Sore in the breaft ; yet it anSwers the pur- pofe better, to lay the glands firft bare by an incifion in the manner I have advifed, and then to diffea them cautioufly out with the Scalpel. In the courSe oS the diffeaion, a good deal of affiftance may be obtained from paffing a ftrong ligature through the largeft gland; by which the whole clufter with which it is conneaed may be elevated from the parts below, fo as to admit of their being more eafily cut out with the fcalpel: and it often happens, that thefe indurated glands run fo near to the axillary artery, as to render it highly proper to ufe every probable means for xen- dering the diffeaion fafe and eafy. In like manner, when a clufter of difeafed glands is found to extend towards the clavicle, or in any oth- er direaion, after the teguments have been freely di- vided, the glands themfelves fhould be totally remov- ed ; and both here and in fimilar affeaions in the arm- pit, the divided teguments fhould be brought together, and retained in their fituation, either by means of compreffion alone, or, when this is not fufficient, by the introduaion of one or more futures. The point that I more efpecially wifh to inculcate refpeding this operation is, the propriety of faving as much Skin as poffible. The neceffity of this had rare- ly, if ever, occurred to our forefathers : and accord- ingly the common praaice has been, to remove all the Skin correfponding to the morbid parts underneath : by which much unneceffary pain is produced ; a very extenfive and ugly fore is left; and the cure is always tedious. Inftead of which, although it may not in every inftance be praaicable by the means that I have Chap. XX. of Cancerous Mamma. 493 advifed, to cover the fore entirely with fkin ; yet, in all cafes, a confiderable part of it may for certain re- ceive this important advantage ; by which the extent of the fore will be much diminiffied ; a cure will be proportionally Sooner effeaed ; and by the cicatrix being lefs extenfive, the rifle of the patient in future will probably be lefs alfo. The propriety of faving as much fkin as poffible, not only in this operation, but in every other where' an extenfive fore is commonly left, particularly in am- putating the extremities, has always appeared to me to be a matter of fuch importance, that, from the time of my entering on the operative part of bufinefs, I have taken all opportunities of putting it in praaice. Ev- er Since the year 1772, I have managed cancerous breafts in the manner I have now mentioned, that is, by endeavouring to fave as much fkin as poffible; and the advantages derived from it have been very con- fiderable. Till of late, the only means put in praaice for Se- curing the fkin in its fituation, fo as to effea an adhe- fion between it and the parts underneath, was com- preffion by the napkin and feapulary bandage, except- ing in a few cafes in which adhefive plafters were em- ployed. But as ligatures give very little pain, and as they retain the parts more certainly in their fituation, I now employ two, three, or more, according to the extent of the divided parts j and they always anfwer the purpofe. 494 Of the Paracentefis Chap. XXI. CHAPTER XXI. OF THE PARACENTESIS OF THE THORAX. SECTION L General Remarks on this Operation. THE operation of the paracentefis, or tapping the thorax, is always indicated where the aaion of the heart or lungs is much impeded by fluids collea- ed in the cavity of the cheft. Hitherto this operation has been fuppofed to be ap- plicable to the evacuation of water or of pus only; chiefly of the latter, in the difeafe termed empyema. But I am clearly of opinion, that it is equally proper for the difcharge of any other fluid as for colleaions of water or purulent matter. The fymptoms induced by colleaions of different fluids, may vary according to the nature of the difeafe, or of the accident giving rife to their formation. But it is their effea on the motion of the heart and lungs, to which praaitioners ought chiefly to attend; and this will always depend more on the quantity than on the kind of fluid that is colleaed. The different kinds of fluids met with in the thorax, and requiring to be drawn off by this operation, are ferum, blood, pus, and air. Of thefe I fliall treat in feparate feaions. Sea. II. *f the Thorax. 49i SECTION II. Of Serum colleded in the Thorax. COLLECTIONS of ferum in the cheft are fre- quently combined with dropfy in other parts : but we often meet with it as a local affeaion; and it is in this cafe chiefly, that any advantage is to be ex- peaed from a chirurgical operation. Independent of general effufions into the two large cavities of the thorax, dropfical colleaions are alfo met with in the pericardium, and in Some inftances they are confined to the mediaftinum immediately below the Sternum. Various and diftreSsful fymptoms accompany thefe Colleaions, but it requires much attention to afcertain their exiftence, and efpecially their particular fituation, with fuch precision as can warrant an operation of fuch importance as the paracentefis of the cheft. A patient who complains of a fenfe of weight or oppreffion in the thorax ; of difficult refpiration ; of more uneafy fenfations in one fide of the cheft than in the other ; of being liable to fudden fits of Starting during Sleep, from fear of immediate fuffocation ; and if, along wkh thefe, he is diftreffed with a frequent cough ; if the pulfe is fmall and irregular ; and if a dry Skin, Scarcity of Urine, Swelled limbs, and other fymptoms of dropfy take place, little doubt can re- main of water being colleaed in fome part of the cheft. A fenSe of undulation, as of w ater paffing from one part of the breaft to another, is Sometimes observ- ed by the patient on rifing Suddenly from a horizon- tal pofture; and this, I may remark, ferves not only to affift in ascertaining the real nature of the difeafe^ but to determine In what particular part of the cheft the water is colleaed. Much attention, therefore, fhould be given to this circumflance ; for by means 496 Of the Paracentefis Chap. XXL of it we may commonly determine, with fome preci- sion, where a perforation ought to be made. That every poffible advantage may be derived from this circumftance, the patient fhould have his cheft uncovered while under examination. When the quan- tity of colleaed ferum is confiderable, it may com- monly be difcovered by placing one hand upon the anterior part of the ribs near to the Sternum, and Strik- ing with fome force near to the back-bone with the other ; and if an undulation is perceived in one fide of the cheft and not in the other, the feat of the difeafe is thereby obvious. But when the quantity of fluid is not great, this trial is not to be trufted. In this cafe, a perfon ftanding behind the patient upon a chair, fhould be direaed to take a firm hold of the upper part of his body, and to Swing it repeatedly by hidden jerks from one fide to another ; and if water is contained in the cheft, it will thus be very certainly found to undulate, and an evident noife will arife from it. I have met with different inftances of this, in which the exiftence of the difeafe was thus precifely determined. In long continued colleaions of ferum, affiftance in the diagnofis is Sometimes obtained, from the part in whidh the water is feated being more prominent than the reft oS the cheft. It has even been alleged, that all the ribs of one fide of the thorax have, in fome in- ftances, been found obvioufly elated, by the water being in fuch quantities as to prevent them from con- traaing in the aa -of exfpiration. This can only hap- pen in the very late ftages of the difeafe; but wher- ever it takes place, it Shews with certainty where the water is to be looked for. When the difeafe is in the pericardium, nearly the fame fymptoms take place wkh thoSe which dropfy produces in other parts of the cheft. The moft accu- rate obfervation indeed will Sometimes fail in judging of this ; but in the hydrops pericardii, it is obferved, that the patient complains chiefly of the middle and Sea. II. of the Thorax. 497 left fide of the thorax: and Senac, in his excellent treatife on the ftruaure of the heart, mentions as a charaaeriftic mark of this difeafe, a firm undulatory motion being perceived between the third, fourth and fifth ribs on every pulfation of the heart. As it is not in any refpea neceffary to enter minute- ly into the investigation of the caufes of thefe collec- tions, all that I fhall fay refpeaing it is, that whatever tends to produce dropfy in other parts of the body, will have a fimilar effea in forming it here. The exiftence of water in the thorax being ascer- tained, and the part in which it is colleaed being dif- covered, if the medicines employed in the cure fhall fail, and if it is evident that the patient muft die if the operation is delayed, it ought certainly to be advifed without farther delay: perforating the thorax is no doubt an important operation, and it ought not to be advifed but in real danger. I do not, however, hefi- tate to fay, that it fhould be performed in every in- ftance where the attending fymptoms are hazardous, and cannot be removed by other means; and the me- thod of doing it is this : The patient fliould be laid in a horizontal pofture, With the fide in which the perforation is to be made laid over the bed: when in this fituation, the fkin over the whole fide on which the opening is to be made, fliould be pulled upwards by an affiftant, by Whom it fhould be preferved in this fituation during the operation; and the Surgeon ffiould now, with a Scalpel, make an incifion two inches in length between the Sixth and feventh ribs, in the very direaion of thefe bones, and at an equal diftance between the Ster- num and back-bone, taking care to avoid the under border of the fuperior rib on account of the blood vef- fels running^in its groove. But although it is necef- fary, in order to obtain fufiicient room for the fcalpel, to have the opening in the fkin and cellular fubftance of this length, there is no reafon for continuing it of Vol. IL I i 498 Of the Paracentefis Chap. XXL the fame extent to the bottom; fo that, as the knife paffes through the intercoftal mufcles, the incifion may in a gradual manner be fhortened to the length of an inch. On the pleura being laid bare, it fhould be flowly and cautioufly divided, in order to avoid all rifk of wounding the lungs, left they fhould at this place happen to adhere. If they do not adhere, the water will rufh out with much force as foon as an opening is made in the pleura; but if the pleura ad- heres to the lungs at this place, the incifion muft ei- ther be carried forward to an inch or two nearer the Sternum, or another opening will be required, either an inch or two higher or lower in the thorax. As foon as water is found to flow, the filver canula, Plate LXXIII. fig. 6. fhould be introduced at the opening ; by which means the difcharge will not only be more eafily completed, but will likewife be more readily ftopped, if this fhould be found neceffary, by the pa- tient becoming faint. By doing it in this manner, air is prevented from finding accefs to the cavity of the cheft ; a circumftance of Some importance in this ope- ration. When the water colleaed is not in great quantity, it may commonly be all drawn off at once; but as from the ftruaure of the thorax, we are deprived, during this operation, of the advantage of compreffion,. except of that which may be communicated through the abdomen, which muft here be very limited, when much water is colleaed, partial evacuations ought to be made, at longer or fhorter intervals according to circumftances. For this purpofe, and with a view to give a temporary fufpenlion to the difcharge, the ca- nula Should be fecured by a ribbon conneaed with it tied round the body of the patient, and ftopped from time to time with a piece of cork adapted to its open- ing. A pledget of emollient ointment fhemld be laid over the wound; and the whole being fecured with the napkin and Scapulary bandage, the patient fhould in this ftate be laid to reft. After a fukable delay of sea. II. if the Thorax, 499 a day or two, an additional quantity of water may be drawn off; and by thus taking it away in a gradual manner, all rifk may be avoided of the patient being injured by the difcharge being too fudden. In this manner any quantity of water contained in the cheft may be drawn off with fafety; and the pa- tient being now relieved from the great diftreSs under which he laboured, the canula may be withdrawn, proper means being at the Same time employed for preventing a relapfe of the difeafe.. I have hitherto SuppoSed, that the Serum is collea- ed in only one of the cavities of the cheft ; but when both fides are affeaed, it cannot be all drawn off by one operation. In this caSe, therefore, after being drawn off from one fide, the operation Should be re- peated in the other ; but fome rifk might occur from performing it in both fides at nearly the fame time, by the external air getting accefs at once to both cavities of the cheft : Sor although I have adviSed the opening in the pleura to be Small, and a canula to be imme- diately paffed into it, yet ftill it is impoffible, even with the utmoft caution, to prevent the air from find- ing accefs, either by the wound or canula, to the fur- face of the lungs ; and if both cavities of the cheft fliould at the fame time be filled wkh air, nearly the fame oppreffed State of refpiration would take place as was produced by the ferum newly difcharged. Be- fore the operation, therefore, is repeated on the oppo- fite fide, fome means fliould be adviSed for expelling the air received into the cavity of the cheft by the firft perforation. This may be done in different ways ; the moft eafy and convenient of which is this: imme- diately after the canula is withdrawn, let the patient endeavour, as far he dare fafely venture, to fill the lungs with air. This will expel a confiderable part of what was colleaed between the pleura and lungs, by the perforation; and if the Skin, which was re- traaed before the operation, be inftantly drawn over i I 2 50Q Of the Paracentefis Chap. XXi* the fore, and preffed down by an affiftant during in-* fpiration, all accefs will thus be prevented to the ex- ternal air ; and by this being frequently repeated, almoft all the air colfeaed between the pleura and lungs will be expelled : after which the fkin muft be drawn over the wound ; and by means of a comprefV and bandage properly applied, the parts may be made to adhere without further trouble. Air may alfo be drawn off from the thorax in the following manner : let an exhaufting fyringe be fitted with fuch a mouth of ivory or metal as will allow it to be clofely applied over the opening in the pleura* When thus applied, every ftroke of the pifton will extraa a confiderable quantity of air ; and as foon as the whole is fuppofed to be nearly exhaufted, the in- ftrument may be removed, and the wound treated as I have already advifed, by drawing the fkin over it, and endeavouring to heal it by the firft intention. Or inftead of an exhaufting fyringe, one of the elaftic vegetable bottles, fitted with the fame kind of mouth, may be employed. By expelling all the air out of the bottle, and applying the mouth of it over the wound in the pleura, a quantity of air nearly equal to the bulk of the inftrument will be extraaed, and it may again be applied as often as is neceffary ; care being taken at each removal of the inftrument to ex- clude all acceSs to the air, by drawing the retraaed fkin over the wound. Air colfeaed in either of the cavities of the cheft,. may not only prove hurtful by impeding the motion of the lungs, but it muft likewiSe do harm by that ten- dency to inflame, that is commonly given to parts naturally Secluded Srom the air, from their being by accident laid open fo as to admit of air being freely applied to them. In all fuch cafes, therefore, this cir- cumftance merits particular attention. When one fide only of the thorax is laid open, either in colleaions of water or matter, the oppreflion produced upon the lungs by the admiffion of air, is not commonly of Sea. II. of the Thorax. 