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OF
OPERATIVE SURGERY
FOUNDED ON
THE BASIS OF ANATOMY.
VOLUME II.
BY CHARLES BELL,
Honfcon t
PRINTED FOR LONGMAN, HURST, REES, AND ORME, PATER-NOSTER ROL- AND CADELL AND DAVIES, STRANU.
1809.
C. STOWEK, Printer,
Faternoster Row.
M SUliGWAL WBRARY 13)
TO THE READER.
JVIany of the members of our profession are accustomed to draw a distinction betwixt the knowledge obtained in classes or dissecting- rooms, and that practical knowledge which they have gained by experience; and they seem willing to extend this distinction in favour of themselves, by maintaining the supe- riority of practice over theory.
There may be a defective system of educa- tion which gives too much importance to theory, but certainly the ignorance of what has been done by men of the first genius in this way, does not make the surgeon more an ob- server or a disciple of nature. Ignorance or weakness is as prone to theory as to super- stition, and it requires a mind of a higher cast, strengthened by education, to subdue the
a 2 natural
IV TO THE READER.
natural inclination to generalize on a few limited facts.
In conversing with medical men, the most remote from the Universities and practical schools of anatomy and surgery, I have found them indulging in the most fanciful and wild theories. No one ought to be more ready than myself to acknowledge the benefit he has derived from the conversation of practical men ; at all times impressed with the import- ance of their information, I have cultivated their acquaintance with a view to improve- ment ; but even these very men, whose chief value consists in the number of facts which they can attest from their actual observation, have always ready a theoretical interpretation which obscures the truth. It is not easy for a man altogether to divest himself of this dis- position, nor is it to be wished that he should ; for then, his lively interest in the profession would abate ; but it is a propensity that re- quires to be chastened by education, and by acquaintance with the errors which have been committed in theoretical reasoning.
In what I have now said, the persons to whom I allude are those who, indifferent to what is doing in the profession at large, over- rate their own resources, and are not fully sensible how little any individual can do iri
improving
TO THE READER. V
improving the general practice of medicine or surgery. Men who assume the merit of hav- ing learned all they profess from practice, and who would raise a distinction betwixt princi- ple and observation, are not aware of the extent of their admission. They confess themselves to have entered on the profes- sion but poorly prepared; which is a great offence, since they must long have groped their way in the dark, doing mischief before they have learned to do good. They want the only secure foundation of experience, ac- quaintance with the structure of the body ; and, by entering on a high and responsible duty with a thoughtless boldness, they render even their very testimony suspicious.
Ever since I became aware of the true means of improvement,, it has been my study to seek the conversation of the elder members of the profession. In this search I may confi- dently say, that I have found their conversation pregnant with information, and their practice safe as well as bold, in the proportion of their acquaintance with ' anatomy. The best sur- geons are, for the most part, the best men in a more extended sense ; for humanity of dis- position does not merely insure careful study before the duties of the profession are under- taken,
VI TO THE READER.
taken, but stirs on to active and virtuous ex- ertions through -a whole life.
So far, therefore, from desiring to put my- self in opposition to men of observation and experience, during the writing of these vo- lumes, I have held myself as in their presence, , and I confidently hope that they will receive this book favourably, if I shall be found to have laid the ground-work securely. I pro- posed to form a System of Operative Surgery, founded on Anatomv ; and between the title of the book and the execution I hope there is a due connexion : for, if it be only in the title and preface that I have made use of anatomy, I have done nothing more than what has been done by all writers of systems.
As I have built my expectation of being tiseful on the union of the studies of anatomy and surgery ; and as. I every day see reason to believe that the neglect of surgical anatomy is still a common defect of education ; I have felt myself called upon at all hazards to prove the necessity of this union. It will not be denied, that there are entering on the practice of the profession crowds of students who are ill pro- vided with a knowledge of surgical anatomy ; and there are many in practice who seem never to have acknowledged anatomy to be a science from which the principles and the
rules
TO THE READER. Til
rules of practice are to be deduced. In short, I cannot help concluding, that though the higher departments of surgery are successfully cultivated by a few, there is not yet a pro- portionate diffusion of knowledge. Men of the first eminence have sought to obtain that rank by exerting the strength of their talents upon particular subjects ; and who is there that can regret this ? But still I think I am borne out in saying, that the general subject has been in con-sequence more remissly cultivated. It has been my endeavour, throughout this work, to reclaim my reader from a loose method of considering the subject ; to carry him back to the study of anatomy ; to make him have recourse to the principles, nay, the very elements of the science. I acknowledge that in the dissecting-room the student learns the elements only ; that to let loose upon the •world a young surgeon, whose education has been confined to dissection, is like arming a man bereft of reason, He is accustomed to use the knife ; and desirous of doing it on all occasions ; dextrous, perhaps, he may be, but he has not studied the structure farther than it has reference to the dead body ; while the acknowledged use of anatomy has reference to the living body. He can perform operations, but does not know the fit occasions for them ;
nor
VU1 TO THE READER.
nor how much the powers of life will bear ; nor how the constitution varies, and disease affects the natural powers of life.
Having acknowledged thus much, I take this position in favour of anatomy, that there is no doing without it ; no advancing in safety one step, either in study or in practice, without its guidance. The ignorance of it makes a surgeon shy and deceitful ; and what a commentary might be written on these two words ! I am in hopes that, when my reader peruses the chapters in this volume., which treat of Fractured Bones, of Dislocations, and of Wounded Arteries, he will think, that, although it be possible to cull from dissertations on the diseases which fall under the care of the surgeon, and from the lectures of eminent men, what might form a book having more of the external character of a svstem than these
ml
volumes ; it is impossible to enter on the dis- cussion, to go to the depth of the subject for the principle of practice, without a continual re- ference to the structure ; and that, by keeping the anatomy continually in view, the rule of practice comes out id ore correctly, with more simplicity and force. It is in this sense that 1 have ventured to call the present work a System ; for I hold a system to be distinguish- ed
TO THE READER. IX
ed more by the governing principle than by the apparent order of enumeration.
I have to regret, that in the very first part of this volume I have not been able to speak decidedly as to the rule of practice. I allude to the operation of bronchotomy, I have not performed the operation ; and surgeons with whom I have conversed upon this subject have not, in my opinion, taken the whole circum- stances into consideration. I hope, however, that I have explained the action of the throat and glottis, and the accidents in practice, so as to prevent the recurrence of some errors which have come to my knowledge. One thing I cannot avoid mentioning : when the patient has struggled for some time with the spasmodic difficulty of breathing, the face is swelled, and of a leaden colour; an apoplectic insensibility follows ; when you raise him up, the head falls upon the shoulder ; he now breathes with less difficulty in the throat, but if the operation be performed it will be too late ; for the difficulty of breathing through the larynx has ceased in consequence of the
5 general
X TO Tilt. READER,
general debility having resolved the spasm; This debility of the muscular fibre and insensi- bility* has resulted from the effusion having taken place in the lungs.
What I have said on the subject of the artificial pupil I wish my reader to consider as a suggestion hitherto ungrounded on the ob- servation of the human eye.
I have considered fractures and disloca- tions as forming the principal matter of the volume ; and before treating of them, I have thrown the subjects of abscess, and of disease of the spine and of the great joints, into short dissertations, as forming the best introductions to the surgery of the bones ; a subject so im- portant to the practical and military surgeon. By the liberality of my friends, and increas- ing opportunities of observation, even since these sheets have been printed, I have had cases and dissections which would more fully have illustrated some part of this subject ; but I am happy to say, that no circumstances have occurred, which in any degree, leave me to regret what I have said under this head.
I hope the manner in which I have set forth the anatomy of the arteries will be ac- knowledged to be useful, For I have found students satisfied with repeating Murray's tables of the arteries, and by that test esti- mating
TO THE READER* XI
mating their knowledge of this important and difficult subject.
I have laboured to discountenance this idea? and to convince them that there is a minute knowledge of the arteries to which they have little turned their thoughts, It is not yet four and twenty hours since I have seen a remarkable example of the effects of inatten- tion to the exact seat of arteries, as they bear reference to the superficial parts, to the nerves and tendons.
To the military surgeon, the book would have been quite incomplete without this last addition of Lessons on the Arteries,
London,
10 & 11, Leicester Street,
Leicester Square.
CONTENTS
OF
VOLUME II.
OF OPERATIONS ON THE THROAT.
Pags
PufFocation from Bodies sticking in the Oesophagus,
or entering the Trachea . . . 1
Ofthe Probang . . . . . -.3
Of extracting Bodies from the OZsophagus . . 5
Of Ulceration of the Glottis . . . .7
Of Bronehotomy . . . . . .8
Of Bodies lodging in the Larynx . . . .13
Of Stricture in the GEsophagus . . . .17
Use of the Flexible Tube . . . .18
Of Wounds in the Throat . . . .22
OPERATIONS IN THE MOUTH.
OfRanula . . ; • . .24
Of the Salivary Fistula . • » • .26
xiv
CONTENTS*
Of the Division of the Franum Linguas ,
Ulcer and Tumor on the Tongue
Operation on the Amygdalae ,
Of the Uvula ....
Cancer of the Lip
0? the Hare Lip
Abscess in the Frontal, or Maxillary Sinus
Perforating the Maxillary Sinus from the Alveoli
Wry Neck .
31
33 ib. 38 41
42
OF OPERATIONS ON THE EYE,
Of Cataract . . » . . .4$
Of Couch ingy or Depressing the Cataract <> .51
Of the Extraction of the Cataract . . .58 Of Inflammation of the Eye, and Treatment after Operation 74
Relaxation of the Eye-lid . . . .79
Eversion of the Eye-lid, (Ectropion) . . . ib.
Of the Inverted Eye-lid . . . . .81
Of Tumors of the Eye-iids . * . .83
Eneanthis . • . . . .86
Of the Pterygron . „ . * . .87
Opacity of the Cornea . . . . .89
Application of Caustic to the Cornea . . .91
Of the Staphyloma . . . . .92
Operation , j& J'. . . . . . 93
Protrusion ofjaa-fris * . . . .94
Dropsy of the Eye • . . . . 9^
Of the Artificial Pupil . . . . ,97
Extirpation of the Eye ..... 100
Operations for the Fistula Lachrymal** , JOS
CONTENTS,; S.V
Page
Diseases pf the Ear , . . . .112
DISEASES OF THE SPINE.
Of the Psoas. Abscess . * . • . llf
Of the Curved Spine ... . . . 125
Comparison betwixt the Skull and Spine . .131
Of Fracture of the Spine .... 132
Of the Dislocation of the Vertebra? . , * 13S
Diseases of the Hip-Joint s » . 140
Diseases of the Knee-Joint ; . s 144
Of Collections in the Bursa? .... 152
Loose Cartilages in the .Knee-joint « • . 153
OF FRACTURES.
Distinctions relative to Fractured Bones . • • 156
How to Examine a Fracture . , ^tt^m ' 1^^
To distinguish Fracture from Dislocation fe. 160
General Treatment of Fracture . ". l6^
Fracture of the Clavicle ..... 174 Fracture of the Acromion Process of the Scapula . . 177
Fracture of the Body of the Scapula . . . 179
Fracture of the Humerus . . . .ISO
Fracture of the Olecranon a . • .181
Xyi CONTENTS.
Page
Fracture of the "Radius . . . . ,183
Fracture of the Bones of the Hand - . . 1 8(J
Fracture of the Thigh Bone . . . .187
Fracture of the External Condyle of the Thigh Bone .193
Fracture of the Neck of the Thigh Bone . . . 1<)4
Of the Fractured Patella . : . 200
Fracture of the Fibula ..... £05 Of the Fracture of the Tibia , . - . 207
Of the Period of Confinement .... 209
Of a Fractured Rib . . . , ,211
Fracture of the Sternum . . . . .217
Fracture of the Bones of the Face . . . 21.9
Fracture of the Bones of the Nose . . . 222
OF DISLOCATION.
?}fsl<3cation of the Clavicle . . . . 233
Dislocation or the Head of the Humerus . 235
Of the Reduction in Simple Cases . . . 240
Accidental Reduction of the Humerus . . . 242
Reduction Impeded by the Muscles . . . 244-
Position cf the Humerus necessary to Dislocation . . 245
Position of the Humerus when Dislocated . . . 246
Dislocation of the Elbow . .".'". . 254
Subluxat^gH^>c Elbow-joint > . . . 255 Disloq^ BFc Head of the Radius at the Elbow-joint . 256 DislocfJ W*nc Wrist ..'... 257
Dislocation of the Bones of the Hand . . . 25S
Dislocation of the Thumb and Fingers „ . .. ib.
Dislocation of the Lower Jaw . . , 202
Dislocation of the Os Hyoides . 264
Dislocation of the ilil} from it$ Cartilage . . , 20 3
CONGESTS.
Dislocation of the Bones of the Pelvis Dislocation of the Os Coccygis . Dislocation of the Thigh Bone Sprain and Dislocation of the Knee-joint Dislocation of the Ankle-Joint
Page 265 268 269
280 283
OF TUMORS
. 289
Opinions regarding the Nature and Formation of Tumors . 295 Classification of Tumors ... . . 304
Treatment of Tumors ..... 3»l6
Operations to be performed on theis, „ . -321
Qs Woundep Arterjei
. 335
Classification of Arteries in the Order of their Importance when wounded . , " «T • .
Of the Difference of an Artery opened by Gun-shot3 by Splinters, and by a Knife, with Cases
Of the Seat of the Vital Parts in the Thorax .
Description of the Manner of cutting- to take up
, the Arteries
To Cut for the. Carotid Artery
To Cut for the External Carotid Artery •
Of the Thyroid Arteries .
To Find the Lingual Artery
Of the Exact Place of the Occipital Artery
To Find the Subclavian Artery ...
The Lower Part of the Axillary Artery, or Beginning of the Llumeral Artery .....
The Humeral Artery lower in the Arm
The Radial Artery • . .
b
337
342
363
366 ib.
367 ib.
369
ib.
370
371
ib. 372
&Viii c Contents.
The Mtkr Artery . . „ 0 . 3731
To Ta'ke up the Femoral Artery low in the Thigh . . 374
To Find the Gluteal Artery . . . . ib.
^eTschiatic Artery . . « . 3/5
To Cut for the Anterior Tibial Artery, high in the Fore- part of the Leg ..... 376 To Cut for the Anterior Tibial Artery, lower in the Leg . ib. To Cut for the Fibular Artery . . . .37? To Cut for the Posterior Tibial Artery . . . 3/S Appendix, containing some Remarks on Gun-shot Frac- tures *.**«. 379
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EXPLANATION
THE PLATES,
DE-
FLATE L
Figure 1. This figure represents the lower head of the femur, with #he capsule of the knee-joint; the bone is suspended by the capsule ; the articulating cartilage is destroyed, and the face of the bone ulce- rated, in consequence of white swelling of the knee-joint; the cap- sular ligament is in part destroyed by ulceration.
A, The face of the bone, rough and carious.
B B B, Small portions of the articulating cartilage remaining, the rest being destroyed by ulceration.
C, Part of the capsule suspended.
D, Ulcerated holes in the capsule, by which sinuses running round the bones in the outside communicated with the cavity of the knee- joint.
Fig. 2. This represents the thigh bone, with the head fixed and anchylosed in the acetabulum ischii. It is one of those cases of dis- eased hip-joint, where the inflammation subsided in consequence of |he granulation and exostosis' of the bone ipterrupting the motions of jhe joint.
XX EXPLANATION
A, Dorsum of the ilium.
B, Tuberosity of the ischium*
C, Femur.
D, The neck of the femur.
Ej The margin of the acetabulum. It may be observed, that the margin of the acetabulum is contracted and eked out, so as to enclose the head of the femur ; and even in the macerated state of the bones, though they are loose, they will not separate.
F, The lesser trochanter, which has approached the pelvis so closely, whilst a granulation, has formed upon the pelvis, that the two surfaces meeting have formed a connexion, by means of a ligTi meat which checks the motion of the thigh.
/
PLATE II.
Fig. I. This represents the os innommatum and thigh bone destroyed by the hip-disease. There had taken place an absorption of the bot- tom of the acetabulum, as well as of the head of the thigh bone; so that here the neck c-T the thigh bone is represented as projecting into the pelvis. Here no anchylosis took place, and_ the motion of the thigh bone in this unnatural position continued the inflammation sft as at last to exhaust the patient by hectic.
A, The os innominatum.
B, The os pubis.
C, The thigh bone.
D, The head, or rather only the neck,, o( the thigh bone, project- ing into the cavity of the pelvis.
Fig. &. In this figure is represented the caries of, the vertebra;, which precedes their yielding to the pressure of the upper part of the
trunk, and the confirmed disease described undejrjhe term curvature of the spine.
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®F THE PLATES. X&l
PLATE III.
In this plate is represented the section of a part of the thigh bone, in the progress of union after fracture.
A, The upper portion of the thigh bone.
B, The lower portion of the thigh bone.
C, An intermediate portion of the bone, which is in a manner isolated.
D D, A tough substance, by which the bones are united, before the new bone is deposited. We may call this the callus, being a tough feed, into which the bony matter is afterwards secreted.
E E, The periosteum much thickened.
F F, The bony particles begun to be deposited in the callus,
PLATE IV.
Tie. 1. The fractured patella, with its ligament.
A, The newly-formed ligament intermediate betwixt the portion of $he fractured bone.
B, The upper portion of the patella, which was broken off, and Receded with the quadriceps muscle of the thigh.
C, The lower portion of the patella.
D, The ligament by which the patella is connected with the tibia.
Fig. 2. Another specimen of the fractured patella.
A, The natural ligament of the patella.
B, The lower portion of the fractured bone.
C, The intermediate tendon formed betwixt the fractured portion* of the patella.
D, The upper portion of the patella.
la the case from whicjfcthe first figure was taken, the portions of
EXPLANATION
still lay on the surface of the thigh bone, and playing oves? of that bone in its motion, threw the action of the tendon the centre of the joint, increasing consequently the force of uscle. The nearer the fractured portions of the bone are to each other, the stronger is the union betwixt them. In the second fig. the intermediate portion of new ligament is longer and proportionably weaker, and, in the next plate, the effect of this will be seen,,
Plan. Fig. 3.
A, The lower head of the thigh bone.
B, The head of the tibia.
C, The patella fractured.
D, The ligament of the patella, which connects the lower fractured portion of the bone with the tibia.
E, The muscle inserted into the upper portion of the patella.
This plan shews that when the patella is mounted on the convex surface of the articulating head of the thigh bone, the sudden and vio- lent action of the muscles on the thigh may snap it across, without the knee touching the ground.
Plan. Fig. 4.
This pUn is designed to shew the similarity in effect of the fracture of the olecranon at the elbow joint with that of the fracture of the pa-* tella.
A, The humerus,
B, The ulna.
C, The olecranon broken off.
D, The cavity into which the point of the olecranon should enter, when the arm is distended in the natural state of the parts.
If the arm be kept bent during the cure, then the space marked by the dotted line betwixt the olecranon and the ulna will be occupied by callus or new bone, and it will then be impossible to extend the arnij for before the fore arm is extended, the olecranon, C, will strike on the back of the humerus, A. We may easily understand, too, that if the arm be too much extended, the ulna, B, will press the olecra- non, C, out of the cavity, D • consequently, after the union, the natu- ral check to the extension of the arm will be lost, and there will be danger of a strain of the elbow-joint, from the insufficiency of tbil interior ligaments to restrain the motion backward.
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OF THE ?LATES. XXitf
PLATE V.
This plate represents the fore part of the knee-joint torn open. It is intended to exemplify the consequences of allowing the upper por- tion of the patella to be drawn up by the action of the quadriceps femoris mucle.
This man had a fractured patella. The new ligament which was formed betwixt the portion t)f the bone incorporated with the integu- ments on the fore part of the joint, so far as to destroy their elasticity m a considerable degree. The man carrying a burden^ slipt, and fell backward, and the knee bending under him, the ligament, and with it the integuments of the knee-joint burst up/ and disclosed the cavity of the joint.
A A, The torn integuments.
B, The articulating surface of the femur exposed. The attempt to janite the integuments failed, and amputation was necessary.
