Chapter VII: Part 7

If the Tumour appears on the outside, the Abcess may be open'd between the Ribs; but if no external Signs are discern'd, the Surgeon may choose a more convenient place to make the Opening. Thus when the Patient is set upon his Bed, and conveniently supported, the Opening is to be made between the second and third of the Spurious Ribs, within four Fingers breadth of the Spine, and the lower Corner of the _Omoplata_; to this purpose the Skin is to be taken up a-cross, to cut it in its length, the Surgeon holding it on one side, and the Assistant on the other. The Incision is made with a streight Knife two or three Fingers breadth long, and the Fibres of the great Dorsal-Muscle are cut a-cross, that they may not stop the Opening. Then the Surgeon puts the Fore-Finger of his Left-hand into the Incision, to remove the Fibres, and divides the Intercostal Muscles, guiding the Point of the Knife with his Finger to pierce the _Pleuron_, for fear of wounding {228} the Lungs, which sometimes adhere thereto, the Opening being thus finish'd, if the Matter runs well, it must be taken out; but if not, the Fore-Finger must be put into the Wound, to disjoyn those Parts of the Lungs that stick to the _Pleuron_.

To let out the Matter, the Patient must be oblig'd to lean on one side, stopping his Mouth and Nose, and puffing up his Cheeks, as if he were to blow vehemently; then if Blood appears, a greater quantity of it may be taken away than if it were Matter, in regard that a Flux of Matter weakens more than that of Blood. It is also worth the while to observe, that in making the Incision, the Intercostal Muscles ought to be cut a-cross, that the side of the Ribs may not be laid bare, by which means the Wound will not so soon become Fistulous.

If it be judg'd that purulent Matter is contain'd in both sides of the Breast, it is requisite that the Operation be done on each side; it being well known that the Breast is divided into two Parts by the _Mediastinum_: But in this case the two Holes made by the Incision must not be left open at the same time, for fear of suffocating the Patient.

_The Dressing and Bandage._

The Wound is dress'd with a Tent of Lint arm'd with Balsam, being soft, and blunt at the end, which enters only between the Ribs, for fear of hurting the Lungs; but a good Pledget of Lint is more convenient than a Linnen {229} Tent, however a Thread must be ty'd to the Pledget or Tent, lest it shou'd fall into the Breast; and Bolsters are to be put into the Wound; as also a Plaister or Band over the whole. This Dressing is to be kept close with a Napkin fasten'd round the Breast with Pins, and supported by a Scapulary, which is a sort of Band, the breadth of which is equal to that of six Fingers, having a Hole in the middle to let in the Head: One of its ends falls behind and the other before; and they are both fasten'd to the Napkin. Thus the Patient is laid in Bed, and set half upright. If the Lungs hinder the running out of the Matter, a Pipe is us'd, and the Wound afterward dress'd according to Art.

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CHAP. X.

_Of the Operation of the _Paracentesis_ of the Lower-Belly._

This Manual Operation is sometimes necessary in a Dropsie, when Watry Humours are contain'd in the Cavity of the Belly, or else between the Teguments. The Disease is manifest by the great Swelling; and the Operation is perform'd with a Cane, or a Pipe made of Silver or Steel, with a sharp Stilet at the end; altho' the Ancients were wont to do it with a Lancet. The Patient being supported, sitting on a Bed, or in a great Elbow-Chair, to the end that the Water may run downward, {230} a Servant must press the Belly with his Hands, that the Tumour may be extended, whilst the Surgeon perforates it three or four Fingers breadth below the Navel, and makes the Puncture on the side, to avoid the White-Line; but before the Opening is made, it is expedient that the Skin be a little lifted up. The pointed Stilet being accompany'd with its Pipe, remains in the Part after the Puncture; but it is remov'd to let out the Water; and a convenient quantity of it is taken away, accordingly as the Strength of the Patient will admit. The Stilet makes so small an Opening, that it is not to be fear'd lest the Water shou'd run out, which might happen in making use of the Lancet, because there wou'd be occasion for a thicker Pipe. When a new Puncture is requisite, it must be begun beneath the former; but if the Waters cause the Navel to stand out, the Opening may be made therein, without seeking for any other place.

