SURGERY. 743 
give way, and an effusion of blood into the substance of the 
brain follows. This occurrence, if the skull were entire, 
would probably occasion apoplexy; but when there is a de¬ 
ficiency of bone, that allows the brain to expand, this vis- 
cus and its membranes protrude through the aperture. The 
dura mater soon ulcerates, and the tumour rapidly increases, 
in proportion as the internal haemorrhage goes on. At last, 
the pia mater, and stratum of the brain, covering the effused 
blood, give way, and the blood oozes out and coagulates. 
In the cases recorded by Mr. Stanley, however, the protru¬ 
sion consisted both of the cortical and medullary substance 
of the brain, and the effused blood is described as merely 
lying upon the surface, and not extending thence to any 
other place. 
The best practice is' to repress the increase of the swelling 
by pressure, which, in cases where the tumour is already 
large, must be preceded by a removal of the protruding 
mass with a scalpel, and to combine with such treatment 
copious evacuations of blood. The pressure may be exerted 
to a very great extent. 
Fungous tumours sometimes grow from the external sur¬ 
face of the dura mater, and, after destroying the superin¬ 
cumbent portion of the cranium, make their appearance in 
the form of an external swelling under the scalp. 
The severe pains in the head, which precede the ap¬ 
pearance of the disease externally, become still more 
violent as soon as the fungus protrudes through the open¬ 
ing in the bone, and is irritated by the i&arp inequalities 
of the edge of the aperture. The swelling has a manifest 
pulsation corresponding to that of the arteries, and when 
compressed, it either returns entirely within the cranium, or 
is considerably lessened. The pain then subsides, the tu¬ 
mourbeing no longer irritated by the irregular circumference 
of the opening in the skull. But should the size of the 
fungus be large, no relief can be thus obtained; for, when 
an endeavour is made to reduce the tumour, all the alarming 
symptoms of pressure on the brain are immediately ex¬ 
cited. 
Fungous tumours of the dura mater constitute an exceed¬ 
ingly dangerous disease, and mostly prove fatal. 
Before a fungus of this description has made its way 
through the cranium, and projected under the scalp, so that 
its nature and existence can be ascertained, the practitioner 
has no opportunity of attacking the disease with any effectual 
means. The ordinary treatment of the severe pain occurring 
in certain parts of the head, after blows or falls on the cra¬ 
nium, and before the fungus protrudes, has consisted of 
bleeding and evacuations. But when the disease has mani¬ 
fested itself in the form of an outward swelling, the nature 
of which is recognised by previous circumstances, as well 
as by the pain which attends it, and subsides on its reduction 
and its pulsatory motion; the surgeon should have the head 
shaved, make a crucial incision in the scalp covering the 
fungus, dissect up the angles, and fairly bring into view 
the whole of the tumour, and the margin of the opening 
through which it protrudes. But as it is impossible to get 
at the entire root of the fungus, while it is closely embraced 
by the cranium, it becomes necessary to saw away the sur¬ 
rounding bone. This object has generally been accom¬ 
plished very inconveniently with the trepan or trephine, 
which, while it cuts away more of the cranium than is re¬ 
quisite, cannot effect the removal of every part of the bony 
circumference, and the surgeon has to break away the pieces 
betwixt the perforations with a gouge and mallet after the 
manner of the French surgeons. The best instruments for 
cutting away the surrounding part of the cranium, are the 
saws described by Mr. Hey. With these, the division of 
the bone may be made in any direction desirable. 
The root of the fungus being thus exposed, the next 
business is to cut the swelling away, which is most effectu¬ 
ally done by carefully dissecting out the part of the dura 
mater with which it is connected. 
The preceding operation is not practicable, when the 
fungus protrudes at the orbit, or very near the ear. The 
upper part of the head is evidently the most favourable situ¬ 
ation for such a measure. 
Diseases of the Dye may be divided into such as are 
deep-seated, and those affecting superficial parts. We shall 
speak, then, first of the eyelids. 
Ectropium is an affection in which the inner lining of the 
palpebra is turned outward, and the lower portion of the eye¬ 
ball is uncovered. The consequence is, that the exposure of 
the eye and sensible lining of the eyelid induces in these 
parts a species of chronic inflammation, not only attended 
with a constant flux of tears and pain, but also with a preter¬ 
natural redness and thickening of the liuing of the affected 
eyelid. At length, the exposed membrane is converted into 
an indurated, callous substance, which lies just under the 
globe of the eye. The disease obstructs the flow of tears 
towards the inner angle, and through the puncta lachry- 
malia, and the complaint is always attended with a weeping 
of the eye. 
One of the most common causes of this malady is a con¬ 
traction of the integuments of the eyelid, or neighbouring 
part of the face, after the cicatrization of burns, ulcers, and 
wounds. 
Slight cases, arising in this manner, may sometimes be 
cured, by keeping the eyelid gradually raised more and more 
every day, with small strips of sticking plaister, which are to 
be applied to the outside of the affected eyelid, and to the 
lower part of the forehead. This method, however, is seldom 
permanently efficacious. 
In most instances, it is necessary to remove a considerable 
portion of the thickened exposed lining of the eyelid, with 
the aid of a convex bistoury, and a pair of dissecting for¬ 
ceps; and afterwards, in proportion as the wound heals, the 
eyelid, being properly supported by a compress and bandage, 
returns to its natural position. In the operation, care must 
be taken not to cut the puncta lachrymalia. The eyelid is 
drawn inward again by the same principle which caused its 
eversion, viz., the contraction of the cicatrix. 
The eyelashes are subject to the diseases called trichaisis, 
in ’tfhich they are turned inward toward the eyeball. Tri¬ 
chiasis is of two descriptions; in the first, there is no defect 
of the eyelid, and the whole grievance depends entirely on 
the wrong direction in which the eyelashes grow; in the 
other, the defect lies altogether in the eyelid itself, the mar¬ 
gin of which is preternaturally turned towards the eye, so 
that the cilia rub against the front of this organ, and cause 
considerable inconvenience. The latter case, which is by far 
the most common, is termed entropium. 
It is observed by Mr. Saunders, that the superior palpebra, 
when inverted in the slightest degree, is the cause of a most 
vexatious irritation of the eye; but when a large portion is 
inverted, the case becomes truly distressing, from the violent 
ophthalmy which is produced. The friction of the cilia 
against the eye is incessant, and from the continual suffering, 
the patient’s health and strength decline. The cornea is 
ulcerated, and becomes opaque, and the sight is ultimately 
destroyed. Nor is this the end of the patient’s misery; ex¬ 
cept, as occasionally happens, the cornea becomes thickened 
and indr.rated in an extraordinary degree, assuming a white 
appearance, like that of a macerated ligament. If this be 
the case, the patient finds ease in the insensibility of this 
new formed substance. 
The appearance of the disease in its inveterate form, is 
truly disagreeable. The discharge, the copious flow of tears, 
the excoriation of the cheek, the opacity of the cornea, the 
villous, granular, or fungous conjunctiva, compose altogether 
a disgusting sight. The patient carries his head obliquely, 
and attempts, in the most awkward manner, to direct the 
pupil towards the objects which he wants to see. Indeed, 
when it is the upper eyelid which is inverted, the patient, in 
order to evade turning up the eye, distorts the head so as to 
seem as if he had a wry neck. 
The cure of the first description of trichiasis consists in 
plucking out the inverted hairs, and preventing their grow¬ 
ing again in the same direction. When many project in¬ 
ward, 