PLATE VI.
This represents a section of the diseased nerve, spoken of in the test binder the head of Tumors.
A A, The tibial nerve.
B B, The fibular nerve.
C C, The tibial nerve enlarged into a great tumor, which occupied tthe ham.
D D, The surface exposed by cutting the tumor in two parts.
Ej The red granulating matter which occupied cells in th* tumor.
XXIV EXPLANATION OF THE PLAT1S.
PLATE VII.
This is a slight etching of the knee-joint and popliteal artery. This #ase is given as an example of the effect of a torn popliteal artery, as distinguished from the common aneurism in this artery.
A, The popliteal artery.
B, The hole torn in the artery.
C, The irregular projection of the shaft of the femur which tore the artery,
D D, The coagulated blood condensed and united to the cellular atiembrane, so as to make an irregular sac.
E, The capsule and integuments of the joint greatly dilated, in con« sequence of the aneurismal blood having been driven into the joint.
F, The patella raised from the femur, in consequence of the dila** tation of the cavity of the joint.
G, A pencil introduced betwixt the heads of the bones, to shew the communication betwixt the irregular aneurism and the joint.
N.B. The irregular bone which projects at C, is a consequence of a previous fracture of the femur; or rather a kind of diastasis ; for, when a lad, the leg was forcibly twisted, and the apophysis of th« femur broken off from the shaft of the bone. The patient was of mature years before this aneurism took place, from an exertion ©f th$. sauscles forcing the artery against the projecting bone,
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CHAPTER 1,
OF OPERATIONS ON THE THROAT.
SUFFOCATION FROM BODIES STICKING IN THE OESOPHAGUS
OR ENTERING THE TRACHEA.
•IT Is on nooccasion a mechanical obstruction to the trachea which we have to dread from bodies sticking eitherin the trachea or oesophagus. It is the spasmo- dic constriction by the muscles of the glottis. There is a provision in the muscles of the glottis, and in the laying down of the epiglottis, against any par- ticle of the food in swallowing passing into the ■trachea. The same correspondence and sympathy which protects the trachea, is the cause of suffo- cation when either any small body has passed the glottis, or when a bone or a piece of meat sticks in and distends the pharynx. In neither of these cases is the tube of the trachea filled up or com- pressed, but while life remains, the presence of these bodies occasions a spasmodic contraction of the glottis and great difficulty of breathing, or actual suffocation.
vol. ii, x Even
2 SUFFOCATION FROM BODIES IN THE CESOPHAGUS.
Even when a piece of tough meat, or cartilage, or a large bone, distends the oesophagus, it does not compress the wind-pipe, but affects the muscles of the glottis only. The most common accidents are these: a piece of meat or cartilage in swallow- ing, sticks betwixt the corhua of the os hyoides or thyroid cartilage :- — coins swallowed by chil- dren and stick in the pharynx: fish bones which stick and irritate very much: a crumb of bread which being popt into the mouth at play enters the trachea: or a husk of grain drawn in by the breath and adhering near the top of the wind- pipe. Even in difficulty of breathing, and of deglutition, proceeding from tumours pressing on the trachea, as well as from these causes, the ob- struction of breathing is not continual, but comes in paroxysms, at intervals, and still depends on the same occasional spasmodic affection of the muscles of the glottis. Every kind of obstruction will of course be aggravated upon violent exer- tion. This in some instances we ought to provide against, as in labour. If a woman have a tumour pressing on the wind-pipe with occasional pa- roxysms of difficult breathing, we should be pre- pared to give relief during the exertion and deter- mination of the blood to the head, in consequence of labour : or by free scarifications, prevent the tumour from being gorged, with blood during la- bour.
If we are called to a patient having a bone in
the throat, we ought not in an impressive and
rapid manner to seize upon him ; for this puts him
1 into
OF THE PBOBANG. $
into terror and anxiety that increases the difficulty of breathing. Without much loss of time, it is ' possible to set down before him in that composed manner which will give him confidence of relief. — Opening his mouth, you press down the tongue with a spatula or spoon and endeavour to see the bone — (we shall often be able to see it, for it may be grasped just upon the entry -of the fauces.) When we can observe it, we should seize it firmly with a pair of forceps, and extract it. Should we not be able to see it, we may put in the finger by the side of the mouth, and so deep into the throat as to touch the bone, and unfix its sharp points, when the effort to cough, and vomit from the presence of the finger in the throat, will throw it out. *
Of the use of the proband.
In the first place, we,may recollect, that if a neigh* bour be choking, we ought not to run in search of a probang, for almost any thing may do> to push the morsel down. The finger if dexterously put in by the side of the mouth, will often unfix a body, when lying across the pharynx. The end of a table spoon, or a wax candle, and on some occasions, the end of a whip, has done good service. Nothing is better for pushing down a morsel than a leek. In a child and sometimes in the adult the finger will extricate the substance, either by pushing it down, or hooking it out.
b 2 The
4 -OF THE PROBAND".
The probang is introduced by forcing it agams? the back part of the pharynx. The yielding of the pharynx; and the elasticity of the instrument, directs it down into the oesophagus. The rule may be taken, that all soft or digestible substances are to be thrust down into- the stomach, whilst we must endeavour to catch, or pull, sharp and indigestible ones up. But when a large piece of meat, or car- tilage, or a crust of bread, or piece of tripe, sticks firmly in the pharynx, We should rather endeavour icy bring it up, though it be a digestible substance ;: for it sometimes is so Wedged in, that it will not pass down, and our efforts only fix it the more firmly. If it be within reach of the finger so thaf it may be unfixed, the effort of the throat will probably throw it out. Or if this be impossible, the polypus-forceps is the best instrument to take hold of it, and pull it forth *. In short, this must be accomplished in some way, or at least we must have it unfixed from the grasp of the horns of the thyroid cartilage, else the struggle of the patient will soon be over.
People suffocating, may be able to speak at first • but this is soon over, and the surgeon will generally know nothing further, than that the patient is struggling in imminent danger of instantaneous suffocation, and of course the first thing to be
* Forceps of various sizes should be an indispensible part of surgical apparatus — A pair of curved forceps on these occasions will perhaps prove a more useful instrument- than the probang.
' \ attempted
OF EXTRACTING BODIES FROM THE CESOPHAGUS. 5
attempted, both because bodies in the oesophagus are the most frequent occasion of suffocation, and because it is in that case chiefly where we can in- stantly relieve the patient, is, to examine the pharynx. A bone we should be unwilling to thrust down, because being sharp, and sticking : to force it down with violence, is to lacerate the oesophagus; we rather endeavour to pass the hook end of the probang beyond it, and endeavour to pull it up. All indigestible bodies, pins, pieces of money, stones of fruit and shells, we should endeavour to pull up with the hook end of the probang. — And it may be remembered, that such bodies sticking about the top of the larynx, have been forced into it, by the use of the sponge end of the probang. As we have mentioned a substitute for the probang, in order to push a piece of meat or cartilage down, it is equally necessary, to suggest a contrivance for a hook, with which to pull up bodies from the oesophagus, or pharynx. For this purpose nothing is so good, as a piece of wire bent in this manner.—
The advantage of this is that it can be made of any form or take any curve, enabling us to adapt
it
6 OF EXTRACTING BODIES PROM THE CESOPHAGUS.
It so, as to operate upon that side where the pin or se is supposed to lodge. (In nine of ten case they rtick across the throat within sight.) Fn the way of a regular instrument nothing is superior to a pair of long slender steel forceps with a slight curve,, for extracting pins.., or feathers, from the gullet.
We are particularly anxious to bring up pins from the throat, becau.se if they pass down into the intestinal canal they may stick there and occasion fatal inflammation, though more fre- quently foreign bodies swallowed and sticking in the intestines,, open a way outwardly by abcess and ulceration. Let us not however take the most unfavourable supposition in the event of a pin being swallowed, for it generally happens that it is passed by stool.
We should not forget that often the soreness left by the body which has stuck in the throat, gives to the patient the sensation of its being- still in the place after it has gone down.
Very often small bodies, as crumbs of bread, peas, and cherry stones, or nut shells, fall at once into the chink of the glottis. Then the breathing becomes sonorous or stridulous with heaving of the chest, and long and difficult respiration — there is not that action, partaking both of coughing and vomiting which is the effect of something sticking in the upper part of the pharynx.
Yet even in this case the patient will not die immediately. Dr. Jeffrey of Glasgow has a prepa- ration in which a piece of coal fills the trachea
almost
OF ULCERATION OF THE GLOTTIS. 7
almost entirely, yet the patient lived for three days.
When the foreign body passes entirely into the trachea and does not stick in the more irri- table glottis, I believe it gives less distress, though there is every moment danger that the breath may throw it again into the grasp of the glottis and suffocate the person ; but of this presently.
The inflammatory affections of the trachea which I have known to prove fatal are, ulceration of the glottis; pustule on the rima glottidis ; many in- stances of croup with the formation of the mem- brane in the trachea. In all these instances the high excitement occasioned spasmodic contrac- tion of the glottis; that agaiii excited paroxysm, or continued difficulty of breathing; and the dif- ficult breathing, watery exudation into the cellular textur.e of the lungs. Which last has always ap- peared to me, on dissection, to be the immediate cause of death.
In two cases of ulceration of the epiglottis where I lately examined the parts I regretted that mercury had not been thought of: for from the history of the case I imagined that there was a considerable probability that the ulceration was venereal. It is I fancy the slight degree of irri- tability so peculiar to venereal sores, which allows of a continued, ulceration of this delicate valve without producing immediate suffocation. I have found too that with nearly similar symptoms an ulcer had made considerable progress in the sac- cuius laryngeus, and even lower in the larynx.
The
5 OF ERONCHOTOMY.
The fact that those who die by suffocation from irritation or obstruction of the trachea are at length carried off by an infiltration into the cellular substance of the lungs, suggests with it an im- portant consideration in surgical practice, viz. that in this as in many other operations, those performed for the relief of the immediate paroxysm are unsuccessful, because they have been too long- delayed and another disease has supervened to the first.
The occasions which may, according to general opinion, call for the operation of bronchotomy are, swelling of the tongue; or swelling of the glands from salivation; tumours of the amygdalae*; ulceration of the upper part of the trachea or epiglottis; sudden and violent inflammation of the top of the larynx; bodies wedged in the pharynx, or upper part of the oesophagus from v/hich there is instant danger of suffocation, while' our efforts to extract the bodies are ineffectual. In these emergencies if the operation is to be done ten to one that no regular apparatus is prepared, but if it should be deliberately set about, then we may thus perforin if.
OPERATION OF BRONCflOTOMY.
There are two places at which the operation may be done. 1. Above the cricoid cartilage.
* These I suspect may cause much alarm, hut not
actual suffocation.
2. Nearer
OF 3R0NCH0T0MY. 9
23. Nearer to the sternum and on the face of the trachea. The latter of these places I should prefer where there is inflammation. In the first place be- cause it is more removed from the moveable glottis, the spasmodic constriction of which is probably the cause of the suffocation ,* and also because I conceive the operation may be performed in the trachea by merely making an incision and holding the edges ■of the trachea asunder with a small spatula., or any such instrument.
To perform the operation betwixt the thy- roid and cricoid cartilages,, the surgeon, placing his finger upon the prominence of the thy- roid cartilage, or pomum . Adami, carries his linger down upon the fore part of the throat* for the space of a full inch ; he finds there a depres- sion and softness ; moving his finger further down he feels the cricoid cartilage like a ring encircling the throat, but it is above this ring and m the spot where he feels the depression into which he is to introduce his canula, Ji large silver catheter, or the canula of a trocar, or even a large goose quill., or best of all, a piece of sheet lead rolled into a tube and smoothed, will be a substitute for regular apparatus,. These I mention now, because it is an operation which requires to be clone on the spur of the occasion The -regular instrument with the double canula h to be found in the shops ; vbut I imagine a simple canula, having a slight but: equal curve, and with a blunt stiletto would serve every purpose. For the perforation being made into the trachea by the common lancet, the conical point of this instrument would easily follow.
The
10 OF BRONCHOTOMY.
The size of the canula should be that ,of one of
the nostrils,
The surgeon makes an incision over this place
with a small scalpel if he has it, or with his common
lancet. He then clears the blood away and if
possible waits until the bleeding is stopt, (using
what means he can to that effect) then with the
point of his lancet he perforates and introduces his
canula obliquely downward and backward.
In performing the operation on the fore part of the trachea these precautions ought to be observed.
As in the other case we ought to have a scalpel^ a lancet, canula, and stilette. When the finger is carried from the cricoid cartilage downward, a softer eminence is felt on the fore part of the trachea, immediately after the finger has passed the cricoid cartilage : — This is the isthmus of the thyroid gland, and is carefully to be avoided. Below this, then, the external incision ought to be made, and carried downward an inch and a half. In the next touch of the knife the thyroid veins are to be avoided, and the sterno-hyoidei and thyroidei mus- cles put aside. If the veins have been put carefully aside, not cut across, and the thyroid gland has been avoided, there will be no bleeding to interrupt the further operation of cutting into the trachea, and introducing the canula. The cut into the trachea is made betwixt two of the rings, with the same knife which is used for the first part of the operation, or with a lancet. It is recommended by some to push in, a sharp stilette and canula without a' previous incision of the trachea. The intention of pushing
a trocar
OF BRONCHOTOMY. 11
a trocar and canula into the trachea without making a cut, is, that the canula may so exactly fill the opening in the trachea that no drop of blood mav fall into it.
Authors speak on this subject, as if a drop of blood entering the wind-pipe at this place, would irritate and excite the lungs, as an excoriating humour, or a hard substance does the glottis or epiglottis. Bleeding is if possible to be avoided, and I believe it always will be possible; but this dread of bleeding is not to make us defer this operation under the idea, that it requires a very particular apparatus. As we have the tube in the hand, cannot the incision be adapted to it, and if there is an oozing of blood, can we not tie a dossil of lint round the canula, and which pressing upon the trachea around the opening, may either suppress the bleeding, or at least hinder the blood from falling into the wind-pipe, should the open- ing be twice the size required to pass the tube ? Hurry and confusion however in this operation, and inattention to this subject, will lead to the most terrible consequences. A friend of mine and a very celebrated surgeon, told me he saw a gentleman die of loss of blood, and the falling of the blood into the trachea ; I suppose the opera- tor must have cut upon the substance of the thy- roid gland. £
In a child the trachea is very4mall, and operat- ing with canula and stilette it has happened that the trachea was transfixed !
The tube being introduced, the surgeon will
naturally
J 2 OF BRONCHOTOMY.
naturally hold it with his fingers until the respirat- ion is fully restored, it may be then fixed and the process is this : folding a large piece of lint to- gether, it is cut into a circular form, then it is slit up to the middle and a part cut out to answer to the canula. This compress (now consisting of distinct pieces) is to be put betwixt the wound and guard of the canula, so as to keep the end of the canula its due length, inserted into the wind- pipe. Now a band put round the neck may be fixed to the tube and compress it sufficiently^ without forcing it too far into the wind-pipe.
When the skin and perhaps the thyroid gland swell in consequence of the operation, then may several of the pieces of cloth be taken from betwixt the wound and the guard of the canula ; so as to allow the extremity of the canula still to keep it* place in the wind-pipe.
Having secured the present safety of the patient, our attention will be naturally called in the next place, to remove the cause of the obstructed res- piration, whether it be a foreign body sticking in the glottis, or something in the pharynx, or an inflammatory swelling.
I have been several times on the eve of perform- ing the operation of bronchotomy, but I haye never done it. And this is the case with many surgeons. I cannot therefore . speak with the same certainty on this subject that other authors have done. But to bring the subject into as short and practical a view as possible, I have thus concerted it on these occa- sions : viz. first to introduce a flexible tube into
the
OF BODIES LODGING IN THE LARYNX. 13
the trachea through the glottis, and if this should not be attended with the desired effect of establish- ing a free respiration, then to perform the opera- tion of bronchotomy.
I introduce the tube through the glottis, because in every case I have yet seen^ the occasion of the difficulty of breathing was to be found in the spas- modic closing of the glottis, and if the tube is introduced into the rima glottidis so as to secure the passage of the air, the play of the lungs will be free. The only question which remains is, whe- ther the presence of the tube in the larynx will not (in the intimate connexion which exists betwixt this part and the respiratory muscles) produce such irritation, as still to cause a spasmodic coughing. But I believe that it will not be found to have this effect.
The substitution of this simple introduction of a tube to the formidable operation of bronchotomy; would have this happy consequence, that it would be resorted to with less unwillingness, and fre^ quently early enough, to save the patient.
When the operation is to be done for a body which has fallen into the larynx or trachea, there may he some circumstances peculiar in the treatment.
OP BODIES LODGING JN THE LARYNX.
When a body is drawn into and lodges in the
larynx, it may be known from the convulsive
2 , cougb\
14 Of BODIES LODGING IN T&E LARYN*.
cough, wheezing, and rattling in the throat, the weakness and hoarseness of the voice. Sometimes when there is a dreadful difficulty of breathing, the symptoms will suddenly remit, and the person become easy. After several changes from tran- quillity, to labourious respiration, and from difficult to easy breathing, the patient may be at the end of some days, suffocated suddenly. It happens thus 1 believe, the body is loose, and is sometimes lodged in the trachea, sometimes near the glottis. When in the trachea, (the sensibility of which is much less than that of the upper part of the larynx), the patient breathes easily, but when the body is moved towards the more sensible glottis, then comes the spasm of the muscles of the glottis, and great difficulty of breathing. Mean time with each successive attack, the parts are inflaming and becoming more irritable, and the violence and difficulty of breathing, is producing a degree of effusion in the lungs which increases the evil. One more severe paroxysm succeeds and the patient is suffocated. It would be easy to furnish many striking cases of children thus suffocated.
1 . We have to ascertain the nature of the accident. See that the cause of suffocation, be not in the up- per part of the pharynx, and ascertain the na- ture, and size of the foreign body. 2. Observe, whether posture by throwing down the body in- to the wind-pipe, does not relieve, and if the sense of suffocation, has been preceded by pos- ture or circumstances, which would favour the shifting of the body, into the rima glottidis.
3. We
OF BODIES LODGING IN THE LARYNX. 15
3. We have to observe, if the breathing become more difficult even in the interval of the spasmodic attack. 4, If from the greater violence of the pa- roxysm, the membrane of the larynx be inflaming and swelling, then the danger is imminent, and the operation seems to be the only remedy. 5 . If there be any puffiness, or emphysematous tu- mour of the neck, during the previous stage of suffering, before the operation is determined on5 there may have occurred a bursting of the tra- chea.
We bleed frequently, and give an opiate in a mucilaginous mixture, which is to be taken by fre- quent sipping, rather than as a draught. For this will often give relief of the teazing;, tickling sen- sation that precedes the parox3^sm. it has been re- commended that we should excite vomiting, or sneezing, which by the suddenness of the aoticn of the respiratory muscles, may throw out the body from the larynx. But should the body be removed more directly into the current of air, by this means and yet not altogether discharged, the consequence would be sudden suffocation.
There are two operations proposed, the one may be thus conducted.
]. To lay bare that part of the trachea, which is inferior to the isthmus of the thyroid gland. 2. Let the bleeding be entirely stopt. 3. Slit across three of the rings of the trachea, that it may be held open by introducing a small spatula, which will allow the patient to breathe freely, and having established free respiration, will then enable
yon
IS OF BOBIES LODGING IN THE LARYNX.
too to introduce a probe, or bougie, upwards through the larynx So that the foreign body may be pushed forth.
But if the body should be fixed as I have seen it, after death, it will be no easy matter to dislodge if, in short we may not find it, and we may not be able to extract it ! which makes the operation pre* carious and dangerous. Before thinking of such an operation, the surgeon will of course provide the complete apparatus for the operation of broncho- tomy, lest he should be obliged to introduce the tube, without extracting the foreign body. And he bugtif to accomplish himself with what variety of probes, probangs, and forceps, he may think eventually necessary, either to extract the bodyt or to push it out from the glottis.
The operation recommended by Desault is this. The instruments are a sharp pointed knife, spa- tula, and forceps.