_The Bandage and Dressing_

Are prepar'd with a large four-double Bolster kept close with a Napkin folded into three or four Folds, which is in like manner supported by the Scapulary.

_The Operation of the _Paracentesis_ of the _Scrotum__

Is undertaken when those Parts are full of Water, after this manner: Assoon as the Patient is plac'd in a convenient Posture, either {231} standing or sitting, the Operator lays hold on the _Scrotum_ with one Hand, presseth it a little to render the Tumour hard, and makes a Puncture, as in the _Paracentesis_ of the _Abdomen_. In an _Hydrocele_ that happens to young Infants, the Opening may be made with a Lancet, to take away all the Water at once: But in Men, especially when there is a great quantity thereof, it is more expedient to do it with the sharp-pointed Pipe; but the Testicles are to be drawn back, for fear of wounding 'em with the Point of the Instrument.

If the _Hydrocele_ be apparently _Encysted_, the Membrane containing the Water is to be consum'd with Causticks, which is done by laying a Cautery in the place where the Incision shou'd be made, and afterward opening the Escar with a Lancet.

When the Puncture is made, it ought to be done in the upper-part of the _Scrotum_, because it is less painful than the lower, and less subject to Inflammation.

* * * * *

CHAP XI.

_Of the Operation of _Gastroraphy_._

This Operation is usually perform'd when there is a Wound in the Belly so wide as to let out the Entrails. If there be a considerable Wound in the Intestine, it may be sow'd up with the Glover's Stitch, the manner of making which we have before explain'd. If {232} the _Omentum_ or Caul be mortify'd, the corrupted Part must be cut off; to which purpose it is requisite to take a Needle with waxed Thread, and to pass it into the sound Part a-cross the Caul, without pricking the Vessels. Then the Caul being ty'd on both sides with each of the Threads that have been pass'd double, may be cut an Inch below the Ligature, and the Threads will go thro' the Wound, so as to be taken away after the Suppuration. Afterward the Intestines are to be put up again into the Belly, by thrusting 'em alternately with the end of the Fingers. But if they cannot be restor'd to their proper Place without much difficulty, Spirituous Fomentations may be made with an handful of the Flowers of Camomile and Melilot, an Ounce of Anise, with as much Fennel and Cummin-Seeds; half an Ounce of Cloves and Nutmegs: Let the whole Mass be boil'd in Milk, adding an Ounce of Camphirated Spirit of Wine, and two Drams of _Saccharum Saturni_, with two Scruples of Oil of Anise, and bathe the Entrails with this Fomentation very hot. Otherwise,

Apply Animals cut open alive; or else boil Skeins of raw Thread in Milk, and foment 'em with this Decoction in like manner very hot.

Before the Suture of Stitching of the Intestines is made, it is expedient to foment 'em with Spirit of Wine, in which a little Camphire hath been dissolv'd: But if they be mortify'd, they must not be sown up again, but fomented with Spirituous Liquors. No Clysters are to be given to the Patient, for fear {233} causing the Intestine to swell; but a Suppository may be apply'd: Or else he may make use of a Laxative Diet-Drink, if it be necessary to open his Body: He ought also to be very temperate and abstemious during the Cure, so as to take no other Sustenance than Broths and Gellies.

