\ Surgeon freireral's Office }*4 R1 r> -'■&■ No. Sj^. )l\ THE SURGICAL WORKS, OH STATEMENT OF THE DOCTRINE AND PRACTICE P. J. DESAULT, SURGEON IN CHIEF OF THE GREAT HOSPITAL OF HUMANITY, AT PARIS; BY XAVIER BICHAT, His Pupil, adjunct Physician of the same Hospital. IN TWO VOLUMES. DISEASES OF THE SOFT PARTS. TRANSLATED FROM THE ORIGINAL, BY EDWARD DARRELL SMITH, M. D. PROFESSOR OE CHEMISTRT, ETC. IS THE SOUTH-CAROLINA COLLEGE V\BKA^, x PHILADELPHIA: PUBLISHED BY THOMAS DOBSON, AT THE STONE HOUSE, No. 41, SOUTH SEQOND STREET. William Fry, Printer. 1814. District of Pennsylvania, to wit: «••••••• BE IT REMEMBERED, That on the twenty-third dav of i seal. J December, in the thirty-eighth year of the Independence of the *•****••• United States of America, A. D. 1813, Thomas Dobson, of the said district, hath deposited in this office, the title of a book, the right whereof he claims as proprietor, in the words following, to wit: " The Surgical Works, or Statement of the Doctrine and Practice of " P. J. Desault, surgeon in chief of the great Hospital of Humanity, " at Paris; by Xavier Bichat, his pupil, adjunct physician of the same " Hospital. In two volumes. Diseases of the Soft Parts. Translated "from the original, by Edward Darrell Smith, M. D. Professor of " Chemistry, &c. in the South-Carolina College." In conformity to the act of the Congress of the United States, intituled, " An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprietors of such copies during the times therein mentioned."—And also to the act, entitled, " An act supple- mentary to an act, entitled, " An act for the encouragement of learning, by securing the copies of maps, charts, and books, to the authors and proprie- tors of such copies during the times therein mentioned," and extending the benefits thereof to the arts of designing, engraving, and etching historical and other prints." > D. CALDWELL, Clerk of the District of Pennsylvania. TRANSLATOR'S PREFACE. apology can be necessary, for presenting to the Medical world, in an English dress, the works of such a celebrated Surgeon as Desault. The first volume of these Works was translated some years since, and its publication, it is believed, has met with general accep- tance. It has probably excited, in all who have perused it, a desire to be acquainted with the illustrious author's other labours, which are comprised in two more volumes. As, from the time that has since elapsed, the translator of the first volume does not appear to have contemplated any further progress, I have been induced to make the following attempt, and now with diffidence offer a trans- ' lation of the two last volumes, which, I trust, will be found no less important and interesting than the first. With regard to the execution of the translation, it is no doubt imperfect; but I have always carefully endeavoured to understand and convey the author's ideas, although I will not presume to say, that I may not sometimes have failed in both. My aim has been accuracy and fidelity in the rendering of the meaning, rather than elegance of expression in the style. Such as the work is, I hope that it will be useful; and that a well meaning, if it be an imperfect attempt, will meet with requisite indulgence s from the candid reader. Columbia, South-Carolina, May, 1813. No CONTENTS. SECTION I. DISEASES OF THE HEAD. Page Wounds of the Head, - - . . _ i ARTICLE I. Wounds of the Integuments of the Head, ... 3 § I. Of the Erysipelas of the Integuments of the Head, and of the Wounds affecting them, - - ib. §11. Of the Treatment, - - - . 8 ARTICLE II. Fractures of the Cranium in Wounds of the Head, - 12 § I. Of the Varieties, - - - - '- - - ib, § II. Of the Causes, - - - - - 14 §111. Of the Symptoms, - - - - - - 15 § IV. Of the Affections, - - - - - 29 § V. Of Compression of the Brain by Effusion, - - ib. § VI. Of Compression of the Brain, from the depression of the Bones of l;he Cranium, - - - 29 § VII. Of the Treatment of Fractures of the Cranium, - 33 § VIII. Of the Treatment of Fractures, unattended with any other affection, - - - - - 34 § IX. Of the Treatment of Fractures, accompanied by the Symptoms pointed out by authors, as signs of Ef- fusion, ------ 37 § X. Of the Treatment of Fractures with Depression and symptoms of Compression, - - - - 42 § XI. Of Cases in which the Affections manifest themselves, without any apparent Fracture, - - 44 § XII. Conclusion, ----- 46 vi CONTENTS. ARTICLE III. Page Commotion of the Brain in Wounds of the Head) - - 48 § I. What is Commotion? .... ib. § II. Of the Varieties and of the Signs, - - - 50 § III. Of the Symptoms, which are the Effects of Commotion, 52 § IV. Of the Treatment, - - - - 55 ARTICLE IV. Inflammation of the Brain and its Membranes, in Wounds of the Head, .... 60 §. I. Of the Differences and the Signs, .... ib. § II. Of the Causes, - - - - - 63 §111. Of the Treatment, - - - . - 67 ARTICLE V. Suppuration of the Brain audits Membranes,in Wounds of the Head, - - - - - - 70 § I. Of the Varieties and Signs, - - - - ib. § II. Of the Treatment, .....72 ARTICLE VI. General Conclusion, ....... 75 Instruments of Trepanning, Memoir upon, - - 80 First Plate, explanation of, - - - - 86 Extirpation of the Carcinomatous Eye, Memoir upon, Section I. - ... Section II. - - - .... Section III. Section IV........ Operation for the Fistula Lachrymalis, Memoir upon, - 102 ARTICLE I. § I. General Observations, .... ^ § II. Reflections upon the two general modes of operating for the Fistula Lachrymalis, - . 103 87 ib. 8? CONTENTS. vii ARTICLE II. Page § I. Of the processes from which that of Desault is derived, 106 § II. Parallel of the two Processes, ... jog § III. Of the different Processes that are grounded on those of Petit and Mejan, - - - -110 ARTICLE III. Process of Desault, - - - - - - - 112 § I. Description of the Process, ... jb. § II. Of the subsequent Treatment, - - - 120 § III. Of the Process of Desault, compared with the others, 122 § V. Remarks upon the Process of Desault, - - 128 ARTICLE IV. VI. Process of Hunter, reflections on, - - 130 Diseases of the Maxillary Sinus, remarks and observations on, 134 Section I., ------ £6. § II. Of Ozenas, - - - - - - ib. §111. Of Fungi,........141 Second Plate, explanation of, - - - - 147 Operation of the Harelip, Memoir upon, - - •'■->' . 143 § I. General Reflections, - - - - - ib. § II. Of the Excision of the Borders of the Division, - 150 § III. Of the means of Contact between the Raw Borders of the Division, - - - - - 154 § IV. Operative process in cases of simple division of the LiP>........164 § V. Of the subsequent Treatment, - - - 169 § VI. Particulars of the Operative Process in the Compli- cated Harelip, - . . . - 171 Third Plate, explanation of, - - - - 178 Diseases of the Mouth, remarks and observations upon, - 180 § I. Diseases of the Lower Jaw, - ib. § II. Diseases of the Salivary Passages, - - 185 § III. Of the Excision and Ligature of the Amygdalae and Uvula, - 193 Fourth Plate, explanation of, 202 viii CONTENTS. SECTION SECOND. DISEASES OF THE NECK*. Page Bronchotomy, Memoir on, and on the means of remedying it in certain cases, .... 203 ARTICLE I. Of the Cases which require Bronchotomy, and of those in which it may be supplied by Elastic Tubes, ... 204 § I. First Class of the Cases of Bronchotomy, - - 205 Drowning, .... - ib. Angina, - ------- 206 Swelling of the Tongue, - - - - 211 Extraneous Substances in the CEsophagus, - 212 Tumours in the neighbourhood of the Trachea Arteria, 213 Wounds of the Neck, - - - - - -214 § II. Second Class of the Cases of Bronchotomy, - 218 Extraneous Substances, formed in the Aerial Passages,' ib. Extraneous Substances from without, - • - - 220 § III. General Recapitulation, - ... 226 ARTICLE II. Elastic Tubes, in the Larijnx, and in the Trachea Arteria, intro- duction of, ------ - 229 ARTICLE III. Of the Operation of Bronchotomy, ... 234 § I. Double manner of Operating, - - - ib. § II. Operative Process, - - .... 237 Cases in which issue must be given to the Air, - 238 Cases in which an Extraneous Substance is to be ex- tracted, ........240 Deglu'iiion Obstructed, Memoir upon, means of nourishing pa- tients, - - - . . - 243 § I. Of the cases in which Deglutition is obstructed, - ib. § II. Of the means that may be substituted, when Degluti- tion is obstructed by one of the preceding causes, - 246 § III. Of the application of the preceding method to practice, 249 CONTENTS. ix Page § IV. Of cases where tubes cannot be introduced through the nostrils, - - - - - 251 Extirpation of the Thyroid Gland, remarks and observations upon, ..-..- 257 § I. Remarks on the preceding Case, - - - 260 SECTION THIRD. DISEASES OF THE THORAX. Dropsy of the Pericardium, observations upon, - - 262 Operation for Cancer of the Breast, observations on, - 266 SECTION FOURTH. DISEASES OF THE ABDOMEN. Umbilical Hernia of Children, memoir upon, ... 273 § I. General Reflections, ------ ib. § II. Of the causes and the differences of the Umbilical Hernia of Children, ..... 274 § III. Of the different Methods of Treatment, - - 277 Parallel of Ligature and of Compression, - - 278 § IV. Of the different modes of making the Ligature, - 282 Treatment of Strangulated Hernia, observations and reflections upon,........287 ARTICLE I. Of the means to be employed before the operation, ib. § I. Of the Taxis and of its inconveniences in Strangulation from Inflammation, - 288 § II. Of the means proper to supply the Taxis in cases of Strangulation by Inflammation, - 293 § III. Of the Taxis in the Strangulation from Choaking, - 297 Vol. I. b X CONTENTS. ARTICLE II. Page Operation for Hernia, - - .... 299 § I. Operative Process, - - - - - ib. § II. Reflections upon the Operative Process, - - 302 Preternatural Ani, memoir upon, ... 306 General Reflections, .... ib. ARTICLE I. Phenomena of Preternatural Ani, ----- 307 § I. Of the state of the parts in the Preternatural Anus, - ib. §11. Of the Effects of Preternatural Ani, - - - 311 ARTICLE II. Of the Treatment of Preternatural Ani, - - - 313 § I. Palliative Cure, ------ ib. § II. Of the Radical Cure, - - - - 317 Fifth Plate, explanation of, ... - 329 Operation for the Fistula in Ano, memoir on, - - 330 ARTICLE I. General Reflections.—Parallel of the Ligature and of Incision, - .... ib, ARTICLE II. Operation by the Ligature, - - - . . -332 § I. Of the operative process in cases where the perforation of the intestine is not necessary, - - 333 Of cases where the Fistula has little depth, - ib. Of cases where the Fistula is deep, - - 335 Reflections on the Process, ... 337 § II. Of the mode of operating, in cases where the perfora- tion of the intestine is necessary, - 342 Of cases where there is only a denudation of the intes- tine without an opening,.....343 Of cases in which there is an opening into the intes- tine, and a denudation" above the opening, - 344 Of cases in which the denudation is much above the reach of the finger, - 347 CONTENTS. xi ARTICLE III. P.;ge Operation by Incision, - - - 349 § I. Mode of operating in cases where there is an opening outside of the intestine, - - - ib. Of cases in which the opening of the intestine is above the reach of the finger,.....354 § II. Mode of operating in cases where there is no external opening, - '• - - - 355 § III. Of the mode of operating in Fistulae, which are an- cient and complicated with callosities, - - 359 § IV. Of the subsequent treatment in the operation by inci- sion, - - - - - - 361 Sixth Plate, explanation of, - - - - 364 Scirrhosities of the Rectum, memoir upon, - - 366 ARTICLE I. Of the causes, - - - - - - - ib. § II. Phenomena of the Disease,.....368 ARTICLE II. § I. Different methods of treatment pointed out by authors, 370 § II. Treatment used at the Hotel Dieu, - - - 371 Of cases in which Fistulae are added to Scirrhosities.— Of the consequent treatment, ... - 377 Different kinds of Hydrocele, remarks and observations upon, 381 ARTICLE I. Reflections on the radical cure of Congenital Hydrocele, ib. Section I. -------- ib, §11. Dcsault's Process, - - ... 382 ARTICLE II. Reflections upon the radical cure of the Hydrocele, complicated with Swelling of the Testicle, - -385 Section 1. - - ib. Section II. .... 388 Operation for Sarcocele, remarks and observations upon, - 590 xii CONTENTS. Page Operation for the Stone, according to the improved process of Hawkins, memoir upon, - 397 ARTICLE I. § I. General considerations, - - ib. § II. Of the original instrument of Hawkins, and the manner of using it, - - - - 398 ARTICLE II. § I. Of the Instrument of Hawkins, as improved by De- sault, and of the manner of operating with it, - 402 Seventh Plate, explanation of, 409 Extraction of Encysted Stones, memoir upon, - - - 410 ARTICLE I. Srction 1. - - - - - ib. §11. Method by Injection,......ib. §111. Method by Laceration, - - 411 § IV. Method by Incision, ... _ 412 § V. Desault's Process, ----.. 413 Ligature of Polypi of the Womb and of other Cavities, memoir upon, - - - . . .4i8 § I. General Considerations, - - ib. § II. Of different curative methods, besides the Ligature, - 419 §111 Of the Ligature, - - - 420 § IV. Of the Ligature of Polypi of the Womb and of the Vagina,........421 Of the different Processes by Ligature,. - _ ib. Desault's Process, - 424 Another Process, - 4g0 § V. Of the Ligature of Polypi of the Rectum, - . 432 § VI. Of the Ligature of Polypi of the Nares, - . 435 § VII. Of the Ligature of Polypi of the Ear, - - _ 442 Eighth Plate, explanation of, 444 Instruments of Desault's Process, - ib Instruments of the other Process, - . . ib' CONTENTS. xiii SECTION FIFTH. DISEASES OF THE LIMBS. Page Treatment of Varicous Ulcers, memoir upon, - 446 § I. General Considerations, - - - ib, § II. Treatment of Varicous Ulcers, .... 449 Growing of the Nail of the Great Toe into the Flesh, reflections upon, - - - . - . . - 456 General Observations, - - - - ib. Desault's method of Treatment, - - - - 457 Amputation of Limbs, remarks and observations upon, - 460 § I. General Considerations,......ft. § II. Circular Amputation of the Fore-arm, - - - 461 § III. Amputation of the Thigh, by the Flap operation, - 465 § IV. General reflections upon Amputation, ... 459 Of the Details preceding the Operation, - - 470 Details of the Operation,.....472 Of the Dressing, - 4^g Operation for Aneurism, remarks and observations upon, - 478 § I. Operation for the false Aneurism in the Axillary Ar- teiT>........ib. §111 False Aneurism of the Brachial Artery, - . 486 § IV. Operation for true Aneurism, in cases where the artery cannot be tied above the tumour, - - 401 SV...... * ......- 494 Erysipelas, remarks and observations upon, - - - 502 § I. General Considerations, - - . • ib § II. Treatment, - - - - . Of the Internal means, ... Of the External means, - Bilious Erysipelas from an internal cause, - - 510 Erysipelas in consequence of Wounds, - - #, Wandering Erysipelas, - - . . . 5U 504 505 506 DIRECTIONS TO THE BINDER. VOLUME I. _, page Plate I. to face......................8g 11..........................147 *"..........................178 !V.........................202 V..........................329 VI..........................364 VII..........................409 VI"'.........................444 / SURGICAL WORKS, &c. DISEASES OF THE SOFT PARTS. SECTION I. Diseases of the Head. MEMOIR UPON WOUNDS OP THE HEAD. l.WO subject in surgery has given more employment to the pens of authors, than that of wounds of the head. It would be reasonable to suppose, on reviewing the im- mense collection of their works, that art had nearly reached perfection in regard to this subject. And yet how distant is it still from it! How many doubts are to be removed, how many uncertainties to be cleared up in the diagnosis, prognosis and treatment! The unfavour- able influence of these wounds upon the important organ with whose functions those of all other organs are so . intimately connected; the numerous phenomena which are the remarkable effects of this influence; the uncer- tainty of the causes on which these phenomena depend; the difficult removal of the veil behind which these causes are hidden; the obscurity resulting as to the choice of means proper to oppose them;—all seem, by obstructing the path of the practitioner, to animate his Vol. I. A 2 Wounds of the Head. exertions. But these exertions will be of no avail, unless guided by observation, a maxim always acknowledged and always too little regarded. 2. It is true that hypotheses have not been multiplied upon this subject; but does it result that the judgment will progress in a right direction, because it has not been led astray by the imagination? In relying upon facts, general principles must be founded upon their number. A few detached examples cannot afford grounds for rules that are to be generally applied. In this many practi- tioners, who were too eager to establish precepts, have erred. Even the celebrated Petit is not free from such a charge, in regard to the present subject. 3. Another method must be pursued. We must ob- serve nature, collect a number of facts, assume their assemblage as principles, and at length venture to make some inferences from them. What reason have we to decline this method, especially in the injuries of an organ, in which the mystery that already envelops its functions in a natural state seems to become still more impenetrable? 4. To treat this subject with order, I will examine the influence of external violence: 1st. Upon the exterior coverings of the head. 2d. Upon the bones of the cra- nium. 3d. Upon the brain and its membranes. Hence arise three divisions. The first, devoted to some reflec- tions on the wounds of the integuments, and particularly on a circumstance frequently complicated with them. The second, to fractures and to compression of the • brain, occasioned either by depression or by effusion. The third, to the commotion, contusion, inflammation and suppuration of the brain and its membranes Wounds of the Head. 3 ARTICLE I. Wounds of the Integuments of the Head. 5. Authors have divided wounds in the head, as in other parts, into puncturing, cutting or bruising, ac- cording to the instrument which has occasioned them; each presenting particular, characteristic phenomena, and frequently different indications. It is not my inten- tion to bestow a particular consideration on these phe- nomena and indications; because nothing new on this point is to be met with in the practice of Desault. I refer the reader to modern authors, as Petit, Pott, Sabatier, &c. for the history of bloody tumours, the effect of contusions, the means of reunion in cutting wounds whether simple or with laceration, and the different complications which the injury of the bones of the cranium adds to these wounds. I wish only to call the attention of the reader to a symptom frequently ob- served here, whatever may be the mode of division, and which very few authors have considered in a proper point of view, although all have made some mention of it; namely, the erysipelatous inflammation of the integu- ments of the head. % I. Of the Erysipelas of the Integuments of the Head} and of the Wounds affecting them. 6. Erysipelas, a kind of inflammation whose cause, in a great number of cases, seems to be fixed in the first passages, is generally a very frequent complication of wounds, especially in large hospitals, where unwhol- some air, the contact of a number of unsound bodies, food almost always prepared badly, contribute greatly to the production of a state of saburra that often be- comes habitual. In no part is the influence of this com- 4 Wounds of the Head. plication more manifest than in wounds of the head. Most of the wounded experience it in a greater or less extent, and with symptoms more or less alarming. It accompanies wounds occasioned by puncturing, cut- ting or bruising instruments, but perhaps the first most frequently. 7. A pain, sometimes dull and heavy, sometimes sharp and burning, is the ordinary precursor; to this is added a swelling of the edges of the wound, at first slight, in a little time extensive. About the same pe- riod the tongue is covered with a yellow fur; the appe- tite fails; nausea, inclination to vomit and throwing up bilious matter harass the patient. He feels a disgust for all sorts of food; sometimes a rigidity [renitence) more marked, and a sensibility more acute than usual are to be perceived in the region of the liver. Finally, under all these forms there is a full display of the affec- tions of the primae viae. 8. If the disease has made some progress, the swell- ing extends, occupies all the hairy scalp, is propagated even to the face, assumes a colour more or less red, always mingled, particularly in the face, with a yellow tint, which quickly recedes under the pressure of the finger, and as speedily returns. It is often complicated with an edematous puffing, and at other times presents scattered vesicles, that are filled with a yellow serosity. 9. The pains of the head increase; the skin becomes dry, manifests a heat, which is always characterized by a degree of sourness, so striking in bilious affections. The pulse is hard, small, tense and frequent. The as- pect of the wound is changed; at the beginning the edges swell, become dry, and suffer no fluid to escape; but if suppuration has been already established, it be- comes a yellow fluid sanies, and often fetid. The tension of the integuments is considerable, and if art is not then Wounds of the Head. 5 able to effect a resolution, abscesses are formed, which make openings for themselves commonly behind the ears and the upper eye-lids, frequently in other places. When the symptoms are more intense, delirium and coma sometimes supervene; but generally, in this state, the bilious character is not so predominant as the phleg- monous. 10. If we reflect on the accurately described progress of the subject before us, it will be perceived, 1st. That the bilious aspect is generally prevalent. 2d. That the seat of the-disease exists essentially in the first passages, whose saburra keeps up the symptoms. 3d. That there is an unknown but real connexion between the abdo- minal organs and the parts affected with erysipelas—a connexion which will appear more obvious, if it is con- sidered how seldom the symptoms become violent with- out a correspondent affection of the liver, or even the formation of an abscess in it; as has been observed by many authors, and by Petit in particular, in a great num- ber of wounds of the head, which were under his care at the same time in the military hospital of Courtray. But our attention will be devoted more particularly to this point, when we treat of commotion and inflammation of the brain. 11. If from these considerations, founded upon a strict observance of nature, it were permitted to adduce rea- sons as to her mode of action in such cases, the follow- ing appear to be the most probable. 1st. One of the pe- culiar effects of wounds of the head is to produce in the abdominal viscera a bilious affection, manifested by the appearance of the ordinary symptoms, which we see in effect preceding all other affections. 2d. This disposi- tion, in a little time diffused generally throughout the system, exerts a more particular influence on the inte- guments of the head, already affected by the wounds, 6 Wounds of the Head. and determines to it the series of phenomena stated, (8 and 9) from whence it follows, that there is really an action of the wound upon the primae viae and a reaction of those upon the wound. What can be the unknown tie that connects with each other the derangements of organs so distant? The knowledge of it is not important. , Its existence is sufficient for us to found the indications of cure. 12. However, it sometimes happens that the bilious character is less decisive in this erysipelas; in that case the nausea, bitterness of the tongue, &c. do not precede; on the contrary the tongue is dry, arid and even red; the thirst ardent; the pulse is stronger and less con- fined; at the same time the swelling becomes consi- derable, but the skin is more tender and redder than in the preceding case; sharp, throbbing pains torment the patient; the face appears red; the eyes inflamed, and then delirium, coma, &e. often manifest themselves. This phlegmonous character of erysipelas is rarely seen, in comparison with the other, especially in large hospi- tals, where every thing disposes the patients to that. Besides, in a little time, the symptoms generally be- come more calm, particularly if suitable bleedings have been employed; and then the tongue begins to be furred, nausea and vomiting supervene, and all the symptoms shortly assume the bilious aspect. 13. Most authors have paid attention to the subject before us, and some have traced its progress; but all have believed its seat to be purely local. Some attribute it to the stagnation of putrid juices in the thickness of the integuments, and sometimes below the pericranium. Pott thinks that the symptoms pointed out (7__io) de- pend solely upon the injury of the integuments and the cellular membrane; and when they assume the character traced (12) they are to be attributed to the injury of the Wounds of the Head. 1 aponeurosis of the cranium and of the pericranium. Most other practitioners, without distinguishing, like Pott, the nature of the symptoms, attribute all of them equally to this injury; pretending at the same time that in the puncture of the aponeurosis, its boundaries limit the extent of the swelling; on the contrary, in that of the pericranium, it is generally diffused; an opinion evi- dently formed from anatomical investigations rather than from the observance of nature. 14. Are these symptoms really to be attributed to the injury of the aponeurosis and of the pericranium? Some doubt may be entertained on the subject, from ob- serving, 1st. That both these membranes are insensible. 2d. That this opinion was formed at a time when they were supposed to possess extreme sensibility. 3d. That in other parts of the body a wound, which affects the aponeurosis or periosteum, is rarely found to be com- plicated with these unfavourable symptoms. 4th. That in the present case there frequently are wounds, which affect only the integuments and cellular membrane, and still they present the phlegmonous character (12). 5th. That, on the contrary, there are cases in which the injury of the aponeurosis and pericranium cannot be doubted, and where no such affection is manifested. 6th. That it is seldom that these affections do not yield to means employed principally in the prima; via;. 15. However when the inflammation is obvious, espe- cially when it attacks the parts subjacent to the aponeu- rosis, it must be acknowledged that the difficulty expe- rienced by the parts swelling from the tension of this membrane, and the kind of strangulation which then takes place, aggravate the affections, even change their character and indicate consequently large incisions to remove the effects by destroying the cause. But in general, the influence of this principle has been too 8 Wounds of the Head. much exaggerated. Most commonly the seat of the swelling is placed in the cellular membrane, above the aponeurosis, whether that has been wounded or not; from whence it follows that the precept of making free incisions, so generally established, ought not to be ex- tended to so many cases as might be supposed, from reading certain authors. § II. Of the Treatment. 16. From what has been said (7—12), it may be easily conceived what should be the treatment of the affection under consideration, if it assume the bilious aspect. The two principal and natural indications are, 1st. To destroy the evil in its source, by attacking the principle which sustains it. 2d. To combat the local effects. In fact, of what service could the local treat- ment be, if the bilious disposition, a cause acting inces- santly, was not first destroyed? 17. The first indication is generally accomplished by evacuants, which clearing the primae viae of the saburra with which they are loaded, remove its influence upon the wound of the head. 18. To satisfy the second indication, emollients and resolvents combined present in general great advan- tages. They allay the irritation, which is the inevitable effect of the wound, dissipate the pain and favour the resolution. Several authors, Richter, Seile, and Stoll in particular, think the employment of all external appli- cations of no use; a principle always well founded, when the disease depends upon an internal cause, (in which cases Desault suffered the part to be constantly exposed to the air) but dangerous to admit in practice, when it originates from a contusion or a wound. 19. On these two indications rested the practice of Desault in wounds with erysipelatous swelling. For Wounds of the Head. 9 such the following treatment was employed. As soon as the abdominal viscera appeared to be affected, or the slightest swelling in the edges of the wound was seen, however considerable the heat of the skin or the fever might seem, a grain of emetic tartar was given in a large portion of water. Every delay would then be perni- cious, and the advice of certain practitioners, who wish the patient to be prepared by some diluting drinks, could not be followed; because by these means time would be allowed to the bilious disposition to unfold itself, for the swelling to extend, and in a little time there would be no possibility of preventing the formation of pus. 20. At the same time, the head having been shaved, must be covered, at the wounded spot, with a cataplasm moistened with a resolvent liquor, or compresses soaked in it. But here an essential precaution is to be ob- served, not to extend these applications much beyond the edges of the division. At that spot is the point of irritation; beyond it, the effect of the remedy would perhaps be the disposing of the parts to swell. 21. Commonly the affection subsides soon after the evacuation produced by the emetic, and a single grain is frequently sufficient, although its only effect may have been the increased secretion of perspiration and urine. Frequently, however, it is necessary to repeat the use of the same means twice or thrice. The following case, recorded by Vincendon, is an example of it. CASE I. A man, aged thirty-two years, was brought to the Hotel-Dieu, with a wound on the head, extending from the union of the sagittal suture with the lambdoidal to the external angle of the right eye. The drunkenness of the patient precluded him from giving any account. Vol. I. B 10 Wounds of the Head. The head was shaved, and the edges of the wound were brought together by adhesive plasters, and covered with lint and compresses moistened in lead water. The next day there were symptoms of saburra in the prima; viae; pain in the neck and shoulders; acrid heat upon the skin. An emetic was given in a large portion of water, which produced copious stools. On the third day, there was an erysipelatous swelling in the right eye and its neighbourhood; the emetic repeated on the next day and the day after; the fourth day the adhesion of the edges of the wound preserved by the simple uniting bandage; the fifth day a fluctuation towards the external angle of the eye; a cataplasm applied upon the part; the erysipelatous swelling being renewed, the same emetic was administered the sixth day; a spdntaneous evacuation of pus through two openings; a bloody tu- mour open in the right temporal region; on the thirteenth day, the wound was completely cicatrized; symptoms of saburra; a fresh dose of the emetic. The thirtieth day, a cicatrization of the opening made in the bloody tu- mour. On the thirty-sixth day the patient, was dis- missed perfectly cured. 22. During the whole course of the treatment, a di- luting ptisan, such as the decoction of dogstooth edul- corated with oxymel, was prescribed for the patient. The diet, abstemious at first and during the existence of the affection, must be relaxed gradually. In general it may be observed that abstinence, kept up too long, aug- ments the acrimony of the humours, and often repro- duces the bilious disposition, especially in unhealthy places, such as prisons, large hospitals, &c. 23. Bleeding, recommended by some authors, al- ways exhibits great inconveniencies. Desault constantly observed, that those patients, on whom it had been prac- tised, particularly several times before their admission Wounds of the Head. 11 into the hospital, experienced symptoms more severe and alarming. 24. When the affection has subsided and the wound is advancing towards cicatrization, it will be prudent not to expose it too soon to the contact of air; otherwise an unfavourable relapse might ensue, as is proved by the following case communicated by Derrecagaix. CASE II. On the 22d of April, 1792, Jean Petit was knocked down by several blows of a pewter pot, which inflicted a wound on the head. He got up and came to the Hotel Dieu, some hours after the accident. Three wounds, one longitudinal upon the forehead, another smaller one dn the top of the head, and a third with a detached por- tion of the integuments near the external angle of the eye, were united and dressed simply with compresses moistened in lead-water. On the next day there was some pain, a slight swelling, a commencement of erysi- pelas and of saburra in the primae viae. The usual emetic was directed. On the third day these affections had al- most disappeared. On the fifth day an almost entire union of the wounds. The patient, thinking himself cured, very imprudently removed the dressing, and re- mained for some time exposed to the air. In the even- ing there appeared swelling, pain and erysipelas about the edges of the wound, fever and symptoms of the affec- tion of the abdominal viscera. The next day the emetic draught was administered. On the seventh day the affection was amended, except the increase of swelling in the forehead. On the eighth, an abscess formed in the centre of the large wound burst spontaneously. The ninth, slight pains; a fresh dose of the emetic. On the fifteenth, the cicatrization of all the wounds was completed, and the patient was dismissed cured. 12 Wounds of the Head. 25. If instead of pursuing the progress indicated (7—10), the affection had assumed the aspect of the symptoms traced (12), evacuants administered first, might increase the irritation, already considerable. In such cases their use should be preceded by means suited to destroy it, such as bleeding, more or less fre- quently repeated, emollient fomentations; and if there is cause to suspect a constriction of the aponeurosis or an incomplete division of the nerves, it will be necessary to make large and deep incisions in order to remove these obstacles. In a little time the bilious disposition will manifest itself, and render it necessary to recur to the preceding mode of treatment, which commonly is the most suitable from the first attack, particularly in large hospitals, where every affection seems to assume the bilious aspect. ARTICLE II. Fractures of the Cranium in Wounds of the Head. § 1. Of the Varieties. 26. Fractures of the cranium are most commonly the effect of the action of hard bodies on "that bony case. They take place generally in two ways, 1st. Directly. 2d. By a counter-stroke. In the first mode of division the seat of the fracture is in the place where the external body struck. The second is characterized by a contrary phenomenon. The fracture may super- vene either in a spot diametrically opposite to that which was struck, or in the bone next to that which received the blow; or the same bone may be broken in a point different from that of percussion, or the internal table alone may be divided, while the external remains en- tire. From hence result four species of counter-stroke, essentially different. Several authors have denied their Wounds of the Head. 13 possibility in general; but at the present day, when the most accurate observations attest their reality, and sound physics demonstrate their mechanism, they can no longer be called in question. Desault has seen a great number of examples. 27. In the fracture by a counter-stroke the division is commonly simple; it may also be so in the direct solu- tion, but frequently it is multiplied, and then there are sometimes several rays running from a single centre, making a fracture in the form of a star; sometimes two or three divisions meet at an angle, &c. 28. The one is never accompanied with splinters, fragments, &c. The other often presents this compli- cation, always more unfavourable, as these portions of bone being depressed by the cause of the fracture, may compress the brain and give origin to numerous acci- dents. The first is commonly covered by the sound in- teguments; the second is often indicated by wounds, contusions and a denudation of the bone. 29. Both vary in their length, which is sometimes limited to two or three inches, and often prolonged from one side of the cranium to the other, or even to its base; in their direction, which is longitudinal, trans- verse, oblique, or sensibly curved; in their breadth, the different degrees of which have furnished authors with the distinction, so often repeated in the schools, of crack, fissure and fracture. A very fine separation indicates a crack, in which the edges are in contact and the inter- nal table is sometimes not affected. In a fissure the edges of the division are not so contiguous; and they are always evidently separated in a fracture, the interstice of which is generally filled up with clots of blood. Sometimes only the external table is divided, the inter- nal having resisted the blow, and then only a crack ensues. 14 Wounds of the Head. 30. The bloody effusion, commotion and inflammation of the brain, are the most common and the most severe affections resulting from the fracture of the bones of the cranium. Sometimes instead of fracture, a separation of the sutures is the result of blows upon the cranium, an accident which is commonly occasioned by the counter-stroke. $ II. Of the Causes. 31. It has been shewn (24), that there are two modes of fracture; the one direct, the other by a counter- stroke. To conceive how these take place, it may be remarked that the first effect of the action of bruising bodies upon the cranium, is to impress suddenly upon it a form different from that which is natural, flattening it in one direction and making it more prominent in another. From thence the bony fibres will inevitably suffer a distension, an agitation, which if they be propa- gated generally through the bones of the cranium, will produce a fracture in that spot where, being superior to the natural ductility of the bones, they find the least re- sistance. Now if the place struck resists as 10, while another point resists only as 5, it is evident that the frac ture will happen in the latter place. This is the counter- stroke. On the contrary if the solidity is less where the blow be struck, the fracture will be direct. 32. But for this process to be observed, it is neces- sary, as has been already remarked, that the motion should be propagated generally throughout the whole cranium, which happens only when the striking body, being round and large, bruises an equally extensive sur- face of the cranium. On the contrary if there is a sen- sible projection or point, the bone yields at the place struck, and the motion being confined to that, cannot be propagated. This will be illustrated by a compari- Wounds of the Head. 15 son: place one hand upon the extremity of a beam, and let the other extremity be struck with a pointed ham- mer. The instrument will sink in, and no vibration will be experienced by the hand. Let the same experiment be repeated with a hammer, whose head is considerably convex; the vibration will be violent. The application is easy. 33. As striking bodies commonly have angles more or less prominent, we may conceive the reason of the frequency of direct fractures, always more numerous / than those from a counter-stroke, which can happen only from the action of large and convex bodies. Finally, it is unnecessary to give more ample theoretical details in a work professedly practical. $ III. Of the Symptoms. 34. To establish with precision the characteristic symp- toms of fractures of the cranium, we must suppose four different states, to which may be referred all the cases offered in practice. 1st. A denudation of the fractured bones of the cranium. 2d. Wound, without denudation, covering the fracture. 3d. Contusion, without wound' corresponding exactly with the division. 4th. No sen- sible appearance of injury in the external integuments. 35. In the first case there can be no doubt, inspection alone being sufficient to discover the division, when the wound carefully cleaned puts the bone in full view. A suture, according to the remark of Hippocrates, the course of an artery, or the impression of the instru- ment which caused the wound, can alone occasion any uncertainty; which, however, in the first case is easily re- moved by anatomical knowledge, which informs whether a suture exists there or not; and in the two others, by the assistance of the scraper, which leaving always the trace <*f a fissure, after removing a considerable portion of the 16 Wounds of the JSead. bony substance, indicates that there is a division of the bone, better than can be done by pouring ink upon the naked surface, a mean so generally employed since the time of the father of medicine. 36. In the second state (34), there must be one of two things. Either the fracture is accompanied with considerable separation, splinters, depression, &c; and then the touch alone is sufficient to ascertain it through the wound of the integuments which cover it; or it presents only a simple crack or fissure. In this.case nothing can indicate it but the dilatation of the wound and the denudation of the bone: an operation always useless, as shall soon be proved, while no unpleasant affection is manifested, and even after it has appeared. Some authors have pretended that the bad state of the edges of the wound, their swelling, and their sanious suppuration indicate a subjacent fracture; but, in the first place, there is often division and wound without these symptoms; secondly, they sometimes exist with- out an accompanying fracture. 37. The preceding rule is applicable to the diagnostic of fracture in the third state (24). Here it is only neces- sary to be attentive in examining the bruised place, in order to ascertain if there be a division of the bone; but we must take care that we are not imposed upon by certain bloody tumours, whose hard and shining edges, soft and compressible centre, offer to an unskilful hand the sensation of a fracture with depression. This re- mark was made by the celebrated Petit, and has been repeated since by all the authors who have written upon the subject. 38. In the fourth state, where no external injury is manifest, as often happens in the counter-stroke, if the touch does not indicate the fracture, what symptoms are there by which it may be ascertained? They are rational Wounds of the Head. 17 or sensible: the first leave always such a degree of un- certainty both df the existence and the place of the frac- ture, that a solid diagnostic can never be founded upon them. A statement of them will be sufficient to form a judgment. 39. 1st. There is a noise, like that of a pot which is broken; but the distress of the patient will then scarcely permit him to distinguish any thing. Is this noise an in- evitable resuh of the division? 2d. An hemorrhage from the nose, ears and eyes. May not the blow rupture some small vessels in those cavities, without affecting the cra- nium? 3d. A p.iin at the fractured place, when the pa- tient eats* or when a body placed between the teeth is forcibly pulled away. What is there to prevent a simple contusion of the bone or pericranium from producing the same effect? Besides, experience proves that it is not always attendant on fracture; this symptom is even in- sufficient, when on pressing the head in every direction we meet with a spot more sensible than others, an index, according to authors, and Bell in particular, of fracture. 1th. The mechanical motion of the patient, who carries his finger to the place of fracture. To occasion this mo- tion one painful spot is sufficient, and how many other causes than fracture may produce this pain! 5th. Tume- faction, puffing and edema at the fractured place. How often does practice exhibit fracture without these symp- toms, and these without fracture! 6th. A mark impressed at the place of division, upon a large cataplasm applied to the head for some time. Experience has contradicted this sign, especially in the practice of Desault, who, with other views, constantly employed cataplasms in wounds of the head. 7th. The force of the stroke, direction of the blow, weight of the instrument, &c. But the instru- ment cannot always be seen, nor can the patient be always able to give an account of the accident. 8th. i he Vol. I. C 18 Wounds of the Head. detachment of the pericranium above the fractured spot. How many fractures are there without this phenomenon, and how many times does it exist without fracture! 9th. Insensibility, vertigo, vomiting, paralysis. All these symptoms indicate an injury of the brain, and we know that this often exists without fracture; besides, how many fractures are there without these symptoms! 40. It results from this examination of the signs of a fractured cranium, that if the sight in the denudation of the bones, or the touch when they are covered by the in- teguments, do not indicate the fracture, it is impossible to pronounce with any certainty its existence or its seat, from the rational signs pointed out by authors. 41. It is then absolutely necessary to lay the bone bare by suitable incisions, in order to be assured of the reality of a fracture. But what rule shall direct the surgeon in these incisions? In the uncertainty left by the signs laid down as the most positive, such as the puffing, the ex- periment of the cataplasm, local pain, detachment of the pericranium, &c, what principle shall guide the knife? Would there not be a risk of wounding to no purpose a part of the integuments of the head, of augmenting by the pains which would be the inevitable result, the symptoms of the disease, particularly of prolonging the treatment, by the slow cicatrization of such extensive wounds? 42. It will be proved (80) that there is never any indi- cation for the use of the trepan until symptoms of com- pressed brain are manifest. Then of what importance is the knowledge of the fracture, until they supervene? would it change the treatment? by no means. Why then should the patient be distressed by painful researches, when there is no real necessity? 43. If the symptoms of compression become mani- fest, such is their uncertainty, as shall be proved (51,65), Wounds of the Head. 19 that there is seldom any indication for opening the cra- nium; but without this indication, of what service is it to know the fractured spot? The fracture being well as- certained will not add to the necessity of trepanning; since alone and on its own account it never demands it. In both cases incisions can have no other advantage than the relief of the cellular membrane and the swelled in- teguments. This may be accomplished by other means. 44. From hence it results that authors have extended to too great a number of circumstances the maxim of incisions for the discovery of fractures of the cranium. It will not excite astonishment, that an immediate con- sequence of a principle so generally adopted is the ap- plication of the trepan to all cases of such fractures. 45. If it is not common to meet with cases, where recourse must be had to these incisions for the discovery of a fissure or crack, without any apparent sign, it is different when there is a considerable separation of the edges of the division. Then they are required to give vent to the fluids which escape through the interstice; or when there is depression or splinters, a case in which it is necessary to remove or replace the bony pieces; or when sanguineous tumours cover the fracture, a circum- stance, in which the effused blood must be evacuted, &c; but then there can be no doubt of the place of the frac- ture, which the touch indicates, and there is no danger of multiplying useless and painful incisions. 46. If the symptoms do not render it indispensably necessary to search for a crack or fissure, without injury of the integuments, the puffing favoured by the applica- tion of cataplasms, the local pain, the motion of the patient carrying his hand constantly to the same spot, would be feeble guides to the practitioner. If a wound exists, by separating the edges we may penetrate to the bone, and if a fracture be discovered, an incision may 20 Wounds of the Head. be made according to the direction presenting, either towards an angle or any other part of the wound. 11 the division be very fine, the scraper will discover it. We pass by the precepts so much insisted upon by authors, and subject to almost as many modifications as there are cases. § IV. Of the Affections. 47. In general, fractures of the cranium are not of themselves dangerous; all means, suitable to their con- solidation, are commonly superfluous, and the unfavour- able prognostic, drawn by practitioners, depends only upon the affections which accompany them, and which they produce. Now these affections, the consequences of fractures, may be referred to a single circumstance, the compression of the brain, which may be occasioned equally by two different causes, effusion and depression^ It is of importance to examine these two causes before treating of the cure of fractures of the cranium, upon which they have a decided influence. § V. Of Compression of the Brain by Effusion. 48. It is not my intention now to treat of purulent effusion, the consequence of inflammation of the brain or its membranes, which inflammation it is previously necessary to be acquainted with. I would only consider the effusion that is formed more or less quickly by the effect of the blow inflicted upon the cranium, referring to a particular article, the suppuration of the brain. 49. Now this kind of effusion may take place, 1st, between the cranium and dura mater; 2d, between the dura and pia mater; 3d, in the substance or cavities of the brain. In the first case there is always a detachment of the dura mater from the bones of the cranium to a greater or less extent; and then the sources of the efrti- Wounds 6f the Head. 21 sion are the vessels of their mutual communication, in- evitably ruptured, and the vessels of the diploe which are also broken by the fracture. In the two other cases the effusion is the effect of the general shock, which ruptures the blood-vessels of the brain in the same man- ner as it does those of the ears and nose, when the hemorrhage comes from those cavities. 50. The first kind of effusion may happen in every part of the cranium; at the basis it is generally mortal; it is always circumscribed in a larger or smaller space. The second is constantly of such a nature, that the fluid, being diffused between the two membranes, occupies almost the whole of their interval, and thus occasions a pressure that is a little sensible, unless the quantity of extravasated fluid is inconsiderable. In the third kind the blood is equally diffused, if the effusion has its seat in the circumvolutions; it is circumscribed if the effu- sion exists in the cerebral substance or the ventricles. These remarks are important, as shall soon be shown. 51. Whatever may be the species of effusion, it hap- pens as often without fracture as with it. Let us examine in both cases what presumptive signs there are: 1st, of its existence; 2d, of its seat. This research is indis- pensable to the forming an accurate judgment of the necessity of trepanning, the intention of which is most generally to afford a vent for the effusion. 52. Authors have stated, as symptoms of the existence of effusion, coma, insensibility, vertigo, stupor, and even delirium in the patient. These phenomena are in fact the result of compressed brain. The experience of those, in whom this organ laid bare in some of its parts has been compressed, does not leave any doubt of the symptoms described above; but they may proceed equally from commotion and inflammation of the brain.. In order then to form a certain diagnostic, it must be determined 22 Wounds of the Head. when they depend upon the one cause, and when they are to be attributed to the others. Petit has made the following distinction: coma, happening at the instant of the blow, is the effect of commotion; supervening some time after, it is the result of effusion. But, in the first place, how many effusions are there so sudden, that a few seconds scarcely elapse between the blow and their formation? does it require a long time for the numerous vessels, which are then ruptured, to produce this affec- tion? besides, in general, what accurate information can we receive of these kinds of diseases? 2d. May not com- motion and effusion succeed each other, and is not this generally the case? A man falls, a slight commotion is the consequence of the fall; at the instant coma comes on. In the mean time the commotion subsides, but effu- sion is formed and the coma continues, although from a different cause. According to Petit, ought not the affec- tion, in such a case, to be attributed to commotion? we see the contrary, however, since the effusion continues the effect which the former had produced. 3d. May not effusion and commotion be complicated, and then to which of the two are the affections to be attributed? If the coma ceases and returns alternately, it is commonly attributed to effusion; but Desault has often observed this phenomenon in patients, whose bodies upon exami- nation showed no trace of effusion. 53. The symptoms, caused by inflammation, are gene- rally more easily distinguished from those of effusion; because the former do not come on until some time after the accident; as six, eight, or even twelve days. But if, as is sometimes the case, the inflammation comes on sooner; or if, as when it has been bruised, the brain is engorged, then what distinguishing sign is there? Petit says, that the fever precedes the first kind of coma and is subsequent to the second. How many times has the re- Wounds of the Head. 23 verse been observed! Two examples are recorded in the Chirurgical Journal: in the one, the fever had preceded coma, and yet no effused blood was found; in the other no fever had been the precursor of this phenomenon, and yet the membranes were inflamed. If effusion and in- flammation are complicated, what are the characteristic signs? But when inflammation exists separately, and does not supervene until the end of a certain time, the assemblage of symptoms assumes a febrile aspect which commonly discovers it. 54. It results from what has been said, that coma, in- sensibility, delirium, &c. offer characters too uncertain, and that from their existence we can never pronounce decisively upon that of effusion. 55. Is paralysis a more certain sign? It is true that, like coma, it indicates a bloody effusion; but, like it, it also indicates commotion and inflammation. Whether it comes on at the instant of the blow, or some time after, we cannot establish a more certain rule than in the pre- ceding case. There is the same uncertainty in the maxim of Petit, who says, that the paralysis of one side announces an effusion on the opposite; that there are also evident relations between the paralysis of the superior, inferior extremities, &c. and the seat of effusion in certain parts of the brain. How many times have the examinations of bodies proved the uncertainty of this principle! how often has it been found at the Hotel Dieu, that there was effusion on the affected side at the same time as on the opposite; or that the blood was generally diffused while the paralysis was local! Supposing this principle to be true, does it clearly distinguish the compression of the brain from other affections of that organ? supposing that it did distinguish it, does it indicate with precision the particular seat of effusion? 56. What has been said of paralysis is applicable to 24 Wounds of the Head. convulsions, which are the same affection in a greater degree that paralysis is in a less. Were it true that they existed constantly on the same side with effusion, who could say that they proved this to be their cause? or that they did not originate from the affection of the brain? on the contrary, experience proves that they are most com- monly produced by it. 57. To convulsions and paralysis, as general effects, may be referred sundry particular phenomena, such as spasmodic vomitings, involuntary discharges of the faeces and urine, the immobility of the pupil dilated or con- tracted in its opening, and other affections that are pro- duced by several causes, and on that account cannot give a peculiar character to any. 58. The same estimate may be formed of the signs drawn from the hemorrhagy of the nose and ears, from the fever, redness of the face, difficulty of breathing, stertorous respiration, force with which the blow was inflicted, &c. So many causes may occasion these symptoms, that the practitioner can never distinguish a particular one. 59. The different phenomena, that have been examin- ed, relate only to the existence of effusion, without de- termining its seat. Now, we think it has been proved (52, 58) that they can never, under any circumstances, positively indicate this existence; supposing however that they could prove it, there is but little indication for trepanning. It is yet to be ascertained where the effused fluid is situated; in the first place, if it is to be found be- tween the dura mater and the bones of the cranium, in the interval of the meninges or in the brain; secondly, in what spot of the cranium it is placed. 60. Now it is evident that no sign, no character can give precise information in which of these three places the effusion is to be met with; nor can they tell, whether, Wounds of the Head. QS when it exists upon the dura mater, it is not also to be found below it, or in the ventricles; and yet this infor- mation would be essential. Even supposing that there was a certainty of the existence of the effused fluid under the bones of the cranium, at what part is it to be found? The same difficulty and uncertainty would still prevail; a statement of the signs laid down by authors will bring conviction. 61. The more acute pain experienced by the patient in one part of the cranium, the mechanical motion of the hand, the disposition to lie upon one spot more than another, may depend upon a thousand other causes be- sides effusion, and practitioners are generally agreed as to the uncertain diagnosis which results from them. The pain felt by the patient in one spot on chewing, or when a body placed between the teeth is pulled away with violence, is not a more positive sign of effusion than of fracture (39). 62. Is it reasonable to admit, as a sign of effusion, the detachment of the pericranium, grounded upon this principle, so much insisted on by some English writers, that wherever this membrane is detached, the dura mater is also separated from the bones of the cranium? At the Hotel Dieu, daily experience refutes this doc- trine, both in the case of effused blood and of the sup- puration of the brain, or its membranes, by showing effusion without separation, and separation without sub* jacent effusion. 