The patient is to be seated, and -the head held to the breast of an assistant, who stands behind. The skin over the thyroid cartilage, is to be a little drawn aside. An incision is now to be made through the skin, laying bare the prominence of the thyroid cartilage and the cricoid cartilage* Then the two lateral parts of the thyroid cartilage are to be slit asunder, and being held so, the foreign body can be extracted with forceps.
OF
OF STRICTURE IN THE (ESOPHAGUS. 17
OP STRICTURES IN THE OESOPHAGUS.
When We consider that the oesophagus is a powerful muscular tube, and that it is liberally be- dewed with mucus, and consequently is of a glan- dular structure, we have a key to the knowledge of its diseases.
It is not wonderful that a muscular tube, con- nected with the stomach, (which is the source or the seat of so many strange and varying symptoms,) should frequently suffer by the irregular action of its muscular fibres *. It is however the permanent stricture of the oesophagus I have to mention here.
The stricture of the oesophagus is marked by a gradually increasing difficulty of swallowing, there occurs often irregular pain in the stomach, and fre- quent reaching with the discharge of mucus col- lected in the oesophagus. Sometimes there is a considerable general irritation, with fits of suffo- cation ; the voice is remarkably weak.
* Spasmodic affections of the oesophagus, may be re- moved by rubbing camphor and opium, or sether, on the sides of the neck; or by swallowing a very little tincture of opium. Valerian and camphor may be given by the mouth, or by injection. The irregularity of the uterine action, the general state of the system, and of the uterine discharges, must be attended to. When the spasm continues obsti- nate, the dexterous use of a bourne will sometimes relieve it.
vol. ii. c For
18 USE OF THE FLEXIBLE PIPE.
Far this complaint, as in the stricture of the urethra, the bougie and caustic are used. We sound with the bougie to ascertain if there be a confirmed stricture, and not merely a spasm or paralysis. We are to endeavour to accommodate the form and size of the bougie so as gradually to stretch the contracted part ; and this failing of its effect, or being attended with an increase of the mischief, we have still the use of the caustic in reserve. This practice is strongly recommended by Mr. Home. I cannot at present take the me- rit of making a single observation on the subject.
OF THE USE OF THE FLEXIBLE PIPE, INTRODUCED INTO THE CESOPHAGUS.
It is not long since, the only means sug^- gested to us of nourishing a patient who had an ob- struction of deglutition, was by clysters, or by forcing down solid food into the oesophagus by the probang. It was therefore a very happy invention of Mr. Hunter, in a case of impeded action of the throat, to cover the probang with an eel-skin, which, being introduced into the stomach, enabled I him to inject nourishing soups. For the same purpose we row use the flexible gum-tube, having adapted to it the nozzle of a syringe, or injecting bag and pipe.
i In
tSE OF THE FLEXIBLE PIPE. 19
In the introduction of the tube, we must be careful that we do not commit a blunder, which though not likely to happen, yet because it may happen and prove fatal, we must always consider; I mean the introduction of the tube into the wind- pipe, instead of the gullet. In the first place then it is wrong to make the patient open the mouth wide and push out the tongue, and at that instant to introduce the tube quickly, for by the projec- tion of the tongue, the epiglottis is raised to the utmost ; and if the patient should have such a command over himself, as to persevere in keeping the tongue thus, while the tube touches the throat, the point of the tube may pass into the glottis. On the contrary the patient should be directed tQ do^ that, which indeed he will naturally do, when he feels the tube in the fauces ; let him imitate, the action of swallowing, draw back the tongue, and consequently push down the epiglottis : and the tube should not be passed quickly into the throat, but slowly, moving the point of it off the soft palate to the back part of the pharynx, when (being flexible) it will be directed into the bag of the pharynx and into the oesophagus.
Yet after this precaution, and when the tube is in the cesophagus/ we pass the upper part of it through a sheet of paper, and then hold the flame of a candle to it. It has happened that in this expe- riment the air, rushing from the tube, has shewn it to be in the trachea, and not in the oesophagus!
The liquid food which is to be thrown into the
stomach in this way, must be cooler than what q,
c 2 person
%0 tSE Of THE FLEXIBLE ITPE.
person could take by the spoon, for it flows cofl- finually hot upon one part of the stomach. And I have dissected a body where I suspected a patch of inflammation, in the inner surface of the stomach, proceeded from this cause.
If it should be thought necessary to keep the tube in the oesophagus for any considerable time, it must then be introduced through the nostril ; and here it is necessary to be still more particular, that the throat be exerted, as in swallowing, in order that the tube may pass into the pharynx. ■" There are many occasions on which the tube is to be used to convey nourishment into the sto- mach: for example, in young women affected with hysteria, paralytic affection of the oesophagus is not unfrequent, and they would die of this trifling complaint but for this invention. I have attended a girl who was nourished for two months in this way, the affection of the throat was entirely cured;,, but some months after she died of a complication of disease.- — The oesophagus on dissection was, quite natural. Ulcerations in the tract of the Oeso- phagus I imagine are perpetuated and increased to a fatal degree by the perpetual irritation of the oesophagus in swallowing. The action itself is an excitement, and the matters swallowed cannot fail to lodge about the ulcerated surface. In this case the use of the tube will form a necessary part of the cure, ,
The oesophagus is subject to a cancerous ulcera- tion.' It becomes hard, and irregular, and ulcerated* 2nd the muscular structure of the tube being de- fy srroyed5
."USE OF THE FLEXIBLE PIPE. 2jt
stroyed, the continuous action, by which the food is carried into the stomach, also fails, and the flexible tube is necessarily employed.
Sacs are sometimes formed of the pharynx. At first, by some accidental lodging of the stones of fruit, perhaps, and afterwards by the accumulation of the food. Each meal forcing a little more into this hoje or sac, it at last is enlarged into a bag, which having formed by the side of the oeso- phagus, and being crammed with the food in the attempt to swallow, presses upon the oesophagus,, and obstructs the passage into the stomach. If the flexible tube be used, the food will no longer accumulate in the lateral sac, and this sac may shrink and be obliterated.
Abscesses, forming by the side of the pharynx, and opening into it, afterwards receive the food in the act of swallowing, with even a worse effect than in the last instance ; this too the flexible tube may palliate or cure.
When a person has attempted self-destruction by firing a pistol into his mouth, and the brain and spinal marrow and carotids have escaped, there is danger of suffocation from the inflammation and swelling of the throat, and the action of swallow- ing is for a long time impeded. Here the tube Jias been of essential service.
When the attempt at suicide is made by cutting the throat, the action of swallowing impedes the cure, because the larynx is pulled up in swallow- ing, and by this means the union of the trachea is prevented, and even the outward wound torn
open,
22 OF WOUNDS IN 'THE THROAT.
open ; and here the flexible tube is also of great service.
OF WOUNDS OF THE THROAT.
The cutting of the throat, in the attempt at suicide, is so very common an occurrence, and re- quires the assistance of the surgeon so frequently, that it becomes necessary to speak of it, under a distinct head.
Of all the ways of putting a period to existence, the cutting of the throat is the most dreadful, to the sane imagination. But it is the horror of the deed, on which the insane wretch broods. It is the vulgar idea, that it is the cutting of the wind-pipe, not the opening of the great vessels, by which the man dies. So the suicide very often cuts only on the fore part of the throat, and does not per- petrate the deed. Or not liking the experiment, or perhaps the edge of the knife striking on the firm cartilage, or bone, the wound is small and the deep vessels are not touched.
Sometimes he draws the knife across the throat, higher than the os hyoides, and then the root of the tongue, and the lingual artery are cut ; the mus- cles uniting the jaw, and os hyoides are cut; the lingual artery bleeds pofusely. Perhaps the ninth pair of nerves, and the salivary ducts are wounded.
The
OP WOUNDS IN THE THROAT. %.s
The saliva and fluids attempted to be swallowed, flow from the wound. The voice is feeble and in- articulate., and there is danger of suffocation., from the fluids and blood falling into the larynx. Some- times he cuts down lower than the os hyoides, and betwixt it and the thyroid cartilage, and then the epiglottis may be separated from the larynx. Speech deglutition and respiration are difficult. When he cuts upon the thyroid cartilage, he does little harm, but when he cuts lower down he strikes the thy- roid gland, and opens its vessels.
In whatever way the throat be cut, the bleeding is the immediate danger; the person dies of hasmor- rhagy or from the blood, entering the wind-pipe, and suffocating ; and the source of the blood is from the deep angle of the wound, generally the supe- rior thyroid artery, or the lingual artery ; if the carotid is touched, the patient is gone. Before the surgeon is called, perhaps the vessels have emptied themselves, and the faintness prevents the full jet of blood, and immediate death.
The thumb is to be pressed into the angle, or a piece of spunge is thrust in by the side of the throat, until a ligature is thrown over the tena- culum ; then lifting the finger from the spot from which the blood flows, one vessel will be observed to project with each pulsation, which being taken up, other lesser branches may require to be tied. During this operation, the posture must be such as to prevent the blood falling into the trachea.
When the bleeding has entirely stopt, the integu- ments are to be brought together by two or more stitches ; then a bandage is put about the head, and the ends of it brought down from the sides of the
head
$24 OF RANUXA.
head to a circular band round the chest, by whicf^ the chin is kept down upon the breast, and the trachea and the lips of the wound kept together. A strait jacket is now put upon the person. The food and medicine is to be given by the flexible tube, introduced into the gullet, if a great part of the trachea is cut across; for the motion of the throat in swallowing, impedes the union of the wound.
What proves the most distressing circumstance during the cure, ( especially if the wound has been near the glottis) is, the rising of inflammation, and the consequent irritation and cough. It is difficult to allay the thirst without varying the position ; lying on the back for example, the patient will be able to swallow a little, or moisten the parched fauces.
RANULA,
RanulaIs, in general, a semipellucid tumour lying under the tongue and in its commencement situate to one side of the fraenulum linguae. It is described as having its origin in the obstruction of the sali- vary glands ; and. accordingly it is not confined to the seat of the sublingual gland, but appears some- times in the cheek, in the place of the parotid duct, and then it is more fleshy and vascular. It is described as beginning without pain/the feeling
of
OF KANULA. 21
of distension being alone troublesome. Such in- deed has been the account of the patients ^1 have seen "with this complaint; but I know that an ob- struction of the salivary ducts is an extremely painful complaint, and so peculiar in the pain and distension of the salivary glands, under the tongue, upon tasting sapid food, or on the action of the muscles of the jaw, that the patient would not be apt to overlook the beginning of the disease.
If we say that Ranula is a semipellucid tumour, like a frog's belly, under the tongue, then there are two kinds, the one arising from the distension of the salivary duct ; the other, a simple in cysted tumour. I believe they have been much confounded. If we define it to be a distension of the salivary ducts, then it is not always under the tongue, but is common to the other ducts. This complaint, under the ton- gue 1 have seen in an infant, and I believe it is frequent in them, from original obstruction of the duct. In adults, it is sometimes found to be com- plicated with, and to have taken its origin from salivary calculi in the mouth of the duct.
When it is in its most frequent place, under the tongue, and is allowed to grow, it forces back the tongue, and occasions difficulty of swallowing, and particulate speech; and in children it prevents sucking.
It would appear that this is sometimes a much firmer tumour than those I have seen, in so much, that, by pressing forward, it has affected the teeth, and so far pressed back the tongue, as to occasion difficulty of breathing. When formed in the cheek,
it
26 OF THE SALIVARY FISTULA.
it has forced itself under the zigoma, and has prevented the free motion of the jaw.
The practice is., to lay these tumours freely open. Unless this be dene freely, it will return. In its re- turn it will often lose its transparency, and by the necessity for frequent punctures, it becomes a thick and fleshy bag, requiring either extirpation, or escharotic and caustic dressings.
Calculi form in the salivary ducts; sometimes they lodge near the mouth of the duct, without producing a tumour, and then with a touch of a lancet over the extremity of the duct, they may be drawn out with forceps ; or the calculus produces much irritation, and a suppurating sac is formed. After the extraction of the calculus, the injection of a slightly astringent fluid, with the syringe for fistula JacrymaliSj cures it.
OF THE SALIVARY FISTULA.
.This fistula differs essentially from other fistulous sores, connected with the natural ducts, or passages. It is not the consequence of obstruction, but of cuts upon the cheek : for it is on the cheek that they chiefly occur, from the very exposed situation of the duct of the parotid gland.
This sore forms a fistula of a very unpleasant kind ; since while sitting at dinner, or when masti- cating^
t>P THE SALIVARY FISTULA. J27
eating, the flow of saliva, is very profuse, and a failure of appetite, we are told, is the consequence of this discharge. I doubt the truth of this latter circumstance.
If there occur a recent division of the duct, by a wound penetrating the cheek, near its termina- tion, we have only to take care that in using the twisted suture, the skin of the cheek be very accurately united, while the inside of the cut is left free, for the discharge of the saliva, from the duct, into the mouth. When we do this, the duct may chance to unite again, or though it do not, yet if the outward skin be united, the saliva will find its way into the mouth.
The chance however is, that the case presents in the form of callous holes, dischanrino- saliva. In which vain attempts have been made to cure the sore, by compresses, and escharotics. The duct may have been divided, as it passes over the masseter muscle, and of course without the wound penetrating the mouth.
In this case of a fistula of some continuance on the cheek, we have to establish a communication betwixt the duct, and the mouth, and then to heal the outward wound. Our first attempt will be, to pass a small silver probe, from the mouth into the natural opening of the duct, and enlarge it, if it shall be contracted ; then to substitute a small tube, which being introduced from the moutji, shall also pass some way into that part of the duct, which discharges the saliva. Lastly, while the tube is retained in its place, the outward lips of
the
fS OF THE DIVISION OF THE FR.ENUM LINGU.E.
the wound are to be made raw, brought together, and healed.
But the circumstances of the case may be such^, that it will be better to make a new duct, from the fistulous opening into the mouth. To do this, we must push a straight needle, obliquely from the bottom of the fistula, into the mouth, and draw through a small seaton, which is to be worn until the passage is callous. Then either with or without introducing the tube, we have to endeavour tQ unite the edges of the outward opening.
DIVISION OF THE FR^ENUM LINGUA.
There are few surgeons who have not cut the frenulum linguse. Notwithstanding this, I venture to say that it is never absolutely necessary. There may be an expediency, when the surgeon has not weight enough with the mother to convince her that her child cannot be prevented from sucking from this cause. Sucking is effected chiefly by the motion of the lower jaw ; and the tacking of the tongue even forward to the gums, will prevent the motion necessary to sucking. I doubt even whether this tying of the tongue, will impede the speech. But at the age, which has such a motive for the operation, I have less objection to it. In infancy, the consequences have been well ascer- tained
OF THE TUMOUR ON THE TONGUE. §9
tained to be suffocation from swallowing the tongue, and death from sucking, and swallowing the blood during sleep.
To do this, or any other little operation under the tongue, an assistant having the child on his knee, puts his fingers into each side of the mouth, and under the tongue so that he pushes it up. With blunt pointed scissors, the surgeon cuts the mem- braneous part of the frsenum, taking care to avoid the larger veins, and that in the motion of the child, he does not cut into the substance of the tongue, so as to touch the ranine arteries.
ULCER AND TUMOUR ON THE TONGUE.
There occurs very frequently on the tongue, an* nicer, with a foul cineritious coloured bottom. We have to examine whether it may not have arisen inconsequence of its being incessantly torn, and irritated by a spoiled and ragged tooth ; in which case the tooth must be drawn, or filed down and smoothed. But chiefly we must be careful to observe the connection with the stomach, for I be- lieve this to be a frequent cause of this ulcer. This will readily be believed, when we consider the inti- mate sympathy betwixt the tongue, and stomach, made apparent to us on many occasions ; as by the
state
SO OP THE TUMOUR ON THE TONGUR
state of the secretion of the tongue, influenced by the healthy and diseased action of the stomach.
When neither medicine, nor diet, have influence on the ulcer of the tongue; when it becomes painful, and the edges rise and are ragged, the ulcer may be cut out, after which the tongue quickly heals.
To do this the common tenaculum is introduced into the substance of the tongue, so as to pass under the ulcer. Then with a common scalpel, run along the convexity of the tenaculum, the diseased part together with the instrument is cut out. The tongue may be cut very freely, but let the operator be aware of the situation of the ranine arteries.
When however the disease of the tongue is deep, when excrescences with deep roots grow upon it, or when there are small, firm tumours, formed in its substance, we adopt the means suggested to us by Mr. Home*.
Having well examined the depth, and utmost extent of the disease, a crooked needle (drawn to the middle of the ligature), is passed through the substance of the tongue, beyond the diseased part, the middle of the ligature being cut, the needle is taken away, and the ligatures remain. There are now of course two ligatures one of which is to be tied, in each side of the diseased part, so as totally to obstruct the circulation in the insulated portion. As is represented in the next pa-e.
* See his Observations on Cancers™
OF THE TUMOUR ON THE TONGUE.
31
In a few days the diseased part drops off, and the surface left by this separation looks sloughy, but becomes soon clean, and fills up in a wonderful degree. The pain is much less than we should be led to expect. A salivation is sometimes the effect of the operation.
A, The diseased portion.
B, B, The ligatures tied.
C, The point at which the needle was passed,
OPERATION ON THE AMYGDALA.
In the inflammatory sore throat, these glands Swell enormously, so as to produce an apprehension of suffocation. But when they suppurate fully, they burst and the relief is perfect. In imitation
of
M OF THE TUMOUR ON THE TONGUE,,
of this, we have sometimes to pierce them in oi&ei to evacuate the matter. Often this does not suc- ceed, that is to say, the matter is not fully eva- cuated. But shortly after the matter is sponta- neously discharged. Perhaps this is, because the matter is behind the glands, or in the duplicative of the arches of the palate ? Be this as it may, deep scarifications of the glands of the throat do no harm* When the tumefaction is thus great in degree, and at hough the matter be not evacuated, the discharge of blood relieves the swelling and tension.
All the glandular apparatus of the mouth, and throat, is subject to disease ; none more frequently than the amygdalae, for often after swelling enor- mously in their inflammatory affections, instead of entirely subsiding, or suppurating, they degenerate into hard tumours, if notscirrhosities. These tumours of the amygdalae, besides occasioning much incon- venience, from the difficulty of swallowing, produce a remarkable change on the voice, and require to
be taken out.
These diseased glands have been violently torrt
away, an operation not to be imitated. The French
surgeons cut them with a concealed knife, but I
conceive the ligature is still preferable.
The ligature may be thrown on the tumour.
in the manner I have described in speaking of tha
cDeration on tumours in the rectum.
m
-€}>? THE UVULA. 33
•Qft THE UVULA,
The uvula often hangs down relaxed, producing a feeling which the patient is most anxious to be rid of. Very simple means will often succeed in causing it to be drawn up, viz. to touch it once, or twice, with a little cayenne pepper and to use astringent gargles.
When this does not succeed, and there is a real enlargement, and prolapsus, the" ligature, or scissarss may Ipe used to free the patient of it entirely,,
.NiEit OF THE LIP, &(*,
When the lip is the seat of cancer, the disease peems to be less virulent in its nature, than when in any other part of the body. Here excision promises perfect security.
This disease I believe is not often a true cancer ■but arises from some accidental irritation, and Is kept up by the incessant motion of the part. And this too I believe to be the reason why the disease is so frequent in the lower lip, and in the angle of the mouth, fens-, the upper lip has least
TOl. i i, ' ;» motion.
34 OF THE CANCERS OF THE LIP.
motion. While other remedies have been applied, 1 have always strongly recommended the use of an ad- hesive strap, to retain the lip, as much as possible from motion. And this fixing of the lip, is the advantage gained by poulticing those sores. My attention was drawn to this circumstance, from observing that in Very bad cases, -some of the slighter ulcerations situated by the side of the greater diseased portion, and which could not be included in the portion Cut out, healed while the pins were in the lip. I naturally conceived this to arise from the perfect repose of the lip, after the operation.
I need here only state the fact, that venereal ulcers have been cut out of the lip, being mistaken for cancers, and that the disease has broke out again, and yielded to mercury. This will be a sufficient caution, to make us examine both the history of the disease, and the concomitant symptoms before we operate.