If the Intestines cannot be put up again, the Wound is to be dilated, avoiding the White-Line, and that too at the bottom rather than at the Top, if it be above. To this purpose the Intestines are to be rank'd along the side of the Wound, and a Bolster is to be laid upon 'em dipt in warm Wine, which may be held by some Assistant. Then the Surgeon introduceth a channel'd Probe into the Belly, and takes a great deal of care to fix the Intestine between the Probe and the _Peritonaeum_, which may be effected by drawing out the Intestine a little; then holding the Probe with his Left-hand, to fit a crooked Incision-Knife in its chanelling, he cuts the Teguments equally both on the outside and within, and thrusts back the Entrails alternately into the Wound with his Fore-Finger.

The Stitch must be intermitted, being made with two crooked Needles threaded at each end with the same Thread. The Surgeon having at first put the Fore-Finger of his Left-Hand into the Belly, to retain the _Peritonaeum_, Muscles, and Skin on the side of the Wound, passeth the Needle with his other Hand into the Belly, the Point of which is guided with the Fore-Finger, and penetrates very far: Then he likewise passeth the other {234} Needle thro' the other Lip of the Wound into the Belly, observing the same thing as in the former, and without taking his Fingers off from the Belly. If there are many Points or Stitches to be made, they may be done after the same manner, without removing the Fingers from the Part, whilst a Servant draws together the Lips of the Wound, and ties the Knots. Afterward the Wound may be dress'd, and the Preparatives or Dressings kept close to the Part with the Napkin and Scapulary. But the Patient must be oblig'd to lie on his Belly for some Days successively, to cicatrize the Wound thereof, or that of the Entrails.

If the Intestine were entirely cut, it wou'd be requisite to sow it up round about the Wound, after such a manner that some part of it may always remain open; for if the Patient shou'd recover, his Excrements might be voided thro' the Wound; of which Accident we have an Example in a Soldier belonging to the Hospital _Des Invalides_ at _Paris_, who liv'd a long time in this Condition.

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CHAP. XII.

_Of the Operation of the _Exomphalus_._

This Operation is necessary when the Intestines or Entrails have made a kind of Rupture in the Navel, and may be perform'd thus: When the Patient is laid upon his Back, an Incision is to be made on the Tumour to {235} the Fat, by griping the Skin, if it be possible, or else it may be done without taking it up. Then the Membranes are to be divided with a Fleam to lay open the _Peritonaeum_, for fear of cutting the Intestine; and as soon as the _Peritonaeum_ appears, it may be drawn upward with the Nails, in order to make a small Opening therein with some cutting Instrument: Whereupon the Surgeon having put the Fore-Finger of his Left-Hand into the Belly to guide the Point of the Sizzers, with which the Incision is enlarg'd, restores the Intestine to its proper Place, and loosens the Caul if it stick to the Tumour: But if the Entrails are fasten'd to the Caul, it is requisite to separate 'em by cutting a little of the Caul, rather than to touch the Intestine; which last being reduc'd, a Servant may press the Belly on the side of the Wound; so that if a Mass of Flesh be found in the Caul, which hath been form'd by the sticking of the Caul to the Muscles and _Peritonaeum_, this Fleshy Mass must be entirely loosen'd, and then a Ligature may be made to take it away, with some part of the Caul, as we have already shewn in the _Gastroraphy_. Afterward the Stitch is to be made, as in that Operation, and the Wound must be dress'd, observing the same Precautions. The Dressing is to be supported in like manner with the Napkin and Scapulary.

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{236}

CHAP. XIII.