63. Fractures have seemed to all authors a more real sign of the seat of bloody effusion. It has been said, that in fact there cannot be a rupture of the diploe without laceration of its vessels, hemorrhagy and consequent effusion; from thence principally the precept of trepan- ning in all fractures. But experience and reason equally Vol. I. D 26 Wounds of the Haad. invalidate this assertion. In the first place, with regard to experience: on the one side, how many fractures does the examination of bodies discover without any kind of effusion! on the other side, how often does effusion take place without any fracture, or in every other place than that which was divided! Desault was certain that he met with those two cases much oftenerthan that where effu- sion was subjacent to a fracture. From whence it follows that there is at least as much probability against as for the operation of the trepan, in the case of naked fractures, even when the affections, pointed out by authors as signs of effusion, are manifest. In the second place does not reason teach us, that there may be fracture without detachment of the dura mater, otherwise than that which is necessary from the separation of its edges, and de- tachment of the dura mater without fracture; or detach- ment in a place distinct from that which was broken, or even when the bones of the cranium are divided else- where than the place struck, that the edges of the division may be so near each other as to render any oozing im- possible, as is commonly the case when the external table is alone affected, the internal remaining unhurt (29). 64. The operation of trepanning confirms what has been here advanced. In large hospitals, where the cus- tom of seeing forms a solid diagnosis for surgeons, who does not know that the trepan is often applied without discovering any thing under the fracture? What practi- tioner can say, at least when no blood escapes between the edges of the division, that he will find an effusion? Supposing that blood does escape, may it not come solely from the vessels of the diploe broken by the fracture, and not from effusion? May not the dura mater remain adhering to the fractured place, or at least be detached from it, as has already been observed, only in a small space and in a quantity proportioned to the separation Wounds of the Head. 27 of the edges of the division? Experience has proved it to Desault in many cases. CASE I. A mason, falling from a scaffold, sustained a large wound with denudation of the left parietal bone, which was divided by a transverse fracture; at the instant of the blow he fell into a coma. He was brought to the * Hotel Dieu, where it was observed that the fracture was sensibly separated at its edges and suffered a fluid and blackish blood to escape. The common dressing was employed and an emetic administered; these remedies were of no avail; the affection augmented, the patient died, and on opening the body no effusion was to be found in any part of the cranium. The dura mater was scarcely separated at the fractured place. 65. From what has been said (60, 63) it results, in the first place, that there is no positive sign to indicate whether a bloody effusion is to be met with above or below the dura mater, or in the cerebral cavities; in the second place, that supposing it to be between the cra- nium and the dura mater, we can never be certain at what point of the cranium it is seated; but it has been previously proved (52, 58) that even the existence of the effusion is constantly dubious. 66. Hitherto we have considered the diagnosis of effu- sion only under the relation of the affections, which may throw some light upon it; but the uncertainty of this diagnosis will be increased, if we reflect how often blood is effused without any affection resulting from it: for ex- ample, when it is found diffused between the membranes of the brain (50), or when it is formed slowly and as it were by drops between the cranium and dura mater, where it then sometimes occupies a large surface; a double circumstance, the reality of which has been often 28 Wounds of the Head. demonstrated by the examination of bodies, compared with the state of the patients during life. 67. If we now resume all that has been said upon the signs of bloody effusion, this will be their summary: there must be one of two circumstances—either the in- juries of the head from external causes are accompanied with accidents, or they are exempt from them. In the former case there is first, no certainty of the existence of the effusion; secondly, supposing this existence, there is no certainty of its seat even when the fracture is ex- posed to view* In the second case there is no certainty of the non-existence of effusion. From these positions, who can presume to found rules of treatment upon the diagnosis? who would hazard imprudent researches, un- less there was such a reunion of symptoms as to induce the strongest presumption? but how rare are such cases. This article will be resumed, in treating of fractures of the cranium. 68. The effects of bloody effusion are not solely to compress the brain; this is only a primitive result. When the patient has not perished from the affections that depend upon it, there is still reason to fear that at the end of a certain time the bones of the cranium may be affected with caries and necrosis, that an inflammation of the membranes of the brain, or of the substance of that organ, may supervene. Many observations attest these secondary ravages; but in general it seems that authors have exaggerated them too much, and that the blood may be absorbed in many cases, especially when it is diffused over a large surface and in small quantity; when it occupies, for example, the interval of the me- ninges, the sinuses of the brain, and sometimes even when it exists between the cranium and dura mater. 69. The following remarks prove what has been ad- vanced: first in the operation of trepanning, most com- Wounds of the Head. 29 monly only a small quantity of effused blood is evacuated; but that which remains, does not always produce the subsequent affections mentioned above: secondly, during the five last years of Desault's practice at the Hotel Dieu in Paris, he did not employ the trepan in the numerous cases of wounds of the head, with fracture of the cranium, which came under his treatment. Notwith- standing, his practice was crowned with the greatest success, unless the nature of the affection indicated the injury of the brain to be such that all means would be superfluous. Now in the great number of patients cured, is it not probable that many had sanguineous effusions. If the symptoms, laid down by authors, afford any cer- tainty, we might be assured that a great number were affected; but whether the effusion is absorbed or not, it is frequently followed by no secondary affection. This observation is important; it diminishes the force of the argument so often repeated, that it is better to make many useless trepannings than to fail in discovering a single effusion, because there is no proportion between the dangers of the operation and those of the disease. § VI. Of compression of the Brain, from the depression of the Bones of the Cranium. 70. The depression of the bones of the cranium results from a fracture, with splinters or fragments, which the action of the striking body depresses below their natural level. Some authors admit a depression independent of all solution of continuity. But this kind can never hap- pen except in two cases: 1st, When the bones are still soft, as in infants, and then, when the cause ceases to act, their elasticity will restore the original form. 2d, In the case of rickets, and then the depression will be gra- dual; it will take place in the bones of the cranium in the same manner as the distortion of the ribs, the curva- 30 Wounds of the Head. ture of the tibia and femur, and the deviation of the vertebral column, happen in this disease. These two kinds of depression are rare and always foreign from in- dicating the trepan, since the first is but for an instant; and the second being formed slowly, gradually accus- toms the brain to pressure, changes its figure insensibly and makes it concave at the corresponding place, so that a cavity would be occasioned, if the depressed portion were removed. 71. The same signs, which indicate compression of the brain from sanguineous effusion, characterise it also when it results from depression, such as coma, vertigo, insensibility, general or partial paralysis, a full embar* rassed pulse, difficult respiration, &c. But here more certainty attends the diagnosis, under certain relations. In effect, the touch, when the bones are not bare, and even the sight in wounds with denudation, sometimes indicate the existence of the cause on which these affec- tions depend, or rather afford a presumption of that cause, which may be not only a depression, but also a commo- tion and engorgement of the brain, these being frequently complicated with it. It may readily be conceived how difficult it is for this organ not to experience some alter- ation in such violent shocks as are necessary to produce these fractures. Effusion itself is also a more frequent complication of depression; so that in general it may be said, it is rare for a single cause to produce the affec- tions which accompany injuries of the head, and that the practitioner can never be certain from which they pro- ceed. Finally, depression is often very difficult to be ascertained, especially if there be swelling of the integu- ments which cover the fracture, and if the bones are but little depressed: in such cases avoid the error in- dicated (37). 72. Although we must almost always be ignorant, if Wounds of the Head. 31 the affections depend exclusively on depression, even supposing that it existed, let us however examine them, abstracting every other cause. They will then present a prognosis more or less unfavourable, according to the degree of depression, the extent and the form of the bony pieces. Death is the inevitable consequence of these large depressions, which, compressing the brain in a wide extent, destroy its organization, break its vessels, or form an invincible obstacle to the circulation. But if the depression is inconsiderable, if the bony piece is not much below the level of the other bones, then the case is rarely mortal. The first effect of such depression is to produce, it is true, coma and the most of the other symptoms of compression; but in a little while the brain becomes accustomed to this state of confinement; the circulation, at first disturbed, is re-established, and if no other cause, such as commotion or inflammation, keep up the affections, they begin to dissipate gradually, the patient returns to himself at the end of a certain time, recovers insensibly his intellectual functions and the en- tire use of all his senses, and gets well at length with his depression, which is sensible to the touch under the in- teguments and which he preserves all his life, or which is spontaneously removed by degrees, in such manner that the bony pieces, at the end of a certain time, become on a level with each other. Desault has often seen these two modes of termination. 73. It being understood how essential it is, for the in- dication of trepanning, to have an accurate idea of the primitive effects of compression of the brain from de- pression, and of the degree of danger which they present, it may not be useless to confirm by a few examples what has been here advanced. All authors, who have written on wounds of the head, cite some cases, in which the depression of the bones of the cranium, abandoned to 32 Wounds of the Head. nature, wras perfectly cured notwithstanding the com- plication of other affections. Magatus relates many such cases; among others, those of a child ten years old, and of an adult, in whom the bones were not elevated, and still they were cured. Scultetus in his Magazine of Sur- gery, Ruysch, Mery, Rohault, Palfin, in like manner speak of cases where all the symptoms were gradually dissipated without any external assistance. Most of the German surgeons, according to Magatus, never trepan- ned in any case, and yet their practice was crowned with as much success as that of the Italian and French sur- geons. A multitude of other facts, scattered through the treatises on operations, prove that the accidents from de- pression are not of themselves most frequently mortal; and no doubt there would be more proofs, were it not for the generally received maxim of trepanning in such cases. This is confirmed by the practice of Desault, who, during the five last years of his life, in which the trepan was banished from the Hotel Dieu, cured more fractures with depression than he had formerly done, when the operation was employed to elevate the depres- sed pieces. Examples have been published in the Chirur- gical Journal, and many analogous cases have been found in the manuscript observations left by Desault. Think- ing it useless to enlarge this memoir, a single case, re- corded by Launay, will be related. CASE II. On the 4th of March, 1793, Jean Fortry, aged forty- five years, was brought to the Hotel Dieu, in a state of insensibility, with cold extremities, pulse hard, small and tense. On examining the head, a large wound, com- plicated with fracture and a sensible depression, was ob- served on the right side. The whole head being imme- diately shaved and laid bare, was covered with a large Wounds of the Head. 33 cataplasm; the patient was covered with warm cloths, and bled copiously. In the evening the pulse was raised and the senses restored; a grain of the emetic was , ie- scribed. The same was continued the next and the fol- lowing days, in order to combat the affections of the brain, which might be added to the depression. On the third day the patient recovered the use of speech, hitherto suspended; all confusion of the ideas was dissi- pated; the edges of the wound lost their swelling; the depression was easily perceived. On the following days the convalescence more obvious. The sixteenth, some heaviness of the head; another emetic. The fortieth, complete cicatrization of the external wound, entire cure of the patient, total disappearance of the depres- sion, level between the bones of the cranium re-esta- blished. 74. This principle may then be established: 1st. That there is a degree of compression of the bi a in from de- pression, in which death is inevitable, unless the bony pieces are quickly restored to their level. 2d. That there is another degree, in which this compression, being con- stantly continued, ceases to be mortal, and the brain may resume all its functions and the patient be cured in the same manner as if the pieces had been elevated. This distinction must be kept in view. § VII. Of the Treatment of Fractures of the Cranium. 75. At the present day it is a principle almost gene- rally adopted, sanctioned in the memoirs of the academy of surgery, acknowledged by Petit and most of the French authors who have written since, and confessed by the most eminent English practitioners, that every fracture of the cranium indicates the operation of tre- panning, either to prevent accidents if they do not exist, or to remedy such as have appeared. We wish to Vol. h E 34 Wounds of the Head. examine this question, on which so many pages hav« been already bestowed, often without any more light being afforded to him who has to decide it at the bed of the patient. To conduct this examination more me- thodically, we will reduce all the cases that offer to two different states: 1st. The fracture of the cranium may be simple and abstracted from every kind of affection. 2d. It may be complicated with that assemblage of symptoms which is the ordinary result of compression of the brain, whether this compression depend upon effusion, or whether it be the effect of depression, a dis- tinction which will be established afterwards. Let us attempt in each of these cases to resolve the problem of the indication for trepanning. § VIII. Of the Treatment of Fractures, unattended with any other affection. 76. Ought the trepan to be applied in cases of frac- ture without symptoms of compression? Practitioners in general answer in the affirmative, grounding their opinion upon this reasoning, specious on a first view: On the one hand no danger arises from trepanning; on the other fatal symptoms may result from the fracture. It is surely preferable then to incur the hazard of an useless operation than of the dangers of the disease. This argument supposes, 1st. That the operation is in itself of no consequence. 2d. That if any other affections supervene, the trepan will remedy them. Let us ex- amine this double assertion. 77. In the first place it is not true that the application of the trepan is harmless. Air can never be admitted with impunity into a great cavity, such as the thorax, abdomen or head; an obvious truth, especially in moist, unhealthy places, where the influence of the air is so un- favourable. For example, it was constantly observed by Wounds of the Head, $$ Desault, that the operation was almost always unsuc- cessful at the Hotel Dieu in Paris. Like others, he per- formed k, on his entrance into this hospital, and he did not abandon it until compelled by uninterrupted ill suc- cess. Boudou, one of his predecessors, had made the same remark, and Quesnay acknowledges the justice of it in his memoir upon trepanning in dubious cases. If indications might be drawn from analogy, we would be much less astonished at seeing the greater part of exter- nal affections assume an unfavourable character in large hospitals, and also that operations there are often mor- tal; whilst, all other circumstances of the case, season and temperature, being similar, they succeed in a more healthy place. Ulcers, wounds, &c. present there an aspect which is unknown to them elsewhere. 78, It is to be confessed, that the ill success of the trepan in large hospitals may be attributed in part to the circumstance that the surgeons, being more skilful than elsewhere, frequently do not operate except in ex- treme cases, where the indications are precise, and then die patient perishes, not from the operation but from the disease; whilst in common practice it is used on the slightest indications, and then the cure is obtained in spite of the opening in the cranium, which is commonly useless. But to this cause may certainly be added, the influence of the air upon membranes almost always dis- eased, often inflamed, as those of the brain are in frac- tures of the cranium. Bell has made this remark, and it deserves particular attention. Supposing the cerebral membranes to be sound, will they not be inflamed by the contact of air? The same author is certain, from numerous experiments upon living animals, that the fourth part of those who underwent the operation pe- rished from its consequences; and he has seen men for whom it was employed, and whose membranes were 36 Wounds of the Head. very sound, perish soon after from inflammation super- vening immediately after the operation. Desault has made similar remarks. It may then be established as a principle, that trepanning is always a dangerous opera- tion, especially in large hospitals. 79. But abstracting the dangers of trepanning, who can tell if it will be useful, supposing that the affections manifest themselves (76)? These will depend either on bloody effusion, inflammation or purulent effusion. As to the first, from the little time elapsed since the acci- dent, it is seldom that there can be any apprehension of bloody effusion. Secondly. Would the trepan remedy inflammation of the membranes? On the contrary it would doubtless favour it, from the contact of air. Thirdly. Would it be advantageous to perform it in an- ticipation, in cases where a suppuration would succeed this inflammation? It would not; because on the one hand it would be uncertain in what part of the mem- branes this effusion would be formed: On the other, supposing that it should be opposite to the opening of the cranium, most frequently that would be insufficient to give it vent; for the pus, viscous, tenacious and dif- fused over the whole surface of the membrane to which it strongly adheres, could not escape except in very small quantity, as shall be proved afterwards:—a double reason which here renders the trepan useless, for pre- venting the purulent effusion. 80. From what has been said it results, 1st. That tre- panning is very dangerous in itself. 2d. That in frac- tures where it is employed, before any affections take place, it may sometimes induce them, can never pre- vent their formation, and very seldom remedy them in cases where they are manifest. After these two general positions, who will presume to make a patient undergo the hazard of a very severe operation, when it is uncer- Wounds of the Head. 37 tain whether any affections will happen;—whether their nature will require the trepan, in case they should hap- pen;—whether engorgement or inflammation have not given origin to them, independent of suppuration;-— whether the trepanning may correspond to the seat of the suppuration if that should succeed the others;—or whe- ther it would be able to vent itself through the opening? Is it not better, when there is so much uncertainty of success and so much certainty of ill success, to delay the operation until the symptoms are manifest, and to be regulated by them? 81. From what has been said (76, 80), this conse- quence may be drawn and established as a practical principle; that the trepan is never indicated by the simple existence of fracture before the symptoms of compres- sion of the brain are manifest; and then that the object of the practitioner should be to prevent the effects of irritation of the brain, produced by the fracture, such as engorgement, inflammation and subsequent suppura- tion. Bleeding, according to the state of the pulse, sti- mulants and evacuants fulfil this indication. We shall again resume the subject of the means. $ IX. Of the Treatment of Fractures, accompanied by the Symptoms pointed out by authors, as signs of Effusion. 82. But supposing that to the fracture are added those affections which authors lay down as signs of compres- sion of the brain, must the trepan be then applied? To examine this question methodically, two states are to be distinguished. 1st. That, where no depression exists, and where the symptoms are supposed to depend on effu- sion, although we may always be uncertain of it (67). 2d. That, where there is a manifest depression of the 38 Wounds if the Head bony pieces. Let us examine what ought to be the con- duct of the practitioner in both, 83. Ought the trepan to be applied in the first case? Here the object of the surgeon can only be to give vent to the effusion. Now to accomplish this object, let us see what advantage may be drawn from the operation. The effusion will be found either in the brain, or be- tween the meninges, or under the bones of the cra- nium (49). 84. If the blood be extravasated in the brain, the tre* pan is useless, not that it would be mortal, as has beeai believed, to wound that organ, especially at its surface; but beeause, there being a constant uncertainty of the existence and seat of the effusion, it would be hazardous. uselessly to make incisions, that are always dangerous, to discover it. Some fortunate examples, related by practitioners, make exceptions, but do not authorise general rules. 85. If the effusion exists between the pia and dura mater, at the surface or in the sinuses of the brain, then as has been observed (50), almost always it is diffused over the whole surface of the membranes and in all their intervals, so that it would be necessary for the cranium to be pierced with openings in different points, in order that these might every where correspond to the effusion; for, as has been stated, experience proves that all the fluid will not proceed from the different parts where it was effused, to escape by a single opening; because at that spot there was the least resistance. In cases where an incision has been made into the dura mater, to give vent to the blood, only a small quantity has escaped, although after death the whole surface of the membranes was found to be covered with this fluid. 86. In the remaining case, where the blood is found between the dura mater and cranium, if, as often hap- Wounds of the Head. 33 pens, the effusion is propagated even to the base of the cranium, what advantage would be derived from the operation? In order then to have a reasonable prospect of success it must be found below the parietal, the coro- nal, the superior portion of the occipital or the squa- mous portion of the temporal bones. 87. But in this case to decide the question (83), let us resume the consideration of the circumstances which may enlighten us. On the part of the operation of itself, great dangers always accompany it, especially in hospi- tals, and when the membranes of the brain have suffered viotendy (77, 79); with regard to its possible advan- tage all is uncertainty; there is no sign, no index for its application. 1st. There is frequendy no certainty of the seat of the fracture (39). 2d. Supposing it was disco- vered, there is no certainty of the existence of effusion, or whether the affections which manifest themselves, are not to be attributed to other causes (52, 59). 3d. Sup- posing the existence of the effusion, there is no certainty whether the injury of the brain, its commotion, its en- gorgement may not be complicated with it, and render the operation useless, by perpetuating the affections in spite of the evacuation of the effused blood (52). 4th. Supposing the effusion to exist separately, there is no certainty whether it may not be in the brain or be- tween the membranes (60). 5th. Supposing that it ex- ists between the cranium and dura mater, there is no certainty whether it may not be found at the base of the cranium (86.) 6th. Supposing that it was not pro- longed to that, there is no certainty of the place to which it corresponds, and where consequently the trepan ought to be applied. 88. It is evident that a single circumstance of those that have been stated, is sufficient to make the operation of the trepan fruidess. Consequently, how many proba- 40 Wounds of the Head. bilities must there be against it, in the case of fracture, accompanied with affections which are regarded as symptoms of compression. Such are these probabili- ties, that we may be assured, says Desault, that the cases in which the operation would be useless, either from an inability to find the effusion, or to evacuate it, or from its being complicated with injuries of the brain, possessing as much and more influence than it in the production of accidents, would be more numerous than those in which it could be useful. Add to this consi- deration that of the dangers of the operation, and it will be seen if both will not counterbalance the numerous arguments of Petit, Quesnay, Pott, Bell, Sabatier, &c. to prove the necessity of trepanning, which, no doubt, would always be urgent if we could with precision de- termine the seat of the extravasated fluid. 89. After this statement, what answer can be given to the question proposed (83). The opinion of Desault on this point was as follows: For a long time he incul- cated the application of the trepan in the case of frac- ture with affections; reasoning in this manner, that it was better to incur the risk of an useless operation than the dangers of effusion. Upon this basis was founded his practice at the Charity and Hotel Dieu, during the first years that he practised surgery there; but in a little time experience convinced him that he incurred not only a risk but dangers from the operation; and that of ten pa- tients, if two or three were saved by it, perhaps as many perished from its consequences, and to the others it was of no advantage. Then he began to employ it only in cases with the most manifest indications; at length he proscribed it entirely during the five last years, on the double reason of its danger and ordinary inutility (87), and on the success obtained by the method he em- ployed, which shall be explained—a success of such Wounds of the Head. 41 nature, that comparing the years of his use of the tre- pan with those of his abstinence from it, the number of patients cured in the latter, surpassed greatly the num- ber of those saved in the former. 90. It may be remarked that this doctrine and prac- tice of Desault, during his latter years, merits from sur- geons a consideration to which that professed at his commencement is not entitled. Then, in fact, experi- ence had not instructed him; but afterwards it alone, disengaged from all theory, pointed out the path which he pursued until his death. 91. There is one circumstance, however, which seems to demand the operation: It is when there is a very sen- sible oozing from the fracture, at the same time that the symptoms of compression are manifest and continue at the same degree in spite of the oozing. But in the first place it has been proved, that even this case is not a certain index of effusion (64). In the second place, it is s metimes possible to give vent to the extravasated fluid in young subjects, without opening the cranium. The following case, by Giraud, is a proof of it. CASE III. A. Pichot, aged eleven years, was brought to the Hotel Dieu on the 27th of Thermidor in the year IV., affected with all the symptoms of compression, in con- sequence of a fall from a second story. Coma, insensi- bility, feeble pulse, difficult respiration, &c. Gault, who was at that time surgeon of the ward, being called to her, thought that he perceived a fracture of the os frontis. He sent for M. Giraud, who made an incision through the integuments, and found, in fact, that bone divided transversely in its whole extent. The edges of the division being separated from each other, suffered the escape of a considerable bloody oozing, which was Vol. I. F 42 Wounds of the Head. the probable index of effusion. To give it vent, a bit of wood in the form of a wedge being placed between the edges, separated them, increased their interval, and sup- plied the place of the trepan. A proper dressing was then applied. The symptoms were equally severe the next day; in the night a bilious vomiting occurred. On the third day, some progress towards amendment; the dressing was renewed, a slight suppuration established, and the usual emetics given. On the fourth day the pulse was stronger; emetic renewed; no evacuation until the eighth. On the ninth, the emetic was suppressed. On the eleventh, the senses partly restored, sleep tranquil for some days past; the bit of wood was now removed. On the fourteenth day, copious stools, and amendment of the pulse. On the fifteenth day, the sensibility was perfectly re-esta- blished. The dressing being renewed every day, nothing new occurred until the thirty-second, when a mild pur- gative was given, which produced evacuations. On the forty-third the cicatrix was greatly advanced, and com- pletely finished, on the fifty-third, without exfoliation of the bone. On the seventy-second day the patient was dismissed. 92. It is obvious that this mean is applicable to a very small number of cases, even in childhood, when the bones yield with facility; and without doubt if there be any circumstance in which trepanning is indicated, it is that of this oozing, with permanent symptoms. But if the fracture is of such size as to permit the escape of the effused fluid, why enlarge the vent? § X. Of the Treatment of Fractures with Depression and symptoms of Compression. 93. Must the trepan be applied in cases where the fracture is attended with depression and symptoms of Wounds of the Head. 43 compression. There must be one of two things: Either the affections are very severe, threaten the patient uith imminent danger, do not seem to diminish at the end of a certain time, and even increase notwithstanding the use of all the general means (74); or, much less severe, they do not act but in an inconsiderable degree, the in- tellectual functions remaining stationary,—they even di- minish after some hours, whether bleeding has been employed or not, and leave a hope of there soon being a real progress towards amendment. 94. In the first case, when the assemblage of pheno- mena affords, if not a certainty, at least a strong proba- bility for believing that they are owing to the compres- sion of the bony pieces rather than to the commotion of the brain, especially if the bones, being bare, appear very much below their natural level, it is always neces- sary to recur to the trepan for the elevation of the de- pression. Desault constantly advised it in this extreme case, which, in fact,, practice seldom offers. 95. In the second case, always abstain from opening the cranium. In reality it has been proved (72, 74) that, most frequently, when the depression is inconsiderable, the brain gradually accustoms itself to the pressure it experiences; that then the symptoms disappear in pro- portion as the circulation of the humours begins to ac- commodate itself to the state of the vessels, and that the patient thus gets well, whether the depression of the bone subsists or becomes effaced. Why then should a patient be exposed to the risk of an operation, when every thing favours the presumption that it will not be necessary; especially if care is taken to combat, by ap- propriate means, those other affections of the brain that do not depend on compression. 96. But how are the limits of the two cases to be as- certained? How is it to be declared when the trepan is 44 Wounds of the Head. required, and when it is useless? The right of deter- mining can result only from extensive experience. The aspect of the symptoms, the state of the pulse and the strength, may offer some grounds for our decision; but they can never be solid until they are confirmed by the habit of seeing. Finally, the degree of depression, when it can be known, elucidates the indications greatly. Is it probable indeed that the symptoms, if they are very severe, should indicate this cause when the bones are depressed but little beneath their level? In such cir- cumstances ought we not rather to presume, there is an affection of the brain, and ought we not to prefer to tre- panning the means proper for remedying that affection? 97. If the depressed pieces can be elevated without recurring to the operation, that method should always be adopted. In it, however, is not to be included the use of the terebra and other analogous instruments, whose inconveniences practice has so often demon- strated. 98. The depressed pieces of bones do not act upon the brain solely by the compression which they exer- cise; being carried against its membranes and into its substance, they lacerate, irritate, bruise and determine inflammation to them. In such cases the trepan is use- less for elevating them, as they are most commonly restored of themselves. We may almost always attain the object by seizing them with forceps or other instru- ments. If, however, they cannot be elevated otherwise, and the symptoms are imminent, recur to the operation. § XI. Of Cases in which the Affections manifest them- selves, without any apparent Fracture. 99. Hitherto we have only considered the symptoms of compression of the brain as being complicated with a fracture whose existence was certain, from its having Wounds of the Head. 45 been exposed either by the wound or by incisions made for that purpose. But if art cannot discover it; if it does not exist, as often happens, whilst the symptoms of com- pression are manifest, what conduct must the practi- tioner adopt? Ought he to trepan? At what part of the cranium shall he attempt it? Where the blow was in- flicted—where the patient complains—where he places his hand—where the bones are denuded and of a duller colour—or where the pericranium is detached? I will not recapitulate the uncertainty of all these signs, which can neither establish the existence nor the seat of the effusion (59, 65). It will be sufficient to relate a case, which will prove the inutility of the trepan under such circumstances. CASE IV. A man fell from a first story upon a heap of hay. He went home a little stunned; complained in the evening of a heaviness of the head, and at the end of some hours fell into coma, delirium and other signs of effusion. Desault was called. It was during the first years of his practice. There was no trace of external injury upon the integuments, except a small puffing on the os frontis. An incision was made, there was no fracture; the trepan was applied, there was no effusion. The symptoms con- tinuing, and paralysis supervening on the right side, the trepan was applied on the left parietal bone, with the same failure of success. Still the patient laid upon the trepanned side. A new application was made without finding any effusion. On the death of the patient, the cranium was discovered to be sound, and an effusion to have taken place under the right temporal bone. 100. Without doubt, among a number of patients, some may offer the fortunate chance of discovering an effusion: But, should a sacrifice be made to the proba- 46 Wounds of the Head. bility of this good fortune, which advances the cure but little, since other affections will certainly remain to be subdued? Should a sacrifice be made to it of the better founded probability of those affections that will result from opening the cranium, considering the small num. ber of patients to whom it would be advantageous, and the much greater number of those to whom it would be useless? Desault did not think so. $ XII. Conclusion. 101. The following general consequences result from what has been said respecting the fractures of the era- nium. 1st. That the precept of trepanning has been extended to too great a number of cases. 2d. That a fracture, independent of all affections, is never an indi- cation for it. 3d. That in the case of affections without depression, the uncertainty of the existence of the seat of effusion, and of knowing whether a more severe affection of the brain be not complicated with it, added to the dangers of the operation, ought, in the greater number of cases, to arrest the hand of the practitioner. 4th. That if there is depression, sometimes the opera- tion is indicated: more frequently it is superfluous. 5th. That it must always be withheld, when no fracture is discovered. 102. What method of cure must then be applied to fractures of the cranium with presumptive symptoms of compression? In order to determine this, it must be re- collected that these symptoms do in reality depend most commonly on commotion existing alone; that if there be compression of the brain, very frequently there is at the same time commotion and engorgement; that if compression exist alone, there is always a tendency of the fluids to proceed to the brain, irritated either by fracture, or by the shock it has received, or by effusion Wounds of the Head. 47 or depression, and to produce a subsequent inflamma- tion. 103. It results from thence: 1st, That evacuants, stimulants, bleeding, and other means, proper to oppose the primitive effects of commotion and to prevent in- flammation, are very often exclusively indicated in frac- tures of the cranium. 2d, That, supposing the indication of the trepan to be real, these are still always essentially necessary, either to destroy the affection of the brain actually existing and complicated with depression or effusion, or to prevent the development of other affec- tions, which may arise from those, if they exist alone. Now, as we are most frequently unacquainted with the indication of the trepan, although it may exist, it follows that we must generally limit ourselves to the use of general means, in fractures, especially to evacuants, which will be particularly examined in the following articles. Here it is sufficient to declare their use, in order to show what were the principles of Desault, in his treat- ment of fractures of the cranium, and that his object was not, as has been asserted of him, to absorb, by means of an emetic, the effused fluid, nor to elevate, in some inexplicable manner, the depressed pieces of bone. What picture will not be disfigured, when presented by the hands of ignorance or envy! 104. Finally, it may perhaps be objected to him, that he did not sometimes combine the preceding method with the application of the trepan; and that he exag- gerated the uncertainty of effusion, and the dangers of searching after it. There is no doubt, that, situated in an atmosphere more sound and less unfavourable to ex- ternal injuries, he would have pursued a different prac- tice, and would have regulated it by these principles, generally acknowledged: namely, 1st. That the trepan saves the lives of many patients, who would perish 48 Wounds of the Head. without it, from the effects of effusion or depression 2d. That in many cases no proportion can be established between the danger and the frequent inutility of the operation, on the one side, and the advantages which it would present on the other, if the seat of effusion should be discovered. It is the province of the practitioner to reconcile, at the bed of the patient, the different reasons that demand and forbid it; and he will perceive, that if the application of the trepan in all cases of fracture, with signs of compression, is too great an extension of its limits, the rejection of it in every case is also too great a.restriction of its use. But we must confess, that it is impossible to lay down here rules of general application, as many surgeons of this age have wished to do. Art furnishes principles, and practice consequences. To' multiply the former too much, is frequently to perplex the latter. ARTICLE III. Of Commotion of the Brain in Wounds of the Head. § 1. What is Commotion? 105. Commotion is one of the most frequent effects of the action of hard bodies upon the cranium. It is not easy to give an exact idea of it, from the writings of authors. They commonly define it to be a concussion of every part of the brain. But what change does this concussion occasion in that organ? What is the imme- diate effect? These are questions of important deter- mination. Is the effect a general sinking, or a kind of contusion, or universal irritation? The celebrated case of Littre, and many others, related since by different practitioners, seem to answer the first question in the affirmative, by showing in the bodies of persons, sud- denly destroyed by violent commotion, a manifest in- Wounds of the Head. 49 terval between the dura mater and the brain, which was sensiblv more sunken than in an ordinary state. But may they not have been imposed upon by the manner in which these bodies were opened, or by an effusion of blood formed under the membranes and occupying that interval! For ir must be difficult to any, acquainted with the organic structure of the brain, to conceive how it can thus withdraw within itself, and suddenly diminish its volume. It appears that pressure, exercised upon it, either by effusion or by depression, is the only cause capable of producing this phenomenon. 106. So far is commotion from occasioning a sinking, that on the contrary it produces an engorgement of the Iirain, which however is only subsequent, and to be dis- tinguished from commotion itself; the one being the cause, and the other the effect. In like manner a vesica- tory first causes an irritation, and then an inflammatory swelling of the parts to which it is applied. 107. From thence it appears that the primitive effect of commotion consists essentially in a kind of contusion and general irritation of the brain, occasioned by the shock it has received in every part; a shock which may be easily conceived, when we recollect the manner in which hard bodies act on the bony case of the cra- nium. Struck by one of these bodies, it changes its form, is flattened in the direction of the percussion and en- larged in the opposite direction, as happens to all round and elastic bodies in such cases. From thence an universal concussion, a total compression of the organ, which is bruised, irritated and thus predisposed to the ingress of the fluids. 108. The truth of this doctrine is proved by experi- ence, which teaches us: 1st. That in the greater number of cases, inflammation of the brain succeeds its commo- tion, which must then be the most probable cause of it. Vol. I. G 50 Wounds of the Head. 2d. That the best means of preventing this secondary effect, is to cause, in another point of the animal econo- my, an artificial irritation, which may oppt>se its influ- ence to that of the irritation produced in the brain by the commotion. § II. Of the Varieties and of the Signs. 109. Whatever the nature of commotion may be, it presents a number of varieties, which are especially marked by the different degrees of which it is suscep- tible. How many shades are there between that slight stunning, the sudden effect of an inconsiderable stroke, and that complete disorganization which annihilates life and motion at the instant of the blow! These shades are to be referred to the greater or less sum of motion com- municated; to the form of the striking body, or of that against which the head is struck; to the resistance pre- sented by the cranium—in general, the concussion is in the inverse ratio of that resistance; to the disposition of the subject. . 110. From thence the numerous modifications of the signs of commotion. Let us examine these signs, which are all to be referred to the nervous system. 111. 1st. Dizziness, offering sometimes a vivid light, sometimes one more obscure, whose degree generally indicates that of the concussion. 2d. The falling down of the patient, which is sometimes sudden, and some- times preceded by staggering motions, similar to those of animals killed for the table, when they receive the fatal blow. In the first case it is not easy to distinguish to which of the two, the blow or the commotion, the fall is to be attributed; in the second, there is no doubt, so that in this case it is characteristic. If the commotion is slight, the patient does not fall; he is only sensible of vertigo, and staggers; the disturbance of the nervous, Wounds of the Head. 51 suddenly communicated by the muscular system, ex- plains these phenomena. 3d. Insensibility, coma, some- times complete, sometimes interrupted; then the patient rouses himself, answers and relapses. 4th. Confusion, derangement, even constant delirium, according to the degree of the affection; loss of memory in such manner that sometimes new things are forgotten, whilst old ones are remembered. Desault cited the history of a water carrier, who, at first, recollected only such objects as had occurred recently, but soon afterwards remembered only those that took place in his infancy. 5th. The pulse soft and feeble. 6th. Respiration confined for a few mo- ments, then suddenly more free. The patient seems to snore, a state designated by the appellation of stertorous breathing, and which may be easily explained from the general deficiency of strength in ail the organs, and par- ticularly in the lungs, which become embarrassed, and at length compel the patients to make a strong inspira- tion, in order to relieve themselves. 7th. Paralysis, par- tial or general; immobility of the iris; insensibility of this membrane to the strongest light; involuntary discharge of the faeces and urine. 8th. Convulsions, spasms of the stomach, from which arise vomitings; these, however, must be distinguished from those produced some days after by the bilious affection of the first passages. 9th. Hemorrhagies from the different cavities of the head. 112. This explication of symptoms, observed in patients affected with commotion, indicates a general disturbance in the nervous system, a defect of harmony between the brain and the organs of motion and secre- tion; a defect which may be equally produced by the compression of this organ from an effused fluid, or a depressed piece of bone. From thence the difficulties of the diagnosis, which will not now be recapitulated, having been already sufficiently explained (52, 59); it 52 Wounds of the Head. will be only necessary to observe the difference of the symptoms, as stated by some of the moderns. 1st. That the respiration is more confined and embarrassed in com- pression; more free in commotion. 2d. The state of the pulse, which is slow and irregular in the one, soft and equal in the other. 3d. The effects produced upon it by bleeding, which always diminishes the strength in the latter, and leaves it nearly the same in the former. This difference is always extremely uncertain, and can never positively indicate their separate existence. § III. Of the Symptoms, which are the Effects of Commotion. 113. Death is always the inevitable consequence of great commotions; the extent of the disorder is then such, that every mean is impotent for re-establishing the functions of the brain. But if the concussion has been less considerable, these functions return gradually and to a degree more or less perfect; frequently the patient continues to feel all his life the influence of the accident. Imbecility, total oblivion of the past, and a marked change in the character, are sometimes the per- manent result. The history of the lunatic, who fortu- nately recovered the use of his reason by a violent commotion, is well known. Commonly these effects do not continue, but there is for a long time derangement, confusion in the ideas, memory, &c. 114. These are only the subsequent effects of com- motion; there are primitive ones, which ought more particularly to fix our attention, with regard to their treatment. They relate either to the brain itself or to bther organs. It has been said, that the first effect of ' commotion of the brain was to determine to it a kind of general contusion, universal irritation; from thence, ac- cording to the expression of the humoral physicians, Wounds of the Head. 53 arises a tendency in the humours to flow to it; from thence different engorgements of the brain, analogous to those, which, in other viscera, are the result of some irritation. Sometimes slight and insensible, these en- gorgements terminate in a speedy resolution, and then being soon dissipated, the symptoms occasion little un- certainty in the treatment; but often more melancholy consequences succeed commotion. The brain becomes the seat of an inflammation, whose character partakes of the place, temperament and constitution, &c. We will not stop to treat of this affection, which will constitute the subject of a particular chapter, but will proceed to consider the effects of commotion upon the other viscera. 115. The actual state of all the organs is connected by means of the nervous system with that of the brain, their common centre; from thence the connection of its affections with theirs, and the influence exercised upon them by commotion; but in none is this influence more remarkable than in the biliary passages. All authors have noticed it, ranking, among the subsequent effects of concussion, nausea, loathings, the saburral affection of the primae vise, bilious vomitings, distinct from those spasmodic ones that take place at the instant of the blow. 116. Most authors also make mention of the different engorgements, of which the liver then becomes the seat; of the tension, hardness, and pain in the right hypo- chondrium, which indicate them; principally of the abscesses that terminate them, and which are so often observed in subjects who died from such affections. 117. Many have sought the explanation of these phe- nomena in the disturbance of the circulation. Bertrandi, Pouteau, and David, have supposed, the one that more, the others that less blood than ordinary was then trans- mitted to the brain; from thence the dangers or advan- 54 Wounds of the Head. tages of particular bleedings, to prevent the affection of the liver. But theory alone gave birth to all these systems, which we may dispense with stating, and the badly con- structed edifice of which is overturned by every day's experience. 118. Let us then confine ourselves to what has been demonstrated by strict observation, namely: 1st. That there exists an unknown but real relation between the brain and the liver, a relation more particular than be- tween the other vicera. 2d. That by means of it the affection of the first almost always occasions in the func- tions of the second, an alteration demonstrated in the dead body by the traces of engorgement, inflammation and abscesses that are observed there; in the living, by nausea, bilious vomiting, &c. This relation is not limit* ed to the brain; its internal and external coverings receive the influence of it equally (10). 119. All practitioners are not equally agreed with re- spect to this immediate connection of the two viscera; and the affection of the liver, in wounds of the head, appears to them to be only the effect of the general con- cussion. But why then is this effect particularly attached to one organ? Why do not others experience it also? This simple reflection removes every difficulty. It seems that the nervous system is here the principal agent of communication, on which the circulation has no direct influence. 120. After considering the action of the brain, affect- ed with commotion, upon the liver, we ought to ex- amine the re-action of that upon the brain; but this will be particularly treated of when we come to speak of bilious inflammation, of which it is one of the prin- cipal causes. 121. Abscesses in the liver are a complication of commotion, that is almost inevitably mortal. It must Wounds of the Head. 55 therefore be the particular object of art to prevent their forming, by means of the treatment now to be examined. § IV. Of the Treatment. 122. Since the primitive effect of commotion is to produce an irritation in the brain (107), from which afterwards arise its engorgement, and often an affection of the biliary passages (114,117); to prevent this double subsequent effect, by destroying the principle that pro- duces it, must be the essential indication. We must also re-animate, by impressions made on the whole system, the disturbed action of the vital forces. Now art has in general three principal means of accomplishing these in- dications. 1st, Bleedings. 2d, Stimulants. 3d, Evacu- ants. Let us examine the advantages of each, and the limits by which they should be circumscribed. 123. The greater number of authors have exaggerated the utility of bleeding, in wounds of the head, and espe- cially when they are complicated with commotion. Here there is most frequently a general feebleness, depending on the injury of the nervous system, and which is indi- cated by the state of the pulse, respiration and all the assemblage of symptoms. Add to this feebleness, the frequent disorder of the first passages, and there will be a general, double counter-indication of this mean. The considerable loss of blood, by means of the blow, and the stomach being full when it was received, are also par- ticular counter-indications. 124. However, if these two last circumstances do not occur, if the pulse is soft and full, the face red, the eyes lively, then have recourse to one bleeding. Frequently the pulse is reduced by it, the face loses its redness, the signs of weakness become manifest, and the first pas- ' sages are disordered; in such cases, a second bleeding is to be abstained from. When circumstances are con- 56 Wounds of the Head. trary, it may be employed; but in general, Desault seldom made use of a third. 125. In general, practitioners attach much importance to opening particular veins, although they are equally indifferent of themselves. If they are distinguished by any circumstances, it must be in this way: bleeding in the jugular vessels, to the advantage of immediately re- lieving the brain, joins the inconvenience of requiring a ligature, which forms a greater obstacle to the descend- ing blood, than the relaxation produced by opening the vessel; on the other hand, no blood will flow without this ligature. Abstain then from opening a vein in this place, unlejss it be very much swelled, as in wounds of the neck. Leeches and cuppings are always to be pre- ferred. 126. In the arm, the opening of any of the veins is indifferent, since they all proceed from a common trunk, and we know not upon what principles certain authors advise the cephalic to be punctured. But in general, it may be observed, that bleeding has here less influence on the brain, than when it is performed upon the foot. This is proved by fainting being more easily produced by that kind of bleeding. Therefore prefer the use of it in that part, if the engorgement is considerable, and the symptoms violent and obstinate. If they are less severe, bleed in the arm, but never in the jugular except in the manner indicated above (125). 127. Stimulants, the second kind of remedy to be ex- amined, present, in general, considerable advantages in commotion. 1st. They determine to some other point than the brain an artificial irritation, that prevents the engorgement, which is the effect of what was fixed upon it. 2d. They act upon the sensible system, which they arouse from its stupefaction. 128. The hairy scalp is the most favourable place for Wounds of the Head. 57 their application, either because it is nearer to the dis- ease, or because there exists between it, the brain and its membranes a marked relation, which is demonstrated by the frequent communication of inflammation from one to the other, and of which the nerves and vessels, that pass through the bones of the cranium, are the un- doubted agents. 129. The most active substances merit the preference here, because their principal object is to produce a vio- lent irritation. The common blistering plaster, thickly sprinkled with cantharides, and the volatile liniment, highly charged, were the two particularly employed by Desault. He applied them from the forehead to the nape of the neck, and from one temple to the other, so as to cover the whole head. 130. At the removal of the dressing, blisters are found only on the forehead; but all the hairy scalp is covered with a thick, whitish, mucous crust, which must be re- moved by scraping it'with a spatula; then dress with common digestives. At each dressing, carefully remove this crust, which is formed anew; be not afraid of occa- sioning pain by resting the spatula upon the naked flesh; this pain is essential, especially if the commotion con- tinues and the patient does not rouse from his stupor and coma. There is not a better irritant, and this method dispenses with the application of new blistering plasters, recommended by Bell. 131. This method is cruel, but its effects are astonish- ing. Patients have become sensible, spoken, and moved themselves before the blistering plasters were taken off. If the change for the better is slower, the pulse first be- gins to rise, the countenance to be animated gradually, the powers of motion to return, and the intellectual functions to be gradually re-established. Every thing may be hoped, when these good effects are observed and Vol. I. H 58 Wounds of the Head. continue for some days. On the contrary, if the patient remains in a state of stupefaction, if he is insensible to the pain of the dressings, if the pulse does not rise and he continues to grow weaker, there is reason to despair. 132. In general, the use of blistering plasters, although sometimes attended with wonderful success, is often in- sufficient; and it may be objected to them that they do not act upon the biliary organs with sufficient power always to prevent the engorgements which make their seat there. Desault has observed, that the favourable change, effected by these means, was not always dura- ble; that the patient relapsed into coma, and that subse- quently abscesses were formed in the liver. These circumstances induced him gradually to relinquish their use, after having long employed them, and to recur in preference to evacuants, the third kind of remedy to be examined, and which he employed solely in the latter years of his life. 133. Evacuants, particularly emetics, add to the double effect which blistering plasters have of causing another point of irritation than the brain and of exciting the nervous system by impressions made upon the whole machine (127), the advantage of acting with efficacy upon the biliary passages, of facilitating the flow of the bile, of preventing the engorgement of the liver, the abscesses which form there, and thereby preventing the re-action of that affected organ upon the brain, already diseased (120); of tending to the skin, of exciting there a salutary perspiration, and under this view dispensing with the sudorifics recommended by celebrated practi- tioners, particularly by Bromfield, who preferred Dover's powder to all others. 