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Cataract is an opaque state of the crystalline lens, inducing blindness. Its at tack is gradual; a slowly-increasing mist surrounding all objects. The pupil becomes opaque, and these symptoms proceed to an almost entire loss of sight, and milky whiteness of the pupil. A power of distinguishing light from darkness, however, generally remains, and the iris still contracts on exposure to light, which two circumstances distinguish the case from amaurosis. It has been divided into the hard, soft, or caseous, and milky or fluid kinds, according to its consistence; but these cannot be recognised before the operation. The case is often complicated by the co-existence of other affections, as chronic ophthalmy, lippitudo, gutta serena, adhesion to the iris, &c. It comes on spontaneously, and the only mode of treatment is by a surgical operation; the lens may be taken out of the eye by a cut in the cornea, or it may be moved backwards and downwards in the vitreous humour, so as to be removed from the axis of vision; the former operation is called extraction, and the latter couching. A favourable case for the operation is where the eye retains its sensibility to light; where there is no headach nor ophthalmy; no adhesion to the iris. If amaurosis accompany the cataract, the operation would be of no use.

Couching is performed by means of a sharp-pointed, slender instrument, called the couching needle, introduced into the globe of the eye, about one-eighth of an inch behind the cornea, carried in front of the cataract, and then moved downwards and backwards, so as to displace the opaque lens from the axis of vision. The cataract will be absorbed in time, when it is thus removed from its natural connections. If the lens should be in a milky or caseous state, the pupil will not become clear at the time of the operation; but the opaque fluid, or any fragments, will be absorbed afterwards. If there be adhesion to the iris, beware of too much violence, and rather repeat the operation. Needles have been made of various shapes, those of Mr. Hey and Scarpa are the best.

Extraction is performed by cutting the lower half of the cornea, near its junction with the sclerotica, with a slender knife carried across the eye by one motion of the hand. A scratch is then made in the crystalline capsule, through which the cataract escapes. The dexterity required in performing extraction, and particularly in making the cut through the

cornea, is only to be acquired by long practice; and this operation has consequently become confined almost entirely. to the oculists.

Much has been written on the respective advantages of the two operations: the merit of ease of performance, simplicity and mildness in the subsequent symptoms, belong to couching; also that of the power of repeating the operation. Extraction is more difficult, attended with greater injury to the eye, and consequently greater inflammation, but it removes the cause entirely.

After both operations light must be carefully excluded, and every precaution taken against inflammation. The use of convex glasses is required as an assistance to the sight, rendered necessary by the loss of the lens.

The capsule of the lens sometimes becomes opaque after the operation, and thus a secondary membranous cataract is formed, requiring the operation.

DISEASES OF THE MOUTH.

Ranula is an indolent tumour, formed under the tongue, consisting of a membranous cyst, containing a fluid, generally like white of egg, and occasioning no inconvenience until its bulk becomes troublesome. If punctured, it will collect again. Cut away that surface of the bag which projects, and rub the remainder with lunar caustic. Tumours under the tongue may be entirely removed; and calcareous concretions in the ducts must also be cut out.

Shortness of the fremum of the tongue, causing a preternatural confinement of the organ, may be remedied by dividing it to the requisite extent with blunt

scissors.

Ulcers of the tongue may arise from the rugged edge of a tooth, which should be made smooth; from the use of mercury, when pushed to salivation; from disorders of the prime viæ, foul state of the stomach, &c. in which case emetics, and afterwards alterative medicines, are required. They may, lastly, be of a cancerous nature, commencing in a small substance of the scirrhous tumour, or an induration of the tongue, and accompanied with hard irregular edges, and foul discharge. This cancerous state of the organ will end inevitably in a miserable death, unless an operation for the removal of the disease be performed. This may be accomplished by the bistoury, or by a double ligature passed through the substance of the

organ, and tied so as to include the dis@ase. If the glands under the jaw have been affected, it is too late to operate.

The tonsils, when inflamed, sometimes swell so as to impede deglutition and respiration, particularly when abscesses form in the neighbourhood. They may be scarified freely by the pharyngotomus (which is a lancet contained in a sheath); and the same instrument may be employed in opening collections of matter. An indolent enlargement of the tonsil may be remedied, by cutting away the projecting portions by means of a hook and bistoury; or by means of liga

ture.

The elongated uvula requires astringent gargles, or the removal of its extremity by scissors constructed for the purpose.

AFFECTIONS OF THE NECK.