_Of the Operation of the_ Bubonocele, _and of the compleat Rupture._

When the Intestinal Parts are fall'n into the Groin or the _Scrotum_, the Operation of the _Bubonocele_ may be conveniently perform'd; to which purpose the Patient is to be laid upon his Back, with his Buttocks somewhat high; then the Skin being grip'd a-cross the Tumour, the Surgeon holds it on one side, and the Assistant on the other, till he makes an Incision, following the Folds or Wrinkles of the Groin; when the Fat appears, it is requisite to tear off either with a Fleam or even with the Nails, every thing that lies in the way, till the Intestine be laid open, which must be drawn out a little, to see if it do not cleave to the Rings of the Muscles. The Intestine must be gently handl'd, to dissolve the Excrements; and those Parts must be afterward put up again into the Belly (if it be possible) with the two Fore-Fingers, thrusting 'em alternatively; but if they cannot be reduc'd, the Wound is to be dilated upward, by introducing a channell'd Probe into the Belly, to let the Sizzers into its Channelling. If the Probe cannot enter, the Intestine must be taken out a little, laying a Finger upon it near the Ring, and making a small Scarification in the Ring, with a streight Incision-Knife guided with the {237} Finger, to let in the Probe, into which may be put a crooked Knife, to cut the Ring; that is to say, to dilate the Wound on the inside; but care must be had to avoid penetrating too far, for fear of dividing a Branch of Arteries; and then the Parts may be put up into the Belly. If the Caul had caus'd the Rupture, it wou'd be requisite to bind it, and to cut off whatsoever is corrupted, scarifying the Ring on the inside, to make a good Cicatrice or Scar.

_The Dressing and Bandage._

The Dressing may be prepar'd with a Linnen-Tent, soft and blunt, of a sufficient thickness and length, to hinder the Intestines from re-entring into the Rings by their Impulsion, a Thread being ty'd thereto, to draw it out as occasion serves. Then Pledgets are to be put into the Wound, after they have been dipt in a good Digestive, such as Turpentine with the Yolk of an Egg, applying at the same time a Plaister, a Bolster of a Triangular Figure, and the Bandage call'd _Spica_, which is made much after the same manner as that which is us'd in the Fracture of the Clavicle.

_Of the compleat _Hernia_ or Rupture._

It happens when the Intestinal Parts fall into the _Scrotum_ in Men, or into the bottom of the Lips of the _Matrix_ in Women. To perform this Operation, the Patient must be laid upon his Back, as in the _Bubonocele_, and the Incision carry'd on after the same manner; which is to {238} be made in the _Scrotum_, tearing off the Membranes to the Intestine. Then a Search will be requisite, to observe whether any parts stick to the Testicle; if the Caul doth so, it must be taken off, leaving a little Piece on the Testicle; but if it be the Intestine, so that those Parts cannot be separated without hurting one of 'em, it is more expedient to impair the Testicle than the Intestine. If the Caul be corrupted, it must be cut to the sound Part, and the Wound is to be dress'd with Pledgets, Bolsters, and the Bandage _Spica_; as in the _Bubonocele_.

* * * * *

CHAP. XIV.

_Of the Operation of _Castration_._

The Mortification or the _Sarcocele_ of the Testicles, gives occasion to this Operation; to perform which, the Patient must be laid upon his Back, with his Buttocks higher than his Head, his Legs being kept open, and the Skin of the _Scrotum_ taken up, one end of which is to be held by a Servant, and the other by the Surgeon, who having made a longitudinal Incision therein, or from the top to the bottom, slips off the Flesh of the _Dartos_ which covers the Testicle, binds up the Vessels that lie between the Rings and the Tumour, and cuts 'em off a Fingers breadth beneath the Ligature: But care must be taken to avoid tying the Spermatick Vessels too hard, for fear of a Convulsion, and {239} to let one end of the Thread pass without the Wound. If an Excrescence of Flesh stick to the Testicle, and it be moveable or loose, it is requisite to take it off neatly, leaving a small Piece of it on the Testicle; and if any considerable Vessels appear in the Tumour, they must be bound before they are cut.

_The Dressing and Bandage._

The Dressing is made with Pledgets and Bolsters laid upon the _Scrotum_; and the proper Bandage is the _Suspensor_ of the _Scrotum_, which hath four Heads or Ends, of which the upper serve as a Cincture or Girdle; and the lower passing between the Thighs, and fasten'd behind to the Cincture.

