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tron may be made to the teeth for a few days, after which they may be kept clean as already di.cted.

481. The teeth are fometimes covered over with a thin dark-coloured scurf, which has by fome been mistaken for a wafting of the enamel, but which is only an extraneous matter covering it. By perfeverance this may be cleaned off as completely as where the teeth are covered with tartar; but it is apt, after fome time, to appear again. When this is obferved, the fame opera tion must be repeated. For applying powders or wathes to the teeth, a brush or a fponge is commonly employed; the latter is certainly preferable, being leis in danger of wearing down the enamel, or of feparating the teeth.

482. The chufes producing toothach may be, expofure of the nerve of a tooth, by breaking or waiting of the enamel, inflammation in or about the tooth, or from fympathy when diftant parts are affected, as the eye, the car, the ftomach, or the uterus, as in time of geftation. After toothach has once been produced and removed, it is ast to return by expofure to cold, by taking hot 4quids, by hard bodies preffed against the nerve in the time of chewing, by the ufe of a pick tooth, &c.

483. With refpect to the cure of this difeafe, no rule can be laid down which will anfwer with certainty upon al. occafions. No remedy has yet been discovered which will at all times even moderate the pain; relief, however, is frequently obtained from acrid fubftances applied to the tooth, fo as to deltroy the irritability of the nerves, fuch as opium, fpirit of wine, camphire, and effential aromatic oils. When thefe fail, blifters behind the ear, or deftroying the nerve by the cautious ufe of strong acids, or by a red hot wire frequently applied to the part, have been attended with advantage.

484. When a black or mortified spot appears on a tooth, if it be quite fuperficial, it may be removed; but if it go through the thickness of the enamel, it will be more advifeable to let it remain. When a small hole breaks out in a tooth, particular attention fhould be paid to prevent the admiffion of air. Tin, lead, or gold-leaf, commonly employed for this purpofe, fometimes give re:ief for many months, or even years; but at other times are of little advantage, and in fome inftances caufe great pain. Gum maftich or bees-wax are often employed, and can be made to fill the cavity of the tooth ftill better than metalline fubftances. When ftuffing is to be employed, it ought to be done in the intervals of the fits of toothach, otherwife it will give great unealinefs. When it is to be ufed, the whole cavity of the tooth fhould be filled; and this is to be done with the inftruments, fig. 52. N° 1, 2, 3.

485. When the remedies made ufe of for the removal of tooth-ach have failed in their effect, and it is found that the complaint ftill continues, it will be neceffary to extract the tooth. In doing this, it may be obferved, that all the teeth may be pulled to either fide, excepting the dentes fapien tix of the lower jaw, which ought to be pulled cutwards, otherwife the jaw may be splintered.

As foor as the focket is cleared of blood, if the tooth be not much spoiled, it may be immediately replaced, when it will become as ufefui as before. It is difficult, however, to replace the large grinders, on account of their diverging roots. The more perpendicularly the teeth are pulled, the lefs contufion and injury will be done to the jaws and alveoli. But as no inftrument has been yet invented capable of effecting this properly, furgeons are obliged to be contented with an inftrument which acts in a lateral direction. One of the best is that (fig. 53.) in form of a key, with a claw and fulcrum. Previous to the operation, this thould be covered with a linen rag, to prevent the gum from fuffering. After dividing the gum, or feparating it from the tooth, the claw is to be fixed as deep between the teeth and gum as poffibie. Then the fulcrum is to be applied on the oppofite fide. The furgeon may now, with one turn of the handle of the inftrument, pull the tooth out at once. But the turn fhould not be effected by a fudden jerk, but in the most cautious and flow minner. When it happens to be one of the great moiares, whofe roots diverge very much, and when they are firmly fixed, after only loofing it with the first pull, the claw of the inftrument is to be applied to the other fide of the tooth, and the turn given in a contrary direction to the first. After it has been fufficiently loɔfened in this manner, it is to be laid hold of by a common teeth forceps, (fig. 54.) and extracted in the easiest manner. Upon extraction of the tooth, any detached fplinters occurring are to be immediately removed, Should any confiderable hemorrhagy take piace, the patient may take fome cold water, vinegar, or fpirit of wine into his mouth, and doffiis of int may be introduced into the focket. After all these fail, recourfe must be had to the actual cautery.

