CLINICAL LECTURES ON SURGERY,

LONDON, SATURDAY, FEBRUARY

9.

[1832-33.

nacious yellow matter furnished by the irritated meibomean glands. CLINICAL LECTURES ON SURGERY, The disease may last a long time in this DELIVERED AT THE foim without making much progress, but a period arrives at length, when the wall.% HOTEL DIEU, PARIS, of the tumour grow thin, when it no longer is evacuated by pressure,-when heat and BY pain are experienced in its site,—when, M. LE BARON DUPUYTREN, lastly, the surface reddens and inflames. This inflammation often extends to the During the present Session, 1832-3. whole of the eyelids, the cheek, the nose, and even to the forehead. The eye be[Revised, before translation, by the Baron himself.] comes red, the liquid which bathes it, and which spreads over the cheek daily, acLECTURE IX. quires more heat and acridity. The tumour the aspect of an acute phlegmon, presents LACHRYMAL TUMOURS AND FISTULÆ. fluctuation is now perceived, and, finally, THE disease which produces lachrymal an external opening forms. At this period fistula’, shows itself under two very distinct the epiphora diminishes in the majority of forms, dependent on its successive degrees cases, the tears finding, through the new of development, and, in ordinary language, opening in the sac, an outlet which was wanting. The liquid discharged erroneously confounded under the same denomination. As long as there exists no by the fistula consists of a mixture of tears openingto establish a communication ex- and purulent mucosities. In many cases ternally to the lachrymal sac, there can be the continuance of the inflammation induces no fistula; but there is then observed a the disorganisation of the affected tissu’ s, dilatation more or less considerable, which and the extension of the malady to the udconstitutes the lachrymal tumotcr. This is jacent parts. Vegetations then appear in the first period of the disease. The perfo- the fistulous track ; callous indurations line ration of the sac, or fistula., constitutes the its edges; the mucous membrane of the sac and the nasal canal become softened second. The lachrymal titmoui, originates and in- and fungous. It is even destroyed to a creases almost in an insensible manner : at variable extent, and the periosteum partifirst it is no more than a barely appreciable cipating in this destruction, the os unguis, swelling, situated within and beiow the and even the adjacent portions of the maxgreater angle of the eye, and below and illary bone, are laid bare, and fall into a behind the direct tendon of the orbicular state of caries at the bottom of the fistula. muscle of the eyelids. Circumscribed in This caries, however, is not always delayed extent, the skin unchanged in colour, and ex- until the disease arrives at the degree just empt from pain, the tumour at first is easily described. Sometimes it is obseived even emptied on pressure, either by the reflux of before the lachrymal tumour is perforated, the matter it contains through the lachry- I and consequently before the fistula is mal points, or, which is less common, by its formed. A case of this kind is now bedischarge through the nostril. Thelachry- fore us, to the history of which we shall mation which accompanies its early pro- presently revert. gress, becomes more and more considerable By the sketch thus traced of the march of fvery day, until at length all the tears fall this disease, you will readily recognise its over the cheek. The eye of the affected characters, and the signs on which its diagside is always i ed, its conjunctiva slightly nosis is established. We not, how. injected, its lids manifestly swollen, espe- ever, enter into every particular of this cially at their free edges, which in the subject, as it is our design only to expose morning are found glued together by a te- the most important practical considerations

I previously

shall

No. 493.