5°! much importance, as for the moft part it is expelled by exfpiration alone. This I know from experience is the caSe ; but inflammation, as I have already ob- served, being Sometimes induced by air finding accefs to thefe cavities, it ought at all times to be rigidly guarded againft ; and, as much diftrefs has been in- duced from both cavities of the cheft being laid open at once, it ought never to be attempted. ^ Our veiws in what I have ventured to advife in the different fteps of the operation, will appear, I hope, fufficiently obvious ; but as fome furgeons prefer a different part of the cheft, as well as a different in- ftrument, for performing the operation, I think it ne- ceffary to confider thefe points fomewhat more mi- nutely. It has been faid, that unlefs the opening is lower in the cheft, the water will not be completly difcharged, as all that part of the cavity that lies below the wound will ftill continue to be filled with it. But, if the pa- tient is laid in a horizontal pofture, wkh his body in- clined to the fide in which the perforation is made, the fpot that I have advifed will be found to be more depending than any other; and in this fituation we have this material advantage, that the lungs do not fo readily adhere to the pleura, as they do farther down, where they come more clofely into contaa with the diaphragm; and here too, the perforation is made wkh more eafe than it can poffibly be nearer the fpine, where the thick mufcles of thefe parts cannot be avoided. With refpea to the inftrument with which the ope- ration is performed, the fcalpel, I think, is the beft. A trocar has been recommended by many : but how- ever well adapted a trocar is for piercing the abdomen or Scrotum, in which none of the contained parts can be hurt if the operation is rightly performed, yet in the thorax much rifle muft attend the ufe of it from the adhefions which often tr.ke place between the lungs and pleura, and from our not being previoufly 502 Of the Paracentefis Chap. XXI. able to determine whether they adhere or not at the very point in which the perforation is made. In the event of no adhefion being met with, the trocar would no doubt accomplifh the intention of the ope- ration, and with perfea fafety if cautioufly introduc- ed. But if it fliould unfortunately be inferted where adhefions between the lungs and pleura take place, the lungs would not only be injured, but the opera- tion would not anfwer the purpofe; for the inftru- ment entering the fubftance of the lungs, it would not come into contaa with the water colfeaed between the lungs and the pleura lining the ribs, and conse- quently no difcharge would enfue. With the fcalpel, this inconvenience is avoided: on the pleura being laid bare, a fmall hole fhould be Scratched in it with the point of the fcalpel; and as foon as this mem- brane appears to be penetrated, if no ferum is dis- charged, there will be much caufe to imagine that the lungs adhere at this place; and the furgeon will now either defift entirely, and make an attempt in another fituation; or if the adhefion between the lungs and pleura is flight, which may be known by the cautious introduaion of a blunt edged probe, as much of them may poffibly be feparated as to allow the canula to pafs into the colleaion of ferum: at leaft this trial may at all times be propofed. If the lungs are eafily feparated, and if the adhefion is not extenfive, the operation will thus be completed; while if the con- trary fhall eyer be the cafe, the operator will at leaft have the Satisfaaion to think that he has done no mif- chief, which he might not in fuch circumftances have been able to avoid, if a trocar had been ufed. After duly attending, therefore, to every circumftance, I am clearly of opinion, that the fcalpel fhould in this ope- ration be preferred to the trocar. When the difeafe is feated in the pericardium, it is in fome inftances fo much diftended, that on exami- nation, it is eafily diflinguifhed. Upon making an Sea. IL of the Thorax. 503 opening in the left fide, between any two of the ribs from the third or fourth to the feventh or eighth, and within the diftance of five or fix inches of the fternum, we can never fail in this diftended ftate to meet with it; and when brought fully in view, by the pleura be- ing freely divided for the fpace of an inch or two, the beft method of finifhing the operation, is to pufh a fmall trocar into the pericardium. If the quantity col- feaed is fmall, it may all be drawn off at once ; but when confiderable, the difcharge fhould be frequently ftopt for a few minutes together, with a view to pre- vent thofe inconveniencies which might enfue from giving a hidden and free flow to the whole quantity. When, again, ferum is colfeaed in a cyft between the lamellae of the mediaftinum, as it is fituated im- mediately below the fternum, any pain or oppreffion which it excites, is more confined to the centre of the breaft, than we find it to be when the colleaion is feated in either of the cavities of the cheft ; and for the fame reafon, any opening intended to discharge it, muft be made directly through the fternum itfelf, by a piece of that bone being taken out with the head of a trepan, fo as to admit of the feat of the difeafe being laid in view. The method of applying the trepan I need not enter upon at prefent, as the operation has been already defcribed in a preceding chapter. All that I need farther fay upon the fubject is, that as foon as the cyft containing the fluid is laid bare, a perfora- tion fhould be made into it wkh a trocar; care being taken to manage the difcharge in the fame cautious manner I have already advifed, and not to allow the parts newly laid open to be more expofed to the air than is neceffary. 5°4 Of the Paracentefis Chap. XXI. SECTION III. Of Blood colleded in the Thorax. HEN blood is colfeaed in large quantities in any part of the cheft, the breathing becomes opprefled, and the motion of the heart and arteries fee- ble and irregular. Thefe, indeed, are fymptoms which occur in every colfeaion Seated in the thorax ; but they arrive at a greater and more diftreSsful height from blood, than from colleaions of other fluids. In other circumftances, the fymptoms arifing from blood and ferum are fo Similar, that they need not again be enu- merated. Blood may be effufed in the cavity of the thorax by different caufes, and of thefe the following are the moft frequent. i. Wounds that penetrate any of the blood veffels in the thorax. 2. The Spiculae of a fraaured rib, and fplinters of the fternum and vertebrae, fometimes injure the blood veffels in the thorax. 3. Thefe veffels are fometimes eroded by the mat- ter of an ulcer or of an abfcefs ; and, 4. They may be ruptured by any violent exertion, particularly in the aaion of coughing. As it commonly happens, where blood is colfeaed in the cheft, that the veSfels from whence it is dif- charged are feated in the fubftance of the lungs, part of the blood is ufually brought up by the mouth in a fit of coughing ; and when the quantity difcharged in this manner is confiderable, it gives relief to the op- preffed ftate oS the lungs as well as of the heart; but whenever the aaion of either of thefe organs becomes much impeded by a great accumulation of blood, fome attempt Should be made to draw it off by a perfora- tion : and as blood, when extravafated, coagulates w Sea. III. of the Thorax. 505 quickly, andjCannot in this ftate be eafily difcharged, an* opening fhould be made for this purpofe as foon as from the iyfnptoms there is caufe to imagine that it is beginning to ftagnate. When the blood is found to be So firmly coagulated as not to pafs off by a perforation, it has been propof- ed to dilfolve or to dilute it by injeaing warm water or emollient infufions. This, however, is a praaice that ought feldom to be advifed ; for injeaions, even of the mildeft kind, muft in this fituation be always attended with rifk ; but when it So happens, that much blood is colfeaed in a coagulated ftate, and that it can- not be drawn off even by enlarging the opening in the pleura as far as can with propriety be done ; and as much hazard would be incurred by allowing it to remain, even a doubtful remedy in fuch circumftances becomes eligible. In this fituation, by Srequently and cautioufly injeaing tepid water, the coagulated blood may be gradually So much Softened and diffolved as to be at laft difcharged. But when we have kin our power to make a choice, it will be much for the inter- eft of our patient, to prevent the neceffity of this rem- edv, which for the moft part may be done by making an incifion in the manner I have advifed, in that part of the thorax where the blood appears to be collected. By fome praaitioners, particularly by Mr. Sharpe, we are advifed, in cafes of blood colfeaed in the cheft, rather to truft to ks being abforbed or coughed up from the lungs, than to endeavour to draw it off by this operation.* Where blood is either extravafated in the fubftance of the lungs, and is freely fpit up, or when colfeaed in any of the cavities of the cheft, and in Such Small quantities as to produce no material im- pediment to the aaion of the lungs or heart, it would no doubt be improper to advife it to be discharged by an operation, as in courfe of time, by bloodlettings * Treatife pf the Operations of Surgery, chap. nir. 5q6 Of the Paracentefis Chap.' XXL being frequently repeated according to «the Strength^ the patient; by the effea of a low die% and other remedies ufual in fuch cafes, there will be caufe to frope that it may be abforbed; and in the mean time, while the quantity of extravafated blood is inconfiderable, no material inconvenience can ariSe Srom it. But what I wifli to inculcate is, that when Such a quantity of blood is colfeaed in either of the cavities of the thorax, as to difturb the funaions of the organs contained in it, it ought to be drawn off by a perforation. It is faid by Mr. Sharpe, that, by allowing the blood to coagu- late in the cheft, the orifice from whence it is poured will be more readily Stopt, than if it were quickly dif- charged; But in anfwer to this, I muft remark, that if the wounded veffel is not large, little or no addition- al rifk will be incurred by drawing off the blood as it is poured out, as in this cafe the hemorrhagy will pro- bably ftop on the patient's becoming faint: and on the contrary, if the divided veffel is large, the remedy propofed by Mr. Sharpe will not be Sufficient for the purpofe ; for a wound in any of the large veffels of the breaft, will probably prove fatal, whether the op- eration of the paracentefis is performed or not. The direaions that I have given for difcharging fe- rum. colfeaed in the thorax, will, in general, prove equally applicable for the evacuation of blood: only, when the colfeaion is produced by a ruptured blood veffel, induced either by a fraaured bone, or by fome extraneous body preffed into it, the incifion fhould be made as contiguous as poffible to the part affeaed, fo that the opening may ferve not only for difcharging the blood, but for extraaing fuch portions of bone as are found to be detached, or any foreign bodies that may be met with. And again, when a wound with a fharp pointed inftrument is the caufe of the colfeaion, inftead of perforating any other part of the cheft, it will commonly anfwer the purpofe better, merely to enlarge the wound; at leaft, this will always be pre- Sea. IV. of the Thorax. 