486. When stumps occur from caries, or when the teeth have broken in time of the extracting, the common key will fometimes remove them; if that fail, the punch (Ag. 55.) is to be ufed. The operator, having this inftrument in one hand, is to place the fore finger of the other, with a piece of cloth wrapped round it, upon the infide of the jaw oppofite to the stump, to protect the neigh bouring parts.

487. Teeth can never be transplanted with propriety in childhood or in old age. The conflitution must be free from thofe difeafes which affect the gums. The tooth to be tranfplanted muft be taken from a perfon of a found conftitution, otherwife it will convey infection. To guard as much as poffible against infection, it should be immerfed for a few minutes in lukewarm water, and then weil dried and cleaned. It ought to fit the focket exactly; if it be too large, it may be filed down, avoiding the ename as much as poffibie. The furface of it thould be at firft on a level with the reft, or rather a little more depreffed, that it may be as fecure as poffible in its place. If the tooth fit the focket properly, there will be no occafion for ufing a ligature to fix it; but if a ligature be found neceffary, it may be made of threads of fine filk properly waxed. After the operation is finifhed, the patient ought to avoid whatever may be in danger of thaking the tooth,

and

and this is to be attended to till the the tooth is perfectly firm. He fhould alfo guard against cold and moist air, and live upon spoon-meat.

they happen to penetrate the antrum. Sometimes a discharge of matter from the noftriis occurs, particularly when the patient lies on the fide op

SECT. V. Of BOILS and EXCRESCENCES of the polite to the tumor. The disease may arife from

GUMS.

488. GUM boils may arise from cold or from ex. ternal violence, &c. but moft frequently they are the confequence of tooth-ach. The complaint begins with pain attended with a-tumor on the parts affected; by degrees the fide of the face fwells confiderably; the tumor of the gum now begins to point; and if it be not opened, it burfts and gives the patient immediate relief. When the bou is owing merely to inflammation, after the matter is evacuated, the complaint goes off; but when it proceeds from a caries of a to th, it will continue as long as the caufe remains; the tooth therefore ought to be extracted. After the abfcefs has burst, if the matter continue to be discharged, it may fometimes be dried up by injecting fome a Atringent liquor; but the most effectual method is to lay the abfecfa fully open, and to heal it from the bottom by dolis of int. Sometimes abfccffes occur of a more obftinate nature, owing to a carious ftate of the jaw. In that cafe fuppuration ought to be promoted, and the part laid open as foon as matter is formed; keeping the paffige oPen for the difcharge, being the only means for effecting a cure.

489. Excrefcences of various degrees of firmnefs fometimes grow upon the gums. Some are soft and fungous, while others are of a warty nature. In general they are not attended with pain. They often originate from caries of the teeth, or of their fockets; in which cale the removal of the Spoiled teeth, and the fubfequent exfoliation of the carious part of the jaw, will often accomplish a cure. But if not, the tumor should be removed as foon as it becomes troublefome, other wife there may be danger of its ending in cancer. The removal may be effected by a ligature or knite, according as the tumor may have a narrow or broad batis. It is fometimes necellary to use a fpeculum oris to keep the mouth open. After the tumor is extirpated, the wound fhould be allowed to bleed freely, to prevent fubfequent inflammation. When the hemorrhagy proceeds too far, it should be restrained by the application of spirit of wine, or tincture of myrrh, or folution of alum, &c. and fhould thefe prove unfuccefsful, the lunar cauftic will feldom fail of having the defired effect. No dreffings can be applied; but for fome days after the operation, the mouth fhould be frequently washed with a warm emollient decoction; and the cure will be afterwards promoted by the application of fome gently aftringent liquor, aş port wine, tincture of rofes, &c. SECT. VI. Of ABSCESSES, &c. in the ANTRUM

MAXILLARE.

490. THIS difeafe is known by a pain and uneafinefs beginning in the cheek, and extending up. wards to the eyes, nofe, and ears, with a fwelling, which in the latter ftages of the difeafe tends to a point, often in the cheek. Sometimes a discharge cafues between the roots of the back teeth, when

cold, or whatever produces inflammation in ge neral; but the most common cautes are violent fits of the toothach, occafioning exceffive pain and inflammation of the membranes of the no and antrum.