610

the facts under our observa- or caries of the bones, autiphlogistic treatNevertheless a few words may bei nient, seconded by revulsion and fumigaadvantageously bestowed on the cause of i tions, will still frequently succfed inob. the principal lesion of the lachrymal sac, taining a permanent cure. Lastly, when in which originates the disease. the disease has reached that degree that the palpebral discharge, thus an operation is indispensable, we must assigns it to the still submit the patient to a preparat )ry -affection of the considering sac as always secondary to the palpebral antiphlogistic treatment, provided there inflammation. According to him, the puru exist, either in the eye, eyelids, or surlent liquid conducted into the lachrymal roundingtissues, any considerable extent But it is not passages irritates and inflames them ; the ’ of in!!ammatorv action. sac, or nasal canal, then ulcerates, mereiv to the local affection that the surtion takes place, and at length the adjacent geon should direct his attention ; he should bony parts are altered. Such are the four’ also caieftilly search after the remote causes stages described by the celebrated surgeon which produced it, and direct his investibut more recent researches have gations to the general constitution and its proved, that the lachrymal passages. like all anterior affections. If the effect of scrofula, venereal or repressed diseases of the &kin, excretory ducts, owe the majority of lesions to their investing mucous mem-: he will combat the former, or recall the B, others to their primitive seat, at the same brane. When a certain point of this time that he employs the local treatment brane is inflamed, immediately the fibro-cellular tissue becomes the seat of an which the circumstances may require. ’ The cure of this disease, however, can, active congestion, which constricts the diameter of the internal duct. This constriction in hospitals, be rarely attempted, except by itself becomes a permanent cause of irrita- operation ; for in general the patients only when the fistula is already of old tion. The now of blood soon increases, the infiamed tunics soften, and the fistula isstanding’; or when the tumour conceals formed. The duct of Steno, the urethra,such disorganization as renders it urgent to and remove the obstructions in the the rectum, the caecum, the oesophagus, canal. often furnish indisputable proofs ofthis species of etiology. All the causes, conse- To perform the operation, the surgeon quently, capable of keepingup permanent only requires to be provided with a comirritation on the eye, the eyelids, or the mu- mon bistoury, with narrow blade and solid cous membrane of the nasal cavity, are also point, and a canula mounted on a stylet, the remote causes of lachrymal tumours. It which we will describe by-and-by. The is for this reason that are so often met patient should be seated on a low and firm with in pale, fair persons, whose conjuncopposite a well-lit window, the head tivæ are habitually injected, their eyelids reclined backwards, and supported on the reddish and swollen. It is thus that they breast of an assistant, whose hands are E’in. ed in holding the patient quiet. The constitute a sequel of measles, small-pox, and scarlatina, which frequently leave be. body should be surrounded by a strong also enfolding the thoracic extrehind them irritations of the omiar apparatus and palpebral edges. The striking mities. The surgeon then, in the first in of cutaneous diseases, old venereal af- place, ascertains the exact position of the fections, the scrofulous state of the consti- maxillary edge of the orbit, close to the tution, operate in the same manner, causes greater angle of the eye. It is not unusual exclusively mechanical, may also determine to find this edge more elevated or tumefaction of the sac and its consequent more p: ojecting or retiring, than you would erosion. In one case, I have observed the suppose by a mere inspection ; and these congenital absence of the nasal canal. The variations might deceive the operator, and him to fail in the opening of the sac. sac was perforated in this case, and the patient cured by the establishment of an arti- Again, the direct tendon of the orbicular must be examined with equal care, ficial passage. It rt suits then from the recognised causes for its disposition is not more constant. It between this tendon, which must be left of the lachrymal tumour and fistula, that antiphlogistic treatment is the most suit- untouched above, and the maxillary edge of able at the commencement of the disease. the orbit, below which die sac is no longer be found, that the instrument is to be These means frequently indeed succeed by themselves, without our Lavingrecourse to plunged. We should never forget these any operation. At a more advanced period, elementary principles, on which the sucbut while the disease is still simple, while cess of the operation depends. The followthere exists only a moderate dilatation of ing case illustrates the process thus folthe sac. or a recent perforation not accom- lowed for several years, a process too panied by callosities, fungous vegetations, which combines facility of execution with disorganization of the mucous membrane, certainty and promptitude in the result.

suggested by tion.