The most frequent beginning of this cancer of the lip, is an irregular warty excrescence with a broad base, or an obscure tubercle within the lip, When a sore, or disease is spreading, from such a commencement, I would not delay extirpation.
The following method I prefer to the commoij one of using forceps. A flat piece of wood, is shaped to go down betwixt the lip, and the gums, having a rude handle, which the assistant holds, at the same time that he stretches the lip upon the piece of wood, and presses it down upon its edgef so as to prevent the bleeding of the labial artery.
Now the surgeon thrusting his tenaculum or-
.hook
OP THE CANCERS OF THE LIP.
35
Iiook, into the diseased part, makes an incision on each side, down to the wood, and meeting so as to make a neat angle below, he cuts out a tri- angular portion of the lip, including the dis- ease.
The nicety, if there be any in this operation, con- sists in adapting the two incisions, so that the cut surfaces may come accurately together, without puckering, or ruggedness at the lower angle.
For example, if the incision of one side should be in a curved direction, and the other more direct, the effect will be, that when the parts are brought together, the side with the curved incision is peeper than the other.
Fig. 1, represents the part cut out;
Fig. 2. represents the pins introduced, and the divided lip brought together.
The triangular piece being cut away, the assistant withdraws the piece of wood, on which the incisions were made, and holds thes two portions of the lip, betwixt his fingers and thumbs. Then bringing
i> 2 them
36' OF TH;E CAKTdERS OF TEE LtF»
them together and applying the surfaces. accurately to each other, the surgeon introduces his first needle, about a fifth part of an inch from the surface of the lip, and rather towards the inner part of it ; the other (for two are sufficient) is introduced in the fniddle betwixt this and the lower part of the cut.
The surgeon should now, put two or three turns of the ligature, about the pins, until the bleeding stops altogether. Then loosening it, he should more accurately wind his .thread about the pins, by throwing the middle part of it over the two extre- mities of the pin, then crossing the ends unde? the points, so as to form the figure of 8. Having done this with the upper pin,, he proceeds in thf! same way with the lower.,
If the disease be in the angle," or commissure of the lips, then must there be made two semilunar inci^ sions, terminating in an acute angle on the cheek.
In making the twisted suture, the lip is more frequently too firmly braced, than not brought together sufficiently. - When the ligature is drawn to stop the bleeding, as in the first instance, and not afterwards loosened, but the operation thus finished, the swelling of the part, makes the ligature much too tight, producing in consequence an irri- tation, which sometimes .brings on suppuration,, and bursting up of the wound.
But when after a short delay, which allows the bleeding to stop, and the parts which are in some degree already swollen, are brought accurately together. I have always found, the operation suc- ceed better, and without deformity.
When
OP THE CANCERS OP TH£ LIP. 37
When a great part of the lip is taken away, and when the surfaces meet with difficulty* there is a straining on the pins, and a consequent fretting of the wound. This is another cause of failure. It may be often prevented, by carrying an adhesive strap, from cheek to cheek, and bringing it over the lip betwixt the pins, or perhaps nearer the chin, so as to support the pins, but chiefly to act as a monitor, and to check the unwary motion of the lips.
The wound should be kept dry, and if possible without motion, that a scab may be formed. If a little matter should form, we are not to throw the parts loose, but let it out, with the point of a fin$ needle, and still retain the parts in contact.
On the fourth day, I take out the lowermost pin, (allowing the threads to remain if they will,) first carefully washing the pin with a camels-hair pencil, and clearing it of the adhering hard mucus, or blood. When the pin is withdrawn, without the point being previously cleaned, it comes through with pain, and difficulty,, and may even tear the new adhesions. After a slight suppuration has loosened the pins, they should not be allowed to remain, for they are jn danger of deforming the lip.
There occur incysted tumours of the fleshy part of the lip, which nothing but the knife will remove. 1 have taken them out by dissection, rather than as the cancerous lip is cut. Stretching the lip ovej4 the finger of an assistant, and exposing its inner surface, we can dissect out the tumour, without cutting its sac. and here as well as in accidental cuts
OF THE HAfcELIP.
of the lip, the edges Will be best brought together
by ligature.
OF THE HARELIP
The operation for the harelip, is the same with that just described, only that in some instances the irregularity of the cleft lip, requires a more peculiar nicety in adapting the incision, so as afterwards to bring the parts accurately together.
Of the simple cleft we need say nothing further., than that the edges of it are to be pared off] with an uniform, firm incision, and then to be brought together, as we haVe described in the case of cancers We first separate the lip from the gums, if they are adhering* then we may either cut the lip on a piece of wood, put in betwixt the lip and gmnsj or use the harelip forceps, to hold the lip while th« edge is cutoff!
Is
OF THE HAXELir. 39
In this form of the disease also, there can be but one way of operating, although it is sometimes performed with difficulty.
The patient's head rests on the assistant's breast. The surgeon separates the lip from the gum, if it be necessary, then takes hold of the lip, of one side, 'with the harelip- forceps, leaving out from under their edge, what he means to cut off, and with one motion of the scalpel he cuts this portion off- Then moving his instrument to the other side, lie places it so, that he may pare off the edge of that also, and bring the termination of the cut accu- rately up, so as to form an angle with the first.
The disadvantage of the harelip-forceps is, that they do not take a firm hold of the lip. They grasp unequally, and when the incision is but half performed, the lip is apt to slip from them — - Sometimes the dryness of the lip in the first cut, gives a firm hold, while in the second, the forceps or lip, being bloody, they slip.
The pins are introduced as in the instance of cancerous lip, and the precautions are of courss the same.
The operation may be done as successfully in an infant, as at the age of 14 years.
Sometimes the fissure of the lip is accompanied with a cleft in the palate^, and a deficiency of the bones. When part of the maxillary bone stands projecting out of its place, it may in young sub- jects be violently pressed down, and made to ad- Jbere in its proper place. The deficiency of
the
40 OF THE HARELIP.
the palate, will diminish as the child advances in years.
On examining the hones of the face of children,, with a cleft palate, I have found that the dimmu- tiveness of the upper maxillary bone of one side* was more apparent than real. The fissure is owing to the bone of one side, being thrust laterally, and of course made also to project somewhat. If this centre piece of the palate project irregularly, I have said it may be broken down, and forced into its place. But if the jaw bone of one side be only pushed laterally, which is the most common kind of deformity, then I imagine by a compress ope- rated upon1, by an elastic steel bandage, coming round the head* the bones may be gradually brought into their places, so as to fill up the fissure of the palate. The cure may then be completed, by the usual operation on the cleft of the lips. Or the operation being done on the lip, the afte? treatment will be, to bring the pieces of %h® superior maxillary bone together,
ABSCESS
1BCESS OF THE FRONTAL SINUS. 41
ABSCESS IN THE FRONTAL AND MAXILLARY SINUS.
The sinuses both of the frontal bone, and the superior maxillary bone, are subject to disease. The membrane of these passages, always acutely sensible and subject to inflammation, becomes either from such general inflammation as we see in catarrh., or from injuries, or the neighbourhood of disease,, the seat of a more confirmed disorder, and of sup- puration.
In the frontal sinuses inflammation is attended with dull heavy head-ach, and pain, in the part. The pain is more severe on stooping ; the integu- ments over the sinuses are swelled, and puffy . The patient is sensible of a peculiar offensive smell, and it will probably be found, that at intervals, there has been discharge of matter from the nose. All this may be, and still we must use general remedies, nor think of performing so formidable an opera- tion, as applying the trepan, on the frontal sinuses. It is much more likely to be a common catarrhal affection, than a formidable disease, or it may prove merely head-ach, assisted by the imagination of the patient. But when there has been injury pre- viously, when there are symptoms of a beginning affection of the brain, when there is occasional sickness, ot much languor, or oppression, or any thing like epilepsy, or paralysis, a slighter indi- cation will satisfy the surgeon of the propriety of fcn operation. If there be a collection of matter,
aiuj
#2 ABCESS OF THE MAXILLARY SINUS.
and an inflamed sinus slowly affecting the brain, the delay of an operation may leave us full of regret.
If the frontal sinus is to be opened, we must pro- ceed with all the precautions, which we should employ in the more common occasion of using the trephine.
1. We have to recollect the thinness of the outer shell of the bone. 2. The obliquity of the inner table. 3. The partition which divides the two cells. 4. We have to remember, that the lining membrane of the cells will probably be thickened, and that if diseased it looks like a suppurating brains and has actually been mistaken for such ! b. That, when the trephiae has taken out the circle of the outer table very neatly, the membrane will stilf be entire, and require to be opened with the lancet. The cure will then be conducted by emollient injections. No tents or dressings .ough| fo be introduced into the cavity.
PERFORATING THE MAXILLARY SINUS FROM THS ALVEOLI.
The abscess of the maxillary sinus is- marked bf a colourless swelling of the cheek, over the bone, by a pulsating pain, deer) seated in the cheek, generally fixed to the check, though sometimes extending over the whole side of the head, but not increased on pressure, by an oozing of matter by the side of one of the molares, sometimes by a
discharge
ACCESS OF tkE MAMILLARY siNt'S. 43
discharge of matter from the nose. We find indeed that the most frequent complaint of bur patients is that of foul matter flowing into their mouth, when they lie in bed.
We are to be careful to distinguish it from rheumatism tooth-ach and a nervous affection of the face. When it arises from tooth-ach, succeeded by high imflammation, or comes after fever, or succeeding to injury of the bones of the face, or has any such ostensible cause, it is favourable ; and by the drawing of one of the molares, or per- forating the sinus, and thus allowing a free exit to the mattef, the disease will be cured.
All the treatment necessary in this disease, is to draw the second molaris, and then to pass up a stilette of the siie of a writing quill, into the sinus; nature seems to point out that this is the betted place for perforating, though it be sometimes done just above the alveolar process of the molares. The objection to this last place is that without taking away a piece of the guni, it is difficult to keep the perforation open.
If the perforation be inade in the side of the sinus, then the instrument, which makes the hole for the point of the trephine^ will answer.
When a patient presents with the sinus opened> and the matter funning from it, the operation* having been done some time before, we are not to despond, but to enlarge the opening, for it has probably been made too small.
After the operation the swelling may require fomentations, or astringent washes. When the swell- ing has subsided, and the discharge remains fcetid,
the
44 OF THE OPERATION FOR WRY-NECK.
the patient can force the fluid from the mouth into the cell by the tongue merely *.
If in this disease there should form an ulcer on the cheek, or just under the orbit, the disease is still to be relieved, by the operation performed below, since that opens into the floor of the antrum while the attempts to preserve the opening on the cheek, and to throw in injections there, will increase the deformity, even if they should be in the end successful in curing the disease.
WRY-NECK.
In the case of wry-neck, which is submitted for operation, the mastoid process, is as it were drawn towards the sternum, the head is inclined to that side, and the chin is pitched up. On examining the cause of this, the mastoid muscle of that side, will be found to be smaller than that of the other side; it feels stringy and hard; it will not stretch when the muscle of the other side acts so, that it suddenly checks the turning of the face towards the same side.
The disease of the muscle which occasions this, is a very singular one. The muscle is changed into a firm
* Tincture of myrrh, and a little camphorated spirit diluted_jis the best when the discharge is foetid.
substance^
OF THE OPERATION FOR WRY-NECK. 45
substance, which to the knife cuts like gristle, and which is equally incapable of contraction, or stretch- ing. I have chiefly seen the portion of the muscle which arises from the sternum, diseased in this manner; it would appear that to others the clavicular portion, has oftener presented thus changed in its texture.
In one instance I traced this disease, to -a fall, and twist of the neck. One cannot imagine a more likely cause of this disease, than a strain upon the muscle. I have seen a similar disease, in a portion of the biceps cubiti, producing the effects of an anchylosis, in fixing the elbow joint.
The only thing that the surgeon has to consider deeply is, whether the twist of the head proceeds from this disease or not. Whether the verte- bras have not greatly suffered, or it may be, there is almost an anchylosis of the cervical vertebras. We have to see that there be no paralysis of the mus- cles ; of the opposite side, rather than a permanent induration of this. If the distortion proceeds from a contraction of the skin of the neck, it will be sufficiently apparent, and distinguishable.
OPERATION,
The patient may be supported upright on a chair, then examining well the tract of the stringy
2 part
4S 0? THE OPERATION FOR WRY-NECK,
part of the muscle, an incision is made twet inches and a half, or three inches in lengthy through the integuments oyer this diseased part of the muscle. This will be found to carry the lower part of the cut, within an inch of the sternum.
Having cut down fairly to the surface of the mus- cle* the muscle is to be relaxed by moving the face to the contrary side,, and then the finger, or the handle of a knife or hook, is to be insinuated behind the contracted and diseased part of the muscle. This part is to be cut across by successive lesser cuts, the handle of the knife, or hook which is under it, guarding the parts below ; or a directory is introduced, by which the knife is guided under the muscle, when the diseased part of the muscle is divided by drawing the knife out- ward; the part as I have said, cuts firm like a tendon or cartilage. When the whole diseased part is cut across, the patient feels as if a cord which had long bound down the side of his head was cut across ; he can turn the head towards the other side, but he brings it round again with more difficulty, and for a time the position of the head is awkward.
New we will see the advantage of the first incision/ being in the length of the neck, for the more we make the patient hold the head towards the other slide, the closer the lips of the wound are drawn., though the space betwixt the cut surfaces of the muscle be considerable. I have not found the ban- dage to be necessary, during the cure of young peo- ple, the antagonist muscle answering the purpose; but
if
OF THE OPERATION FOR WRY-NECK. 47
if after a long continuance of the disease, there should be such a change in the form of the ver- tebra?, that it requires the continued operation of a bandage, then a roller is to be put around the head, and brought over the opposite ear, so as to come down forward and pass under the arm-pit.
If the distortion be owing not to the rigidity of a particular muscle, but to a more general defect of the muscles of the side of the neck, or to ge- neral thickness, and induration of the integuments, we must be contented with the trial of such re- medies as friction, with mercury and camphor, and the use of the bandage, electricity &c. If the cicatrix of the skin should be the .cause, it is advised that it be cut through, and the head kept in an opposite direction. It is a very troublesome business, and I would rather endeavour perseveringly to relax the contraction of the skin, by giving motion to the head, and here emollient embrocation may be also recommended.
or
OS* f HE CAtfAXACT*
OF TEE CATARACT.
The cataract is the chrystalline humour of the eye, become opaque. It is characterised in the beginning by these symptoms, The .per- son has a haziness before his eyes, he thinks lie sees black specks or flies, or streaks of black, moving before him, the vision is indistinct and rather diminished in strong light. Upon in- specting the eye, there is a whiteness and turbid opacity in the pupil. This is an affection not peculiar to any age, though snore common a'Ftejv the middle age. Sometimes it comes suddenly., though oftener very gradually. It may arise from inflammation, in some rare cases it has been dis- persed by a casual inflammation. Sometimes there is only a cloudy opacity to be seen in the pupil*, oftener the whole pupil is of a greyish colour, or it is of a deep milky whiteness.
When the cataract comes as a consequence of a blow, or of inflammation, it ought to be a reason of delaying the operation as long as possible, for these opacities will sometimes spontaneously dis- appear.
The following circumstances previous to ope- ration, have to be attended to. 1. Is the pa- tient, though blind, still . sensible of the varia- tions of light, does he distinguish when an opaque body is passed before his eyes, or can he distinguish
light
OP THE APPEARANCE OF CATARACT. 49
tight from darkness? The reason of attending to this circumstance is, that we may discover if the retina be yet sensible, though the rays of light are with difficulty transmitted, through the opaqud crystalline humour. S. Is the iris still move- able? becaiise if it still enjoys its motion, light being its only stimulus, and the retina being alone sensible to light, it indicates the sensibility of the nerve. 3. Further, in the motions of the iris, we have to observe if the pupil remain perfectly regular. The irregularity of the pupil, may* most probably, be owing to some adhesion of the cataract, to the edge of the iris, and indicates to us, that there has been a deep inflammation there. The irregularity of the pupil; is an unfavourable circumstance, but not a total bar to the operation,
4. The cataract which has arisen from a blow on the eye, or after violent and deep ophthalmia, is, for the same reason, unfavourable. Since it is reason^ able to suppose, that the membrane of the lens has been thickened, and has formed a firm adhesion to the surrounding parts. But fortunately the cata- ract is not often preceded by this inflammation.
5. When we look into the eye, to discover the seat of opacity. We look first nearly perpendi- cularly into the pupil, but then we must turn the patients head gradually* until we see the profile of the cornea; and now if the opacity should be caused by an effusion in the back part of the cornea, it is distinctly seen to be before the iris.
6. The deep black transparency of the pupil, and the want of motion in the iris, will sufficiently
vol. n. e distinguish
50 OF THE CATARACT.
distinguish the amaurosis (the insensible state of the retina) from the cataract.
7. The cataract may be of a consistence firmer than the lens is naturally; it maybe soft as cheese? it may flow liquid like milk, when punctured, but I know not how to foresee these distinctions by at- tending to the appearance of the cataract, before operation.
Surgeons of eminence, and oculists, still dis^- pute this point, viz. whether the depression, or extraction of the cataract, be the preferable ope- ration. The depression of the cataract is done by introducing a needle into the eye, and removing the opaque lens from the axis of the eye. The extraction is a very improper term, but it means the making an incision into the cornea, by which the cataract escapes, being pressed forward by the vitreous humour. In the performance of these operations, the Utmost delicacy is required, and they have a result the most interesting of any or the operations of surgery. Although the general opinion, at present, be in favour of the operation of couching or depressing the cataract, yet all I have seen makes me prefer the operation of ex- traction. I shall* however, describe the operation -of couching the cataract, first,
OF
&F COUCHING, OR DEPRESSING THE CATARACT. 51
OF COUCHING, OR DEPRESSING THE CATARACT*
The operation should not be performed on 'ting teye, while the other is sound ; and when both eyes have cataracts, though we have great temptation to operate on both, (by which on the whole we in- crease the chance of success) yet I conceive the operation should be done on one side only at a time. If the eyelids be much affected with a chronic inflammation, we ought to endeavour to correct this, previous to the operation. But if this is obstinate and habitual, and to no great extent, it makes no objection to the operation. No cross light must be admitted into the room; the north light is to be preferred, and it should strike oblique- ly on the eye.
1. The patient is seated on a chair, with a lortg upright back. A pillow is placed to receive his head; the assistant stands behind him to press, his head upon the pillow, and in part to support it with his breast A napkin is thrown over the other eye.
2. The assistant puts the points of his fore and middle finger, on the upper eyelid, and raises the eyelid, at the same time he gives a slight pressure to the eyeball, but rests his fingers at the, same time on the margin of the orbit, so that what pressure they give to the eye may be steady.
b £ g. The
52 OF COUCHING, OR DEPRESSING THE CATARACT.
3. The surgeon sitting down before the patient, places his foot upon a stool of such a height, that when the elbow rests on the knee, the hand may be opposite the eye. Now with the fingers of one hand, he presses down the lower eyelid, and when he wishes to fix the eye, as he is about to intro- duce his needle, he pushes upon the eyeball with the point of his fingers. It is to be particularly observed, that any change of the degree of pres- sure on the eyeball during the operation, is to be made by the motion of the operator's fingers, the assistant has only to keep steady.
4. The surgeon having dipt his needle in oil, he takes it as he would a writing pen, he rests his little finger on the bone of the cheek, and he pierces the white part of the eye, in the middle betwixt the margin of the cornea, and the angle formed by the eyelids, the patient's eye being directed straight forwards. The needle should pierce the sclerotica in a direction perpendicular to the convexity of the surface, or, in other words, point- ing to the centre of the eye.