491. The cure is performed by giving a free difcharge to the contents of the tumor: and this is done in two ways; either by extracting one of the two anterior great molares, which are fituated under the antrum, and making a perforation with a round trocar (fig. 56. Pl. 325-) through the botto of the focket; if this has not already been perfo rated by the fangs of the tooth or eroded, in which cafe the matter will pafs out immediately after the extraction; or the perforation may be made bị the inftrument reprefented in fig. 57. through that part of the antrum which projects outwardly over the molares. As moft people with to avoid the pulling of a tooth, when it does not appear to be abfolutely neceflary, the perforation is commerly made in the way laft mentioned. Some authors, however, object to this, as not giving a fufficiently depending opening to the matter. As foon as the matter is difcharged, a plug may be introdu ced into the perforation, which may be removed frequently to allow the matter to pafs out, and to admit aftringent folutions of bark, &c. to be occafionaily thrown into the cavity of the antrum. In this way a cure is obtained, if the bones be found; but if they are carious, it is impoffible to expect a cure till the diseased portions of the bone exfoliate and be removed. When clotted blood is formed in the antrum, it is to be removed in the fame manner. Sometimes the tumor of the cheek is owing to a fwelling of the bones, and no matter is found in the antrum: In that cafe the operation does harm. No external application has yet been discovered for removing fuch a fwelling, though a long continued courfe of mercury has been found to be of fome service.

SECT. VII. Of RANULA.

492. THIS is a tumor under the tongue, moft frequently owing to an obftruction in one of the falivary ducts. Sometimes it contains matter like the fynovia of the joints, fometimes a fatty matter, now and then ftony concretions, but most con monly a fluid like faliva. It often acquires fuch a fize as to prevent fucking in infants, or maftication and speech in adults. When the perfon attempts to fpeak, he only makes a ereaking no:fe; hence the name of the disease.

493. The beft mode of treatment is to lay the tumor fully open by a scalpel or large lancet, to evacuate its contents completely, and then to waft the cavity with any mild fluid, as milk and water. If the fore be difficult to heal, tincture of bark or other aftringents may be used. When the tumor is obferved to be filled with a fatty or any other firm fubftance, it ought to be removed entirely. The only application neceffary in the time of the cure, is the frequent injection of milk and water, or any other mild fluid, by means of a fyringe.

SECT.

SECT. VIII. Of ULCERS in the MOUTH.

494. WHEN ulcers of the mouth arife from a general affection of the fyftem, this must be removed before a cure can be expected. When they originate from harp points in the teeth, thefe are to be filed off, and fome aftringent folution taken cccafionally into the mouth. Notwithstanding, thefe and other remedies, the fores fometimes become worse, difcharging a thin fetid fanies, attended with much pain, and putting on every appearance of cancer. In this fituation, extirpation is the only thing that can effect a cure. If the fore be only fuperficial, it may pretty readily be extirpated; but when deep feated, it may fometimes be neceflary to cut through the whole subftance of the cheek, and heal the fore by the harelip future. When the tongue is the fubject of operation, the operator ought to be ready to take up the bleeding veffels by the tenaculum or the needle. Along with iigature, it may be neceffary to ufe aftringent gargles, or a mixture of fulphuric acid in water. If thefe fail, the potential or even actual cautery muft be used.

SECT. IX. Of the DIVISION of the FRÆNUM

LINGUÆ.

495. SOMETIMES the frænum linguæ extends to the point of the tongue, and tyes it down; whereas, in the natural ftate, it ends about one fourth of an inch farther back. When this is the cafe, it is to be divided, guarding againft wounding the neighbouring vessels, or the ends of the falivary ducts. The divifion may be made with a common fcalpei, but still better with a pair of very sharp fciflars with blunt points.

496. The child being laid across the nurse's knee, the furgeon fhould open the mouth, and raife the tongue with the two firft fingers of the one hand, while with the other he introduces the fciffars, and divides the frænum in the middle, and as far back as is neceffary. SECT. X. Of ENLARGEMENT of the TONSILS

and JVULA.

497. THE tonfils fometimes grow fo large and hard as to become incurable, and even to threaten fuffocation. The tumors here have commonly been confidered to be of a feirrhous nature; but they are neither attended with thooting pain, nor are they apt to degenerate into cancer; neither do fwellings return after the tonfils have been extirpated: hence they ought not to be removed till by their fize they impede deglutition or refpiration; but whenever they do this, they may be removed with fafety. The only proper method of removing them is that by ligatures, which are not only void of danger, but feldom fail to perform a cure. If the bafe of the tonfil be fmaller than the top, the ligature is to be used as for poJypi in the throat; but however broad the bafe of it may be, much difficulty will seldom occur in fixing it, for the fwelling is always very prominent. In difeafes of this kind both tonfils are generally affected; but if the removal of one of them forms a fufficient paffagé for the food, the other may be allowed to remain. When, howe. ver, it is neceffary to extirpate them both, the

