hours the bleeding returned, continued through the night, and till the afternoon of the 10th March, when a small iron at black heat was introduced, and lint soaked in solution of alum applied to the part; after sixteen hours the bleeding returned, and on the morning of the 11th he had a little bleeding from the left nostril. The solution of alum was continued, and now was ordered pulv. gallarum, alum. sulph. aã gr.v. 4tis., but without benefit, and at 3 A.M. March 12th, a small iron at black heat. was introduced; but the bleeding did not cease till the socket was plugged with lint soaked in alum. At 9 A.M. the bleeding returned; a bladder of ice was then applied to the throat and cheek, and he was ordered plumb, acet. gr.j. op. gr.† secundá quáque horá per sex vices, tunc tertia vel quartá quáque hora per sex vices sequentes, et postea sexta quáque hora. There was not any recurrence of the bleeding till the evening of the 14th March, when he again bled freely, and the lead and opium were again ordered every two hours, but on the following day, only every four hours. March 16th, he was directed to take a grain of muriate of morphia, which was continued for a few days. On the 18th the bleeding was again free, but finally stopped on the 21st; and he left the house well on the 29th.

How long the lead was continued in the second part of this case, the notes I have quoted, which were not my own, do not distinctly state, and I think it doubtful whether the cure was to be ascribed to it or simply to the loss of blood, by which in a case related by DAVENPORT (a), the bleeding had certainly been put a stop to after thirty hours' continuance, and depressing the patient very considerably. I cannot help, however, thinking that in the second part of this case the actual cautery was never effectually applied; for as I have said before, Ihave never failed when using it, neither has my colleague GREEN, who also employs it.

From the above cases it will be perceived how various have been the remedies made use of to stop these violent bleedings after drawing a tooth, but many other plans have been advised and strongly urged as most efficient. Some persons reinsert the extracted tooth in the socket as the best plug which can be used. CORTEZ (b) recommends the introduction of a wax model into the socket, which he has found effectual in three or four instances. PETER CULLEN (c) prefers a very fine soft phial-cork gently squeezed into the socket, and upon the point of the cork, a bit of lint with some styptic may be put. KENDRICK (d) advises a pledget of cotton dipped in the strongest alcohol as very efficacious. And among the cases of hæmorrhage effectually treated with the internal use of ergot of rye, one of bleeding after drawing a molar tooth is given by Dr. RYAN (e). An interesting circumstance in reference to these cases is, that not unfrequently other individuals of the family to which the patient belongs, are subject to this bleeding disposition. It was so in my own patient's family, and with that of KENNEDY's patient, and I have known it in many other instances.

It is scarcely needful to observe, that if the practitioner be aware of the patient or his family being subject to this disposition to bleed, he should be extremely cautious in undertaking the removal of a tooth, or indeed of any operation; and if compelled to resort to it, should at once be prepared to attempt arresting its bleeding at the onset, and not permit its continuance for hours, much less for days, before employing any efficient remedy.-J. F. S.]

897. Tooth-fistulas (par. 883) require the speedy drawing of the decayed tooth, and the use of astringent gargles. If the fistula do not then close, it is probable that there is still another decayed tooth, which must be drawn; or caries of the alveolar process may exist, which must be treated in the usual way.

Carcinomatous excrescences on the gums (par. 884) are mostly consequences of a decayed tooth or of a carious part of the alveolar process. They must be removed from their base with the knife, and the great bleeding which generally ensues must be stopped with astringent remedies and pressure, or with the actual cautery, which last is also serviceable in preventing the recurrence of the excrescence. If after the removal of epulis a decayed tooth or caries of the alveolar edge be discovered, the former must be drawn, and the latter treated according to the general rule. Cancerous sores and schirrus will be considered with degeneration of the organic tissues.

(a) Medical Gazette, vol. ii. 1842. New Series, p. 58. (b) Ibid., vol. iv. p. 490. 1829.

(c) Medical Gazette, vol. v. p. 564. 1830. (d) Ibid., p. 788.

(e) Ibid., vol. xiii. p. 368. 1833.

II. OF FISTULAS.

(Fistula, Lat.; Fisteln, Germ.; Fistules, Fr.)

898. Unnatural, old apertures, by which fluids are emptied from any cavity or duct externally, or into another cavity, are called Fistulas. By this definition fistulas are distinguished from fistulous sores.