134. From thence the preference which these means merit, especially in large hospitals, an abode in which is already a predisposing cause to the bilious affection of Wounds of the Head. 59 the abdominal organs, independent of the commotion of the brain. 135. With this view, Desault made use of emetic tartar, commonly giving it in the dose of a grain in a large quantity of water. But the dose cannot be fixed; it must vary like the degree of commotion and be pro- portioned to it. Sometimes one grain will vomit in a slight concussion, when four would have no effect if the shock has been violent. Thus, in palsy, the strongest purgatives sometimes have no influence on the patient. The sensibility, being then blunted generally, and par- ticularly in the intestinal canal, serves to explain this phenomenon. 136. The emetic tartar does not always produce vomiting; sometimes it occasions stools, and even when it has no sensible effect, it is of service. By it the stomach and intestines are irritated, more fluids are car- ried there and less to the brain; in a little while, a sensible alteration for the better becomes manifest, and the symp- toms are calmed gradually. The emetic is not then to be laid aside; the irritation of the brain being permanent, that of the prima? via; must also be made so; its use must therefore be continued during six, eight, ten, or even twelve days without interruption. The affection is not here as in a redundancy purely saburral; it is not the object of the practitioner to evacuate, but to irritate;- add to these means the use of purgative and stimulating injections. 137. If the affections continue in the same degree, and the remedy appears to have no influence upon them, it will then be advantageous to combine with it the ap- plication of blistering plasters to the head. Desault has sometimes obtained success from the union of these two means, when he could procure it from neither sepa- rately. In ordinary cases, he was accustomed to cover 60 Wounds of the Head. the whole head with a large emollient cataplasm, which, by keeping the hairy scalp in a moderate and moist heat, invited the fluids to it, and diverted them from the brain. At the end of this memoir, we will again treat of the evacuating method, exclusively adopted by De- sault in his last years. ARTICLE IV. Of the Inflammation of the Brain and its Membranes, in Wounds of the Head. § I. Of the Differences and the Signs. 138. The commotion of the brain is very often suc- ceeded by an inflammation of that viscus, which may also arise from contusion inflicted in any part of its ex- tent by the action of a hard body. Whatever may be the causes that produce or modify this affection, causes that will soon be examined (155), it presents in general two different aspects: 1st, the phlegmonous; 2d, the bilious. 139. In the first kind, the pulse is hard, frequent and full; the respiration slow and full; sleep interrupted; tongue red; countenance inflamed; the retina excessively sensible to the impression of light; the eyes prominent and often haggard; a sharp and throbbing pain in the head; heat generally diffused; absence of all the symp- toms of saburra in the primae viae; soon after, vertigo, insensibility, delirium, coma, convulsions, &c. If there is any wound of the external integuments, a swelling of the edges takes place, also tumefaction of the neigh- bouring parts, redness, tension and erysipelas with the character indicated (12). 140. In the second kind of inflammation, the pulse is locked, frequent and small; the fever general, offering Wounds of the Head. 61 that assemblage of phenomena, which are so exactly de- scribed by Stoll; dull pain in the head; dryness, and acrid heat in the skin; bitterness of the mouth; nausea; bilious vomitings; clammy crust upon the tongue; often- times weight, pain and tension in the region of the liver; stools of a deep yellow; urine frothy, thick and of the colour of saffron; a more or less marked assemblage of the symptoms of abdominal affections; as in the pre- ceding case, delirium, insensibility, &c. but in a less remarkable degree; if there are external wounds, tume- faction of their edges, a purulent and ichorous sanies instead of the laudable pus that flowed from them; and erysipelas more or less extensive, and offering the char- acters traced (7, 10). 141. Sometimes, all united and sometimes more or less separated, such are the symptoms that indicate to us the inflammations of which the brain or its mem- branes are so often the seat in wounds of the head. If we reflect on these different symptoms, we will perceive that, if the inflammation always presented itself in a distinct form, it would be easy to ascertain it. Indeed, in the first the inflammatory character is very decided; every thing announces the increase of vital strength; the irritation is considerable; the delirium is sometimes fu- rious. On the contrary, in the second, the symptoms are less violent; their progress is slower; but particularly they are all modified by the appearance of abdominal affections, which evidently reveals their nature and which is never met with in the other. The former has its seat particularly in the substance of the brain, as is proved by the opening of dead bodies. The latter, ex- clusively affects the superficies of that organ, and also its membranes. The one, commonly shows itself on the sixth or tenth day from the accident, and is preceded by- no symptoms of abdominal affections; the other, com- 62 Wounds of the Head. monly more slow in forming, sometimes does not appear until after the fifteenth day, and is constantly preceded by a disturbance of the primae viae. Finally, great light is thrown upon the difference of the two inflammations by an examination of the causes that give origin to them, the consideration of their seats, the prevailing constitu- tions, the temperament of the patient, &c. (151). 142. But it does not always happen that their charac- ter is so decided. Frequently they are combined and reciprocally borrow phenomena which make them ap- pear to be mixed; or if one prevails, it at least receives from the other more or less numerous modifications. 143. Although the symptoms in both inflammations often exhibit the same appearance as in commotion and effusion, it is more easy, it is said, to distinguish them from these two affections, than from each other. 1st. In inflammation, whatever may be its kind, the appearance of the symptoms is more slow than in the two other affections. We must confess, however, as it often suc- ceeds them and then continues to produce the symptoms to which they gave origin, it would be very difficult to say when it began to be manifest, unless it was a long time after the accident; often it is impossible to warrant its existence. Thus we are sometimes uncertain, if there is commotion or effusion; because the latter succeeding the former may continue to produce the same effects and cause a false diagnosis. 2d. The hard, frequent pulse, the inflamed countenance, the sensibility of the iris to the impression of light, have appeared to make an essential distinction of inflammation; but frequently the pulse is feeble, the face pale, the eyes dull, and yet inflammation does not the less exist; a circumstance, thaMnay perhaps be attributed, in part, to the custom of making immediately, in wounds of the head, a great number of bleedings, which weaken the patient, and, so Wounds of the Head. 63 to speak, give an unnatural appearance to the inflam- mation. 144. In general, we may be assured that it is not so easy to pronounce with certainty upon the difference of the signs of inflammation from those of effusion and commotion, as Bell and Pott have pretended; especially if the first is very quick in showing itself, as is some- times the case. However, less uncertainty exists here than between commotion and effusion. § II. Of the Causes. 145. To explain, in order, what is to be said respect- ing the causes of the inflammation of the brain, in wounds of the head, we will consider: 1st. Those which produce it generally. 2d. Those which determine the kind, making it, for example, phlegmonous rather than bilious, or reciprocally. 146. The primitive effect of commotion being the production of a general irritation of the brain (107), it is evident that this affection will be one of the most active causes of inflammation. Then indeed, as was said by the ancients, the fluids are carried in abundance to the irritated organ; it becomes the seat of an engorge- ment, which terminates in a speedy resolution, if it be inconsiderable, or if the means indicated (122,136) have been sufficiently employed; but to which succeeds an inflammation, if the concussion has been violent, or if nothing has been done to prevent it. Having treated separately of commotion, we shall add nothing at pre- sent respecting the consideration of it as a cause of in- flammation, excepting that the passage from one to the other is not always easy to be marked; and that some- times nothing is more difficult, than to say when the symptoms are to be attributed to commotion, or when the engorgement of the brain succeeding it, occasions them. 64 ■ Wounds of the Head. 147. A second cause, not less frequent, is the contu- sion of the brain and its membranes. We have seen how, in a blow inflicted upon the head, one of its diame- ters diminished, while the others were proportionally elongated (107). From this position, it is easy to con- ceive how the contusion happens. For example, let a body be struck against the anterior part of the forehead: the antero-posterior diameter will be immediately shortened, the motion suddenly impressed upon the place struck, will be communicated to the corresponding portion of brain; there the fibres of this viscus or of its mem- branes will be pressed, rubbed against each other, and some small blood-vessels be ruptured; there will then be contusion, which may take place equally, and for the same reason, in the place opposite to the blow. Experi- ence confirms this theory, by showing us, in the opening of dead bodies, either place bruised, inflamed, or in a state of suppuration. 148. The same mechanism produces, as has been said, commotion (107), a kind of general contusion of the brain, which often seems to be in the inverse ratio of local contusion. In fact, if the motion is universally diffused, the place struck will experience it less forcibly. On the contrary, if it acts particularly on the spot where the blow was inflicted, the cerebral mass will be affected less. Finally, both affections may be complicated to- gether, or exist separately. Frequently we perceive a perfect soundness in the brains of persons who have been killed by commotion, or a great contusion in those who were exempted from the primitive symptoms of commotion; or finally a concussion of this viscus at the same time local and general. 149. Considering the local contusion of the brain, abstract from its commotion, it is evident that here, as every where else, it must frequently produce inflamma- Wounds of the Head. 65 tion, which supervenes first in the bruised place, and soon extends more or less, according to the disposition of the subject. Desault has often seen, in dead bodies, a suppuration at the place struck, joined with a phlogosis of the surrounding membranes. 150. In wounds of the head, such are then the two general causes of inflammation. 1st. The commotion. 2d. The contusion of the brain. To these may be added the presence of a fluid, effused upon the membranes, irritating them and occasioning swelling and inflamma- tion (102). Let us now proceed to those causes vvhick determine the species. 151. To this second kind of causes is to be referred particularly the influence of age, climate, temperament, constitution, season, &c. If the patient is young, robust and vigorous; if he resides in a brisk and pure air; if he is naturally sanguine; if an inflammatory constitution prevails; if the accident has occurred in the spring—then commonly the brain becomes the seat of a phlegmonous inflammation. On the contrary, if the subject is of a middle age, and naturally bilious; if the constitution is analogous; if it is the season for abdominal affections; if the place of residence is damp and unhealthy—then the engorgement assumes the character of bilious erysipelas. 152. From thence it is easy to conceive, why, as a consequence of commotion or contusion of the brain, the phlegmonous inflammation is common in dry and elevated countries, for example, among the peasants of the mountains; and on the contrary, why it is so rare in most large hospitals and prisons, where the bilious inflammation prevails so often. 153. But, besides the general causes, there is a par- ticular one which merits in this place great attention, with respect to the second species of inflammation. We have seen that one of the subsequent effects of commo- Vol.I. I 66 Wounds of the Head, tion was, from the relation that exists between the brain and the biliary organs, to excite in those a kind of irri- tation (115, 118); from whence arises the saburral state of the prima? viae; a state which is announced by the loathings, bitterness of the mouth, nausea, vomitings, &c. Now to this action of the brain upon the biliary organs there soon succeeds a re-action of those upon the brain. 154. The bilious disposition then predominating in the system impresses its character on this viscus, already engorged; so that it may be said, that the material cause which modifies the inflammation here, exists essentially in the primae viae. But how does this cause act? Is it the saburral matter of the intestines which is then car- ried ¥o the brain? Stoll does not presume to decide; he says, fortasse nihil omnino morbosae materiae ad cerebrum ablegatur sed aegrotante ventriculo, ob inex- plicabilem quemdam consensum incephalum quoque aegrotat. 155. Of what importance is the manner provided we know the fact, the reality of which is attested by daily experience. Examine a subject that has died from wounds in the head, with an abscess in the liver, and almost always there will be found a mucous, yellow, viscous suppuration covering the membranes of the brain; a certain index of the bilious inflammation that preceded it. In a patient where it is manifest, remove, by vomit6, the bilious turgescence, and the symptoms will abate; let this turgescence re-appear and they will also be re-produced; it is always antecedent and gives them the appearance under which they show themselves. 156. The re-action of the biliary organs upon the brain, whose commotion has acted upon them, may then be considered as an essentially active cause of bilious inflammation. Frequently there is no re-action, but only a simple action of these organs; that is, when abstracted Wounds of the Head. 6$ from the concussion of the brain, the bilious disposition has been excited by errors, regimen, unwholesome air, and the other causes stated (160). 157. In general, the causes of inflammation of the brain, in wounds of the head, have a disposition to act for a long time. Hence the danger to which the patient is exposed, and the necessity of attentive observation. § III. Of the Treatment. 158. The treatment of inflammation of the brain, in wounds of the head, must vary with the species of which it is susceptible. From thence, two methods, that are essentially different: the one relative to phlegmonous inflammation; the other to bilious inflammation. 159. Bleeding, repeated more or less frequently, ac- cording to the strength of the patient; leeches and cups, applied to the temples; the use of acidulated drinks and laxative and cooling injections; a strict diet; the con- stant application of emollient substances to the head, shaved and naked; coolness of the air which the patient breathes;—such are the principal bases of the first method, which under every view enters into the class of anti-phlogistic means. The happy effects of this method are found in country places, where it is not rare to bleed six or eight times, in wounds of the head. 160. The second method must be particularly direct- ed to the causes which excite and keep up the bilious disposition. Now these causes exist specially in the prima viae (154), from whence it follows that evacuants must form the base of this method. 161. Bleeding must be constantly proscribed, as it would rather tend to favour than prevent the evil. As in the preceding case, the head being shaved, should be covered with emollient cataplasms. On the appearance of the symptoms, give in a large portion of water the 68 Wounds of the Head. emetic tartar in the dose of one, two or more grains, according to the difficulty of producing the effect. Re- peat the same means every day, without apprehension of the vomiting producing an unfavourable irritation of the brain, already inflamed. There is never any danger; on the contrary, the pulse becomes soft and loses its tension; the tongue is cleansed, the weight and pain of the head diminish; all the symptoms abate when the pa- tient has vomited. Do not stop at this first success; in a little time the symptoms will return, if the use of the emetic is interrupted. Desault often continued it for fifteen successive days. 162. It must be relinquished gradually; giving it at first every two days, then every three days, and at length ceasing; but if the least symptom of abdominal affection manifest itself, or any weight be perceived in the head, recommence the administration. The brain remains in a state of irritation longer than other organs; from thence the frequent relapses, unless the most accurate attention is paid. It is a commonly received opinion, that after the fortieth day, there is no reason to apprehend acci- dents; but experience proves that the danger lasts much longer, and that the patient is not secure at the end of two, three, and even four months. It is the duty of the surgeon to watch his situation during this time; heavi- ness and confusion of the head being the ordinary pre- cursor of relapses, these circumstances must be observed with attention. 163. All errors in regimen, even the slightest, have un- favourable consequences and must be carefully avoided. CASE V. Recorded by Chorin. A man fell from a scaffold, and fractured his cranium, but did not experience for eight days any kind of affec- tion. At that period, fever supervened, the primae viae Wounds of the Head. 69 were disturbed, the head became heavy, the region of the liver painful, and in a little time, all the symptoms of bilious inflammation were manifest. The patient was brought to the Hotel Dieu; an emetic was administered immediately, and repeated every day; on the twelfth day, the symptoms had nearly disappeared; on the fourteenth, the patient seemed to be doing very well, when being suffered to eat abroad, he indulged his appetite and drank immoderately. In the evening, there was an inclination to vomit, nausea, and general indisposition; the next morning, the symptoms of inflammation were renewed, and in a little while there was insensibility, coma, deli- rium, and death on the seventeenth day. 164. These excesses in regimen are so much the more to be feared, from the constant use of the emetic giving the patient a voracious appetite, which he incessantly seeks to satisfy. On the other hand, too strict a diet would be as prejudicial, by continuing the prostration of strength; the middle course between these two extremes must then be pursued. Food, that is light and easy of digestion, must be given in small quantity. As soon as the patient begins to be better, he must increase it a little, and thus return gradually to his ordinary diet. 165. With the use of the emetic, must be conjoined diluting, acidulated drinks, laxative injections, and emol- lients, which being applied to the head, have the advan- tage of favouring the afflux of humours to the external integuments, and of diverting them, as the ancients asserted, from above the cerebral membranes. See, at the end of this memoir, the other details of this method of treatment. 79 Wounds of the Head. ARTICLE V. Of the Suppuration of the Brain and its Membranes in Wounds of the Head. 166. However accurate the means used to combat inflammation may have been (158, 164), sometimes they are insufficient, and cannot prevent the suppura- tion of the brain or its membranes—a suppuration often inevitable, if the treatment has not been methodical. Let us examine this last affection, from wounds of the head, considering it only as the result of inflammation. § I. Of the Varieties and Signs. 167. The suppuration of the brain varies here, ac. cording to the species of inflammation preceding it. In the phlegmonous, it is seated in the substance of the brain, where it forms an abscess or collection of matter, analogous to that which phlegmon produces in different parts of the body. On the contrary, in bilious inflam- mation, it is not a purulent collection, but a clammy, yellow, viscous crust, adhering tenaciously to the mem- branes or to the superficies of the brain, a great extent of which it occupies. Most commonly this adhesion is so strong, that even in the dead body it is extremely difficult to remove all the matter. 168. This second species of suppuration, analogoui to that of all the membranes, is most commonly ob- served at the Hotel Dieu. Almost all the wounded, who die some time after their accident, show traces of it, evidently proving, if it were indicated by no other signs, that the bilious inflammation always predominates there. 169. But whatever may be the nature of the pus formed in the brain or its membranes, we have reason to presume its existence when, at the end of the eighth Wounds of the Head. 71 or tenth day of the inflammation, the symptoms do not diminish, but on the contrary the head grows heavy, and a coma, more profound than in the beginning of the inflammation, manifests itself;—when the patient is seized with shiverings and experiences night sweats, with a more marked discoloration of the features of the countenance;—when to the primitive affections are added paralysis and convulsions, signs in general more charac- teristic of compression than of any other affection of the brain. 170. From these symptoms it may generally be pre- sumed that suppuration exists. But where is it to be found? This question is essential to the indication of the trepan. In suppuration of the first kind (167) it is always impossible to answer it, because the pus, being collected in mass, occupies too small a space, and no- thing indicates to us to what portion of the cranium this space corresponds. The spontaneous detachment of the pericranium, a symptom so much insisted on by Pott; the collection of putrid humours between that membrane and the bones of the cranium; the bad aspect of the edges of the wound, if one exists; the sanious Suppuration that escapes from it; the side which is affected with paralysis or convulsions—offer only uncer- tain probabilities, and we may be assured, according to Desault, that the practitioner can never say nor even presume where the purulent effusion is situated. 171. In the second species of suppuration there are more probabilities, because being diffused over the brain and its membranes, it occupies a much larger space (167); but even here we can never say on which side of the cranium it exists. Finally, if we were sure of discovering it by opening the cranium, it will be proved that this knowledge would be useless. 72 Wounds of the Head. § II. Of the Treatment. 172. All authors advise, that here, as in the case of bloody effusion and fracture of the cranium, the trepan should be applied, being in their opinion the only means of cure. Let us examine this doctrine in both species of suppuration. 173. Must the trepan be applied, if the symptoms of suppuration manifest themselves as a consequence of phlegmonous inflammation? Before an answer is given, it may be remarked: 1st. That we never know posi- tively if there is a purulent collection. 2d. Supposing there was a probability of it, nothing can lead us to sus- pect where it may be found. 3d. That it is very diffi- cult, often impossible, to determine which of the two species (166) of suppuration exists; and yet this is very essential, since, as will be seen, the trepan is useless in the second. 4th. That the opening of the cranium, very dangerous when the brain is sound (77), is almost con- stantly mortal in those cases in which all its parts are affected, where inflammation is without doubt still ex- isting, where a collection of matter, more or less exten- sive, will be exposed. The access of air immediately renews the fever with violence, the phlogosis increases around the centre of suppuration, it comes on afresh if it had disappeared, delirium and madness supervene, and in a little time death terminates the affections. Such has been the series of symptoms observed by Desault in those patients, whom, in the commencement of his practice at the Hotel Dieu, he had occasion to trepan for purulent effusions. Analogy would persuade us of it, although experience should fail to convince. Indeed, who does not know that opening .purulent collections in large cavities almost always hastens the death of the patient, especially in great hospitals, where a thousand Wounds of the Head. 73 causes tend to impress upon the air a pernicious charac- ter, which is otherwise foreign to it, and whose action is immediate upon the open abscess? Who does not know that the operation for empyema is generally more injurious than useful, &c. 174. From these positions it will be easy to answer the question proposed. In fact, said Desault, let there be ten patients, all affected with suppuration of the brain and subjected to the application of the trepan;— take away from this number, 1st. those in whom the access of air to the diseased surfaces would cause death: 2d. those in whom the operation would be useless, either from the non-existence of effusion, or because it cannot be found; either from the pus, when the effect of bilious inflammation, being diffused, or the disease from its nature being mortal,—how many would be left, in whom some advantage might be obtained? Without doubt there would not be sufficient to encourage an operation, against which there are so many probabili- ties, which has so little in its favour, and which might be attempted oftener, supposing the place of effusion to be accurately known. 175. This doctrine will acquire a new degree of cer- tainty, if we reflect, that the purulent collection of the brain is not always necessarily mortal; that there are cases, although seldom, in which it has passed through the bones themselves or their sutures, either in a single point or in a greater extent. In such cases suffer nature to act; do not remove any pieces of bone but such as are already detached spontaneously; exfoliation will su- pervene, and a new substance will fill up the place of the fallen portion. Too great eagerness to give vent to the pus by the trepan will occasion accidents, which would not be experienced, if a patient practice were adopted. We must certainly assist nature, when she is incom- Vol. I. K 74 Wounds of the Head. petent, but why overwhelm her with aid, when she does not ask it! But it is not pretended to deduce from this practical fact, which Desault sometimes met with, con- sequences generally applicable. Daily experience would contradict the assertion, by showing victims of purulent effusion in the brain. Still this proof, added to those already stated, appears sufficient to answer the question in the negative (182). 176. Let us proceed to the treatment of the second species of suppuration, that which succeeds to bilious inflammation. Must we resort to the trepan, to remove the symptoms, which depend on it? Let us examine the probabilities for its demand or rejection: 1st. There is no more certainty with regard to the existence of effusion than in the preceding case. 2d. Supposing this existence to be ascertained, the place of its seat would indeed be more probably discovered on making an open- ing with the trepan, because the pus is more largely dif- fused. 3d. The danger of the operation would be the same. From whence we may perceive that under this first view, its necessity will not be better proved than in the first species of suppuration.. 177. But here it will always be evidently counter- indicated by the state of the pus, which it has been said is largely diffused and adheres in an intimate manner to the dura mater or superficies of the brain (167); from thence the impossibility of making the whole of it flow out through the opening of the trepan. That portion only can be removed that answers to this opening; so that it would be necessary to expose a large surface, often the whole dura mater, for the effusion to be com- pletely evacuated, which is manifestly impossible. On some occasions Desault experienced this difficulty of giving vent to the purulent matter, when he was in the habit of employing the trepan. Besides, analogy directs Wounds of the Head. 75 Us:—would we attempt to perform the operation of em- pyema in those cases, where, in consequence of certain inflammations, the pleura is covered through its whole extent with that kind of lymph which is inflammatory, whitish, viscous, hard, and of the consistence of lard at a certain period, and which we so often meet with in examining dead bodies? 178. Here then, still more than in the preceding case, the operation of the trepan is never indicated; even if we had ascertained the exact seat of the fluid, or rather the mucous and tenacious crust adhering to the membranes. Indeed, the least inconvenience of the operation would be its absolute inutility. ARTICLE VI. General Conclusion. 179. From what has been said in this memoir, it re- sults, 1st. That the same signs characterise, in wounds of the head, affections of the brain that are essentially different. 2d. That these affections are specially com- pression, commotion and inflammation. 3d. That this identity of their signs leaves us most commonly in uncertainty to which particular one they are to be attri- buted. 4th. That the uncertainty is especially applica- ble to commotion, and to compression as the effect of sanguineous effusion; inflammation being more easily distinguished. 5th. That from thence result difficulties which are great and generally acknowledged, and upon which less light has been diffused than was at first hoped, from the labours of Petit, Pott, and all authors who, like those, have sought into the signs and circum- stances which might render them exclusively character- istic of particular affections. 180. What rule must then guide the practitioner here? Must he go blindfolded to combat that of whose 76 Wounds of the Head. nature he is often ignorant? Employ remedies, when he is uncertain of their being indicated, or run the risk of injury with a view of doing good? We have sufficiently shown what particular means are demanded by each of the affections of the brain, in wounds of the head, sup^ posing those affections to be known. But, when their existence is doubtful, there must be a mode of treat- ment, which, if not equally applicable to commotion, compression and inflammation, will at least be favourable to one and not pernicious to the others, and which, in fulfilling all the indications of one, may satisfy some of those of the others. 181. To illustrate this matter as much as possible, and at the same time to give an exact and general idea of the motives which directed Desault in his treat- ment, let us suppose a patient, with or without a frac- ture of the cranium, experiencing, in consequence of a blow received on the head, coma, insensibility, delirium and the other symptoms pointed out as the effects of sanguineous effusion (52, 59), of depression (71), of commotion (111), and of inflammation (131 and 140). Let us suppose also, as is the case most commonly, that no particular circumstance indicates to us on which of these different causes they depend. Now, when a patient in this situation was brought to the Hotel Dieu, the following method of treatment was employed by Desault during the latter years of his practice of sur- gery, founded upon the following motives. 182. If the stomach was not filled with food, if the pulse was excited, if the patient had not lost too much blood, a bleeding was prescribed first, but rarely re- peated, lest it should occasion a weakness always unfa- vourable. The head, being shaved and laid bare through its whole extent, was covered with an emollient catap- lasm, and the wounds, if there were any, dressed ac- Wounds of the Head. 77 cording to their nature. A few hours after, or at the moment of the patient's arrival, if bleeding was not in- dicated, a grain of the emetic tartar was given in a large portion of water. Sometimes the patient vomited, fre- quently a few stools were produced, and frequently there was no sensible evacuation. In this last circum- stance the effect of the remedy is not less important, as has been stated (136). An irritating injection was also administered. 183. The next day, and each successive day, the dressing was renewed, and the emetic tartar regularly prescribed, in the same dose, if it had produced evacu- ations, and if it had not, in the dose of a grain and a half or even two grains. The use of it was continued for eight, ten, and even fifteen successive days, according to its more or less speedy effect. 184. When on the first day, sometimes the second, or even the third, the patient was relieved from coma, then the intellectual functions were re-established in proportion as the emetic tartar was administered. At length the patient was entirely recovered at the end of fifteen, or at latest twenty days. Then the use of the emetic was gradually relinquished, as already stated (162), and at last entirely dropped, with the precaution of renewing it as soon as there appeared to be any heaviness in the head, any change in the pulse, or any signs of fulness in the primae viae. The ulterior details of the treatment may be seen in the articles of commo- tion and inflammation. 185. But, if on the third or fourth day of the treat- ment, the symptoms do not diminish, and even increase, generally the means are impotent, and death is certain. It takes place more or less speedily, according to the nature of the affection of the brain and the different de- grees of that affection. In general, if it be true that 78 Wounds of the Head. experience is the sole arbiter of our curative means, the advantages of this may be certified. 186. Let us now examine the bases of this method, which, at first view, seems very empirical; since it is applied to all cases where the symptoms are manifest, although these symptoms may depend on very different causes (179); yet, if we reflect on what has been said respecting these causes, it will be perceived, whatever they may be, that the preceding method is always indi- cated, if not exclusively, at least under a greater or less number of relations. 187. If there is sanguineous effusion, the trepan, which is without doubt very advantageous to combat that complication if it could be ascertained, is rarely indicated by the symptoms that result from it and strike our senses, on account of the uncertainty which they leave, 1st, of the existence; 2d, of the seat of the effused fluid (52, 65). In this uncertainty we must then combat the effects, if we cannot remove the cause. Now these effects are inevitably an irritation, an en- gorgement of the brain, a disposition to inflammation (102), which will be successfully repressed by the daily repetition of the emetic. The application of a cataplasm to the head, by favouring the afflux of the humours to the external integuments, will divert them from the brain, to which they have a tendency to go. Blistering plasters will be an advantageous substitute for the catap- lasm, if there is need for more active means (127). Be- sides, there is generally added to the effusion during the first days, a more or less considerable degree of com- motion (52), and to combat its effects upon the brain, evacuants and stimulants are exclusively indicated (127, 137.) 188. When the symptoms depend on a depressed portion of bone, whether this case demands the trepan Wounds of the Head. 79 or not (94 and 95), we must not the less combat and prevent the affection of the brain. Indeed, is it possible that from a blow sufficiently violent to produce such an effect, this viscus should not be bruised and injured; that it should not consequently be disposed to inflam- mation, and that there should not exist at the same time a slight commotion? Here then the preceding me- thod is still exclusively indicated, if we do not trepan; and if we do, it is an important auxiliary. 189. If the commotion of the brain is the origin of the symptoms, it has been proved that an artificial irri- tation, produced either upon the intestines (133), or upon the hairy scalp (128), was the only mean of ar- resting them or of calming their violence. 190. If inflammation exists, we have seen that its nature was generally bilious, especially in large hospi- tals (162). The evacuating is still, then, generally indi- cated here (160). As to purulent effusion, it occurs at too remote a period to cause in the diagnosis any un- certainty that may influence the curative means. 191. This short recapitulation of all that has been said in this memoir, suffices to give a conception of the principles upon which the practice of Desault was grounded, in wounds of the head complicated with the ordinary affections, such as coma, delirium, insensi- bility, &c. His object was to subdue the irritation of the brain, which is the only indication in commotion and bilious inflammation, and an essential one in effu- sion and depression. The experience of five successive years proved that he seldom failed in it. 192. There is no doubt that in many cases he might have added the perforation of the cranium to the eva- cuating and stimulating method, and perhaps that many patients under his care were victims to the non-applica- tion of the trepan; but, if we consider those to whom 80 Wounds of the Head. it would have been mortal at the Hotel Dieu, and who have been saved, we will be convinced that his doctrine, which proscribes this operation in the treatment of wounds of the head, with some cases of effusion and depression, rests upon more solid and less arbitrary bases, than the opinions in which we have been edu- cated would seem to persuade us. MExMOIft UPON THE INSTRUMENTS OF TREPANNING. Although the preceding memoir has reduced the ne- cessity of trepanning to a very small number of cases, still practitioners will, without doubt, find some in which this operation may be of real advantage, and under this consideration I do not deem it useless to offer some remarks on the perfection of the instruments which it requires. These remarks were unknown to Desault, and were suggested to me by the simplicity of most of his instruments, compared with the complication of those used for the trepan. They have been already published in the Memoirs of the Medical Society; but, notwith- standing, it is presumed they will not be out of place here. The actual state of operative practice offers two means of perfecting it. On the one hand, to simplify the processes already known, by retrenching their super- fluities; and on the other, to supply the void which they leave, by adding new modifications. It may be said that there is more to be done under the first than under the Instruments of Trepanning. 81 second view, and that the progress of this art is less retarded by the deficiency of operative methods, than by the great number of those in existence, which em- barrass by their useless complications. The end of the last century was remarkable in sur- gery, on account of the extravagant prodigality of in- struments which it displayed. Every operation was sur- charged with them; all were desirous of the easy merit of inventing a new instrument. Every surgeon had his arsenal, and did not perceive that the scarcity of success originated from the very abundance of resources. At length the middle of this century has seen these errors of genius disappear gradually. Art has returned to nature, and like it, has become frugal of means and prodigal of results. Still all traces of the false taste of the past century are not effaced. Many processes yet have their impression. On beholding the great assemblage of pieces intended, in operations of the trepan, to make a small opening in the cranium, who does not recall the times of Hilden, Garengeot, &c? It is difficult to conceive how all this apparatus could escape the genius of those celebrated men, who recalled their art to that happy simplicity which characterises it at the present day. I have at- tempted to supply this forgetfulness, by giving to the trepan the new form now to be stated. It is well known, that the common trepanning instru- ment is composed of fourteen pieces, three of which being useless in the operation, as it is performed at pre- sent, only figure as instruments in the box. 1st. The actual mode of dressing excludes the meningofilax, which besides may be advantageously replaced by the lenticular knife, supposing that it was still necessary. 2d. At this day, the danger of the terebra, formerly em- ployed to draw back the separated piece of bone, is no Vol. I. L 82 Instruments of Trepanning. longer problematical. 3d. The exfoliative is only in su- perannuated practice a mean of procuring exfoliation. It follows from thence, that the number of the pieces of the instrument is reduced, in fact, to the wood of the trepan, to the crowns, their pyramids, the elevators and scrapers. These last, the elevators and scrapers, are evi- dently necessary. Whatever may be the form of the instrument employed, it must always take up the bony piece and previously strip the bone of its periosteum. The corrections of the operative process must then principally comprise the difficulties that result from the necessity of mounting or dismounting successively the perforator and crown upon the handle; of their employ- ing that with its pyramid; of laying aside at length this last, and finishing with the crown only the section of the bony piece. Indeed, we may conceive, that all these different parts of the operation cannot succeed each other with rapidity, and that they must occasion the loss of much time, which is troublesome to the operator and cruel to the patient. If, then, a single moveable crown fixed upon a perforator and placed at a different height, according to each part of the operation, could replace all the apparatus of the process, it may be conceived that this would be a step towards its simplicity, and consequently towards its perfection. Such is precisely the mechanism of the instrument now to be described. It is composed of a stalk (fig. 1.) analogous, in its handle and in the curvature of its body, to the stalk of the ordinary trepan, but which differs below in having a steel blade {cc) soldered to it, and degenerating insen- sibly to a point similar to that of the common perfo- rator. Upon this fixed blade a crown is mounted (fig. 2.); this being of a cylindrical form and indented outwards, differs from ordinary crowns: 1st, in the deficiency of a pyramid: 2d, in the prolongation (bb) which rises from Instruments of Trepanning. 83 its base, and is pierced with a quadrilateral opening, proportioned to the size of the blade, which it is in- tended to receive and upon which it moves. A screw (d) serves to fix it at the desired height. These things being premised, the operative process is as follows: 1st. The integuments being divided, the bone that is to be trepanned is laid bare and stripped of its perios- teum by the common means, which it is useless to describe. 2d. The surgeon grasps the trepan, whose crown being fixed very high, as at b (fig. 4.), leaves the point of the blade (a) projecting, with which he makes a small hole in the bone, in order to fix it there during the operation. 5d. The crown is lowered to the height b (fig. 5.) in such manner, that the blade (a) does not exceed the level of its teeth in a greater degree than the common pyramid, which it is intended to replace. The surgeon then holding the instrument like a writing pen, fixes its point in the hole already made in the bone, and per- forms with the crown, whose motions by that mean have a point of support, a circular section sufficient to secure it. 4th. The section being sufficiently deep, the crown is disengaged by a half-turn, unscrewed and then lowered to b (fig. 6.) in such manner that the point of the blade, being withdrawn towards the superior part of its conca- vity, cannot wound the dura mater by penetrating into the cranium. Free from apprehension in that quarter, the surgeon continues the section of the bony piece, following the general principles of the operation. 5th. The piece being removed, the rest of the opera- tion is performed as usual. A cursory parallel, made be- tween the old method of opening the cranium with the trepan and that which is now proposed, will enable the 84 Instruments of Trepanning. reader to judge of their respective advantages and in con- leniencies. 1st. In the first part of the common process, the per- forator must be mounted upon the handle to make the opening in the bone, and then dismounted. Here, on the contrary, only the opening is to be made, because the blade, being soldered to the instrument, will re- place the perforator. 2d. The second part of the operation in common use, consists in mounting the crown, arming it with its py. ramid, and then making a semi-circular section. Here it is sufficient to lower the crown a little before making the section, which then becomes so much the more easy, as the blade being cut like a perforator penetrates without difficulty at the same time with the crown; whilst the square form of the common pyramid makes the perforation of the bone difficult, when that part of the instrument is employed. 3d. In the third part, the pyramid is unscrewed, lest it should wound the dura mater, and the section is finished with the crown, which, being then deprived of support, often moves with little solidity. Here, on the contrary, the simple lowering of the crown produces the triple advantage, 1st, of equally avoiding the injury of the dura mater, because the extremity of the blade is elevated above the level of the crown; 2d, of fixing the bony piece during its motions, of preventing its vacilla- tions, and consequently that inequality of depth in the circular section, which is almost inevitable in the com- mon process; 3d, of retracting, after the section, the bony piece in which the point of the blade is fixed, and thus very often dispensing with the elevator. If the piece should be fastened, as sometimes happens, in the cavity of the crown, in order to draw it out, it will be sufficient to unscrew that, and to push the blade down, Instruments of Trepanning. 85 which will carry the bony piece in the same direction, We perceive that the different parts of the operation here succeed each other with a rapidity that nothing im- pedes. It is only requisite to lower to a certain degree, the moveable crown of the instrument upon the blade which is soldered to it, and whose disposition supplies the place of the perforator, the pyramid and consequently the key, intended to mount and dismount it. Add to this, the result of the experiments made with this pro- cess, which have constantly succeeded on dead bodies, with me and also with all the pupils whom I have made perform it. It must be confessed, that no occasion of employing it upon the living Jias yet offered; but in this case, the practice on dead bodies is sufficient. In fact, it is not with instruments intended for the hard parts as with those for the soft; which, being more or less stretched or relaxed by the influence of disease, increased or di- minished in thickness and density, offer in their division, difficulties which are done away by death. The division of the prostate gland, in a calculous person, who has perished from his pains, is not the same as that of one who is living. On the contrary, the change caused by death in the organic texture of the bones, is of no con- sequence with regard to the instrument to be applied to them. I will here limit my reflections to the application of the instrument which I have proposed. I have pro- hibited myself from all scientific parallel with the instru- ments in use at the different periods of the art. Experi- ence has banished them nil, to substitute that which is now generally received; that alone must then be the ob- ject of the parallel. Of what service is it to relate things already a thousand times repeated? Erudition is a pom- pous frame, which seerns to me often to serve no other purpose than to divert the attention of the reader from 86 Instruments of Trepanning. the picture which it embellishes. Take away from the greater part of our memoirs, the pages which are filled with useless eloquence, those that are usurped by eru- dition, and those which a strict discussion of the sub- ject would retrench, and what will there be remaining? Explanation of the First Plate. Fig. I. Stalk of the trepan; (aa) its handle, (bb) its body, (cc) its declivity soldered to the body and cut in the shape of a perforator. Fig. 2. The crown; (bb) its summit pierced with an opening, in which the fixed point of the stalk is en- gaged; (d) the screw to fasten it. Fig. 3. The stalk armed with its crown,"which is mounted very high to (b), in order that in the first part the point (a) may serve as a perforator. Fig. 4. The crown lowered upon the stalk to (b) in such manner, that, in the second part, the point (a) may replace the pyramid. Fig. 5. The crown lowered very low to (b) in such manner that it may exceed the level of the point, and to prevent that from wounding the dura mater in the third part of the operation. Fy.l. M E M 0 I R UPON THE EXTIRPATION OF THE CARCINOMATOUS EYE. SECTION I. 1. CANCER of the eye attacks all sexes and manifests itself at every age; but still it seems, more than other tumours of this nature, to be attached to childhood. Experience has proved this at the Hotel Dieu, where more than one third of the patients, on whom Desault operated, were under twelve years. It succeeds some- times to an obstinate ophthalmy, sometimes to a blow received upon the eye, sometimes to wounds and sta- phylomas of that organ, often to fungous excrescences that arise on its surface or in its cavities. It has also been produced by the imprudent use of topical irritants, and is frequently the effect of an internal disease. 2. Whatever the cause may be, the following is the series of symptoms that commonly announce its attack and accompany its progress: Pains in the head and heat, greater than usual, are the precursors; a troublesome itching harasses the eye and its environs; frequently it is filled with tears; and at first sensible to the impres- sion of light, in a little time it supports it with great pain, except when a preceding malady has already occa- sioned blindness, as is the case when the cancer occurs after the formation of a film, &c. At a certain period the itching is succeeded by a sensation of pricking, which is replaced by a pain, at first dull, then poignant and lancinating. The eye swells and assumes, not the 38 Extirpation of the Carcinomatous Eye. red colour of ophthalmy, but a hue, dull, and somewhat livid, yellowish and black; the sight becomes obscured and then extinguished; the pains are more severe; the volume of the organ augments, not as in hydrophthal- my, according to its natural dimensions, but by an increase unequally spread over its surface, which be- comes rough and uneven; the hardness increases with the volume; the transparent cornea, having become white, then red and livid, is excoriated, ulcerated, opens, and through it fungosities proceed, from which a puru- lent and fetid sanies flows. 3. The disease still progressing, in a little time a manifest disproportion exists between the eye and the cavity in which it is lodged—as in hydrophthalmy it is pushed outwards, exceeds the level of the orbit and makes a hideous prominence on the face. The portion of the conjunctiva reduplicated upon the posterior part of each eyelid, which it lines in a natural state, is detached from it, and being stretched by the eye, is ap- plied to its anterior part, where it forms a red band, that covers it. 4. The suppuration assumes a more unfavourable character; the fungosities increase, become livid and black, hemorrhagies supervene more or less frequendy and in greater or less abundance. More constant pains torment the patient incessantly, and if art does not relieve him, the eyelids swell, inflame, and become schirrous. The inferior eyelid, upon which the sanies flows, is excoriated, fungosities arise there, the affec- tion is propagated to the cheek, to the nose, and per- haps then offers one of the most frightful of all the pic- tures that are so often presented by external diseases. The flat portion of the os ethmoides becomes carious, also the os unguis; the pituitary membrane is affected; the pains increase and become general; the cancerous Extirpation of the Carcinomatous Eye. 89 diathesis manifests itself, and then the history of the disease becomes the same with that of cancers in general. 5. The progress of the disease does not always follow exactly the order in which it has been traced; it varies accordingly as it originates from an external blow, a disease of the eye, or an internal disposition. To trace these differences would only be a repetition of what has been so often said respecting all cancers. It is sufficient to observe that here, as in analogous cases, the patient is inevitably dragged on to death through a road strew- ed with frightful sufferings, unless art affords a radical remedy for the evil. But, barren in the means of cure, art can only accomplish the object by removing the af- fected part; but for a long time more timid, than with other cancers, it has not presumed to attempt the extir- pation of the cancerous eye until several ages after per- forming that operation upon other parts attacked with the same disease. SECTION II. 6. The ancients are silent respecting this operation, and art is indebted to the German surgery for the first notions of it. It was first performed in the sixteenth century, with an instrument clumsily constructed, in the shape of a spoon with cutting edges, by means of which the eye, being separated from the surrounding parts, was extracted from the orbit; but being too wide to penetrate to the narrow bottom of that cavity, the spoon of Bartisch (for he first proposed it) either left a portion of the diseased part, or fractured the delicate and fragile bones, when it was pushed too deep. Experience mani- fested these inconveniences to Fabricius Hildanus, who to avoid them, invented a kind of knife with a button at its extremity, an instrument without doubt more per- Vol. I. M 90 Extirpation of the Carcinomatous Eye. feet than that it was intended to replace, but inconve- nient in the operation, and forgotten by practitioners for near a century. Sometimes they employed that of Bar- tisch, sometimes they had recourse to means that were cruel and not methodical, such as a kind of pincers, hooks, &c. Muys, Bartholin, Job a Meckren furnish examples of operations thus performed. More judicious than his predecessors, Bidloo made use of scissars and an angular knife: his process, although not methodical, was crowned with much success, a strong prejudice in its favour, as Louis remarks. A lancet appeared to La- vauguyon sufficient for the extirpation of the eye: he is the first of the French surgeons who mentioned this operation. Almost all of them considered it as useless, cruel, and dangerous, until St. Ives, who, without de- scribing his process, says that he performed it success- fully. In the institutions of surgery there are engravings of two tumours of the kind now under consideration, which the celebrated author of that work removed with the scalpel alone, that being sufficient, according to him, and preferable to the means of Bartisch, Hildanus, and Muys. Many English surgeons made use of a kind of curved scalpel, with a fixed handle, whose figure is to be found among those in Bell's work; but which, in the dissection of the tumour, presents inconveniences not experienced with the straight form of that instrument. 7. Hitherto the processes, indicated by authors, had not been submitted to fixed and invariable rules. Louis attempted to lay down those rules, and his process, de- scribed by himself, and retraced by Sabatier who adopts it, has for a long time been most generally used in France. It consists in dividing the attachments of the eye with the lids, in then cutting first those of the small, after- wards those of the great oblique muscle, and then those of the elevator of the superior eyelid; varying, accord- Extirpation of the Carcinomatous Eye. 91 ing to their insertion, the manner of holding the scalpel; at length separating the globe and dividing, with scis- sars curved on their flat side, the muscles that move it, and the optic nerve. 8. This manner of operating, founded upon anatomi- cal principles, seems at first view to offer a method, where, as Louis said, each stroke of the instruments was directed by the knowledge of the parts. But we may observe that these parts, being altered from their natural state by the disease, most commonly then cease to offer the structure and relations that are natural; that the situation of the muscles, which are flattened, lace- rated, destroyed or confounded with the eye, cannot serve, as in the operation for the stone, for example, as a basis to the precepts of this operation; which may be performed very methodically and according to general principles, but not after any marked, precise method. Besides what necessity is there to combine the use of the knife and the scissars? The addition of an useless instrument to an operation is a retrenchment of its per- fection. Now it is easy to see that, in fact, the scissars are useless, although Louis did not think the operation could be performed methodically with the scalpel alone. The inclination of the external side of the orbit always permits this last instrument to go to the bottom of the cavity, and to cut both above and below the optic nerve and the muscular attachments pulled forwards, by put- ting them in a state of tension. SECTION III. 9. Reasoning upon the principles stated above (7, 8), Desault, after having performed and taught the method of Louis, adopted the opinion of Heister, who advises the scalpel alone to be used. In order to form an exact idea of the process, always simple and easy with this 92 Extirpation of the Carcinomatous Eye. single instrument, we must suppose the carcinoma to be in three different states. 