inflammatory fymptoms produced by the extirpa tion of the first thould be allowed to fubfide be fore any attempt be made to remove the other. 498. When the form of the tonfis happens to be conical, fo that the ligature would be apt to flip over their extremities, Mr Chefelden has recommended a needle (fig. 58.) with an eye near the point: a double ligature being put into the eye, the inftrument is to be pushed through the centre of the bafe of the tumor, and the ligature being laid hold of by a hook and pulied forwards, the inftrument is to be withdrawn; then it is to be divided, and fo tied that each part may furround one half of the tumor. This method however is scarcely ever found to be necessary. 499. Enlargements of the uvula, from inflammation or from other caufes, may generally be removed by the frequent ufe of aftringent gargles, as of frong infufions of red rofe leaves or of Peruvian bark. But when these fail, and the enlargement is fo confiderable as to give great uncafinefs by impeding deglutition, irritating the throat, and fo caufing cough, retching, and vomiting, extirpation is the only thing upon which any dependence can be placed. Excifion is the readieft method when the uvula is only elongated; but when the fize is confiderabie, dangerous lemorrhagies fometimes attend this method; on which account a ligature is preferable. The operation may be readily performed by thofe of the common kind; fome prefer the curved probepointed biftoury.

500. In performing the operation, the speculum oris (fig. 59. Pl. 325.) is necellary to keep the mouth fufficiently open, and the uvula fhould be laid hold of by a pair of forceps or a small hook, fo as to keep it firm, and prevent it from failing into the throat. After the operation, if the bleeding be confiderable, it may be checked by aftringent gargles, or by touching the part with lunar cauftic; but this will feldom be neceffary.

501. When the ligature is to be employed, it may be readily done according to the method recommended in the extirpation of polypi. A double canula with a ligature may be paffed through the nofe, or the ligature may be applied according to Chefelden's method in extirpation of the tonfils.

SECT. XI. Of SCARIFYING and FOMENTING the

THROAT.

502. IN inflammatory affections of the throat, the means commonly employed are gargles, fomentations, fearification, or top bleeding. Gargles are useful for cleaning the fauces from thick mucus or other fordes; they may likewise be useful in cafes of ulceration. In relaxation of the parts, they are employed to advantage when made of aftringent materials. Fomentations may be of fome ufe externally applied; but the steam of water, &c. drawn into the throat, by means of Mudge's inhaler, is preferable. (See INHALER, MEDICINE, Index; and pl. CXCIII fig. 14. Sometimes it is neceflary to draw blood from the part affected. Here recourfe may be had to fearifying with a common lancet, the tongue being depreffed with a fpatula. It may fill be more readily done by the fearificator, g. 60. plate

325.) After a fufficient number of punctures have been made, the flow of blood may be promoted by the patient's frequently applying warm water to the punctures. When abfcefs forms, notwithftanding the use of these remedies, the matter may be difcharged with the fcarificator already mentioned.

CHAP. XVI. OF DISEASES OF THE EAR

AND OPERATIONS UPON IT.

503. SOMETIMES a thin membrane is fpread over the mouth of the external paffage, while at other times a confiderable part of the paffage is filled up with a fleshy looking fubftance, occasioning deafness. When the first circumstance occurs. the fkin is eafily divided by a fimple incifion, and the accretion of its fides may be prevented by a doffii of lint or a bit of bougie inferted between the edges of the wound, and daily cleaned and returned till the part be rendered callous.

504. When the other caufe is prefent, the incifion must be continued confiderably deeper, till the resistance be removed, or till the inftrument reach near to the membrane of the tympanum, when the operator should defift, leaft the membrane should be wounded; then the fame kind of treatment may be formed as in the former cafe. The proper time for performing the operation is when children ufually begin to fpeak; for previous to this the patient may be too weakly to bear it, and after this fpeech would be impeded. Sometimes the meatus externus is entirely want. ing in the temporal bone. For this an opening through the matoid procefs has been propofed; but the operation has not been performed, at leaft in this country.

505. Children fometimes push hard bodies into their ear, or different kinds of infects occafionally creep into it, fo as to caufe confiderable uncafinefs. Substances lying near the outer end of the paffage may generally be extracted by the fame forceps (fig. 61.;) but round, hard bodies fituated deeper in the pailage are more readily removed by a crooked probe. When infects are deep feated in the ear, they ought first to be killed, by filling the paffage with oil, or any other fluid which proves noxious to them, without hurting the tympanum. They may then be washed out by injecting warm water frequently by means of a fyringe.

