purulent matter, that they are now generally confidered as fuch, though Mr Pott and feveral others have been of a different opinion, confidering the fluid as merely mucus under a different form; allowing, however, that pus is sometimes difcharged. If the puncta lachrymalia be naturally large and open, and the inflammation confined to the furface of the fac, its contents will pafs off pretty freely, and the fkin will remain entire.

445. But when the skin covering the lachrymal bag has been for fome time inflamed, or subject to frequently returning inflammations, it most commonly happens that the puncta lachrymaiia are affected by it, and the fluid, not having an opportunity of paffing off through them, diftends the inflamed fkin; fo that at laft it becomes floughy, bursts externally, and forms an opening in the most prominent part of the tumor, at which the tears and matter contained in it are discharged. When the opening thus formed is fmal, it commonly heals again in a few days, but it bursts as foon as a confiderable quantity of this fluid is collected; and it continues thus to collect and burft alternately, till the opening becomes fufficiently large to prevent any farther collection. This ftate of the diforder exhibits exactly the appearances of a finuous ulcer, with calious, and fometimes with retorted edges; and this ftage forms properly the real fistula lachrymalis. Tears, mucus, and purulent matter, are now abundantly difcharged from the fore. When the bone beneath is found, this discharge is seldom either acrid or offenfive to the fmell, for the opening being in general in the under part of the tumor, the matter is readily evacuated; but when any of the contiguous bones are carious, they are not only found to be fo by the introduction of a probe, but by the appearance, fmeil, and effects of the matter upon the neighbouring parts. In this cafe it is thin, fetid, and commonly to acrid as to fret and corrode the integuments moft contiguous to the ulcer; and when the disorder is connected with fcrophula or with lues venerea, which is a frequent occurrence, the difcharge and appearance of the fore will vary according as it happens to be combined with one or other of these difeafes.

447. We may divide this disease into four general states, under which ail its more minute dif. tinctions may be comprehended. The firft confifts in a fimpie dilatation of the facculus and obftruction of the nafal duct, difcharging, upon pref. fure, a fluid either quite clear or a little cloudy; the fkin covering the bag being entire and per fectly free from inflammation. In the 2d the tumor is fomewhat larger; the skin which covers 't is in an inflamed ftate, but entire; and the difcharge made through the punéta lachrymalia is of a pale yellow or purulent colour. In the 3d, the skin covering the facculus is become floughy, and burfts; whereby the fwelling is in fome meafure leffened: but the matter which, while the skin was entire, used to be prefied out through the puncta lachrymalia, now difcharges ittelf through the new aperture. The ductus ad nares, both in this and the preceding Rate, are not other wife difeafed than by the thickening of its lining, In the 4th, the paffage from the facculus lacbiymalis into the note is totally obliterated, the in

fide of the former being either ulcerated or filled up with the fungus, and attended fometimes with a caries of the bone underneath.

448. In the firft and moft fimple fate of the disease, viz. that of mere obstruction without in. flammation, much pains have been taken to reftore the parts to their natural state and use, without making any wound or divifion at all. The intro duction of a probe, the injection of aftringent fluids, and a conftant compreffion made on the outside of the facculus in the corner of the eye, are the principal means by which this has been attempted.

449. Several years ago, M. Anel made a probe (Plate CCCXXV. fig. 38.) of so small a fize as to be capable of palling from the eyelids into the nofe, being introduced at one of the puncta la chrymalia, and paffing through the facculus and duct, with which he propofed to break through any fmall obftruction which might be found in its paffage. He alfo invented a syringe (fig. 39.) the pipe of which is fmall enough to enter one of the puncta, and thus furnithes an opportunity of injecting a liquor into the facculus and duct; and with these two inftruments he pretended to be able to cure the difeafe whenever it confifted in obstruction merely, and the discharge was not much discoloured. The first of these has a plau. fible appearance; but is, upon trial, very unequal to the task affigned; the very small size of it, its neceffary flexibility, and the very little refiftance it is capable of making, are manifeft deficiencies in the inftrument; the quick fenfation in the lin ing of the fac and duct, and its diseased state, are great objections on the fide of the parts, fuppofing it were capable of answering any valuable end, which it mcft certainly is not.