There is also another Bandage of the _Scrotum_, having in like manner four Heads, of which the upper constitute the Cincture; but it is slit at the bottom, and hath no Seams; the lower Heads crossing one another, to pass between the Thighs, and to be join'd to the Cincture. Both these sorts of Bandages have a Hole to give Passage to the Yard.

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{240}

CHAP. XV.

_Of the Operation of the Stone in the_ Ureter.

If the Stone be stopt at the _Sphincter_ of the Bladder, it ought to be thrust back with a Probe: If it stick at the end of the _Glans_, it may be press'd to let it out; and if it cannot come forth, a small Incision may be made in the opening of the _Glans_ on its side.

But if the Stone be remote from the _Glans_, it is requisite to make an Incision into the _Ureter_; to which purpose, the Surgeon having caus'd the Skin to be drawn upward, holds the Yard between two Fingers, making a Longitudinal Incision on its side upon the Stone, which must be prest between the Fingers to cause it to fly out; or else it may be taken out with an _Extractor_. Then if the Incision were very small, the Skin needs only to be let go, and it will heal of it self; but if it were large, a small Leaden Pipe is to be put into the _Ureter_, lest it shou'd be altogether clos'd up by the Scar: It is also expedient to anoint the Pipe with some Desiccative Medicine, and to dress the Wound with Balsam. Afterward a little Linnen-Bag or Case is to be made, in which the Yard is to be put, to keep on the Dressing; but it must be pierc'd at the end, for the convenience of making Water, having two Bands at the other end, which are ty'd round about the Waste.

* * * * *

{241}

CHAP. XVI.

_Of the Operation of _Lithotomy_._

This Operation is undertaken when it is certainly known that there is a Stone in the Bladder; to be assur'd of which, it may not be improper to introduce a Finger into the _Anus_ near the _Os Pubis_, by which means the Stone is sometimes felt, if there be any: The Finger is likewise usually put into the _Anus_ of young Virgins, and into the _Vagina Uteri_ of Women, for the same purpose. But it is more expedient to make use of the Probe, anointed with Grease, after this manner: The Patient being laid on his Back, the Operator holds the Yard streight upward, the _Glans_ lying open between his Thumb and Fore-finger; then holding the Probe with his Right-hand on the side of the Rings, he guides it into the Yard, and when it is enter'd, turns the Handle toward the _Pubes_, drawing out the Yard a little, to the end that the Canal of the _Ureter_ may lie streight. If it be perceiv'd that the Probe hath not as yet pass'd into the Bladder, a Finger is to be put into the _Anus_, to conduct it thither. Afterward in order to know whether a Stone be lodg'd in the Bladder, the Probe ought to be shaken a little therein, first on the Right-side, and then on the Left; and if a small Noise be heard, it may be concluded for certain that there is a Stone: But if it be judg'd that the {242} Stone swims in the Bladder, so that it cannot be felt, the Patient must be oblig'd to make Water with a hollow Probe.

Another manner of searching may be practis'd thus: Let the Yard be rais'd upward, inclining a little to the side of the Belly; let the Rings of the Probe be turn'd upon the Belly, and the end on the side of the _Anus_; and then let this Instrument be introduc'd, shaking it a little on both sides, to discover the Stone.

