Lachryma lis. äre a of the Nofe. Fistula fides of the wound, now already fufficiently contracted, are gar, and fecured by a ligature, by adapting itself to all the Affections to be laid together, and covered with fome adhesive plafter., parts, and preffing equally on them, has been attended with If this be ineffectual, the wound is to be touched with cauf- advantage. When these remedies likewife fail in their ef tic, when the cure will generally be quickly completed. fect, a piece of catgut or wire may be introduced through To give tone to the parts, moderate preffure fhould fre- the nofe into the throat, and brought out at the mouth quently be made upon the fac, either by the patient's finger piece of sponge, or a bolfter of lint of a fize fufficient to fill or by the machine already mentioned, and this fhould be the back-part of the noftril, is then to be fixed to it; the continued for a confiderable time. Sometimes the difeafe fponge is next to be drawn back and properly applied. Anreturns after a cure has been made, owing to diseases of the other is to be applied to the anterior part of the noftril and conftitution, carious bone contiguous to the fore, or fome- fecured. The fame may be done to the other noftril, if it times to too small an opening having been formed. In this be neceffary; or the sponge may be of such a size as to fill cafe a canula of gold, filver, or lead, is fometimes introdu- the ends of both noftrils at the fame time. By this conced into the artificial paffage, and the skin healed over it; trivance the blood not finding an outlet, will foon coagulate, by which means the paffage will afterwards remain com- and prevent any farther evacuation. pletely open, and no difeafe of the conftitution can ever affect 230 Mr Pel zion, opera it. We shall defcribe Mr Pellier's method of performing this operation, who has made feveral improvements on it. The patient is to be feated, and his head properly fuplier's me ported by an affiftant; then the fac is to be laid freely open thod of at its inferior part; the nafal duct is to be fearched for with performing this a firm probe, or with a conductor (fig. 41.) made for the purpofe; and Pellier afferts that he never fails in finding it. As foon as this is difcovered, a conical tube (fig. 42.), with a projection at the top, and another in the middle for fecuring it in its place, must be put upon the conductor, previoufly furnished with a compreffor (fig. 43.), and it fhould be of fuch a fize that the conductor may fit it exactly. The point of the conductor is now to be paffed 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 drops of blood falling from the nose, 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. This being done, the compreffor must next be taken out; and to difcover whether the canula be at a proper depth, a little milk or water should be injected thro’ it. If the injection pass, it will show that the canula is properly placed. If, on the contrary, any obftruction occur, there will be reafon to fufpect that it is already pushed too far, and that it preffes against the os fpongiofum inferius; in which cafe the canula must be withdrawn, fhortened, and reintroduced as before. The fore ought to be kept open for eight or ten days after the operation with soft lint spread with emollient ointment, and the whole covered with a compress of soft linen fecured with a bandage. 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 plafter laid over it. In this ftate it is to be left to heal; but the plafter must be renewed, if matter appear to form beneath it. By this method Mr Pellier finds, that fiftula lachrymalis, not depending upon diseases 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. XV. Of Affections of the Nofe SECT. I. Of Hemorrhagies from the Nofe. WHEN the means mentioned for this complaint in the article MEDICINE have failed, recourfe must be had to compreffion. Doffils of lint introduced into the noftrils are fometimes effectual; or the gut of fome small animal, tied at one end, then introduced by a probe into the nofe as far as the pharing, and filled with cold water, or that and vine SECT. II. Of Ozana. By this is understood an ulceration within the nose, which may be occafioned by external violence, by expofure to cold, by irrritating fubftances, or by whatever produces inflammation in the membrane lining the noftrils. Sometimes it arifes from venereal infection; and in this cafe the dif charge becomes fo acrid as to corrode, and produce caries in the bones of the nofe. When the difeafe is local, and not depending upon any conftitutional affection, aftringent folutions are found to be the most useful, fuch as a decoction of bark or that mixed with alum. Doffils of lint dipped in these are to be introduced into the noftrils three or four times a-day, or fome prefer the injection of fuch fluids by means of a fyringe as being more effectual. If ftronger aftringents be neceffary, a folution of ftyptic powder ought to be used. At bed-time an ointment prepared with zinc or with lapis calaminaris ought likewife to be applied. Upon fome occafions the application of a blister to the temple has cured the disease. Inftances, however, occur, where the difcharge is occa fioned 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 discharge will cease, nor the disease be otherwise com pletely cured. SECT. III. Of Imperforated Noflrils. SOMETIMES the noftrils 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 conformation, for it has been observed in new-born children. When any opening appears in the obstructed nostril, it may be readily dilated by the introduction of a furrowed probe, and then cutting upon it in the course of the adhefion: but when no paffage appears, the operator muft endeavour, by means of a fcalpel, to discover one of the nof trils; and when discovered, it must be enlarged by a director and bistoury, as in the former case. 