Scarpa

lachrymal !

perfora-

I

ofPavia ;

their mem-

exterior

apply

open

nasal

they

chair ploy cloth

depressed,

cause

muscle is

to

611 Case 1.—Alexandrine Chalon, astat. 36, escaued above with a manifest hissing. If of emphatic constitution, and regular in again the nasal fossa be left free, and the her courses, came to the Hotel Dieu, to be action of blowing the nose expels blood or treated for a lachrymal fistula at the inner matter by the nostril, the counterproof of The disease, the free communication is obtained. A contrary angle of the left cuuse of which she did not know, was of result shows that the operation is imperfect. In this patient the success was such, that in more than six years duration. For the five first years there was con- four days it was almost impossible to tell tinual lachrymation, and consequently great that any fistula existed. The little wound embarrassment of the vision, a dryness of in the sac was heuled ; there was no trace the corresponding nostril, and headache at of tumour; no lachrymation or embarrassthe same side. At the end of this time, ment of vision ; she was even unconscious in the month of September, a minute tu- of the presence of a foreign substance in the In twenty days she mour showed itself at the inner angle of lachrymal passage. the eye. It was compressible, and in some was dismissed perfectly cured of the fistula, degree removed by a voluntary effort. By and in good general health. pressing with the finger on the swelling, all The canula now requires attention. The the fluid escaped through the lachrymal indication had long been acknowledged by points. Shortly after this there appeared surgeons of leaving the nasal canal its full ..an erysipelatous redness which extended to liberty, and this object was sought by the inthe neighbouringparts. The tumour then troduction of inert cylinders destined to be burst, and discharged its contents. Never- substituted for the mucous membrane, the theless this opening became obliterated, surface of which they covered. Foubert, and Mirault, and a new tumour appeared more volumi- Pellier,Benj amin nous than the first. This also opened ; a de- conceived and practised during the last finite fistula was the result. The patient century, the substitution for the leaden came to the hospital the fullowing January, wires and gut previously used, a canula the tumour was then the volume of a small which would act at the same time as a dilanut, and presented in its centre a fistulous tor used as a conduit for the tears ; at first opening, which established a communica- short, and of the same diameter throughtion between the lachrymal sac and the ex- out, and liable to escape very quiclily through terior, and by which it could be completely the nasal fossae, it was improved by Tlaemptied. T he discharge of tears was very jani, who made it longer and of a conical great, the eye of extreme sensibility, and form. But the instruments of these survery red ; the nostril of the same side dry, geons were still extremely defective, and and the head painful ; the lower eyelid their modes of operation have long fallen lifted up, and covering more than half the into neglect. The instrument used in the eye; the surrounding parts strongly en- case described is different from those forflamed, and the check furrowed by the flow employed ; its canula is perfectly of tears. adapted to the nasal fossse; it is more easily After some days rest and antiphlogistics, less liable to escape into the nasal the operation was thus performed. The ! fossaa, or ascend into the lachrymal sac. In patient beingseated, as already described, aword, it is perfectly proper to fulfil the the operator placed himself before her, cut uses for which it is destined. into the lachrymal sac to the extent of The canula in question is either of gold or some lines, plunged the bistoury into the silver, and made expressly for the patient on superior part of the nasal canal, the blade whom the operation is to be performed. Its of the instrument being a little elevated and length is eight or nine lines for adults, five urged backwards. He then introduced, and or six for children. It is rather larger above ghded before the anterior face of the blade, than below, and furnished at its larger the free and smooth extremity of a little extremity with a circular, rounded, and canula placed on its sound ; next, with- rather thick rim. If longer, it would lean drew the bistoury, and sunk the canula by below on the floor of the nasal fossae, or moderate pressure into the nasal canal, would lift up the anterior wall of the lachrywhich it should occuny in its entire length, mal sac. If shorter, it would not descend so that its end should be entirely hidden in below the vascular fold of the nasal canal, the bottom of the inferior part of the la- and would become use’ess in certain cases. chrymal sac. The sound being in turn Verv slightly curved forwards, in order to withdrawn, the canula was left. During its better adjustment to the direction of the the operation a few drops of blood only nasal canal, its lower extremity is cut lika escaped from the nostril. ’fo ascertain if the the end of a flute. this instrument is tube was properly placed, the anterior orifice mounted on a stylet, formed of a steel stalk, of the nasal fossa was closed, and the patient bent to a right angle. The part which desired to make an effort of expiration, enters the canula should fill it exactly. when the air, passing along the canula, The other branch, which serves as a handle,

eye.