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The wounds of this part, inflicted in at tempts at suicide, often require the surgeon's assistance. After stopping any bleeding vessels, let the wound be approximated, by bringing the head forwards on the neck, and retaining it in that position. Sutures, placed in the trachea, cause great and very detrimental irritation yet if the tube be cut completely through, and position alone will. not bring the ends together, a suture should be placed, so as not to affect the lining of the tube. If the esophagus be wounded, a hollow bougie should be introduced through the nose, for the purpose of conveying nourishment into the stomach; and this may even be necessary when the trachea alone is injured. Inflammation may require bleeding, and the antiphlogistic plan. If there be cough, almond emulsion, with opium, will afford service. Foreign bodies, lodging in the œsophagus, may be either thrust down into the stomach, or drawn upwards through the mouth. The former plan may be pursued with those which can produce no harm when in the alimentary canal; the latter, with such as might prove hurtful from their hardness, indissolubility, pointed angular shape, &c. Indeed, bodies of the latter description, if very low down, must still be pushed on into the stomach, as they hardly admit of extraction. When the substance is near the throat, a curved pair of forceps may remove it; there is also an instrument made of strong flexible wire, doubled and twisted together, and bent at the end into a noose like a hook; and other mechanical contrivances have been suggested. A common probary, probably,

is the best instrument for pushing bodies onwards to the stomach, which must be done, whatever their nature is, when they cannot be got out, and produce troublesome symptoms. Often they are loosened, after a time, by suppuration, if small; or they may be discharged by abscesses; or, as pins and needles, may traverse parts of the body, and appear at a considerable distance.

Bronchotomy is an operation in which an opening is made into the trachea or larynx, for the purpose of inflating the lungs, in cases of suspended animation; for the continuance of respiration, when the natural passage is obstructed by disease; or for the extraction of foreign bodies from the trachea. In instances of apparent death, from drowning, &c. it is our first object to restore respiration; the suspension of that function has caused the stoppage of the other actions, and its restoration is essential to the putting of the animal machine again in motion. If this cannot be done by the means laid down in the article DROWNING, the simple operation which we shall describe may be performed. Again, in diseases or tumours about the throat or trachea, and in cases where suffocation is threatened by a foreign body in the latter tube, the same remedy is necessary. A longitudinal incision of two inches should be made in the middle of the neck, commencing just above the sternum, and continued upwards; the parts should then be separated with the finger and handle of the knife, so as to expose the trachea, which may be opened by a longitudinal cut of half an inch. Some have advised this operation to be performed by a transverse cut between the thyroid and cricoid cartilages; and others by a longitudinal incision in the projecting part of the thyroid, called pomum Adami.

Wry Neck, is a deformity in which the head is drawn towards one of the shoulders; arising either from undue contraction of the sterno-cleido mastoideus, (whose fibres will be found in a very tense state) or from a relaxation, or paralytic condition of the opposite muscle. Perhaps cicatrices from wounds may sometimes be a cause. If it occurs in early life, and continues long, the vertebræ of the neck, and even of the back, may become deformed.

Treatment; camphorated mercurial frictions, and other stimulating applications, electricity, blisters, issues, mechanical means being at the same time employed: this plan is more particularly proper when there is induration. Divi

sion of the clavicular portion of the mus cle, by a surgical operation, is most to be depended on.

Bronchocele, is an indolent enlargement of the thyroid gland, the causes of which are unknown, but which often attains an immense magnitude, and is endemic in several mountainous countries, as Switzerland, Savoy, Derbyshire, &c. Burnt sponge, in the dose of a scruple, two or three times a day, formed with syrup into troches, which should be placed under the tongue, and allowed to dissolve gradually, is the most certain remedy for this disease. Previously to commencing this plan, a grain or two of calomel should be given at bed-time for three nights, and a dose of the magnesia vitriolata on the following morning. This should be repeated again in three weeks, the sponge being then omitted, and the same alternation should be observed during the cure. Topical means may be combined; as friction with a dry towel, or camphorated liniments, &c.

Wounds of the Thorax. Much probing should not be employed to ascertain whether the cavity is penetrated or no, as symptoms will best indicate this point. Passage of air from the cavity, or protrusion of the lung, are appearnaces which show immediately that the cavity is exposed.

Emphysema, is an inflation of the cellular substance, commencing at the chest, and extending over the whole body, arising from a wound of the air-cells of the lungs, and generally produced from broken ribs, or narrow punctured wounds: for in either of these cases, the air, which issues from the wounded lung in inspiration, has no external discharge, as in instances of large and open wounds. It is surprising to what extent this inflation may proceed and as the lung at the same time collapses, the greatest distress is experienced in breathing; yet the swelling of the body is not the dangerous part of the case. Our object is to give a free exit to the air, which may be done by a cut near the injured part, and even, if symptoms require it, into the chest. The air may be discharged from other parts by incisions through the skin, and pressing towards the wound. In about three or four days, the wound in the lung heals, and the air in the chest and cellular substance is absorbed. Bleeding, and other parts of the antiphlogistic regimen, must be used without restraint. Bandages on the chest generally increase the distress.