506. WAX is one of the most frequent caufes of Deafness, and it may be readily detected by looking into the ear in a clear funshine. Various methods have been propofed for removing wax from the ear; but one, not inferior to any, is to throw in frequently, by means of a fyringe, (fig. 62.) warm milk and water, or water in which a little foap has been diffo.ved. Affittance may ikewife be given here, by ufing along with the injection a blunt probe or fine hair pencil, by which the bottom of the paffage may be cleared out. After the wax is removed, the patient ought to guard against the effects of cold by introducing a little wool for fome time into the meatus. When deafness is owing to a deficiency of wax in the ear, a little oil of almonds, or even oils of a hotter nature, or foap, or galbanum, &c. have been of fervice. Purulent matter is now and then form

ed in the ears of adults, but oftener in those of children. Sometimes it is produced by ulcers fituated in the lining of the meatus, or upon the membrane of the tympanum. It seems to be merely a local affection, and does not, as many have fuppofed, originate from morbid humours of the fyftem. The remedies best calculated for removing it are fuch as are of a moderately aftringent nature, as a weak folution of acetite of lead. A little of this may be dropped in 2 or 3 times aday, but it is better to ufe a fyringe. If the dif charge has continued long, it may be proper, in addition to the other applications, to keep open a fmail blifter for fome time in the neck or arm.

507. It fometimes happens, particularly in cid people, that, from expofure to a ftream of cold air, the tympanum becomes affected, and a noite is heard by the patient like the rushing of water. In other cafes the patient is incapable of accurately diftinguishing the words of fome pertans fpeaking in a loud tone of voice; or, in mixed companies, he hears only a confufion of founds, Complaints of this kind frequently originate from a relaxation of the foft parts of the tympanum: and though a complete cure is not very frequently performed, yet confiderable advantage is fcmetimes derived from the use of hot ftimulating oils, and from keeping the part warm at the fame time with a little wool. When deafne's arifes from affections of this nature, fome affiftance may be derived from collecting the found, 15 as to make a ftronger impreffion upon the internai ear. A variety of instruments have been invented for this purpose. Some ufe a convoluted tube, called an Ear-trumpet, fig. 63.; others a fort of cup. Az. 64. which is concealed under the hair, and fixed to the head with ftraps.

508. Mr P. Martin, furgeon at Dunning, has been very fuccesful in curing deafnes, by introducing the electric fluid into the meatus auditorius. To aflift the paffage of the electric fluid into the ear, he ufes tubes made of elastic gum. The meatus internus, or Euftachian tube, may fometimes be affected by inflammation, or swells ing in the throat, fo as to produce deafnefs. la fuch cafes it has been advised to introduce a pipe, fg. 65. pl. 325. crooked at the end, through the mouth or nofe, and thereby inject any mild fluid into the Euftachian tube; but little dependance can be placed on this method. In ferophulous habits, when fuppuration occurs in the tymp‹num, and the fmall bones become carous, a degice of deafness enfues which can never be removed; in which cafe al that can be done is to keep the parts clean and free from a putrid fine, by washing with milk and water, injected julewarm every morning and cvecing by a fyringe.

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509. Formerly piercing the lobes of the ess was recommended in complaints of the head, cars and eyes; but is now feldom practifed, căcept for ornament, when ear-rings are fhion; in which cafes, the expert jeweller gele rally performs the operation with more expec+ tion and le pain and ceremony, than the mot experienced furgeon. Corks, lead aires, al moveable points, &c. only increate the pain are trouble. Pain filver piercers, made of final wire. pufhed through the lobes in the implett man

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and left in the lobes of the ears for 3 or 4 days, anfwer every purpose, and the young lady is generally surprised to find the pain fo trifling, and that the does not lofe a drop of blood. All that the furgeon or jeweller has to do, is to take care that he does not prick his own fingers, and that the lobes be pierced at equal heights, nearly in the middle, so that they may not be in danger of being worn through, or torn down by heavy ear-rings.

CHAP. XVII. OF THE WRY NECK.

510. A WRY neck way be owing to different causes; as contraction of the skin in consequence of burns, or other kinds of fores; relaxation of the muscles of one fide of the neck, particularly the mastoid, while those of the other fide continue to act with vigour; preternatural contrac. tion of the muscles of one fide of the neck, the others having their ufual power; or, a bend in the vertebræ of the neck.