1st. When the tumour, be- ing concentrated within the orbit, barely exceeds the limits of the eyelids, which remain free. 2. When, be- ing much more voluminous, it makes a considerable prominence forwards, draws in that direction the sound eyelids that are applied upon it, and also the portion of the conjunctiva which lines them posteriorly and which has been detached from them. 3. When in a still more advanced period the eyelids partake of the cancerous state. In the first case we must separate them from the eye by cutting the conjunctiva in that spot where it is reduplicated to be reflected on it; in the second, we must dissect the eyelids and.the conjunctiva, that are applied to it, from the diseased globe; in the third we must amputate these moveable veils at the same time with the globe. The operative details adapted to each of the three cases, will be found in the three following examples: CASE I. M. D. aged 45 years, came to Paris to consult De- sault respecting a carcinomatous tumour, which had been formed for a year past in his left eye, and had suc- ceeded a film that took place in consequence of a blow. The pains, dull at first, had been for some months so severe as to deprive the patient entirely of rest. Hard, unequal, and strewed wtfh varicose veins, the eye had not acquired a very large bulk. The eyelids, being sound, covered it as usual. A phenomenon, not com- mon in this affection, was observed here;—this was the constant oedema of the eyelids on the opposite side, since the development of the cancer, an cedema that no other cause seemed to have occasioned. Extirpation was the only resource. It was proposed by Desault. Extirpation of the Carcinomatous Eye. 93 Some general means, administered during eight days, prepared the patient, who was operated upon in the fol- lowing manner on the 7th of January, 1794. He was seated upon a chair, with his head about the height of the surgeon's breast and supported upon that of an as- sistant, whose hands, crossed upon the forehead, served at the same time to lift up the superior eyelid. The sound eye was covered with a cloth, lest it might be alarmed by the appearance of the instruments. The surgeon then lowering the inferior eyelid with his left hand, took an ordinary scalpel in his right, with which he cut first towards the small angle the union of the two lids for the space of half an inch. The instrument, being then introduced between the globe of the eye and the inferior eyelid near the internal commissure, was conducted circularly, with its cutting edge turned out- wards, to the external commissure, and divided the con- junctiva at the place of its reduplication, as also all the parts which constituted the lower attachment of the organ to be extirpated; then carrying the point of the instrument upwards, where he began the first incision, the surgeon conducted it anew to the small angle, be- tween the superior lid and the eye, cutting all the upper attachments. The insertion of the great oblique muscle which still remained within, was also divided. Being disengaged anteriorly, the eye was grasped by the thumb, index and middle finger of the left hand so as to stretch the optic nerve and make its division more easy. The scalpel being slipped between the diseased organ and the external side of the orbit, with its cutting edge turned below and applied to the nerve at its escape from the optic hole, divided it with the artery of the same name and the attachments of the muscles, and thus com- pletely separated the globe of the eye, which was drawn out by the hand that secured it. The index was carried 94 Extirpation of the Carcinomatous Eye. into the orbit to examine if there was any remnant of the engorged cellular membrane. Small knots that were found in the upper and outward part, were removed by the cutting instrument. The lachrymal gland was also extirpated, although it did not seem to partake of the engorgement of the surrounding parts. The hemorrhagy being considerable, in order to ar- rest it the cavity of the orbit was filled with pledgets of lint, sprinkled with colophony, and upon these the eye- lids were applied, they being covered with other pled- gets disposed in such manner as to be on a level with the eyebrows, nose and malar eminence; a square com- press covering the whole, was secured by another long one, which was retained in its place by an oblique ban- dage, whose circular turns passed upon the frontal ine- qualities of the side opposite to the posterior part of the head, under the ear of the affected side, and at length finished by covering the sound eye. The blood being completely stopped ceased to flow, and the patient was laid down. In the evening a bleeding from the foot was pre- scribed; a strict diet was observed for several days, with the use of diluting ptisans. On the fourth day the lint placed externally upon the eyelids was removed, and some more moistened with the water of guimauve substituted. On the fifth day the suppuration beginning to detach that which was placed in the orbit, it was re- moved in part, first opposite to the upper eyelid which was carefully raised, and then opposite the under one. On the sixth day all the lint that was first applied was taken away. From that time the dressings were renew- ed regularly every day. The wound resulting from the incision of the external commissure of the eyelids, was brought together by adhesive plasters. On the fifteenth day fungosities, arising through the Extirpation of the Carcinomatous Eye. 95 whole extent of the sides of the orbit, filled it in part; but they having perished in a little time, it was covered with a prolongation of the conjunctiva which lines the two eyelids posteriorly, and which extending to the op- tic hole, served for its cicatrization. The eyelids being drawn by it, sunk in and left a vacuity which was cor- rected by an artificial eye. 10. In this operative process there are some circum- stances that merit a particular attention, of which authors have taken little notice. The precaution of pre- viously cutting the external commissure is always essen- tial, both because more facility results in the section of the nerve, the introduction of the instruments into the orbit being then more free, and because after this sec- tion, there can be no obstacle to the escape of the organ from its cavity. On the contrary, when the eyelids are not divided, if it should be a little bulky, they will im- pede it and incur the risk of being irritated or torn by attempting to force the passage. There can be no ap- prehension of more deformity, because as soon as the suppuration is established, the edges are reunited and nothing appears. 11. Instruments, intended to fix the globe of the eye during the operation, such as the purse of Fabricius Hildanus, the forceps with double handles of some, that with a single handle recommended by Sabatier, are in general of no use. The fingers of the surgeon are suffi- cient alone, when they have the advantage of being armed with long nails, an advantage trifling in appear- ance, but really precious in many operations, which it renders more simple by retrenching artificial aid. 12. After the tumour is removed, whatever may be its form and size, we must never omit the extirpation of the lachrymal gland; for either it partakes of the en- gorgement, and will then become the germ of a new 96 Extirpation of the Carcinomatous Eye. cancer; or it remains sound, and in that case the tears which are there separated, flow upon the wound and retard the cicatrization. Even when this is complete, a fistula remains, and the patient always experiences the fatiguing inconvenience of an habitual weeping. 13. We will not here repeat the inutility of the scis- sars curved upon their flat side. Experience has proved the facility of substituting the scalpel in the section of the nerve, provided the precaution is used of stretch- ing, as has been already said, the parts to be cut, and of not pushing with too much violence the instrument, whose point might be broken against the internal side, or rather might penetrate the fragile substance of the ethmoid bone. 14. If the tumour, being much enlarged, has arrived to the second state indicated (9), there must be some modifications in the operative process, a detail of which will be found in the following case, recorded by Mouillet. CASE II. Therese Gillotte, aged five years, was brought to the Hotel Dieu with a carcinoma of the right eye, whose size, four times as great as natural, made a hideous pro- minence on the face. The eyelids being drawn forward, covered the posterior part of it. Tht portion of con- junctiva, which lines these moveable veils, being detach- ed from their internal surface by the tension of the tumour which was protruded forwards, was applied upon it anteriorly in such a manner that it formed a red band, about an inch wide, which did not seem to par- take of the disease. The ordinary preparations having been made use of, the little patient was carried to the amphitheatre, where Desault operated in the following manner. The exter- nal commissure of the eyelids was previously divided, Extirpation of the Carcinomatous Eye. 97 for the reasons stated (10), and to a greater extent than in the preceding case, on account of the size of the tumour. Then the surgeon divided the anterior edge of the red band, from the internal to the external side, at the place where it was confounded with the portion of conjunctiva that ought naturally to cover the eye. The scalpel then gliding under it, separated it inferiorly, as also the eyelid, from the affected globe. Superiorly a second semi-lunar incision united with the two extre- mities of the first. The eyelid and the corresponding portion of the conjunctiva that were applied to the eye were also separated. The scalpel being carried more deeply, divided all the cellular membrane of the orbit; then being engaged between the tumour and the exter- nal side of that cavity, it cut the optic nerve and the attachment of the muscles of the eye. The dressing, as in the preceding case, consisted in filling the orbit with dossils of lint sprinkled with colophony, in applying the eyelids upon them, and in laying upon these fresh dos- sils, which were secured by two compresses and a cir- cular bandage. On the fifth day the dressing was partly removed, and the external lint changed. The whole was renewed on the sixth. The rapid progress of cicatrization offer- ed nothing particular in the treatment. The cure was completed by the forty-ninth day. The portion of conjunctiva saved having served to cover the fleshy granulations, the deformity was much less. A glass eye replaced that which had been removed. 15. In this case the operation presents difficulties that are not to be contended with in the preceding, in which the conjunctiva was divided at the place where it reduplicates from the eyelids upon the eye. Here this reduplication no longer existed; the portion of the mem- brane forming it being stretched, as also that which Vol. I. N 98 Extirpation of the Carcinomatous Eye. lined the eyelids posteriorly, by the increase of the tumour, had been brought to its anterior part, which it covered, and there formed the red band spoken of (3). Now if this portion of conjunctiva does not partake of the disease, if it retains its natural colour, always pre- serve it, by beginning the incision at its anterior edge and then gliding the knife under it, in order to dissect it as in the preceding case. By these means there will be a greater extent of parts for the cicatrix; the portion saved will sink into the orbit in order to form it, and the eyelids being compelled to yield very little to meet it, the deformity will be less. 16. But if the disease should be propagated to that portion of membrane, and if its very deep red colour ex- cites suspicion, cut it off, beginning the incision at the level of the free edge of the eyelids, which is then found adhering to the tumour, but is indicated by the place where the white colour of the coverings of the eyelids ceases and the red of the conjunctiva commences. Let the nail be placed upon the border to protect it, during the double semi-lunar incision, from the contact of the instrument. 17. If the eyelids, as well as the portion of conjunc- tiva which lines them, partake of the engorgement, they must be removed. This forms the third state (9) of ex- tirpation of the eyeball. In the following case, the parti- culars of the operative process, in this circumstance, may be seen. CASE III. A man was brought to the Hotel Dieu, in 1792, to be there operated on for a cancer of the eyeball, which had already extended to the eyelids. The superior, adher- ing to the organ, was affected with sensible schirrosity through its whole extent; the inferior, ulcerated by the Extirpation of the Carcinomatous Eye. 9W contact of the ichorous pus that fell upon it, was more- over affected by fungosities that arose from its internal surface. The evil did not seem to extend to the bones of the orbit, and no sign of cancerous diathesis mani- festing itself, Desault determined on the spot to operate, as further delay would, no doubt, only add useless pains to those the patient already experienced. On the third day from his admission, he was conducted to the am- phitheatre, where Desault operated in the following manner. The position of the patient and surgeon was the same as in the preceding case; an assistant, standing behind, drew upwards the skin of the superior eyelid, while another lowered that of the inferior towards the cheek. The surgeon, elevating this eyelid on the other side, in order to stretch the integuments, plunged his scalpel, held as if he were cutting against himself, be- tween the great angle and the commissure of the eyelids, pushed it considerably forwards into the orbit and then bringing it outwards cut the skin, orbicular muscle, large inferior ligament, the small oblique muscle, and the cellular membrane which unites the eye to the orbit; then lowering with one finger the superior eyelid, which the assistant drew upwards, he carried back the scalpel into the internal extremity of the first incision, the cut- ting edge being turned outwards, plunged this instru- ment into the orbit, and conducting it circularly towards the small angle, he reached the external extremity of the first incision, by including the skin, orbicular mus- cle, its tendon, the large superior ligament, the great oblique muscle and the cellular membrane. Being sepa- rated forwards, the eyeball adhered behind only to the optic nerve and to the insertion of the muscles. The scalpel, carried along the external side of the orbit, cut these, as in the preceding cases; and the eye, having been secured solely by the fingers during the operation, 100 Extirpation of the Carcinomatous Eye. was easily extracted from its cavity. The engorged cel- lular membrane was removed, and the dressing was the same as that indicated (case 1), only with this differ- ence, that the eyelids being wanting, the lint formed a single pyramid, whose summit was at the bottom of the orbit and the base at the level of the eyebrow, nose and malar eminence. The treatment and mode of dressing were the same as in the preceding cases. The cicatriza- tion was much longer, because here it could take place only at the expense of the skin of the cheeks, nose, and forehead, which, being gradually stretched, sunk into the orbit and united at the bottom to form it. The pa- tient was dismissed in the fifth month, entirely cured, but with a considerable deformity, which it is difficult to remedy in such cases by an artificial eye, on account of the extent of the wound. It was learned from later information, that at the end of a year, the cancer broke out again and destroyed the patient. SECTION IV. The preceding cases show, as has been said, the dif- ferent varieties of the operative process in the extirpa- tion of the eye; but, whatever means may be adopted to remove that organ, the subsequent dangers of the opera- tion are always the same. The reproduction of the tumour is always to be feared, and is the terrible con- sequence of most of the cancerous tumours that are extirpated. We endeavour in general to shun this con- sequence, by removing as much as possible all the affected parts; but the disposition of the orbit does not always allow an exact removal of the whole of the en- gorged cellular membrane. This removal is often very- difficult in the bottom of the cavity; besides, the perios- teum may partake of the affection, and how can it then Extirpation of the Carcinomatous Eye. 101 be extirpated with accuracy! In certain cases, might not the sides of the orbit be scraped by employing in- struments analogous to the form of the orbit, and thus obtaining the assurance that nothing remains? This idea is proposed, because in many cancers, for example, in those of the mouth, fire is employed to destroy what remains after extirpation; and here this mean would be more dangerous, on account of the proximity of the brain, than that indicated would perhaps be, and might be replaced advantageously by it, although Desault never thought of this remedy. MEMOIR UPON THE OPERATION FOR THE FISTULA LACHRYMALIS ARTICLE I. General Observations. 1. IF the progress of art in the treatment of a dis- ease, were estimated by the multitude of operative pro- cesses, no operation would have arrived nearer to per- fection than that for the fistula lachrymalis. Since the commencement of the present age, a number of surgeons have made it the object of their researches. Anel, Voolouze, Laforet, Palluci, Mejan, Petit, , Monro, Foubert, Pouteau, Lecat, Louis, Heister, Cabanis, and Jurine, seem by their ingenious processes as it were to have overwhelmed nature with the means of art, and to have offered resources in greater profusion than the ex- isting obstacles. 2. Still, in the midst of so many obvious paths, the artist is often uncertain and hesitates which to prefer. Let us endeavour to point it out to him, by presenting the practice of Desault on this subject. If he has not invented a new operation, the methodical assemblage which he has made of those already known, the useful modifications under which he has presented them, the practical details with which he has enlarged them, enti- tle his name to rank in celebrity with those already mentioned. Operation for the Fistula Lachrymalis. 103 3. It is not my design to recapitulate the multitude of processes, some of which have perhaps been more frequently described in books, than practised upon pa- tients. Those only will occupy attention, which relate to that of Desault. Thus, as it results essentially from those of Petit, and Mejan, I will examine them first, appreciating their advantages and inconveniencies; and will then consider the various modifications which have been given them, by different authors; afterwards passing to that of Desault, I will describe both his mode of operating and subsequent treatment; but it will not be useless to offer previously some views of the disease itself and the different methods of treating it. ARTICLE II. Reflections upon the two general modes of operating for the Fistula Lachrymalis. 4. It is well known that this disease generally consists in a contraction or obliteration of the nasal duct, which is produced by some accidental cause; whether the sides of the sac remaining entire present a lachrymal tumour from whence there is a continual reflux of the tears upon the cheeks through the lachrymal puncta; or, whether these sides, being partly ulcerated and destroyed, pre- sent a fistula that offers an unnatural passage to the tears, which is incessantly kept up by them;—it follows that these two states of the tumour and fistula are almost always different degrees of the same affection, and that the treatment which answers for the one, rests upon the same basis, as that for the other. 5. Now this treatment is divided here, as in all fis- tula;, into two general methods, each including a great number of processes and conducting to the same end by two routes, essentially different. 1st. The supplying the contraction or obliteration of the nasal canal, by an 104 Operation for the Fistula Lachrymalis. artificial route. 2d. The re-establishing the diameter of this canal in its natural state. Let us make a brief examination of the advantages, and inconveniencies of these two methods, abstracting those that are peculiar to their processes. 6. The one offers to the tears an artificial passage, where they have not much more tendency to flow than through the unnatural opening already existing. It is the establishing an internal, instead of an external fis- tula. The other presents to them a vent through which they are naturally disposed to pass, and which re-esta- blishes the soundness of the organs. In the first the edges of the opening are incessantly disposed to close; because, nature always endeavours to destroy that, which is contrary to the organic system she has adopted. In the second, if a methodical, long continued compres- sion has destroyed the obstacles to the flowing of the fluid, if the sides of the canal have become sound, a new contraction is less frequently to be apprehended. Less facility is sometimes met with in this, especially when the canal is almost entirely obliterated; because, then a new passage, as it were, must be opened in the midst of very resisting parts, and more space is to be passed through before arriving at the nasal fossae; the other is exempt from this inconvenience, having only the thickness of the os unguis to pass through. The sides of the artificial opening can never possess that or- ganic action which is necessary to the motion of liquids. In this case will we find here the mucous fluid, intended to lubricate the nasal canal, to render the membrane more smooth and to preserve it from the impression of the tears? Certainly not, but a cicatrix, easy to swell and to give origin to excrescences that are evident obstacles to the passage of the fluid, will line the sides of this opening, if nature has preserved them; the re- Operation for the Fistula Lachrymalis. 105 establishment of the natural passage, will never be at- tended with these different inconveniences. In the first method, the injury of the bones, and their loss of sub- stance may occasion inconveniencies as grievous as those we wished to remedy. With regard to this, there can be no apprehension in employing the second method; experience frequently seems to condemn both, by show- ing the frequent inefficacy of the most methodical ef- forts; but, in one oftener than in the other, success is mingled with the reverse. 7. From this brief parallel of the two methods of treating the fistula lachrymalis, it results: 1st. That the artificial opening always presents a sum of incon- veniencies greater than of advantages. 2d. That the re-establishment of the natural passage is preferable to it, under the greatest number of views. 3d. That this re-establishment should be the object of the practitioner, in operating for the fistula. 4th. That if there are any cases in which the artificial opening is indicated, they must be only in a complete obliteration of the nasal canal, an obliteration rarely met with in practice. 8. These consequences would appear to be deduced from still more solid grounds, if we considered the dis- advantages peculiar to the different processes of the first method, such as those of the ancients, of Voolhouse, &c; disadvantages that are not intended to be retraced; how- ever, we must allow that among those processes there is one, that of the celebrated Hunter, that merits a dis- tinction to which the others have no claim, and which has been sanctioned by the practice of Desault himself: but, it will be resumed at the end of this memoir, in a particular article, and in the interim we will pass on to the processes of the second method, which have served as a base to what is now to be described. Voi. I. O 106 Operation for the Fistula Lachrymalis. ARTICLE II. § I. Of the processes from which that of Desault is derived. 9. It has been declared (3), that there would not be an examination of the processes of either method, fo- reign to this which is now to be made known; let us therefore take a cursory view of those, of which this is an assemblage, and then make a comparison between them. 10. We are indebted to the celebrated Petit for the ingenious idea of re-establishing the natural passage. It gave rise to his process, the common base from which all those that came after him have proceeded. A com- mon scalpel, another narrow and short, with a blade grooved on its anterior surface, a common canula, a bougie;—such is the assemblage of instruments neces- sary for the operation, which is performed in the fol- lowing manner. 1st. Divide, with the common scalpel and by a semi- lunar incision, the integuments, from the straight tendon to the distance of six lines lower and more outwards, following the edge of the orbit. 2d. Penetrate into the interior of the sac by a second incision made with the grooved scalpel, and keep it there with the left hand, in the direction of the canal. 3d. Glide the canula along the groove, and then withdraw the knife. 4th. Let the canula, moved in every direction in the nasal canal, overcome the obstacles that are found there, and open itself a passage into the nasal fossae, where some drops of blood will announce its presence. 5th. Pass through the canula a bougie, proportioned to the diameter of the canal, secured by a thread, which, being attached to its superior extremity, retains it above, Operation for the Fistula Lachrymalis. 107 and is supported by some compresses that are covered with a suitable bandage. 6th. The first days of the operation having passed, and suppuration being established, the bougie must be changed, renewed every two or three days, and its use continued until it goes in and out without causing pain, and draws after it nothing but a little mucus. It is then to be entirely suppresse and after supplying its place by detersive injections, the cicatrization of the external wound is to be encouraged. 11. Mejan took another route to attain the same ob- ject. His process was as follows: The instruments re- quired, are, 1st, a probe, six inches long, flexible, ter- minated at one end by a button, at the other by an opening, through which a thread intended to withdraw the seton is passed; 2d, a seton, being a cylindrical assemblage of some threads of lint united together; 3d, a blunt hook, a forceps, a canula with a hole at its extre- mity, or rather the pallet (palette)*, which Cabanis sub- stituted for it. Every thing being thus disposed, and the patient placed as in the other methods, we must 1st. Introduce the probe through the superior lachry- mal punctum, first from without in, then from above to below, to arrive at the lachrymal sac. 2d. Penetrate into the nasal canal, pass the obstacles to enter the nostrils, and if we cannot reach there, sub- stitute a pointed probe for the blunt one that is com- monly employed. 3d. Withdraw the probe with one of the instruments mentioned above, and disengage the thread, which re- mains thus for twenty-four hours, passing through the lachrymal punctum and the nasal fossae. 4th. Fix to this thread the seton, smeared with diges- tive ointment, and let it be drawn from below upwards. * A small thin silver plate, with several holes at one end. 108 Operation for the Fistula Lachrymalis. 5th. Withdraw the seton every day, by means of the thread fixed to its inferior extremity, substitute for it another charged like it, with different medicaments, and continue this treatment until the seton allows no more pus to flow, or until it goes up and down at pleasure. § II. Parallel of the two Processes. 12. Such is in general the detail of the processes of Petit and Mejan; let us now inquire into the respective advantages and inconveniencies of both, and let us prove—that both must be retrenched, that either when separate is insufficient, and that their perfection can arise only from their union. For this purpose, we must dis- tinguish two parts in the operation: 1st, that of the inci- sion of the sac and the clearing of the canal; 2d, that of the dilatation of the latter. 13. In the first part of the operation, the artificial route of the canula, in the process of Petit, is preferable to the natural route followed by the probe of Mejan. In fact, in the one, there is the advantage of exposing to view the sac, whose internal membrane, almost always diseased, requires to be suitably treated; there is less space to be passed to arrive at the canal, and a more free opening, facilitating the rest of the operation. In the other, to the narrowness and defective direction of the passage, to the length of the space, and consequently to the difficulty of introducing the instrument into the sac, is added the inconvenience of the constant presence of the thread in a natural canal, whose sides may excori- ate, inflame, even be divided, as has been seen, then re- unite and be obliterated, or lose their organic action, and their faculty of absorbing the tears. 14. Still we may object to this first part of the pro- cess of Petit, the inutility of a particular knife with a groove in its blade, the too great extent of his incision, the manner of performing it with two repetitions, the Operation for the Fistula Lachrymalis. 109 semilunar form which he gives it, from whence may arise the reversion of the edges and even of the eye-lids. 15. The ordinary canula is preferable to the proof be Mejan, for clearing the sac. Having more resistance, it overcomes the obstacles without difficulty and gets into the nose; whilst the other, being very flexible, bends and yields before the least resistance; and if then re- course be had to the pointed probe (11, 2d), false pas- sages may be the result of it. Its extraction from the nasal fossae is difficult; the introduction of the instru- ments which it requires is painful, and capable of pro- ducing an unfavourable irritation. 16. However, we may object to the canula of Petit, that it is too large, and consequently liable, when con- ducted with little precaution, to fracture the os unguis. 17. In the second part, the seton of Mejan claims an exclusive preference to the bougie of Petit. More soft and flexible, it accommodates itself to the figure of the canal, which the other irritates by its presence and pressure. The latter, being placed from above down- wards and left between the edges of the wound, inverts them inwards, separates them, compresses them, and by these means retards their reunion more or less;—incon- veniencies that belong in part to the canula of Foubert, which is left in the place during the treatment, and upon which it was attempted to cicatrize the wound. Besides, this canula may become obstructed; it rarely remains fixed in the canal; when free, it escapes into the nose, the patient swallows it, or it gets entangled in the throat. If it remain in its place, being pushed against the cica- trix of the great angle, when the patient sneezes, coughs, or hawks a little stronger than usual, it irritates, in- flames, and perhaps lacerates it. Finally, the first prin- ciple of the union of wounds is here manifestly violated, since the presence of an extraneous body is an evident 110 Operation for the Fistula Lachrymalis. obstacle to it. On the contrary, the seton of Mejan, being drawn from below upwards, is secure from this inconvenience. 18. Notwithstanding these advantages, Mejan me- rits the double objection, 1st, of not increasing his seton sufficiently to enlarge the canal gradually; 2d, of consi- dering it rather as a mean proper to carry medicaments, than as a mean of dilatation. 19. From this comparison between the processes of Petit and Mejan, it results, 1st. That the former is pre- ferable for clearing the canal. 2d. That the second is most advantageous for its dilatation. 3d. That still the merit of both is disfigured by some inconveniencies. 4th. That, in order to have a good process, we must borrow from the one its first part, and from the other its second; then unite these two parts, by modifying the defects of each. This idea has not escaped some sur- geons, who have attempted to realize it; but their pro- cesses, more or less insufficient, do not present such advantages as might be expected from such solid bases. § III. Of the different Processes that are grounded on those of Petit and Mejan. 20. Monro, in adopting the process of Petit, substi- tuted for his bougie a thread, introduced by means of a curved, semi-oval canula, straight for the space of half an inch towards its extremity, and which he caused to penetrate into the nose with much ease. The thread which it had introduced was charged every day with desiccative and detersive remedies, and its use was con- tinued as long as was deemed necessary. But, 1st. It is well known how useless are all these medicaments, for- merly so vaunted in the treatment of fistulae. 2d. The thread, which serves for a seton, will either be too large to adapt itself to the diameter of die canal, and then it Operation for the Fistula Lachrymalis. Ill will separate too far the edges of the external opening, which it will prevent from uniting; or it will be so small as to leave the edges in contact, except in one place, and it cannot dilate the canal, whose sides will not be compressed by it. 21. Lecat employed the seton of Mejan, introduced nearly in the same manner as the bougie of Petit. Being drawn at each dressing, from above downwards, like the thread of Monro, it had here, besides the two preceding ineonveniencies (20), that of inverting downwards the edges of the wound each time, of drawing in the same direction the membrane of the canal, and of bringing it towards the inferior orifice, where it may form an excre- scence that will impede the flowing of the tears by con- tracting their passage. 22. At the same time with Lecat, Pouteau associated with the incision of the sac, performed within, the use of the seton. But, the place of this incision, capable of causing the irritation and inflammation of the conjunctiva and the eye, accidents which cannot be compared with the advantage of shunning a slight deformity, the defect of a gradual increase of the threads of the seton, and the difficulty of passing it, place his process in the same rank with that of Lecat, who disputed it with him. 23. Of these different modifications, that of Jurine would, no doubt, be the most advantageous, either be- cause the external opening (having only the necessary extent for the passage of the thread) permits the union of the edges, or because the seton is drawn from below upwards. But, as remarked by M. Sabatier, is there not cause to fear that the trocar, which opens the passage for the probe that conducts the thread, being carried at hazard and without a guide into the nasal canal, may wound its sides, make false passages, pierce even the os unguis and penetrate into the nose? 112 Operation for the Fistula Lachrymalis. 24. From these different considerations it results, that authors leave in general much to be desired, in the as- semblage which they have wished to make of the pro- cesses of Petit and Mejan; and that their processes, although advantageous under certain views, cannot be admitted under many others. Let us examine if more advantages and fewer ineonveniencies are to be found in that of Desault. ARTICLE III. PROCESS OF DESAULT. § I. Description of the Process. 25. In general it consists sometimes in dividing the sac, clearing the canal, and then passing the thread that serves to withdraw a seton, which must effect during the treatment what Petit performed with his bougies: sometimes in only enlarging, by bougies, the fistulous opening and the canal, without any incision, and then passing the thread and seton. 26. In this case the preparatives of the patient have nothing particular, being relative to the degree of his strength, to the cause on which the affection depends, a cause which if known must always be previously com- bated, to the state of the abdominal organs, whose in- fluence upon operations is so great. They vary accord- ing to these different circumstances, and are most com- monly useless if there is no error in the animal economy, and if there is, they are, as has been said, only pre- cautionary. 27. The instruments necessary for the operation vary accordingly as an incision of the sac is to be performed, or the existing opening to be only diluted. They are, 1st. A common scalpel, with a narrow blade and strong point, lest when pushed too violently into the sac, it Operation for the Fistula Lachrymalis. 113 may bend or break. 2d. Bougies of catgut, of a size gradually augmented, and of a length proportioned to that of the canal, each surmounted with a thread des- tined to secure them, and prepared in such manner that they have superiorly a rounded head, which the surgeon himself makes with the flame of a candle, and inferiorly a blunt point made with a penknife. 3d. A common whitlow director, or what is still better, a silver probe six inches long, and solfd enough to overcome the ob- stacles of the canal. 4th. Small canulae of silver or lead. Either metal is indifferent, when the canula is introduced upon the whitlow director: if it be of lead, the surgeon may make it at the time of the operation, with a sheet disposed in such way that it may be rolled round a mandrin,* after having folded one of its edges so as to make a prominence which may arrest it above, and after taking externally the measure of the length of the canal. But if, as will be mentioned (30), the canula is introduced upon a probe, it will be better that it should be of silver, because it then has more solidity, and in this case its diameter will be exactly proportioned to the size of the silver probe. Whatever may be its com- position, it should be a little larger superiorly than infe- riorly, and should have above, a small hole or ring, to fix there a thread, intended to secure it. 5th. A thread, not waxed, intended to pass the seton. 6th. The seton, a cylindrical assemblage of many threads of lint, whose number being augmented every day, enlarges it at plea- sure. 28. Every suitable arrangement being made, the pa- tient is seated upon a high chair, with the head sup- ported, as in all the other processes, against the breast of an assistant, whose hands are crossed upon the forehead. * Mandrin (Fr.), a solid silver probe used for the urinary pas- sages. Vol. I. P 114 Operation for the Fistula Lachrymalis. 29. Then there are two modes of operating, relative to the state of the sides of the lachrymal sac. 1st. If these sides are sound, as in the lachrymal tumour; if, being open, the fistulous opening is very narrow, and out of the direction of the canal; if a probe, carried through the hole to sound the parts, perceives a great resistance and cannot reach the nasal fossa—the incision of the sac is then necessary. 2d. But if the fistulous hole is sufficiently large, if it is in the direction of the canal, and the contraction being inconsiderable, will permit the probe, which sounds the passage, to go through it, it will be sufficient first to dilate it with bougies, during some time, and then with the seton. Let us examine the manner of proceeding in both cases. 30. If the incision of the sac is indicated, 1st. The assistant, who supports the head, must draw upwards the superior eye-lid, while the surgeon assures himself of the situation of the sac by seeking the edge of the projecting apophysis, marks with his nail the place of incision between the edge and tendon of the orbicularis, stretches the integuments with the index placed upon the nose and the thumb on the maxillary bone, and makes the tendon project, below which the scalpel is to be conducted. 2d. He holds the scalpel like a writing-pen, in the right hand, if the fistula is on the left side, reciprocally turns the back against the nose, and plunges it at once into the sac in the superior part of the canal, and even into the nasal fossae if the blade is sufficiently narrow; thus including in the same incision the skin, the fibres of the orbicularis, and the sides of the sac. If a consi- derable swelling exists, the incision of Petit at two dif- ferent times (10, 1st and 2d), merits the preference. 3d. From thence results an oblique incision from above downwards and from within outwards, two or three lines in extent. When the direction and situation Operation for the Fistula Lachrymalis. 115 of the sac are known, it is easy to reach the mark, without the previous precaution of Pouteau, who suf- fered the pus to collect in order to make the sides more prominent The scalpel meeting with no resistance, in- dicates that it has penetrated. If the tumour extends above the tendon of the orbicularis, the incision must be commenced there; because in the following treat- ment the fraenum which results, preventing the pus from running down, might give origin to a new tumour. 4th. Upon the anterior surface of the blade of the scalpel, firmly secured in the direction of the canal and a little inclined outwards, the surgeon glides his silver probe, withdraws the scalpel, now become useless, and at the same time opens the sinuses, if, as sometimes happens, they are found along the edge of the orbit. The neglect of this precaution might be pernicious to the success of the operation. 5th. The probe is inserted into the nasal canal with precaution and slight rotatory motions, if a very consi- derable contraction opposes its passage. Sometimes an- other cause prevents its advancing. The superciliary arch, when too projecting, forms an obstacle above, which renders it necessary to take an oblique direction, in such manner, that being carried too much back- wards, its extremity may bruise the opposite side of the canal, be stopped by it, and if force is used, perhaps make a false passage. In this case, curve the probe slightly opposite the arch, in such manner as to be ac- commodated to the projection. Desault, being one day a spectator of an operation in which an entrance into the nasal fossae could not be obtained, advised this mean, which was indicated by the disposition of the eye-brows, and the probe penetrated immediately. Its presence in the nasal fossae is announced by a tickling which the patient experiences there, and by the escape 116 Operation for the Fistula Lachrymalis. of some drops of blood, especially if the obstacle has been hard to overcome. Then turn the probe in differ. ent directions, in order to clear the canal. 6th. When the passage is sufficiently enlarged, take a canula whose diameter must be well proportioned to the size of the probe (27, 5th), make it slide upon it, ex- actly as in the operation for the fistula in ano, withdraw the probe when the canula has arrived in the canal and nasal fossae. It is seldom difficult of introduction, if its inferior edge is nicely tapered and accurately adapted to the probe. 7th. The canula being thus introduced, serves to pass the thread which must withdraw the seton. The extremity of this thread, several times reduplicated, is to be made to slide into it and to be pushed down with a probe, so that an end sufficiently long may reach the septum of the nasal fossae. 8th. When the patient perceives that it has arrived diere, he must blow his nose with force, taking the pre- caution of closing the mouth and the opposite nostril, so that the whole column of the expired air, passing into the nostril where the thread is, draws it towards the anterior opening; whence we perceive the necessity of not waxing it, as in ordinary operations, for it would then be too rigid. The first attempts are sometimes fruitless. Do not, therefore, be discouraged, but after permitting the patient to rest a little, begin again to make him blow his nose; the thread will at length pass. It must be confessed, however, that sometimes we are obliged to wait a long while. If success cannot be ob- tained in this manner, a blunt hook or curved probe would be of service to seek for it. Sometimes the diffi- culty of extracting the thread proceeds from this cir- cumstance—that the canula, resting immediately upon the septum, retains it there; or from this—that being di- Operation for the Fistula Lachrymalis. 117 rected backwards, it removes the thread from the ante- rior opening of the nostrils. The first obstacle is avoided, either by raising the canula a little, when the patient blows his nose, or by giving it inferiorly an oblique inclination, like the mouth of a pipe, which allows the thread to escape through it. The second will be reme- died, by giving a curvature, whose concavity being directed forwards would carry its inferior extremity in that direction. This correction is due to M. Giraud. 9th. To the thread thus passing through the nasal fossae a seton is attached, of a size analagous to the actual contraction of the canal, previously smeared with cerate to make it slip more easily, and terminated infe- riorly by another end of thread, to the other part of which a small ball of lint is attached. The portion of thread that passes below the great angle being then drawn from below upwards, carries the seton into the lachrymal sac, without however causing it to ascend between the edges of the opening, where the thread re- mains alone, an essential precaution, as will be men- tioned (50). If the operation has been very painful and there is too much irritation in the canal, the introduc- tion of the seton may be postponed until the next day, but in general it is better to do it at once. 10th. The ball of lint and the end of thread which unites it to the seton, are then concealed in the nostril, from whence it is withdrawn at each dressing, and with it the seton. The rest of the thread, rolled around a card, is enveloped in a piece of white paper, which is concealed in the hair. 11th. A small plaster of gum diachylon is applied upon the fistula and sustained by a compress, secured by the monoculus. 31. Such is the process to which recourse must be had in cases where the incision of the sac is previously 118 Operation for the Fistula Lachrymalis. indicated. It has undergone many variations, and those who have followed Desault will not be surprized at it; for they know that his genius modified, almost every time, the details and even the operative processes. 32. He combined for a long time the use of the seton and bougies; the latter being placed in the canal after the incision of the sac, remained there during some days, and dilated the passage gradually, into which the canula being then introduced, served to pass the thread that retracted the seton. But this is an useless multipli- cation of means, and it is better, when there is a neces- sity for introducing the probe to clear the canal, to make the canula slide upon it at once, to place the seton and to reserve the bougies for the cases that are to be yet examined. 33T Instead of the probe, a whitlow director was formerly employed to clear the canal; the canula then glided upon the groove turned forward; but it is evi- dent that the probe would experience less resistance, when introduced as has been indicated (30, 6th), because its inferior extremity would present less surface to the obstacles which arrest it. Let us proceed to other more minute changes. 34. It has been said (29) that, if the fistulous opening is sufficient and the contraction inconsiderable, the in- cision of the sac would be useless; that then it would be requisite first to enlarge the canal by the use of bougies, and afterwards substitute the seton for them. This method, although slower, is in general preferable, when possible; because the gradual compression of the bougies will irritate the already diseased membrane of the canal less than the momentary violent introduction of the canula and probe. 35. In this case take a bougie proportioned both to the opening and contraction of the canal; for example, Operation for the Fistula Lachrymalis. 119 the treble string of a violin, if the one is very small and the other very large; prepare it as has been indicated (27), then insert it, smeared with cerate, impressing on it slight rotatory motions; if successful, in reaching the nasal fossae, let it be fastened superiorly to an adhe- sive plaster by the thread which is attached to it, as without this precaution it might escape and it would be very difficult to draw it out. The next day, the mois- ture having doubled the size, the canal and fistulous opening will be a little dilated; then pass a bougie a little larger. On the third day one still larger, and so on until the dilatation is sufficient to admit the canula which must conduct the thread (30, 6th). The canal is known to be sufficiently dilated: 1st. By the ease with which bougies of an ordinary size ascend and descend in it. 2d. By the free passage of air through the fistulous open- ing, when the patient blows his nose. 36. In this case Desault sometimes employed another method of passing the thread. He twisted it round a bougie, folded it upon itself many times at its extremity, fastened it there with a piece of wax, so that it was in- corporated with it, and inserted it thus. The next day, the heat having melted the wax, the thread was at liberty in the nasal fossae, and was drawn out either by an instrument or by making the patient blow his nose. The seton was attached to the thread, its size being al- ways determined by that of the last bougie used, and then the process became the same as that indicated (30, 9th, 11th), to which reference may be had for fur- ther details. If the fistulous opening was considerable and the dilatation of the canal sufficient, we might dispense with the previous use of bougies, and pass the thread, with the canula and probe, immediately. 120 Operation for the Fistula Lachrymalis. § II. Of the subsequent treatment. 37. In whatever manner the seton may have been in- traduced, whether it has immediately followed the inci- sion of the sac, or whether this incision not having been made, bougies have been previously employed, the following is the subsequent treatment to which re- course must be had after this introduction. 38. The next day the seton is withdrawn through the nasal fossae, covered with a purulent crust of more or less good quality, sometimes blackish in a portion of its extent, often in the middle, a circumstance which in- dicates the denudation of the bony canal, and caries of the corresponding place; the portion of thread which has passed through the sac must be cast off, and another seton placed at the extremity to be drawn upwards as at first. 39. It is thus changed every day, with the precaution of adding to it a thread of lint each time, so as to aug- ment the size gradually and thus dilate the canal in an insensible manner. 40. Sometimes a local inflamation is the result of the operation, especially when much exertion has been made to overcome the obstacles with the probe; then an emollient cataplasm must be applied upon the opening and continued until the affection disappears. 41. When the thread is worn another replaces it. It is made to pass by fixing it superiorly to the remnant of the old, which is withdrawn through the nasal fossae. Perhaps it may not be a matter of indifference to point out the form of the knot that unites the two threads; because, having to pass through parts already irritable, it is essential that it should present the least size and inequality possible. A noose, first formed with the ex- tremity of the new thread, is held with the two first Operation for the Fistula Lachrymalis. 121 fingers of the left hand by the surgeon, who passes there from behind forwards, the superior extremity of the old thread, with which he makes a second noose, whose anterior branch being the smallest, is carried to the right, then backwards, then to the left, and finally be- fore the posterior which is the longest; it is then passed into the superior noose, so as to form a kind of love knots, that are tightened at pleasure; the new thread is thus drawn downwards, the seton as usual being at- tached to its extremity and enlarged every day. 42. When by its successive additions it has attained a size equal, or even superior to the ordinary diameter of the canal, so that it slips easily, and the external wound being almost closed, presents only an opening sufficient for the passage of the thread; when the seton, instead of being covered with a purulent and sometimes blackish (28) matter, comes out imbued only with the natural mucus of the canal, then the use of this mean may be suppressed, with the precaution, however, of still leaving the thread in the canal during a certain time, so that the seton may be again introduced, if there should be any further necessity for its use. 43. A small plug of lint is attached to the inferior extremity of the thread, which is then concealed in the nostril, from whence it is easily withdrawn (40, 10th). The small wound is covered with a plaster of gum diachylon; the tears, which hitherto still flowed upon the cheeks, the presence of the seton forming an ob- stacle to them, then begin to resume their natural route, and at the end of a longer or shorter time, the epiphora is completely cured; then, the thread being taken away, the edges of the opening close spontaneously, or their cicatrix may be favoured by a slight cauterization with the lapis infernalis, and the patient is cured. 44. Such is the most favourable progress of the dis- Vol. I. Q 122 Operation for the Fistula Lachrymalis. ease and the subsequent treatment to be pursued after the operation; but how often do matters take another turn? How many times, in spite of the most methodical and most constantly continued efforts, does the fistula continue to subsist, or if closed for a time, is soon re- produced? The obstacles met by the practitioner in this case, have been exposed by different authors, and es- pecially in France, with a precision that dispenses with any further details. 45. Finally there is nothing constant in the duration of the treatment; two months have sometimes been suf- ficient; but more frequently six months, or even one year's use of the seton is necessary; and Desault, in the case of a patient whom he cured in 1787, did not take away the thread entirely, until the fifteenth month. § III. Of the process of Desault, compared with the others. 46. Since as has been seen (13 and 15), the first part of the operation for the fistula, which relates to the clearing of the canal, has, in the process of Petit, more real advantages than in that of Mejan; and that this latter process, on the contrary, offers more facility in the second part, that is to say, in the dilatation of the canal (17), it results from thence, that the process of Desault, being an assemblage of the good properties of the two preceding, claims in general the preference to either of them separately. 47. But it remains to demonstrate: 1st, The perfec- tions which he adds to each of the parts of the process that he borrows. 2d. The advantages which he has over those who, like him, have taken the discoveries of Petit and Mejan for their base. 48. The defects which disfigure the first parts of the process of Petit, so advantageous in other respects, Operation for the Fistula Lachrymalis. 123 have been pointed out. Now it is evident, that here these defects disappear. 1st. If the incision of the sac is made, it is of small extent, has not the semi-circular form which would expose it to inversion in the dressings, to irritation of the edges from the kind of flap which it forms, and after the cure to a deformed cicatrix. 2d. Being performed at one single period, it does not prolong the operation. 3d. A common scalpel is suffi- cient, without making one of a particular form. 4th. The probe which clears the canal, or the whitlow director intended for the same use, being less bulky than the canula of Petit, do not run the risk of breaking the long sides of the canal. 5th. Frequently the incision is avoided, and at the same time the use of every instru- ment which, by suddenly forcing the resistance that the contraction of the canal offers, always occasions a considerable irritation in the already diseased mem- brane (34). 6th. The incision of the callosities that surround the fistula, recommended by Petit, is almost always useless; the passage of the tears produces and keeps them up, and they will disappear when this fluid is diverted by being brought back into its natural chan- nel. In like manner, the indurations in the fistula in ano get well, when the oozing of the stercoral moisture ceases. 49. Under these first considerations, the means re- lating to the clearing of the canal, and which have been described (30, 35), have then real advantages over those which correspond to them in the process of Petit (01). 50. Mejan employed the seton, less as a mean of dilatation than as a proper vehicle for conveying into the canal medicaments necessary, according to him, to cure the affection of the membrane (18). In fact, he charged it with basilicon, with green balsam, &c. But we now 124 Operation for the Fistula Lachrymalis. know, that its action can be of advantage in no other way than by dilatation, and that the least inconvenience of all this apparatus of topical applications, is their con- stant inutility; so that there is no other manner of em- ploying the seton but by increasing its size insensibly, as was done by Desault (39), who under this second consideration improved that part of his process which was borrowed from Mejan. 51. Finally, if this process is compared with those which, like his, have aimed at the union of the two others, it will be perceived to have decided advantages over them. The double inconvenience applicable to the process (20) cannot take place here. The lips of the division are not separated during the treatment; in fact, the thread alone, and not the seton, passes between these lips, which gradually approach each other and adhere, while the dilatation of the canal is going on. When this is complete, only a point remains to be cicatrized at the place of the thread; so that, when the natural canal is re-established, there does not still remain a wound to be healed, which would then be more difficult, as the lips, fatigued by the dressings and by the presence of an extraneous body continued for so long a time, would become callous, and almost lose the property of forming adhesion. The seton being drawn upward at each dressing, does not pull down the membrane of the canal. No excrescence, opposing the passage of the tears, is to be apprehended (21). No irritation can result to the eye from the incision, and the pus that escapes from it. The thread seldom finds any difficulty in en- tering the nasal fossae (22), nor is there any danger of making a false passage (23) when the probe is methodi- cally introduced and directed with the precautions that have been pointed out. 52. On the other hand, this process is simple, always Operation for the Fistula Lachrymalis. 125 tasy to the surgeon and never fatiguing to the patient. It dispenses with that multitude of instruments, which by their abundance, impoverish our other methods of treatment. This statement is sufficient to answer the numerous objections that were at the time accumulated against it. " I grant,'* said .Chopart one day to some members of the academy, who proposed them to him, " that other processes may be more ingenious, but this is the most successful." In fact, there are many cases, in which it has been crowned with complete success, both in the hands of Desault, and in those of other sur- geons. If this success is not always constant, it is be- cause it seems that nature, intending most fistulae to exist always, rejects all means that are contrary to her views and mocks our best combined efforts. 