507 ferable, in wounds of the inferior part of the thorax ; but, when feated fo high in the cheft, as to be unfit for difcharging the blood contained in it, the operation in that cafe fhould be performed between the Seventh and eighth ribs, in the manner I have already advifed. SECTION IV. Of an Empyema, or a Colledion of Purulent Matter in the Thorax. THE marks of oppreffion on the heart and lungs produced by purulent matter colfeaed in the cheft, are very Similar to thoSe which proceed Srom Serum, but in colleaions oS pus, Symptoms take place which direa our opinion, not only in regard to the nature of the difeafe, but in pointing out the fpot in which it is feated. It has been afferted, that pus is fometimes depofited in particular parts without any previous inflammation. ■But this is fo very uncommon, that we may lay it down as a fixed principle, that inflammation is a ne- ceffary forerunner of purulency ; So that an empyema can never be met with, but as a confequence of an in- flamed ftate of a particular part. When, therefore, fuch Symptoms take place, as indicate the exiftence of a fluid in the thorax, if they have not been preceded by inflammation, we conclude that they are not induc- ed by purulent matter. But when a patient who has for fome time complained of a fixed pain in fome part of his cheft, attended with heat, a quick pulSe, and other Symptoms oS inflammation, is at laft Seized with oppreffed reSpiration ; an inclination to fit in an erea pofture ; with a total inability of lying on the found fide ; a conftant tickling cough ; frequent rigors or fliiveiings ; and efpecially if thefe Symptoms are acr companied with an enlargement of the affeaed fide,' 508 Of the Paracentefis Chap. XXI, or with a foft oedematous fulnefs of the part in which the pain was at firft feated; we may conclude wkh much certainty, that a large colfeaion of matter is formed. Inflammation of Some portion of the lungs, or of their coverings, may be induced by various caufes. In fome inftances, families appear to have an heredi- tary tendency to tubercles in the lungs, which every flight attack of cold is apt to affea with inflammation. A natural contraaed ftate of the thorax feems like- wife to predifpofe thefe parts to inflame ; and inflam- mation may be produced here, in the fame manner as in other parts of the body, by every variety of exter- nal violence. But by whatever means the contents of the cheft may have become inflamed, when this terminates in fuppuration, if the matter, inftead of being freely dif- charged by the mouth, as is frequently the caSe, is found to produce all the fymptoms that I have already had occafion to enumerate of oppreffed refpiration, the only remedy upon which any dependence can be placr ed, is a perforation, Praaitioners have in general confidered this opera- tion as more hazardous than it really is; and it has been Said, that it ought never to be adviSed, but when the Seat of the abfcefs is clearly pointed out by an ex- ternal fwelling between two of the ribs. When the lungs become inflamed in a part that adheres to the pleura, abfceffes may form there; and when difcover- ed, they fhould no doubt be laid open. But although the operation for the empyema, as it is commonly termed, is of Some importance, and fhould never be employed but when indicated by neceffity ; yet I am not of opinion that it can ever be attended with fo much riSk as to render the formation of an external abfceSs the only cauSe for performing it. When there is reafon to think, that previous inflammation in fome part of the breaft, with evident marks of its having terminated in fuppuration, is the caufe of oppreffed Sea. IV. of the Thorax. 509 breathing, and when the fymptoms are not fpeedily relieved by a free expeaoration of matter, the opera- tion of the paracentefis fhould be performed immedi- ately on that Spot where the collection is SuppoSed to be feated, whether any external marks of an abfceSs exift or not. It may frequently happen, that no mat- ter will be difcharged on the perforation being made into the cheft, for we know from experience, that ab- fceffes are often feated in the fubftance of the lungs, and not in either of the cavities of the cheft. But, even in fuch inftances, the perforation may prove ufe- ful, as the lungs, by lofing their uSual Support at a particular point, will more readily yield than they oth- erwise would do to the matter colfeaed in them: while, if the matter is already poured into the cavity of the cheft, a perforation being made into it, is the only remedy that can fave the patient. I am therefore clearly of opinion, that, in all fuch cafes, the paracen- tefis of the thorax fliould be advifed. The direaions given in the two preceding feaions, for conduaing the perforation, will apply with equal propriety in colleaions of pus : only, it muft be re- marked, when the feat of an abfceSs is pointed out, ei- ther by a long continuance of pain in any one point, or by matter being diftinguiffied between two of the ribs, that this is by much the beft direaion Sor the place of the incifion. But when no fuch mark is met with, the place that I have advifed for the operation when water or blood is to be difcharged, will anfwer equally well for the difcharge of matter. It is likewife neceffary to obferve, that, in purulent colleaions proceeding from external injuries, particu- larly from penetrating wounds, no operation can be neceffary, if the wound by which the abfcefs is produc- ed is fo fituated as to difcharge the matter ; but when the wound is found to be too high in the thorax for anfwering this purpoSe, an opening in a more depend- ing place becomes neceffary ; and again, when the matter is feated fo immediatclv below the fternum that 510 Of the Paracentefis Chap. XXI. it cannot be difcharged by an opening between two of the ribs, a piece of tfyat bone muft be removed wkh the trepan, as I have already adviSed, when Speaking of colleaions of ferum. In abSceffes of thefe parts, the matter is commonly firft formed in the fubftance of the lungs, and after- wards difcharged into one or other of the cavities of the cheft. It fometimes happens, however, that large quantities of pus form between the pleura and furface of the lungs, without any apparent affeaion of that organ ; and feem to proceed from an inflamed ftate of the furface of the pleura. Thrfe colleaions, how- ever, feldom continue long without producing ulcera- tion ; and when ulceration has taken place, the dif- charge of matter that fucceeds to the operation of the paracentefis generally continues for a great length of time. Different caufes concur to render the cure of ab-> feeffes in the cavity of the cheft tedious : the conftant motion of the lungs; our not daring to induce that degree of inflammation that we know to aa power- fully in producing a reunion of parts that have been divided by the formation of matter; and the effea of compreffion being precluded by the intervention of the ribs. Although, in a few inftances, the quantity of matter gradually becomes lefs, and the external open- ing contraas and heals, yet, from the caufes I have mentioned, in a great proportion of thofe who have undergone the operation for the empyema, or who have had large colleaions of matter in the breaft, as the effea of accidental wounds, the difcharge contin- ues for a great length of time, moft frequently for life. The fore, indeed, will often heal, if it be not artificial- ly kept open ; but the matter almoft coriftantly burfts out again, or another operation becomes neceffary. to difcharge it, when it colfeas again in Such quantities as to produce a renewal oS the Symptoms oS oppreffion on the lungs and heart. Seft. IV. cf the Thorax. 51 % I have already had occafion to advert to this fub- jea when treating of v/ounds of the thorax, in Chap. III. Sea. XL At prefent, I only think it neceffary to obferve, that although in the treatment of wounds, the general ufe of tents, whether Solid or hollow, has been condemned with much propriety ; yet that we are evidently milled by fafliion, when we lay them entirely afide in wounds that penetrate the breaft. I know that it is the opinion oS many praaitioners, that tents of every kind fliould be exploded; but I alfo know, that patients who might otherwise have been faved, have frequently fuffered by this rule being too generally followed. As long as the matter of an ab- fcefs in the thorax continues to find an eafy vent, and is difcharged freely, either by the wound by which it was produced, when this is Sufficient for the purpofe, or by a perforation made for drawing it off, when this is found to be neceffary, there can be no caufe for employing tents ; and in fuch circumftances, indeed, it would be improper to ufe them. But when the opening in the thorax heals too quickly ; when, in confequence of this, the matter does not find a free vent, and fymptoms of oppreffed breathing fupervene; in fuch circumftances, the propriety of preferving a paffage for the matter is obvious. Repeated experi- ence has convinced me, that this may be done both with eafe and fafety, by introducing a ffiort tube of gold, filver, or lead, into the opening, and allowing it to remain for a few hours, as often as a tendency to heal makes it neceffary. By negfeaing this, and al- lowing fuch fores to heal, as now commonly happens, much mifchief is done, which wkh this kind of atten- tion, might be eafily prevented. 512 Of the Paracentefis Chap. XXL SECTION V. Of Air extravafated in the Thorax. AIR colfeaed in either of the cavities of the cheft, excites the fame fymptoms of oppreffion on the lungs and heart, as thofe arifing from water, blood, or matter; it therefore becomes equally an objea of chirurgical management. Colleaions of air may be produced in the thorax by different caufes. i. As the procefs of putrefaaion tends to extricate air from every part of the body in which it takes place, air may be colfeaed in the thorax, from any of the organs contained in it being Seized with mortification. This variety of the difeafe, however, will Seldom fall under the care of the furgeon ; for the caufe by which it is produced can fcarcely be Suppofed to yield to any remedies that may be employed for it; and unlefs the mortification is removed, no benefit could refult from any operation. 2. Air may pafs into one or both of the cavities of the cheft, from a rupture of the investing membrane of the lungs, and this again may occur from violent exertion in coughing, laughing, and crying, as well as from other caufes. 3. The furface of the lungs may be eroded by ul- ceration, or by purulent matter in contaa with them becoming acrid, by which a paffage may be given for air into one or other of thefe cavities. 4. Wounds penetrating the lungs have Sometimes produced colleaions of air in the cheft ; but in fuch inftances, the wound muft be made with a fmall point- ed inftrument pufhed in an oblique direaion. A wound produced by an inftrument carried forward in a direa line into the lungs, does not readily produce colleaions of air, as the air that efcapes from the lungs Sea. v. of the Thorax. 5*3 paffes out at the wound: but in oblique wounds, the air does not eafily eScape, as the parts naturally Sail together; in which ftate they operate in the Same manner as a valve, So that the extravaSated air muft neceffarily colfea in one or other of the cavities. 5. The point of a fraaured rib wounding the lungs, is apt to induce colleaions of air in the thorax ; and a fraaure of the fternum, or arty of the vertebrae, may be attended with the fame effea. Thefe feveral caufes may occafionally produce ex- travafated air in the thorax ; but we meet 'with it more frequently from fraaures of the ribs than from any of the others. The fymptoms produced by air effufed in the tho- rax differ only from thofe that occur from ferum and purulent matter, in their arriving more quickly to an alarming height: inftances have occurred of death being induced in the fpace of a few hours from the fraaure of a rib, merely by air colfeaing in large quantities between the pleura and lungs : in Some, perhaps in the greateft proportion of all that occur, along with this colfeaion of air in the cheft, the cel- lular fubftance of the breaft becomes inflated ; and if means are not foon employed to prevent it, the air in- finuates through every part of the body. It is truly aflonifhing to obferve, how quickly a frac- tured rib, when it wounds the furface of the lungs, Will in fome inftances induce the moft alarming fymp- toms. The patient at firft complains of tightnefs in the breaft, attended with oppreffion in breathing, along with pain in the parts chiefly affeaed. This difficult refpiration becomes more diftrefsful. The patient can- not breathe in a recumbent pofture, and is always ea- fieft when erea and leaning Somewhat forward: the face becomes flufheJ and Swelled: the pulfe is com- monly feeble, and at laft it becomes irregular: the extremities become cold ; and if relief is not quickly Vol. IL K k 514 Of the Paracentefis Chap. XXL obtained, the patient is at laft carried off with every mark of fuffocation. The emphysematous Swelling of the external parts or" the cheft, which Sometimes takes place here, is eafily diflinguifhed from watery effufions, by the crackling produced on preffure ; the SenSation it communicates being nearly Such as is received from preffure upon a dry bladder when nearly filled with air. For the remo- val of this fymptom, fcarifications have been employ- ed. By making feveral incifions, each about half an inch in length, along the courfe of the Swelling,-a good deal of air may be difcharged, efpecially if the air con- tained in the fwelling is frequently preffed towards thefe openings. A confiderable quantity, too, of the air col- feaed in the thorax, will be drawn off by the fame means : for, as foon as any part of it paffes off from the cellular membrane,, its place will be immediately fupplied from the cheft ; and if the quantity that ef- capes by the wound in the lungs* is not greater than the quantity difcharged by the fcarifications, the whole in this manner may foon be removed. But it fre- quently happens, that the air forced out from the lungs is much more than can pafs off by any number of fcarifications that can be made; in which cafe, any relief that takes place in the oppreffed ftate of refpira- tion, is commonly inconfiderable. Till of late, patients in this fituation almoft con- ftantly died ; for when Scarifications failed in discharg- ing the air, and even this remedy has not been long. in ufe, praaitioners were not acquainted with any oth- er means of relief. But we now know, that in all fuch cafes, where the oppreffed ftate of breathing is great, and the fymptoms are evidently induced hy air collected in the cheft, that the Same remedy fhould be employed for removing it, as is found to fucceed in colleaions of any other fluid, viz. the operation of the paracentefis ; and it has accordingly, of late years, been frequently performed, and always with complete Sea. V. *f the Thorax. 515 fuccefs; the tenfion in the breaft, difficulty of breath- ing, and every other fymptom being immediately re- lieved on a perforation being made through the pleu- ra.