511. When the disease is owing to a contraction of the skin, this is to be divided through the whole of the contracted part, guarding againft cutting the external jugular vein. When the contraction of the mastoid muscle is the cause of the disease, the muscle should be divided by gentie ftrokes, so as to run no risk of wounding the great veffels fituated under it. When an incifion is made either with a view to divide the muscle or the skin, the head is afterwards, by means of a machine, (fig. 66. pl. 326.) to be kept in a proper pofture during the cure, until new granulations form and fill up the empty space. When the disease is merely owing to a curve of the bones of the neck, the fame kind of machinery may be useful with that recommended for cure in the other parts of the fpine. But fometimes the disease arifes from an affection of the bones of a more serious nature. Here the disease in the vertebræ commonly begins with a flight pain, which gradually becomes worse, and the head is turned over to the found fide. As the difcafe becomes worse, a fulness can be observed very painful to the touch; and moving the head becomes fo diftreffing as to be almoft impracticable. The only method which has been found effectual in this cafe, is the infertion of a pea-iffue on each fide of the tumor, and retaining it till the pain and Atiffness are entirely removed.

CHAP. XVIII. OF BRONCHOTOMY AND

OESOPHAGOTOMY.

512. THE operation of Bronchotomy is an incition made in the trachea, to make way for air into the lungs, when refpiration is obstructed to fuch a degree that life is in danger. If the patient's breathing be already ftopped, the opera tion ought to be done with the greateft expedition; uling any inftrument which will moft readily make an opening in the trachea, as the delay of a few moments will often put a period to the perfon's exiftence. Experience has thown, indeed, that in by much the greater number of cafes, by a total stoppage of refpiration for only five or fix minutes, life is irrecoverably destroyed.

513. In performing the operation, where, from the nature of the cafe, fufficient time is allowed,

VOL. XXI. PART II.

the patient is to be laid on his back upon a table and properly secured by affiftants. A longitudinal incition is to be made, about an inch and an half long, thro' the skin and cellular fubftance; beginning at the under edge of the thyroid cartilage: the fterno-hyoid and thryoid mufcles are then to be separated; the thyroid gland is to be avoided as much as poffible, on account of its vafcularity. As foon as the trachea is laid bare, the bieeding veffels, to prevent coughing, are to be fecured; then, with a common lance, a puncture is to be made as high as may be feen practicable between two rings of the trachea, of such a size as to admit the introduction of a double canula, (fig. 67. pl. 326.) large enough to allow the patient to breathe freely, and of fuch a length as neither to be in danger of flipping out, nor of irritating the back part of the trachea. Such a canula has long been recommended by Dr Monro in his courfe of surgery. Previous to the introduction the canula may be put through several plies of linen comprefs; or these may be first slit half way down, and applied fo that any of them may be removed and replaced at pleasure. This double canula is to be fixed by a strap round the neck; and when mucus obftructs the paffage of the inftrument, the inner tube can be withdrawn, cleared, and readily replaced; while the patient is, during this time, breathing through the outer one; and by means of a screw the tubes can be regulated according to the motions of the trachea. After the canula is fixed, it ought to be covered with a piece of muffin or crape, to prevent the admission of duft, infects, &c. As foon as the causes inducing fuffocation are removed, the canula is to be withdrawn, and the skin immediately brought over the orifice, and retained there by a flip of adhefive plafter.

514. By afophagotomy is understood the cutting open the cefophagus, to allow fubftances sticking in it, and which cannot be extracted otherwife, to be removed. It is only to be done, however, in cafes of the moft extreme danger, as it is at tended with much hazard; and there are only two inftances yet on record of its having been performed with fuccefs, though there are feveral inftances of wounds in the cefophagus being healed. The operation may be rendered neceffary, where obftructions of the cefophagus become fo into the ftomach, or of air into the lungs. But complete as to prevent the passage of nourishment it is evident, that when the obstructing caufe is in the under end of the cefophagus, any incifion becomes ufelefs.

515. In performing the operation, the patient is to be fecured in the fame manner as for bronchotomy, and an incifion made through the skin and cellular fubftance as directly opposite as poífible to the part obftructed. If it be done with a view to remove an obstruction, the muscles over the trachea are to be pulled to one fide, and the tra chea to the other, by means of a blunt hook; by which the oefophagus will be brought into view. If the obftructed part now come in fight, the incifion is to be made directly upon the obstructing body, which is to be extracted by a pair of fmail forceps; but if the obstruction happen to be tar2499

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