5. The needle is now to be somewhat changed in its direction, and carried horizontally until the point appears behind the pupil, for it is to be ob- served that, although the opacity of the lens is con- siderable, yet the needle is seen through it, or when it is immersed in its substance. The fiat surface of the point ought to be towards the iris, as the sharp edge might cut the iris. •
6 The first motions of the needle, I conceive, ought to be calculated to pierce and fear the an- terior
OF COUGHING, OR DEPRESSING THE CATARACT. 53
terior part of the capsule of the lens. And this for two reasons. Before the cataract can be dis- placed from its seat in front of the vitreous hu- mour, its capsule must be broken, and this being done, by piercing it on the fore part, of course facilitates the descent of the cataract. Again, with- out this precaution, it happens that the cataract being couched, the fore part of the capsule re^ mains, and in the inflammation which necessarily follows the operation, it becomes opaque, and .forms what is called the membraneous cataract. We have, therefore, to push the needle in a direction parallel to the iris, and get before the lens, then carry the point through the pupil, so as to burst through, or cut the fore part of the capsule.
7. Supposing that on first touching the capsule of the lens, a white fluid escapes, and makes the aqueous humour turbid, we are not on this account to despair of success; for this milky, and dissolved state of the cataract promises a quick absorption, and restoration of vision. It is our business in this case to tear the anterior half of the capsule, as widely as we may, without hurting the iris, and to plunge the needle repeatedly into the cataract, and then to tie up the patient's eye as usual.
8. Having torn the capsule, the surgeon withdraws the needle a little, and puts it over the cataract, or pierces the cataract high on its disk. Now the point of the needle is to be depressed, by raising the handle of the instrument; but at the same time that the point of the needle is depressed, (carrying the cataract with it) it must be moved backward.
For
54 QF CCUCHING, OR DEPRESSING THE CATAT,ACT'.
For example A, being the lens in its natural situation, to remove it from the axis of the eye, or course of the rays of light B, Gs it is not to be pressed directly downward in the line D, but in the circular line E, which answers to the concavity of the coats, and by- this movement it will be car- ried down, and lodged at F.
9. When by raising the handle of the needle, the operator has carried the opaque cataract thus below the level of the pupil, and the pupil is clear, the operation is not done, for in all proba- bility, the cataract has not escaped from its capsule, and, on "withdrawing the needle, it will rise again. He therefore would have to blame himself, if, having withdrawn the needle from the eye, he saw the cataract again forced up, and take its place be- hind the pupil, for the operation would be still to do. When, perhaps after repeated efforts, he has sunk the cataract out of sight, he must cautiously with- draw the needle from its hold upon the cataract, but not altogether from the eye; then, if the cata ract does not appear in the pupil, the needle is to be slowlv withdrawn.
Thf
OF COUCHING, OR DEPRESSING THE CATARACT. 5 3
The fact is, that when the needle has carried down the cataract, the cataract is not yet unseated from its capsule, and instead of being separated from the vitreous humour that body has revolved with; by the elasticity of the membrane it will resume its former relation, and of course carry up the cataract, so as again to present it in the axis of the eye. But the cataract may have been separated from its connex- ions to the fore part of the vitreous humour, and yet rise in a partial manner, on withdrawing the needle; this is, because it has not been so forced into the vitreous humour, as to break on its capsule, and make a lodgment for itself; the elasticity of- the vitreous humour throws it out again. It is incor- rect to sav, that the cataract has been buoyed up; i>ince it is specifically heavier than the vitreous humour.
There is a possibility, that the cataract mayescape from under the pressure of the needle, and pass through the pupil, into the anterior chamber of the aqueous humour. If the whole or part of the cataract escape thus, we ought to let it remain; it will dissolve in the aqueous humour, and be finally absorbed. The cataract may start backwards, too, so as to be deeply immersed in the vitreous humour. I have seen it faintly shining half an inch behind the pupil. I fancy this is not a frequent accident; if it should happen, we are to do no violence in endeavouring to remove it, as we are assured it will dissolve, since it must, in this case, be freed of its capsule.
10. It
56 OF COUGHING, OR DEPRESSING THE CATARACT,
10. It is a more difficult thing to fulfil the in^ tention of the operation, when the cataract is soft or cheesy, for when the needle is pressed upon the cataract, the needle passes through, without dislodging it from its place., nor does the matter flow out from the capsule.
We ought, jn this case, to break, or burst through the capsule, and, as freely as possible, admit the aqueous humour through the anterior part of the capsule; and a second intention ought to be to break down the cataract, which is increasing the chance of its dissolution afterwards. By persever- ance in pressing with the broad edge of the needle, without injury to the eye, it will often be possible to remove the cheesy matter from the centre of the pupil, so that afterwards the patient shall see a little.
11. If there be an adhesion of the cataracf: to the iris, we shall discover this by the irregular figure which the pupil assumes upon the variations of light, admitted to the eye. During operation, if the depression of the cataract should disorder the regular circle qf the pupil, it is owing to an adhesion, and we must endeavour to separate the cataract, and iris, by the edge of the needle, before we attempt finally to depress the cataract.
12. If after a few days the eyelids are opened, and there appear any fragments of the cataract, they are again to be depressed, or pushed before the pupil by the needle; but this is not to be done until the inflammation and irritability, the conse- quence of the first operation, have entirely subsided.
13, The
OF COUCHING, OR DEPRESSING THE CATARACT. 57
13. The remains of opacity behind the pupil, may be what is termed the membraneous cataract. To tear away these shreds, and to push them below the level of the pupil, or through the pupil into the anterior chamber of the aqueous humour, a needle should be used so curved near the point, that by merely rolling the needle, betwixt the finger and thumb, the point of the needle may be moved pretty extensively. With such a needle the operation may be done with less violence, and a smarter motion may be gtven to the point of it, than where, in order to give motion to the point of the needle, we have to raise the handle.
14. Any portion of the cataract, or any shreds of the cataract, or its capsule, which are accidentally pushed into the anterior chamber of the aqueous hu- mour, are to be allowed to remain there, for they }vill be dissolved, and carried away by absorption.
15. The secondary cataract is the opacity of the remaining capsule, which is not carried down with the opaque lens, but remains in its situation. The secondary cataract may be perfect or partial. It may be said to be perfect when the lens has escaped from the back part of the capsule, and has been immersed in the vitreous humour, without the anterior half of the capsule being torn from its con- nexions to the ciliary process, or rent in anv way. This is more apt to take place, than we at first would imagine likely, from the greater tenuity of that part of the capsule which is towards the vitreous humour, than the anterior portion of it. The imperfect, or partial secondary cataract, is the
remaining
58 OF COtJCHTNG, OR DEPRESSING THE CATARACT*
remaining shreds of the anterior part of the cap- sule. It is an opinion, that only the anterior part of the capsule is liable to become opaque, and I think this is very likely ; there is a foundation in anatomy for supposing that the anterior, and posterior part of the capsule of the lens, are of a different nature. It is this conviction, that the fore part of the cap- sule is most frequently opaque, and that it is the most liable to be so after the operation, that induces us to be careful to pierce, and breakdown this fore part, before couching the opaque lens.
If this has been done, only shreds of opaque mem- brane can be visible in the pupil, after the operation. And if they appear, we ought to let them remain for some time, in the expectation of their wast- ing, and acquiring transparency again. I have seen, on dissection, an opaque spot on the back of the capsule, and therefore I am forced to say, that the secondary cataract may be in the posterior segment of the capsule of the lens. But whether the opacity be in the back, or fore part of the cap- sule, is of little consequence, since it cannot be distinguished in the living eye, (because the vi- treous humour forces the back part of the capsule into contact with the iris, after the depression of the lens itself,) and happily it is of little conse- quence to know what part of the capsule is thus diseased, as this supposed distinction would make no variation in the practice.
16. hi operating for the membraneous or secon- dary cataract, the intention with which we use the needle may be somewhat varied. We first endea-
OP THE EXTRACTION OF THE CATARACT. 59
vour to tear down the opaque membrane, and to place it under the level of the pupil, or we may attempt to gather the shreds of the membrane toge- ther, to loosen them from their natural attachment, and to push them through the pupil, into the ante- rior chamber of the aqueous humour, where they will be dissolved and absorbed. We ought not to be too persevering in our attempts to clear the pupil of the membraneous cataract at once, on the contrary we should be careful to do little injury, so that we may avoid raising inflammation. - We re- peat the attempt after a time. The needle should be very fine, and curved at the point, not like that which is adapted for pressing down the cataract of the body of the lens,
OT THE EXTRACTION OF THE CATARACT,
The extraction of the cataract, I allow to be a more formidable operation than couching; but when it is well done, it is more uniformly success- ful. I do not know that it is more difficult to per- form extraction, than it is to perform couching; but the blunders in this operation are at once ap- parent, while in couching the errors are concealed ; and even the initiated cannot precisely say from the motion of the hand, whether the operator be, with delicacy and niceness of intention, remov- ing the opacity from the pupil, or making un- meaning:
60 OF THE EXTRACTION OF THE CATARACT.
meaning, and consequently, unsuccessful motions of the needle.
Freedom from tumefaction and inflammation of the eyelids, and of all tendency to ulceration in their edges, or to opacity in the cornea, is more essentially necessary, previous to performing the operation of extraction, than of couching.
Extraction, let me say, is a bad term, as it in- dicates that the intention of the operation is to make an incision, and to pull out the opaque body. This idea is as dangerous, as it is incorrect. The principle on which the operation is done, is simply this. The coats of the eye are tense over the con- tained humours. Over the coats of the eye, are expanded the tendons of the muscles, while the,eye- lids have in them the fibres of the orbicularis muscle. The moment that the eye is wounded therefore, the humour escapes at that part. If an accidental wound be made on the white of the eye, the vitreous humour escapes in part. If the cornea be wounded, the aqueous humour escapes. But al- though the cornea be punctured, and the water escape, it does not fall flaccid. But the iris and the' lens are pushed forward by the tension of the coats on the vitreous humour, and they take the place of the aqueous humour. Should the cornea not be punctured merely, but cut with so wide a wound, as to allow the lens to pass, the pressure on the vitreous humour by the coats and muscles of the eye will be so great, that the lens will be thrown in through the pupil, and escape by the wound.
the
OP THE EXTRACTION OF THE CATARACT. 61
The operation to be performed, then, is not to extract the cataract, as we speak of extracting the stone from the bladder; but only to make such an opening in the cornea, as to allow the cataract to be forced out by the tension of the coats of the eye, which is continual ; or by the action of the muscles of the eye. The necessity of attending to this principle during the operation, I hope will be presently evident.
INSTRUMENTS.
If the operation is successfully done, no other instrument need be used, but a knife, of a form somewhat peculiar, and adapted to make the pro- per incision of the cornea. The knife is of the form seen in the succeeding marginal plate p. 64. The point must be very sharp, the back straight, not sharp, and yet not thick; the curved edge very sharp, and the middle of the knife the thickest, and strongest part of it; in the first place, that the knife may have strength to be pushed through the cornea, and in the next place, that it may effec- tually fill up the wound as it is pushed forward. The broadest part of the knife must be fully two thirds of the diameter of the cornea.
The incision is made, by passing the point of the knife through the cornea, and across the fore-part of the eye, with one uniform motion, and the point entering on one side the cornea, near its attachment to the sclerotica, transfixes the opposite
point
b% OF THE EXTRACTION OF THE CATARACT,
point, and being still carried forward, the lower* edge of the knife cuts freely through the whole lower segment of the cornea, until it is disen- gaged. But if the breadth of the knife be not sufficient to make its way out, when thus uniformly pushed onward, the edge requires to be pressed down; an incision larger than the knife can fill up is conse- quently made, the aqueous humour escapes, and the iris is pushed forward on the edge of the knife! A little oil should be on the point of the knife.
To suspend the eyelid, and in some degree to fix the eye; the wire speculum is best in the hands of the assistant; the pressure to fix the eye must be made by the tips of the surgeon's fingers, at the same time that he holds down the lower eyelid.
A gold needle is among the apparatus of the oculist. The use of this is, to break or cut the capsule, when after cutting the cornea, that mem- brane strongly resists the effort of the muscles, to protrude the lens. The point should rather be rough than sharp, whether it be made of gold or of any other metal, is of little consequence.
Forceps too are necessary, and they must be of such a form and niceness, that we may introduce them under the flap of the cornea, and seize any shred of opaque membrane, that may present in the pupil.
For the same purpose, and to extract any broken piece of the cataract that is detained, a very deli- cate hook is to be provided.
The cornea scissars are absolutely necessary too, to increase the incision of the cornea, if it shall
be
' OP THE EXTRACTION OF THE CATAHACT. 68
be necessary, or to separate any protruding cap- sule. A fine probe will be found convenient to replace the prolapsed iris, when it shall have fallen out from the incision. Such a probe will also serve to dilate the pupil, if it be necessary ; but of this, we will speak presently
OPERATION.
The patient is seated on a low chair; the surgeon is seated opposite to him; the light must be stea- dy, and without glare. A cloth is put over the other eye. The surgeon turns the patient's head until the light falls a little obliquely on the eye to be operated upon; the depth of the pupil, and its nearness to the cataract, is then distinctly seen.
1. The assistant standing behind the patient brings his breast so as to support the back of the head; puts his left hand under the chin, and with the right taking the speculum of Pelier, he raises the upper eyelid by pressing in the integuments of the eyelid, betwixt the eyeball and the margin of the orbit.
2. The surgeon, with the tips of hisx fingers* presses the lower eyelid against the eyeball, so as to fix it; the margin of the eyelid is at the same time carried down so that the cornea standi prominent. The other hand holds the knife^ He rests the elbow on the knee, the little finger on the cheek-bone,
3. When
64
OF THE EXTRACTION OF T&E CATARACT.
3. When the eye is steady, the point of the knife is made to pierce the cornea, within half a line of the sclerotica, and on the outside and a little above the middle of the cornea, the flat side of the knife is towards the eye, its straight back up- wards. The knife is now carried in a direction towards the nose, and at the same time downwards. The nicety of this part of the operation is to carry the knife uniformly forward, to press in that de- gree which will keep the eye steady, and yet so to manage the pressure, that the aqueous humour does not escape by the side of the knife.
4. The point of the knife is made to pass over the lower half of the pupil, and enter the opposite side of the cornea, at the same distance from the sclerotic coat, as where the point first entered. Now, being carried uniformly forward, the lower edge of the knife will cut the lower segment of the cornea, at the distance of half a line from its connexion with the sclerotica.
The
OF THE EXTRACTION OF THE CATARACT. 65
The knife is here represented, passed, not direct- ly across the eye, but entering near the margin of the cornea, a little further up than usual, and the point coming out a little lower.
The intention of this is, to prevent the eye from turn- ing towards the nose during the operation; which it is very apt to do, when the knife Nis pushed directly from without inward. Although in pushing the knife in this direction, the eyeball should be turn- ed as much downward, as in the other way it would be inward, yet, when the eye is turned downward, we can better proceed with the operation, or more easily turn the eye to the proper direction.
When the eyeball moves before the knife, we must suspend, as it were, the progress of the knife, but not in the slightest degree withdraw it; we wait a little for the ceasing of the spasm, and then, with the knife, bring back the eye to its original position. Often, I may say, the oculist distracted by this simple accident, brings out the point of the knife too socn, and instead of making a semi- circular incision of the cornea near its margin, makes a cut, terminating nearly in the middle of the cornea, thus :
vol. it. ir A. The
99 OF THE EXTRACTION OF THE CATARACT.
A. The proper course of the incision, marked by a dotted line. B. The course which the knife has taken in cases, where I have seen the ope- rator embarrassed, by the eye turning inward.
5. It is to prevent this motion of the pupil towards the nose, that practitioners have exerted all their ingenuity, to form a speculum to fix the eye. The first objection to the use of the specu- lum, is, that it engages the hand of the surgeon, when he should have his finger free, to press upon the surface of the cornea; and secondly, that the speculum operating by pressure on the eye, is apt to force the aqueous humour out, before the in- cision is completed.
6. Some oculists have recommended, that the capsule of the lens, should be punctured, before the incision of the cornea be completed, viz. as the knife is carried through the anterior chamber of the aqueous humour, they depress the point into the pupil, to pierce the capsule. But this is a prac- tice not to be imitated, as the advantage of it, bears no proportion to the danger. The conse- quence of this manoeuvre, too often will be, that the aqueous humour will escape; then the iris will press forward on the edge of the knife, and the incision cannot be completed with the knife.
7. If by any accident the aqueous humour should escape, and the margin of the iris should fall before the edge of the knife, in this manner, we canno* then carry forward the knife.
Thi's
OF THE EXTRACTION OF THE CATARACT. 67
This accident requires calmness. We know how it has happened, and this knowledge teaches us to remedy it. A little of the aqueous humour has escaped, and the iris is pressed forwards: we must restore the equilibrium then, by pressing gently on the cornea. This throws back the margin of the iris behind the edge of the knife, and again we can carry the knife straight forward *.
8. But if the aqueous humour, has escaped in such a quantity, that the iris has come in contact with the cornea, and lies before the edge of the knife, we cannot finish the section of the cornea with the knife. The point of the knife must be withdrawn a little, * and brought before the edge of the iris, and made to pierce the cornea lower down, than would be necessary to make an incision of
* Baron Wenzel and Mr* Ware, give the direction to rub the cornea, as if there was a sympathy betwixt the cornea and iris: but as I have not been able to ascertain that any connexion subsists betwixt the rubbing of the one, and the contraction of the other, I have given this intel- ligible reason for pressing the cornea.
ji g
due
68 OP THE EXTRACTION OF THE CATARACT.
due extent. By this change of the direction of the knife, we have made a section of the cornea, without injury to the iris, but it is not of suffici- ent size to let the cataract pass, we must therefore have recourse to the scissars to enlarge it.
9. When we have made the section of the cornea too small, and the lens or cataract does not come spontaneously forward, we must insinuate one of the blades of the fine scissars under the flap of the cornea, and enlarge the incision.
10. I shall suppose that the section of the cornea has been duly made, and the cataract does not im- mediately follow. Some oculists have recom- mended that we introduce a curette into the pupil, and enlarge it. This is an ignorant way of dilating the pupil. We ought simply to shut the eyelids, and cover the eye with the hand, so as to relieve the excitement of the eye, and by excluding the light the pupil will be dilated, and ten to one but the cataract will be seen coming from under the eyelids, on lifting up the flap of the cornea. — If the cataract be still retained, then it is not the contrac- tion of the pupil which prevents its discharge, but a particular strength in the capsule. And now the gold needle, or some such instrument, must be passed under the flap of the cornea, and into the pupil, to break or puncture the capsule, when the cataract will be discharged.
10. The Baron Wenzel and other oculists who have gained dexterity by practice, without ascer- taining the principle, have asserted that " The in- cision of the cornea is not the most difficult part
of
OP THE EXTRACTION OF THE CATAEACT. 69
©f the operation, and that it afterwards requires much dexterity as well as judgment successfully to extract the cataract/' All that I know of the struc- ture of the eye, and what I have seen of these ope- rations, and the difficulties I have myself experienced, contradict this opinion. The successful incision of the corneals the operation, and all the untoward cir- cumstances that may trouble the operator, have their source in the imperfection of the section of the cornea* or from some previous disease of the eye, as for ex- ample, the thickening of the membranes, or the ad- hesion of the capsule of the lens to the iris, Sec.
As soon as the knife has cut itself out, the upper eyelid should be allowed to fall ; for the uniform support of the eyelid prevents the cataract from being thrown out too quickly, or the vitreous humour from following it, if it should escape before the eyelid can be closed. If upon raising the eyelid the lens does not make its appearance, the capsule is to be punctured, and the eyelids again closed to allow the pupil to dilate. If it does not now come forward, the small probe is to be introduced under the flap of the cornea, to examine if the in- cision be large enough ; for, from the thickness of the cornea and the oblique direction of the knife, the incision of the cornea may seem to be of suf- ficient length on the surface of the cornea, when the knife has not penetrated to the inner surface nearly to the same extent: if the incision should prove too small, it must be a little enlarged with the scissars, as I have said. If the cataract does not now come eut spontaneously when the incision is evidently
1 sufficient,
i 0 OF THE EXTRACTION OF THE CATARACT.
sufficient, and when the capsule is punctured, we are forced to press the eyeball.
12. We ought not to press the eyeball if it can be avoided ; for there being a difficulty in forcing the cataract through the pupil, when that difficulty is overcome the vitreous humour is apt to follow the cataract ; and often it will happen, that the vitreous humour will escape without the lens being dis- charged. By this pressure the lens is not carried through the pupil, but only the edge of it is* pro- truded, and the vitreous humour escapes under it, while the firmer cataract is retained*.