* With a view to prevent the inconveniencies that re- fult from the external air finding accefs to the cavities of the cheft, it has been propoSed to make the open- ing with a trocar inftead of a fcalpel; and by enter- ing the inftrument in an oblique direaion, this pur- pofe would no doubt be anSwered. When the cheft is completely filled with air, and if certainty could be obtained that no adhefions exist- ed between the lungs and pleura, the operation might be performed with fafety, and with more eaSe by the trocar than with any other inftrument: But as we can never know with precision whether the lungs adhere or not, I am, for theSe and other reaSons mentioned in a preceding part of this chapter, induced to think that the operation maybe done with more Safety wkh the fcalpel. And if the direaions that I have given are obServed, of. retraaing the fkin from the part to be perforated ; of introducing a canula immediately into the opening in the pleura, as foon as air begins to ef- cape ; and drawing the retraaed fkin over this perfo- ration into the cheft, as Soon as the canula is with- drawn, the operation may be done with more certain- ty oS avoiding the lungs, in the event of their adher- ing to the pleura, and probably with more SucceSs in every reSpect, than when the trocar alone is employed.' The praaice, thereSore, that I would incline to Sol- low, is, in the firft place, to make Several incifions along the courSe of the fwelling, each of a half inch in length, and of fuch a depth, as to pafs entirely through the fkin into the cellular membrane : and, if thefe do not afford relief, which, however, they fre- * This operation, for the evacuation of air from the cheft, was firft pro- pofed by Dr. Monro, about the year 1760, in his lectures in this Univer- ftty. i £ K 2 516 Of the Paracentefis Chap. XXL quently do, to proceed immediately to perforate the cavity of the cheft in the manner I have advifed, and as near as poffible to the injured part, when the malady has been induced by external violence, if this be not near to the back-bone ; in which cafe the per- foration fhould be in the moft depending part of the thorax, as I have already advifed in colleaions of wa- ter, blood, and matter. And when produced by vio- lent exertion in coughing, crying, or laughing, the particular feat of the complaint will in general be dif- covered by fome degree of pain in the injured part.- Chap. XXII. of the Abdomen. 517 CHAPTER XXII. OF THE PARACENTESIS OF THE ABDOMEN. IT is the effea of various difeafes to produce col- leaions of fluids in the cavity of the abdomen : occafionally theSe colleaions are removed by the in- ternal exhibition of medicines, though in a great pro- portion of cafes, we are obliged to employ the opera- tion of paracentefis or tapping. There is naturally fecreted into the cavity of the pe- ritonaeum, a ferous exhalation, for the purpofe of lu- bricating and keeping moift the Surface of the intef- tines. Various caufes may concur to produce a mor- bid increafe of this fecretion ; and whenever the quan- tity colfeaed in the abdomen is large, it conftitutes a difeafe termed afcites. This variety of dropfy often accompanies a gener- al difeafe of the fyftem, being frequently combined with anafarca ; but in fome inftances it is local, and is evidently induced by compreffion of the lymphatics ; moft frequently by fchirrous fwellings of fome of the vifcera ; commonly indeed by an enlarged ftate of the liver. The prefence of a fluid in the cavity of the abdo- men, is known by the fwelling that takes place ; by a fenfe of tightnefs all over the belly ; by the breath- ing being difficult and laborious, when the patient is in a horizontal pofture ; and by a SenSe of ffoauation being communicated to the fingers placed on one fide of the belly, when it is forcibly ftruck on the other. A concurrence of thefe circumftances will always, to" a difcerning praaitioner, point out the real nature of the difeafe ; but a further confirmation is obtained of 518 Of the Paracentefis Chap. XXII. it when the patient complains of much thirft, a dry fkin, Scarcity oS urine, and other Symptoms of dropfy. When the fwelling is found to extend equally over the abdomen, the ferum is commonly diffufed among the different vifcera, and is contained within the peri- tonaeum only. It Sometimes happens, however, that it is colfeaed in different cyfts, or perhaps in one or both of the ovaria ; in which cafe, the tumor is not commonly fo equal, nor the fluauation fo diftinaiy percdved, as when the water flows freely through the whole cavity. This circumftance of fluauation de- pends alfo on the confiftence of the fluid; for, we fometimes find it thick and gelatinous, whilft moft frequently it is thin and perfectly ferous. In fome in- ftances, too, an innumerable quantity of fmall hyda- tides are found Swimming in the Serum of afcitical Swellings, by which the fluauation is commonly made obScure. Whatever may be the influence of diuretics and oth- er evacuants in the cure of general hydropic fwellings, they rarely prove ufeful, as I have elfewhere obferved, in local colleaions. The principal objea, therefore, to be kept in view here is, to difcharge the water col- feaed in the abdomen, by a chirurgical operation, as foon as its exiftence is ascertained ; while the moft ef- feaual remedies fhould in the mean time be employ- ed for preventing a recurrence of the diSeaSe. This indeed is often impraaicable: but, in fome cafes, cures are accompliffied; and it would probably happen more frequently, if the fluid colfeaed in the belly was more early difcharged. In general, this is delayed too long; for the bowels muft furely be greatly injured by being fo long foaked in water, as ufually happens in afcites, before the operation is advifed. This, too, is the more improper, as the operation of tapping is in itfeli exceedingly fimple. It excites little pain; and any danger attending it does not proceed fo much from the nature of the operation, as from the conftitution bdng, in general, much debilitated by the long con- Chap. XXII. of the Abdomen. 519 tinuance of the difeafe before it is performed ; which renders it liable to confequences that otherwife would not So readily occur, and which frequently terminate fatally. I am fo perfeaiy convinced indeed of this, that I commonly advife the water to be drawn off as foon as a fluauation is diftinaiy perceived; and I have never been fenfible of any harm being done by it. In large colleaions of fluids, wherever they are fit- uated, more particularly in the abdomen, the fituation of a large proportion of blood veffels, it is found to be exceedingly hazardous to difcharge their contents fuddenly ; owing, as we fuppofe, to the immediate in- fluence produced upon the circulating fyftem, by our thus depriving it too quickly of a fupport to which it had for a long time been accuftomed. But whatever may be the immediate caufe of the fymptoms refulting from Sudden evacuations of this kind, the effea is always certain. Syncope often hap- pens ; and death itSelf fometimes enfues from it. This, in former times, made tapping a hazardous operation ; and when the colfeaion was large, in order to avoid thofe inconveniencies that enfued from the water being all drawn off at once, it was done at different times, a day or two being commonly allowed to intervene be- tween one operation and another. This, however, proved very inconvenient and dif- trefsful ; and by the frequent introduaion of the tro- car which thus became neceffary, mortification of the wound, and other troublefome confequences were apt to enfue. The late Dr. Mead, reffeaing on the probable caufe of thofe fymptoms arifing from the hidden difcharge of large colleaions of water, was induced to try the effea of preffure upon the parts in which they are feated, as a fubftkute for the fupport of which they are deprived by the evacuation; and the fuccefs at- tending the praaice has fully justified the ideas that he entertained of it; for when preffure is properly ap- plied, almoft any quantity of water that the abdomen 520 Of the Paracentefis Chap. XXIL can contain, may with fafety be drawn off. It ought however, to be applied wkh much equality, over the whole belly ; and continued without interruption for the fpace of feveral days after the operation. Various mean's have been propofed for applying equal preffure in this operation ; but none of them anfwers the purpofe fo eafily, and with fo much effea, as a bandage invented by the late Dr. Monro, repre- fented in Plate XCI. fig. 2. Two different Sizes of this bandage fhould be always in readinefs; fo large as to cover the whole abdomen, and to prefs wkh equality upon every part of it. It is not neceffary to recapitulate the means ufed in former times, for difcharging hydropic colleaions ; for they are now very univerfally, and with much propriety, laid afide ; the trocar being the only in- ftrument at prefent employed for this purpofe. This inftrument, till of late, was always round, with a tri- angular point. As this form, however, is evidently ill calculated for an eafy entrance of the inftrument, an objea of much importance in the operation, I was led a good many years ago to the ufe of a flat trocar with a lancet point, reprefented in Plate I. figure 1. This has always anfwered the purpofe properly; but fome Improvements have been propofed upon it, by which it is made to enter with ftill more eafe. In Plate LXVII. fig. 2. I have delineated a very neat in- vention by Mr. Andree. It has been objeaed, how- ever, to this inftrument, and I believe with good rea- fon, that the canula, by confifting of two fides which fall together wkh fome force on the ftilette being with- drawn, may thus lay hold of a portion of inteftine; and if this fhould ever occur, much diftreSs ; nd even danger might enSue from it. In Plate LXXIII. fig. 2, an improvement upon the trocar is given, to which no fuch objeaion occurs : it enters with the fame eafe as a lancet; and the two fides of the canula, by not fall- ing clofe together, can never injure the inteftinej. Chap. XXII. of the Abdomen. 521 In performing the operation, it has been faid, that the opening may be made with almoft equal proprie- ty in any part of the inferior boundaries of the abdo- men. This, however, is not the cafe : for, in the cen- tre of the abdomen, immediately below the umbilicus, and in the courfe of the recti-mufcles, it might fall upon the epigaftric artery ; and, if carried near to eith- er of the offa ilia, the inteftines would more readily be hurt than if made nearer the navel. The fafeft and beft part for the perforation feems to be, at a point lying at nearly an equal diftance between the umbilicus and centre of the fpine of the ilium. No Jarge blood veffels can probably be wounded here. The abdominal parietes are not in this part entirely tendinous ; but are fomewhat fleffiy, fo that they more readily heal when wounded. None of the inteftines can in this fituation be readily injured ; and when the patient is laid in a horizontal pofture, in v, hich he ought always to be during the whole courfe of the operation, the point that I have mentioned will be found to be more depending than perhrps any other. The operation being determined upon, the method of performing it is thL- ; the point in which the perfor ration is to be made, fhould be marked wkh ink ; and in applying the bandage, Plate XCI. one of the open- ings fliould be placed exaaiy oppofite to this mark. The bandage being accordingly applied in this man- ner, and the ftraps being put through the buckles, and drawn fomewhat tight, the patient fliould now be laid in a horizontal pofture, with his head elevated, and the fide to be perforated lying over the fide of the bed. The furgeon is now to take the trocar in his right hand ; and fixing the head of the ftilette in the palm of his hand, while his forefinger direas the point of the inftrument, he is now to pufli it forward till he * finds that the eni of the canula is entirely through the mufcles, and lodged in the cavity of the abdomen ; which he may be certain is the cafe, when he finds no farther refiftance to the ftilette. The ftilette is now 522 Of the Paracentefis Chap. XXII. to be withdrawn, and the canula allowed to remain as long as the difcharge continues, care being taken to pull the bandage gradually tighter as the water flows off; or, if the patient, notwithftanding this precaution, Shall become languid, a total ftop fhould be put to the difcharge for a few minutes, which is eafily done by the Surgeon placing his finger from time to time on the mouth of the canula. It Sometimes happens, that the diScharge ftops be- fore the Swelling is much diminiffied : when this is owing to a portion of omentum or interline flopping the extremity oS the canula, the diScharge is eafily re- newed by inferting a blunt probe into it, So as to pufh back whatever may have plugged it up ; or when the ferum is thick and gelatinous, in order to effea a complete evacuation, it may Sometimes be neceffary to introduce a trocar of a larger fize than that which was firft employed. But when it proceeds, as is Some- times the caSe, from the Serum being colfeaed in par- ticular cyfts, no attempt of this kind will have any ef- fea : in fuch circumftances, the canula muft be with- drawn, and the wound being covered in the ordinary way wkh a pledget of any Simple ointment, the ope-. ration may be renewed either immediately or on the following day, on the oppofite fide of the abdomen \ or if the fwelling is confined to any other part of the belly, the perforation muft be made in the moft de- pending part of it, wherever that may be. Dropfical Swellings of the ovaria exhibit nearly the fame appearances with encyfled dropfies of any other kind : only, in colleaions of this kind in the ovaria, the fluauation of a fluid is not commonly very dif- tina ; and unlefs they are complicated with afcites, the Swelling is commonly confined to one fide of the abdomen. The propriety of drawing off the water by a perfo- ration, is here, however, equally obvious as in any other variety of the diSeaSe : that is, when we wifh to diminifh or remove the tumor, it muft neceffarily be Chap. XXII. of the Abdomen. 