Bell, Wathen,

merly

borne,

612 is much

longer, and shaped like a spatula. It is important that the free end of this stylet should be so adapted to the back of the canula that no projection can result which might wound the walls of the duct. The canula, lastly, shouldhave no lateral opening. Nothingcan exceed the promptitude with which this operation is thus practised. All is over so quickly that the patient is generally unaware that anythinghas been introduced into the lachrymal passages. They are often sceptical of its presence until the stylet is introducecl and struck against the caitula in order to convince them. Other

fossae, by the lower end of the nasal canal. The first of these accidents, in a shoi ter or longer period, gives rise to inflammation, ulceration, and abscesses, which necessitate

the extraction of the canula. To perform this extraction, T proceed as follows :-I have had made a little steel sound, like that which serves to introduce it at first. The part of the sound which is introduced into the canula is cleft, and its two portions separate by their own elasticity. Each of them is terminated by a minute notch, the points of wliich are directed outwards. When introduced they are kept together by patients experience a slight tickling or a little clasp, which can be withdrawn at obscure uneasiness, which disappears in pleasure. As soon as their inferior extretwenty-four hours. The following case mities pass the beak of the canula, they exempLSes still further the prompt success separate by their elasticity ; the two little of this method despite of the long duration notches catch the edges of the canula, so of the disease, and the disorders to which that the sound cannot be withdrawn, without bringing this with it. This mechanism it had given origin. is very simple, and the instrument of very Case 2.-T. L. A. Galan, agtat. 15 ; good easy application. This proceeding may, constitution, and of regular courses ; had a nevertheless, be altogether omitted, when well-marked lachrymal fistula of the right the canula ascends high into the sac. In eye. The lachrymation had been of seven this case it suffices to make a little incision the sac, in order to seize the canula, years duration, and unknown origin, and for which she had been repeatedly blistered and extract it with the ligature forceps. The eversion of the upper edges of the without advantage on the neck and arm. Two months only before her admission, a canula is designed to prevent its fall into tumour appeared, which ran a closely Simi- the nasal fossae, and this object it generally lar course to that described in the first case, answers. Nevertheless, this accident someand was operated on in the same manner. times happens, and then the instrument She was unconscious of the introduction of irritates and inflames the mucous membrane the sound. In five days the little wound of these cavities, ulcerates and destroys it, was entirely cicatrized, and the inflamma- and even perforates the palatine vault. We tion subdued. On the eighth day there have often seen the point of it even proscarcely remained any traces of the malady, jecting, more or less, into the mouth. From and on the eighteenth she was dismissed, the conical shape of the canula, its extraction through the palatine vault is attended cured. The following modification of this process with difficulty, and requires very considerahas been proposed. When the sac is cut ble, and necessarily injurious efforts. Uninto, the extremity of a long stylet is intro- der these circumstances, the best plan is to duced into the nasal canal. Forced in push it from below upwards into the nasal deeply, it passes the obstacle with the fossa, and then extract it by the anterior greater ease, from its narrowness of diame- nostrils, either with the ligature or common A case requiring the ter. The canula is then pushed down, hav- dressing forceps. ing been previously placed on the stylet, former kind of extraction, occurred in a which serves as its guide, and prevents its female who had been operated on according missing its way. When the upper end ofto the usual process, and who wore the the canula arrives near the surface of the canula for eighteen months. During this skin, the stylet is withdrawn, and it is re- period, she was free from every trace of her placed by an extremely short sound, byold disease. But in a few days after that the assistance of which the canula is de- time, some pain, swelling, and redness, pressed to a suitable depth. But even the were experienced at the greater angle of author of this modification acknowledges withthe eye. On pressing on this point, fluctu. reason that, while much more complicatedtion was perceived, and the canula was felt than the process of the Hôtel Dieu, it pos- to have reascended into the lachrymal sac. sesses over this no special advantage. Some It would have been easy to have pushed it accidents too, to which the presence of this into the nasal canal, but believing that canula may give rise, have been laid hold. the stay of eighteen months was sufficient re-establish the freedom of this passage, of as objections, founded on special defects, Amongst these inconveniences is prinei-. it was determined to remove the canula. incision was accordingly made below pally remarked the ascent of the canula in the lachrymal sac, or its fall into the nasal tendon of the orbiculans muscle, as if

into

back

. to

An the

613 alteration of the parts. But in many cases there exist complications to ture forceps. The inconvenience ceased im- which it is necessary to apply a special mediately, and the patient was cured in a treatment. Sometimes the orifice of the

operation of fistula, and the readily extracted with the liga-

for the ordinary canula was

few

traordinary

fistula is surrounded with little

days.