["The term 'fistula' gives a very inadequate notion of the disease," observes Jons HUNTER," the fistulous canal being only the sign of the disease,-the means of conveying a fluid or extraneous matter to the surface. A fistula is the consequence of the powers of a part not being able to remove the original cause, so that the original cause and some of its effects remain." (p. 577.)]

899. The causes of fistulas, are either injuries, by external violence, of the cavities in which the fluids are collected, or of the ducts by which they are discharged, if they be not cured by quick union, or stopping up of the ducts, by which the fluids collected in large quantities produce tearing, inflammation, suppuration, and mortification, causing extravasa tion of the fluid, and the cellular tissue, and an unnatural opening for its escape; or inflammation and ulceration on or in the walls of the cavities and ducts, by which the latter are destroyed. Fistulas, if not consequent on injury, usually commence with abscess, which, on bursting, discharges pus of different kinds, by one or several apertures, communicating either directly with the cavities, or running in various turns and windings. If the fistulous passage be very short, it diminishes in size, as the inflammation lessens, the external opening contracts, and its edges scar, but without closing. If the fistulous canal be longer, the external opening contracts, is surrounded by a little fungous wall, which presents in its middle a narrow and often scarcely observable opening. By the continuance of the inflammation, to a certain degree, in the whole canal, and in the neighbouring parts, the whole internal lining of the canal is gradually converted into a mucous tissue, distinguished only from true mucous membrane, by the absence of mucous glands, and of the epidermoidal covering, and itself prevents the healing of the canal. But, for the most part, in long continued fistulas, the neighbouring parts become hardened, and form, more or less, grayish white, thick hard masses, (callosities,) between which the fistulas run. The same changes also occur in fistulous passages (par. 65.)

["The causes of fistula," says HUNTER, "are various, but may be divided into two classes: first, the obstruction of the passage of some natural secretion, as fistula of the parotid gland; or of the canal for the passage of extraneous matter, as the intestines being strangulated, so as to mortify, or being wounded; but all obliterations of the ducts, where the fluids make a new passage, will not be termed fistula; secondly, the formation of pus or extraneous matter in a part requiring a passage, as in fistula in ano, fistula in the joints, and fistula from diseased bone." [It will be observed that this second class of fistulas has not been enumerated by CHELIUS, although, however, he subsequently treats of them.-J. F. S.] "We shall consider the causes of fistulas,—1st, The obliteration of ducts, or canals, is the first cause. This arises from obstruction of the natural passages, in consequence of which a new one is formed for the passage of the natural secretion. These obliterations often arise from a thickening of the sides of the ducts, as in the urethra, nasal duct, &c., from inflammation; sometimes from the venereal disease, or scrofula; and sometimes from accident, as in the parotid duct. These obliterations are often very troublesome, obstructing the evacuation of the natural secretions, which is very teasing to the part, and when complete is very serious in its consequences. In most there is a new passage when complete, which is made by inflammation and ulceration; these new passages are called fistulous; the discharge is the natural secretion, mixed with the pus from the inflamed vessels of the sides of the passage. If this new passage answers all the purposes of the original one, it cannot well be called fistulous; when from a mortified or wounded intestine, it is called an artificial anus; when in the perinæum, it is for the passage of the urine. There are often accumulations of secreted

juices besides the above, arising from the same causes and producing the same consequences, yet not called fistulous." (pp. 577, 78.) 2nd. The second species of fistula or that from disease, arises from the disproportion in the disposition to heal of different parts, viz., the internal and the external; the skin healing, while the deep seated parts or seat of the disease, have no disposition for it. It may arise from two causes: 1st, from any extraneous substance in the inner parts; 2ndly, from a diseased state of the original part when the disease formed. The first happens in large deep-seated abscesses, which are prevented healing at the bottom by the pressure of the matter. The second has two causes; the first, from the part being naturally indolent, as tendons; the second, from a disease in parts naturally ready to heal, but the disease being deep seated, the skin is more ready to heal than the bottom of the fistula, and thus obstructs the necessary free discharge." (p. 579.)]

900. The prognosis in fistula depends on the possibility of conducting the fluid through the natural ducts; farther, on the condition of the fistulous openings, whether they be accompanied with or without loss of substance, whether they communicate immediately, or by a more or less long canal with the cavity, or with the duct, and whether their walls be converted into a mucous tissue, or callosities. In fistulas of long standing that part of the duct in front of the fistulous opening, and through which fluid no longer escapes, loses its natural area, shrivels up, and the cure is only possible by making an artificial aperture in the cavity, into which the fluid should be conveyed by the natural duct, as for instance, in Salivary Fistula.