523 done in this manner ; but I think it right to obferve, that, in dropfical Swellings in the ovaria, the diSeaSe does not increafe So rapidly as in common caSes of af- cites ; neither does it appear to injure the conftitution fo much, and the water not being in contaa with the inteftines, we are not in this variety of the difeafe un- der the fame neceffity of advifing the perforation early. The ferum being all drawn off, and the opening-^ dreffed in the manner I have advifed, the bandage muft ftill be continued Sufficiently tight Sor preventing thofe diftreSsful feelings which the hidden difcharge of it would otherwife be fore to induce : and there is even reafon to think, that the fupport which the bandage affords to the weakened parts may have Some effect in preventing a return of the difeafe ; but when, notwith- ftanding of this, and of fuch internal remedies as are employed, the water is again found to colfea, the op- eration fails to be repeated whenever the fwelling be- comes large. Afcites is perhaps the moft frequent variety of tu- mor to which the abdomen is liable ; but in fome in- ftances, inftead of water, tumors of the abdomen are found to contain air, conftituting a difeafe termed tym- panites. The effea produced by this upon the breathing, is nearly the fame as what enfues from colleaions of wa- ter ; but the fwelling itfelf is much more tenfe than the other, and affords to the touch and preffure near- ly the Same SenSation as is received from a bladder filled with air. < . In a great proportion of cafes of tympanites, the air after death is found in the inteftines ; which, in fome inftances, have been inflated to a moft enormous fize. This I fuppofe to proceed from the inteftines lofing their tone ; but there is another variety of the difeafe, in which the air is diffufed in the cavity of the perito- neum, in a fimilar manner to water in afcites. I have feen one inftance of this, and I have heard of another., 524 Of the Paracentefis Chap. XXIL which happened lately in this place; but in both, the air was found to have efcaped from a fmall hole* in one of the inteftines. I am therefore inclined to be- lieve, that this variety of tympanites very commonly proceeds from communication having taken place be- tween the alimentary canal and the cavity of the peri- tonaeum ; and therefore, that any remedies we can employ, muft, where this is the cafe, be of no avail. But from whatever caufe the diSeaSe may have arifen, and whether the air fhould be contained within the bowels themfelves, or diffufed in the cavity of the pe- ritonaeum, no doubt fhould be entertained of the pro- priety of difcharging it, as foon as it appears to have brought the life of the patient into danger. This may be eafily done in the very manner I have direaed for afcites ; taking care to ufe a trocar of the fmalleft fize, and to employ preffure in the Same guarded manner as when the tumor is formed by wa-? ter. For, as the air will by its preffure produce near- ly the fame effeas upon the neighbouring parts as we find to ariSe from water, it is equally neceffary to em- ploy fuch a degree of compreffion after it is discharg- ed as will obviate the effeas of abftraaing it. To perforate the abdomen for air colfeaed in the inteS? tines, is no doubt a very -formidable operation, and ought not to be attempted but in cafes of the greateft danger ; but as death has often enfued from this vari- ety of the difeafe, and of which I have met wkh difr ferent inftances, I am clearly of opinion, when the remedies prefcribed by the phyfician for removing it have failed, that the affiftance of forgery ffiould always be defired, rather than allow the patients to die in cer- tain mifery. The Same remedy is frequently and fuc- cefsfully employed for difcharging air colfeaed in the ftomach and bowels of other animals : we have much reafon, therefore, to hope, that In the human fpecies the fame effeas would refult from it. After the operation of tapping, whether in afcites or colleaions of air, we are commonly advifed to rub Chap. XXII. of the Abdomen. $25 the abdomen from time to time with aftringent fpiri- tuous applications. This can never do harm : it may fometimes ferve to reftore the tone oS the integuments, and as the friaion employed in it may tend to pro- mote abforption, it ought never to be omitted. For the firft two days after the operation, it cannot be em- ployed, as during that period the*bandage ought not to be removed: but this being elapSed, the bandage may be removed daily Sor about a quarter oS an hour at once, for the purpofe of rubbing the abdomen with camphorated fpirit of wine, or volatile liniment; care being taken to preferve the body during the time of it in a horizontal pofture, and to renew the applica- tion of the bandage as foon as the friaion is over. 526 Of Hernia. v Chap. XXIII. CHAPTER XXIII. OF HERNIjE. * • - SECTION I. Of Hernia in general. THE term hernia might with propriety be applied to every fwelling produced by the diflodgement of parts from thofe boundaries within which in a ftate of health they are contained; but the term in its gen- eral acceptation, implies, a tumor produced by the protrufion of parts from the cavity of the abdomen. The parts in which herniae ufually appear, are the groin, Scrotum, labia pudendi, the upper and fore part of the thigh, the umbilicus, and different points be- tween the interfaces of the abdominal mufcles. If the fituation of thefe tumors is various, the vifce- ra which they contain are ftill more fo. Inftances have occurred of the ftomach, uterus, liver, Spleen,^ and bladder, being found in them. But they moft frequently contain a portion of the omentum or ali- mentary canal, and in fome inftances a portion of both. From the fituation and contents of herniae, all the appellations are derived by which this kind of tumor is diflinguifhed. Thus herniae are termed inguinal,' Scrotal, femoral, umbilical, and ventral, from their ap- pearing in the groin, Scrotum, thigh, navel, or belly. When confined to the groin, a hernia is faid to be in- complete, and is termed bubonocele ; but, when the tumor reaches to the bottom of the Scrotum, the rup- ture is then Suppofed to be complete, and the difeafe obtains the name of Scrotal rupture, or oScheocele. Sea. I. Of Hernia. 5*7 When a portion of gut alone forms the tumor, it is called an enterocele, or inteftinal hernia; when a piece of omentum only has got down, it is termed epiplo- cele, or omental hernia; and if both inteftine and omentum are down, it is called an entero epiplocele, or compound rupture. As all the abdominal vifcera are apparently contain- ed within the cavity of the peritonaeum, and as it was judged to be impoffible for that membrane to admit of fuch a degree of diftention, as to furround tumors containing fuch large portions of the viScera as are Sometimes pufhed out, it was till of late imagined, that, at leaft in a great proportion of cafes, the peritonaeum is burft or ruptured ; and from this the term rupture feems to have been adopted : the opinion was farther confirmed, from its being obferved, that in Scrotal her- nia, the protruded vifcera were in fome inftances found in contaa with the tefticle; a circumftance, which it was fuppofed could not happen, if the peritonaeum had not been previoufly ruptured. Since the anatomy of thefe parts, however, was bet- ter underftood, this circumftance, of parts protruded from the abdomen being in fome inftances found in contaa with the tefticle, is explained in a more fatis- faaory manner than on the Supposition of a rupture of the peritonaeum ; and as the nature of herniae will b'e better underftood by an anatomical defcription be- ing premiSed of the parts concerned in their produc- tion, I fhall, before proceeding farther, endeavour to defcribe them : the parts chiefly concerned in herniae, are, the abdominal mufcles; the peritonaeum; tefti- cles, and fpermatic veffels. The fides and other fleffiy boundaries of the abdo- men are formed by five pair of mufcles ; the reai, pyramldales, tranfverfales, obliqui interni, and obliqui externi. In fome fubjeas, the pyramidales are wanting ; and as the obliqui externi are thofe which in hernia are 528 Of Hernia. Chap. XXIIL moft conneaed with the difeafe, I fhall here defcribe theSe only. The obliqui externi are two thin, broad mufcles : on their pofterior and upper parts they are flefliy ; and tendinous on their anterior and lower parts. They originate from the eighth, ninth, and inferior ribs, by fleffiy portions which intermix in a ferrated manner with correfponding parts of the latiflimus dorfi, ferra- tus major amicus, pedoralis major, and intercoftales: and afterwards becoming tendinous,' they form the greateft part of all the anterior furface of the abdo- men, and are inferted into the linea alba, tlie fpine of the os ilium, and the 6s pubis." On each fide of the under part of the abdomen immediately above the pubes, two openings are met with in thefe tendons,' intended for the paffage of the fpermatic veffels in men, and for the ligaments of the womb in women.1 Thefe openings, or rings? as they are termed, which feem to be formed merely by a Separation of the fibres of the tendon from one another, are of an oval figure, and have an oblique direaion from the fpine of the ilium downwards; they are fomewhat wider above than below, and are rather of a larger fize in men than in women. Although thefe rings or openings have been com- monly defcribed as paffing through not only the ex- ternal oblioue, but the tranfverfales and internal ob- lique mufcles alfo; yet we now certainly know, that it'is in the tendinous parts of the external oblique mufcle only, that any fuch opening exifts. It is of Some importance to be thoroughly acquainted with' this ; for, by the accounts received of it from books, W£ are led to fuppofe, that, inftead of one diftina paf- Sage, there are always three. TheSe mufcles are like- wife perforated in the middle by the uinb'licus, which affords a paffage for the conneding veffels between the mother and uterine fetus, and which is fo far con- tinued through life, that the fpace is filled up with cellular fubftance only. Sea. I. Of Hernia* 529 From the inferior border of the tendinous part of the external oblique mufcle, a detachment of fibres is fent off, which, after affording a firm covering to the inguinal glands, are loft in the fafcia lata of the thigh ; and the under edge of this tendon being folded in- wards, obtains the appearance of a ligament, which ftretches from the forepart of the os ilium to the pubes, forming a kind of arch, through which the great blood veffels of the lower extremity pafs to the thigh. It is this ligamentous like portion of the external oblique mufcle, that is known by the appellation of the liga- ment of Poupart or Fallopius. This paffage for the blood veffels of the thigh, being larger in women than in men, owing to the greater fize of the pelvis in the former, by which the arch formed by Poupart's ligament is rendered both longer and wider ; fo in women the crural hernia, or that va- riety of the difeafe formed by a protrufion of parts through this paffage, is more frequent than in men. The internal furface of the mufcles of the abdomen, together with every other part of that cavity, is lined With a fmooth fomewhat elaftic membrane, termed pe- ritonaeum. This membrane, befides lining the cavity of the belly, furnifhes the external covering to almoft all the viScera contained in it; but, in So Singular a manner are theSe coverings produced, that although at firft fight the different vifcera appear all to be contain- ed within the cavity of the peritonaeum, yet on minute Examination they are in reality found to lie behind it. The peritonaeum, after having completely lined the cavity of the abdomen, is continued or refleded over all the vifcera, So as to give an external covering to each. After furrounding one of the vifcera, it ftretch- es along to the moft contiguous, forming in its courfe the fupporting membranous ligament of the liver, and Other vifcera ; and affording in its duplicature a kind pf fupport or conneaion to the various blood veffels, as they ftretch along to their deftined fituations in the ^inteftinal canal and other organs. Vol. II. L 1 530 Of Hernia* Chap. XXIII. Behind the peritonaeum there is a quantity of loofo cellular fubftance, by authors commonly termed its ap- pendix. In fome parts this fubftance is filled with fat; and in others it is empty, and can eafily be filled with air. The teftes in the fetus, till near the period of deli- very, are lodged in the cavity of the abdomen, in the fame manner with the reft of the abdominal vifcera. They are fituated immediately below the kidneys, on the forepart of the pfoae mufcles, near to the upper end and by the fide of the redum, where their external covering adheres by its pofterior furface to thoSe parts of the peritonaeum on which they reft, while all their anterior and lateral Surfaces lie looSe in the abdominal cavity in contad with the other vifcera. Even in this fituation, however, a conneaion takes-place between the teftes and Scrotum. This is formed by means of a fubftance that runs down from the under end of the teftis to the Scrotum, forming a kind of pyramidal Shaped ligament; its large bulbous head bdng fixed to the lower end of the teftis and epididymis; and its under extremity, after having paffed through the ring in the external oblique mufcle, being loft in the cel- lular membrane of the Scrotum. This ligament is evi- dently vaScular and fibrous, and Seems in part to be compoSed of the cremafter mufcle turned inwards.* All that portion of the ligament contained within the parietes of the abdomen paffes behind the perito- naeum, and receives a covering from it in the fame manner with the teftes and other viScera: the perito- naeum even gives a coat to a portion of the ligament after it has got into the groin, by paffipg down along wkh it from the abdomen into the upper part of the inaruen. At this place, viz. at the annular opening of the ex- ternal oblique mufcle, the peritonaeum is very loofe; and when the ligament and Scrotum are drawn down- * See a very accurate account of the Anatomy of iiiL-fe parts by Mr. J. Hunter, in Dr. Hunter's Medical Commentaries. Sed. I. Of Hernia. 