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 answer the purpose 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. XVI. Of Affections of the Mouth and Threat. SECT. I. Of the Divifion of the Parotid Dua. WHEN the parotid duct is divided, the faliva which it tranfmits passes over the cheek instead of going into the cavity of the mouth. When the surgeon is called to a recent division of the duct, he ought to lay the divided ends of it as exactly together as poffible, and to retain them in their fituation till they are united by adhesive plasters, or by the twisted future if there be confiderable retraction of the parts. But when the portion of the duct next the mouth is entirely obliterated, an artificial paffage 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. The artificial paffage ought to be as much as poffible in the direction of the natural duct. For this purpose a perforation of a proper fize is to be made obliquely into the mouth with the trocar (fig. 44.), from the fide 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 introduced by means of the canula, and be kept in the cheek till the fides of the opening become callous; when the lead being withdrawn, the extremities of the artificial and natural ducts are to be brought into contact, and retained there by adhesive plaster till the cure is completed. Another method has, in a few inftances, been followed by Mr 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 adhefive plafter till the wound is healed. Whichever way the operation is done, the patient should live upon fpoon-meat, and make as little motion as poffible with his lips or jaws. SECT. II. Of the Hare-lip. 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 resemblance 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 substance is so great, that the edges of the fiffure cannot be brought together, or at least where they can but just touch, and then the attempt should be forborne. It is likewife improper in infants, and ought not to be performed till several 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. In proceeding to the operation, the patient, if a child, fhould be fecured 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 so much as to prevent the parts from being brought properly together, it is to be extracted; or when the fiffure runs through the bones of the palate, if a small portion of the bone project, this must be removed. Matters being fo far adjusted, the operator is to lay hold of one fide of the fiffure between the thumb and fore-finger, or between the forceps (fig. 45.), then with a pair of sharp and very strong seiffars (fig. 46.), or with a scalpel, to cut off a thin portion of the lip, and to repeat the fame thing upon the other fide of the fissure, so as to render the whole edges of the fiffure completely of the Mouth and raw; by which, if the operation be properly performed, a piece Affections. will be separated in form like an inverted V. After the incisions have been made, the veffels should be allowed to bleed -Throat. 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 ftate by the twisted future. The firft pin ought to be as near as poffible to the under edge of the lip; another is to be inferted 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 lip, that the edges of the wound may be kept properly in contact. An affiftant now keeps the parts together, while the operator applies a firm waxed ligature first to the under pin; and having made three or four turns with it in the form of an eight figure (fig. 47.), it should then be carried about the fecond, and in a fimilar way about the third, care being taken that the thread be drawn of a preper 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 neceffary. When, however, from a great want of fubftance, the retraction has been confiderable, some advantage is derived from the use of adhesive plasters 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, otherwise the cure might be confiderably retarded. At the end of five or fix days the pins may be taken out, when the parts will commonly be found completely united. 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. Of Extirpation of Cancerous Lips. 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 applications or internal remedies, recourse must be had to the knife as the only certain method of cure. When the disease has not attacked any confiderable part of the lip, the difcaled 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 broughtproperly together. 'The general fteps of the operation are nearly the fame as in the operation for hare-lip, and therefore need not be repeated. It is only to be observed, that all the diseased parts are to be removed, taking care to make the cut in fuch a way as will most readily admit of the twifted or hare-lip future. When the parts can be brought together, the lip will have nearly the fame appearance as in the operation for hare-lip; but when the difeafe fpreads over a confiderable part of the lip, fo as to prevent the found parts from being united after the difeafed parts have been removed, all that can be done is to remove the part affected, secure the bleeding veffels, and dress the fore like any other recent wound. SECT. IV. Of Affections of the Teeth. of the Teeth. of the 235 any adventitious matter being obferved in them; at other Affection times they become foul, and give a taint to the breath, in confequence of the natural mucus of the mouth, or part of Teeth. the food remaining too long about them. The most frequent caufe of foul teeth is the fubftance called tartar, which of cleaning feems to be a deposition from the saliva, and with which the the teeth, teeth are often almoft