53. The following cases, recorded by Gavard and Giraud, will confirm the doctrine established in this memoir. In the first only the bougies and seton were employed; in the second, the incision and clearing of the sac preceded the employment of the seton, without the intermediate use of bougies; a process which was exclusively adopted by Desault, in cases of lachrymal tumour, where the fistulous opening was very small and the contraction of the canal considerable (29). CASE I. A mason, named Boudin, aged fifty years, entered the Hotel Dieu, on the 14th of November 1795, to be treated there for a fistula lachrymalis, which he had for two years, and for which he had already undergone dif- ferent treatments. The parts were in the following state: a fistulous opening, with hard and callous edges, two lines below the tendon of the orbicularis, swelling and redness of the inferior eye lid, habitual weeping, and 126 Operation for the Fistula Lachrymalis. the escape of a whitish matter, through the fistulous opening, on compressing the tumour. The patient being in good health otherwise, all pre- paratives were useless, and Desault proceeded to the operation on the same day. A catgut, of a size measur- ed externally on the distance that separates the septum of the nasal fossae from the great angle, was introduced into the fistulous opening, then pushed into the nasal canal, whose obstacles it overcame without difficulty, in order to arrive in the nostril. It was left in its place until the next day, when it was replaced by another double in size, to which one still larger succeeded on the third day, and so on until the seventh; when the passages being very free, the air escaping freely when- ever the patient blew his nose, recourse was had to the seton, which was easily introduced by the process indi- cated (30, 7th, 10th). On the eighth day it was withdrawn by the nostril, charged with a purulent coat, white, coherent, and of good quality except in the middle, where its blackish colour indicated, a denudation with caries of the bone at the corresponding place. A new seton was introduced, and a ptisan of dock prescribed. On the thirteenth day the thread, being entirely worn out, was renewed in the manner indicated (41). There was nothing new until the twenty-second, the erysipela- tous redness of the eyelid always continuing. On the twenty-second day there was an entire disappearance of the blackish trace, impressed upon the seton at each dressing, and a sensible withering and softening of the lips of the fistulous opening. On the twenty.fifth an almost complete disgorgement of the eyelid, and a contraction of the fistulous opening, only allowing a thread to pass. On the thirty-fourth, the seton in the canal moved very freely, and the natural mucous humour substituted lor the purulent coat which imbued the lint. On the for- Operation for the Fistula Lachrymalis. 127 tieth the seton was suppressed, only the thread being left in its place, and this suppressed on the forty- seventh; the edges of the opening were slightly caute- rized to favour their union. On the fiftieth the cicatrix was completed, the passage of the tears entirely re- established, and the patient dismissed from the Hotel Dieu. CASE II. Pierre Benevent, aged 34 years, entered the Hospital of Humanity on the 2d of May, 1790, to be treated there for a fistula lachrymalis of the right side. In 1788 he had at the great angle a tumour, without any change of the colour of the skin and without pain, accompanied with weeping and dryness of the nostril on the same side. A surgeon being called to him, thought he discovered an abscess, which he endeavoured to bring to maturity by exciting applications. Their effect was to produce an inflammation of the skin, to which there soon succeeded an ulceration that opened the sac and occasioned a fistula whose edges, having become hard and callous in a little time, were uselessly dressed with resolvents for one year. At his entrance into the hospital, Desault wishing to sound the passage, experienced a considerable resist- ance, before which the probe bent and could not pene- trate into the nasal fossae. The external opening besides being extremely narrow, indicated the incision of the sides of the sac; this was done on the 10th of May. The operation was attended with nothing particular, except much difficulty in withdrawing the thread, which could be brought without only by a curved probe. The seton being then passed as usual, dilated the canal gra- dually by the successive additions it received. On the forty fifth day it was suppressed, the thread still remain- ing until the sixtieth day, when the flowing of the tears 128 Operation for the Fistula Lachrymalis. seemed to be completely re-established. The patient, when examined a long time after, appeared to be per- fectly cured. § V. Remarks upon the Process of Desault. 54. Although, under a great number of views, the process of Desault claims an exclusive preference as we have seen, still there is one difficulty in this process which may embarrass the practitioner, and which De- sault himself sometimes experienced; it consists in the extraction of the thread from the nasal fossae. The me- thod of making the patient blow his nose, after the thread is introduced there through the nasal canal, is not always very sure; it often occasions delay, because, being folded upon itself, moist with the mucosity of the nose, and retained under the inferior spongiosum, the thread obeys with difficulty the air which tends to draw it from within outwards. 55. Since the publication of Desault's works, I have twice had occasion to perform the operation of the fis- tula lachrymalis. In the first, which was on the brother of citizen Pigault-Lebrun, an esteemed dramatic author, I could never accomplish the egress of the thread, by making the patient blow his nose, although the incision had been accurately made. I experienced also the great- est difficulty in drawing it out with a blunt hook. I then postponed finishing the operation until the evening, that the patient might not be too much fatigued: the thread was left in the nose, and in the evening new attempts were as fruitless. 56. Perceiving that success could not be obtained, I took a thread of lead, found accidentally upon the toilet of a lady, and analogous to that used in the operations for the fistula in ano; a sufficient length of it was insert- ed into the nose, so that being many times folded upon Operation for the Fistula Lachrymalis. 129 itself, it might be easily caught by a blunt hook. In fact, the introduction of this instrument brought it out immediately; the two extremities being thus free, I twisted a linen thread around the superior, and then drawing it from above downwards, it brought the thread out and the operation was finished as usual. 57. The facility of this process induced me to repeat it frequently upon dead bodies. The success was always complete, and from that time my pupils have been con- stantly exercised in this manner. The following is the detail of the operation: 58. The canula being placed in the sac previously opened, instead of inserting the linen thread I passed into it that of lead, which may be folded upon itself many times without its folds pressing against each other, as inevitably happens to the linen thread. The thread of lead being thus doubled many times in the nose, it is sufficient to separate the anterior opening most fre- quently to see it and always to seize it with facility. In general it is better to employ a leaden thread that is rather too long than one too short, because the more folds there are in the nose, the more easily is it laid hold of. When it has once passed out both on the side of the eye and on that of the nose, the linen thread is to be attached to it, and every- thing is then the same as in the ordinary process for the operation. 59. This process is by no means painful; the pre- sence of the leaden thread incommodes a little, but when extracted immediately, the patient is scarcely sensible of it. I have not, as has been said, but two facts to prove its advantage on the living body; but it is evident that here the experience on the dead subject is sufficient. For the introduction of the leaden thread, and for its folds, there is not in fact, any difference in the state of the parts during life and after death. It is one of those Vol. I. R 130 Operation for the Fistula Lachrymalis. operations in which a constant success on the dead body is sufficient, and I can assert that I have constantly obtained it in exercising the pupils in my courses of operations. 60. Finally, I am not the only one who perceived that the part of Desault's process which consists in the in- troduction of the thread, might be improved. Citizen Giraud, second surgeon of the Hotel Dieu, who has already given an advantageous curvature to the canula of Desault, has also invented a small instrument that conceals an elastic shank, which going through the na- sal fossae, is intended to receive a thread fixed there, and then to draw it out with facility. ARTICLE IV. § VI. Reflections on the Process of Hunter. 61. The first method of operating for the fistula la- chrymalis, or the re-establishment of the natural passage (5), sometimes presents difficulties, that in certain cases give a decided pre-eminence to the second method or artificial route. It is principally when the contraction is of long standing, very considerable, and almost ap- proaching to obliteration; when the membrane has ac- quired a schirrous hardness, and when all hope is lost of clearing it by compression, that we must, if we may so speak, open an artificial route in the midst of the narural passages. It is when a polypus of the nasal fos- sae, or of the maxillary sinus, an exostosis of the max- illary bone, the position of the inferior meatus, whose edge touches the septum of the nasal fossae, prevent all communication between these fossae and the lachrymal sac. 62. The process of Hunter then presents advantages which are not to be found in others of the same method, such as those of Voolhouse, of the ancients, &c. Th'rs Operation for the Fistula Lachrymalis. 131 process must then be had recourse to, if that indicated (30) cannot be used, or if when possible, the sum of its ineonveniencies is too great. Desault employed it at one time on many patients. Some successes that were at first obtained, induced him to believe that perhaps it was indicated in cases where the re-establishment of the natural passage was practicable, which would have been without doubt, a real advantage; since its execu- tion is always more easy than that of the ordinary pro- cess, where the incision of the sac, the clearing of the canal, and the passage of the thread especially, involve great difficulties. But experience soon brought him back to his former method of operating, and the pro- cess of Hunter was reserved for the very rare cases in which the abovementioned circumstances (61) occur- red. Although my object in this memoir is only to make known the process of Desault, I will however relate a case in which this has been used, both be- cause few authors in France have spoken of it, and because Manoury, then first pupil of Desault, has add- ed to it a modification useful for those who may wish to perform it. CASE III. Recorded by Jadelot. Madeleine Benard, aged 11 years, entered the Hotel Dieu on the 25th of June, 1792, to be there operated upon for a fistula lachrymalis, which she had had for five years. At that period she had a mild smallpox, which was confined almost exclusively to the face, and in con- sequence of which there supervened, in the great angle of the right eye, a small, round, fluctuating tumour about the size of a button. This tumour burst at the end of fifteen days and occasioned a fistula, that was kept open by the habitual passage of the tears. They collected during the night in the lachrymal sac, which 132 Operation for the Fistula Lachrymalis. they distended until morning, when a slight compres- sion sufficed to procure their discharge through the fis- tulous opening. During the day a troublesome weeping continually distressed the patient. Some diluting drinks, administered during the first days after the patient's admission into the hospital, with the use of the emetic tartar to keep the body free, were the preparatives for the operation, which Manoury per- formed in the following manner: 1st. Having seated the patient upon a high chair, with her head supported against the breast of an assistant, whose hands were crossed upon the forehead, he first made an incision in the sac, commencing immediately under the straight tendon of the orbicularis and pro- longing it to the extent of four lines, according to the direction of the base of the orbit. 2d. The sac being opened, he divided by a second longitudinal incision, the internal part of the membrane of the saci and laid the os unguis bare. 3d. To hold the edges of those two incisions separate, and to facilitate the introduction of the boring piece, he made use of a kind of forceps, whose anterior branches being bent to a right angle at their end, were each hol- lowed within by a groove, so that when united they offered a canal, which might be increased at pleasure by separating the branches. The extremity of this in- strument was applied to the denuded portion of the os unguis, between the borders of the incision of the sac and that of the internal part of its membrane. An assis- tant secured it firmly. 4th. At the same time a shell of horn introduced into the nasal fossa, was applied against the external side, and fixed opposite to the os unguis to serve as a point of support to the boring piece. 5th. The surgeon, grasping this last instrument, in- Operation for the Fistula Lachrymalis. 133 serted its cutting extremity into the canal formed by the curved branches of the forceps, which preserved from its action the soft parts that might otherwise be wounded, or whose approximation would at least have formed an obstacle to it, pierced the os unguis by a ro- tatory motion impressed upon the boring piece, removed a portion of that bone about a line in diameter, withdrew the forceps, and at the same time the shell of horn and afterwards the boring piece. 6th. A small canula was introduced into the opening so as to keep up, and at the same time give a passage to the tears. 7th. The dressing consisted in the application of a little lint between the lips of the opening, and sustained by two small compresses which were secured by a sim- ple bandage. The weeping, already less considerable the day after the operation, diminished manifestly on the following days. The cicatrization of the wound was completed by the twenty-fifth day; at this period there only existed an oozing of tears almost insensible. On the thirty-third a purulent collection being formed in the sac, distended it in such manner as to present a new tumour; a slight compression served to prevent the stagnation of the matter which flowed through the artificial opening; this compression, continued until the fortieth day, caused the swelling of the sac to disappear entirely. On the fiftieth the oozing had almost ceased, and two months after the operation the patient was dismissed, perfectly cured. REMARKS AND OBSERVATIONS ON THE Diseases of the Maxillary Sinus. SECTION I. 1. 1HE mucous membrane of the maxillary sinus, like that of the nasal fossae, often becomes the seat of« different affections, which external medicine alone can attack with efficacy. Among these affections ozena and fungus must especially engage the attention of practi- tioners, both because they are more frequent and because, being of a more severe nature, they demand more active and more difficult succours. To treat them here in their whole extent, would be to repeat in part what is to be found every where, especially in the me- moirs of the Academy of Surgery. Let us only trace in the following cases and reflections, the operative details with which Desault has enriched their treatment. § II. Of Ozenas. CASE I. Recorded by Baratte. Joseph Henry, aged 32 years, entered the Hotel Dieu on the 3d of October, 1792, having in the left cheek a tumour, that extended from its prominence to the lower part of the canine fossa. Hard, without any change in the colour of the skin, and accompanied with pain net augmented by pressure, this tumour presented above the second molar tooth, a small fistulous opening, from which a considerable quantity of pus flowed habitually. This discharge had ceased for six days, and from that Diseases of the Maxillary Sinus. 135 time the pains had become very severe. From these symptoms the seat of the disease was easily presumed, and confirmed by its history. The whole of the left side of the face had been violently bruised by a fall a year before. Some general means, and the external use of some emollients dissipated the first affection, and the patient thought himself cured; but at the end of two months, pains at first obtuse, in a little time more sharp, began to be felt deeply under the malar eminence. Some time after a tumour arose in this place; its slow but constant progress soon brought it to a considerable size; the pains increased with it, but were one day suddenly calmed by the spontaneous bursting of the tumour. The patient's mouth was immediately filled with a fetid pus; the fistulous opening appeared at the place mentioned, and from that time the oozing was habitual. Sometimes it was suppressed, and then the pains became severe until it re-appeared. Such was the state of the patient when he presented himself to Desault. The indication was evident, viz. to enlarge the fistu- lous opening, to make a large vent for the pus, and then to cleanse the diseased sinus by injections. Some gene- ral means prepared Henry for the operation, and on the third day of his arrival he was conducted to the clinical amphitheatre. 1st. Being seated upon a high chair he was held by an assistant, upon whose breast his head was turned back and secured by the hands crossed on the forehead. 2d. The mouth being opened wide, Desault with a sharp perforator enlarged the fistulous opening, which was situated, as we have seen, above the second molar tooth, and extracted that tooth, which having been cari- ous for a long time, was nothing more than a shell. 3d. In the enlarged opening he inserted a second per- forator, with the point cut off that it might not wound 136 Diseases of the Maxillary Sinus. the opposite side of the sinus; and with this he destroy- ed by rotatory motions, that portion of the jaw which was comprised between the alveolus and the opening. 4th. From thence resulted a large opening capable of receiving the little finger, which gave vent to a great quantity of purulent matter, and by which a fluid thrown into the sinus might clean it completely. 5th. The patient was directed to wash his mouth fre- quently with barley water and honey of roses, and occa- sionally to introduce his finger into the opening to pre- vent too speedy cicatrization. The success of this treat- ment was soon manifest; at the end of a few days the tumour began to diminish, the pus at first sanious, to acquire gradually a more laudable character, and the opening made with the perforator to contract sensibly. A month after the operation the discharge had ceased entirely, without any affection being' the result as for- merly. The tumour had disappeared, and the opening scarcely permitted the introduction of the most slender probe. The patient was dismissed in this state, and later information was received of his perfect cure. 2. The treatment of ozenas of the maxillary sinus may be referred to two general methods: 1st. Injections through the natural opening. 2. The perforation of this cavity in some point of its extent. The first method proposed by Jourdain, often impossible, always very difficult in its execution, constantly insufficient in its results, died almost in the birth, in the opinion of men of information; the second can alone fulfil the indica- tions efficaciously, but the dtgree of its advantages is relative to the operative mode that is adopted, which varies according to the place where the sinus is opened 3. As Lamoirier has judiciously remarked, there is a place of necessity and a place of choice in the opening of this cavity. The first is indicated by the affection or Diseases of the Maxillary Sinus. 137 absence of one or more of the molar teeth, and the second is permitted by the soundness of the dental range. 4. In general, if one of the molares appears to be rot- ten, if it vacillates in its alveolus, if a purulent oozing is established between it and the gum, extract it, as Mei- bomius first advised. But the opening, which results from this extraction is always insufficient. Whether it has any communication with the sinus or not, the bone must always be included in a greater extent, and the preceding case shows the process then indicated. Let us resume some of the operative details. 5. The instruments, that are necessary in this case, are limited, as has been seen, to two perforators, one of which (fig. 1.) sharp at its extremity (b), does not differ from that of the common trepan, except that it is mounted upon a handle cut in diamonds, that it may the less easily slip in the hand; this form is more easily handled than if the stalk of the trepan was employed. The second (fig. 2.) mounted like the preceding, is cut off at the extremity (c). The use of the one is to open a route for the other into the cavity of the sinus, and it is essential to enlarge the opening with the latter, which, from its being too short, cannot reach the opposite side, and if it did, cannot pierce it. The fragility of the supe- rior or orbital, internal or nasal sides of the sinus, attaches a great importance to this precept. 6. The opening should always be at least sufficiently extensive for the introduction of the little finger. A fragment more removed from the jaw is nothing in the cure, and it is always of much importance that there should be a free vent to the pus, whose continuance kept up the disease. 7. It may be supposed that the inconvenience of closing very late would be found in large orifices; but on Vol. I. S 138 Diseases of the Maxillary Sinus. the contrary, experience proves that this objection is applicable only to small ones. CASE II. While Desault directed the surgery of the Hotel Dieu, a child was brought to him with an ozena of the right maxillary sinus, for which two teeth had been ex- tracted a year before. A probe, passed through the alveolus into the cavity, had discharged a considerable quantity of purulent matter; but the orifice, remaining fistulous from that time, furnished a continual oozing and showed no appearance of a cure. Desault, judging that the non-obliteration of the passage was owing to its narrowness, enlarged it in the manner above mentioned, and in a little while after it was closed and the ozena cured. The same process had the same result, in the case of another patient. 8. When the opening is sufficiently dilated, it is a prudent practice and recommended by Desault, to cut off the corresponding portion of the gums which had been detached to lay the bone bare, lest, by becoming engorged after the operation, it should prove an obstacle to the discharge of the pus. 9. On the first days there is often much swelling, which is calmed by emollient fomentations. In a little time it is dissipated, and then detergent injections and gargles, with the occasional introduction of the finger into the orifice, lest it should close too. speedily, com- pose the whole of the treatment. 10. Some practitioners have multiplied the necessary places of opening the sinus, beyond the caries of the molares. For example, if a fistula is formed on the face below the orbit, they have proposed to enlarge it, and to pass through it the injections proper for cleansing; but the inevitable deformity of the cicatrix, the inconvenient Diseases of the Maxillary Sinus. 139 situation of the orifice towards the superior part of the cavity, the stagnation of the pus below and consequently the difficulty of healing, proscribe this method. In this case, a counter opening made, either in the alveolar range, if the circumstances mentioned (4) exist, or at a place of choice, which will be pointed out, is always sufficient to cure the ozena and to cicatrize the fistula, which will close as soon as the pus ceases to ooze be- tween the borders, an advantage that will evidently be obtained by piercing the sinus below it. Let us proceed to the opening this cavity at a place of choice. 11. In general, when the teeth are sound, and the cir- cumstances stated (4) do not exist, another place than the alveoli is to be chosen for opening the sinus. The necessity of the molares for mastication imposes this as a law. Lamoirier fixed this place below the malar emi- nence, in that hollow concave from above downwards, convex from before backwards, which separates the canine from the zygomatic fossa. Bordenave also adopts it, and when the opening of the alveolus is counter indi- cated, it is the common method. But the place where Desault perforated the sides of the sinus claims the pre- ference in general: That is the inferior part of the canine fossa. 1st. There less thickness of the bony substance is found. 2d. The operation there is more easy, because it is necessary to carry the instrument to a less depth in the interior of the mouth. 3d. The hook, employed by Lamoirier to retract the commissure of the lips, becomes useless, and therefore the process is simplified. 4th. After the operation, the treatment is more easy; the orifice being more exposed, the state of the parts can be distinguished better. The following case, recorded by B-----, offers an example of the operative process then employed by Desault. 140 Diseases of the Maxillary Sinus. CASE III. Joseph Maugra, entered the great hospital of Hu- manity, in 1791, to be treated there for an ozena of the maxillary sinus, that had supervened a year before, in consequence of a violent inflammation, which had itself been produced by a sudden change from a warm to a very cold air. The pus, accumulated in the bony cavity, had soon affected its sides; a spontaneous opening, formed in the superior part of the canine fossa, had trans- mitted into the cellular membrane of the cheek a con- siderable quantity of purulent matter, which made a prominence outwards. From thence, a fistula was form- ed in the face, through which a sanious and yellowish fluid had oozed for seven months; and as soon as this oozing was suppressed, sharp pains ensued. The sides of the sinus had already begun to swell. The superior dental range, being sound in its whole extent, offered no point for penetrating into its cavity. Still the indica- tion was evident; an opening must be made below the fistula to prevent the pus from passing through it, and to furnish a free vent. The place mentioned (10) was favourable. Desault operated in the following manner, after having employed some general means as prepara- tives. 1st. The patient being seated upon a high chair, with his head supported against the breast of an assistant, he began by separating the cheek of the diseased side from the corresponding gums; then he cut with a scalpel the internal membrane of the mouth, and the other parts which unite the internal part of the cheeks to the max- illary bone. 2d. The bone being exposed, he drew back the com- missure of the lips with the fingers of his left hand, and took in the right hand a sharp perforator, whose point, Diseases of the Maxillary Sinus. 141 being applied to the inferior part of the canine fossa, penetrated by rotatory motions into the sinus. 3d. The opening was enlarged by a blunt perforator, especially above, where it was prolonged to the fistulous opening. A portion behind, affected with caries, was removed. 4th. He cut off the flaps of the gums, corresponding to the opening, which was filled by a plug of lint, sup- ported by others, that were placed between the jaw and the cheek. The next day a considerable swelling appearing over the whole face, an emollient cataplasm was applied upon this part; there were sharp pains on all that side. On the second day the symptoms diminished, and on the third the dressing was removed, when the swelling was found to have disappeared almost entirely. From that time the patient used the simple precaution of gargling the mouth frequently with an emollient decoction, and introducing the finger into the orifice to prevent, its closing too speedily. On the fifteenth day, the exterior fistula was cicatrized and the swelling of the sinus dimi- nished. On the twentieth, the cure had progressed very sensibly, and was completely finished six weeks after the operation. §111. Of Fungi. CASE IV. J. Gaillard, having a good constitution, experienced in 1790, severe pains in the maxillary sinus, in conse- quence of the introduction of a piece of wood into the nasal fossae, which, according to his relation, appeared to have bruised the opposite side. These pains continu- ed of the same degree for a certain time, at length were dissipated and alternately returned and disappeared, without any exterior symptom, for six months. At this 142 Diseases of the Maxillary Sinus. period the patient had a fall, in which the cheek-bone was violently bruised against a beam; from that time the pains increased, became habitual, and about fifteen days after the accident, this bone was sensibly elevated, the maxillary bone acquired more size, especially out- wards; at the end of some time the tears ceased to flow into the nasal fossae, and spread over the cheek. Five months after, the tumour, always increasing, began to raise up the inferior side of the orbit; and the eye, more prominent than ordinary, was already pushed forwards; the pains still small, did not become severe but at cer- tain periods. Two of the molares had fallen out; the ex- ternal side of the sinus, being worn through, was open and suffered a small portion of fungus to pass, that was easy to be seen and especially to be felt with the finger. Such was the condition of the patient when he entered the Hotel Dieu, to seek more skilful aid than what he had received from several surgeons, who had confined themselves to general means. In this case, the only re- source of art was to open the sinus and then to destroy the enclosed tumour, either by excision or by caustic. Desault determined upon it immediately, and on the seventh day from his admission, Gaillard, being con- ducted to the amphitheatre, was there operated upon in the following manner. 1st. This patient being placed like the preceding, the cheek was previously detached from the maxillary bone, by the incision of the internal membrane of the mouth, at the place where it is reflected upon that bone, which was accurately denuded of all the soft parts on its ex- ternal surface. 2d. The sharp perforator, applied to the middle of this surface, served to make there an opening before that which already existed. 3d. The bony lamen, comprised between the two, Diseases of the Maxillary Sinus. 143 was removed by means of a cutting instrument, curved in the form of a vine knife, (fig. 3.) which, being di- rected from behind forwards, made the section without difficulty. 4th. The opening not being sufficient, Desault at- tempted to enlarge it inferiorly at the expense of the alveolar range and with the same instrument; but meet- ing with too much resistance, he had recourse to the gouge and mallet. A considerable portion of the arch was separated by their means, without the preliminary precaution of drawing the corresponding teeth, three of which were carried away by the same blow. 5th. From thence there resulted in the external and inferior side of the maxillary sinus, a hole sufficient to receive a large nut. 6th. Through this hole a considerable portion of the tumour was removed by a scalpel curved on its flat side and fixed on its handle. A frightful hemorrhagy pre- vented any further researches at that time. The specta- tors were alarmed by the quantity of blood, which the patient discharged by mouthfuls. But enlightened by experience, which had taught him how easily this acci- dent might be stopped in these kinds of tumours, De- sault was content to push into the sinus a plug of lint, which he kept there for a moment. 7th. This plug being withdrawn, the actual cautery, of a white heat, was applied to the remainder of the fun- gus, and reiterated several times. 8th. For the dressing, plugs of lint, sprinkled with colophony, filled the cavity of the sinus, and to sustain them the lower jaw was made to approach the upper; a sling serving to prevent its falling down. In the evening, a little fever supervened, and aug- mented during the night; a considerable swelling ap- peared on the cheek, and made the application of an 144 Diseases of the Maxillary Sinus. emollient cataplasm necessary, which was from that time renewed twice a day. On the third day, a part of the plugs was removed and replaced by soft lint, which again was changed the next day, without, however, touching that at the bottom for fear of renewing the hemorrhage. On the eighth, this was detached spontaneously by the suppuration, as also the eschars arising from the appli- cation of the cautery. Frequent garglings were pre- scribed for the patient. On the eighteenth day, the tumour was sensibly diminished, the eye less prominent and the epiphora less sensible; but a portion of fungus appeared again at this period. The iron, of a red heat, being applied twice to it, destroyed it almost entirely; it re-appeared about the twenty-fifth day, and rendered a third and last application necessary. From that time the cure progressed rapidly; instead of fungosities, healthy granulations arose from the bottom of the sinus, whose sides, gradually approximating, effaced the large open- ing made in the operation, and reduced it to a small hole hardly capable of admitting a probe, which was itself obliterated by the fourth month, a period at which there remained no other traces of the disease than the absence of the teeth that were removed, and a sensible depression, corresponding to their natural place. 12. In the preceding article, reason and experience have established the necessity of large openings, to give vent to the pus that is contained in the maxillary sinus. This precept is not of less importance here; indeed, if we neglect to put it in practice, how can we ascertain the size, form and extent of the tumour? How shall we be able to remove the whole of it through an opening, which will permit only a small portion to be seen;—can we ever be certain that the evil is radically destroyed? This certainty can scarcely be procured when the sinus is laid open to a considerable extent; how then can it Diseases of the Maxillary Sinus. 145 be, when tht re is only a small part exposed to view? yet it is an essential article of the treatment. If any portion remains, it soon becomes the germ of a new tumour, whose progress is more rapid and its character often more unfavourable, on account of the subsequent irritation and inflammation produced by the cutting in- struments and the actual cautery. Desault often had occasion to observe this, particularly in two cases, which he was accustomed to relate in his courses, that occur- red, one in the hospital of St. Sulpice, the other at La Charite, and both which issued most deplorably for the patients; one only will be cited. CASE V. A man came one day to La Charite, having upon the external surface of the alveolar border, a fistula that ex- tended into the maxillary sinus. Desault introduced a probe and ascertained the presence of a polypus, for the treatment of which he proposed the ordinary means to the patient. He refused, and went to consult a dentist, who, by means of a small orifice, applied fire to the polypus. A very great inflammation and a considerable increase of the tumour were the result of this imprudent operation. Then the patient came to the school of sur- gery, where, in a consultatidn called on his case, Desault advised to open the sinus freely below and then to am- putate the whole of the fungus. This advice was reject- ed, and it was agreed to make an inconsiderable opening in the cheek, through which only a small portion could be removed. The remainder, being irritated and in- flamed, soon acquired an excessive size, raised up the bones of the face, made them carious, and caused a hideous prominence forwards, and at the end of a month was beyond the reach of art. 13. It may then be established as a principle that the Vol. I. T 146 Diseases of the Maxillary Sinus. success of the treatment is immediately connected with the extent of the opening, intended to expose the fungus to view. Be not afraid of removing a considerable por- tion of the superior alveolar arch, or of making three or four of the teeth fall out with it; do not make the delay of previously drawing them; a single blow is sufficient to extract them as well as the piece that sustains them. In a little time the opening, however large it may be, will close, and scarcely a trace will be left behind. Finally, if more tediousness and difficulty in the treat- ment, and more deformity after the cure were to be the result, what are these inconveniences compared to those (12) which would arise from a different practice? 14. To return to some of the operative details. The instruments necessary to expose the sinus to view, are first the perforators, intended to open the passage, as in the ozena (5). In enlarging this passage, the instrument in the form of a vine knife (fig. 3.) presents great ad- vantages; its blade should be thick and its temper strong, so as to cut the bony pieces more easily, which in this case do not often present a great resistance. If however the resistance should be very considerable, the gouge and mallet must be employed as in the preceding case, but in general the preceding instrument is sufficient. Its use is not confined to the maxillary sinus; in the hands of Desault, it was usefully applied to fungi, spina ven- tosa, necrosis of the lower jaw, and other diseases of the hard parts of the mouth, in which it was necessary to remove bony pieces. It may be perceived that its em- ployment cannot be directed by any general principle; all is relative to the state of the disease, and it is well known that its variations are such, that hardly two cases are alike. 15. The section of the fungus also sometimes requires scalpels differently curved upon their edges and their yy ? Diseases of the Maxillary Sinus. 147 blades, so as to reach it with more facility in its extreme ramifications; but commonly the ordinary scalpel is suf- ficient, and the simplicity of operations imposes the law of extending its use to as many cases as possible. .16. The actual cautery has here a double advantage: 1st. Of stopping the hemorrhage, which it does so much the more efficaciously, as the blood does not escape from any considerable vessel, but flows, as may be said, in a sheet from the excised tumour. 2d. Of destroying all that escapes the cutting instrument, and thus pre- venting any chance of its regeneration. The precaution of making it of a white heat is essential, both because by the sudden disorganization of the part, the pain of the patient is less, and because burning deeper, it ac- complishes better the object proposed. Be not fearful of repeating the application frequently, if new fungosities are formed; on the contrary watch their development. It is easy to destroy them in the beginning; but, if they are suffered to attain any growth, the greatest difficul- ties will be experienced. Explanation of the Second Plate. Fig. 1. A sharp perforator, intended to open the max- illary sinus. A. The handle cut in diamonds. B. The point. Fig. 2. A blunt perforator, proper to enlarge the opening of the sinus, without danger of wounding the opposite side. C. Its extremity cut off. D. The handle also cut in diamonds. Fig. 3. An instrument in the form of a vine-knife, to remove the bony parts of the sinus. E. Its thick blade, strongly tempered. F. Its handle. MEMOIR UPON THE OPERATION OF THE HARELIP. SECTION I. General Reflections. 1. JN ATURE does not in the organization of animals always follow invariably the laws that direct their eco- nomy. Sometimes she departs from the circle that cir- cumscribes them, seems to play around it, and then produces different deformities, which are very common in the human species—less frequent in others. To these, surgery can often oppose but impotent means; but in certain cases they can be combated with success. Of this nature is the deformity so frequent and so well known under the common name of the Harelip. Here, at least, art corrects and beautifies nature. Alas! how many times does she disfigure it! 2. All authors have spoken of the harelip, and many of them have endeavoured to improve its treatment. Who would not suppose, said a celebrated man, on comparing their efforts with the simplicity of the dis- ease, that in this respect a sound practice must be in- variably fixed? Yet opinions are still divided, and in the sentiment of many skilful persons much obscurity re- mains. Let us attempt to throw some light on the sub- ject, by presenting the doctrine of Desault on this par- ticular point; not that art is indebted to him in this case Operation of the Harelip. 149 for any very acute improvement; but because a great experience had acquired for him the right of deciding upon the question, so much agitated latterly, respecting the ineonveniencies or advantages of the processes em- ployed in the operation. 3. It is known that the harelip borrows its name from its resemblance to the natural disposition of the upper lip of the hare; that it has in general a great number of modifications; that, sometimes simple, it presents only a single division, easy to be united; sometimes double, it offers, in the middle of that division, a fleshy appen- dix, more or less elongated, that divides it equally; that, finally, it is sometimes complicated with the sepa* ration of the maxillary and palate bones, with the pro- jection of a portion of the first into the middle of the cleft, with the division of the membranes of the palate, also of the pituitary and of the uvula, and also with a troublesome communication between the nostrils and mouth. 4. To trace the view of the different kinds of harelip, and the unfavourable results, either in sucking or in other functions, would be only to add to the annals of the art, descriptions repeated a thousand times since Celsus, who first transmitted to us a methodical descrip- tion of this affection. Therefore, without further delay, we will proceed to the surgical treatment that the dis- ease demands. 5. We are indebted to the ancient physicians for the ingenious idea of applying, to the cure of the harelip, that property of living animal parts, by virtue of which a recent division, whose edges are brought in contact - unites and disappears at the end of a certain time. From this general principle, the treatment of all simple wounds proceeds; upon it also rests the operation now to be ex- amined. In this operation, two great consequences result 150 Operation of the Harelip. from it; the one, that the cleft must be reduced to the state of a recent division; the other, that the bloody edges of this division must be brought together and kept in contact. 6. All surgeons have agreed upon this double indi- cation; but they have not all pursued the same route to accomplish it. Some have had recourse to cauteries of different kinds, and to active stimulants, to reduce the edges to a state of rawness. Others, and by far the greatest number have employed cutting instruments; but among those, the form of the instruments has va- ried; the reciprocal priority of the scissars and the knife has been disputed; and, as will soon be mentioned, too much importance has perhaps been attached to this point, which is of little consequence in practice. In the approximation of the raw edges of the division, dry or bloody sutures, alternately employed and rejected, have also, but with more reason, engaged the attention of practitioners, as to the respective preference which is due to them. 7. Let us enter into some details of the practice of Desault, in both parts of the operation, and of the rea- sons that supported it. Let us describe in the second place, his operative process, supposing the harelip to be simple; and finally, let us trace the particular modifi- cations which the process must undergo in the different complications that this deformity presents. § II. Of the Excision of the Borders of the Division. 8. At the present day all practitioners have agreed upon the exclusive preference claimed by cutting in- struments in this first part of the operation, over all other means. The danger of the actual and potential cauteries, which were sometimes used by the ancients, the slowness, the difficulty of the treatment accompa- nying their use, and the deformed cicatrix resulting Operation of the Harelip. 151 from it, all concur to proscribe them from a rational practice. The action of the most active stimulants, such as blistering plasters, proposed and employed by some, is almost always insufficient; and in the use of these means the probability of some cures cannot com- pensate the certainty of an habitual ill success. A sur- geon employed this process at the hospital of the schools, at a time when the memoirs of Louis had excited at- tention on this point of practice. The blistering was ' suffered to remain twelve hours, and then the borders of the division were approximated by means of adhesive plasters; but their union took place only in a.fevv points, and the ordinary operation became the only resource. 9. Most practitioners seem to have attached very little interest, until lately, to the exclusive choice of the instrument intended for the excision of the borders of the divided lip. The scissars or the scalpel are advised indifferently by Franco, Heister, and Ledran, and did not appear to possess any decided advantages over each other. However, the greatest number had adopted the scissars, and this choice, justified by great success, found few to contradict it, until Louis exerted himself strongly against their use, and with an exaggerated im- portance, proclaimed their ineonveniencies and the ad- vantages of the scalpel. The authority of this celebrated man caused the opinion of Desault, who was then timid, to be wavering for some time; but in a little while, ex- perience and accurate researches fixed his practice on this point, and brought him back to the ancient manner of proceeding. 10. Let us trace, in the parallel of these two instru- ments, the reasons which determined his preference;__ not that this preference is exclusive; since, in skilful hands equal success often crowns both means; but, be- cause where there is a best, we must even abandon that which is good. 152 Operation of the Harelip. 11. The knife acts by cutting, and does not bruise the parts. The pressure of scissars upon bodies which they divide, is almost nothing; because the action of their blades is always very oblique with regard to those bodies. Experience also proves, that the part cut by them never shows any contusion. The same sensation of pain is attached to the two instruments;* but the first augments the sum of it more than the second, by prolonging the process. The latter scarcely ever requires the separation of the lip, which often adheres to the upper jaw; the former commonly necessitates this pain- ful preliminary, in order to introduce the card upon which the incision is to be made. The use of this card or of other means, as conductors of the knife, is very painful in certain cases. The use of the scissars is not attended with this difficulty: in employing the one, the parts being violently drawn downwards to facilitate its action, are often unequally divided; in making use of the other, the flesh (being fixed without tension between their double blades) is always cut even. Many cele- brated practitioners at this time, both in France and England, employ the knife exclusively. Almost all the great masters of the art have used the scissars, which still have illustrious partizans in Europe. It is objected to them, that they render the alternate use of both hands necessary, and that they seldom divide with a single stroke the border which they make raw; but the history of the operative process will reply to the first * The experience of Bell leaves no doubt upon this subject. He cut off in the same operation, one of the borders of the division with the knife, and the other with the scissars; and the patient affirmed, that the first was more painful to him than the second incision. If this result is not always constant, we may at least con- clude, contrary to the assertion of Louis, that a painful impression is not more peculiar to the one instrument than to the other. Operation of the Harelip. 153 objection (36), and the second, is as common to the knife. Frequently the angle of the division and the borders, which terminate there, may be divided in two strokes. Finally, it is a general principle, that whenever a part is loose, slender and as it were floating, the scis- sars which fix it, are better for dividing than the knife, which previously demands a mean of securing it. 12. From this parallel, which is perhaps too minute, it follows: 1st That if equal advantages are attached under some views to the scissars and to the knife, the second never has a real priority over the first. 2d. That, on the contrary, in the greater number of cases, the scis- sars present to the practitioner a facility which he would seek to no purpose in the other. Upon this double mo- tive Desault grounded his preference of the scissars to accomplish the first part of the operation. In describing the operative process, we shall perceive his manner of employing them. 13. At the present day there is a general consent re- specting the angular form of the incision of the borders. The facility which it offers to the union; the certainty which it affords of avoiding—above, the inconvenient hole that results from the deficiency of contact—below, the deformed hollow that is produced by the non-divi- sion of the rounded angle that terminates their borders; the faculty possessed by the lip of yielding to extension more considerably below than above;—-all concur in justifying the practice universally adopted on this point, and in banishing that which, first presented by Celsus, then modified by different authors, recommended by Guilleraeau and Thevenin, consisted in giving the form of a crescent to the two lateral incisions. The general rules of the excision of the borders, are, 1st. To remove all the red pellicle that covers them, and consequently to cut upon the skin. 2d. To give them an equal size, Vol. I. U° 154 Operation of the Harelip. so that when they approximate they may be adapted with accuracy, and may not make, as may be said, a fowl's rump; so that if one, being more oblique, is longer than the other, the former must be cut in such manner as to remove more towards the loose than to- wards the adhering extremity; whilst, on the contrary, in the former method, as much would be removed above as below, from whence would result an equal ob- liquity and length. 3d. The incisions must not be made sloping, but discover as much of the anterior as of the posterior part of the lips; however, if needles are em- ployed, perhaps it would not be improper to include a little more of the borders at the expense of the second; and on the contrary to cut away a little more at the ex- pense of the first, if recourse is had to adhesive plasters. 4th. The border to be first cut should be that in which most difficulty is experienced in fixing it between the fingers, because being bloodied by the first incision, they would slip upon the parts, and could not secure them so efficaciously. § III. Of the means of Contact between the Raw Borders of the Division. 14. The union of the borders of the division in the harelip is never attended with difficulties that can delay the practitioner. Here the loss of substance is almost nothing. The lips being loose and easily extended, yield without resistance to the smallest effort that ap- proximates them; only muscular contraction is to be overcome, and it is well known how easily this power may be surmounted. But if the contact of the borders of the lip is always easy to be procured, we do not ex- perience the same facility in maintaining it with accu- racy during all the time that is necessary for the reci- procal adhesion of the raw surfaces. In this case it is Operation of the Harelip. 155 not, as in most other wounds, that only a simple union is required; it is an union precise and regular, which will scarcely leave a.trace of its existence upon the parts. If the first object of art be to correct a defect of con- formation that is injurious to the functions, the second not less interesting to some persons, is to add to the figure those charms which nature had refused. 15. It must then be perceived, that the choice of the means suitable for maintaining in contact the borders of the division, cannot be indifferent to the surgeon, who is anxious to improve the processes that he employs; and the parallel of these means claims without doubt a more serious attention than that of the cutting instru- ments intended for the division of the parts (11). 16. In the harelip, as in most longitudinal wounds, the , uniting bandage and sutures are the two only means of union; the situation, which is another mean of contact between the borders of a wound, not being capable in this case of being profitably used. Sutures have always been and still are universally employed, and the exclu- sive use of the uniting bandage is attended with ineon- veniencies too obvious to find judicious partizans. But, what sutures should be employed? May the dry or bloody be used indifferently? The one or the other must possess particular advantages which ought to assign the preference. 17. If the history of the art is consulted to decide this question, we behold the bloody suture almost generally used by the great masters, whose practice was always in favour of this process, a prejudice at least advan- tageous. Celsus practised or rather saw it practised by the physicians of his time. The Arabians borrowed this practice, and Guy de Chauliac, their copyist, employed it with advantage. Van Home did not seem to know any other. Pare has caused it to be engraved. Guille- 156 Operation of the Harelip. meau recommended it. Fabricius de Aquapendentc always used it. All our modern treatises of operations propose and describe it as exclusively proper. Garen- geot, Ledran, Heister, Petit, &c. indicate this as the Qnly mean of contact between the raw edges. 18. But, in the midst of this practice, almost generally adopted, several distinguished men quitted the com- mon track; and the dry suture or adhesive plasters also counted their partisans. Franco describes two processes, one of which is performed with needles; the other, con- fined to adhesive plasters, is followed, according to him, by less deformity. According to Muys, Silvius has cured a great number of harelips by this latter method. G. Wolf Wedel hoped, by its use, not to prolong the cure of a child beyond the eighth day. Wounds of the face in general and the harelip in particular, according , to George Purman, never require any but the dry suture. 19. At length Louis, considering on the one hand, that most authors do not prescribe the bloody suture, but from the supposition of a loss of substance, and per- suading himself on the other hand, that this supposition is almost always erroneous in the case under considera- tion, and that muscular action is the only power to be surmounted, establishes as a principle, 1st. That the power which approximates the lips ought to be exer- cised, not upon their borders, but upon the muscles which separate these borders. 2d. That the uniting may alone represent that power. 3d. That the suture is a mean of contact, and not of approximation between the lips of the division. 4th. That adhesive plasters, being sufficient to maintain this contact, and not determining to another part, like the bloody suture, an irritation favourable to muscular contraction, ought always to in- duce the practitioner to give them the preference. Operation of the Harelip. 157 20. The bases upon which this doctrine rests are in general true, as well as the three first principles laid down by the author (19), and under this point of view, art is indebted to him for a step towards its improve- ment. But the last principle does not bear the same stamp as the others; and it is easy to demonstrate that if we even consider the bloody suture as a mean of con- tact and not of approximation, it offers always advan- tages superior to those of adhesive plasters. The parallel of the mode of action of these two means will suffice fo» conviction; only the twisted suture, which is the most generally received, will be first considered, some observations upon the interrupted being reserved to another time. 21. 1st. The dry suture is always exempt from pain, both before and after the operation. The use of the needles causes little during the operation, because their passage into the flesh is hardly sensible, and only the skin is painfully affected by the small wounds resulting from their entrance and exit. Experience proves that after the operation their presence is not painful. 2d. The adhesive plasters do not produce an irritation capable of increasing muscular action. If this irritation should re- sult from the bloody suture, its effect is always of no importance, either from the action of the bandage being opposed to that of the muscles, or from the resistance which itself opposes to their efforts. 3d. By recurring to the first mean, the lacerations sometimes caused by the second are avoided; but, when the latter is methodi- cally employed, the practitioner never experiences this accident. 4th. In the dry suture there are no new wounds, from which too great inflammation and too long suppuration might result; but experience proves that this double accident is not attached to the bloody suture. 158 Operation of the Harelip. 22. It follows from these first considerations, that the so much talked of inconveniences of the twisted suture scarcely merit entering into the balance in the choice of a process; but, if we place there its advantages, it will be easy to perceive its value. 23. The adhesive plasters do not unite the borders of the division accurately except at their anterior part, Posteriorly there remains a cleft, from whence the blood may escape, and into which the saliva may be introdu- ced. From thence, in the first case, the possibility of a hemorrhage, which I have seen supervene five hours after an operation performed by a celebrated surgeon; in the second, the defect of the agglutination of the bor- ders; this double inconvenience cannot be attributed to the use of the needles. Being carried considerably backwards into the thickness of the lip, they unite the edges posteriorly, while the threads, that are twisted around them, secure them anteriorly; from thence there will always be an accurate contact in the whole thickness of these borders. 2d. If one of the maxillary bones is more prominent than the other, the two united portions of the lip, having an unequal point of support and not being sufficiently retained by the adhesive plasters, will loose their level and be displaced, according to their thickness. The one will remain forward, being sustain. ed by the projecting maxillary bone, the other will be depressed backwards, and then there will happen what Desault experienced one day, in a case in which he em- ployed the process of Louis. The anterior part of the left border of the division united to the posterior part of the right border; so that both before and behind there remained two surfaces not united, which became the seat of a long suppuration and the cause of a deformed union. I have seen, in another case, the same incon- venience result from the same method. The soliditv of Operation of the Harelip. 