In order to perform the Operation of Lithotomy, the Patient must be laid along upon a Table of a convenient height, so as that the Surgeon may go about his Work standing; the Patient's Back must also lean upon the Back of a Chair laid down, and trimm'd with Linnen-Cloth, lest it shou'd hurt his Body; his Legs must be kept asunder, and the Soles of his Feet on the sides of the Table, whilst a Man gets up behind him to hold his Shoulders: His Arms and Legs must be also bound with Straps or Bands. Then a channell'd Probe being put up into the Bladder, a Servant standing upon the Table on the side of the Chair, holds the Back of the Instrument between his two Fore-fingers on that Part of the _Perinaeum_ where the Incision ought to be begun, which is to be made between his Fingers with a sharp Knife that cuts on both sides: The Incision may be three or four Fingers breadth on the left side of the _Raphe_ or Suture: But in Children its length must not exceed two Fingers breadth. If the Incision were too little to give Passage to the Stone, it wou'd be more expedient to enlarge it than to stretch the Wound {243} with the Dilatators. When the Convex Part where the channelling of the Probe lies, shall be well laid open, the Conductors may be slipt into the same Channelling, between which the _Forceps_ is to be put, having before taken away the Probe. Some Operators make use of a _Gorgeret_ or Introductor to that purpose, conveying the end of it into the Chanelling of the Probe; which is remov'd to introduce the _Forceps_ into the Bladder: And as soon as they are fixt therein, the Conductors or _Gorgeret_ must be likewise taken out. Afterward search being made for the Stone, it must be held fast, and drawn out of the Bladder: But if the Stone be long, and the Operator hath got hold thereof by the two Ends, he must endeavour to lay hold on it again by the Middle, to avoid the great scattering which wou'd happen in the Passage. The Stones are also sometimes so large, that there is an absolute necessity of leaving 'em in the Bladder. Again, if the Stone sticks very close to the Bladder, the Extraction ought to be deferr'd for some time; and perhaps it may be loosen'd in the Suppuration. Lastly, when the Stone hath been taken out, an Extractor is usually introduc'd into the Bladder, to remove the Gravel, Fragments, and Clots of Blood.

After the Operation, the Patient is carry'd to his Bed, having before cover'd the Wound with a good Bolster; and if an Haemorrhage happens, it is to be stopt with Astringents. A Tent must also be put into the Wound, when it is suspected that some Stone or Gravel may as yet remain therein: But if it evidently appears that {244} there is none, the Wound may be dress'd with Pledgets, a Plaister, and a Bolster, of a Figure convenient for the Part. The Dressing may be staid with a Sling supported by a Scapulary; or else the Bandage of the double T. may be us'd, the manner of the Application of which we have shewn elsewhere. The Patient's Thighs must be drawn close to one another, and ty'd with a small Band, lest they shou'd be set asunder again.

The Operation of Lithotomy in Women is usually perform'd by the lesser Preparative, which is done by putting the Fore-finger and Middle-finger into the _Vagina Uteri_, or into the _Rectum_ in young Virgins, to draw the Stone to the Neck of the Bladder, and keep it steady, so that it may be taken out with a Hook, or other Instrument.

This Operation may also be effected in Women, almost in the same manner as in Men; for after having caus'd the Female Patient to be set in the same Posture or Situation as the Men are usually plac'd, according to the preceeding Description, the Conductors may be convey'd into the _Ureter_, to let in the _Forceps_ between 'em, with which the Stone may be drawn out: But if it be too thick, a small Incision is to be made in the Right and Left side of the _Ureter_.

The lesser Preparative was formerly us'd in the Lithotomy of Men, after this manner: The Finger was put into the _Anus_, to draw the Stone toward the _Perinaeum_; then an Incision was made upon the Stone on the side of the Suture, and it was taken out with an Instrument.

* * * * *

{245}

CHAP. XVII.

_Of the Operation of the Puncture of the _Perinaeum_._

This Operation is necessary in a Suppression of Urine, where the Inflammation is so great, that the Probe cannot be introduc'd. Then an Incision is to be made with the Knife or Lancet, in the same Place where it is done in Lithotomy; and a small Tube or Pipe is to be put in the Bladder, till the Inflammation be remov'd.

* * * * *

CHAP. XVIII.