entirely incrufted. When this subftance is allowed to remain, it infinuates itself between the gums and the teeth, and then gets down upon the jaw, in fuch a manner as frequently to loosen the teeth. This indeed is by far the most common. cause of loose teeth, and when they have been long covered with this or with any other matter, it is feldom they can be cleaned without, the affiftance of inftruments. affiftance of inftruments. But when once they are cleaned, they may generally be kept fo by rubbing them with a thin piece of foft wood made into a kind of brush, and dipped into white-wine vinegar; after which the mouth is to be washed with common water. Affections are molt effectual in allaying irritation; as opiates, blif ters, and especially warm-bathing. When thefe fail, cutting the gum by means of a fleme (fig. 48), over the approaching tooth, is frequently found to remove every fymptom; but this ought to be done earlier than it commonly is to have the full effect. Whenever the fymptoms give reafon to think that a tooth is approaching, the gums fhould be cut freely over that part where the teeth may be firft expeeed. When the fymptoms recur, the operation fhould be repeated. A crucial incifion is attended with ftill more effect; and the bleeding which afterwards takes place is of confiderable fervice. The incifion fhould always be carried as far as the tooth, which ought to be fomewhat expofed; and when properly done, is frequently followed with immediate relief. Sometimes the fame kind of fymptoms attend the cutting of the fecond fet, particularly of the dentes fapientiæ. When this is owing to the thickness of the gums, fcarifying gives the greatest relief; but fometimes itis for want of room in the jaw, and then the tooth should be drawn. teeth. 233 Derange. Derangement of the teeth happens more frequently in ment of the the fecond than in the first set, and more commonly in the fore than in the back teeth. This may be owing to the firft set remaining in the jaw after the fecond have appeared. Another caufe is a waste of space in the jaw; and a third is a mal-conformation of the teeth, where they are too large in proportion to the jaw, and therefore overlope each other. The remedy is the fame in each of these cases, viz. to extract the teeth which stand in the way of the reft, to allow those which are out of their place to come into the row, and put on a more uniform appearance. The usual method of moving teeth which are out of the row is, by fixing them with a ligature to the nearest teeth; or the fame thing is done by metalline plates or pieces of wire. But thefe methods have not been found fully to anfwer the purpose intended, though in fome cases they may be useful. When one or more front teeth are accidentally drawn out of the jaw, they ought to be immediately repla ced. When the teeth are broken over or otherwise inju red, they may be supplied with others tranfplanted from the jaws of another perfon; but this can only be done when the fockets have been newly emptied, for after inflammation comes on it is impracticable. In thefe cafes the inflammation must be allowed to fubfide, and then artificial teeth can be readily adapted. When the teeth are loofened by external violence, by falls and blows, or by improper ufe of inftruments in pulling difeafed teeth in the neighbourhood of found ones, they may again be made tolerably faft by preffing them as firmly as poffible into their fockets, and preferving them so with ligatures of catgut, Indian weed, or waxed filk, and keeping the patient upon spoon-meat till they are firm. When loofe teeth are owing to tartar, nothing will fasten them till the cause be removed; and this ought to be done early, otherwife it will have no effect. Frequently the teeth become loose from a fponginess in the gums, often, but improperly, attributed to fcurvy. The beft remedy is fcarifying the gums deeply, and allowing them to bleed freely; this hould be repeated till they are fully faftened. Mild aftringents, as tincture of bark, are here attended with good effects, tho' those of a trong nature will certainly do harm. The mouth fhould be frequently washed with cold water ftrongly impregnated with these, and the patient should not ufe the teeth which have been loofe till they become firm again. The loofening of the teeth in old age cannot be remedied, as it is owing to a wafting of their fockets, from which the teeth lose their support. The teeth fometimes become yellow or black without When the teeth are to be cleaned by inftruments, the operator ought, with a linen cloth or with a glove, to prefs againft the points of the teeth, fo as to keep them firm in their fockets, with the fingers of the one hand, while he cleans them with the neceffary inftruments, fig. 51 fig. 51. n° 1, 2, 3, 4, 5, held in the other; taking care Plate not to scrape them fo hard as to loofen them, or to rub off CCCLXXXIX. the enamel. This being done, the teeth fhould be rub. bed over with a small brush, or a piece of sponge dipped in a mixture of cream of tartar and Peruvian bark. The fame application may be made to the teeth for a few days, after which they may be kept clean as already directed. The teeth are fometimes covered over with a thin dark coloured fcurf, which has by fome been mistaken for a wa fting 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 operation must be repeated. For the purpose of applying powders or washes to the teeth, a bruth or a sponge is commonly employed; the latter is certainly preferable, as being lefs in danger of wearing down the enamel, or of feparating the teeth. 