53* wards, an aperture is obferved from the cavity of the abdomen all around the forepart of the ligament, that feems ready to receive the teftis; and this aperture gradually becomes larger as the teftis defcends behind the peritonaeum in its way to the Scrotum. While the tefticle is ready to defcend, it does not fall down, as has been commonly imagined, along the forepart of the peritonaeum, between it and the other vifcera ; but the ligament I have defcribed, as lying behind the pe- ritonaeum, and conneded with the teftis at its under and pofterior parts, by direaing or pulling it down as it were, from behind, brings it in this manner along the pfoas muScle between it and the peritonaeum ; and that part of this membrane to which I have fhown that the tefticle adheres, being neceffarily drawn along with it, a kind of pouch or bag fomewhat refembling the finger of a glove, is thus formed by this elongation of the peritonaeum; the under extremity of which ftill continues to Surround the teftis as it goes along, in the fame manner as it did while the tefticle refted upon the pfoas muScle ; and the entrance from the abdomen to the cavity of this procefs, is exadly at that point where the teftis was originally fituated; for it is there that this procefs commences when the teftis begins to deScend. The peritonaeum being in a fetus remarkably lax and dilatable at this part, and being conneaed pofte- riorly, as we have feen, wkh a quantity of loofe cel- lular fubftance, its elongation produced by the defcent of the tefticle is in this manner provided for by na- ture, and of courfe is eafily admitted of. It muft not, however, be fuppofed, that the teftis and peritonaeum in coming down fall loofely and Without connedion ; for, as they Slide down very flowly, they ftill continue to adhere to the parts lying behind them, as they did when in the abdomen. The precife time at which the teftis paffes down from its original fituation in the abdomen, cannot be ascer- tained ; but in general, this change takes place about the eighth month. About this period, the teftis, Surround- l l 2 S32 Of Hernia. Chap. XXIII. cd with the peritoneal procefs, moves downwards, till its under extremity comes in contad with the moft in- ferior point of the abdominal parietes; and by this time the paffage through the tendon of the external ob- lique mufcle is found much enlarged, by the ligament of the teftis having funk downwards fo as to dilate it.- After the teftis has paffed the tendon of the mufcle, it commonly remains for fome time by the fide of the penis, and by degrees only defcends to the bottom of the fcrotum ; and even when it has got entirely into the fcrotum, its ligament is ftill conneded with it, and lies immediately under it, but is Shortened and compreffed. The procefs of the peritonaeum, which appears to defcend with the tefticle, continues to cover it when it has reached the Scrotum: it is this looSe covering or bag, which is afterwards converted into what anato- mifts term the tunica vaginalis teftis; and from the defcription which I have given of it, it is evident, that the cavity of this bag muft at firft communicate with the great peritoneal cavity of the abdomen. This it accordingly does, as a probe may be paffed readily and eafily along this procefs or bag, from the belly down to the bottom of the fcrotum ; and if laid open through its whole length on the forepart, it will be plainly Seen to be a continuation of the peritonaeum; the teftis and epididymis will be found at the lower part of it with- out their loofe coat the tunica vaginalis; and as the fpermatic veffels and vas deferens, while the tefticle remained in the abdomen, entered the body of that gland behind, and between the refleded lamina of the peritonaeum, fo here, when in the fcrotum, they will be found covered by the pofterior part of the bag, in their whole courfe from the commencement of that procefs down the groin to the tefticle. This paffage from the cavity of the abdomen to the Scrotum is in general very Soon cut off, by a firm ad- hefion taking place between the fides of the peritoneal procefs at its upper extremity where it defcends from the abdomen. What the caufe of this adhefion may be Sea. I. Of Hernia. 533 is uncertain; perhaps it may proceed from fome flight degree of inflammation being excited upon the conti- guous parts by the forcible paffage of the teftis; but whatever the cauSe may be, the fad is, that at the time of birth this paffage in general is completely obliterated.* It is in the neck only, however, or in the fuperior part of this procefs, that this adhefion takes place : the lower extremity of the fac remains open and loofe through life, and forms as I have already obferved, the tunica vaginalis teftis, the common Seat oS a hydrocele. If attention is given to this defcription, it muft ap- pear, that if immediately upon the tefticle deScending from the abdomen, and before the paffage is Sufficient- ly contraded, any portion of the alimentary canal or omentum fhould likewife fall into the opening, fuch parts muft for certain lodge in the fame bag or cover- ing with the teftis itfelf; and as long as they remain there, that they muft effeaually prevent the ufual ob- literation of the paffage from being accompliffied. It is this occurrence, of a portion of fome of the abdominal vifcera getting into the tunica vaginalis tef- tis, which forms that fpecies of hernia to which new born infants are liable, termed hernia congenita. The tefticle and protruded interline being here in contad, the tunica vaginalis teftis forms the hernial fac. If the gut, or other parts which have fallen down, are again pufhed into the abdomen, and retained there by a truSs, the paffage foon fills up, and no return of hernia takes place. But if this is negfeaed, and the gut allowed to remain long down, the parts forming the paffage Seem thereby to loSe that power of adhe- fion which naturally they are known to poffefs; in- ftances being often met with where no art is able to produce this wifhed for obliteration. The hernia congenita is ufually produced in the manner 1 have defcribed : I believe, however, that it * The defcent of the teftes from the abdomen is a phenomenon very difficult to account for, and its immediate caufe may probably always remain a myftcry ; but their being in almoft every inftance found in the fcrotum before birth, is a clear proof of their not being forced down by tlre effeOls of id'piration, as h:is been commonly fuppofed. 534 Of Hernia* Chap. XXIII. may happen, and I think I have feen inftances of its doing fo, from this paffage between the abdomen and tefticle, after having been once clofed, being again ren- dered pervious, in confequence of the parts being over- stretched by thofe violent fits of coughing, crying and other convulfive affedions to which children Soon af- ter birth are liable. The inteftinal canal and other vif- „ cera, being pufhed with violence againft the contain- ing parts, thefe will moft eafily give way that are the leaft firm, and this will moft probably be the caSe with thoSe that have been moft recently united. In this manner, it is probable that a great proportion of thofe herniae are produced which happen in early infancy ; and I am inclined to think, that even in more advan- ced ftages of life, the fame variety of hernia may ocr cur from the fame caufe. It is evident then, in what manner the hernia con- genita is produced : we fhall now inquire into the caufes of hernia in its more ufual form. I. The containing parts of the abdomen are elaftic and compreflible ; whatever, therefore, tends by com- preffion or otherwife to leffen the cavity of the abdo- men, muft occafion a proportional rifk of Some of the contained parts being pufhed from their natural fitu- ations. The abdominal muScles and diaphragm are excited to Severe contradion, by various caufes, par- ticularly by violent coughing, crying, laughing, andl fevere bodily exertion ; and as the contraaion of thefe mufcles muft always leffen the abdominal cavity, thefe caufes therefore are frequently produaive of hernia. II. Falls, in confequence of the derangement which they produce in the abdominal vifcera, from the fudden ; and violent fhock wkh which they are often attended, are not unfrequently the immediate caufes of hernia. r III. Perfons of a preternatural laxity of frame, are very liable to hernia. The containing parts of the, abdomen, from the want of fufficient tone and firm- nefs, are unable in fuch people to refill the weight of the different viScera: they are therefore more particu- Sed. I. Of Hernia. $35 Iarly liable to hernia on the application of any of thoSe cauSes that uSually give riSe to it. IV. Sprains are apt to induce a laxity of the inju| ed part; and have therefore a fimilar influence in ducing hernia, with general laxity. V. It has been obferved, in thofe countries whe: •oil is much ufed as an article of food, that the people are particularly liable to herniae. In confirmation of which I may remark, that all who have attended the. hofpitals in France, where much oil is ufed, and wh hernia is one of the moft prevailing difeafes, are aff__ ifhed to find that it is not frequent in the hoSphgils of London and Edinburgh : one foreigner in parr^^ar remarked to me, that in a Single hofpital in Paris, ihe operation for ftrangulated herniae during his refidence there had been performed upwards of a hundred times in one year, while in fome of the largeft hofpitals of London, it was only performed twice during the fame period, and in eight or nine months here he had only feen it once. In whatever parts the parietes of the abdomen are weakeft, theSe various cauSes will moft readily operate in producing herniae; and accordingly we find, that de- Scents of the bowels ufually occur only in fuch parts. The parts which from anatomy we would a priori juSped to be moft liable to herniae, are, the openings already deScribed in the external oblique muScles; the arch forrried by Poupart's ligament for the paffage of the great blood veffels of the thigh ; and the umbili- cus, where'the Same firmnefs does not take place as in ^ the reft of the tendinous expanfion of the abdominal * mpbles. ^ . «f heSe, as I have already obferved, are the ufual feats of hernia ; but it fometimes happens, that parts of the vifcera are protruded between the interftices of the dif- ferent mufcles of the abdomen : this, however, is not frequent. In whatever part a defcent of any portion of intef- tines occurs, except in hernia congenita, as all the vif- 536 Of Hernia. Chap. XXIIL cera are contained in the manner already defcribed, within the peritonaeum, a portion of that membrane, it is evident, muft be carried down along with the parts that are protruded; and in every fuch inftance, it is this portion of the peritonaeum going down along with the gut that is termed the hernial fac. The fize and thicknefs of this fac is various in different fubjeds^ and in different ftages of the fame diSeaSe. On the firft appearance of hernia, the fac is com- monly fmall, for the protrufion feldom becomes large at once; but by repeated defcents of the bowels, the fac is puflied lower and lower, till in fome inftances its bulk is very confiderable indeed ; and when in this ad- vanced period of hernia the fac is laid open, it is found to contain either large quantities of omentum, or in- terline, and frequently large portions of both. As the peritonaeum has this property in common with other parts of the body, of thickening according to the degree of gradual extension applied to it, So the thickneSs and SirmneSs of the hernial fac is often Sur- prisingly great, a circumftance which every operator fhould keep in view. Although every inftance of any portion of inteftlne protruded from its natural fituation, is to be confider- ed as a derangement, and as fuch demands our atten- tion, yet daily inftances occur, both of recent herniae^, and of thofe of longer duration, from which no bad fymptoms enfue. Thus we often meet with large herni- al fwellings, without the patient fuffering in any other manner, than from the inconvenience arifing from the bulk of the tumor. In general, however, it is other- wife ; and troublefome Symptoms moft frequently take place; but whether they do or not, when the reduc- tion of a hernia can be accompliffied, it ought always to be done as quickly as poffible. All the bad fymptoms arifing from hernia, proceed either from obftruaion to the paffage of the feces when the inteftinal canal forms the tumor, or from a ftoppage of circulation occafioned by ftiidure on the Sea. L Of Hernia, .K37 prolapfed parts; fo that the danger of the attending fymptoms, it is evident, will always in a great mea- / fore depend on the nature and importance of the parts that are protruded. Thus, when a portion of omentum alone forms the fubftance of a hernial fwelling, as that organ is not So 5j immediately neceffary to life as many of the other vif- cera, it is not fo frequently produdive of danger, as when a part of the alimentary canal is either protrud- ed by iyelf, or along with the omentum. Although this, however, is in general the cafe ; yet it fometimes happens, that even an omental rupture is attended with danger. When the ftriaure is So com- plete, as to put a ftop to the circulation in the protrud- ed part, mortification, with all its bad conSequences, muft enfue. And befides, the connedion between the omentum, ftomach, and other vifcera, is fuch that a fudden defcent of any confiderable portion even of omentum, is apt to bring on vomiting, hickup, and other fymptoms of diftrefs. And, laftly, although a rupture containing omentum only, might not of itfelf prove hazardous; yet as the paffage through which the omentum has flipped, muft remain open as long as the protrufion continues, and as this muft render it eaSy Sor a portion of gut likewife to get down, this of itfelf is a fufficient reafon for bellowing even upon an omental hernia our moft ferious attention. But whatever the contents of herniae may be, when- ever ftridure occurs on them, fufficient^to produce ei- ther a ftoppage of the circulation, or of the fecal con- tents of the alimentary canal when a portion of gut forms the difeafe, the following in general are the Symptoms that take place. An elaftic colourlefs fwelling is obferved at the part affeded ; a flight pain is felt, not only in the tumor itfelf, but, if part of the alimentary canal is down, an univerfal uneafineSs is perceived over the whole abdo- men, and the pain is always rendered worfe by cough- ing, Sneezing, or any violent exertion. The patient 53S Of Hernia. Chap. XXIIL complains of naufea; an inclination to retch ; he can get no difcharge by ftool; he becomes hot and reft- lefs; and the pulfe is commonly hard and quick. If the fwelling is entirely formed by a portion of gut, and if no feces are contained in it, it has a fmooth, equal furface ; and although eafily compreffible, it in- ftantly returns to its former fize on the preffure being « removed. But, in gut ruptures of long duration, where hard feces have colleded in the protruded bow- els, firm inequalities very commonly take place. When again the tumor is compofed both of gut and omentum, its appearance is always unequal: it feels foft and fomewhat like dough, nor is it fo elaftic as when part of the inteftinal tube only is down ; for al- though like the other it is compreffible, it does not fo readily regain its former dimenfions on the preffure being taken off. It has been a received opinion, that in Strangulated hernia," the Symptoms fhould be leSs violent when the inteftine is accompanied with a portion of omentum, than when the gut alone is down. Little or no dif- ference, however, occurs from this; for when the gut becomes obftruded and inflamed, the fymptoms which enfue are nearly the fame whether the omentum is down or not. It will readily, however, be fuppofed, that the fymp- toms defcribed above, can never take place from the prefence of omentum only ; for although ftridure pro- duced on a portion of omentum, even when no part of the inteftinal tube is down, may excite much dif- trefs, fuch as pain, ficknefs, vomiting, and twitching pains through the whole belly; yet no obftrudion of the gut ever occurs from it, and of courfe none of the fymptoms ever prove fo alarming as when any part of the gut is concerned. => If the fymptoms arifing from a ftrangulated gut, are not foon obviated by the ftriaure being removed, the naufea and retching terminate in frequent vomit- ings, firft of a bilious, and afterwards of a more fetid Sea. I. Of Hernia. 