13. When the iris is cut by the edge of the knife, no pressure must be made on the eyeball, or the vitreous humour will escape while the cataract is re- tained. When the pupil is of its natural form, and the iris entire, the cataract presents behind the pupil, and no part of the vitreous humour escapes before it is protruded, but when the iris is cut, the
* Thus we find the Baron de WTenzel describing a thing which should never be seem — u The cataract did not give way to the gentle pressure that is usually found sufficient to dislodge it. Its upper edge repeatedly advanced into the pupil, and sometimes almost came through it," &c. Every time the chrystalline advanced, a small bladder was perceived on its posterior and inferior edge, strongly adherent, to it, and formed by the hyaloid membrane, &c. To press the eyeball in such a stjite of the lens, and the bladder which is here described, is out of all rule. The bladder is simply the vitreous humour pushing forth under the lens or ca- taract, which has turned its edge forward instead of being carried bodily through the pupil,
v vitreous
OF THE EXTRACTION OF THE CATARACT. 71
vitreous humour being softer, is carried through the slit of that membrane, and the lens is only turned a little,, but not unfixed, and pressure may force out all the vitreous humour before the lens will come. By inattention to this consequence of the iris being cut, I have seen a great part of the vitreous humour lost. If the iris be cut, we should then indeed ex- tract the cataract by piercing it with the crooked needle ; unavoidably, 1 am afraid, some part of the vitreous humour will escape.
1 4. When there is a detention of the cataract by adhesion, it is recommended that we should carry the golden needle all round the cataract, and in different directions, to separate these adhesions. This appears to me as absurd as dangerous. The ad- hesion is betwixt the capsule and the ciliary pro- cesses and iris ; we have then only to pierce the anterior part of the capsule, to open it freely, if it be very tough, and then the cataract is discharged, for there is no adhesion betwixt the capsule and the cataract*. If, after the discharge of the opaque
chrystalline
* (i After the cornea and capsule had been properly divided, my father found that the cataract did not come through the wound on his making the usual pressure. He was therefore obliged to introduce the needle and carry it in different directions round the chrystalline, in order to destroy the adhesions it had formed to the posterior parts of the iris. This part of the operation took up at least fifteen minutes." This is the recommendation of the Baron de Wenzel, his son, and the commentator, Mr. Ware.
On this account we first ask ourselves, why was the
capsule
72 OF THE EXTRACTION OF THE CATARACT.
chrystalline or cataract, opaque membranes fill the pupil, we may be tempted to extract them ; but if the anterior part of the capsule of the lens be rup- tured, though the shreds of that membrane may be visible, (owing to their opacity), yet I conceive we have nothing farther to do, but to close the eye. By holding the patient's eye thus exposed to the light, and introducing instruments under the cornea, we excite spasm in the muscles, and as the mem- branes we are tearing away, are connected with the vitreous humour, it is scarcely possible in this at- tempt to avoid losing much of that humour.
If the anterior part of the capsule be opaque, the lens having burst through it, it will, I imagine, be better to let it take the chance of wasting in the aqueous humour, than by tearing it away to endanger the entire loss of the organ, in con- sequence of the discharge of the vitreous humour,
15. When the cataract is discharged entire, we ought to have little further anxiety, I imagine, than to see that the iris does not hang relaxed into the incision of the cornea; as light contracts the
capsule punctured, but that it might burst freely open, and allow the cataract to escape; and if the cataract did not escape, was it not owing either to a bad incision, or if that is notlikely in so dexterous hands, to the strength and tough- ness of the capsule ; why therefore was the intention of the operation changed ; why, because the lens would not come forth, and drag the capsule with it? To have cut th& capsule freely open, and to have dilated the pupil, was what should have occurred to us as proper to be done.
pupil,
OF THE EXTRACTION OF THE CATARACT. 73
pupil, so will opening the eyelids make the relaxed iris draw up ; but if it be at all engaged betwixt the edges of the cornea, it will require to be replaced by insinuating the small probe into the incision.
16. When the operation is finished, we must see that the edges of the incision come accurately to- gether, then the eyelids should be closed, and some plies of wet lint, hung before the eye ; the clothes must not pi ess much upon the eyelids. Before putting the patient to bed, we must see that the margins of the eyelids are properly together, and that none of the eyelashes are turned in upon the eye. The eyelids should be looked to the next morning, and if necessary, bathed and cleaned of any secretion ; the eye should be examined carefully on the third day, but the eyelids instantly replaced, and the patient enjoined repose and darkness for ten days. ,
17. It is, in my opinion, entirely out of the question, to perform the operation of extracting the cataract a second time. If there occurs any neces- sity for removing a remaining opacity of the pupil, after the chrystalline humour has been discharged, and the incision of the cornea healed, it must be done by the needle, as practised in couching.
OF
fk OF THE TREATMENT OF THE EYE,
OF INFLAMMATION OF THE EYE, AND OF THE TREAT- MENT AFTER OPERATION.
The eye is necessarily of the most delicate struc- ture, and exposed more than any similar part of our frame. The natural delicacy and transparency of its membranes are preserved in a manner truly admirable. The tears which wash its surface, we must have observed, are acrid and stimulating, and wrhen they run over the cheek, inflame and excoriate the surface. But the delicate surface of the eye and eyelids are accommodated to the presence of this fluid, and the advantage resulting from this is, that the surface is not disordered or irritated by any lesser degree of stimulus, and consequently it bears the variations of the atmosphere, and the ex- citements it is necessarily exposed to.
Yet when we consider the exposure of the sur- face of the eye, and the delicacy and vascularity of its membranes, we cannot wonder that it should be often inflamed, and often suffer from those derange- ments of the constitution which are not to be remarked but by some such local affection as chronic inflammation of the eye.
I see chiefly these distinctions in the inflamma- tion of the eye: 1. An acute inflammation, with evident symptoms of constitutional derangement, 3 marked
AFTER OPERATION. i%
marked by nausea and a furred tongue, or accom- panied with inflammation of the mucous membrane of the nose, and sinuses, and symptoms of inflam- matory fever; or an inflammation similar in symp- toms,, but most commonly resulting from outward impression. 2. A lower degree of inflammation, chronic, and resisting local remedies, which is re- sulting from some derangement of the system. 5. Lastly, an inflammation, only resembling the others in appearance, the effect of local debility in the eye, and characterised by a relaxed state of the vessels, and a fullness of the membranes, the con- sequence of a preceding violent inflammation.
1. In the first example, while the inflammatory action is to be subdued, all that will excite, is to be removed in the first stage ; every surgeon of good practice forewarns us to notice well that change which takes place, when instead of the violent throbbing, the acute pain, and hot watery discharge, there is only a swelling and turgessence in the membranes, with a diminished irritability, the eye- lids more flaccid, the fieriness being gone though the redness remain, and the*pupil be more dilated ; now the evacuations, the soothing and emollient appli- cations, which were necessary at first, will only con- tinue the symptoms, and tend to fix the complaint, while cold stimulating and astringent applications are to be employed.
The mere, consequences of violent ophthalmia, and which are not to be considered as fixed or pe- culiar diseases, are the phlyctence, which are small vesicles formed on the surface of the eye; the che-
mosis,
76 OF THE TBIATMENT OP THE EYE
Miosis, which is the swelling and projection of the conjunctiva; the pur if or m discharge from the eye- lids, (which when in a remarkable degree, I am in elined to believe is always owing to matter com- municated to the eye) ; the hypopion, which is a deposition of coagulable lymph in the anterior chamber of the aqueous humour ; the bursting and total destruction of the eye ; all these, as sure con- sequences of the high inflammation, are to be pre- vented or cured by removing the inflammation. But the several diseases I have now to mention, as requiring operation, we may better consider as the consequences of the continued chronic ophthalmia, and which from the slowness of their formation do gradually acquire a kind of constitutional perma- nency which requires excision.
I may say once for all, what I conceive to be ne- cessary in the examination of these diseases, in order to discover if any thing should be done previous to operation, and what treatment is to be pursued after the operations upon the eye, when inflamma- tion is a consequence.
When any new membrane seems to be formed on the eye, any pustule, ulcer, or opacity, accompanied with clusters of turgid veins, or a general relaxation and fullness of the vessels, before taking the knife to- these, we ought to examine if any accidental cause has existed which is now happily removed ; or whether or not by the foulness of the tongue, the want of appetite, the languor and sickness, the occasional rheumatism in the face and head, or head-ache, or any such slight affections, there exists
derangement
AFTER OPERATION'. 77
derangement in the system, or debility and conse- quent accumulation in the stomach and bowels. We must examine well whether the local disease partakes of the character of scrophula or syphilis. — The in- fluence of these causes ought, if possible, to be removed before operating on the eye.
Previous to an operation the patient should take a smart purge; from the immediate debility proceed- ing from this he ought, however, to be recovered. The immediate effect of a severe or protracted ope- ration on the eye will often be a nervousness and sickness, or coldness, shivering, and head-ache ; this state an opiate with an aromatic will remove, and as it will often happen, that the irritability of the stomach will prevent the medicine from being re- tained, if the opiate be given in the form of clyster to the quantity of what would be a double dose if taken by the mouth, it will cause the commotion and sympathy of the frame with this most irritable organ to subside:
If. blood flows from the eye in consequence of the operation, it is to be promoted by bathing the eye with tepid water. Afier all operations on the eye, the patient must be condemned to darkness, and low diet; a wet rag be put on the eye, the bowels must be kept open. He must not indulge in bed, nor lie with his head low, nor have his head and eye loaded with bandages and dressing. Opiates should be held in reserve as long as may be. That inflammation which proceeds from the stimulus of the knife, should be treated with emollients, and the eyelids washed with tepid water. The astringent collyria should be reserved for that
sta£e
78 OF THE TREATMENT OF THE EYE, &C.
stage when there remains not the smart action of vessels, and the acute sensibility, but, on the con- trary, a relaxed state of the parts only. There is a niceness of observation necessary, to be able to say when the operation has ceased to produce its effect, when it may be repeated, or when a caustic may be applied to assist in the cure, supposing an excres- cence or tumour has been cut off. Even after this effect of the mere irritation of the knife might be expected to have subsided, there will often come on symptoms of general disorder, headache, and in- crease of heat, with restlessness and watching. But the tongue, the bitter taste of the mouth, and nausea, point out to us the necessity of gently moving the bowels; these symptoms will yield to quietness, low diet, and occasional clysters.
This lowness of diet, we must remember, is not to be the universal order, but observing when there is a tendency to high action, or irritability of weak- ness present, we must half starve some, and give more generous diet to others. Above all we must guard against the complaint being fostered and supported by confinement and bad air, low diet and despon- dence, for this reduces the system to that state which, though not actually disease, is particularly unfavourable to the cure of surgical diseases.,
RELAXATION
.KI1AXATI0K OF THE EYELID, > §
KELAXATION OF THE EYELID*
There may be a difficulty of raising the eyelid, from an irregular motion and spasm of the orbicu- laris palpebrarum*. There may be a difficulty of raising the eyelid, from a loss of power in the levator palpebra3 superioris. There may be a re- laxation of the upper eyelid, in consequence of inflammation long since subsided ; a fullness of the cellular membrane, which prevents the action of the levator muscle. In this last case a portion of it may be cut off, so as to relieve the eyelid, which otherwise hangs over the cornea, and obscures vision.
AVERSION OP THE EYELIES. {Ectropion).
The conjunctiva having been inflamed, there some- times remains a tumefaction in the conjunctiva, with a weak chronic inflammation. The edge of the eve- Kd is turned outward, and there is a semilunar, pale,
* An irregular nervous affection producing it, as in hysteria.
fleshy
SO IVERSION OF THE EYELID3.
fleshy tumour betwixt it and the eyeball. The cornea sometimes appears sunk within a circular tumour. The eyelids no longer wipe the dust from the cornea ; they are removed from it ; the eye is hot, and the tears fall over the cheek, there being no longer the gutters left between the meeting of the ciliary cartilages, to convey the tears to the pun eta*, and there occur of course frequent attacks of more violent inflammation, and in the end an opacity or ulceration of the cornea takes place. In slight cases the tumours are only to be scarified, or the surface, (if it shall have granulated) may be destroyed with the lunar caustic. The object in both these ways is to produce a cicatrization and consequent contraction of the conjunctiva.
When the disease is more confirmed and the semilunar tumour of the conjunctiva considerable, the whole protruding part is to be cut off. To do this, it is seized^with the hook or forceps, and with the crooked scissars it is to be cut off. After this a few touches of the knife may still be necessary, and. during the cure the end may be further secured, by touching any prominent granulation with the caustic and by the use of astringent washes.
* There is a lesser degree of this disease, comma* to old people> which is not meant to be spoken of here.
©F
OF THE INVERTED EYELID. 11
OF TFIE INVERTED EYELID.
Inversion of the eye is where the margin of the eyelids and consequently the eyelashes are turned inwards upon the eye, proving a continued source of irritation and inflammation.
No spasm or violent action of the muscles of the eyelids will produce this inversion, nor will the paralysis of the same muscles have any tendency to form if. It is one of the many consequences of chronic inflammation, which making, as it were, a permanent growth of the superficial part of the eyelid, while the conjunctiva remains contracted it follows of course, that the edge of the eyelid iu turned in. It is then in all respects the exact re- verse of the evers;ion, and tumour of the conjunctiva. But perhaps this position of the tarsus is not merely the consequence of a fulness of the cellular membrane, or growth of the skin, but in consequence of ulcers ; the inner surface of the eyelid and tarsus may be contracted by the forming of the cicatrix.
The surgeon then has to determine by careful examination, whether or not the inversion be owing to the growth or relaxation of the outward skin and cellular membrane of the eyelid, and if it be, there is this method recommended of removing the evil.
With the finger and thumb a portion of the skin
VOL. II, G Of
82 OF THE INVERTED EYELID.
of the eyelid is raised, so as to hold a ply or double of the skin, parallel to the margin of the eye- lid. In doing this the surgeon will be able to dis- tinguish betwixt the skin and the muscle, and will of course be careful to avoid catchins: hold of the orbicularis muscle. The scissars are now applied so that an oval piece of skin, or rather apiece of the form of a myrtle leaf is cut out. The appearance of the eye is frightful, but first by means of an adhesive plaister, and then by a compress and bandage the skin of the eyebrow is brought down so as to allow the margins of the wound to approach. The cicatrix forming consolidates and gives firmness to the outward skin, so as to keep the cilia? from being longer inverted upon the eye.
But if this inversion. of the eyelid be a conse- quence of ulcers and contraction of the inner and cartilagenous edge of the eyelid, forming a kind of stricture which prevents the inner edge from rising fully over the eyeball, and which drags in and in- verts the margin of the eyelid, then a different operation is performed. Having forcibly turned out the inside of the diseased eyelid, the inner mem- brane of the eyelid, and the ciliary cartilage are to be cut across by the point of a lancet. If the in- version of the eyelid has arisen from the, alleged cause, it will be immediately relieved.
OP
OF TUMOURS OF THE EYELIDS. 83
OF TUMOURS OF THE EYELIDS.
There are tumours of the eyelids which th.e patient is very willing to have taken off, and which should be taken off because they push in the tunica conjunctiva, and pressing upon the eyeball, in the motions of the eye-lid, they inflame it. These are small incysted tumours growing in the place of the meibomean glands, and it is natural to suppose that they are the enlarged glands.
But we must observe, that there are tumours of the eyelids which ought not to be cut. These are small tumours with a broad base, and of a dark red colour. Sometimes they have the appear* ance of a small boil, being white on the most pro* minent >part : yet this is not pus*. On the contrary, the tumour we have to cut out is colourless, only in as much as sometimes by exciting the eye there may be some general inflammation.
These incysted tumours of the eyelids, it is needless to attempt to remove either by local re-
* Hordeolum. In this tumour of the eyelid we should do very little, unless it be to move the bowels. When, however, the little swelling advances, this white speck bursts and discharges a little fluid, and then a slough is seen within, which is by and by pushed out, and the sore closes, to promote which, fomentation and poultices are used.
c 2 medies,
©4 OP TUMOURS OF THE EYELIDS.
medies, or by attention to general remedied, they must be cut out, or the patient must submit to the inconvenience ; I must add, however, that there is more pain and bleeding than would be imagined to be the consequence of so trifling an operation.
The first thing to be examined is, whether or not the tumour be so united to the inner membrane of the eyelid as fo force us to cut through the eyelid altogether, before we can take away the tumour, if we should operate by making our first incision on the outward skin. If the conjunctiva seems inti- mately united to the tumour upon our everting the eyelid, we have to proceed thus :
As in all operations on the eye, the patient is firmly seated, and an assistant standing behind him supports the head against his breast. 1. The as- sistant must invert the eyelid, by catching the eye- lashes and margin of the eyelid with his finger and thumb, and turning, his fingers, so that the fore- finger pushes forth the tumour and everts the eye- lid. 2. The surgeon now draws his lancet pointed scalpel across the tumour, so as to divide the tunica conjunctiva in a direction parallel to the edge of the eyelid. 3. Having by scratching a little se- parated the membrane, so that the tumour is thrust out, he has to push a hook or small tenaculum into it, and then to dissect it away altogether.
But if the conjunctiva be not diseased or very firmly united to the tumour, we had better operate without everting the eyelid, and this is possible without leaving an observable scar on the eyelid.
1. Thsf
OF TUMOURS OF THE EYELIDS. 85
!„ The surgeon fixes the eyelid by pressing the two angles down by the points of the fore and middle fingers, and having stretched the outer skin of the eyelid over the tumour, he draws his knife di- rectly over the tumour and parallel to the edge of the eyelids, consequently separating the fibres of the orbicularis, not cutting them across. 2. Having exposed the outward half of the tumour he pushes the fine tenaculum round under it, and then dis- secting it a little more, he applies the curved scissars, and cuts it off from the tunica conjunctiva.
The orbicularis muscle holds the lips of the, wound together, without our assistance, and then it is only required that we bind lightly on the eye a cloth wet with cold solution.
When tumours grow within the socket, they are to be early extirpated, for though they should be of a harmless nature, yet their increase, simply by pushing the eyeball forward, and stretching the optic nerve, will cause blindness and deformity, while by filling the socket and pressing more and more on the eye, the operation of cutting them out becomes daily more difficult.
SKCAxymss,
$6 ENCAN^TSlS.
JSNCANTHI5.
The Encanthis is a tumour arising from or at least involving the caruncula lacrymalis, it is of a pale red colour, and irregular on its surface ; as it increases it draws into its substance the semilunar fold of the conjunctiva and stretches its root along both eyelids. When this tumour is of a darker hue and hard, and has lancing pains in it, and still more when becoming more active and vascular, it bleeds easily or ulcerates, it is becoming cancerous.
Even before the tumour shews this cancerous cha- racter there occur good reasons for cutting it off. When, it becomes rooted in the eyelids, and the can- cerous disposition has spread, nothing but the extirpa- tion of the whole eye will avail, if even that is effec- tual. When the tumour is not of a malignant nature, and when it has only produced the lesser evil of a weeping eye, by its pressing the puncta, and caused inflammation of the eye, by preventing the eyelids from meeting, it may be cut out with more hopes of success. We may do it thus :
1. The assistant turns down the lower eyelid with his finger, or with the assistance of a flat and blunt hook ; the surgeon then with a pair of nice forceps, and very sharp knife, dissects off the root which the tumour has shot along the inside of the
eyelid
OF THE PTERY6I0N; . 87
eyelid. 2. The assistant then turns up the superior eyelid, when the • surgeon in the same way dissects off the root of the tumour from this eyelid. 3. Now the body of the tumour is to be pierced with the hook and drawn outward, and if it should appear that the caruncula lacrymalis is natural and distinct from the tumour, then the latter is to be dissected off from the caruncula lacrymalis ; but if they shall be incorporated, the whole is to be taken away. 4. The last part of the operation is to dissect up the diseased conjunctiva from the surface of the eye- ball.