1 236 The caufes producing toothach may be, expofure of the of tooth nerve of a tooth, by breaking or wafting of the enamel, in- ach. flammation in or about the tooth, or from fympathy when diltant parts are affected, as the eye, the ear, the ftomach, or the uterus, as in time of geftation. After toothach has once been produced and removed, it is apt to return by expofure to cold, by taking hot liquids, by hard bodies preffed against the nerve in the time of chewing, by the use of a pick-tooth, &c. 237 With respect to the cure of this disease, no rule can be Me hod of laid down which will anfwer with certainty upon all acca-cure. fions. 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 destroy the irritability of the nerves, fuch as opium, fpirit of wine, camphire, and effential aromatic oils. When these fail, blifters behind the ear, or deftroying the nerve by the cautious use of strong acids, or by a red hot wire frequently applied to the part, have been attended with advantage. When a black or mortified fpot 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 advisable 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 purpose, fometimes give relief for many months, or even years; but at Chap. XVI. of the Teeth. S URG ER Y. Affections at other times are of little advantage, and in fome inftances create great pain. Gum-maftich or bees-wax are frequent ly 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 uneafinefs. When it is to be used, the whole cavity of the tooth fhould be filled; and this is to be done with the inftruments, fig. 52. n° 1, 2, 3. 338 Method of the tooth. When the remedies made ufe of for the removal of toothextracting 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 observed, that all the teeth may be pulled to either fide, excepting the dentes fapientiæ of the lower jaw, which ought to be pulled outwards, other wife the jaw may be splintered. As foon as the focket is cleared of blood, if the tooth be not much (poiled, it may be immediately replaced, when it will become as ufeful 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 as in a lateral direction. One of the beft is that (fig. 53.) in form of a key, with a claw and fulcrum. Previous to the operation, this fhould 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 poffible. Then the fulcrum is to be applied on the oppofite fide. The furgeon may now, with one turn of the handle of the inftument, pull the tooth out at once. But the turn should not be effected by a fudden jerk, but in the moft cautious and flow manner. When it happens to be one of the great molares, 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 fuft. After it has been fufficiently loofened in this manner, it is to be laid hold of by a common teeth forceps (fig. 54.), and extracted in the eafieft manner. Up. on extraction of the tooth, any detached splinters occurring are to be immediately removed. Should any confiderable hemorrhagy take place, the patient may take fome cold water, vinegar, or spirit of wine into his mouth, and doffils of lint may be introduced into the focket. After all thefe fail, recourse must be had to the actual cautery. 239 Of tranf planting teeth. When fumps 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 (fig. 55.) is to be used. 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 ftump, to protect the neighbouring parts. Teeth can never be transplanted with propriety in childhood or in old age. The conftitution must be free from those diseases which affect the gums. The tooth to be transplanted must be taken from a perfon of a found conffitution, otherwise it will convey infection. To guard as much as poffible against infection, it fhould be immerfed for a few minutes in lukewarm water, and then well dried and cleaned. It ought to fit the focket exactly; if it be too large, it may be filed down, avoiding the enamel as much as poffible. The furface of it should be at first 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 Af. ligature to fix it; but if a ligature be found neceffary, it may be made of threads of fine filk properly waxed. ter the operation is finished, the patient ought to avoid whatever may be in danger of fhaking the tooth, and this is to be attended to till the tooth is perfectly firm. He should also guard against cold and moift air, and live upon fpoon-meat. SECT. V. Of Boils and Excrefcences of the Gums. 143 Boils and Excrefcen ces of the Gums. 2.40 GUм boils may arife from cold or from external violence, Of gun &c. but moft frequently they are the confequence of tooth-boils.. ach. The complaint begins with pain attending a tumoron 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 boil is owing merely to inflammation, after the matter is evacuated, the complaint goes off; but when it proceeds from a caries of a tooth, it will continue as long as the caule 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 aftringent liquor; but the moft effectual method is to lay the abfcefs fully open, and to heal it from the bottom by dofils of lint. Sometimes abfceffesoccur 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 paffage open for the discharge, being the only means for effecting a cure. 240 Excrefcences of various degrees of firmness sometimes Excrefcen grow upon the gums. Some are foft and fungous, while ces in the others are of a warty nature. In general they are not at gums. tended with pain. They frequently originate from caries of the teeth, or of their fockets; in which cafe the removal of the fpoiled teeth, and the fubfequent exfoliation of the carious part of the jaw, will often accomplish a cure. But when this does not happen, the tumor fhould be removed as foon as it becomes troublesome, otherwise there may be danger of its ending in cancer. The removal may be effected. by a ligature or knife, according as the tumor may have a narrow or broad bafis. It is fometimes neceflary 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 hemorrha gy proceeds too far, it fhould be reftrained by the