159 the bloody suture, and the point of support given by the needles to the lips through which they pass always prevent this unfavourable displacement. 3d. In employ- ing the dry suture, the two borders, being always more strongly retracted inferiorly by the muscular powers, form there, on uniting, a small hollow instead of the but- ton more or less prominent, that is presented in the natural state by the middle and inferior part of the upper lip. In describing the operative process it will be demon- strated, that it is always easy, by directing the lower needle properly, if not to form^ the button, at least to avoid the hollow. 4th. If the cleft is prolonged into the nose, especially if the maxillary bones are not on a level, it will be difficult to unite the superior angle of the division by adhesive plasters, and then there will re- main an inconvenient hole above the union; it is very seldom that the use of the needle, with proper precau- tions, involves this inconvenience. I believe the practice of Desault never furnished him but one case, which was of a patient entrusted to my care after the operation, with whom, being then but little instructed, I left off the bandage too soon. 5th. However perfect this ban- dage may be, it is never so solid as to be in no case subject to derangement; if it should be displaced, could the adhesive plasters supply the deficiency of its action more efficaciously than the needles? 6th. Besides, does not a part of the twisted act like the dry suture? Do not the threads, adhering intimately to the skin through the medium of the gluten of the blood, represent adhesive plasters? By keeping the two borders of the division in contact, do they not prevent the laceration of the needles? 7th. Let us terminate these comparisons between the dry and bloody suture, by the result of experience, and we will perceive that this last method has been constantly followed by the most happy success, during ten years 160 Operation of the Harelip. in which Desault employed it at the Hotel Dieu. Mo- rcau, who preceded him, used it, as well as many others, and the same success crowned his operations. 24. We must then conclude that if, under certain points of view, adhesive plasters have some advantages over the bloody suture (22), they are always attended with an infinitely greater sum of inconveniences; that perhaps they might answer in some unions, but that in general they are insufficient to procure that precise con- tact, necessary for the accurate and regular union that is desired in the harelip (14). In the operation of the harelip then, theory and experience unite in justifying the use of the twisted suture, which was proscribed in France, in these latter times, until Desault first main- tained and then re-established it. 25. But is not this preference, which the twisted ob- tains over the dry suture, also applicable to the inter- rupted? This has had its partizans, and in general, com- pared to the adhesive plasters, it presents very great advantages; but, if compared with the twisted suture, the same result does not ensue: 1st. The soft parts are never so solidly fixed as in this, when the needles be- hind, and the threads before, invariably secure it. 2d. If, as frequently happens in the separation of the maxil- lary bones, the dental range offers to the united lip an unequal point of support, the interrupted threads cannot like the needles, sustain the two borders at the same level; and here it may be observed, that the objection made to the interrupted suture, of leaving in the flesh solid bars, offers precisely one of its advantages in the cases, where the support furnished by the jaw is not uniform. 3d. It is difficult, with the threads alone left in the parts, to avoid the small inferior hollow of which we have spoken, and which it is always easy to prevent by the needles. We must allow, however, that if the Operation of the Harelip. 161 harelip is simple, and if the dental range offers no in- equality, the interrupted suture may in general be at- tended with a success upon which it would be imprudent to reckon in a complicated case. 26. I have attempted to establish (23, 25), the al- ways real priority of the twisted suture; let us now pro- ceed to the manner of making it and to the choice of instruments which it requires. The needles necessary for that kind of suture have varied both in their form and composition; alternately flexible or inflexible, they have, under this view, divided the opinion of practi- tioners. The greater number of them, however, do not use those of the first form, although they are admitted by some. 27. The ancients employed only those of steel, whose extremities being easily rusted, irritate the passage of the wound, when they are withdrawn. Sharp in England, and Houstet in France, substituted those of silver, ter- minated by a steel point; at length those of gold were adopted, proposed by Ledran, and which on the one hand, have not, like those of iron, the inconvenience of rusting, and on the other, possess solidity enough to form a cutting edge proper for opening a passage to them. Desault adopted their use: Bell employs them indifferently. 28. The form as well as the composition of the nee- dles has varied. The ancients did not flatten one of their extremities like the head of a spear, and we are indebted to the moderns for this point of improvement. To the other extremity are adapted, sometimes heads similar to those of pins, and sometimes holes to pass the threads through. But, in the first case, the cutting point, oblig- ed again to pass through the wound, when the needle is withdrawn, cuts the parts a second time. In the second, the hole is useless, since the threads are always suffi- VOL. I. X 162 Operation of the Harelip. ciently fixed around the needles by their intercrossing. From these considerations Desault had given to the needles the form expressed (fig. 5, and 6*); he varied them according to the size of the lip, and in introducing them he never employed the porte noeud, adopted by a great number of practitioners, but an instrument always useless and easily replaced by the fingers*. 29. The English commonly suffer the blood to flow for some time, before they unite the borders, hoping by this local discharge to prevent the inflammation of the lips; but experience demonstrates the uselessness of this precaution. 30. At this day it is a practice generally adopted in France, to assist, by the uniting bandage, the effect of the sutures in the harelip; and it may be said, in order to give a just idea of these two means, that the first is particularly intended to procure the approximation, and the second, to maintain with accuracy the contact of the two borders of the division (19). Most of the English, however, reject the bandages proper to overcome mus- cular action. Sharp finds them inconvenient to the pa- tient; Bell adds to this inconvenience, that of compress- ing the extremity of the needles, and cites, besides, various examples of ill success, occasioned by their as- sistance. But at the end of some hours the inconvenience * Is the round form used in our needles for the harelip the most advantageous? Would it not be better to flatten them in the body, and thus prolong to their whole extent, the figure of their cutting extremity, only a little less wide? By this mean the borders of the small wounds, which their passage forms, would be less distant from each other, since their separation is in the direct ratio of the thickness of the bodies left in this passage. Less irritation would result, consequently less suppuration and a more speedy cicatriza- tion of these small wounds. The form proposed would be, in fact, only a slight advantage, since the other is attended with but a slight inconvenience. Operation of the Harelip. 163 is trifling. When the cushions have a sufficient thick- ness, the bandage never exercises the compression that Bell objects to it. Finally, to the success, which he re- lates, may be opposed a multitude of the reverse on which he is silent, and which would not have been ex- perienced if the bandage had been employed. 31. The form of these bandages varies, according to the inventive genius of the practitioners who employ them. In general they are founded upon a common prin- ciple: almost all make them with a bandage rolled into two balls, whose ends, after having passed over the two cushions placed upon the cheek and intended to push the parts forward, cross under the nose; whether, in this place, several threads, passing one into the other, have been adapted to the bandage; whether one of the ends being divided into two, passes through two openings made in the other; or whether, finally, that on one side is reversed upon that of the opposite side. 32. From thence it follows that the bandage of the harelip is in general the same as that for long wounds, modified in different ways. Desault did not depart from this principle in the invention of that which he made use of. His bandage (bb) was rolled in a single ball: on the one side it brought forwards one of the compresses as in other bandages; on the other, only passing over the opposite compress it fixed it at the place to which the hands of an assistant had first brought it. From thence it resulted that only a single turn passed over the united division, and in this place there were never any folds or reverses, which are always inconvenient to the patient and injurious to the operation. Frequently in the ordinary bandages, the compresses being fixed trans- versely, are displaced from above downwards. Two small bands of linen (ii) crossing the principal bandage (bb) at right angles over the compresses, served to avoid 164 Operation of the Harelip. this inconvenience. These advantages will be again con- sidered in the description of the bandage. § IV. Operative process in cases of simple division of the Lip. 33. In the present case the harelip is supposed to be simple, in order to facilitate the description of the pro- cess, whose variations in complicated harelips will then be examined. Desault seldom used preparatives, which according to him, are rarely useful and often unfavour- able to patients. In this species more than in the others he pursued this practice, and almost always limited him- self to some precautions, minute in appearance, but of- ten more advantageous to the success of the operation, than certain points that have been long disputed; as for example, to comb carefully the head of the child who was to be operated upon; to put in his hair a little gray ointment lest, being troubled with vermin, he might de- range his dressing; to place some lint behind the ear, to fill with it the cartilage of the concha, so as to avoid the pain of compression being made upon the ear and to absorb the matter of perspiration, which becoming acrid by its long stay, irritates and sometimes even excoriates the parts; to fix firmly by means of a band the cap which is to serve as a point of support to the bandage. 34. The pieces that compose the apparatus are: 1st. For the operation, a pair of very strong scissars, cutting keenly and whose blades must be carefully sloped on both sides; some needles of gold, of a size proportioned to the lip of the patient, a noose of simple thread, a cord formed of two threads waxed and parallel to each other, two small compresses of the height of the upper lip, a pledget and compress, of an equal length with the nee- dles. 2d. For the bandage, two cushions of a size pro- portioned to the cheek of the patient; a bandage of three Operation of the Harelip. 165 ells, rolled into a ball and of the same width as the lip; two small bandages, two feet long, and nearly as wide as the cushions, a sling and a common band. 35. The situation of the patient, most favourable for the surgeon, is as follows. He must be seated upon a high chair, with his head supported against the breast of an assistant, whose hands, being applied to the cheeks, push them forwards, at the same time that the middle fingers keep up an exact compression on the external maxillary at its passage before the masseter. Every thing being thus disposed, the operation is to be proceeded to and it may be considered in three very distinct parts: that of the excision of the borders; that of their union, and that of the application of the bandage. 36. In the first period: 1st. The surgeon, standing before and a little to the right of the patient, so that the hand of the side which is to act may correspond directly with the part affected, seizes and pinches, with the thumb and index of the other hand, the left border of the division,* cuts from below upwards and a little from without inwards all the red part of this border (13), observing to hold the blades of the instrument always perpendicular to the lip and to remove inferioriy a larger portion of flesh, where it is necessary to take away all the rounded border, rather than superiorly where it is sufficient to make that border raw. 2d. He seizes between the fingers of the left hand, the right portion of the lip, not upon the border itself as in the opposite side, but a little beyond it. He draws it downwards and with the scissars removes, by an oblique * In this process of Desault, there is not the inconvenience of changing the instrument from the hand during the operation, and thus the objection (U), made by Louis, to the scissars, falls of it- self. 166 Operation of the Harelip. incision corresponding to the preceding, all the red bor- der of that side. 37. From this double incision, for which a single stroke of the scissars on each side is commonly suffi- cient, a triangular wound results, to the union of which we must proceed immediately. This is the second part of the operation, and to be executed in the following manner: 3d. The raw edge of the left portion is seized anew, and in the same manner as for its excision; then a needle held in the right hand like a writing pen, and previously smeared with cerate, is to be inserted into the lip, at the distance of one line from its loose border and of three lines from the wound, to be directed back- wards and upwards in such a manner as to make the point come out two lines above the loose border, be- tween the posterior fourth and the anterior three fourths of the lip. 4th. The assistant upon whose breast the head of the patient is supported, presses the two cheeks very strong- ly forwards, whilst the surgeon seizing as for excision, the right portion of the lip, approximates it to the other, inserts into the bleeding border the point of the needle, carries it in the same direction, and makes it describe the same course, but in an inverse sense, as the oppo- , site side; so that the point comes out at the place cor- responding to that where it entered. From thence in the passage of the needle results the form of a V reversed; a disposition proper to push downwards the quantity of flesh that is necessary to form the button, which in its natural state the middle and inferior part of the lip presents. 5th. The surgeon taking in the left hand the pointed extremity of the needle, constantly retaining in the right hand its other extremity, draws downwards the two Operation of the Harelip. 167 borders of the lip, which stretch, approximate and unite; and while they are thus kept in contact, an assistant passes the noose of thread between the lip and the nee- dle, draws the two ends down, and thus replacing the hands of the surgeon, maintains the contact. 6th. The surgeon fixes upon the noose the middle of the cord of thread, crosses its two ends anteriorly in the form of an 8 upon the union of the two borders, brings them back between the lip and the needle, passes them below the latter, returns above and recommencing the figure of 8, he covers with it the inferior portion of the lip, with the precaution of placing them crossed above each other; the two ends of the cord are then trusted to an assistant, who holds them on the side opposite the noose. 7th. A second needle is placed three lines below the first, at the same distance from the bleeding edges, with the same precaution of leaving more parts before and less behind, but without giving to the course of the needle the angular form of the first. 8th. The surgeon takes the two ends of the cord of thread, crosses them between the needles, fixes them on each side behind the superior, makes some figures of 8 before it, then re-descending to the inferior and re- mounting alternately to the superior, crossing always in the middle, he covers the lip with figures of 8, as may be seen (fig. 2). 9th. If a third needle was necessary, the process of its introduction would be the same as that of the second; as to the threads they must perform with the second and third what was done with the first and second. 10th. The noose of thread intended to stretch the lip is cut. Small compresses are placed under the needles to support their extremities. A pledget moistened with 168 Operation of the Harelip. lead water is laid upon the lip, and this is covered by a compress analogous to the form of the parts. 38. The approximation of the borders and the direct means of their contact, are the object of the partial pro- cesses of the second part of the operation. The third has for its object the indirect means of this contact, or the application of the bandage. It consists in the fol- lowing: 11th. To place upon the cheeks two cushions (dd, dd, fig. 3.) in the space circumscribed behind by the mas- seter, before by the commissure, above by the malar eminence, below by the sides of the lower jaw. An as- sistant fixes them by pressing them against the cheek and pushing them forwards. 12th. To fix around the head by some circular turns, the narrow bandage rolled into a single ball, attaching the end behind the right ear, conducting it over the cushion (dd) on the cheek of the same side, then under the nose to the place of the intercrossing of the threads (cc), then over the cushion of the other side (dd), taking care at the same time to bring that strongly forwards, then behind the ear, where it is fixed, and terminating its application by circular turns round the head. 13th. To place the two small bands (», ii), which, passing over each cushion, there cross the bandage, and are fastened to it by a pin, and are then carried oblique- ly to the superior part of the head, where they cross each other and are fixed. 14th. The application of a sling, intended to prevent the motions of the jaw, terminates the bandage, whose different pieces are secured by a band, enveloping with its circular turns (aa, *a) the superior part of the head. Operation of the Harelip. 169 $ V. Of the Subsequent Treatment. 39. The subsequent treatment of this operation is always simple. The most celebrated practitioners con- fine themselves to avoiding every thing that may pro- duce motion of the lips, and to renewing the dressing every day. There are, however, some precautions in the renewing of the dressing, in the management of the child, and finally in withdrawing the needles, which are essential to the success of the operation, and will be traced in detail in the following case; referring to it the practice of Desault in the particular case of which this is the subject. CASE I. Jeanne Debol entered the Hotel Dieu on the 7th of July, 1787, to be there operated upon for a simple hare- lip, which dividing the lip unequally, crossed it at the level of the dens caninus of the left side. This child having been hitherto exempt from any infirmity, there was nothing to forbid the operation, which was the only mean of remedying a deformity that gave her but little pain, but marred the budding charms of her physiog- nomv. The operation being performed after the process that has been described, was attended with nothing particu- lar, and appeared to occasion only a slight pain. In the evening a little swelling, the ordinary effect of the pres- sure of the dressing, occupied the whole face; no pain supervened: the patient being tranquil enough, took some broth by means of a flattened pap-boat, placed in the interval of two molares. The swelling was dissipated by morning, and gave place to a slight itching. The dressing was removed and the pledget renewed, after being moistened with lead-water; three drinks of broth Vol. I. Y 170 Operation of the Harelip. were given with the same precaution as the day before. On the third day the same treatment as on the second; the fourth a light panada was allowed. In the dressing, the needles were withdrawn, with the precaution of care- fully cleaning the extremity that was to pass through the course of the wound, of previously smearing it with cerate, of making each needle perform a rotatory mo- tion in order to disengage it with more facility; finally, of resting two fingers upon the border of the lip answer- ing to the point, so as to sustain it while the instrument was withdrawing. The threads adhering to the parts were left in their place; the fifth day there was nothing particular; the sixth the threads fell, and some solid ali- ment was allowed to the patient; the ninth day the ban- dage was suppressed; a slight suppuration appeared on the tenth at the orifice of the passage of the needles. There remained no trace of it on the twelfth, and the child being perfectly cured, distinctly articulated sounds which before it uttered with difficulty. 40. The treatment described in this case was such as Desault constantly employed after the operation of the harelip; in general he never left the needles in the wounds more than three or four days, experience hav- ing taught him that their longer abode often occasions those lacerations that have been so much objected to the needles. The evident property which the lead water possesses of retarding suppuration in penetrating wounds, in this case affords more time to the raw sur- faces to unite, and under this point of view is a very advantageous medicament. The manner of withdraw- ing the needles is always the same; no pain accompa- nies and no new irritation results from it. Finally, it is the province of those who attend the patient and give him food, to favour the success of the operation. There is no particular rule to be laid down for them; they must Operation of the Harelip. 171 only be guided by one general principle, which is to avoid every thing that may produce the least motion of the lips. $ VI. Particulars of the Operative Process in the Com- plicated Harelip. 41. The operation of the harelip, always easy in the case of a simple cleft of the upper lip, presents under certain circumstances difficulties which necessitate, in the operative process, particular modifications of which it will be useful to take a cursory view. 42. It is not rare to see a double fissure, or rather a middle button, separating the division of the lip into two parts. The size of this button varies; if.it is incon- siderable, it is comprised in the excision. The angle of the wound is found at the place which it occupied, and then there is no change in the operative process. But if it occupies more space, if it descends to the middle, to two thirds, and even to the level of the inferior border of the upper lip, it will be necessary to make the bor- ders raw on each side, with the precaution already indi- cated, of leaving more flesh superiorly than inferiorly, where the button must be angular. From this form re- sults the facility of adapting it to the interval between the two borders. Being then penetrated by the needles, which also pass through the borders, it unites accurate- ly with them. If it descends only to the middle of the division, before making the edges raw, it will be neces- sary to disengage it from its adhesions to the frasnum of the upper lip that corresponds to it, and then to bring it down as low as possible. 43. Some practitioners have questioned, whether it would not be more advantageous in this case, to per- form the operation at two different times; first uniting one of the edges of the flap to the corresponding edge 172 Operation (fthe Harelip. of the lip, and when that union was complete, then to repeat the same operation. Bell supports this mode of operating, from the danger of inflammation to which a very delicate flap is exposed when the needles pass through it. But experience proves that this danger is never real; that a success always equal to that of the operation for the simple harelip, crowns that of the dou- ble harelip methodically performed at one time. Why then seek by repeating the pain, to obtain that which may be had by occasioning it only once? Desault con- stantly performed the operation upon this principle, and always in his hands it has been followed with success, of which the following case, recorded by Gavard, offers an example. CASE II. Marie Delone, aged eight years, entered the Hotel Dieu with a double harelip, on the 8th of June, 1789. From each ala of the nose there proceeded a division prolonged into the whole lip; in the middle there was a separate portion about four lines wide. It required a double operation at the same time to remedy a double deformity. After the ordinary precautions, Desault pro- ceeded to it according to the rules indicated (42); by oblique incisions he made raw the four borders that were to be united, then placed inferiorly a needle, which, entering three lines from the wound, came out between the posterior fourth and the anterior three fourths of the left border, was carried into the flap whose thickness it passed through at the same level, entered into the right border, which it passed through in an inverse sense, and came out three lines from this border. The noose be- ing placed, as in ordinary cases, a second needle was passed like the first; around both the cord of thread was Operation of the Harelip. 173 twisted in the figure of 8, and the application of the ordinary bandage terminated the operative process. The little patient, who during the operation had scarcely uttered a cry, appeared tranquil in the evening, and only complained a little of the confinement of the bandage. In the night this pain was dissipated, and no swelling supervened. The treatment was the same as that of the preceding case, only the union, being more tardy, made it necessary to prolong it a little more. The double cleft not appearing to have adhered on the third day, the needles were not removed until the sixth. The bandage was still continued* and at the end of fifteen days, Marie Delone was perfectly cured, without the pain of two operations, performed in succession. 44. The fleshy portion which separates the division into two parts, is not always, as in the preceding case, of the same size with the lip. Frequently it terminates at the middle of the fissure, and then the operation is again modified. CASE III. Joseph Delarue, aged nine years, entered the Hotel Dieu with a double harelip, whose middle button, of a round form, terminated about the middle of the divi, sion. The operation was performed on the third day after his arrival. The excision of the left bolder of the lip having been made, Desault seized the button, disen- gaged it from its adhesion with the frsenum of the upper lip, removed its left border obliquely, so as to give it a triangular form. The right border of the lip having then been made raw, he placed inferiorly a needle, which united the two borders of the lip, as in the simple hare- lip, and was secuied by the noose of thread. A second needle being introduced three lines above, traversed the 174 Operation of the Harelip. button in its middle point, and fixed it firmly between the two borders that were already united below, and with which it was accurately kept in contact by the threads twisted in figures of 8. A slight hemorrhage supervened in the evening; the dressing was renewed and applied a little more tighdy. On the third day there was no pain, but a little swelling appeared on that day, which was dissipated in a little time. The needles were taken away on the fourth day, and the patient was dis- missed, cured, twelve days after the operation. 45. In the harelip a double fissure is not the most unfavourable complication which art has to overcome. Frequently to the division of the soft parts is added that of the bony palate. An inconvenient projection often appears between the borders that are to be united, and in this latter case new modifications must be added to the operation that is to be examined. The fissure of the palatine arch varies in extent and in size. Sometimes limited to the maxillary bones, it always unites after the operation; but frequently occupying the palate bones, it crosses the velum palati, and then examples of union are not so commonly observed. In general, Desault has observed, whatever was the form of the fissure, that as a consequence of the operation, there was constantly, if not an exact union, at least a very sensible approxima- tion. If the direct cause of this phenomenon escapes our researches, we are at least certain that the re-estab- lishment of the lip in its natural state is the disposing cause. From thence this consequence may be drawn, that the operation should be more speedily performed, in proportion as the symptoms resulting from the fis- sure of the palate are more pressing. 46. The approximation of this fissure is more or less slow. It is only by degrees that nature re-establishes the regular conformation which she had originally neg- Operation of the Harelip. 175 lected. Still there are cases in which she departs from this rule, and where, more rapid in her progress, she ef- fects speedily the union of the bones. The following example is a proof of it. CASE IV. A child was brought to the Hotel Dieu, having a harelip complicated with a separation of the palatine arch of half an inch. Deglutition was very much con- fined, and pronunciation so difficult, that he scarcely "Uttered articulate sounds. The operation was attended with nothing peculiar, and at the end of ten days the lip was completely united. At this period, the palatine fis- sure, being examined for the first time, was found to be diminished one half. The child was less embarrassed in speaking and also swallowed almost without difficulty. On the fifteenth day the borders, being more sensibly approximated, scarcely allowed liquid aliments to pass into the nose. On the nineteenth day the fissure was hardly to be seen. On the twenty-seventh the edges were so united, that scarcely a trace of their separation was left. The entire facility of speaking was a little longer in returning than the cause which prevented it had been in dissipating. 47. The separation of the bones of the palatine arch, which is seldom a direct cause of any modification in the operation, is frequently accompanied with a projec- tion of a portion of the upper jaw, which always requires a particular process. The varieties of this complication are very numerous. Sometimes one of the maxillary bones, exceeding the level of the other, forms the pro- jection by its nasal spine; sometimes, in cases of double fissure, a separated portion of the jaw pushes forwards the middle button of the lip, as may be seen (fig. 1.); sometimes one of the maxillary bones, inclining back- 176 Operation of the Harelip. wards, presents in front the dental margin, which pre- vents the union; and frequently, one tooth surpassing the level of the others, produces an obstacle. It may be perceived, that, in this last circumstance, it will always be easy to overcome the difficulty by extracting the projecting tooth. But, if the maxillary bone itself pro- jects, this more embarrassing case has given origin to different processes. 48. Most of the moderns (for in this case the ancients did not presume to operate) have proposed and per- formed the previous excision of the prominent bony portion. Daniel Ludovic performed this operation only to facilitate sucking. Franco and Van Home recom- mend it. We find in the memoirs of the academy of surgery different cases, in which it was practised by Gerard, Lafaye, &c. But this excision is seldom neces- sary, and is always very painful. If an interval of time is left between it and the union of the lips a double operation is necessary. If they are both operated upon at the same time, sometimes an inflammation, injurious to the adhesion of the wound, is the consequence. A cavity more or less considerable, constantly results, and then the two united portions of the lip are in want of a favourable point of support at the place of their contact. 49. Finally, an inconvenience still remains to be ap- prehended, supposing the union of the lip to be com- pletely finished. Desault experienced it at the time, when he still followed the practice that is now to be analysed. CASE V. He was one day consulted respecting a child who had a deformity similar to that represented (fig. 1.); a bony eminence, separated by a double fissure of the maxil- lary bones, made a projection forwards, that rendered the Operation of the Harelip. 177 operation impossible. Experience had not yet instructed Desault, who removed, according to the ordinary me- thod, all the projecting bony portion. From thence a very large fissure resulted, which the approximation of the maxillary bones diminished gradually after the opera- tion. At the end of three months it had disappeared, leaving only a slight trace of its existence; but the trans- verse diameter of the upper jaw, diminished by the whole width of the projecting button, did not corres- pond any more to the lower jaw, and as is often ob- served in old persons, there supervened a setting of the upper in the lower jaw, which is extremely inconvenient for mastication. This inconvenience, being the obvious result of a loss of substance in the superior maxillary bone, changed the practice of Desault on this point; and from that time he conceived that if he could by a previous compression re-establish the lost plane of the projecting portion, he would obtain the double advan- tage of avoiding a pain always unfavourable, and an in- convenience still more so. 50. The maxillary bones being separated from each other, and consequently always less firmly fixed, yield without difficulty to the force which pushes them back; and the projecting portion being frequently almost iso- lated, opposes little resistance. Acting on these consi- derations, Desault made trial of this method, which has since succeeded constantly. A simple bandage passing over the portion to be depressed and drawn strongly backwards, and there fixed on each side, was sufficient for this compression, which he prolonged more or less, according to the resistance of the parts, and for which more efficacious means might no doubt be used. Vol. I. Z 178 Operation of the Harelip. CASE VI. Recorded by Chorin. Marie Dehannes, aged five years, was received into the Hotel Dieu, on the 7th of September, 1790, to be there operated upon for a double harelip with a pro- jection of the middle button, represented (fig. 1.), and the description of which will be found in the explana- tion of the plate. Mastication was difficult, and during deglutition a part of the aliment passing into the nostrils, incom- moded the patient much; but experience had accus- tomed him to lessen this inconvenience by taking only a small quantity of food at one time. His vowels were sufficiently distinct, but custom alone could render the consonants intelligible. In order to reduce the button to the plane of the lip, and to depress the projecting portion of the maxillary bones, recourse was had to the method indicated above, which from the first day had a very sensible effect. It was continued during eighteen ■> days, when the parts, being exactly on a level, permitted the operation to be performed, which was attended with nothing particular in its execution; and as to its consequences, showed a perfect union on the tenth day, and an almost complete approximation of the palatine arch at the end of a cer- tain time. The difficulty of deglutition and pronuncia- tion was dissipated with the cause that kept it up. Explanation of the Third Plate. Fig. 1. This figure represents the complicated hare- lip of the patient, mentioned in Case VI. a. The projecting portion of the jaw, six lines wide. b. A button, rounded and continued to the end of the nose', forming the middle part of the lip. FtQ.l (%j$ M -<0£kv^ m£k jLaw.ton sc. , ? Operation of the Harelip. 179 ff. A fissure, three lines wide, separating the button on each side from the corresponding portions of the lip. cc. Rounded angles of the division. Fig. 2. The twisted suture, seen without the ban- dage. The intercrossing of the waxed thread around the needles, in figures of 8. pp. Points of the needles. tt. Their heel. Fig. 3. The bandage which Desault employed, ap- plied upon the suture. cc, cc. Small compresses placed upon the wound. dd,dd. Thick compresses, intended to push the cheeks forwards. (In this figure they are too high and too much behind.) bb. A portion of the uniting bandage, passing over the compress of the lips and upon those of the cheeks. ii, ii. Small bands, sustaining the compresses of the cheeks. ff The sling. aa. Turns of the bandage, fixing all the dressing. Fig. 4. State of the lip after union. Fig. 5. and 6. Different form and size of the needles. REMARKS AND OBSERVATIONS UPON THE DISEASES OF THE MOUTH. § 1. Diseases of the Lower Jaw. CASE I. Recorded by Seignettc. Fungus of the Lower Jaw. FRANCES METON, aged thirty-four years, of a strong and robust temperament, but habitually subject to defluxions and pains of the teeth, was attacked, in 1790, with violent pains of the head, which lasted for some time, then dissipated, and at length fixed on the right arm, where they were accompanied with a trou- blesome sensation of cold. The use of warm baths and of diluting and slightly diaphoretic ptisans, seemed for two months to calm the pains, when they were sud- denly translated to the right side of the lower jaw, be- came fixed there and tormented the patient much. At the same time a tumour, indolent and insensible to the touch (although there were continual shootings from its centre), arose before the branch of this side, and ex- tended gradually inwards and outwards. The teeth, being almost all carious, began to vacillate and were successively extracted, accordingly as the pain which they occasioned rendered their remaining insupporta- ble. The gums swelled, the tumour increased, occu- Diseases of the Mouth. 181 pied the half of the bone, impeded deglutition and the articulation of sounds, and made it painful to open the mouth; at length it burst, discharged a little sanious pus and became the seat of two fistulas, the one above, the other without; fungous flesh arose upon their ori- fices. At the same time the bone was carious below and in the middle of the tumour. Many of its detached por- tions caused small abscesses to be formed under the internal membrane of the mouth, which being opened, gave them a passage. The breath became fetid and fre- quently insupportable. For two months such had been the state of the patient, when she came to the Hotel Dieu to consult Desault. Until then some acidulated drinks and the external use of cataplasms had com- posed all her treatment. The examination of the parts discovered a fungus rising above the right side of the jaw, extending from the place occupied by the last molaris to that where the canine is found, in the natural state, enlarging from behind forwards, showing near three inches in this dimension, and complicating itself with a necrosis of the subjacent portion of bone, which was found to be bare, by means of a probe passed through the fistulous openings. Here extirpation was indicated under a double view; 1st, to remove the tu- mour; 2d, to extract the dead portions of bone, and fa- vour the formation of a new substance. It would have been proceeded to immediately, had it not been for some local causes, which then made common erysipelas and even the hospital fever, species of affection so unfa- vourable to the after treatment of great operations. A month was therefore suffered to elapse, during which two of the portions, affected with necrosis, were de- tached. The constant use of cataplasms without, of diluents within, and at intervals of evacuants, were the 182 Diseases of the Mouth. preparatives of the patient, who was operated upon on the 19th of Fructidor, in the following manner: 1st. On a fair day she was seated upon a high chair, with her head supported against the breast of an assis- tant, whose hands being crossed upon the forehead, held her firmly. Desault caused the mouth to be opened very wide, and kept it so, by means of a body placed between the two jaws, on the sound side. 2d. He made, with a knife concave upon its cuttmg edge and fixed on the handle, a semi-lunar incision, which, extending from the branch of the jaw to the in- cisores, exactly circumscribed the tumour without. 3d. In order to separate it within, the tongue was pushed back to the opposite side, the point of the in- strument inserted in the superior angle of the first divi- sion, and directed forwards to reach the spot where the first had finished. 4th. By this double incision the soft parts were cut round exactly. To remove the bony portions, Desault made use of a strong and thick instrument, curved in the form of a vine-knife, (whose description may be found in the article of the diseases of the maxillary sinus), which being inserted deeply into both incisions and following their direction, completely separated the tumour. 5th. A considerable hemorrhage supervened; plugs of lint were, for an instant, applied to the parts so as to suspend it; being then withdrawn, they gave place to the actual cautery, which was repeatedly applied over the whole extent of the wound, with the double view of stopping the blood, and of destroying all that remained of the tumour, either in the bone or the soft parts. 6th. Cooling gargles were administered in abun- dance, for fear of too great heat in the parts. 7th. The cavity, resulting from the extirpation, was Diseases of the Mouth. 183 filled with lint, and care was taken that the head of the patient should be placed in such a manner, as that the saliva and the oozing from the wound should flow through the mouth and should not fall into the prima? viae. The next day there was no pain and little swelling— prospect of a fortunate issue; but on the fifth day, there was pain in the loins and looseness; at the same time, swelling of the amygdala?—deglutition impeded—fever —lint taken from the mouth. On the sixth, the symp- toms were the same. On the seventh, the looseness was augmented—a fixed pain, manifested on the left side of the breast—respiration impeded—emetic given in la- vage, without success. On the eighth, fever augmented •--erysipelas over all the face. The ninth, shiverings, sweats, general weakness. The tenth, death. CASE II. Recorded by Cagnion. JYecrosis of the Lower Jaw. Francis Gray, aged twenty-five years, was attacked in the month of June, 1792, with sharp pains in the lower jaw. A surgeon who was consulted, in attempting to extract the next to the last molaris, broke it and then abandoned the patient, who from that time was tor- mented with sharper and more frequent pains. The spontaneous opening of a small abscess near the dens caninus appeared to dissipate them a little, but in a short time they were renewed. A purulent oozing proceeded through the opening of the tumour, which remained fistulous: a considerable swelling occupied all the left side of the jaw. At the end of three weeks, a new ab- scess formed upon the border of the maxillary bone, at about an inch from the tuft of the chin; it was opened by a cutting instrument, and like the preceding, the 184 Diseases of the Mouth. opening remained fistulous. The surgeon being again consulted, prescribed strong emollient, suppurative ap- plications, &c; useless means—the fistulae remained; the swelling increased without the skin's participating in it, impeded mastication and deglutition, and in a little while did not permit the jaws to separate more than six lines. Such was the state of this patient, when he came to the Hotel Dieu, to be there treated. The progress of the disease, the existence of the two fistula? constantly kept up, the swelling of the bone, without the skin itself being swelled, and the shaking of the correspond- ing teeth, already gave strong presumptions of the ex- istence of a necrosis. Desault became certain of it, by introducing a probe through the openings, by means of which he immediately felt the bare sequestra. To re- move it, by cutting the soft parts, was the speediest route to arrive at the cure—no.danger would be in- curred. Desault determined upon it, and without fur- ther preparation, performed the operation in the follow- ing manner, on the third day after his entrance into the Hotel Dieu. 1st. The patient being seated upon a chair of small height, with the head slightly inclined backwards, an assistant separated the commissure of the lips, whilst the surgeon made upon the gums, with a knife fixed on its handle and concave on its cutting edge, two semi- lunar incisions, united at their angles, and whose flap being removed, exposed to view the external side of the portion of bone that was affected with necrosis. 2d. The teeth, corresponding to the sequestra, and already moveable (as has been said) were removed by a steel blade in the form of a buckler. 3d. The fingers, applied upon the portion affected with necrosis, extracted it with ease, after a small por- Diseases of the Mouth. 185 tion of the soft parts had been separated from it on the internal side. It was of the size of a very large nut. 4th. By again applying the fingers to the place from which the affected portion was removed, the surgeon informed himself if others were not still to be extracted; a small one was taken out. 5th. The operation had not been impeded, either by the cries of the patient (little pain having been the re- sult), or by the effusion of blood, which flowed in very small quantity. It was then useless to stuff plugs of lint into the bony cavity. All dressing was abstained from, and the patient was only advised to gargle his mouth with a mixture of vinegar and water. The next day the cavity resulting from the extrac- tion of the sequestra had diminished nearly one half; the opening of the mouth, become more easy, rendered mas- tication less difficult. No accident supervened, only a slight puffing occupied the corresponding part of the cheeks. On the following days the purulent oozing from the fistulous openings dried up gradually; from the diminished cavity there escaped a pus, at first bloody, in a little time white and of a good quality; the borders approximated; a new substance replaced the portion of the gums that was removed; the sur- rounding teeth, which vacillated a little, became firm. The patient was debarred from his usual diet a few days; in a little while he returned to it, and a month after the operation he was discharged, perfectly cured. $ II. Diseases of the Salivary Passages. CASE III. Recorded by Hernu. Operation for the Ranula by Excision. Julienne Regley, aged twenty-four years, had under the tongue, from infancy, a soft tumour, almost indo- Vol. I. 2 A 186 Diseases of the Mouth. lent, which kept in the same state until 1790, when it acquired suddenly so considerable a size, that a negli- gent surgeon would have taken it for the tongue, which it pushed upwards and backwards, and impeded its motions very much. Such was the state of this patient when she came to the Hotel Dieu, in 1791. It was easy to recognize a ranula, which the operation alone could efficaciously destroy. Desault performed it thus: 1st. The patient being seated upon a high chair, and secured by assistants, she was directed to open her mouth very wide, which was kept so by means of a body placed between the molares. 2d. The surgeon cut with a scalpel from behind for- wards, the right side of the tumour, along the fraenum of the tongue. 3d. All the superior part of the cyst was cut off with the scissars introduced through the first opening; the sides were removed as accurately as possible. 4th. A matter, whitish, grumous, and of an insup- portable odour, escaped from the sac thus laid open. 5th. A slight hemorrhage, that supervened during the operation, was stopped by plugging the wound with lint. The next day a considerable swelling appeared in the cheeks and at the edge of the wound. The external application of an emollient cataplasm, and a gargle of barley water and honey of roses were prescribed. On the following days there was a sensible diminution in the engorgement: suppuration, at first sanious, soon laudable. The sixth day, the pus again became sanious —heat, and dryness of the skin—loathing—bitterness of the mouth—appearance of gastric symptoms;—emetic drink, repeated twice—speedy disappearance of the symptoms. From that time, cicatrization progressed rapidly. On the fifteenth day, only a small opening re- mained in the upper part of the wound, for the excre- Diseases of the Mouth. 187 rton of the saliva. The patient dismissed, perfectly cured. CASE IV. (Extractedfrom Desault's Lectures.) Salivary Fistula of the Duct of Stenonius, cured by Compression. In fighting, a man was struck by a fragment of a bot- tle, which caused a longitudinal wound about an inch and a half deep, at the level of the origin of the sali- vary duct. Much blood escaped at the moment of the blow; it was stopped by a compressing bandage, and the patient came the same day to the Hotel Dieu. At his evening visit Desault removed the dressing which had been applied, and, by making a ligature on the small arteries that had been divided, replaced the com- pression exercised upon them, so as to avoid irritation and inflammation of the parts, consequently their abun- dant suppuration, and the deformity of the cicatrix, to which this latter method of stopping hemorrhagies often gives origin. A superficial and dry dressing was then employed. It was renewed regularly on the following days; the ligatures fell gradually; the first on the fifth, and the last on the twelfth day. At this period, the cicatrix, which was considerably advanced at the ex- tremities of the wound, left in the centre a small open- ing, through which a serous fluid escaped whenever any motions were impressed upon the upper jaw. The patient was directed to abstain from speaking, and permitted to use only liquid aliments. From that time the oozing ceased, and the cicatrix seemed to be completed; but at the end of fifteen days, some solid food having been given him, the oozing returned, raised up a pellicle that was formed in the centre of the cica- trix, and established a fistula, for which the constant 188 Diseases of the Mouth. rest of the jaws, and compression upon the duct of Ste- nonius, were used in vain during a month. The open- ing of this duct being certain, the only means of closing it consisted in preventing the passage of the saliva. Desault, in order to accomplish this more efficaciously than by the mode of compression heretofore adopted, had recourse to compression exercised upon the gland. Several graduated compresses were laid in the space comprised, from above downwards, between the ear and the angle of the lower jaw, from before backwards, between the anterior border of the masseter and the mastoid apophysis. They were sustained by a ban- dage, whose perpendicular turns, passing first under the? chin and to the top of the head, were crossed by others, directed horizontally from the forehead to the nape of the neck. All motion of the jaw was prohibited. The bandage, being relaxed every day, was applied anew with a greater constriction. This method, con- tinued for a month, caused the gland to wither, and prevented its functions. The saliva having ceased to flow through the opening of the duct, the fistula closed; a solid cicatrix occupied the whole part, and at the end of three months there remained only a slight trace, joined to an inconsiderable depression, corresponding to the plane of the gland that was withered by the compres- sion. REMARKS. The method of compression in the treatment of sali- vary fistulae of the duct of Stenonius is divided into two processes relative to the place in which that compression is exercised. In fact, recourse is had to it, 1st. With the view of suspending, only for a time, the passage of the saliva through the canal, so that its flowing may not pre- vent the cicatrization. 2d. To prevent the secretion in the Diseases of the Mouth. 189 gland, which is thus withered and for ever deprived of its functions. Jn the first case, the means of compression must be applied between the fistula and the gland. In the second they must be applied upon the gland itself. In general, this last mode of compression, of which the preceding case offers an example, has greater advan- tages over the other; its effect is more certain, less dif- ficulty accompanies it—no danger results from it: do not be afraid that the saliva, being in consequence less abundantly separated, should disturb the digestion. The parotid of the opposite side and the other salivary glands supply the functions of that which has perished, by augmenting their secretion. Perhaps also nature may herself reject a part of the saliva that commonly mois- tens the mouth, and this is proved by a part of it being thrown out; from thence the place which this fluid oc- cupies among those termed recrementitial excrements; besides, in the animals who are deprived of these glands in our experiments, does digestion proceed less favour- ably? Finally, experience, the sole arbiter of our ope- rative processes, is evidently favourable to this; it suits exclusively, when the canal is obstructed; when it is free, the other mode of compression may be previously employed, and recourse had to this* when that fails of success, which almost constantly happens; from thence the practice of Desault, who, even in cases where he was sure of the liberty of the canal, often recurred im- mediately to the withering of the gland. Let us proceed to the other methods of curing salivary fistulae, in which surgery is indebted to him for some progress. CASE V. Salivary Fistula, cured by an artificial Duct. Marguerite D— aged 37 years, had, for five years, upon the course of the duct of Stenonius, a tumour of 190 Diseases of the Mouth. the size of a small nut, pierced anteriorly with a fistu- lous opening from which a serous and limpid fluid flow- ed at intervals. This tumour had succeeded a blow of a club received upon the cheek, where a large ecchymosis first appeared, and then gradually disappeared, leaving after it this tumour ai d a constant pain. When the patient remained, for some time, without any considerable mo- tions of the jaw, a crust formed over the fistulous orifice, closed it, and the oozing ceased; but in a little while it appeared anew, as soon as solid food was taken in a lar- ger quantity than usual. Such was the state of the patient when she came to Paris, in 1793, to be treated there. The surgeon, to whom she applied, cut the tumour according to the di- rection of the canal, gave vent to the matter which it contained, scarified the sac in its whole extent, applied the potential cautery to it and then made a gradual com- pression along the duct. This mode of treatment for some days appeared to have a happy result; but in a little while the oozing recommenced, and even preceded the complete fall of the eschar; the compression became painful and the patient could not support it. He then sought to establish the natural passage; a probe was in- troduced into the portion that corresponded to the mouth, which, being too much contracted, refused to admit it, even when of the most slender form; then only two means remained: 1st. To make the compression, not upon the course of the passage, as had been done before, but upon the gland itself, so as to wither it, prevent the secretion of the saliva and consequently its flow. 2d. To open an artificial passage for this fluid into the mouth. Desault, being called into consultation, advised the for- mer method to be tried first: a bandage, analogous to that described in the preceding case, was employed with this view; but the extreme sensibility of the patient, and Diseases of the Mouth. 191 still more her impatience, did not permit the use of it to be continued long, and it was necessary to have recourse to the second process, which Desault executed in the following manner. 1st. The patient being seated upon a high chair, with the head supported against the breast of an assistant, he introduced into the mouth two fingers of the left hand, which, being placed opposite to the fistula, between the dental range and the cheek, served at the same time to stretch the integuments and to preserve the gums from the point of the instrument. 2d. He took in his hand the ordinary trocar for the hydrocele, armed with its canula, applied the point of it before the opening of the superior portion of the duct, which the oozing made sensible, and inserted it into this place, directing it a little forwards. 3d. An assistant was directed to secure the canula, while the surgeon withdrew the stylet, and then to pass a thread through it into the interior of the mouth. 4th. The canula was withdrawn. To the thread passed into the mouth was attached a seton, which it drew from within outwards in such a manner as not to bring it be- tween the borders of the external opening, where the thread alone passed, and was then secured upon the cheek by an adhesive plaster. 5th. The external wound was dressed with lint, sur- mounted by some compresses moistened with lead water. The next day there was a little swelling, probably the effect of the operation, which however had not been at all painful. It was soon dissipated; red flesh arose from the wound, and being too prominent, was cauteriz- ed. On the twelfth day the cicatrix, being closed at the circumference, left only a small hole in the middle for the passage of the thread. Every day the precaution was observed of changing the seton, increasing it a little, and 192 Diseases of the Mouth. with the essential precaution of not bringing it between the borders of the wound, which was covered with an adhesive plaster to prevent the passage of the saliva. Any considerable motion of the jaws was prohibited; for a long time only liquid aliments were permitted. On the thirtieth day there was nothing externally but an oozing hardly sensible; the forty-fourth, the seton was suppressed; the thread was left until the fiftieth, at which period it was taken away, with the precaution of cauterizing the small external opening that remained for its passage. It was soon cicatrized, and three months after the operation the patient left Paris, perfectly cured. REMARKS. The opening of an artificial duct is one of the means most anciently used to cure salivary fistulae. Every author has had his method of performing it, and a num- ber of variations are met with, both in the instrument employed to pierce the cheek, and in the body intended to keep up the opening. For the first part of the operation, sometimes we be- hold surgeons employing an iron made red in the fire, as Saviard has preserved an example of. Sometimes an awl, as was done by Monro; sometimes a simple knife or lancet; sometimes a straight needle, which draws a thread after it;—but the trocar, employed by Desault, in general claims the preference; because the canula re- maining in the wound, serves, after the stylet is with- drawn, to pass the thread, which by the other processes is either very difficult to be introduced, or requires the employment of different instruments which complicate the operation. For the second part of the operation, or to keep the opening dilated, canulae were used by Duphenix, who made a point of suture upon them—a method in general Diseases of the Mouth. 