Wounds of the lungs are indicated by the coughing of blood, by the discharge of that fluid, with air, from the wound, impaired respiration, &c. Though they are often very speedily mortal, yet patients have in many instances recovered. The freest use of the lancet is required, with every other part of the antiphlogistic treatment; perfect rest; light dress. ing of the wound, which must not be probed. Paracentesis thoracis is requir ed, where it appears that water, air, blood, or pus, are accumulated in the cavity, and give rise to danger by their presence. When there are symptoms indicative of these circumstances, the operation is easy; and it may be done, unless the circumstances point out any other spot, between the sixth and seventh true ribs, about midway between the sternum and spine. The integuments should be drawn aside before the first incision, that the opening may be valvular. After cutting about two inches through the skin, dissect down cautiously to the pleura, keeping close on the upper edge of the rib; when a small puncture is made in the pleura, it may be enlarged to the requisite extent with the director and curved knife.

Removal of a diseased breast. In this operation, and in the extirpation of tumours in other parts, the surgeon must attend carefully to remove all the disease; hence the integuments should be included, when they deviate at all from the healthy condition; and the pectoral muscle should also be taken away, if the tumour adheres to it, as far as it may have become indurated. In all cancerous complaints, it is most advisable to extend the incision even beyond the seat of actual disease: as a morbid disposition may have been formed, and would lead to the reproduction of the disorder. Where the skin does not participate in the disease, its removal is unnecessary; the first incision, therefore, may be a simple cut in such a case; while in others two semicircular cuts should be made, meeting at their extremities in acute angles. The tumour should then be separated all round from the surrounding parts; and lastly, the base is to be detached from its connections from above downwards. The cut surface should then be carefully examined, to see if any indurated parts have been divided, for in that case some portions have been left behind, and ought to be taken away. Arteries may be tied as they are divided, if they bleed profusely. When enlarged glands in the axilla re

quire removal, the incision must be extended in that quarter, and the indurated parts completely removed, caution being necessary, on account of the proximity of the large vessels and nerves. When the hemorrhage is stopped, the sides of the wound must be brought together by sticking plaster.

Wounds of the abdomen. These may, or may not, injure the contents of the cavity; but the mere circumstance of their penetrating it constitutes a source of great danger, from the peritoneal inflammation which is likely to ensue. We may not be able to discover whether the cavity is exposed or no; but this is of no consequence. A small, feeble, and contracted pulse; pallid countenance; cold. ness of the extremities; great and sudden debility; hiccough; vomiting; and tension of the abdomen; show that some important parts are injured. A bloody state of the urine; discharge of blood by vomiting and stool; escape of urine, feces, or chyle, by the wound; indicate to us what particular parts are included in the injury. A protrusion of the viscera is a frequent attendant on these cases. The subsequent occurrence of the symptoms described as belonging to peritonitis (see MEDICINE) is the natural consequence of the injury, and brings the greatest danger to the patient.

The treatment divides itself into two parts as regarding the wound, and the constitution in general. An over anxiety to discover the extent of the wound, and the parts injured, is useless and reprehensible; if these facts cannot be made out with facility, the surgeon must be contented to remain ignorant of them. Protruded parts must be immediately restored in the most gentle way, and the wound may probably require dilatation for this purpose; which the surgeon may accomplish with the probe-pointed curved knife, guided by his finger or a director. Fomentation of such parts is perfectly useless. A discoloured state of intestine is no reason why it should not be replaced; if it looks very suspicious, it may be retained near the wound by a suture through the mesentery. If the gut be wounded, three simple stitches may be made at three different parts of the circumference, and the part retained near the wound. To attempt to unite the edges by making them touch at every point, would be obviously nugatory. The ensuing inflammation agglutinates the gut to the surrounding parts, and thus the breach becomes gradually closed,

while the extravasated matter readily escapes through the wound, behind which the injured part is confined. If the wounded portion of the gut be within the cavity, we must trust to the powers of nature, observing only to facilitate the discharge of the intestinal contents. Sometimes in such a case a perfect cure is obtained; sometimes the feces are discharged for ever after through the wound, and sometimes a fistulous opening remains. Should the return of a large piece of omentum be very difficult, it may be cut off, and any bleeding vessels secured. The wound should then be accurately and firmly closed by means of sticking plaster, aided by an attention to position, which is much better than using sutures. The introduction of tents is a part of the old practice, contrary to all principle, and therefore universally exploded. The general treatment of the patient requires a strict observance of the antiphlogistic plan; perfect quiet, abstinence from animal food and fermented liquors, and mild purgatives, should be employed in every case; and where symptoms of inflammation exist, even although the pulse should be small, copious bleeding from a large orifice is absolutely necessary. Cupping, or leeches to the abdomen, followed by fomentations and blisters, will also be necessary.