450. That the paffing a fine probe from one of the puncta lachrymalia into the nofe is very practicable, is known from experience; but the pain it gives, and the inflammation it often excites, are much greater than any benefit which does or can arife from it. Befides the obftruction of those ducts, which this probe is to clear, is a circumstance feldom, if ever, met with. Nor, even if it did happen, could it ever produce the disease m queftion; the principal characteristic of which is a difcharge into the miner corner of the eje upo preffure made in the angle.

451. The SYRINGE, if ufed judiciously while the difeafe is recent, the fac very lit le dilated, and the mucus perfectly clear, will fometimes be ferviceable; it gives no pain; and a few trials ren der the ute of it by no means trouble fome. But there is little occafion, to put the patient to tɔ much trouble; for if the fac be emptied by com. pretion, if the liquor which was to have been injected be applied to the punéta, they will abforb it as readily as the fluid which naturally paffes through them.

452. FABRICIUS AB AQUAPENDENTE invented an inftrument, which was fo contrived as by means of a forew to make a preffure externally on the lachrymal bag; from the use of which, be fays, his patients received much benefit. This inftrument has been confiderably improved by late practitioners, and is still recommented as very uictul. (See fig. 41.) All the good that can be

obtained

inferior part; the nafal duct is toe fearched for with a firm probe, or with a conductor (fg. 43, Plate 325.) made for the purpofe; and Peilier afferts that he never fails in finding it. As foon as this is difcovered, a conical tube (fig. 44) with a projection at the top, and another in the middle for fecuring it in its place, muft be put upon the conductor, previously furnished with a compreffor (fig. 45.) and it thould be of fuch a fize that the conductor may fit it exactly. The point of the conductor is now to be pafled into the lachrymal duct; and being pushed in till it reaches the noftril, which may be known either by inferting a probe into it, or by a few crops of blood failing from the nofe, the conductor is to be withdrawn; leaving the compreffor upon the brim of the canula, which must be firmly preffed down with the left hand, while the conductor is removed with the other. The compreffor muft next be taken out; and to discover whether the canula be at a proper depth, a little milk or water fhould be injected through it. If the injection pafs, it will how that the canula is properly placed. If any obftruction occur, there will be reafon to fufpect that it is already puthed too far, and that it preffes against the es fpongiofum inferius; in which cafe the canula must be withdrawn, thortened, and reintroduced as before.

460. The fore ought to be kept open for 8 or 10 days after the operation with soft lint spread with emollient ointment, and the whole covered with a comprefs of foft linen fecured with a band age. An injection of milk and water fhould be daily paffed through the canula; and as foon as the fore looks clean and healthy, the dreffings fhould be entirely removed, and a piece of court plaster laid over it. In this ftate it is to be left to heal; but the plaster must be renewed, if matter appear to form beneath it. By this method Mr Pellier finds, that fiftula lachrymalis, not depending upon difeafes of the contiguous bones or of the conftitution, may commonly be completely cured in two or three weeks, which, by the ufual practice, might require feveral months.

CHAP. XIV. OF AFFECTIONS OF THE NOSE. SECT. I. Of HEMORRHAGIES from the NOSE. 461. WHEN the means mentioned for this complaint in the article MEDICINE have failed, recourfe muft be had to compreffion. Doffils of lint introduced into the noftrils are fometimes effectual; or the gut of fome fmall animal, tied at one end, then introduced by a probe into the nofe as far as the pharynx, and fiiled with cold water, or that and vinegar, and fecured by a ligature, by adapting itfelf to all the parts, and preffing equally on them, has been attended with advantage.