193 defective, because, besides the inconvenience of leaving a solid body in the parts, it is attended with that of not being able suitably to secure the instrument, which is incessantly disposed to slip into the mouth. The seton, a kind of filter for the salivary humour, then claims the preference. Monro discovered it; but, although this ce- lebrated surgeon saw the benefit, he erred in the man- ner of obtaining it. His seton, equally thick in its whole extent, passing through the two internal and external openings, and tying upon the cheek, was either so large as to dilate the artificial duct sufficiently, and then sepa- rating the borders of the external wound, it retarded the cicatrization; or so small as to procure only a slight se- paration, and then the dilatation was not sufficient. The manner in which the seton was placed in the preceding case, avoids this double inconvenience. A simple thread without, it suffers the wound to cicatrize, while thick within, it keeps open the natural duct; and when this is sufficiently formed, and the saliva accustomed to pass through it, only a single point on the cheek is to be cicatrized, and there will not be a long time lost in the cure. Thus, in the fistula lachrymalis, according to the process iof Desault, the outward wound is almost cured when the dilatation of the canal is completed. § III. Of the Excision and Ligature of the Amygdala and Uvula. The amygdalae become, like all the other neighbour- ing organs of the posterior fauces, the frequent seat of different engorgement, as variable in their nature as in their results. Some, rapid in their progress, and particu- larly observed in persons of a sanguine temperament, in young persons and in those who are compelled to hard labour, partake essentially of the inflammatory charac- ter. Others, slower in their progress, appear in moist Vol. I. 2B 194 Diseases of the Mouth. and cold weather, are attached to phlegmatic tempera- ments, and partake more or less of catarrhal affections. Finally, others that are commonly contagious, pass spee- dily into the gangrenous state, sometimes extend to the neighbouring organs, and are generally more or less fatal to the patient. From thence the different kinds of angina, inflammatory, catarrhal and gangrenous. The two first often terminate in resolution, but they are fre- quently succeeded by a scirrhosity of the tumefied gland which impedes respiration and deglutition and requires their ligature or excision, the only resource in the last species of angina. Let us examine this double operation. The excision of the enlarged amygdala was performed by the ancients in different ways; sometimes they lacerated with the fingers the membrane that covers it, and then plucked it from the place which it occupies between the columns of the velum palati. Sometimes, when there was great resistance, they seized it with an instrument curved like a hook, and then removed it with a knife, which Paul of Egina says should be concave on the side corresponding to the tongue. The moderns, for a long time timid in the employ- ment of these two processes, substituted more cruel ones for them. The actual cautery was proposed, and some success obtained by its means accredited its use for a while; caustics replaced it, but the inconvenience of not being able to limit their effect, and the danger of their falling into the oesophagus, soon banished them from a rational practice. Then excision was resumed, and sometimes perform- ed after the manner of the ancients, sometimes with scissars curved on their flat side, with a knife equally curved on its surface, and sometimes by means of the concave scissars of Levret. A forceps with double hooks was substituted for the simple hook of the ancients. Diseases of the Mouth. 195 Each varied the choice of his instruments at the pleasure of his genius; this operation, at one time simple and easy, was divided into several. Finally, at the present day, the ordinary manner of performing it is as follows: The patient being properly seated, the surgeon causes his mouth to be opened very wide, depresses the tongue with a shell of horn, which he then trusts to an assist- ant, takes a hook, seizes the amygdala, applies to it a common knife fixed on the handle, by means of a small bandage which leaves only a part of the blade exposed, cuts off the quantity to be retrenched, (this is ordinarily at the plane of the columns of the velum palati), re-ap- plies the instrument if all has not been removed, and when the operation is finished, he prescribes to the patient to gargle his mouth frequently with an appro- priate wash. This process was simple and easy. It was used by Desault a long time, but is liable to an objection. The extremity of the instrument, being inserted deeply into the mouth, may wound some parts—not the carotid, as has been said, which its remote situation puts out of danger, but the palatine membrane, in some other place than where it corresponds to the amygdalae—a fear which is much better founded, especially when the instrument is held in the left hand, as when the operation is per- formed on the right. At the instant the gland is seized with the hook, all the throat is put in commotion; a general spasm seems to affect all the parts of the mouth. It was to avoid this inconvenience, that Desault thought of applying to the excision of these glands, an instru- ment first invented to divide the cysts of the bladder, and the figure of which is shown in plate IV. It is a cut- ting blade, concealed in a silver sheath, which, being hollowed at its extremity, there receives and fixes the gland to be extirpated. The instruments for the operay 196 Diseases of the Mouth. tion, which are added to this, are the same as in the preceding case. The proceeding is as follows: 1st. The patient being seated upon a high chair, with the head supported upon the breast of an assistant, the surgeon caused him to open the mouth wide, and to keep it so, placed some solid substance between the teeth, which was secured by an assistant. 2d. The tongue was depressed by a metal spoon, which was held by another assistant. 3d. With a double hook the surgeon seized the gland, which he drew towards him, raising it up a little, took the kiotome, engaging the index and middle finger in the rings (vv), the thumb in the ring (c), made it slide under it, sought to engage it in the rounded hollow (y), at the level of the spot to which the section should cor- respond. 4th. When the portion to be excised is fixed, he draws it more to him, in order to stretch it, presses the instrument against it from below upwards, and pushes the blade, which, in passing through the hollow, per- forms the section. If it is not complete, which especially happens when the size of the tumour is considerable, the blade is withdrawn, and the kiotome being reapplied in the same wound that it had made, completes the sec- tion. If it is not yet finished, a third attempt must be repeated. 5th. The patient was directed to wash his mouth, and a gargle was prescribed for him. The operation thus performed, is as simple, as easy, and more certain than in the preceding case. Such is the disposition of the blade of the kiotome, that when it traverses the hollow, h pushes and fixes solidly the parts to be divided; an advantage that is not possessed either by the scissars or the knife, before which these parts recede when they are moveable. From thence the difficulty of their Diseases of the Mouth. 197 section. If the introduction of the instrument is difficult below, let it be withdrawn and applied above, turning the hollow in an opposite direction; but in general, the first manner of cutting is preferable, because the gland being half divided, cannot then be inverted, and menace with a speedy suffocation by the obliteration of the glottis, as Wiseman and Moscati have experienced. Louis has attempted to prevent this inconvenience, in advising the use of the common knife in the same manner as that of the kiotome just described, that is to say, with the cutting edge directed upwards; but the kiotome, more sure and easy, should be preferred. To the advantage of fixing the soft parts, in cutting them, it adds that of not bruising them, as the most part of the instruments of this nature, for example, the scissars; the oblique disposition of its blade causes it to divide them in a sawing manner. It is true, that this is an instrument added to the arsenal of surgery, but it is not exclusively applicable to a particular operation. It comprises, with the exci- sion of the amygdala, that of the uvula, the section of the fraena of the rectum, of the vagina, of the bladder, the amputation of fungous excrescencies, of polypi of the nose; for example, if that mode of removing them was preferred to extirpation; and in general, of the dif- ferent tumours which are deeply seated in cavities, where our instruments, guided by chance, may include parts that should be respected; where, the base of the tumour, liable to recede from the knife, should be fixed while the section is performing—an use which the scis- sars cannot fulfil without danger. If the tumour to be removed is too bulky for its base to be contained in the hollow, after having cut one portion, let the other be engaged in it, and let the same process be reiterated until the section is complete. In the after part of this 198 Diseases of the Mouth. work, there will be occasion to state these different ap- plications of the kiotome; but, at present, its use rela- tive to the uvula is to be considered. When any affection has increased the size of this ap- pendix so as to impede deglutition, to occasion at the base of the tongue, an inconvenient and painful tick- ling, and to place an obstacle to the pronunciation of the sounds, the only resource of art is to remove its super- fluous portion. To accomplish this, Celsus recom- mends to seize it with forceps, and then to cut it off inferiorly,—a process in use for a long time, then re- placed by cauterization, then by the ligature, renewed and executed by means of different mechanical instru- ments, too tedious to be related here. At length re- sumed, such as Celsus had proposed, and thus adopted with some corrections by Sabatier, who employed the concave scissars of Levret for the section; but their edges being horizontally approximated to each other, bruise the parts in cutting—an inconvenience that is avoided, as has been observed, by the obliquity of the blade of the kiotome. With this last instrument the operation is always easy. 1. To seize the uvula at its inferior extremity with a forceps, and to stretch it by drawing it forwards. 2d. To engage this appendix in the hollow of the instrument, in a line with the place where the section is to be made. 3d. When it is en- gaged, to push the blade which fixes and cuts the super- fluous portion. Such are the details of the operative pro- cess. It is seldom that a troublesome hemorrhage results from the excision of the amygdalae or uvula. There is only an oozing, which is useful to the disgorgement of the parts, and nothing should be employed to check it, as it will soon cease. The patient should gargle his Diseases of the Mouth. 199 mouth, and in a little time the consolidation will be completed. The ligature of the engorged amygdalae is not proper in general, except for such pusillanimous patients as refuse to submit to excision, or upon whom the fear of the operation might produce unfavourable subsequent effects. This method is longer and not less painful than the first, and always occasions more irritation. Moscati having employed it once, a sharp pain and a considerable inflammation supervened; the difficulty of swallowing and of breathing compelled him to cut off the tumour at the place of the ligature, when all the symptoms imme- diately disappeared. On the other hand, in employing this process, there is none of that bloody oozing, fur- nished by the extremities of the divided vessels, which is so favourable to the disgorgement of the part. Be- sides, the base of the tumour being most commonly larger than its apex, cannot be embraced by the noose of thread. If it be sustained by a narrow pedicle, it is then so easy to remove it, by placing this pedicle in the hollow of the kiotome, and so little pain results, that this method is always preferable. However, the ligature has had its partisans. Heister commends it in certain cases; also, Sharp. Many authors have admitted it, and here the processes have varied like the inventive genius of their authors. Some made use of the double pipe of Levret, carrying a noose of silver thread, in which the tumour was engaged and then constricted by a twisting motion, which by daily repetition intercepts its circu- lation and life, and occasions its fall. Others, after placing a noose of thread of Brittany upon a hook, seize the amygdala with it, and make the noose slide along the hook up to the enlarged gland, which was strangled without any proper means of augmenting the constric- tion daily. In order to apply the noose upon the tumour 200 Diseases of the Mouth. to be tied, others had recourse to the instrument of Bellocq. Some reject every instrument, and are satis- fied with their .fingers. Let us pass over more ample historical details, and only remark, that a general double inconvenience is applicable to these different processes. Some do not allow the degree of constriction to be gra- dually increased, and under this view are generally in- sufficient. Indeed it seldom attains it, and then a new ligature must be applied to the tumour. The others, although not attended with this advantage, have those of leaving in the mouth a very large substance, whose pre- sence causes pain, and when a silver thread has been employed, as has been stated, of being liable to fail from the breaking of this thread—a rupture which, being often unavoidable in the successive twistings that it receives, requires a new operation, more painful than the first. To obviate these ineonveniencies, De- sault thought of applying to the ligature of the amyg- dalae, his serre-noeud, intended for that of the polypi of the nose, vagina, rectum, &c. an instrument which will be described in the article of that ligature, and its figure there found. Being a simple stem of silver, it is not large, and receives a thread of Brittany, which is not liable to break, and which may be tightened at pleasure by means of it. The process is as follows: 1st. The patient being seated upon a high chair, with his head reversed upon the breast of an assistant, the surgeon causes the mouth to be opened wide, depresses the tongue, and catches with a double hook the gland to be tied. 2d. He takes the serre-noeud into which the thread of Brittany has passed, so as to form a noose superiorly, engages this noose upon the hook, which he trusts to an assistant, and makes it slide upon the gland, until it embraces it exactly. Diseases of the Mouth. 201 3d. He draws the thread forcibly towards him, and at the same time pushes forwards the serre-noeud, which strangles the tumour to the degree that is suitable. In general, on the first day it must be tightened but little. 4th. The constriction being sufficient, the hook is withdrawn. The thread is twisted round the inferior hollow of the serre-noeud, and the patient is left to himself. 5th. The next day the gland becomes larger than usual, because the venous blood cannot return. The surgeon disengages the thread from the extremity of the serre-noeud, draws it towards him to augment the constriction, twists the thread again when it is sufficient, and thus goes on until the fall of the tumour, which commonly happens at the fourth or fifth day. If, to re- trench the superfluous portion of the uvula, become scirrhous, the ligature should be preferred to excision, which is a method always more easy, more simple, less painful, and more speedy, the same instrument may still be used, and here the manner of employing it would still be the same. The noose of the serre-noeud must be slipped upon the hook which is to catch the extremity of that appen- dix, and being applied to it, will effect the constric- tion, which should be gradually augmented every day until the separation. This method is more simple than those described in Pare, Fabricius de Hilden, Scultetus, &c; but in general, as has been said, when it is possible, prefer excision to the ligature. Vol. I. 2C 2Q2 Diseases of the Mouth. Explanation of the Fourth Plate. ..T Fig. 1. The kiotome seen entire. AB. Sheath of silver, that receives the blade. vv. Rings soldered to the sheath. y. Portion of the blade seen naked in the hollow. ATC. Stalk of steel terminated by a ring, and serving as a handle to the blade. BC. Total length of the instrument, nine inches. Fig. 2. Sheath of the kiotome, seen separate from the blade. xyz. Semi-circular hollow, nine lines in diameter. AB. Total length of the blade, six inches, four lines; width, near the rings, eight lines; near the hollow, seven lines. Ba:. Distance from the extremity to the hollow, seven lines. Fig. 3. Blade of the kiotome, seen without its sheath. E.s, Ds. Blunt sides of the blade more slender than the middle. DE. Cutting edge of the blade, obliquely directed, ten lines long. ss. Projecting edge to prevent the blade from entering too much forwards into the sheath. Ew. Length of the blade, six inches, four lines. Tss. Stalk of steel terminated by a ring, sustaining the blade, whose width is seven lines and a half near the stalk, six near the cutting edge. PL A. 37 SECTION SECOND. DISEASES OF THE NECK. Memoir on Bronchotomy, and on the means of remedying it in certain cases. 1. .LIFE, which is a kind of slow combustion of the vital principle, receives the double aliment that prevents it from being extinguished, through two tubes placed with their backs to each other; the one membranous and cartilaginous, a continual conductor of a fluid that is constantly necessary; the other purely membranous, a conductor at intervals, of solids and liquids, that are to undergo digestion. Death is the certain result of the ob- literation of both; but more speedy in the first, it de- mands the most active succours. These succours con- sist, in general, in establishing an artificial passage, to supply the deficiency of the natural. Now this passage may be of two sorts: 1st, an opening made in the trachea arteria, with a cutting instrument; 2d, the introduction of a tube into this passage, through which the air may escape. The first of these methods, universally em- ployed, is not always the most favourable; the second, as yet little known, is supported only by some success obtained by Desault in the last years of his practice, and by some of his pupils. 2. My object, then, in this memoir is, 1st. To deter- mine the cases that require bronchotomy, and those in I 204 Diseases of the Neck. which this operation may be supplied by the use of elastic tubes. 2d. Supposing the use of these tubes to be indicated, to demonstrate both the manner of intro- ducing them, and the possibility of their remaining in the trachea arteria. 3d. To indicate the most advan- tageous method of opening the aerial canal, in cases where bronchotomy is unavoidable. ARTICLE I. Of the Cases which require Bronchotomy, and of those in which it may be supplied by Elastic Tubes. 3. The cases in which bronchotomy has been pro- posed by authors, may be reduced into two general classes: 1st. Those where the only indication is to afford a passage to the air. 2d. Those in which, to this indi- cation, is added that of extracting some substance from the trachea arteria, or from the larynx, or only of laying open the sides. 4. The first class comprehends drowning, and the different species of angina; the development of a tu- mour between the oesophagus and the trachea arteria, or before this last; the presence of an extraneous body in the first of these ducts, and deep wounds of the neck. To the second, may be referred the introduction of an extraneous substance into the aerial passages, either through a wound or through the glottis, the develop- ment of certain tumours in the same passages, and the caries of the cartilages of the larynx. Let us take a cur- sory view of each of these cases, not to go deeply into the history of the affections which they present, but only to consider them with regard to the operation or the in- troduction of tubes. Diseases of the Neck. 2Q5 Fistula in Ano. complete and operate as in the preceding case. The fol- lowing case offers us an example of this practice. CASE VII. Recorded by Levacher. About the beginning of August, 1789, Victor Gui- terme, aged nine years, felt strong pains in the rectum. Soon after a considerable inflammation extended from the anus to the middle of the left thigh, and was succeed- ed by an abscess, that opened into the rectum at the height of an inch. Although the sinus did not empty itself completely, there was no external opening; and three months after, when the patient came to the Hotel Dieu, the skin only began to grow thin and to be disor- ganized to a small extent. Desault first cut the skin along the whole extent of the purulent collection; then, after laying open by a second incision, a sinus, which went towards the coccyx, he seized with his fingers the angle of skin resulting from these two incisions, and he cut off the thinned and disorganized skin, which he had left entire on the side of the anus, so that he might be able to remove it with a single stroke of the bistoury. He then introduced a grooved director into the fistulous canal, and cut the intestine upon the gorget of wood. The patient was dressed in the usual manner, with a tent, pledgets of coarse lint and two compresses, sus- tained by the T bandage. In the rest of the treatment there was nothing remarkable, and the patient left the hospital, perfectly cured, thirty-four days after the ope- ration. ^7. Without doubt the preceding case is not the most embarrassing in internal blind fistulae. The principal dif- ficulty is, when, the skin being sound and no swelling taking place in the neighbourhood of the anus, there is no sign to indicate whether a purulent collection exists there. In this case, Petit has directed to introduce and On Fistula in Ano. 357 leave for twenty-four hours in the rectum, a large tent, which, by stopping up the internal orifice of the fistula, prevents the discharge of the pus, and forces it to col- lect and produce an external tumour, which is an index of the place where we should cut. This mean is almost always useless: 1st. Because the compression can never be sufficiently exact to prevent all purulent oozing. 2d. Because most commonly the thickness of the parts, lying under the skin, would prevent the swelling. 28. With the same view others employed a different method. It consisted in introducing into the rectum the index finger, which was then, in the withdrawing, to be bent upon itself, so as to push outwards the collection of matter and at the same time to press upon the environs of the anus. The spot where the patient experienced pain from this pressure, was that on which the incision was to be made. A third process consisted in inserting into the anus, for the length of the index finger, a probe folded in two, in such manner that one of its ends should be shorter than the other; this was attempted to be en- gaged in the internal orifice, and in withdrawing the other end, it was carried into the collection; it was then made to point outwardly, in such a manner as to show the collection and of course the place of incision. But, besides the difficulty of introducing this probe into the fistula, and the pains that would inevitably result from it, this process has an inconvenience, which is common to the two just examined, that of making a double inci- sion necessary, first to make a way for the instruments, and secondly to cut the intestine. 29. Desault advised to make the incision of the inter- nal fistula at a single stroke, by employing an ordinary bistoury, the concealed lithotome, or even in certain cases the kiotome, of which we spoke in the article concerning excision of the amygdalae. If the common 358 On Fistula in Ana. bistoury is employed, the surgeon, after having placed the patient in a suitable position, 1st. Introduces the left index finger into the rectum, and ascertains the place and state of the collection by the* presence of induration, by the fluctuation, and by the small tubercle and de- pression which correspond commonly to the fistulous orifice. 2d. He slips along his finger a bistoury, turning the fiat side of the blade against the palm of his hand, and pushes it a little higher than the bottom of the si- nus. 3d. He makes an assistant stretch the skin on the side corresponding to the fistula, and turning the blade of the bistoury he makes an incision, which lays open the bottom of the collection, and extends, more or less, upon the margin of the anus, according to the more or less considerable extent of the collection. 4th. Intro- ducing his finger into the wound, he ascertains if any additional sinus or any callosities exist, and if he meets with any, he opens the one and scarifies the others. 30. If he prefers using the instrument of Friar Come, the finger, being previously introduced into the rectum, serves to direct this instrument into the intestine, being graduated to a degree suitable to the extent of the inci- sion that is to be made. When it has arrived there the finger is withdrawn, and whilst he stretches the skin of the margin of the anus with his left hand, with the right he opens the lithotome, and in withdrawing it makes a sufficient incision. 31. If there is only a small collection, and its orifice is very near to the anus, the kiotome is sufficient for its incision. The portion of the edge of the anus, corres- ponding to the small collection, is engaged in the slope of the sheath; the blade is depressed and the division is made. On Fistula in Ano. 359 § III. Of the mode of operating in Fistula, which are ancient and complicated with callosities. 32. Notwithstanding the multiplied success obtained by the simple incision of the rectum, it is very neces- sary that this operation should be generally adopted, especially for ancient fistulae, whose canal is often ac- companied with indurations, and whose sides are callous. Most practitioners, prejudiced by a false idea respecting these pretended callosities, have thought that fistulae could not be cured without cutting away all the parts which appeared to them to be affected with an unnatu- ral hardness. In Aetius we see that Leonidas passed into the sinus a flexible director, which he bent, after bringing it back through the anus; and that he cut off, around this director, all the parts which it comprised. Almost all modern authors have recommended this method, which was also, until within a few years, most generally followed by practitioners. Experience, how- ever, had demonstrated, and Guy de Chauliac already knew that these callosities, which were caused princi- pally by the presence of the pus and the passage of ster- coral matters, were dissolved and dissipated, as soon as their cause was destroyed by the incision of the fistula. Petit agrees to this truth in his posthumous works; but, no doubt carried away by custom and prejudice, he does not the less recommend the excision of the callous parts, while at the same time he proyes its inutility. 33. This method has, however, very great disadvan- tages. Besides prolonging the treatment, occasioning much sharper pains than the simple incision, and in- creasing the danger of hemorrhage, the loss of substance which it occasions, produces frequently a contraction of the anus, and sometimes leaves, on the side of the natu- ral anus, a kind of artificial anus, by which the faecal 360 On Fistula in Ano. matters escape involuntarily during life. Desault saw an instance of it, in a man who had formerly undergone this operation at the Hotel Dieu. Another, whom the excision had not cured of his fistula, and to which had supervened an unnatural anus, similar to the preceding, came to the Hotel Dieu in the last stage of marasmus, and died some days after his entrance. 34. It is not without reason then that Bell asserts, that we ought absolutely to reject excision, which is founded only upon prejudice; and that in cases, where the considerable decay of the anus would seem to indi« cate a necessity for it, one incision or more, on each side of the rectum, is always sufficient to effect a cure. 35. There is another kind of excision, very different from the preceding, and which often becomes necessa- ry; it is that of the skin, which is commonly found thinned, and so disorganized by inflammation and the presence of the pus, that it is impossible for it to reco- ver its natural state, and to unite to the other parts. No doubt Celsus knew the necessity of this excision, since he advises a double incision to be made of the skin which covers the sinuses, and to remove a portion of it. Fabricius Hildanus also recommended to cut away the skin, or to destroy it in some other manner, when it is so thinned that there can be no hope of its uniting to the bottom of the ulcer. This kind of excision abridges the treatment much, at the same time that it renders the dressings more easy and less painful. 36. It may then be established as a principle, 1st. That the incision is always sufficient to procure the dis- sipation of the callosities, which, being only kept up by the presence of the pus, would soon disappear with the purulent discharge. 2d. That the disorganization of the skin is almost the only case in which excision should be associated with it. If the long abode of the pus in a On Fistula in Ano. 361 vast collection had so disorganized a portion of the in- testine, that there remained no more hope of preserving it, it should also be removed at the time of the opera- tion. $ IV. Of the subsequent treatment in the operation by Incision. 37. Whatever may be the manner in which a fistula in ano has been cut, the dressing consists in introducing every day, between the lips of the wound, a tent of lint, whose length and thickness should be proportioned to the depth and extent of the incision. This is an essen- tial precaution, and recommended, with reason, by Saba- tier, to keep it constantly between the lips, especially at first. If it slips into the anus, the wound may re-unite and the fistula would soon appear again; on the contra- ry, with the precaution indicated, the re-union takes place from the bottom towards the surface, and the cure is certain. 38. If the operation is accompanied with hemorrhage, an accident that sometimes occurs in practice, it may be stopped by pushing up to the top of the incision a dossil tied with a long thread, and then introducing into the wound, with some force, several pledgets of lint sprinkled with colophony, applying above it a layer of lint, long compresses, and supporting the whole with a T bandage. 39. When the blood escapes in great quantity, and this method is not sufficient to stop it, it spreads into the cavity of the intestine, where it finds less resistance than towards the external part; the patient then experi- ences slight colics and a sensation of heat similar to what would be occasioned by a lukewarm injection; the pulse becomes feeble and small, the extremities cold, and syncope takes place. As soon as this internal he- Vol. I. 2 Z 362 On Fistula in And. morrhage is suspected, the dressing should be quickly removed. We must not then be astonished if the blood should escape in a flood, and as if it had been poured out of a bason; it is that which has been accumulated in the intestine, and which then comes out all at once. Desault has sometimes had occasion to make this ob- servation. In a little time the flowing ceases, and there is none but what is furnished by the open vessel. In this case we must employ more powerful means of compres- sion than those mentioned above. Many practitioners, after the manner of Levret, make use of a bladder, which is introduced into the intestine empty, and then filled with air to compress the sides of the intestine; but the difficulty of then directing the compression in a special manner upon the open vessel, renders this method, in general, of little advantage. The process, mentioned by La Faye, should constantly merit the preference. One day, Desault had occasion to prove the insufficiency of the bladder, in a patient upon whom an excision had been made of the internal coat of the rectum, that had been for a long time protruded outwards and considera- bly swelled, in consequence of a prolapsus ani. The hemorrhage was considerable; to stop it he had recourse to Levret's method; in spite of this the blood continued to flow, collected in the intestine, and already the pa- tient experienced the symptoms mentioned above. The bladder was then removed to try another mean, and at that ihstant the blood ran in a flood. It was soon stop- ped, all the clots were removed, and compression was made in the following manner: A piece of square cloth, having at its four angles strings of thread, was introdu- ced into the anus. In the cavity, which resulted from it, pledgets of lint sprinkled with colophony were stuffed, and upon these layers of lint were applied and retained by tying'the threads. This dressing, being left for four On Fistula in Ano. $6$ days in its place, was taken away at the end of that time, without the least hemorrhage supervening. The patient was cured soundly. 40. It is rare that the incision of fistulae is followed by an accident, which the ancients feared especially, and which Paul of Egina regards as inevitable, namely, the incontinence of the faecal matters. The division of the sphincter seemed to involve this consequence; but at this day we know that divided muscles unite again* like other parts, and perform their functions equally well, after this re-union. Besides, the ligature ought evident- ly to be subject to the same inconvenience, with which no person, however, has ever thought of reproaching it. It is true that sometimes it happens that, during the first days after the cure, the patient experiences a little diffi- culty in retaining the faeces; but this seems independent of the division of the sphincter. Desault attributed it to a kind of groove, which is still to be seen in the anus at the end of the treatment. In reality, this difficulty ceases as soon as the groove, of which we speak, is efr faced and the cicatrix consolidated. If, however, it should happen that the sphincter of the anus caimot repover its original action, we must attribute this tp the disease, which may have eaten and destroyed a portion pf this muscle, and not to the operation itself, which may be repeated many times without bringing on this inconve- nience, as is demonstrated by reason ^nd experience. 364 On Fistula in Ano. Explanation of the sixth Plate. Fig. 1. Gorget of wood, concave on one side, convex on the other, seven inches long, seven or eight lines wide, serving for the incision of the fistula. Fig. 2. A metallic probe, six or seven inches long, about two thirds of a line in diameter, cylindrical, with- out a button, and the ends a little rounded. Fig. 3. A canula of gold or silver, about six inches long, exactly fitted to the probe and terminated, like the extremity of the canula of a trocar. Fig. 4. A trocar of gold or steel, of the same size as the probe, exactly fitted to the canula, which it surpasses in length by the whole of its point, terminated on one side by a kind of button. Fig. 5. Metallic forceps, used to draw back the leaden thread, about seven inches long. The width of each of its branches is about six lines, afg, A gutter formed by the re-union of the branches, cut in a slope accord- j ing to their length, fg, A cleft, a line and a half deep, resulting from the separation of the branches, and in- tended to receive the end of the probe and of, the liga- ture. It is a little less than a line at its larger extremity f so that it cannot admit the end of the canula. r, A spring intended to separate the branches. Fig. 6. Female branch of the forceps, t, Top of the cul de sac, which is to retain the other branch, t u, A blunt sheath, exactly fitted to the convexity of the male branch, and covering over all the cleft, when the forceps is open. Fig. 7. Male branch, terminated by a prolongation y, corresponding to the cul de sac t. This prolongation is narrower than the cul de sac, through the whole extent of the opening of the forceps y z. The side of the branch is cut at the edge, and furrowed, as also the correspond- £aws< ; On Fistula in Ano. 365 ing side of the other branch, that it may hold the leaden thread the better. Fig. 8. A section of the forceps, to show the sheath. Fig. 9. A canula of gold or silver, flattened, five or six lines long, two wide, intended to tighten the liga- ture; this is a front view. Fig. 10. A similar canula, longer, a lateral view, so as to show the cleft x, which is intended to receive and fix the ends of the leaden thread. The ends of these canulae must be very blunt, lest they might cut the ligatures. Fig. 11. A repelling gorget, intended to replace the forceps in the extraction of the thread. This figure represents a front view, a b, The concavity of the instru- ment, a, Cul de sac, in which the ligature is engaged; its size must be such that the canula cannot penetrate into it. d, A button, fitted to the metallic stalk, which slides in the internal groove of the instrument. By push- ing this down or up we may draw the stalk in the same direction, and thus take hold of or abandon the ligature, that is engaged in the cul de sac. c, The handle of the instrument bent backward, e, The rounded extremity. Fig. 12. The same instrument in a back view, a b, The inferior end of the internal groove, in which the me- tallic shank slides, seen after the sheath has been taken away, a, The internal orifice of the cul de sac, in which the thread is engaged, d e, The superior end of the groove, e, The end of the metallic shank seen in its groove, c, The handle of the instrument. Fig. 13. The sheath of the inferior end of the groove a b; by removing this we can take off the shank and clean the instrument. •s MEMOIR UPON THE SCIRRHOSITIES OF THE RECTUM. ARTICLE I. Of the Causes. 1. 1 HERE is no portion of the intestinal canal which is more liable to scirrhus, than its two extremities. Th$ pylorus above and the rectum below, afford us frequent examples of it. The last, in particular, is very frequent- ly affected, and the practice of the Hotel Dieu furnishes frequent occasion of observing this malady. Notwith^ standing, it seems to have engaged the attention of authors very little. Only some desultory observations are to be remarked in their works; there is nothing me- thodical in its description—nothing complete—almost nothing judicious in its treatment, Let us show what Desault has added to both. 2. Scirrhosities of the rectum appear in all ages and attack all sexes; but women are much more liable to them than men. There is no doubt that it would be dif- ficult to determine the reason of this difference, which is nevertheless real; since, in the comparative table of these diseases, the proportion has been nearly ten to one in the Hotel Dieu. Persons, advanced in age, are also more subject to it in general than the young; frequently they appear at the time of the cessation of the menses. Scirrhosities of the Rectum. 367 Weak and phlegmatic temperaments seem more dis- posed to it. 3. This affection is a very common consequence of venereal affections, contracted a long time before, and in whose treatment the internal virus had been imperfectly destroyed. Morgagni, who had often observed it, found the remains of this disease existing in most of his pa- tients. Desault made the same remark: considerable hemorrhoids are also a frequent cause of these scirrho- sities. Manget relates the history of a man, who, being operated on by excision, for the hemorrhoids, was at- tacked with these shortly after. Vasalva cites different cases, where the same cause produced a similar effect: it even appears that these affections have often been con- founded with each other, and Morgagni supposes that from this circumstance the first is still so little known by physicians. At the Hotel Dieu, we have also often seen this succeeding to the second, and probably depend- ing upon it. 4. Amongst the causes, we may also rank the metas- tasis upon the intestines of different cutaneous diseases, such as the itch, tinea, ring worms, &c, a metastasis so much the more easy, from there being, as is well known, a very direct relation between the two organs. Desault had under his care two women, who, having imprudently caused a retrocession of ring worms, by the application of a greasy ointment, were affected, soon after, and without any other apparent cause, with a considerable swelling in the membranes of the rectum. Simon Schultz relates, that a German lord had his skin covered with pustules, which tormented him more in the inferior ex- tremities than in the other parts; besides that he expe- rienced sharp pains in the left side of the face, and towards the lower jaw. He had refused to subject himself to the use of an issue. Purgatives, taken occasionally, 368 Scirrhosities of the Rectum. diminished the symptoms, but they soon returned; at length the disease of the skin disappeared without any evident cause, and soon after all the signs of scirrhosity of the rectum shewed themselves. Add to this the change from a warmer to a colder climate; the different affections of rheumatism, gout, &c; the suppression of habitual evacuations, of perspiration, &c; the abuse of anti-venereal injections, &c. In fine, the action of dif- ferent mechanical causes, which may, when introduced into the intestines, irritate, occasion inflammation and consequently scirrhus; and thus there will be a table of the numerous and various causes of this affection. § II. Phenomena of the Disease. 5. Whatever may be the causes, the disease announ- ces itself by a weight in the fundament, by pains, more or less prolonged, in the rectum, and by disagreeable prickings which are felt there; in a little time tenesmus and straining are added; every stool becomes more painful, and there arise frequent desires, but mostly useless, to go to the close stool. Hard and reddish tubercles elevate themselves upon the internal surface of the rectum, or even without the intestine; they do not differ from the hemorrhoids, which they resemble in the beginning, except by being more hard and painful. More or less rapid in their progress, they assume a thousand different forms, sometimes having a pedicle, at others a large base, often so multiplied, that the whole membrane of the intestine seems scirrhous. Morgagni, on opening a subject who died of this disease, found the sides of the intestine hard, thick and strewed with tumours, which were of the size and form of large beans, and which seemed to be conglobate glands. Their surface was smooth, their substance firm and compact; and they Scirrhosities of the Rectum. 369 were larger and harder in proportion to their neighbour- hood to the anus. 6. When situated externally, these tubercles take more room in the efforts that are made to stool; when placed internally they are then often pushed outwards. They still increase, partly shut up the intestinal canal, and extending sometimes six or seven inches up the anus into the rectum, they even occupy occasionally a portion of the intestine colon, whose cavity is partly obliterated, as has been observed by Cortesius, Haasius, Wenkerus, De Haen, Benevenius. At other times being more su- perficial they form a hard and callous collar around the anus, as Desault has recorded an example of in his jour- nal, and as, before him, Vasaiva had observed. They always impede the passage of the faeces, which in passing through, take the figure formed by their mould, appear as if they had passed through a wire drawer, are covered with the pus that escapes, often accumulate above, and in the efforts when at stool, produce sometimes the in- vagination of the intestine, and frequently such pains, that at the Hotel Dieu, we have seen patients prefer almost dying with hunger in order to protract the neces- sity of going to stool. 7. If nothing opposes their progress, these tubercles increase, shut up the intestine completely, finally ulce- rate, are covered w ith varicose veins, occasion frequent hemorrhagies, assume a cancerous character, produce pains that are always increasing and are propagated to the neighbouring parts; at this period it is not rare for a crack to be made in the vagina, and the faecal matters then escape through it. Desault observed this symptom many times. Finally, in the last stage of the disease, we behold a hideous spectacle of the intestine, bladder, va- gina, womb, and all the neighbouring parts, confounded in one common ulceration. Vol. I. 3 A 370 Scirrhosities of the Rectum. ARTICLE II. $ I. Different methods of treatment pointed out by authors. 8. Having arrived at the last period described (7), the scirrhosities of the rectum, are always beyond the re- sources of art, which can only afford an impotent aid. Practitioners have even supposed that most generally it was the nature of the disease to arrive at this stage; also, for the most part, they have only sought to protract the symptoms, without attempting to combat them radically: from thence the long train of palliative means, which they employed; from thence the oils, the ointments and the mucilages that were applied to the part; the emollient decoctions that were taken in injections or semi-cupiums; soothers of every kind; resolvents; mineral waters, sul- phureous or aluminous; terebinthinates, opiates, &c; and a thousand other varieties, according to each prac- titioner who employed them. Some, in order to make suitable applications to the evil, made use of tents. Ciaudinus advised them with this view, and not as being themselves a mean of curing. Vasalva placed in the anus of his patients, while they were in the bath, a canula pierced with many holes, so that the fluids might more easily get into the intestine. 9. The small number of practitioners, who attempted a radical cure of the scirrhosities of the rectum, did not extend their views farther than the general disorder of the humours, without attending to the local affection, which is the contraction of the intestine. Morgagni, persuaded that all these affections partook more or less of the 'syphilitic character, made anti-venereal remedies. the basis of his treatment., He recommends to avoid purgatives, which, irritating the intestine, would not fail to increase the swelling: others, in order to divert the Scirrhosities of the Rectum. 371 humours, proposed to have issues upon the sacrum, thighs, &c. 10. There were some, who, confounding scirrhosi- ties with hemorrhoids, proposed and even performed excision; examples of this are' to be found in Morgagni. 11. All these methods of treatment are, generally, in- sufficient, irrational, and even dangerous. 1st. Those • who have employed nothing but palliative remedies, have gone upon a false principle, namely, that the dis- ease is incurable: no doubt it is, as has been already said (8), in its last stage, when the cancerous state is confirmed; but when there is as yet no ulceration, when the scirrhus is only beginning, being yet remote from carcinoma, we may then hope for a radical cure by the process which will be pointed out. 2d. Those, who have sought this radical cure only by general means, have not reflected that scirrhus, once formed, seldom yields to these means, which no doubt, ought to be em- ployed previously to destroy the internal disease; but, which, having no effect upon the local affection, must necessarily be associated with remedies that act directly upon it. 3d. We will say nothing of the radical cure by means of excision. In fact how can this operation be hazarded, when we are uncertain both of the height to which the disease has extended in the intestine, and of the thickness of the parts which it occupies? These re- flections did not escape Morgagni, who relates a case, in which this bad practice was employed. § II. Treatment used at the Hotel Dieu. 12. This is the general indication: 1st. To subdue the constitutional disease: 2d. When this is destroyed, to treat the local malady. The means of fulfilling the first part of this indication are as various as the numerous causes which we desire to subdue by them. In certain 372 Scirrhosities of the Rectum. cases anti-venereal remedies, in others those which act upon the skin, irritants applied externally, &c. compose these means principally. But, it is not an object to ex- amine them here, because, being common to a multitude of local affections, they have nothing particular with re- gard to this. Let us suppose then that the internal dis- ease has been destroyed, or that it does not exist, as when the disease depends upon irritations produced by extraneous bodies, hemorrhoids, &c. 13. But in this case there still remain two things to be done by the practitioner: 1st. To restore its natural diameter to the contracted cavity of the rectum, to facili- tate the passage of the fasces through it, and to destroy the irritation and pain which result from their passage: 2d. To press down the callosities, to soften and dissipate them, so that the intestine, being restored to its natural state, may not again experience a new contraction, after the treatment. Desault attained this double object, by a simple method, tents kept constantly in the rectum, and whose size was every day increased gradually. Let us consider this method with relation to both the objects, which we propose to attain by its use. 14. The dilatation of canals, which have been con- tracted by any cause, may be accomplished by bodies of different natures. Sometimes art makes choice of those that are hard and solid, and sometimes it employs those that are more soft and flexible. The former are always attended with great disadvantages; they fatigue, irritate and bruise the parts upon which they are applied, either by their weight and hardness, or because, being moulded with difficulty to the inflexions of the canal, they keep it habitually in a state of torturing pain. It is also neces- sary that this inconvenience should be compensated by a superior consideration to induce us to disregard it. For example, in our catheters; the disadvantage of Scirrhosities of the Rectum. 373 solidity is effaced by the advantage of having a continu- ally free canal through them, and which, without derang- ing them, allows the evacuation of the fluid contained in the bladder. But this advantage is of no account here; for it has been proved that, although we make use of canulae of a large diameter in contractions of the rec- tum, the faeces never can escape through them. The internal membrane of the intestine becomes invaginated in the artificial tube, and forms an obstacle to them. Even wind does not pass out, and Desault, who some- times employed canulae, with a view to give them vent, never obtained any good effect from them. It follows from thence that tents, which, with regard to the eva- cuation of the faeces, are not more inconvenient than canulae, and which, on the other hand, being supple and flexible, accommodate themselves to all the folds of the intestine, and, not exercising a painful pressure upon it, cannot by that mean fatigue the patient, merit in this case a decided preference over every other dilating body. It is useless to appreciate the necessity of only increas- ing the size gradually; by that mean \he dilatation is made almost in an insensible manner, and, if I may so express myself, without the patient perceiving it. We must conclude then, that in order to fulfil the first ob- ject (13) of the local treatment of scirrhosities of the rectum, namely, the dilatation of this intestine, tents, such as Desault used, have real advantages over all other means. 15. To attain the second object of this treatment, or to procure the diminution and disappearance of the cal- losities (13), this method is not less advantageous. Here authors have multiplied topical, discussing and resolving applications, &c; but there is no better discutient than a methodical compression upon these scirrhous tumours. The analogy of other tumours would indicate this, if 374 Scirrhosities of the Rectum. experience had not assured us of it. It is by their pre- sence alone, by their pressure upon the swelled sides of the rectum, that tents procure the reduction of it, and not by the medicaments with which they are charged. Desault never greased them with any thing but cerate, to facilitate their introduction. It would seem that the intestine, being surrounded on every side with cellular membrane,1 should \ ield with difficulty to this compres- sion, and that in making dilatation we would only press the scirrhosities into the rectum. Experience, which is , always an invariable judge, answers to the contrary, by showing us, in a number of cases, that these tumours have completely disappeared, at the end of some time, by the use of this method. 16. It follows from what has been said (14, 15), that tents, gradually increased in size,, accomplish the double object of the local treatment of scirrhosities of the rec- tum, namely, 1st. The dilatation of the canal: 2d. The diminution and resolution of the tumours appearing on its sides. Desault employed them with this double view, and in his hands the most happy effects resulted. Upon this point many facts have been published in the Jour- nal. A number of others exist in his manuscripts, and it would be useless to swell this memoir by their collec- tion. Some practitioners, in employing the tents, did not obtain the success which those of Desault seemed to promise them; no doubt the stage of the disease being too far advanced, and perhaps the deficiency of that as- semblage of cares, which is so necessary in this case, were the cause of this. In fact, what can be hoped when carcinoma has succeeded to scirrhus? Then the presence of the smallest body becomes insupportable, and to at- tempt to introduce tents would be rash and irrational. This was never the practice of Desault, although it has been attributed to him. * Scirrhosities of the Rectum* 375 17. The introduction of tents is always simple and easy, as also the treatment which accompanies their use. The following case will show the details of this treat- ment, at the same time that it will serve to confirm by experience what has been already advanced. CASE I. Reine Collot, aged forty-four years, of a sanguineo- bilious temperament, and of a very good constitution, experienced, about the end of the year 1787, very sharp pains and prickings at the margin of the anus, which returned every time that she went to the close-stool. There then appeared at this part hard and painful tuber- cles, which impeded the free passage of the faeces. An almost continual straining supervened, and the pains became insupportable whenever this woman made efforts. to stool. Many physicians and surgeons, being consult- ed in turn, considered this disease as a simple inconve- nience, produced by the hemorrhoids, and thought that it would quickly yield to the remedies used in such cases. Ointments of every kind, fomentations, baths, drinks, soap boluses, pills, &c, were all employed and without success for many months in succession. The disease increasing and even making rapid progress, in a little time the voiding of the excrements became so dif- ficult, that the patient would go twenty times before she could pass some small portions. They came out moulded in the form and size of a goose-quill and with such violent pains, that this woman (who had borne nine children) judged them to be more severe than the pains of child- birth. She almost starved herself to protract the neces- sity of going to stool. Her sufferings and inanition had reduced her to such a state of debility, that she could scarcely support herself, when she came to the Hotel Dieu at Paris, the 15th of January, 1791. 3T6 Scirrhosities of the Rectum. Desault attempted, in vain, to introduce into the rec- tum the end of his finger smeared with cerate. He could not even pass a female catheter into it, but by twisting it alternately from right to left, in every direction, so as to avoid the hard and painful tubercles and lumps which filled up nearly the whole capacity of the canal, and which prevented the catheter from being introduced in a straight line. This affection was treated by pressure, which was made by means of a tent of long lint, knotted and folded in the middle, smeared with cerate and pushed into the rectum by the assistance of a forked probe. Although this was not at first larger than a goose-quill, it could not be made to penetrate more than two inches in depth. Thick compresses, sustained by a triangular bandage, were placed upon the external tubercles. The patient was put upon the use of a drink slightly diaphoretic, and was entirely nourished by rice. This woman appeared to be relieved on the same day. Excited without doubt by the kind of supposito* ry, which she had in the rectum, she had in the evening a copious stool, which did not cause such sharp pains as she experienced commonly. She was then dressed again, as before; but the tent of lint penetrated farther. The dressing remained until the next morning. It was then removed to give an injection, and the faeces, thus delayed, came away without causing much pain. A much larger and longer tent, than that in the morning, was introduced with ease. The patient was dressed twice every day until the sixth, increasing the size and length of the tent a little at every dressing. The strength then began to return, and the excrements came away without pain, by the assistance of an injection which was taken in the morn- ing. The intestine had acquired sufficient capacity to Scirrhosities of the Rectum. 377 admit the finger. By this Desault discovered, wherever he could reach, callous lumps, that were very sensible and very hard at their base, but less so towards their loose edge, which had, without doubt, been softened by the compression made upon it by the tent. Afterwards the dressing was not changed but once in twenty-four hours. The tents, being gradually increased, soon ac- quired a considerable size. The patient was nowise incommoded by them, and her health and strength became more established every day. On the twenty-fifth, Desault again examined the state of the intestine, and instead of the hard and painful tubercles and lumps, which he found at first, there were nothing more than soft, compressed folds, which were not painful to the touch. The tubercles, that were situ- ated at the margin of the anus, were so compressed, that scarcely any vestiges of them could be perceived. How- ever, the use of the tents was continued, and their size still increased, so that on the thirty-fifth day they were an inch in diameter. On the forty-fifth day this woman began to introduce the tents herself, so that by using them occasionally she might be in a state of preventing the return of the dis- ease hereafter. She dressed herself, for eighteen or twen- ty days that she still remained in the hospital, to confirm her cure. She finally went away to resume her labours in the country, on the sixty-seventh day from her en- trance into the hospital, and twenty-six months after the- commencement of her disease. Of Cases m which Fistula are added to Scirrhosities.— Of the consequent treatment. 