application of spirit of wine, or tincture of myırh, or solution of alum, &c. and fhould thefe prove unsuccessful, the lunar caustic will feldom fail of having the defired effect. No dref fings 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, as port. wine, tincture of rofes, &c. SEGT. VI. Of Abfceffes, &c. in the Antrum Maxillare. Some THIS difeafe is known by a pain and uneafinefs beginning in the cheek, and extending upwards to the eyes, nofe, and ears, together with a fwelling, which in the latter ftages of the disease tends to a point, most frequently in the cheek. Sometimes a ditcharge enfues between the roots of the backteeth, when they happen to penetrate the antrum. times a discharge of matter from the noftrils takes place, particularly when the patient lies on the fide oppofite to the tumor.. The difeafe, may arife from cold, or whatever produces inflammation in general; but the most common caufes are violent fits of the toothach, occafioning exceffive pain and inflammation of the membranes of the nose and antrum. The cure is performed by giving a free difcharge to the GQD Ranula. contents of the tumor: and this is done in two ways; either Plate 488. The child being laid acrofs the nurfe's knee, the furgeon fhould open the mouth, and raise the tongue with the two first 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. Divifion of SECT. IX. Divifion of Franum Lingue. by extracting one of the two anterior great molares, which SOMETIMES the frænum linguæ extends to the point of Lingua. are fituated under the antrum, and making a perforation the tongue, and tying it down; whereas, in the natural state, with a round trocar (fig. 49.) through the bottom of the it ends about one-fourth of an inch farther back. When focket; if this has not been already perforated by the fangs this is the cafe, it is to be divided, guarding against woundof the tooth or eroded, in which cafe the matter will pafsing the neighbouring veffels, or the ends of the falivary out immediately after the extraction: or the perforation may ducts. The divifion may be made with a common scalpel, be made by the inftrument represented in fig. 50. thro' that but ftill better with a pair of very sharp fciffars with blunt part of the antrum which projects outwardly over the molares. points. As moft people wish to avoid the pulling of a tooth, when it does not appear to be abfolutely neceffary, the perforation is commonly made in the way last mentioned. Some au thors, 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 introduced into the perfora tion, which may be removed frequently to allow the matter to pass out, and to admit aftringent folutions of bark, &c. to be occafionally 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 difeafed portions of the bone exfoliate and be removed. When cloated blood is formed in the antrum, it is to be removed in the same 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 course of mercury has been found to be of some service. SECT. VII. Of Ranula. THIS is a tumor under the tongue, moft frequently owing 1 to an obstruction in one of the falivary duets. Sometimes it contains matter like the fynovia of the joints, fometimes a fatty matter, now and then ftony concretions, but most commonly a fluid like faliva. It often acquires fuch a fize as to prevent fucking in infants, or maftication and fpeech in adults. When the perfon attempts to speak, he only makes a croaking noife: hence the name of the disease. The best mode of treatment is to lay the tumor fully open by means of a fcalpel or large lancet, to evacuate its contents completely, and then to wash 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 subftance, 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 syringe. SECT. VIII. Ulcers within the Mouth. WHEN ulcers of the mouth arife from a general affection of the system, this must be removed before a cure can be expected. When they originate from sharp points in the teeth, these are to be filed off, and fome aftringent folution taken occasionally into the mouth. Notwithstanding these and other remedies, the fores fometimes becomes worfe, difcharging a thin fetid fanies, attended with much pain, and putting on every appearance of cancer. In this fituation, extirpation 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 neceffary to cut through the whole fubftance of the cheek, and heal the fore by the hare-lip future. When the tongue is the subject of operation, the operator ought to be ready to take up the bleeding veffels by the tenaculum or the needle. A long with ligature, it may be neceffary to use aftringent gargles, or a mixture of vitriolic acid in water. If these fail, the potential or even actual cautery must be used, 242 The ment of the tou SECT. X. Of Enlargement of the Tonfils and Uvula. When the form of the tonfils happens to be conical, fo 243 Enlargements of the uvula, from inflammation or from And of the other caufes, may generally be removed by the frequent ufe uvula. of aftringent gargles, as of strong infufions of red rofe-leaves or of Peruvian bark. But when these fail, and the enlargement is fo confiderable as to give great uneafinefs by impe ding 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 rea- Extirpation diet method when the uvula is only elongated; but when of the uvu the fize is confiderable, dangerous hemorrhagies fometimes la. attend this method; on which account a ligature preferable. The operation may be readily performed by thofe of the common kind; fome prefer the curved probe-pointed biftoury. In performing the operation, the fpeculum oris (fig. 57.) is neceffary 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 falling into the throat. After the operation, if the bleeding be confi-, derable, it may be checked by aftringent gargles, or by touch. 244 |