After the operation, the eye may be fomented until a considerable quantity of blood be lost, and afterwards emolient fomentations will only be re- quired, if no cancerous affection has prevailed,
.OF THE PTERYGION.
The Pterygion is a pale red film, which stretcher generally from the inner angle of the eyelids, across the cornea. It is one of the pure consequences of continued inflammation. When this web covers the whole eye it is called pannus. But the terms film and web deceive us, for this is not a new membrane formed on the surface of the eye, but only a congestion in the cellular membrane, under the conjunctiva, which, as it were, loosens it from
the
SS OP THE PTERYGIO^
the Sclerotica, at the same time that its vessels are increased in number, and become tortuous. This diseased state of the conjunctiva encroaches in a co- nical form on the lucid cornea : it is there too of the same nature-; the transparent outer lamina of the cornea becoming opaque, and being at the same time loosened in its texture.
OPERATION.
1. The patient being seated with a cloth tinder his chin, the assistant stands behind him and supports his head, having in one hand a sponge full of tepid water, which from time to time, in the progress of the operation, he pours into the eye, as it becomes obscured by blood. The assistant opens wide the eyelids.
2. The surgeon now with very fine forceps raises the apex of the pterygion which is on the cornea ; he then pushes the knife, used for the extraction of the cataract, under the fold of the membrane which he has raised ; he carries the knife forward until the edge shall have cut itself out, and have separated the very apex of the membrane from the cornea.
3. Now holding the membrane up it is to be dissected a little from the white part of the eye, and lastly the scissars are to be applied (pointing up- ward or downward), so as to cut across the middle of the membrane, where it is attached to the •albuginesk
The
OF OPACITY OF THE CORNEA. 881
The eye is to be now washed with tepid wateiv while the blood flows, and then a light compress of wet linen is to be put on the eye. The surface which has been diseased acquires a peculiar yellow colour; it is some weeks of contracting fully, and xforming a cicatrix. The, treatment after this is only such as would be prescribed to suppress any ap- pearance of returning inflammation.
That part of the cornea from which the pterygion has been cut oflC does never entirely recover its transparency.
Opacity of the cornea*.
h The cornea becomes opaque in several wayjj. Inflammation may leave in it a milky opaque spot or spots, from an effusion under the outward la- mina. There is at the same time a flaccid state of the conjunctiva and tortuous or varicose veins lead to the opaque spot of the cornea. This has been called nebula, from its producing only a cloudiness in the vision.
2. If the cornea be opaque in consequence of a preceding very violent attack of ophthalmia, the effused matter will be found to be deposited deeper in its substance, and is supposed to be coagulable lymph ; this is the ai.buco.
5. Again, their occurs in consequence of inflam* mation, a pustular opacity, which, breaking, forms
an
§0 OF OPACITY OF THE CORNEA.
an ulcer, which leaves a firm opaque cicatrix* viz*
LEUCOMA.
The practice in the first instance of opacity (the nebula) is to extirpate the tortuous fasciculus of vessels, whose elongation over the cornea caused, or necessarily accompanied the formation of this opacity, and which we may now suppose, feed and support it as it were. The fine eye-scissars and a common housewife needle, stuck with its head in a piece of wood, are sufficient apparatus for this end. The head of the patient is supported against the breast of an assistant, and the eyelids held asunder while the eyeball is at the same time pressed so as to steady it.
2. The surgeon passes the needle under the fasciculus of vessels, so as to lift them from the sclerotica near the margin of the cornea. He then places the scissars so under the needle as to cut out a considerable portion of the conjunctiva and the congeries of vessels. The eye is to be fomented so as to continue the bleeding from the cut vessels. The opacity of the cornea will often disappear the first or second day after the operation. When a young man asks how is this supposed deposition in the cornea absorbed, I cannot give him a satisfactory answer.
The practice in the more permanent opacities of the cornea, viz. the albugo and leucoma is very vague, because of the great difficulty erf removing them, and the frequent disappointment in the at- tempt to cure them. ' All that is to be said, seems to resolve into this—if there be a remaining inflam- mation
OF OPACITY OF THE CORNEA. .91
mation or laxity of the vessels of the eye, this is to be removed by local and general means ;— if, on the contrary, all inflammation has subsided, and the speck is stationary, we endeavour to excite such an action in the part by stimulants, as may produce eventually some change in the disposition of the part.
APPLICATION OF CAUSTIC TO THE CORNEA.
Ulcek in the cornea may be a consequence of violent inflammation, or a direct effect of external injury. It has been roundly asserted that the ulcer of the cornea isoftener the cause of the ophthalmia, which accompanies it, than the ulcer is a conse- quence of the ophthalmia. This teaches us not to trust to general remedies for the removal of the inflammation. The ulcer then is to be touched with the lunar caustic. This of course deadens the very sensible surface of the ulcer, and it being no longer sensible to the acrid stimulus of the tears, the irritation subsides.
The best way of applying the caustic is to have it set in a quill, and put on the stick of a pretty large camel-hair brush ; the caustic must be cut down to a small point ; a little milk is beside the surgeon, in which he dips the brush. He then raises the eyelids, and at the same time presses them to fix the eyeball, he touches the ulcer with the caustic,
and
%t OF THE STAPHYLOMA,
land presses it to the bottom of the ulcer, and when he has done this he brushes the liquified caustic from the eye with a motion of his brush. — In a day or two the irritability of the eye returns, for the deadened surface of the ulcer has separated, and the tears again come in contact with the sensible surface, but the pain and intolerance of light is less than before ; it is to be touched again with caustic, with *a more permanent relief of symptoms. And if things go on successfully on the clearing of the ulcer in successive times, instead of being eaten deep it is shallower, and fills up, and the inflamma- tion subsides.
The caustic need not be applied after the irritability ceases, and the ulcer looks red and granulating, instead of being irregular and «ine- ritious in colour.
OF THE STAPHYLOMA.
The "Staphyloma is an opaque conical tumour of the cornea, it is often of a white or pearl colour, sometimes dark or variegated by the accretion of the iris to it. The staphyloma is most generally a con- sequence of small-pox.
The opacity of the cornea produces blindness of that eye, but the worst circumstance of the disease is, that although it has no malignity, it is always liable to be aggravated, and to affect the other eye also. The tumour of the cornea projecting from 3 betwixt
OP THE STAPHYLOMA. 9.c)
betwixt the eyelids, remains dry, and becomes ul- cerated ; there is a continued inflammation of the eye produced, and from the intimate sympathy which exists betwixt the eyes, the other becomes sore also, and even ulcers form on the cornea of it. When we know this to be a consequence of the staphyloma, we cannot hesitate about cutting it off.
The intention of the operation is to evacuate the humours of the eye, that the coats may contract, and be within the margin of the eyelids.
OPERATION.
The patient is seated as for the extraction of the cataract, and the assistant supports the eyelid in the same manner. The surgeon takes the largest of his knives for the extraction of the cataract, and pushes it through the tumour, in the direction he would cut the cornea in the operation of extraction ; but he does not enter the knife so near the margin of the cornea as in that operation. Having made a section of the lower half of the tumour, he takes hold of the flap with the forceps or sharp hook, and completes the circular incision. The tumour being cut off, and the chamber of the aqueous humour largely opened, the humours of the eye are gently squeezed out of the coats, when the eye subsides within the, eyelids.
The cornea being the only part cut in this opera- tion, and this being a part neither vascular nor very sensible, the inflammation is some time of com- mencing.
94 OP THE PROTRUSION OF THE IRIS.
i
mencing. On the fourth day the eyelids are in- flamed, and on the seventh or eighth there is pus on the poultices applied to the eye. Scarpa in particular recommends the operation to be perform- ed as I have here described, saying, that very terrible consequences result from including the sclerotic coat in the incision. But I have seen the operation performed by cutting off the whole anterior seg- ment of the eye without any bad consequence ; not- withstanding this, the reasoning as well as the facts alleged by Professor Scarpa, must sway us, where there is no advantage resulting from a practice op- posed to his.
After the operation a pledget of soft lint soaked in oil, may be applied over the eyelids, and when the inflammation rises, if the fever and pain be great, we must bleed largely, and, as we wish to produce suppuration on the surface of the membranes, we must foment and apply poultices, not repellent cold applications.
PROTRUSION OP THE IRIS.
The protrusion of the iris is marked by these characters. There is a small prominent tumour or speck on the cornea of the colour of the iris. Around its base the cornea is opaque. The pupil is a little removed from the centre, and somewhat changed from its regular form, and the plane of the
iris
OF THE PROTRUSION OF THE IRIS. 95
iris is more oblique than natural ; the vessels of the conjunctiva are large and numerous, and the eye is particularly irritable.
This is a kind of hernia of the iris, which is apt to occur after the operation of extracting the ca- taract, or in consequence of wounds or ulcers of the cornea penetrating to the chamber of the aqueous humour. This is not a relaxation and falling down of the iris, but it is pushed out as an intestine is in hernia, by the contraction of the eyeball, and in the narrow opening of the cornea it is sometimes strangulated too like a hernia. It is impossible to reduce this protrusion when it is the consequence of ulcers of the cornea ; for supposing that the iris was separated from the cornea, would not the aqueous humour again be discharged, would not the lens again press forward the iris, so that it would be pushed through the opening of the cornea ? The entangling of the iris in the ulcer is not owing to this membrane floating with the cur- rent of the aqueous humour, towards the opening ; but, as I have described in speaking of the extrac- tion of the cataract, the whole contents of the eye press forward to the breach, and the iris presents first. It has been well observed that this presenting of the iris in the ulcer, saves the eye from total destruction, though it be a painful disease in itself. The practice in this disease is simple. We have to touch it with the lunar caustic : this must be done with- the precautions already recommended ; the small black tumour formed by the protruded iris must be eat down within the level of the cornea by
repeated
96 DRorsr of the eye.
repeated application of the caustic. After this wef kre to endeavour to promote the cicatrixation of the ulcer.
In the same way are treated the small lymphatic tumours, which project from the cornea, after an ulcer or wound. Scarpa proves that this tu- mour is the protrusion of the vitreous humour and its capsule.
DROPSY OF THE EYE-.
Like every other part of the body the vessels of the eye receive a constitutional disposition that keeps the form and proportions of the hu- mours and coats to a limited form. If this natural action of vessels be changed, the effect is some defect of transparency, or some preternatural growth ; there is an atrophy or wasting of the eye, or a great increase of the humours, a distention and growth of the coats — a dropsy of the eye.
Dropsy is sometimes a consequence of injury done to the eye, or of high inflammation ; sometimes it attacks slowly and without any very evident cause. The symptoms are, a sense of distention with pain in the orbit and difficulty of moving the eye- ball. Blindness ensues, and there is no longer con- traction Gf the pupil. In a still greater degree of the disease, the eye projects conically from the eye- lids, and they no longer shut upon the eyeball-;
the
OF TIIE ARTIFICIAL PUPIL. 97
the exposed surface becomes acrid ; there is inflam- mation and ulceration of the eyelids ; the eyeball is inflamed, with great pain and headach ; the other eye is affected, by sympathy; and an operation becomes absolutely necessary.
The Operation is sufficiently simple. The eyelids are held open; a sharp tenaculum is thrust through the anterior half of the eyeball, and all the pro- jecting part is cut off with two motions of the scalpel. The humours are of course spontaneously evacuated, and the eye shrinks within the eyelids. But Scarpa again frightens us, and recommends instead of this, that the middle of the cornea be cut, as in the Staphyloma.
©F THE ARTIFICIAL PUPIL,
In deep inflammation of the eye, following the operation of extraction or depression of the cataract, the pupil contracts and closes altogether ; for during the inflammation there being also great irritability of the eye, attended with contraction of the pupil, the iris fixes and adheres, so that there is an entire obstruction to the light. The contraction of the pupil is sometimes more unaccountable, being gra- dual, and only accompanied with a slight degree of wnusual irritability in the eye. The contraction of
tol. il h the
9S OF THE ARTIFICIAL PUPIL.
the pupil is, however, a rare complaint One should naturally suppose that it would be an easy operation to introduce the couching needle, and cut the iris- in the middle part, so as to enlarge the contracted pupil, or form a new one. But it is found, that when the pupil is made in the centre of the ids it quickly closes again. So it happens when the circle of the iris is divided from the circumference through its edge. Scarpa has substituted another operation, of which I should say little, not having performed it on the human eye, were I not certain of its practica- bility by tyal on brutes, and did I not conceive that it is a means of restoring sight in a case not yet thought of. — Scarpa performs the operation in this way :
The patient is seated as for the operation on. the cataract. The surgeon uses a very small, straight couching needle. He perforates the sclerotic coat, as for the depression of the cataract, and about two lines from the margin of the cornea ; the point of the needle is carried behind the iris, and before the lens, if it has not been extracted. It is made to advance as far as the upper and internal part of the outer margin of the iris, viz. on the side next the nose. The point of the needle is then made to pierce the root of the iris, where it is attached to the ciliary ligament, and when the surgeon sees the point of the needle projecting through the outer margin of ihe iris, he draws the instrument towards him, so as to separate the iris from the sclerotic coat.- Blood is effused during ihe operation, so that the aqueous
h n Hi our '4
OP THE ARTIFICAL PUPIL.
99
humour becomes turbid, the pain is greater than in the depression of the cataract, and for these reasons the motion of the needle should be decided and
quick.
Some time ago, before 1 had occasion to con* sider this subject of the contraction of the natural pupil, a patient applied to me who had an opa- city of the cornea, covering the natural pupil. As the gentleman possessed the sight of the other eye, I did not advise an operation, which yet I thought practicable, if he had been blind altogether. I thought of opening the iris opposite to the trans- parent part of the cornea.
These sketches of the eye will illustrate what I conceived it possible to do. In figure I. the opaque cornea at A. covers the pupil, the relative place of which is marked by a circular line of dots. In figure 2. I have represented a pupil formed by cutting the iris opposite the transparent part of the cornea. A. The opacity of the cornea cover-
h 2 ing
100 EXTIRPATION OF THE EYE.
ijag the natural pupil. B. Part of the iris seen. C. The artificial pupil*.
It was with great satisfaction I read Scarpa, on the subject of the artificial pupil. The cause for M'hich he performs that operation is rare, but if it shall prove effectual for those opacities which are opposite the natural pupil, how much more ex- tensive must the benefit prove.
rXTlBFATlQH OP TIIE EYeV
"The patient is placed on a chair, with his head resting on the assistant's breast. The assistant should hold in his hand a blunt hook with which he is to raise the eyelid. The surgeon 'is seated before the
* I have at present a gentleman under my care for stricture in the urethra^ who has submitted to the opera- tion of extraction of the cataract on one eye. The operation has been very successful, but on the other eye the operator has been obliged to bring the point of the knife out at a wrong place, and now the scar of the incision begins at the margin of the cornea and turns in with a spiral line so as to cover the pupil. With this eye the gentleman cannot see but Yery obliquely, and imperfectly, although the pupil is quite clear of cataract. In such a case as this, supposing that vision was not perfect in the other eye, the sight might be restored, by making an artificial pupil in the iris op- posite to the transparent part of the cornea,
patient.
EXTIRPATION OF THE EYE. 10 I
patient. He now pierces the anterior segment of the eye with his tenaculum. The first strokes of the knife are two semicircular incisions,, to cut through the tunica conjunctiva, and to separate the eyelid from the eyeball. Then if the eye is very much distended and fills the socket, the next motion of the surgeon's knife ought to be to punc- ture the eyeball, and allow some of the humours to escape; for, if this is not done, he is cutting in a constrained and narrow way, betwixt the distended eye and the socket, making a tedious operation, and endangering more than necessary, the bones of the socket.
When the conjunctiva is cut, and the knife has gone quite round the eye, and the attachments of the two oblique muscles are cut through, the eye would lie loose, only that the optic nerve re- tains it very strongly. I have seen the surgeon un- accountably forget this, and make repeated and most painful efforts, by cutting and pulling, when it only was required that he should have cut across the optic nerve.
To cut across the optic nerve, the knife ought to be carried flat under the superciliary ridge, and made to glide along the orbital plate. When passed over the eyeball in this direction, a single cut will sever the nerve and muscles which surround it, so as to relieve the diseased parts, and they may be drawn out with only a little adhering cellular nlembrane.
A good deal of blood should be allowed to flow. If it be required to stop the too profuse bleeding,
H
102 EXTIRPATION OF THE EYE.
it may be done by pre?sing a little dry lint in the inner angle.
INSTRUMENTS.
A strong flat tenaculum may do to pierce the ball of the eye with ; or a large ligature is put through the eye with the common surgeon's needle., or what will be found more useful, and which will much shorten the painful period of preparation, is a hook of the form of the tenaculum, with a shoulder, to prevent its going farther into the globe of the eye than just to permit the point to transfix it. A crooked knife is recommended for this ope- ration, but it will be found a bad exchange for the common scalpel.
The disease sometimes returns. It may be expected if the disease has been really cancerous,, and if the parts external to the eyeball have been the seat of the disease. From the confined nature of
the
EXTIRPATION OP THE EYE. 103
the part, the whole soft parts within the bone may have been tainted. If so, it will probably happen that when the wound has gone on regularly towards a cure for some time, when you would expect that it was about to close finally, it will stop, and in- stead of merely filling up, a fungus will rise from the orbit. When this has got to some head, the acute lancinating pain in the head will follow. Or if the wound has healed some months perhaps after the operation, hard tubercles will be felt in the sur- rounding integuments. Then comes pain striking to the back of the head, with burning pain deep in the orbit, and the brain being at last affected, the patient dies.
•OPERATIONS FOR THE FISTULA LACHRYMALIS.
The Fistula Lachrymalis is a disease of the la- chrymal canal. — In what may be called its complete state, there is an obstruction of the duct which carries the tears into the nose, and a fistulous sore discharging the tears and pus near the inner angle Of the eye ; the patient only complains of a weakness of sight, the eye is watery, and on every little excite- ment the tears faU over the cheek, which is some- times excoriated, the nostril of that side is dry. But this complaint will not admit of a description
in
104 EXTIRPATION OF THE EYE.
in the form of a definition ; in common discourse we call all the various degrees pf the disease of these passages, which might in a latter stage form an open weeping sore, fistula lachrymaiis.
]t The first state of disease I shall describe is this: the eye is considerably inflamed and irritable ; the edges of the eyelids are tumid, and the glands secrete profusely ; the internal membrane of the eyelid is very red, and flakes of mucus are seen upon turning down the eyelid; the integuments over the lachrymal sac are full and puffy, and on pressing these, mucus and pus escape from the puncta. To account for this appearance, there is no occasion to suppose that there is an obstruction in the nasal duct, the disease is general, and all the continuous surface of the eyelids, puncta, sac, and duct, are unusually vas- cular and spongy.
The natural resource against such symptoms is to endeavour to subdue and counteract this general ten- dency to a chronic inflammation in the whole mucous membrane and ducts. By astringent injections or collyria the general relaxation may be removed, and the soreness and swelling of the eyelids relieved by the citrine and tutty ointments ; then the sac and ducts must be kept also clear, pressing out the ac- cumulated mucus, and injecting into the ducts until the fluid passes into the nose.
2. When there is not only a watery eye, and tumid eyelid, but a distinct tumour of the lachrymal sae and an excoriated cheek, something must be done to make the duct pervious. In this state of the flisease, it seems to be ill-judged practice to en- deavour
EXTIRPATION OP THE EYE. 10i"
deavour to give firmness and resistance to the sac, to make it contract, by cutting open and stuffing it. with dressing. This is the same as if a surgeon would continue to scarify and dress a fistulous sore in the perineum, after he knew urine was discharged from it, and that there was an obstruction in the urethra. The only questions to be determined on previous to the operation are these: 1. Is this a disease owing to a general sponginess and thickening of the mucous membrane ? 2. Has this general dis- eased state terminated in a particular stricture, or obliteration of the lachrymal duct ? 3. Is there a stricture, or obliterati©n of the passage which has been the primary cause of the symptoms, and still keeps up the disorder ?