_Of the Operation of the _Fistula in Ano_._

Fistula's are callous Ulcers: If one of these happen in the Fundament, and is open on the outside, it may be cur'd thus: After the Patient hath been laid upon his Belly on the side of a Bed, with his Legs asunder, the Surgeon makes a small Incision with his Knife in the Orifice of the _Fistula_, in order to pass therein another small crooked Incision-Knife, at the end of which is a Pointed Stilet with a little Silver Head which covers it, to the end that it may enter without causing Pain. When the Surgeon hath convey'd his Knife into the {246} _Fistula_, having the Fore-finger of his Left-hand in the _Anus_ or Fundament, he pulls off its Head, holding the Handle with one Hand, and the Stilet that pierceth the _Anus_ with the other; and at last draws out the Instrument to cut the _Fistula_ entirely at one Stroke.

If the _Fistula_ hath an Opening into the Intestine, an Incision is to be made on the outside at the Bottom thereof, to open it in the Place where a small Tumour or Inflammation usually appears, or else in the Place where the Patient feels a Pain when it is touch'd. If the Tumour be remote from the _Anus_, it may be open'd with the Potential Cautery, to avoid a greater Inconvenience. After having thus laid open the very bottom, the little Incision-Knife and Stilet, with its Head, is to be pass'd therein, the end of the Stilet is to be drawn thro' the _Anus_, and the Flesh is to be cut all at once. But if the _Fistula_ be situated too far forward in the Fundament, the _Sphincter_ of the _Anus_ must not be entirely cut, otherwise the Excrements cannot be any longer retain'd. Lastly, when the _Fistula_ hath been treated after this manner, all its Sinuosities or Winding-Passages ought likewise to be open'd, and the Wound being fill'd with thick Pledgets steept in some Anodyn, is to be cover'd with a Plaister and a Triangular Bolster; as also with the Bandage call'd the T.

* * * * *

{247}

CHAP. XIX.

_Of the Suture or Stitching of a _Tendon_._

It is requisite to undertake this Operation when the Tendons are cut, and when they become very thick. If the Wound be heal'd, it must be open'd again to discover the Tendon, and the Part must be bended, to draw together again the ends of the Tendons. Then the Surgeon taking a flat, streight, and fine Needle, with a double waxed Thread, passeth it into a small Bolster, and makes a Knot at the end of the Thread, to be stopt upon the Bolster. Afterward he pierceth the Tendon from the outside to the inside, at a good distance, lest the Thread shou'd tear it, and proceeds to pass the Needle in like manner under the other end of the Tendon, upon which is laid a small Bolster, for the Thread to be ty'd in a Knot over it. Then he causeth the Extremities of the Tendons to lie a little one upon another, by bending the Part, and dresseth the Wound with some Balsam. It may not be improper here to observe, that Ointments are never to be apply'd to the Tendons, which wou'd cause 'em to putrifie, but altogether Spirituous Medicaments; and that the Part must be bound up, lest the Extension of it shou'd separate the Tendons.

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{248}

CHAP. XX.

_Of the _Caesarian_ Operation._

When a Woman cannot be deliver'd by the ordinary means, this bold and dangerous Operation hath been sometimes perform'd with good Success. The Woman being laid upon her Back, the Surgeon makes a Longitudinal Incision beneath the Navel, on the side of the White-Line, till the _Matrix_ appears, which he openeth, taking great care to avoid wounding the Child: Then he divides the Membranes with which it is wrapt up, separates the After-Burden from the _Matrix_, and takes out the Child. Lastly he washeth the Wound with warm Wine, and dispatcheth the _Gastroraphy_ or Stitching up of the Belly, without sowing the _Matrix_. After the Operation, Injections are to be made into the _Matrix_, to cause a Flux of Blood; and a pierc'd Pessary must be introduc'd into its Neck.

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{249}

CHAP. XXI.

_Of the Operation of _Amputation_, with its proper Dressings and Bandages._

The Leg is usually cut off at the Ham; the Thigh as near as can be to the Knee; and the Arm as near as is possible to the Wrist: But an Amputation is never made in a Joynt, except in the Fingers and Toes.