901. The indications for the cure of fistulas are, therefore,-1. The restoration of the natural ducts and the conduct of the fluids from the fistulas. This is usually sufficient, and the fistula closes of itself, if the mucous lining, or the callosities, have not formed. In this case the canal of the fistula must be either divided, or a sufficient degree of inflammation and adhesion produced by stimulating remedies and suitable compression. The callosities usually subside, if the flow through the fistula be prevented by the use of soothing applications. 2. The establishment of an artificial duct, if the restoration of the natural passage be not possible, which effected, the fistula closes, either of itself or under the abovementioned treatment. If the fistula be an immediate opening to a duct, without narrowing of the latter, cauterization about the fistulous opening is the best remedy to produce gradual lessening and ultimate closing of the fistula. The paring the edges of the fistula, and their union, has rarely had satisfactory results. This treatment by cauterization (with caustic remedies, or with the actual cautery) is founded on the central contraction occurring in burns (a). If with such fistula there be considerable loss of substance, the opening can often be only closed by implanting or drawing forward skin from the neighbourhood.

["The cure of fistula," observes JOHN HUNTER, "consists in first removing the immediate cause; for frequently they get well by simply removing the obstruction. *The cause of our first division of fistula, arising from confined matter, is sometimes easily removed, but not always, by opening the suppurated part in the most depending situation, when, if the parts are readily disposed to heal, a cure takes place. The second, from a diseased state, must have the disease removed or extirpated if possible; but this is often impracticable. A perfect exposure is the next object; but the case will not often admit of it, and then becoming incurable, it sometimes produces hectic, as in lumbar abscesses and abscesses of the liver which open externally, but cannot be exposed. The constitution in such cases is to be most attended to, and every thing done to lessen the irritation; but in most cases life is miserable, and we only protract it a little longer by our best efforts.” (p. 581.)]

(a) ROSER, Ueber eine besondere Art von Fisteln, welche durch Cauterisation im Umfange der Fistelöffnung zu heilen sind; in Archiv. für Physiologische Medicin, vON KOSER und WANDERLICH, 1842, pt. i. p. 145.

A.-OF SALIVARY FISTULA.

(Fistula Salivalis, Lat.; Speichelfisteln, Germ.; Fistule Salivaire, Fr.)

DUPHENIX, MORAND, LOUIS, Observations sur les Fistules du Canal Salivaire de STENON; in Mém. de l'Acad. de Chir., vol. iii. p. 431.

DESAULT, (Euvres Chirurgicales, vol. ii. p. 216.

VIBORG, Vorschlag zu einer verbesserten Behandlung der Speichelfistel; in Sammlung von Abhandlungen für Thierarzte, Copenhagen, 1797, vol. ii. p. 33.

JOBERT, Observations des Fistules Salivaires, suivies de quelques réflexions sur ces Maladies; in Arch. Génér. de Médecine, 1838, Sept., p. 58.

902. Salivary Fistula is characterized by an opening surrounded with callous edges most commonly very narrow, in the neighbourhood of STENO'S duct, or of the salivary glands, out of which the spittle flows, espe cially during talking and chewing. The flow of spittle is often so great, that loss of appetite, disturbed digestion, and wasting result from it.

903. Salivary fistula is produced either by accidental injury of the salivary glands, or their ducts, if the first union do not take place; or by ulceration of this tissue, or by the salivary duct being stopped up by means of stony concretions; and in the latter case, a fluctuating swelling arises in the course of the duct, which gradually enlarges, bursts, and discharges the spittle.

904. The treatment of salivary fistula varies according as it is situated on the duct itself, or on one of the small ducts from the gland.

905. The salivary fistula, which can be distinguished, partly by its seat, and partly by a probe introduced from the mouth into STENO's duct, is usually cured by continued pressure, which diminishes the secretive activity of the gland. A compress an inch and a half thick is to be put on it, and fastened with the halter bandage. At every renewal of the bandage, camphorated oil is to be rubbed upon the region of the gland, and the fistulous opening touched with lunar caustic. The mere repeated application of caustic, especially of nitrate of silver, is commonly sufficient for the cure.