But even the answers to these questions are of nq great importance, because if an operation is to be done, the entire operation is not more severe, or troublesome, than a more partial attempt to cut into the sac and make it contract and fill up. If it should be found that a more general disease of the mem- brane prevails, or even if the general affection be proved to be the original cause, this only teaches us to be careful to correct the slight and chronic inflam- mation of the surface, after the course of the tears is established, and during the progress of the cure. A great part of this disease consists in the con- stant excitement which the suppurating sac gives to the eye ; and that again is a consequence of the absorption still continuing by the puncta, after the duct is obstructed— -for if the sac be closed up and obliterated, and there be no disease originally
m
1 06 EXTIRPATION OF THE EYE.
in the coats of the eye, a great deal of the irritation and even the watering of the eye will subside — and if the puncta be closed, so will the inflammation of the sac subside, because it has no longer the irri- tation of the acrid tears. Accordingly it is one kind of operation, attended with much relief of symptoms, to obliterate and fill up the sac altogether. The intention of the following operation, how- ever, is to restore the course of the tears into the nose, and entirely to cure the disease,
©DERATION,
The patient is placed before the surgeon, and tliey are both seated.. The patient's head is sup- ported on the breast of an assistant, who stands behind him. The surgeon applies his thumb, (in this manner) to the eyelids, and stretches them from the inner angle, so that the small tendon of the orbicularis muscle A. is made particularly dis- tinct. Beginning his incision by piercing the skin just below this tendon, he carries his small knife
in
EXTIRPATION OF THE BYE. 107
in a semicircular direction, B. (viz. following the curve of the edge of the orbit); raising the point of the knife again, he thrusts it deeper into the upper part of the incision, and penetrates the sac, and slits it downwards.
Or again, if the opening be free enough, it is better to introduce into it a small probe, and fol- lowing the probe with a sharp pointed bistiffy, to cut open the sac. The next part of the operation is to pierce the bone with the stilette.
In piercing the bone, we have, in the first place, to take care that the point of the instrument be lodged within the natural sac before the perforation is made ; for if it is not, as I have known it happen, the latter treatment will only serve to obliterate the sac, and I believe to close the tubes leading from the puncta. Now, if the young surgeon does not perfectly recollect the relation of the os unguis to the nasal process of the upper jaw-bone, and if he points the instrument directly into {fee nose, he may chance to hit upon the very strong process of the maxillary bone. But if after beiftg fairly in the natural sac, and of course with the point beyond the sharp ridge of the maxillary bone, which forms the margin of the orbit towards the nose, he carries on his point obliquely downward and inward, he comes to be opposed only by the thin plate of 1: (as delicate as a piece of paper), which is called the os unguis, and now he will find this part of the operation very simple indeed. By keeping the side of the instrument pressed upon the nasal pro- cess of the maxillary bone, and carrying the
point
10S EXTIRPATION OP THE EYE.
point forward it will pierce this thin lamina of bone the os unguis, and then the point should be more turned towards the cavity of the nose, so as to enter it just before the lateral cells of the ethmoid bone and above the lower spongy bone. That we are right in the direction of the in- strument, is known from the very slight resistance which we meet with, and the flowing of a few drops of blood from the nostril, or which may fall into the throat, according as the head is thrown backward or forward.
The instrument being withdrawn, a piece of leaden wire is introduced. This, being worn for a week or a fortnight, is taken out and replaced by a piece of bougie. . In the course of two months, when the passage is become like a natural canal, the bougie is withdrawn and the wound allowed to heal; and the tears which have been all this time ab- sorbedby thepuncta and carried into the sac, andhave passed by the side of the bougie into the nose, con- tinue, upon its being withdrawn; to run by this new passage into the nose. The perfection of the cure is ascertained by the eye having no more than its na- tural moisture, and that side of the nose which was before dry having now as moist a discharge as that of the other side.
The following is the method of Mr. Ware. Having opened the sac, or supposing that it has been opened by ulceration, he introduces the blunt end of a probe, (of a size rather smaller than the common dressing probe), and pushes it on gently and steadily in the course of the natural duct. Tie over- • i conies
EXTIRPATION OF THE EYE. 109
comes the obstruction by force, and he passes the instrument into the nose by the nasal duct*.
The probe being withdrawn a small silver style of nearly the same size of the probe, and with a flat head, which is to prevent its sinking altogether into the nose, is now introduced; and the operation is finished, This little style, passed down into the nose, keeps the duct permeable, while its head being covered with black wax, or a bit of court plaister stuck upon it, has every appearance of a common patch.
This operation is ingenious, whilst its simplicity ensures success. It is not followed by the high in- flammation and quantity of matter which will some- times follow the use of the bougie, and does not therefore endanger the closing of the upper part of the sac or puncta, while from the beginning there is neither confinement nor unseemly dressing re- quired.
Few people, however, will submit to a palliative remedy, such as this operation is, when it is in- tended that the style shall remain in the nose, and if the operation be performed with the intention of removing the style, and closing the sac, I would re- commend that it should be performed as first de- scribed, 'vis. by piercing the os unguis, and then substituting the style for the bougie, with the ex- pectation that the patient will submit -longer to its use. By this means while the patient enjoys comfort
* The full descent of the point of the probe into the nos.e will sink the instrument fully an inch and a quarter.
during
110 EXTIRPATION OF THE EYE.
during the cure, he has the better chance of its being perfect in the end,
Whether we perform the operation by wearing th^ leaden wire and bougie, or perform it in Mr. Ware's method, we must withdraw the bougie or style, and wash the passage by means of the small syringe ; at first every day, afterwards only oc- casionally, as it may seem to be required. This pre- vents the lodgment of matter, and the formation of abscesses.
From what has been said, it will readily be un- derstood that during the cure must carefully at- tend to the state of the conjunctiva, and the general secretion of the eye.
As we have already hinted, there was for- merly a method practised, the object of which was to fill up the abscess with granulations, and entirely to obliterate the sac, treating the disease like a common abscess. This, on first thoughts, would appear to be a method of increasing the evil, but a great part of this complaint of fistula lachrymalis arises from the excited state of the lachrymal sac and ducts, which produces, by sympathy, an irritation of the eye and of the lachrymal gland.
There may occur ulceration and much internal disease in the part, which may nake us still prefer this method to the long continued use of the bougie or the introduction of a style.
Where the ducts are merely obstructed, there is only an occasional flow of the tears over the cheek, when the eye is accidentally excited. The patient complains little of the disease until the sac inflames;
and
EXTIRPATION OF THE EYE, 111
and I know there are cases of the common operation, producing abscess, followed by total obstruction* without the patient having an idea of any failure in the operation he has suffered.
Scarpa has thought it necessary to recommend in a, particular manner, that the sac should be dressed with escarotics to the bottom. I have always seen that the presence of the bougie in the passage was suf- ficient to inflame and cause the due contraction of the sac. He has thought it necessary too to recom- mend the use of the actual cautery, to destroy the os unguis, when a new passage is to be formed ; a thing which I think I can say with confidence, is never necessary, and must be kept altogether out of the enumeration of our resources.
CHAPTER
]]$ OF THE EAR.
CHAPTER II
OF THE EAR.
Matter which flows from the ear may be a mere change of secretion^ in the glandulas ceruminosie. In this case we may inject any mild astringent, as lime water, for cleanliness, and anoint the passage with the diluted citrine ointment.
Sometimes the passage ulcerates, and there is a great purulent discharge from the ear, or after some occasional increase of the inflammation, an abscess or sinus forms behind the tube of the ear. The following consequences may ensue from this suppuration. I. The thickening of the mem- brane of the tympanum. 2. The growth of fun- gous excrescences from the passage. 3. The de- struction of the membrane of the tympanum by the progressive ulceration. 4. The communication of the inflammation and suppuration to the cavity of the tympanum.
We
OP THE EAR, l\$
We must then in suppuration keep a free outlet to the matter, by preventing the swelling of the tube from closing the passage, and by opening the abscess if formed by the side of the tube ; we must prevent the lodgment of the matter by every pos- sible attention. Our injection should be some mild fluid at first, and afterwards we may endeavour to correct the diseased surfaces : for this purpose a common injection is the muriate of mercury with lime water.
If the hearing be dull to all outward sounds, but increased to all vibrations of the head or jaws, and there is a confused and loud noise often heard, there is probably only an adherence of tough mu^ cus, about the opening of the Eustachian tube into the throat, or perhaps an inspissation of the ear- wax, which both prevents the sound from entering the tube freely, and by pressing on the membrane of the tympanum prevents the free motion of the membrane. In this deafness from the inspissated wax, we need only wash out the tube with a syringe and tepid water.
When the Eustachian tube has been obstructed by a disease in the throat, deafness is the conse- quence. It is in this case that it is proposed to purtcture the membrane of the tympanum, that like the hole in the side of a drum it may give freedom to the contained air, and free play to the mem- brane of the drum ; the perforation becomes a sub-^ stitute for the Eustachian tube.
The patient is placed with the ear towards the 4irect light of the sun ; the surgeon is behind him,
■yci.. U. . i and
114 OF THE EAR,
and he turns the head until the light is admitted mt& the bottom of the tube. The point of the silver probe, (a small stilette is used by Mr. Cooper), is pushed through the lower and fore part of the membrane of the tympanum. As it is found that the perforation in this membrane very soon heals, it has been thought necessary to lacerate it pretty freely, but the greater the injury the greater is the probability of the membrane inflaming, be- coming thick, and of consequence, incapable of delicate vibrations. I should imagine that it were better for a time to allow a small probe of silver to remain in the passage of the ear, supporting it by a little cotton in the passage. It is an operation of great uncertainty, and leaves the patient to regret the very short enjoyment of the benefit he has been led to expect from it.
But I deem it to be of more consequence to speak here of the dangers of deep suppurations in the cavities of the ear.
Suppuration may take place in the cavities of the ears, and in the mastoid cells, either from the com- munication of inflammation from the outward tube,, from the throat, by the Eustachian tube, or it may be a scrophulous disease, originating in the bone itself. Any one who thinks of the principle of Pathology, which guides us in our surgery of the head, must at once foresee danger from suppura- tion and caries of the temporal bone, for though it contain the organ of hearing, yet it takes more importance, in this instance, as ^a bone of the cranium.
2 The
OF THE EA5?o } 15
The worst character of the disease is when, after the patient has had violent pains, he is attacked with shivering and fever, and the organ is destroyed, and the passages of the ear are full of pus, and the bones of the tympanum have come away. This discharge may continue long, without any further apparent bad consequences than the loss of the organ-, but if there comes drowsiness, and oppression, and a feebleness or degree of paralysis in the opposite side of the body, then the petrous portion of the bone is ca- rious, the dura mater attached to it has partaken of the disease, and the side of the cerebellum and base of the cerebrum are diseased and covered with purulent matter. *"
The abscess sometimes forms in the mastoid cells, and making a slow progress, such as characterises the scrophulous action, after a time the tumefaction of the integuments over the mastoid angle of the bone betrays its presence. The bone in some instances becomes carious, and the finger can depress the in- teguments into the bone, and, when this is opened, it is not merely a disease of the bone which we dis- cover, but the surface of the brain is exposed, and the probe can be introduced deeper than the thick- ness of the temporal bone; a circumstance which shews the danger of the experiment. Thrice I have seen such suppuration fatal by the com- munication of disease to the brain, before the spoiled bone gave way outwardly ; and I have ascertained the nature of the disease by dis- section.
1 2 We
I}S Ot THE EAR.
We learn from this view of the subject, how carefully we ought to attend to symptoms when there is disease in the ear, lest it should become ir- recoverably bad, and end in communicating the disease to the brain. We must bleed and purge and foment, to allay the pain and inflammation, if it be active. Blisters are to be applied behind the ear, if a slow continued action is proceeding within; and where we can ascertain that there is caries in the posterior angle of the bone, with danger of the con- finement urging the progress of the diseased action to the brain, we have to apply the trephine and penetrate into the cells of the bone ; even when this is done, if the petrous portion of the bone be carious, there remains only a hope, that by great care, soothing the action, and guarding against the matter collectings we may gain time, so that the diseased bone may separate, and au abscess in the brain be prevented from forming.
OF TfTS PSOAS ABSCESS. I IT
OF THE PSOAS ABSCESS.
In the treatment of sinuses and abscesses, the most essential point to be known is, what has produced the collection of matter, and whether the cause be removed — for if we are to cut up fistulas during their tendency to form, we shall find that only deeper and larger passages open themselves. If we are to open an abscess, we ought first to consider by what means we are to produce a change in the action of the part. The matter of an abscess is not collected, but, like the fluids of the cavities of the body, it is suffering a change ; the absorption of the pus is performed at the same time that pus is thrown out by the vessels ; and the increase or diminution of the matter of the abscess depends on the relative action of the arteries or absorbents. We have to observe what further change, besides evacuation of the matter, is accomplished by opening an abscess.
Experience teaches us that a scrophulous abscess will seem to point, being soft and prominent, and having fluid evidently in it ; and yet that when the lancet is thrust into this tumour, only a pale watery fluid escapes, and the walls of the tumour acquire an inelastic, but irregular, firmneis, like a cake : and the
progress
!1S OF THE PSOAS ABSCESS,
progress of the action, or at least the softening &t the tumour towards the surface is not promoted but checked. The scrophulous action is here, I suppose, of a slow and sluggish nature, and the phlegmonous action, the consequence of the wound, has some- what of a contrary tendency, so that the original progress of the disease is not promoted.
Agiin, in the scrophulous action about joints which has produced abscess, by cutting into this ab- scess the slow nature of the disease is changed ; the matter, though evacuated, collects again, no longer bland or mild, but putrid and acrid, and an irre- coverable caries may be the consequence*.
It is of little importance whether the change hi this particular instance is to be attributed to the air getting access to the secreted matter, and pro- ducing an alteration upon it, making it acrid and Stimulating ; of whether the incision changes the nature of the action in the surface of the cavity, so as to produce bad and foetid matter. But it is par* ticUlarly of consequence to observe this contrast, that by stimulating the surface and making counter irritation on such a scrophulous joint, the original action might have been changed, and the limb and patient saved ; while Under this surgical treatment the disease has rapidly advanced.
* Experience teaches us that it is useless to open scrophu- lous and venereal abscesses 5 but further, we find the practice bad as complicating the case, and dangerous as sometimes -productive of the phagedenic ulcer. Read the section on ab- scess in Ford's Observations on the hip disease^ which i$ very valuable
Where
OF, THE PSOAS ABSCESS, 11Q
Where an abscess or extensive fistula forms, in consequence of a wound, it may be permitted to rouse the activity of the surface by an injection or seton, for perhaps there is nothing peculiar in the action ; there is only a weakness and inactivity ; and by habit the secretion continues. — But even here it will in general be better to raise the life and activity of the whole limb, by admitting freer mo tion, by warm stimulant fomentation and rube- facients.— For though these communications and abscesses have formed after an injury, it by no means follows that they are merely the consequence of that Injury ; they have often a serophulous action ; and the injections or seton raise a violent inflammation, and general tension of the limb, which instead ot ^promoting the -adhesion of the cavities form others in succession.
AM abscesses ©r fistulas connected with ducts or natural passages form a class by themselves, which ought not to enter into the present inquiry. Such are flstula in ano, fistula lachrymalis, fistula in perineo. In these the difficulty of discharging the natura fluids, produces an inflammation in the ducts; ab scess forms by the side of the passages; and a com- munication is made betwixt the duct and abscess by ulceration, and an irritation is kept up; until the passage be freed the abscess will not heal.
Where an abscess is very large, there is one cir •cumstance ' requiring particular attention ; it is this, if the abscess burst, that is, if the ulcera- tion proceeds outwardly to the skin, the whole .surface of the abscess wilj inflame, the discharge will
become
120 ©f The psoas absciss,
Ibecome bad, and the patient will die. We open such abscesses, not with the intention merely of evacuating the mattes*, nor for the purpose of procuring an adhesion and obliteration of its sides, but to allow the cavity gradually to contract so that when it fills again it may not be so extensive fiOr apt to disorder the system when it is finally opened*
For example, if a large abscess be pointing, and about to ulcerate and burst, it is to be punc- tured, and the matter evacuated • but it is not to he lanced just upon the most prominent, and thinnest part The opening should be made by the side of that part of the abscess where it naturally may be expected to open. The opening is thus to be made In the healthy skin, so that the wound may close again without any ulcerative action taking place, and without the risk of inflammation being propa- gated over the sides of the cavity. From the eva- cuation of the matter, and contraction of the cavity* the walls of it thicken. When the cavity fills again, it is less extensive ; it is to be punctured again, and the opening immediately closed; the abscess still further contracts, and perhaps by the third or fourth opening the abscess is so much di- minished that no care need be taken to close the opening ; it may be left to common treatment,.
These introductory observations will be found •necessary to the understanding of the short state- ment I am now to give of the nature of the lum* ibar abscess, and the treatment of it.
#«OAS
O^ THE PSOAS ABSCESS. 121
f*SOAS, OR LUMBAR ABSCESS, CONTINUED*
The Psoas Abscess is the consequence of a slow and almost imperceptible inflammation of the cellular membrane, by the side of the lumbar ver- tebra^ and around the psoas muscle*. These deep parts, from their nature as well as their situation, being little sensible, and the disease being a slow, scrophulous action, the nature of the complaint is only suspected when there is a weakness in the loins, a numbness and weakness of one thigh, and a dull wearying pain in the loins like rheumatism ; nor is there at first general symptoms to mark the diag- nosis more distinctly. Sometimes the pain in the loins is very severe, with a total inability of raising the thigh. But when a compressible tumour appears in the groin, the fluctuation is perceptible in the tumour, and pulsation is felt in it when the patient coughs ; then the nature of the case is too evident, and the surgeon has that painful conviction, of a patient being in the utmost degree of danger,
* The abscess "is sometimes in the centre of the psoas magnus. This disposition to form abscess in the centre of the larger muscles, 1 have seen very generally prevailing; on dissection^Ihave found them in thepsoae, the gastrocnemii, and in the muscles of the thigh.
while
122 OF THE PSOAS- ABSCESS.
while he is little conscious of it himself, and but imperfectly comprehends how a matter so trifling in appearance, and so little troublesome, is pregnant with so great evil.
If there precedes or accompanies the appearance of abscess at the groin, a curvature of the spine, the prognosis is still more unfavourable, for caries of the bodies of the vertebra? is sometimes the origin, or at least, the precursor of the psoas abscess. As might be naturally expected, especially when the disease is complicated with a caries and sinking of the spine, the abscess sometimes makes its way- outward upon the loins, forming a tumour by the side of the spine.
If the tumour in the groin is opened, and the matter of the abscess evacuated, the sac inflames, the loins become weak and painful, rigors, a rapid pulse, white tongue, and hot skin succeed, the discharge becomes thin and foetid, and often pro- fuse, the appetite entirely fails, the nights are restless, and a rapid hectic is confirmed.
The cure is to be thus conducted: 1. To evacuate the matter and yet endeavour to prevent the in- flammation of the sides of the abscess. 2. To pro- duce a counter irritation by an artificial ulcer on the loins. 3. To correct or change the action, or pro- duce an absorption of the remaining matter bj emetics or by electricity.
If the abscess have formed a tumour in the groin, and the fascia be yet entire, and the integuments on the prominent part of the tumour thick and not yet possessed of much increased vascularity, the
abscess
OF THE PSOAS ABSCESS. 1S3
aWess lancet is to be thrust into the most promi- nent part, a little slantingly through the skin ; but If the tumour be threatening to burst, we should puncture it not on the highest part, but more towards th,° base of i^e tumour, so that the opening be made m sound skin, which will more readily close and heal.
When the pus and coagulable matter are evacuated, the wound must be treated tenderly, united by a small piece of plaister, and bound down with a soft Compress and bandage. We must be careful that nothing intervenes betwixt the lips of trie wound, that the union of the skin may be secured; and by the compress the integuments are pressed upon the fascia of the thigh, so that the opening through it is closed also, and the matter of the abscess pre* vented from passing under the skin. The patient for a time must be confined to the horizontal pos- ture, and use no exertion in raising himself, or in moving the abdominal muscles.
When the small wound is healed, then more freedom is allowed to him., and gradually the tumour appears again When it has acquired a size and prominence sufficient, it is