539 matter; the belly becomes tenfe ; the pain more vio- lent ; a diftrefsful convulfive hickup takes place ; the fever, which at firft was of little importance, begins to increafe ; the patient is all along exceedingly reft- leSs, and continues in a diSagreeable ftate of anxiety through the whole courfe of the difeafe. Thefe fymptoms having Sor Some time gone on with violence, the patient is apt at laft to be Suddenly re- lieved from pain, when he flatters himfelf that every rifk is at an end ; but inftead of this, the pulfe, from being hard and frequent, becomes languid and inter- rupted ; cold Sweats break out over the whole body, and eSpecially on the extremities ; the eyes become dull and languid ; the tenSeneSs of the abdomen fob- fides, and the tumor in part difappears ; the fkin cov- ering the tumors, which before was either of a natur- al appearance, or red and inflamed, now becomes liv- id, and a windy crepkous feel is diftinguiffied in the fubftance of the tumor. If the protruded parts have not of themfelves gone entirely up, their return is now in general eafily ef- feded with gentfe preffure, and the patient then dis- charges freely by Stool; but the cold Sweats increafing, the hickup turns more violent, and death itfelf Is at laft ufliered in by its uSual forerunners, fubfultus ten- dinum, and other convulsions. Thefe are the ordinary fymptoms of what Is termed a ftrangulated or incarcerated gut rupture ; that is, when the parts protruded become So affeded by ftric- ture, as to produce pain; and do not either return to their natural fituation on the patient getting into a horizontal pofture, or cannot be replaced by the hands of a praaitioner. In whatever fituation a ftrangulated hernia may oc- cur, our only rational method of cure muft confift in the removal of that ftriaure by which the return of the protruded parts is prevented. It is this that we are to confider as the caufe of the mifchief; and un- 540 Of Hernia. Chap. XXIII. lefs it is completely removed, nothing effeaual can be done for the relief of the patient. Various methods have been propofed for the remo- val of thefe ftriaures ; all of them, however, may be comprehended under two general heads. I. Such as tend to the reduaion of the protruded parts, without the interposition of any chirurgical op- eration ufually fo called ; and, II. A divifion of the parts producing the ftridure, fo as to admit of a replacement of the deranged vifcer ra, constituting what in general is termed the opera- tion Sor the hernia. The remedies to be employed for the firft of thefe. are, a proper pofture of the patient, with the manual affiftance of a praditioner ; bloodletting ; Stimulating glyfters ; opiates ; the warm bath ; and proper ap- plications to the tumor itSelf. As foon as a praditioner is called, the firft circum- ftance requiring his attention, is, the pofture of his pa- tient, which ought to be fuch as will moft readily fa- vour the return of the protruded parts. Thus, when the tumor is in the groin, or in the forepart of the thigh, the patient fhould be fo placed, as to raife his thighs and legs considerably higher than his head and trunk;. that is, he fhould be placed nearly perpendic- , ularly upon his head. This pofition caufes almoft the whole quantity of inteftinto to hang or fwing by the protruded parts, and it frequently proves a means of reducing them : plac- ing the patient's feet over the fhoulders of another perfon, while his body is allow ed to hang downwards, and caufing him in this pofture to be jolted about, has in Some inftances anSwered when every other means have been tried in vain. For the Same reaSon that in the inguinal and femo- ral hernia this pofition is more adviSable than any oth- er, the uSual ered pofture of the body becomes moft proper in caSes oS exomphalus or umbilical rupture; and again, a horizontal pofture is moft likely to prove uSeful in ventral hernia. Sed. I. Of Hernia. fat While the patient is thus placed in the moft Suita- ble pofture, the Surgeon fliould endeavour to affift the return of the protruded parts, by gentle preffure wkh his hands and fingers. In the inguinal or Scrotal her- nia, the preffure fliould be made obliquely upwards towards the os ileum, So as to correfpond as nearly as poffible with the opening in the external oblique muf- cle. In the femoral hernia, the preffure fhould be di-> redly upwards ; in the umbilical hernia, downwards and backwards; and in the ventral hernia, diredly backwards. In herniae of any considerable fize, preffure is moft conveniently made, by graSping the Swelling with one hand from the bottom upwards, while with the fingers oS the other we endeavour to pufh forward the con- tents at the Superior part of the tumor. Some Sur- geons, in puffiing forward the inteftine\ employ the fmgers of both hands at the upper part of the tumor ; * but the fame purpofe is anfwered equally well wkh the index and middle finger of one hand, while the other is employed with advantage in preffing the under part of the tumor upwards fo as to co-operate in this man- ner in the redu-ition. It is this operation which by authors is termed the taxis. No defcription, however, can convey an adequate idea of the manner in which it fliould be performed: for, like many other points in the art of furgery, a knowledge of it can only be obtained from experience and obfervation : but this muft always be had in view, that any preffure we em- ploy fhould be of the moft gentle kind ; for whatever Creates much pain, proves prejudicial, and ought to be avoided. In attempting to reduce the contents of herniae, fo much force is often employed, and in fuch a rough manner, as can fcarcely fail to injure the protruded parts : nor is the rifk, that enfues from this, ever com- pensated by the pradice proving more fuccefsful ; for Where a proper ripplication of gentle preffure does not anfwer, we never Succeed with much force. 542 Of Hernia. Chap. XXIII. If moderate preffure, therefore, does not foon prove effedual, other means fhould be immediately advifed. Bloodletting is here to be confidered as a principal remedy; for in no diSeaSe does it afford more relief. The quantity to be taken muft in a great meaSure de- pend on the ftrength of the patient: but if in any cafe we can with propriety venture upon abltrading large quantities of blood from weakly patients it is here; and we often perceive with furprife to what length it may be carried without hurting the Syftem. A ftate of deliquium being known to produce more complete relaxation of all the mufcular parts of the body, than can be obtained in any other way, it has fometimes been adviSed, in the treatment of hernia, to take off fuch large quantities of blood, and in fuch a fudden manner, as to excite fainting ; and the pradice has in fome inftance? proved effeaual. As obftinate coftiveneSs is commonly one of the moft alarming Symptoms of hernia, it has been the ° prevailing praaice to prefcribe not only flimulating purgatives by the mouth, but injeaions of the moft acrid kind. In judging, however, from experience, I would fay, that the praaice fhould not be adopted ; for when it does not prove ufeful, it very univerfally does harm, by increafing the ficknefs at ftomach which always prevails here, while at the fame time it adds to the pain and tenfion of the tumor. I am clearly,, therefore, of opinion, that remedies of this clafs fliould not be pufhed fo far as is commonly done; and in- ftead of purgatives by the mouth, I would recommend injeaions of tobacco fmoke. A variety of machines* have been invented for injeaing fmoke by the anus ; but none anfwer the purpofe So well as the inftruments reprefented in Plates LXIII. and LXIV. They are eafily procured ; and by means of either of them, fmoke may be injeaed with any neceffary force. I would not have it fuppofed, however, that I re- commend tobacco fmoke ufecl in this manner as an infallible purgative, as many have done. For the con- Sea. L Of Hernia. 543 trary is certainly the cafe: I have known it ufed in various inftances, both of hernia and ileus, and not often with advantage. I only advife it as the moft ef- fedual remedy of this clafs with which I am acquaint- ed ; and I know that this mode of injeding it, is the moft effedual hitherto invented. It has been objeded to the inftruments I have delineated, that we cannot by means of them afcertain the quantity of fmoke we injed. But this is a nicety of little importance ; as the rule in all fuch cafes Should be, to continue to throw up the fmoke, either till it has produced the wiffied for effed ; till a confiderable degree of SickneSs is induced ; or till the abdomen is found to be dif- tended, for which in fome patients much more is re- quired than is found to anfwer in others. But although this remedy does not frequently an- fwer as a purgative, it proves often ufeful as an ano- dyne both in hernia and ileus. And as we are often °in fuch cafes deprived of the advantage of opium, by the ftomach not being able to retain it, we may occa- sionally, in fevere degrees of pain, have recourfe to glyfters of tobacco fmoke, as one of the beft means oS procuring eaSe. Among the lift of purgatives employed in herniae, acrid fuppofitories, compoSed of foap, aloes, and other Stimulating materials, have been much recommended ; and when remedies of this clafs are to be ufed, thefe may be confidered as a neceffary addition to the others ; but no great dependence fhould ever be placed on them. We are told, indeed, that in fome cafes of hernia, draftic purgatives have been of advantage ; but I have fo Srequently known them do harm, by increafing the naufea, pain, and inflammation of the ftrangulated gut, that I am under no difficulty in Saying that they ought never to be uSed. Opiates prove often ufeful, not only by relieving pain, but as tending to relax thofe parts which, by be- ing preternaturally conftrided, we confider as the prin- cipal feat of the difeafe. I have already obferved, 544 Of Hernia. Chap. XXIII. however, that the retching which takes place in moft caSes of hernia, prevents the exhibition of opiates by the mouth ; but in fuch inftances they may be appli- ed with advantage in the form of injedion, and their ufe may be alternated with injedions of tobacco fmoke, as I have already pointed out.- Warm bathing is another remedy from which much advantage has been derived in the treatment of her- niae : not the local application of heat, however, as conveyed in the form of poultices and fomentations, but the univerfal warm bath, in which the whole body is immerfed, and which we know to be poffeffed of very relaxing powers. . Immerfing the whole body in a warm bath, by tending to relax the conftridion on the protruded in- teftines, may prove uSeSul by promoting their replace- ment ; but the local application of heat to the Swelled parts, although commonly adviSed, is very apt to do harm. On the conftrided tendon it can have no influ-• ence, for it lies So deep as to be little affeded by re- medies of this kind. And as the heat conveyed in this manner muft tend to rarefy the contents of the tu- mors, and muft thus increafe the bulk, inftead of an- fwering any good purpofe, on this principle it is evi- dent they muft do harm ; and accordingly, whoever will attentively obServe their effeds, will find that they do fo. When the external teguments are much in-, flamed and painful, by their emollient properties, they may afford relief; but the eafe thus obtained proves only momentary, as the pain commonly foon becomes more fevere than it was before. Whoever attentively confiders the nature of hernia, and the means that prove moft effedual in the cure,' muft be of opinion, that all the bad fymptoms that ap- pear in it, arife from ftridure produced upon the pro- truded parts. By fome, however, a different opinion has been held forth, and all thefe Symptoms have been imputed to SpaSm or inflammation in the protruded Sed. I. Of Hernia. 545 parts themfelves, independent of ftriaure or any other affeaion oS the parts through which they have paffed. That inflammation of the prolapfed bowels, in what- ever way it may be induced, will in general terminate in all the fymptoms of ftrangulated hernia, nq perfon will doubt; but that ftriaure in the tendons, through which the bowels have paffed, is the moft frequent caufe of this inflammation, is alfo obvious. Admitting however that the caufe of all the bad fymptoms in her- nia fhould originate in the parts that have been pro- truded, and that they are not induced by the opening through which they have paffed, being leflened by ftriaure, ftill the application of /heat to this kind of tumor muft be improper, as the rareSaaion which it excites, by giving an increaSed bulk, muft necefiarily increafe the danger. While we might, a. priori, be warranted to argue in this manner, I can Srom pradice and experience af- Sert, that we derive more advantage Srom the external application of cold than I have ever perceived from any other remedy. In various inftances I have applied ice and fnow with much advantage, and I never faw them do harm.