fungous

be cut invalidate the results away with a curved scissors, or cauterised of the mode of operation ; and instead of with the fused nitrate of silver. If the being very frequent, as has been asserted, lachrymal points are closed, the operation they are, on the contrary, extremely rare. does not destroy the epiphora, and the tears Again, this affection is often the effect of continue to flow abundantly over the cheeks. general causes, such as syphilis or scrofula ; This may be easily remedied by the use of and if the surgeon cannot obtain information Anel’s stylet, if the points are only enabout these diseases, from the dissimula- gorged ; but the complication is almost intion of the patients, and consequently does curable, it being dependent on the adhesion not institute a general as well as local treat- of the walls of the ducts to a certain extent. If there exist a simple denudation, or ment ; or if, as often happens, the patients after having renaglect the general measures directed, it is caries of the os evident that the failure cannot be ascribed moved the obstruction of the nasal duct to the operation itself. Lastly, the imper- and placed the canula properly, the cavity fect manner in which some practitioners of the sac is dressed with soft charpie, and perform the operation in question, is scarce- before allowingthe external wound to close, ly, with justice, to be considered a fault of we wait until the bone is covered, or until the process recommended. It has hap- exfoliations have taken place. These dresspened, for example, that instead of placing ings, however, are not rigorously necessary, the canula in the nasal fossa, it has been as by the process employed the denudation thrust into the orbit, or into the maxillary and caries are spontaneously cured in many sinus, after having perforated the orbit, or cases, without special treatment. In the even into the substance of the soft parts, perforation of the os unguis, and of the porand through the supra-maxillary bones. tion of the pituitary membrane which lines The following is a curious fact of this kind. its internal surface, the cavity of the lachryA man was operated on in this townaccord- mal sac communicating with that of the ing to this process. The disease did not nasal fossae, the tears, mucosities, and pumend; the same accidents persisted ; no im- rulent matter, find by this mode of Comprovement supervened. Having been called munication a more easy discharge, than by to examine the patient, the canula was found the external fistula. This must necessarily protruding beneath the skin, before the be obliterated, and the end of the surgeon greater angle of the eye, and to the side in performing an operation is thus already of the nose. The surgeon, who had per- accomplished. He has only then to allow formed the operation, and who was a very things to follow their natural course, with competent person, immediately recognised the exception of being prepared to practise his error. The operation was recommenced the operation, as in cases of simple fistula, and suitably performed, and the patient was if the openingin the os unguis should hapwell in a few days. pen to close inside, we find, in the work of But the general results of this practice, J. L. Petit, the case of a child who had this which are very curious to consider, will re- bone perforated, and who wore in this openduce to their just value, much better than ingalarge sound placed accordingto the the history of isolated cases, the reproachesmethod of Woolbcuse. This foreign body directed against this operation. The num- irritatingthe parts, and keepingup their ber of sounds remaining after the operations,ulceration, was obliged to be extracted. the examination of the registers of the Hu- The wound in the bone closed, and the cure tel Dieu, and the data given by the cutlers; was accomplished by removing the obstrucwho furnished the instruments, demonstratetion of the nasal duct. It does not enter into our plan to describe that the number of persons operated on for fistula, accordingto this mode of practice, the different methods of treatment, the numodes of operation followed by amount annually, in my practice alone, tc> merous 150, two-thirds of which are hospital cases . surgeons since the last century. Some Thus, in twenty years’ practice, there havEare definitively condemned and abandoned ; been 3000 operations performed, and o f others await the sanction of experience ; these the number of cures has been nine ou t but the present affords immense and inconof ten. There is surely no other procesf3testable advantages over the others. In which can claim so fortunate a proportion. conclusion, then, a rapid sketch of the hisWe have hitherto only spoken of thE: tory of this disease may be of some in treatment of the simple lachrymal tumoui and fistula-that is to say, without any ex. It was known by Hippocrates, Celsus,