906. The treatment of fistula of the Stenonian duct, consists either in the restoration of the natural passage for the spittle, or in the formation of an artificial passage by which the spittle may flow into the mouth.

907. The restoration of the natural salivary duct, is only possible when its division has not been of long standing, and the lower end is still pervious, which may be ascertained, with a fine probe, from the mouth, or by injection into the fistulous opening. The modes of treatment proposed for this purpose are,-1. The union of the edges of a recent division by the twisted suture, in which one, two, or three stitches, according to the size of the division, are put in. 2. The introduction of a silken thread, by means of a delicate eyed probe, through the lower end of the duct into the fistula, and its removal when the duct is thought to be sufficiently widened; after which the fistula closes, either of itself, or by the application of caustic (a). 3. Compression of the duct from the fistula up to the gland, in consequence of which oedematous swelling of the gland and the neighbouring parts ensues, which soon destroys the use of the divided parts (b). 4. The efficient touching of the fistulous opening with nitrate of silver, or the application of a paste of sublimate and bread crumbs

(a) Louis and MORAND, above cited.

(b) MASSENEUVE; ín Mémoires de l'Acad. de Chirurg., vol. iii. p. 432.

moistened with decoction of marshmallows, which should be covered with a compress dipped in spirits of wine, and supported with a suitable compress, for the purpose of preventing the escape of the spittle by the slough produced, and also to induce its flow into the lower end of the duct. By this plan, as well as by compression of the duct, in most cases its closure and destruction is effected, which DESAULT and RICHTER aim at in reference to the salivary gland, by endeavouring to destroy its function with continued pressure.

SCHREGER (a) also notices a fistula which closed by compression of the duct behind it, with a steel neck circlet descending from the top of the head, and by touching it with lunar caustic. Here also belongs VIBORG's proposition in cases of salivary fistula, where the usual modes of treatment have been inefficient, to lay bare the hinder end of the duct, by a cut directly down from the cheek-bone, and to bind and unite the wound with sticking plaster. In this way, from VIBORG's experiments on brutes, it results, that after tying the Stenonian duct, the parotid gland swells, gradually subsides, and the destruction of the gland is effected.

908. The production of an artificial duct is the usual mode of treating a salivary fistula, and is always indicated, if the division of the duct have been of long standing, the fistulous opening callous, and the lower end of the duct have become impervious. It is effected in different ways:

1. The callous edges of the fistula having been pared with the knife, a tube with a small trocar is thrust through the cheek, near the hinder opening of the salivary duct, somewhat downwards, and in an oblique direction, in doing which the tongue is to be defended from injury by the finger introduced into the mouth, or by a piece of cork. The trocar is now withdrawn and a thread of silk-worm gut introduced through the tube, which is also then to be removed. The patient should now chew, for the purpose of discovering the aperture of the salivary duct by the flow of the spittle, and the gut in the wound is then to be thrust into this opening for about six lines; the patient then chews again to see whether the spittle flows out between the gut and the wall of the duct, on failure of which, a thinner gut must be introduced. The end of the gut hanging in the mouth is to be brought out to its corner, and fastened with sticking plaster on the cheek. The edges of the wound are to be brought, by properly applied sticking plaster, into the closest union, covered with lint, which should be fastened with sticking plaster, and a cloth placed beneath the chin and bound together on the head. The bandage must not be renewed till the edges of the wound have united, which happens in from thirty to forty hours, if the operation succeed; and some hours after, the gut also may be removed.

DE ROY was, according to BOYER (b), the first who employed an artificial opening by means of perforating the cheek, for which purpose he used the actual cautery which he thrust directly from without inwards.

PERCY (c), after penetrating the cheek, introduced a leaden thread into the upper end of the Stenonian duct, and the other end of the thread through the artificial opening in the mouth, where he bent it round, and fixed it by slight pressure of the cheek against the teeth. This treatment renders the suture and cauterization unnecessary.

2. The cheek being penetrated, as in the former case, a leaden thread or string is introduced through the tube, the two ends of the thread bent round like a hook after the removal of the tube, and left for four or six weeks; the external fistulous opening, after having been pared, is to be (a) Grundriss der chirurgischen Operationen (b) Traité des Maladies Chirurgicales, vol. xxvii. vol. i. p. 84. Third Edit. (c) BOYER, above cited, p. 280.

p. 276.