462. When thefe remedies likewife fail in their effect, a piece of catgut or wire may be introduced through the nofe into the throat, and brought out at the mouth; a piece of fponge, or a boliter of lint, of a fize fufficient to fill the back part of the noftril, is then to be fixed to it; the fponge is next to be drawn back and properly applied to the anterior part of the noftril and fecured. The fame may be done to the other noftril, if it be

neceflary; or the fponge may be of such a size as to fill the ends of both noftrils at the fame time. By this contrivance the blood not finding an outlet, will foon coagulate, and prevent any farther evacuation.

SECT. IL Of CzÆNA.

463. OZENA is an ulceration within the nafe, which may be occafioned by external violence, by expofure to cold, by irritating substances, or by whatever produces inflammation in the membrane lining the noftrils. Sometimes it arifes from venereal infection; and in this cafe the discharge becomes fo acrid as to corrode, and produce caries in the bones of the nofe. When the difeafe is loca', and not depending upon any corftitutional affection, aftringent folutions are found to be the moft ufeful. fuch as a decoction of bark or that mixed with alum. Doffils of tint dipt in thefe are to be introduced into the nostrils three or four times a-day, or some picfer the injection of fuch fluids by means of a fyringe as being more effectual. If stronger aftringents be neceffary, a folu tion of fty ic powder ought to be used. At bedtime an ointment prepared with zinc er lapis calaminaris ought alfo to be applied. A blifter applied to the temple has fometimes cured the dif

eafe.

454. Inftances, however, occur, where the difcharge is occafioned by a collection of matter within the antrum maxillare; and then it is apt to refift every effort till a proper outlet be given to it. When the complaint is owing to venereal infection, the primary disease is to be attended to, and mercurial preparations are to be applied to the part; but when the bones are carious, till thefe are removed we need neither expect that the difcharge will ceafe, nor the disease be otherwife completely cured.

SECT. III. Of IMPERFORATED NOSTRILS.

465. SOMETIMES the noftri's are in part or entirely obliterated. This may be owing to burns; fmall-pox; different kinds of fores, especially thofe of a venereal nature; and fometimes it is the effect of original conformatiou, for it has been obferved in new-born children.

466. When any opening appears in the obstructed noftril, it may be readily dilated by the introduction of a furrowed probe, and then cutting upon it in the course of the adhesion: but when no paffage appears, the operator muft endeavour, by means of a fcalpel, to discover one of the noftril; and when difcovered, it must be enlarged by a director and bistoury, 'as in the former cale. The other noftril is to be treated in the fame manner. After the openings are formed, they might be preferved of a proper fize by the introduction of doffils of lint, which fhould be frequently cleaned or renewed; but metallic tubes anfwer the purpofe better, and allow the patient to breathe freely through them till a cure be performed. Previous to their introduction, they ought to be covered with soft leather spread with emollient ointment, and retained till the fores are completely healed.

CHAP.

CHAP. XV. OF AFFECTIONS OF THE

MOUTH AND THROAT.

SECT. I. Of the DIVISION of the PAROTID DUCT. 467. WHEN the parotid duct is divided, the faliva which it tranfmits pafies over the cheek inftead of going into the cavity of the mouth. When the furgeon is calle i to a recent divifion of the duct, he ought to lay the divided ends of it as exactly together as poilible, and to retain them in their fituation till they are united by adhefive plaf ters, or by the twisted future if there be confiderable retraction of the parts. But when the portion of the duct n-at the mouth is entirely obiter ated, an artificial pailage must be made into the mouth, and an union formed between the opening and that part of the duct which proceeds from the parotid gland.

458. The artificial passage ought to be as much as poffible in the direction of the natural du&. A perforation of a proper fize is to be made obiiquely into the mouth with the trocar, fig. 46. Pl. 324. from the file of the wound exactly oppofite and contiguous to the under extremity of the upper portion of the duct; and then a piece of leaden probe of the fize of the perforator fhould be intro. duced by means of the canula, and be kept in the cheek till the fides of the opening become calious; when the lead being withdrawn, the extremities of the artificial and natural ducts are to be brought into contact, and retained there by adhefive platter till the cure is completed. Another method has been followed by M: Latta (fee his Syftem of Surgery), of introducing one end of a bit of catgut into the artificial opening, and bringing it out at the mouth, while the other is introduced a little way into the extremity of the natural duct, and retained by adhetive plafter till the wound is healed. Whichever way the operation is done, the patient fhould live upon fpoon-meat, and make as little motion as poffible with his lips or jaws.