18. The preceding case offers a view of the treatment of scirrhosities in ordinary cases, those of simple con- traction of the intestine; but when to this contraction Vol. I. 3 B 378 Scirrhosities of the Rectum. there is added an opening into the vagina, it will be per- ceived that this must occasion a difficulty. But this case does not seem to be always beyond the resources of art, if we make use of the means that have been proposed. The following case will prove this assertion, with respect to which we have not, without doubt, facts enough to establish general principles, but which nevertheless we may bring forward with assurance. CASE II. Louisa Grandner, aged forty-six years, had been treated, at the age of twenty years, for a venereal affec- tion. Affections of the periosteum, that supervened some time after on different parts of the cranium, ter- minated in abscesses. Other symptoms then appeared, and this woman, during many years, dragged on a lan- guishing life. Her health was at length a little re-estab- lished, and her life was tranquil enough until the com- mencement of the year 1787. At this period she felt a pricking heat in the rectum, and soon after pains that became so sharp, whenever she went to stool, that she had convulsions. The difficulty of passing the excre- ments increased every day, and in a little time there came away nothing but a kind of wire-drawn stuff and mixed with pus. A new anti-venereal course was then advised for her, which she underwent completely in the hospital Bicetre, and from which she derived no advan- tage. Some time after, on making violent efforts to expel the faeces, she perceived that they came through the vagina. From that time the wind and excrements always followed this new route, and the last, especially when liquid, ran through almost continually and without the patient's perceiving it. In this state she came to the Hotel Dieu on the 10th of September, 1790. Desault Scirrhosities of the Rectum. S79 having, with much difficulty, introduced the index fin- ger into the rectum, found, two inches above the mar- gin of the anus, a hard and callous lump, which closed the intestine. Having dilated it a little, he got over it, and found above its anterior part the opening through which the excrements passed into the vagina; it was about an inch in diameter, and its edges were hard and callous. At first he placed in the vagina a large plug, that was a little conical, smeared with cerate and having the base turned upwards, so that it might slip the less, and that the canal of the urethra might not be compressed by it. He then introduced into the rectum a tent, whose end was pushed beyond the scirrhous lump. He prescribed besides a sudorific ptisan, to each pint of which were added six grains of the mineral alkali; and she took, morning and evening, a pill composed of one grain of calomel and as much sulphurated antimony, in a suita- ble conserve. On the first days of this treatment, the faeces ceased to pass through the vagina. The tents were soon intro- duced with more ease into the intestine; they were increased by degrees, and the excrements did not expe- rience any more difficulty in passing through the anus. On the twenty-fifth day the scirrhous lump, having been worn away by the compression, was no more to be found. The hole communicating with the vagina was diminished, and its edges were thinned. There still ex- isted callosities, that could be felt with the end of the finger, and which extended far beyond its reach, as might be judged by the difficulty of making tents pass them. These callosities were not yet entirely destroyed, when the patient, not suffering any more, and believing her- self entirely cured, left the hospital. She soon repented of this, for two months after the pains appeared again, 380 Scirrhosities of the Rectum. This woman then went into another hospital, where she was treated for three weeks by internal remedies. At length she came back to the Hotel Dieu, with the same symptoms that brought her there at first. The treatment was re-commenced, and had all the success that could be expected. At the end of two months, there remained no more callosities in the intes- tine; the fistulous opening of the vagina was hardly three lines in diameter, and it might have been hoped that the treatment, continued for some time, would make it disappear; but at this time also the woman would not wait for the fistula to be closed before she left the hospital. She was advised to use the tents, which she knew how to introduce herself. REMARKS AND OBSERVATIONS UPOK THE DIFFERENT KINDS OF HYDROCELE. ARTICLE I. Reflections on the radical cure of Congenital Hydrocele. SECTION I. C/ONGENITAL hydrocele, with which the ancients were unacquainted, was not known until lately by the moderns. We are indebted for its history to Viguerie, a surgeon of Toulouse, who, in a memoir presented to the academy, has marked the symptoms and described the treatment of it. I will not repeat the former; but it is necessary to state the latter, that we may have a right conception of Desault's additions to it. It is known that the special characteristic of this kind of hydrocele, is the communication of the water con- tained in the tunica vaginalis, with the serosity of the abdomen;—a communication which results from the non-obliteration of the sheath, furnished to the chord by the peritonaeum, and which, permitting the effused fluid to ascend and descend alternately, keeps up the dilata- tion of the ring and prevents it from contracting, while at the same time the presence of the fluid also prevents the re-union of the sides of the sheath. If, therefore, this communication be intercepted, the water being pre- 382 On Different Kinds of Hydrocele. viously made to return into the abdomen, we might hope for the double advantage of contracting the ring and obliterating the sheath of the chord. This is the object proposed by Viguerie, who advises, 1st. To make a re- gular pressure upon the tumour, which causes the ascent of the fluid that had descended into the tunica vaginalis. 2d. To retain it in the abdomen, and to prevent it from descending again, by means of a truss, whose cushion, being placed exactly upon the ring, should be kept there habitually and constantly, until nature shall have accomplished the double object contemplated by art. Many cases of this author support the marked success of this method, and Sabatier himself has been a witness of this success. Desault also wished to attempt the radical cure by this method, but he was not so fortu- nate. However exactly the bandage was applied, the smallest effort caused the tumour to re-appear, by the falling down of the fluid into the scrotum; and after the long continued use of pressure there was no appearance of obliteration. The insufficiency of these attempts in- duced him to employ a process more sure in its results, more speedy in its execution, and the efficacy of which is confirmed by many cases. $11. DesauWs Process. This process consists, 1st. In causing the greatest possible quantity of the fluid to descend into the tunica vaginalis, in order to distend its sides, and thus faci- litate their perforation. 2d. To make, with the trocar, a puncture in the tumour at the usual place, that is to say, at the anterior and inferior part of the scrotum, and thus to give issue to all the aqueous collection. 3d. To ascer- tain if, as is sometimes the case, a portion of the intes- tine has not descended into the sac, and to reduce it, if On Different Kinds of Hydrocele. 383 that should be the case. 4th. Through an assistant to make a strong pressure upon the crural arch, by means of a cushion, which intercepts all communication be- tween the abdominal cavity and that of the tunica vaginalis. 5th. Then to throw into this latter cavity, at two different times, an injection of red wine, which must be suffered to remain and then be evacuated as in the ordinary operation for hydrocele by injection. 6th. When the wine is evacuated, the assistant discontinues the pressure, the surgeon withdraws the canula, and the scrotum is wrapped up in compresses, soaked in the wine which was used for the injection. 7th. The pres- sure, that was made by an assistant, is replaced by that of a truss, which is applied upon the ring, with the dou- ble view of preventing the intestines from descending into the sac, irritated by the injection, and of preventing the little wine, which might remain there, from passing into the abdomen. The irritation occasioned by the momentary presence of an extraneous fluid, upon the internal surface of the sheath of the chord and of the tunica vaginalis, soon produces an inflammation there, from which proceed the adherence and obliteration of both cavities; and by tohe same means we may accomplish the radical cure, not only of hydrocele, but sometimes even of hernia., which is most frequently complicated with it. This method has the advantage, over the preceding, of being more sure, more speedy, of never risking the regeneration of the tumour, and of being always practi- cable. Perhaps it may be feared that the inflammation, which is here necessary to the obliteration, might be propagated to the viscera of the abdomen, through the continuity of the peritonaeum with the sheath of the chord; but experience has never realized this fear, from 384 On Different Kinds of Hydrocele. which the practitioner is always secure, by taking care that the pressure made* upon the ring is very exact, while he throws up the injection, so that no portion of the fluid can penetrate into the abdomen; by attention to its complete evacuation, leaving nothing in the sac be- fore the canula is withdrawn, and then placing a bandage, as has been related. CASE I. Alexander Mourot, aged nine years, from his birth had, in his scrotum, a tumour, that was fluctuating, semi- transparent, without pain, of the size of a large c^t which disappeared by pressure and a horizontal posi- tion, and the nature of which could not be ascertained by several of the profession. Desault, being called to the patient and being certain, from such evident symptoms, of the existence of a con- genital hydrocele, proposed the operation described above. He first made a previous puncture in the tu- mour, and by it gave vent to a quantity of fluid, which was much more considerable than the sac seemed to contain; the water being evacuated, he examined the state of the parts, and perceived that a small portion of intestine was down; he reduced it, and being then free from all fear on that account, he made a compression at the groin, so as to prevent the injection from ascend- ing, injected lukewarm wine at two different times, evacuated it as in the ordinary case of hydrocele, and then substituted, for the pressure made by an assistant, that of a bandage* for the reasons stated above. The pains, which were severe during the operation, soon abated. A slight swelling of the scrotum super- vened the next morning, increased on the third day, then diminished and disappeared on the fifth. The pa- tient was then made to cough, to see if the hydrocele On Different Kinds of Hydrocele. 385 would re-appear as usual. A small tumour was formed at the ring, but without fluctuation, and did not pass below the pubis; this was the intestine, which made a simple inguinal hernia. The patient, having remained a long time without the bandage, did not perceive any trace of his tumour in the scrotum; the tunica vaginalis having, no doubt, been obliterated by the injection, and not the smallest inconvenience remained from the double affection. ARTICLE II. Reflections upon the radical cure of the Hydrocele, com- plicated with swelling of the Testicle. SECTION I. One of the precepts that is most recommended in the operation for hydrocele by the method of injection, is to examine with care the state of the testicle, after having given vent by puncture to the effused fluid, so that we may confine ourselves to the palliative treatment, if any swelling should be found in this organ. The fear of increasing this swelling, by the irritation which the injected liqour produces, has given rise to this precept, which has been almost universally adopted in practice. But it seems that the application of this has been too general, and that many cases present a contrary indica- tion* Several cases have proved it to Desault, who, by making use of injection, has been able, at the same time, to make a radical cure of the hydrocele, and to procure the resolution of the swelled testicle, as will be seen in the following cases, recorded by Larbaud. Vol. I. 3C 386 On Different Kinds of Hydrocele. CASE II. Francis Moisseron entered, on the 21st of September, 1793, into the great hospital of Humanity, to be treated for a hydrocele of the tunica vaginalis, complicated with a swelling of the testicle. No cause appeared to have given rise to this double affection, whose slow and in- sensible progress offered nothing particular; but which, considering the quantity of the effused fluid, demanded pressingly that it should be evacuated. Before making the puncture, Desault prepared the patient, as for the operation by injection, hoping in fact to perform it, if the swelled testicle seemed susceptible of resolution. A strict regimen, veal broth taken abundantly, some grains of emetic tartar, given to keep the belly free, were the means employed during five or six days, at the end of which the patient.was brought to the amphitheatre to be operated upon there. After the previous puncture and evacuation of all the fluid that was confined.in the tunica vaginalis, the state of the testicle was examined. Its size was much aug- mented; but it was soft, yielded easily to the pressure of the fingers, and did not seem to have any of the characters of scirrhus. This circumstance determined Desault to continue the operation, by throwing twice into the tunica vaginalis, an injection of luke-warm wine, which remained there three minutes each time. The scrotum was then covered with compresses soaked in the wine, and the patient, who during the operation had suffered sharp pains, was carried to his bed. The swelling of the testicle increased the next day. Pain and inflammation also supervened: emollient poul- tices were substituted for the compresses. A strict regi- men was prescribed. The progress of the swelling and inflammation were sensible for the four following days, On Different Kinds of Hydrocele. 387 but they began to diminish on the fifth; light food was then allowed to the patient. The symptoms diminished gradually from the sixth to the twelfth day, at which time the testicle was smaller than before the operation. On the twenty-third, it was almost reduced to its natural size: at length the patient went from the Hotel Dieu, perfectly cured, both of his hydrocele and of the swelled testicle, on the 10th of December, one month and a half after the operation. CASE III. J. B. Maudieu, a butler, native of St.-----, depart- ment of Calvados, was attacked, in the month of Febru- ary, 1793, with a pain in the right testicle; a swelling succeeded a few days afterwards; its rapid progress soon forced the patient to come to the Hotel Dieu, where rest, and the application of emollients, soon dissipated this symptom. Returning home he found, in the month of August, a new swelling, which was accompanied, at this time, by a manifest fluctuation, and whose slower pro- gress permitted him to attend to his business for a month. He returned at the end of that time to the Hotel Dieu; and on examining him, Desault immediately recognized a considerable hydrocele. The indication was, as in the preceding case, to make a puncture, examine the testicle, and then make use of the injection, if the swell- ing was of a nature to be resolved. Desault determined upon this. The operation being performed as in the preceding case, exhibited the same phenomena and had the same results. The testicle, which was at first more swelled than before the operation, diminished gradually in size, and was reduced, on the thirty-fifth day, to its natural bigness. 38& On Different Kinds of Hydrocele. SECTION II. We might add to these many other cases, in which the same process has been employed with equal advantage. Among others Desault mentioned, in his lectures, the example of a goldsmith, in whom a double hydrocele was complicated with a double swelling, and who was cured in a few days by this method. From thence it follows that this general maxim, of abstaining from the operation in the cases under consideration, ought to be modified under many circumstances. Reason would tell us this, if the experience of Desault had not assured us of it. In fact the testicle is subject to different kinds of swelling, which, being essentially distinct in their nature, demand also very different treatment. Without doubt it would be imprudent, when the scirrhus is at ks last stage, to add to the irritation already existing, that of the contact of a foreign fluid. The passage to the can- cerous state would probably be the consequence: but, when the scirrhus of the testicle is commencing, when it is only in its first stage, all practitioners advise that we should attempt to obtain its dissipation by resolvents placed upon the scrotum. Now the effect of these re- solvents would be much more powerful, if, instead of applying them upon the testicle, through the integu- ments, they were applied immediately upon its surface, which is done in this case by injecting the wine into the tunica vaginalis. What takes place, in consequence of the injection, proves evidently that the injected fluid acts as a resolvent. In fact, as in swellings which are dissipated by these remedies, we behold here the swelled organ at first increasing in size, for some days; but in a little while this new swelling, coming to a resolution, seems to involve with it the resolution of the primitive swelling. On Different Kinds of Hydrocele. 389 It may therefore be established a£ a principle, that the swellings of the testicle, which are in their commence- ment, and in which this organ has not yet acquired that degree of weight that is essentially characteristic of confirmed scirrhus, so far from being an obstacle to the operation for hydrocele by injection, present on the contrary a manifest indication for it, in order to cure at the same time the disease of the tunica vaginalis and that of the testicle. The scirrhous enlargement of the testicle, is not the only one that may be complicated with hydrocele; there is another kind of enlargement, different from this, which depends essentially on the relaxation of this organ, and in which its substance, while increasing in size, becomes soft, relaxed, and extends, so to speak, by choaking; a state which is easily indicated by the touch, after the water, contained in the sac of the tunica vaginalis, has been evacuated. But here also to strengthen by tonics the enfeebled elasticity of the parts, is the indication that presents itself. But how can tonics act more effica- ciously, than by applying them to the spot, as is done by injection? Our remedies would have a more certain ef- fect, if we had always, as here, the facility of applying, Without an intermedium, other bodies upon that irr which we wish to produce some changes. REMARKS AND OBSERVATIONS UPON THE OPERATION FOR SARCOCELE. DESAULT has added nothing very important to the operation for sarcocele. In this, however, as in all the other operations, his practice carries the stamp of that surgipal genius, which, by modifying, knows how to appropriate to itself, even to the least detail, whatever places its subject in the most proper light, and which seems to create anew, by repeating what another has done. It is therefore by presenting here, so to speak, his practice put in action, that we must give an idea of it. This is the end proposed in the two following cases, extracted from the Surgical Journal, one of which will exhibit the operative details, in the most simple case of scirrhous testicle; whilst the other will present them to us in the most essential complication, and with which we meet most frequently, the enlargement of the chord. CASE I. Recorded by Plaignaud. Jean Gautier, after having enjoyed good health until the age of forty-one years, was attacked suddenly, on the 18th of September, 1788, with a very painful swell- ing of the right testicle, without being able to suspect the cause of this symptom. After some hours the pain was alleviated by the use of general remedies; but the Operation for Sarcocele. 391 size of the part affected remained the same, and in a little time the testicle became hard and scirrhous. Things remained in this state during six or seven months, without Gautier's feeling any other inconve- nience than the weight of the tumour. Lancinating pains and the rapid increase of the size of the testicle, at length determined this man to come to the Hotel Dieu, into which he was received on the 10th of October, 1789, one year after the commencement of his disease. The tumour then had the size and form, of a goose- egg; it was very hard and but little sensible to the touch; the skin, which covered it, did not participate at all in the affection of the testicle, neither did the chord of the spermatic vessels. Otherwise the subject appeared well formed; every thing, in short, seemed to promise a suc- cessful issue to the operation, which was rendered in- dispensable by the accelerated progress of the tumour, and the approach of lancinating pains. With the view of making the success still more certain, some weeks were employed in preparing the patient by general re- medies, and especially in encouraging him against the fear of the dangers of amputation, which he had exag- gerated much. Desault operated at length, at the end of a month, when he saw him prepared suitably and in the state of mind which he desired. 1st. The patient being laid upon his back, with the thighs and legs extended, the surgeon made, a little below the ring and perpendicularly to the direction of the chord, a fold of the skin, one end of which was held by an assistant, while he held the other himself. 2d. Placing the end of the bistoury upon the middle of this fold, he cut it obliquely up to its base. Then raising up the skin of the scrotum, and seizing with his fingers the lower part of one of the edges of the wound, whilst an assistant did the same on the other side, he 392 Operation fur Sarcocele. prolonged this incision to the posterior part of the scro- tum and of the tumour, whose lateral parts he then dis- engaged. 3d. Before finishing the dissection, he separated the chord, which he found entirely sound, and cut it as low as possible; slipping the cutting edge of the bistoury behind it, whilst he raised it up with the left hand, by holding its upper part between the thumb and the index finger. 4th. After this section, and without abandoning the chord, he seized, with the dissecting forceps, the ends of the spermatic arteries, one after the other, and an assistant secured them immediately with a ligature of double waxed thread. 5th. He then abandoned the chord, and finished the separation of the tumour, by dissecting it from above downwards, holding the cutting edge of the bistoury turned towards the testicle. This is then done without pain, since there remained nothing to be divided but the branches of the nerves, the trunk of which had been already cut in the section of the chord. 6th. That he might not be incommoded by the blood, during the operation, he had taken care to tie the small arteries, as fast as they were divided, so that when he had finished, the wound was almost dry. The whole of the skin of the scrotum had also been preserved, because, as was remarked above, it was perfectly sound, and because the size of the testicle was not great enough to make him experience a very considerable distension. There was then nothing to cure but a simple wound, the uniting of which it was thought might be attempted without inconvenience. 7th. In consequence of this the edges of the wound were brought together and were kept in contact by a cushion of lint placed on each side, and by some other Operation for Sarcocele. 393 lint applied to the wound itself; some long compresses, sustained by a double T bandage, composed the rest of the dressing. The patient did not suffer during the first two days. He was kept on a strict regimen and the use of a dilut- ing drink, acidulated by oxymel. Fever appeared on the third day; it increased a little the two following, but was still moderate. The wound did not then appear dis- posed to unite; but suppuration had not yet taken place, and it was not well established until the seventh day. The ten following days exhibited nothing particular; the state of the wound even seemed to announce a speedy cicatrization. But towards the twentieth day, the suppura- tion of the edges, which until then had been moderate, became extremely abundant; the flaps of the scrotum became thin and folded themselves inward, becoming inverted in spite of the care with which the dressing was made. From that time the strength of the patient diminished daily, and his mind became restless; in a little while a colliquative diarrhoea, which resisted all 'reme- dies, completed his exhaustion, and this man died the forty-fifth day after the operation. The most accurate research could not discover any thing extraordinary in the body. The chord, in particu- lar, was sound through its whole extent. CASE V. Recorded by Cagnion. Joseph Lenoir, aged thirty-seven years, and of a fee- ble constitution, came to the Hotel Dieu, on the 25th of April, 1792, with a sarcocele much more considerable than the preceding. The right testicle was as large as two fists. The chord, being swelled near to the ring, was more than twice the size of the natural state. This mass, which was very hard and but little painful to the touch, occupied the whole of the scrotum and pushed up the Vol. L 3D ^94 Operation for Sarcocele. left testicle towards the groin; the skin of the bag was sound and without adhesions. The patient almost con- tinually experienced a sharp pain, which corresponded to the inferior part of the chord and was prolonged into the abdomen, and even to the region of the kidneys, when the tumour was not relieved and kept up carefully. He also felt, at intervals, lancinating pains in the testicle. This disease was of long standing: two years before, Lenoir had bruised the testicle in a violent exertion and although the pain went away of itself in a few days, there always remained a swelling, to which this man had never paid more than a slight attention. The progress of the tumour at first had been too slow to occasion much inquietude; but the pains, that came on afterwards and the rapid increase of the disease, had at length com- pelled him to seek the aid of art, which he had heretofore rejected. At this period there was no other resource than the operation, which became the more necessary as, in the existing state of affairs, it was to be feared that the dis- ease might soon be propagated into the interior of the abdomen. No more time therefore was lost than what was necessary for the patient to make up his mind and to prepare him by rest, a temperate regimen, the use of diluting drinks, and some gentle purgatives. This operation was not without difficulty, especially on account of the extensive enlargement of the chord. This enlargement, as has been said, was prolonged even to the ring, and it might be supposed that the sound part of the chord, answering to this opening, had been deeply situated within the abdomen, before it was drawn down- wards by the extraordinary weight of the testicle, and that it would retract much above the ring, as soon as this same weight should cease to act upon it. After hav- ing foreseen all that might happen, Desault commenced Operation for Sarcocele. 395 the operation, as in the preceding case, by cutting the skin and cellular membrane, upon the chord, from the ring to the bags, and dividing the scrotum by two semi- lunar sections, which left between them all the superflu- ous skin that was to be cut away. He then separated the lateral parts of the scrotum from the testicle, whose posterior part he dissected, proceeding from below up- wards, and always directing the cutting edge of the bistoury against the tumour. After having in the same manner separated the chord, by continuing the dissec- tion unto the ring, the surgeon drew it downwards care- fully and gently, until he could seize the sound portion between the thumb and the index finger of the left hand. Then he finished the separation of the tumour, by cutting the chord above the enlargement, and near his fingers: afterwards he laid hold of the spermatic vessels with the forceps and had them tied by an assistant, before he let go the end of the chord, which was kept out. It was soon seen how necessary these precautions were; for the chord was no sooner left to itself than it retracted into the abdomen. The operation was thus terminated fortu- nately and without the patient losing blood, because all the arteries were tied as fast as they appeared, which Desault did in all his operations. The tumour, that was extirpated, presented to the examination nothing but a uniform mass, similar to ran- cid lard, and in which no trace of organization could be recognized. Its consistence in some parts was like that of the cartilages of young animals. About the spot, which corresponded to the insertion of the chord, there were several red points, in the centre of which there were some drops of a sanious fluid. The chord had not as much consistence as the principal tumour; but it was already decomposed at its inferior part, and no doubt it would soon have become like the testicle. 396 Operation for Sarcocele. The patient slept in a few hours after the operation, and passed nearly the whole day and the greater part of the following night in profound repose. The wound progressed as usual, until the eleventh day. At this time there came on a general distress, pains in the head, shiverings and fever. The patient stooled with difficulty, his mouth was bitter, and his tongue was covered with a thick yellow slime. The edges of the wound were of a dull red, and furnished a scanty suppuration, which was also thin and of a bad colour and smell. The fever ceased the next day, after evacua- tions had been produced by emeticised veal broth. The other symptoms diminished at the same time. The cica- trization was completed on the thirty-second day. MEMOIR UPON THE OPERATION FOR THE STONE, ACCORDING TO THE IMPROVED PROCESS OF HAWKINS. ARTICLE I. § I. General considerations. 1. .LIKE all others, the operation for the stone is a field, where every one wishes to sow, and where few reap; which all think themselves able to enlarge, and which almost all contract; making an immense mass for the man of erudition to investigate, but which is reduced to a small space for the practitioner. Amidst a multitude of processes, we find that in the books of their authors opinion stifles in the birth some happy processes which genius conceived, which experience has consecrated and which have survived the ruin of others. In the method of the great lateral apparatus, these processes, especially those of Friar C6me, and Hawkins, are at this day the most generally adopted in France, being the same in their effects, but different in their action; the one divid- ing the neck of the bladder and the prostate from without to within, and the other from within to without; each of them attended with their advantages and incon- veniences. Desault employed them indifferently; but, 398 Operation for the Stone. for the second he had a kind of predilection, founded upon the numerous and useful improvements, by which he had made it almost his own. To make these improve- ments known, and to show the mode of operating by means of the instrument thus improved and perfected, is the object of this memoir. $ II. Of the original instrument of Hawkins and the manner of using it. 2. The numerous processes which compose the lateral apparatus, do not differ, as is well known, except in the instrument intended for the incision of the neck of the bladder and the prostate. Hawkins, wishing on the one hand, to diminish the number of the instruments that are necessary for the operation, and on the other to avoid injuring the bladder, thought of making this incision by means of the conductor which serves to direct the for- ceps into the bladder, and which with this view he made with a cutting edge upon the right side. The instrument, which he used, engraved (fig. 1), is a real gorget, con- vex on one side, concave on the opposite side, five inches and an half long from (B) to ( the parts which it embraced, so that by pressing it, the blood, being stopped, might fill the artery and make it sensible; but we did not perceive any change, any swell- ing above the pressure. By the assistance of the tourni- quet the parts were compressed, and I placed a securing ligature above. The patient did not lose three ounces of blood dur- ing this operation. I put a very small quantity of lint into the bottom of the wound; two slight pledgets pre- served the edges of it from the impression of the tour- niquet; two or three slit compresses were placed upon a pledget smeared with the balm of Arcceus, which covered the wound. I did not employ any circular dressing; little sacks, filled with warm sand, were laid along the leg and foot. These parts did not experience the least change in their warmth and sensibility; but the patient was extremely fatigued by the length of the ope- ration, which had lasted near an hour, and by the sharp pains, the distensions and tearings that were occasioned by the different researches. The progress of the tumour had been very sensible from the tenth to the fourteenth day of the operation; it was not arrested at this period, and the pulsations were the same. The fifteenth and sixteenth, its bulk had al- most reached the crural arch; we remarked at its sum- mit a small violet spot, which could not be perceived Unless much attention was paid to it; the thigh and leg preserved their natural warmth; there was very little pain in the thigh, which however appeared to be slightly swelled. On the sixteenth, the first pieces of the dress- Vol. I. 3 R 498 Operation for Aneurism. ing were raised, and the ligature, which had become a little relaxed, was tightened. On the seventeenth day, the nature of things was not changed; the pulse was frequent, small and locked. In the night of the seventeenth and eighteenth, the patient experienced much pain in the thigh, and more particularly a dull pain in the aneu- rismal tumour, whose size increased. I saw the patient at one in the morning, and observed a sensible enlarge- ment, which was a little painful, along the external sur- face of the thigh, without hardness, and the tumour did not cease to be circumscribed. On the eighteenth, which was the fourth day from the operation, we examined the patient with all the attention which his situation de- manded; the tumour, as has been said, continued to prdgress; the pulsations were perceptible at the same degree; the thigh and leg were swelled. All these cir- cumstances proved in an evident manner, that the liga- ture, which was placed below the tumour, had not pro- duced the effect which we expected from it: we were confidently persuaded, that the artery had been tied, although several of the assistants doubted it. The ap- pearance of the patient was very unfavourable; his pulse small, locked and frequent; his age, and all the fears which I had manifested before the operation, were not calculated to assure us of the success of a second operation, which the circumstances of the patient de- manded imperiously, if we did not mean to abandon him to a certain and speedy death. All these considera- tions being maturely weighed, we decided to open, the aneurismal sac. On the same day (eighteenth), at four o'clock in the afternoon, we proceeded to this operation, in the pre- sence of MM. Marigues and Valentin, our associates. We prepared a narrow cushion, which was a little elon- gated, firm and solid, and fixed upon a handle, that it Operation for Aneurism. 499 might have the double advantage of occupying little space, and of being held firmly, by a strong and intel- ligent assistant; another assistant being ready to second and replace the first. This cushion being placed upon the artery at its egress from the abdomen, and press- ing against the pubis, I plunged the bistoury into the superior part of the tumour, and down to the lower part. The sac and the skin, comprised in it, which was perfectly sound, and the first lymphatic layers, were an inch and a half thick; a great quantity of fluid arterial blood escaped immediately, and I took out a mass of clots and lymphatic concretions, of a size ex- ceeding that of the fist. The sac sinking and leaving more room between the superior angle of the incisions and the compressing mean, I cut upwards to the hand that compressed, in order to find precisely the arterial crevice, which I could see only for an instant, being every moment inundated by the blood, in spite of the care which was taken to compress the artery; a thorax probe was passed into the superior tube of this canal, which was raised up as quick as possible; the enormous loss of blood making me accelerate the ligature. Directed entirely by the touch, and taking the arterial tube and the probe between my fingers, I passed the needle under the raised artery; the cord being intro- duced, I drew its extremities upwards, and placing a finger between them, upon the artery, the compression was suspended; no more blood appeared. I raised up the artery by means of this noose, and thirteen to eighteen millimetres (six to eight lines) higher, I passed a flat cord under the artery, in case it might be needed. I then placed the tourniquet, and compressed the arterial tube; the blood appearing to come from below upwards, I made a ligature below the sac, by means of a waxed 500 Operation fir Aneurism. thread, tied with a double knot. After these two liga- tures were made, there appeared no more blood in the aneurismal sac, which was lightly dressed with soft lint and covered with a pledget, smeared with balm of Arcceus, upon which I laid some compresses supported only by the long pieces, which embraced the thigh, without compressing it. The tourniquet, which was ap- plied to the first wound, having become useless, was withdrawn. As I had foreseen, at the time of the consultation, the patient, in spite of all the haste which I could make to tie the artery, lost such a quantity of blood, that he fell into a swoon, from which he could not be revived, not- withstanding all the assistance that was given him. His pulse could no longer be felt, he expired gradually, and died at midnight, eight hours after the operation. The anatomical dissection being made the next day, at the amphitheatre of the hospital, in the presence of our colleague Allan, and of a great number of pupils, demonstrated, 1st. That the deep artery, which is usually a part of the femoral to the distance of four or five centimetres and a half (an inch and a half to nearly two inches) from its egress from the abdomen, took its origin at twenty- three millimetres (ten lines); that, according to the usual order, it gave out almost immediately the two cir- cumflex; that these canals followed their ordinary di- rection; that the subaltern arteries had a considerable diameter; that the trunk of the deep artery, before its division, almost equalled the diameter of the femoral artery; that the superior articulars were also sensibly di- lated; that the deep artery was attached to the aneuris- mal sac by such an adhesion, that it followed the sac when raised up by a probe introduced into the arterial Operation for Aneurism. 501 tube, as may be seen in the anatomical preparation, in such a manner, that it was almost impossible to pass the needle between it and the femoral, without incurring the risk either of wounding it, or including it in the ligature. 2d. That the ligature, which was made in the first operation, embraced the artery, the femoral vein and a small portion of the fibres of the great adductor muscle; that, in the second operation, the superior tight ligature was placed at six millimetres (three lines) from the aneurismal sac; that it embraced the femoral artery and a third of the deep artery, which was pierced by the needle; that the security ligature, which was placed above this, had passed precisely between the deep and the femoral artery, and that this last was embraced accu- rately; that the inferior ligature comprised the artery, six lines below the sac, and that the vein had been wounded by the needle. We may observe, that not- withstanding both these punctures, the blood had ceased to flow into the wound. 3d. That the artery was lacerated to the extent of five centimetres and a half (two inches) to seven centime- tres two milimetres, (two inches, eight lines), from its origin; that the entrance and egress of the sac had the shape of a funnel; that the width of the artery in the centre could not be ascertained precisely, its edges be- ing confounded with the cellular membrane, which made the greatest part of the aneurismal sac; that twenty-se- ven millimetres (or one inch) below this sac, there was a dilatation, or cul de sac, in the arterial tube at its pos- terior part, that is to say, there was a true aneurism com- mencing, whose interior was smooth, polished and with- out any alteration; that the rest of the extent of the arte- rial tube, as also the femoral on the right side, were in their natural state. 502 Operation for Aneurism. 4th. That the diseased thigh was already affected with a purulent infiltration, extending upon the surface of the muscles, from the anterior and external part of the thigh, under the fascia-lata; that this suppuration had not been remarked between the muscles, except at the spot of the first incision. REMARKS AND OBSERVATIONS UPON ERYSIPELAS. $ I. General Considerations. 1. IN general, erysipelas is an inflammatory, superficial, uncircumscribed tumour, with sensible heat, and sharp and pungent pain. All the affected parts are of a lively red, clear, and shining, which disappears under the fin- ger, and returns as soon as the pressure is removed. These general characteristics apply to every erysipelas; but, being more or less marked in each, they offer themselves with different symptoms, which circum- stance determines the different kinds of erysipelas. 2. The first and most simple, is that which Suavages and Cullen call erythema, a name employed by Hippo- crates to designate every erysipelatous redness; but this term is not general, and the idea which is attached to it, is indeterminate. It appears to be more suitable to appropriate to this kind the name of bilious erysipelas, which is employed by the greatest number of authors: not that we ought to adopt the metaphysical theory of the Galenists; but because it seems that this term in- cludes the idea of the bad disposition of the primae viae, which is one of the principal symptoms, and especially On Erysipelas. 503 distinguishes this erysipelas from others. Its symptoms are these: the tumefaction is slight, most frequently in- sensible; the skin has a rose colour bordering upon yel- low; the sensation experienced by the patient, is less of a drawing or pulsative pain, than a painful smarting, simi- lar to that of being scalded with hot water or the rays of the sun. When it is coming on, most frequently the ap- petite is lost, the mouth becomes bitter, the tongue is moist and covered with a yellow fur; nausea supervenes and sometimes bilious vomiting. The patient, being dejected, feels lassitude, wandering pains, and a sharp sensation of heat, without having, however, a great dry- ness of the skin or much thirst. Frequently the disease commences with a fever more or less ardent, preceded by chills, and accompanied by a violent headache. This kind is the true or bilious erysipelas, or rather the ery- sipelas, properly so called, of the ancients; and it is also the simple erysipelas of some moderns. 3. The other kind, which we call phlegmonous ery- sipelas, corresponds to the erysipelatous phlegmon of the ancients, and in part to that which they also called phlegmonous erysipelas. It is the erysipelas, compli- cated with phlegmon, of modern elementary books. In this the skin is more elevated, the tumour deeper harder, and presents a more durable colour. There is but little tension in the skin; the pain, which is con- stantly pungent, becomes throbbing at intervals. The patient at first has neither bitterness nor nausea; he has a dry skin and tongue, an ardent thirst, a full and hard pulse, indicating a sanguineous plethora. At the end of a few days, especially when bleeding and the antiphlo- gistic regimen have been employed, the tongue becomes foul and moist at the edges; bitterness and nausea supervene, and the disease then becomes a bilious ery- sipelas. 504 On Erysipelas. 4. All erysipelas may be naturally referred to these two classes; and we should especially pay attention to the original state of the primae viae, to place each in the class to which it belongs. 5. There is, however, a kind of erysipelas which dif- fers from the others, in that it demands a local treatment, although its symptoms do not exhibit any thing extra- ordinary. It is that which supervenes to wounds, contu- sions, &c. 6. The prognosis of erysipelas, whatever may be its kind, must be regulated by its extent, its intensity, the part it affects; the most dangerous is that of the head and the neighbouring parts. A'etius, Paul of Egina, Oribasus, apprehend, in this case, that the inflammation intercepts respiration, and that the patient may perish from suffocation. Pare regards the erysipelas of the womb as mortal. Hippocrates also gave an unfavoura- ble prognosis of the erysipelas, which abandons the external surface suddenly, and is translated to the in- ternal. Obstinate ulcers and even gangrene are also, according to the ancients, frequent consequences of erysipelas; although these accidents depend, without doubt, most frequently upon the want of care, or upon the manner of treatment, rather than upon the nature of the disease. We may say as much of the erysipelas, following wounds, ulcers, fractures, and luxations, the consequences of which authors describe to us as greatly to be dreaded. § II. Treatment. 7. The treatment of erysipelas has varied much in the different periods of art. We may consider this treatment under two views: 1st, with respect to die internal means; 2d, to the external,-4—employed by prac- titioners. On Erysipelas. 505 Of the internal means. 8. The internal means have been extremely multi- plied by authors. Celsus recommended bleeding indis- criminately, when the strength of the patient permitted it. Aetius employed it only in cases of sanguineous plethora; he treated the bilious erysipelas by purgatives. Paul of Egina had recourse to these last, only when there was some obstacle to bleeding, for which he gave a general precept. Oribasus and Avicenna recommend nothing but evacuants of the bile. Guy de Chauliac, Thevenin, Munnick, Sydenham, &c. on the contrary, prescribe bleeding for all cases of erysipelas that are rather severe, and they are followed in this by the most of moderns, of whom some, determining by the appear- ance of the pleuritic crust of the blood, repeat the use of it three or four times. 9. Thevenin sometimes employs a slight emetic, but only after having found other means insufficient. Pare" remarked that the disease commonly terminates itself by bilious vomitings and purgings; but he did not then make use of emetic tartar, which is so well adapted to aid and accelerate this termination. And now that we know the effect of this remedy so well, there are many practitioners who are afraid of it; and Stoll himself did not employ it, until after he had prepared the patient by incisives and dissolvents. Richter advises it from the first moment, except in rare cases, which require pre- vious bleeding. Cullen adds to this mean what are called 6ooling purges. He is inclined, however, to the method of Selle, who, regarding erysipelas as a kind of putrid fever, associates, with evacuants, kino, wine, and other antiseptics. Bell prefers the antiphlogistic regimen and bleeding, forbidding, however, topical bleeding, which, in this case, produces ulcers difficult to be cured. Vol. I. 3 S S06 On Erysipelas. 10. Fresh air has also been an important remedy in the treatment of erysipelas. Alexander of Tralles recommended it. Par6 also looked upon it as of conse- quence, when joined to cooling and moistening appli- cations. It is with the same view that Sydenham advised the use of small beer, and some others have employed red wine and water; that Thevenin, in obstinate erysi- pelas, prescribed baths, milk-whey, veal broth, and cold mineral waters. Of the external means. 11. External means have been for a long time in general use in the treatment of erysipelas. However, Hippocrates says nothing that can authorize the pre- sumption that he ever had recourse to them; but the physicians, who succeeded him, have been prodigal of liniments, fomentations, cataplasms, and even ointments of every kind. It was not that they did not soon per- ceive their ineonveniencies. Galen had remarked it, but this did not prevent him from also using the diapalma plaster. Fabricius Hildanus saw the use of oil of roses, continued for some days, produce gangrene in a phleg- monous erysipelas. 12. The stupefying and narcotic applications, recom- mended by Galen, Paul of Egina, and many others, have also induced mortification frequently. 13. Resolvents and repellents have been advised very generally. But, besides that they may occasion fatal metastases, they often produce induration or gangrene of the diseased part. Paul of Egina observed it, and therefore rejected astringents and spirituous resolvents. From thence also the practice of Avicenna, who prefer- red the effusion of cold water upon the part, to the most active topical applications. From thence the use of oxy- On Erysipelas. 507 crat, of a little salt of lead dissolved in much water, as recommended by Thevenin, &c. 14. Emollients have also had their partisans. Celsus made use of cataplasms, covered with compresses soak- ed in cold water. Galen made them resolvent by oxycrat. Paul of Egina advises a cataplasm of barley meal; Thevenin one of rye meal; Diemerbroeck one of oak leaves and the meal of beans. 15. Cullen, persuaded of the inutility and danger of all kinds of topical applications, rejects them absolutely. He only permits the sprinkling of the affected part with fine flour, as has been since done in England, to absorb the acrid humour, which escapes through the skin and tends to ulcerate it. Bell, agreeing with Cullen respect- ing the bad effects of topical applications, applies how- ever upon the skin, when the pain is very sharp, a light layer of the extract of lead. Richter, far from approving this mean, places it upon the same footing with all the astringent remedies, which, he says, have often occasion- ed fatal accidents; he applies nothing, absolutely nothing to the tumour. It seems that Actuarius was not very far distant from this method; since he has observed, with respect to herpes, that local remedies were abso- lutely useless. 16. Besides the remedies that have been mentioned, there is another, which has been much employed since the time of Thevenin. These are vesicatories, which he thought suited to evacuate or turn the erysipelatous humour, when they were applied at a distance from the diseased part. An observation of Alix, proves in what estimation this remedy should be held. He applied vesi- catories to the legs of a peasant, on account of a shifting and obstinate erysipelas, which had successively occu- pied the back, the breast and the face. The erysipelas 508 On Erysipelas. was immediately translated to the feet and followed di- rectly by gangrene. 17. Such is nearly the substance of what has been said upon erysipelas. It will perhaps appear a little con- fused; out the distinctions established between the dif- ferent kinds of erysipelas, having almost always been neglected in practice, and most authors having in all cases, pointed out but one and the same treatment, we cannot make the history of the remedies correspond with the division of the books. As to the rest, this sum- mary is sufficient to enable the judicious reader to com- pare what authors have written, with the practice of Desault, a view of which will be presented in the succeeding articles. 18. In the bilious erysipelas, whatever heat there might be upon the skin, and however considerable the fever, Desault gave, in the first instance, a grain of tar- tar emetic diffused in much fluid. The symptoms usually diminished immediately after the operation of this drink; and he has even seen them cease entirely, although the remedy produced no other effect than the increase of the perspiration and urine. 19. Sometimes, however, the symptoms were obsti- nate, notwithstanding these evacuations. He then re- peated the emetic draught once, twice, and even more. When the erysipelas had disappeared the fever ceased, and there remained no more bitterness in the mouth; in order to finish the cure, he employed one or two purges of cassia, manna and a grain of tartar emetic. During all this time, the patient drank abundantly of a diluting ptisan, acidulated with oxymel. As soon as the first symptoms were abated, some food was given; because Desault remarked that too strict a regimen increased the acrimony of the humours and often reproduces the bilious disposition, especially in hospitals, where in On Erysipelas. 509 general the air is insalubrious. The bilious erysipelas, however considerable it may be, and whatever part it may affect, yields usually in a few days, to this treatment. Desault never met with a case, which was not finally dis- sipated. He has also constantly observed, that the disease was more obstinate and severe, when the patients had been bled before their arrival at the hospital, and espe- cially when this had been done several times. 20. In the phlegmonous erysipelas, emetics and other evacuants would still increase the irritation, which is already considerable. Therefore Desault never had re- course to evacuants, until after he had destroyed the irritation, and diminished the sanguineous plethora, by one or more bleedings, according to the severity of the symptoms and the strength of the patient. The bilious disposition, which then manifests itself, indicates the necessity of evacuants and the time for administering them. During the treatment he also gave nothing but a diluting drink, such as milk-whey, or dog's-tooth tea, with oxymel. 21. No topical applications were used in either kind of erysipelas, proceeding from an internal cause. The affected part was exposed, as much as possible, to the air. But when the erysipelas, either bilious or phlegmo- nous, supervened to a contusion, wound or ulcer, regi- men and internal medicines would be insufficient, if we did not add to them topical applications, suited to destroy the local irritation and to recall the suppuration. It was with this view that Desault employed cataplasms, whose good effects in these kinds of cases, are proved by nu- merous observations. But he regarded it as an essential precaution, not to extend this topical application far be- yond the bruised part, or the edges of the wound or ulcer. If some application is permitted upon the rest of the erysipelatous surface, it must be only an aqueous 510 On Erysipelas. and very slight resolvent, like the vegeto-mineral water, as it has been constantly used at the Hotel Dieu; that is to say, made with only a dram of the extract of lead to a pint of water. Let us confirm, by some examples, the doctrine established above. Bilious Erysipelas from an internal cause. CASE I. Ad. Goyde, aged twenty-seven years, of a bilious temperament, in consequence of a violent head-ach, ar- dent thirst, and difficulty of breathing, was attacked with an erysipelas in the upper part of the face and es- pecially about the eye-lids, which she could not separate. When she arrived at the Hotel Dieu, she had a furred tongue, bitter mouth, fixed loathing, desire to vomit, a burning heat, and a full, hard and frequent pulse. The menses, which were then present, compelled a delay of of the use of the remedies, that were proper for com- bating these symptoms. A grain of the emetic, given in a pint of water, on the third day, procured several bili- ous stools, which relieved the patient a little. The same remedy was repeated, and on the fifth day the redness and swelling were almost entirely dissipated. Three laxatives, composed of an ounce of the pulp of cassia, two ounces of manna and a grain of the emetic, which were taken on successive days, completed the cure. Erysipelas in consequence of Wounds. CASE II. Marie Framay, aged sixty years, 'came to the Hotel Dieu on the 7th of September, 1789, with an erysipelas on the left leg. The tongue was furred and moist, the mouth bitter and the pulse a little feverish. A grain of the emetic was administered to her and produced an On Erysipelas. 511 abundant evacuation of bile. Notwithstanding this re- medy was continued for three days, the erysipelas extended over all the posterior part of the leg. The cicatrix of an old wound, which was ready to break out, was then perceived near the internal ancle. This circum- stance produced a change of the treatment. The whole leg was enveloped in an emollient cataplasm, and the administration of the emetic continued. A slight sup- puration was formed in the wound; the erysipelas dimi- nished sensibly7, disappeared on the twelfth day, and the wound was closed, some days after, by a solid cicatrix. Wandering Erysipelas. CASE III. Louisa Chevalier, aged forty-eight years, having been operated upon at the Hotel Dieu, for a cancer in the right breast, appeared to be nearly cured, when the wounds that was almost cicatrized, became covered with a glairy suppuration; the tongue was furred and the mouth bitter. Towards, the right elbow there appeared a swelling, which was dissipated after several bilious vomitings and stools, procured by a grain of the emetic. A cholera supervened some days after, and there was a slight ulceration in the edges of the wound. These new symptoms disappeared and the cicatrization recommenc- ed; but, in a little time the pulse was raised, the sup- puration became abundant and serous, the face red and the mouth clammy. The same day an erysipelatous disposition was perceived in the right arm, which on the next day was swelled, red and painful in two thirds of its lower parts. The patient had nausea and a bitter mouth; and the cicatrix was already destroyed in part. She took a grain of tartar emetic in the watery solution, which diminished the swelling for three days. On the fourth an issue, which had been made in the left arm, 512 On Erysipelas. ceased to suppurate, and there appeared above it an en- largement, which was dissipated as soon as the suppu- ration of the issue was restored, by covering the pea with a little basilicon stimulated with powder of cantha- rides. The erysipelas then attacking the lower part of the same arm, it was soon driven away by the use of emeticised milk-whey; but, in proportion as it disap- peared, the right fore-arm swelled and became painful. A few days after it had acquired a considerable size; the skin was tense, of a clear and shining red. The cellular membrane yielded however to the impression of the finger, and did not re-establish itself but slowly. The redness and pain were not dissipated totally, until after repeated emetics and purges. The wound of the breast cicatrized speedily; but the fore-arm remained oedematous for a long time, and notwithstanding a com- pressing bandage, it did not entirely resume its natural size, a month after the disappearance of the erysipelas. END OF VOLUME I.