Gunshot wounds of the abdomen are very seldom attended with protrusion of the intestines. The treatment is here limited to the employment of general means, which have sometimes the happiest effect under very unpromising circumstan

ces.

Wounds of the abdominal viscera are often attended with extravasation of various substances into the cavity; these may consist of intestinal contents, bile, urine, or blood. Besides the swelling which they cause, their presence irritates the surrounding parts, producing inflammation, constitutional disturbance, and sometimes even suppuration and a manifest fluctuation. If bile or urine be effused, the symptoms come out very rapidly, and are extremely urgent; but in other cases the symptoms are not so pressing. The resistance arising from the pressure of the respiratory muscles occasions the effused matters to be collected into one mass, and prevents them from becoming generally diffused over the cavity. When swelling, attended with local pain, fluctuation, &c. and the other symptoms which will attend the case, clearly indicate a collection of

this kind, it may be opened by the surgeon.

Psoas abscess, is a collection of matter behind the peritoneum, in the cellular substance surrounding the psoas muscle. It forms in a very gradual manner, generally without inflammatory or febrile symptoms. There is a dull pain in the loins, and a slight weakness of the affected thigh. After some time, the matter, descending by its own weight, passes Poupart's ligament, and forms a swelling in the groin: or it may be present in the back just under the last rib. At this period the motions of the thigh_are considerably impaired, particularly those in which the psoas muscle is concerned. There is an impulse in the tumour when the patient coughs, and the swelling is larger in the erect position. Sometimes disease of the vertebræ accompanies this affection. When the abscess bursts, the whole cyst falls into a state of inflammation; violent irritative fever ensues; and there is a copious suppuration, under which the patient gradually sinks. The most successful plan hitherto adopted is, that of opening the abscess as soon as it has presented fairly, by a pretty free incision with the abscess lancet; bringing the wound together, without allowing the introduction of any air, and closing it accurately with sticking plaster.

This

of any of the abdominal viscera from the cavity in which they are naturally contained, into a preternatural bag, formed by the protrusion of the peritoneum. The protruded portion of perito neum is called the hernial sac. peritoneal sac is covered by another investment, of various degrees of thickness, consisting probably, in great part, of the surrounding cellular substance, condensed into a membrane-like appearance, by the pressure of the hernia; in the same way as tumours acquire their investing cyst. In the inguinal hernia, this external coat of the sac possesses some tendinous fibres in its structure, derived from the aponeurosis of the external oblique, where it forms the ring. The chremaster muscle is also expanded on its surface; it consists usually of several layers, the division of which, in the operation, often leads the surgeon to suppose that he has opened the hernial sac. Scrotal ruptures often descend to various distances on the thigh, sometimes indeed even to the knee, yet the whole inner surface of the bag, in which all the loose viscera of the abdomen may be contained, is lined by a continuation of peritoneum; indeed, the hernial sac, taken altogether, is generally thicker and stronger in proportion to the size of the tumour, and to the duration of the complaint. The exterior covering is every where closely connected by cellular substance to the proper peritoneal sac. Hence the latter part is not returned into the abdomen when the contents of the swelling are replaced, but remains behind, ready to receive any future protrusion. When the parts have descended through the abdominal ring, the case is called a bubonocele, or inguinal hernia; if they are in contact with the testis, it is termed congenital. The crural or femoral is that which takes place under Poupart's ligament; and the exomphalos or umbilical rupture, occurs at the navel. The names of enterocele, epiplocele, and entero-epiplocele, are applied according as the swelling contains intestine, omentum, or both together. These are by far the most frequent forms of the complaint; yet there are several others, as ventral hernia, which takes place between the fibres of the abdominal muscles; hernia of the foramen ovale, ischiatic notch, &c. While the viscera descend and return freely, the complaint is said to be in a reducible state; but Is a tumour formed by the passage when,from increase of bulk, preternatural

This is to be repeated when the matter has accumulated again, and thus the contraction of the cyst will be promoted; a third and fourth puncture may be necessary. Electricity and emetics of the metallic salts may be combined with this plan, to favour the absorption of matter; and a blister kept open by the savine serate will be an useful auxiliary means. Disease of the bone requires blisters, or issues in the loins.

Paracentesis abdominis is an operation performed for the discharge of dropsical fluid, and consisting merely in penetrating the parietes of the cavity by means of a trochar. The instrument is to be introduced three inches below the navel, in a perpendicular line drawn from that spot and it should not be pushed more deeply, when it meets with no further resistance. Pressure by a belt or the hands of assistants should be kept up during the evacuation, as faintness is frequently produced by the sudden removal of the support from the abdominal vis

cera.

HERNIA

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