Moreover, the accidents thus pointed vegetations.

out,

can

in

no

They

are

degree

unguis,

’

r terest. .

either

to

614 Galen, &c., but they had but very vague notions regarding its nature, being altogether ignorant of the anatomical dispositions of the lachrymal apparatus. It was only in the sixteenth century that the lachrymal tumour and fistula were well described bv Fallopius of Leon. Its causes, then, are of three kinds,—the specific, such as scrothe fula, scaly eruptions, syphilis, &c.; general, having their seat in some other part besides the lachrymal conduits ; and the local, which affect these latter channels. The development of the tumour takes place usually below the tendon of the orbicular muscle of the eyelids, but sometimes it occurs above and below this tendon, so as to form two projections, the swelling assuming a bilobular form. The mai-eit of the affection divides itself into two periods, that of the growth of the tumour, and of the formation of the fistula. The diagnosis is established on signs which do not permit its being confounded with other lesions, such as hernia or dropsy of the sac. The antiphlogistic treatment should be applied at the commencement, when the stricture of the canal is due to inflammation; and if this proves insufficient, derivatives must be applied to. The specific causes, such as cutaneous eruptions, syphilis, and scrofula, must be combated each by the peculiar treatment it otherwise demands. Lastly, as to the local treatment, the mode of operation above described is more advantageous than all others, as the results of its application on an immense scale have clearly demonstrated.

LECTURES

The consideration of these varieties would complete the series of sketches I have given. Time, however, does not permit me to enter on them. I proceed, therefore, to the last order of menial alienation which remains to be discussed. Hitherto I have spoken only of the kinds of mental alienation in which there still remained manifestations of thr) intellect, in which the ideas were not abolished, and in which these ideas were susceptible of combination, and aflorded premises for conclusions which might have been rational, had the principles from which they proceeded been correct. same.

DEMENTIA

AND

IDIOTISM.

examine dementia and idiotism ; those varteties in which the mind is perfectly annihilated, or at least shows no trace of its operations. You will refirst lecture I pointed member, that in out to you, that as far as symptoms were concerned, idiotism and dementia were precisely the same thing. They differ in these respects, that idiotism is strictly speaking congenital, while dementia supervenes during maturer life. We may also find in a subsequent lecture, that they differin their organic causes, at least frequently. But, reserving this consideration fur its appropriate time, I proceed with dementia. This may occur in either of two modes; primary and secondary. The primary kind is exemplified by the cases of old persons, who, without any known cause, are deprived of all intellectual faculties. The secondary is that which so frequently supervenes on mania and epilepsy, which is known to folI have

now

to

my

very

intoxication, low several

excessive masturbation,

diseased affections of thebrain, such as hemorrhage into its substance, chronic diseases of its meninges, &c. MEDICAL PATHOLOGY, The .symptoms of dementia in either of DELIVERED IN THE UKIVEHSITY OF PARIS, these varieties, exhibit some very remark. able phenomena. While the impression cf BY M. ANDRAL, D.M.P., &c. &c. recent events is so evanescent from the mind, that the memory of things recently Session 1833. observed is completely abolished, it is ON

truly singular to find how perfectly the recollections of older impressions may be preserved in some cases. In the occurrence MENTAL ALIENATION. of the alienation again in both varieties, several phases or augmentations graùual!y MONOMANIA CONCLUDED. there maybe defective conTHERE still remains, Gentlemen, ano- occur. At first nexion of ideas, and consequently imther species of monomania to be mentioned, This gradually proceeds but I intend to allude to it without entering paired judgment. until utter stupidity is the result. Before into details, I mean the monomania having at this degree, other functions religion as its predominant feature. Demo- arriving nomania is a congenerous variety of the for the retention of what they have heard, these will not be of use to the readers of recapitulations * At the commencement of this lecture, M. An accurate reports. We therefore pass at once to the dral recapitulated the leading points of those we direct subject of the present discourse, and shall have already published. Although a useful plan to pass by similar repetitions in our future publications LECTURE VII.*

those who

are

compelled

to trust to memory alone

of these valuable discourses.—ED. L.