* But in general, the remedies upon which I depend are cold faturnine Solutions, and cloths kept constantly moift with a mixture oS cold water, vinegar and brandy. By theSe remedies alone we Sometimes Succeed, with- out further affiftance : but it frequently happens, not- withftanding every attempt, that the protruded parts cannot be returned ; the fymptoms, inftead of abating, become more violent; and the event of the difeafe becomes of courfe more doubtful. In this fituation, we Should again endeavour to re- turn the contents of the tumor, by a proper applica- tion of preffure with the hand, affifted with due atten- * By fome writers, this practice has been confidered as hazardous; but I fiO.d it rtcommended by others to whom much credit is ckte, particular- ly by the late Dr. Monro. See his worVs, <)ty. editionrp. jjo: Vol. II. M m 546 Of Hernia. Chap. XX III. tion to the pofture of the patient; but where this does not foon prove fuccefsful, the divifion of the parts by which the ftridure is produced fliould be advifed as our only refource. This, it may be remarked, is one of the moft im- portant points on which a furgeon has ever to decide : I mean the exad period at which the treatment of her- nia, by means fuch as I have pointed out, fhould be laid afide, and the operation be put in pradice. If a furgeon, without having given a full trial to all the ufual remedies, Should early proceed to the operation, and if unfortunately it Should not fucceed, he would probably be blamed by the friends of the patient as the principal caufe of his death ; and again, even al- lowing a recovery to be obtained by the operation, he is apt to be blamed, not only by his brethren of the profeffion, but by the patient himfelf, for having made him fuffer an unneceffary degree of pain. In fuch circumftances, a praditioner is very apt to feel himfelf embarraffed. But we ought here, as in every critical fituation, to be entirely direded by ex- perience ; and if this rule was kept in view, inftead of the ufual delays in almoft every inftance of ftrangula- ted gut, we would advife the operation at a more ear- ly period. The operation of the hernia is no doubt liable to fome hazard ; but the danger attending it has by many been magnified more than it ought to be ; for, fo far as I can judge from experience, the rifk from the op- eration being long delayed, is infinitely greater than from the operation confidered abftraaedly. Were we able, from the fymptoms, to determine' the exaa period at which the operation fhould be per- formed, no kind of difficulty would occur from it , but this is fo far from being the cafe, that the moft experienced furgeons Seldom agree on it. In Some in- ftances, hernia, with every fymptom of Strangulation, continues for fix, eight, or ten days ; and after all, the protruded parts are replaced, and the patient does Sea. I. Of Hernia. 547 well: and in many fimilar cafes when the operation has afterwards been found neceffary, although the fe- vereft fymptoms may have fubfifted for feveral days, yet, on laying the parts open, no appearances either of inflammation or gangrene have been difcovered. With others, again, the fame fet of fymptoms, with perhaps no more tenfion in the tumor, prove quickly fatal. In fome of thefe, the rapid progrefs of the dif- eafe is often aftonifhing ; the Space of forty-eight hours hardly intervening, from the firft attack till the death of the patient: I have, even known the inteftines be- come perfeaiy gangrenous in the courfe of one day from the time of their firft expulfion. Every praaitioner of experience knows, that this is the ftate of the queftion ; and if fo, it muft at once be obvious, that long delays muft in Such critical cir- cumftances be always hazardous ; and as the danger from the operation itfelf, is trifling when compared with the risk accruing from delays, it ought, 1 think, to be an eftabliffied maxim, to proceed in every in- ftance to the operation, if in the fpace of a fhort time bloodletting and the other remedies that I have men- tioned, or which happen to be ufed, do not prove ef- fedual. Two or three hours at fartheft, even when praditioners are early called in, is, perhaps, the great- eft length of time that fhould be confumed in trials of this kind, In the treatment of herniae, it has been remarked, that the French furgeons prove ufually more fuccefs- ful than German or Britifh praditioners ; and fo far as I know, no reafon can be affigned for the difference, but that the French proceed more early to the opera- tion than the furgeons of almoft any other nation. They will thereby, no doubt, perform it on fome pa- tients who might have recovered by more gentle means ; but any inconvenience arifing from this to a few, is fully compenfated by the number of lives that muft be faved by having recourfe to it in due time, which otherwife might probably have been loft. 548 Of Hernia, Chap. XXIII. Although for obvious reafons the redudion of the contents of herniae fliould in every inftance be attempt- ed, yet cafes often occur in which it cannot be accom- plished. When the redudion has once been completed, we have it in our power to prevent the difeafe from re- turning, loy the conftant application of a proper trufs to the opening at which the parts were pufhed out. But, from this being negleded, ruptures which might at firft have been eafily cured, come at laft by repeat- ed defcents, and by the great quantity of parts that fall down, to form tumors of fuch magnitude, in propor- tion to the opening through which they were forced, that no art can replace them by the more fimple means of redudion. But befides this, Such adhefions frequently take place, between the vifcera forming the fwelling and the Surrounding parts, as render it impoffible to return them by any other means than the operation. By this, indeed, perhaps every cafe of hernia may be reduced; but, however neceffary this operation may be when a patient is in danger, as it is always attended with Some hazard, it fliould Seldom be adviSed where Symptoms of Strangulation do not adually exift. In that indolent or chronic ftate of hernia we have juft been defcribing, although by interefted and igno- rant praditioners the operation has been often pro- pofed as a radical cure; yet furgeons of charader would in fuch circumftances Seldom adviSe it: they would reft Satisfied with preventing any accumulation oS feces in the inteftines, by prefcribing a proper diet, and the occafional uSe of gentle laxatives ; and with obviating, by a fufpenfory bandage, any inconvenience that might arife from the weight of the tumor. By thefe means alone, even the largeft herniae are often made eafy and Supportable for a great length of time; the circulation of the parts contained in the fwelling goes freely on, as well as the periftaltic mo- $ tion of fuch parts of the alimentary carral as are pro- , Sed. I. Of Hernia, 5-; 9 truded ; and hence it is, that we have many inftances of large portions of the gut falling down even to the bottom of the fcrotum, and continuing there for a great number of years, without giving any interrup- tion to the ufual difcharge by flool. In this ftate of the difeafe, therefore, the operation can feldom be admiffible. But although people wkh hernia in this fituation frequently enjoy good health, and fometimes feel little inconvenience from the tu- mor, yet it muft not be fuppofed that their fituation is free of danger: on the contrary, we often obferve, that the difeafe, after fubfifting in this ftate Sor a great length of time, will inflame and become painful, fo as to excite every bad fymptom commonly induced by real Strangulation of a gut. As long, too, as the tu- mor continues, as the opening through which the parts have been puffied is thereby prevented from clof- ing, fo the patient ftill remains liable to deScents of other portions of inteftine which have not formerly been down, and by which the moft fatal fymptoms may be induced. But what I here wifh to eftablifh is, that, till once theSe bad Symptoms adually occur, eith- er Srom an affeaion oS that part oS the gut which has 0 been long down, or of a portion more recently pro- truded, the operation for the hernia ought feldom to be advifed. All that can here be done with propriety is, to fit the patients with proper fufpenfory bandages ; to warn them of the rifle they will incur from laying them afide ; and to caution them againft violent exer- cife, particularly leaping, and every fudden exertion. ■ Although with praditioners of reputation this cir- cumftance cannot require much difcurilcn, yet the- public at large are much concerned in it. The for- mer know, that the operation fliould be feldom per- formed in any cafe of hernia where violent fymptoms do not adually exift; but the latter, not being abfe to judge of the various circumftances to be taken in- * to confideration, are too frequently impofed on by that numerous fet of Linerants with which everv com:- *M 550 Of Hernia. Chap. XXIII. try abounds. By thefe a variety of operations are put in pradice for performing what they call a radical cure of ruptures; by which they mean to fay, a pre- vention of future defcents. But as no remedy with which we are acquainted, a well adapted truSs only excepted, can be depended on for this purpofe; and as all the other means that have been advifed for it, are not only painful, but highly dangerous, the magiftracy of every comniimity ought to interfere in fuppreffing them. The objed in view by all thefe attempts, is, either to deftroy the hernial fac entirely, or to procure an acr cretion of its fides ; which, by thofe who are ignorant of the anatomy of the parts concerned, has been com fidered as fufficient to prevent any return of the difeafe, In order to effed a total dcftrudion of the fac, our forefathers employed not only the knife, but {he po? tential and even the adual cauteries ; and with a view to produce a firm union of its fides, which was con- fidered as equally effeaual, it was afterwards propofr ed by praaitioners of more tender feelings, to employ the needle, and ligature, or what was termed the roy- al flitch : and for the fame purpofe was invented the • famous punaum aureum, which was performed in the % following manner. After reducing the inteftines into the abdomen, the Sac was laid bare with a Scalpel; and a piece oS gold wire being paffed round the up- per end of it, the wire being likewife made to include the Spermatic cord, it was then ordered to be twifted with forceps to fuch a degree of tightnefs as to pre- vent the defcent of the gut, but not to interrupt the circulation in the fpermatic cord.* But none of thefe methods being found to anfwer, for even the adual cautery, although carried to the depth of the bone itfelf, does not fecure the patient againft a return of the difeafe, our modern pretenders * For a more particular account of thefe various modes of practice in ^ hernia as employed in former times, fee the writings of Albucafis, Paulus ™ iKgincta, Fab. »b A-piapeudente, Hildanus, and Ambrofe Parey. « Sea. I. Of Hernia. 551 have therefore ventured to improve upon the igno- rance of ancient praditioners, and adually go the length of destroying, not only the hernial Sac, but the teftis alSo : without any knowledge of the anatomy of the parts, and having no reputation that can fuffer by any confequences that enfue, they proceed without fear ; and, by promifing all that patients can hope for, they are fore to be well received. In confequence of this, in every large town, many operations are per- formed by them ; numbers are accordingly mutilated, and many thereby even lofe their lives. Their meth- od of operating is Shortly this: they lay bare the her- nial fac, and having reduced the prolapfed parts, a ftrong ligature is paffed round both the fac and Sper- matic cord, and drawn So tight as to cfeftroy, not on- ly the paflage along the Sac, but the cord itfelf, and of courfe the tefticle. In Some inftances nothing Surther happens; but in others, Such a degree of inflammation is induced, as to terminate in the death of the patient. If any of thefe means, however, were to produce . the wifhed for effed, the prevention of future defcents, the riSk would in fome meafure be compenfated by , the advantage : but the faa is much otherwife ; for unlefs a trufs is kept conftantly applied, the patient continues liable to a return of the difeafe in nearly the fame degree as if no operation had been performed.- Even the operation for the hernia itfelf, does not, as has been fuppofed, fortify the parts againft a return of the difeafe, the continued ufe of a trufs being nearly as neceffary after that operation as if it had not been performed. In a few cafes, the opening may be fo completely elofed by the inflammation induced by the operation, that no farther defcents Would take place ; but as I have known different inftances of its failure, in which, from negleding to wear a trtrfs, the difeafe returned with the fame fymptoms of ftrangulation as before, I gcan without hefitation fay that the principle fhould be ^Lidopted. 552 Of Hernia. Chap. XXIII. In Plate LXV. truffe9 arc reprefented Sor different varieties oS hernia. They are intended Sor the more ufoal forms of the difeafe, the inguinal, crural, and umbilical rupture. When others are wanted for par- ticular parts, tradefmen in this line of bufinefs fhould be applied to, with diredions to fit the inftruments with the niceft exadnefs to the parts for which they are intended. Indeed, the advantages to be obtained from a trufs, depend entirely on the exadnefs with which it is .fitted ; and nothing but the niceft atten- tion can prevent it from doing more harm than good. The Sole purpoSe of a trufs is to prevent the parts newly replaced from falling down. If therefore the pad or bolfter with, which it is furniffied does not bear properly againft the opening upon which it is placed, a portion of gut may flip out,, and be materially in- jured by the preffure of the pad. I have met with different inftances oS this, where bandages by not be- ing exadly fitted did much harm, and every praai- tioner muft have obServed them : it is thereSore a mat- ter oS the firft importance, that tradeSmen be made to • pay the moft exaa attention to this. All rupture bandages fliould be oS the fteel Spring kind ; Sor thoSe formed of linen and other foft materials, can never be kept properly applied. Even in infancy the fteel trufs may be made fo light and eafy as to be ufed with fafety. Having premifed theSe general observations, which relate equally to every variety of hernia, I fnall new proceed to confider more particularly the different forms of the difeafe. F.ND OF VCfLUME SECOND/ \ !• t * / ~*ftg. i.