SECT. II. Gf the HARE-LIP.

469. THE hare-lip is a fiffure in the upper lip, very feldom in the under one. It is attended with want of fubftance, and has its name from a refemblance to the lip of a hare. In general it is only a fimple fiffure, though fometimes it is double; in which cafe it renders a cure more difficult to be executed. There are many lips where the want of fubftance is fo great, that the edges of the fiffure cannot be brought together, or at least where they can but juft touch, and then the attempt fhould be forborn. It is likewife improper in infants, and ought not to be performed till feveral months after they have been weaned, when they will have acquired more ftrength to undergo the operation, and will be lefs liable to be attacked with bowel complaints, which frequently make them cry at an earlier period of infancy.

470. In proceeding to the operation, the patient, if a child, should be secured upon a perfon's knee, or rather perhaps upon a table; but if an adult, he is to be feated upon a chair, in a proper light. The frænum connecting the gums to the upper lip is to be divided; if a fore-tooth project fo much as to prevent the parts from being brought

properly together, it is to be extracted; or when the fiffure run through the bones of the palate, if a fmall portion of the bone project, this must be removed. The operator is then to lay hold of one fide of the fiffure between the thumb and forefinger, or between the forceps, (pg. 47. Pl. 325-) then with a pair of fharp and very strong feitars, (fig. 48.) or with a fcalpel, to cut off a thin portion of the lip, and to repeat the fame thing upon the other fide of the fiffure, fo as to render the whole edges of the fiilure completely raw; by which, if the operation be properly performed, a piece will be separated in form like an inverted V.

471. After the incifions have been made, the veffels fhound be allowed to bleed freely to prevent inflammation; and when the bleeding has ceafed the fides of the wound are to be brought accurately together, and kept in that state by the twisted future. The first pin ought to be as near as poffible to the under edge of the lip; another is to be infested near the upper angle; and if the patient be an adult, a third pin will generally be neceffary, half way between the other two. In paffing them, they ought to go rather deeper than half through the , that the edges of the wound may be kept properly in contact. An affiftant now keps the parts together, while the operator applies a firm waxed ligature first to the under pin; and having made 3 or 4 turns with it in the form of an 8 figure (fig. 49.), it should then be carried about the 2d, and in a fimilar way about the 3d, care being taken that the thread be drawn of a proper tightness. After the ligature is fecured, a piece of lint, covered with fome mucilage, fhould be laid over the wound to protect it from the air; and this is commonly all the bandage neceflary. When, however, from a great want of fubstance, the retraction has been confiderable, fome advantage is derived from the use of adhefive plafters applied to the cheeks and tied between the pins. During the time of the cure the patient should be fed upon fpoon,meat, and prevented from making any exertion with the lips, otherwife the cure might be confiderably re▾ tarded. In 5 or 6 days the pins may be taken out, when the parts will commonly be found completely united.

472. In the cafe of a double hare-lip, the operation fhould be firft done upon one fiffure; and when a cure is completed there, it may be done fafely upon the other.

SECT. III. Oƒ EXTIRPATION of CANCEROUS LIPS.

473. THE under lip is much more frequently attacked with cancer than the upper, or indeed than any other part of the body: And as little dependence is to be placed upon external applicarions or internal remedies, recourse must be had to the knife as the only certain method of cure.

474. When the difeafe has not attacked any confiderable part of the lip, the difeafed part is to be cut out, and the wound cured by the twifted future. The operation ought therefore to be performed early, to allow the parts to be brought properly together. The general steps of the operation are nearly the fame as in the operation for hare-lip; only, all the difeafed parts are to be re. moved, taking care to make the cut fo as will PPPP2