In order to cut off a Leg, the Patient is to be set on the side of his Bed, or in a Chair, and supported by divers Assistants; one of 'em being employ'd to hold the Leg at the bottom, and another to draw the Skin upward above the Knee, to the end that the Flesh may cover the Bone again after the Operation. In the mean while a very thick Bolster is laid under the Ham, upon which are made two Ligatures, _viz._ the first above the Knee, to stop the Blood, by screwing it up with the _Tourniquet_ or _Gripe-Stick_; and the second below the Knee, to render the Flesh firm for the Knife. Before the Ligature is drawn close with the _Gripe-Stick_, a little piece of Paste-board is to be put underneath, for fear of pinching the Skin. Thus the Leg being well fixt, the Surgeon placeth himself between both the Legs of the Patient, to make the Incision with a crooked Knife, turning it circularly to the Bone, and laying one Hand upon the Back of the Knife, which must have no Edge. Afterward the _Periosteum_ is to be {250} scrap'd with an Incision-Knife, and the Flesh with the Vessels that lie between the two Bones are to be cut. When the Flesh is thus separated, a Cleft Band is to be laid upon it, with which the Heads are cross'd, to draw the Flesh upward, to the intent that the Bones may be cut farther, and that it may cover 'em after the Amputation, as also to facilitate the Passage of the Saw. Then the Surgeon holds the Leg with his Left-hand, and saweth with his Right, which he lets fall upon the two Bones, to divide 'em asunder at the same time, beginning with the _Perone_ or _Fibula_, and ending with the _Tibia_. But it is necessary to incline the Saw, and to go gently in the beginning, to make way for it, and afterward to work it faster. The Leg being cut off, the Ligature must be unty'd below the Knee, loosening the _Gripe-Stick_, to let the Blood run a little, and to discern the Vessels with greater facility; and then the _Gripe-Stick_ may be twisted again, to stop the Blood; which some Surgeons effect, by laying Pieces of Vitriol upon the Opening of the Arteries, and Astringent Powders, on a large Bolster of Cotton or Tow, to be apply'd to the end of the Stump; but if such a method be us'd, it is requisite that some Person be employ'd to keep on the whole Dressing with his Hand during twenty four Hours. However this Custom hath prevail'd in the Hospital of _Hotel-Dieu_ at _Paris_.

Others make a Ligature of the Vessels, taking up the ends of 'em with a pair of _Forceps_, having a Spring; or with the _Valet a Patin_, which is a sort of Pincers that are clos'd with a small {251} Ring let down to the bottom of the Branches. These Pincers being held by a Servant, the Surgeon passeth a Needle with wax'd Thread, into the Flesh, below the Vessel, bringing it back again, and with the two ends of the Thread makes a good Ligature upon the same Vessel; then he looseth the _Gripe-Stick_ and the Band, the Stump is to be somewhat bended, and the Flesh let down to cover the Bones.

_The Dressing and Bandage._

After the Operation, it is requisite to lay small Bolsters upon the Vessels, and dry Pledgets upon the two Bones, as also many other Folds of Linnen strew'd with Astringent Powders; and over all another large Bolster or Pledget of Cotton or Tow, cover'd in like manner with Astringent Powders; then the whole Dressing is to be wrapt up with a Plaister and a Bolster, in form of a _Malta_ Cross; so that there are three or four Longitudinal Bolsters, and one Circular.

The Surgeon usually begins to apply the _Malta_ Cross and Bolster under the Ham, crossing the Heads or Ends upon the Stump, and causeth 'em to be held by a Servant that Supports the Part; then he likewise crosseth the other Heads, and layeth on the two Longitudinal Bolsters that cross each other in the middle of the Stump, together with a third Longitudinal, which is brought round about the Stump, to stay the two former: These Bolsters ought to be three Fingers broad, and very long, to pass over the Stump. Afterward he proceeds to apply, {252}

_The Bandage commonly call'd _Capeline_ by _French_ Surgeons, or the Head-Bandage._

Which is prepar'd with a Band four Ells long, and three Fingers broad, roll'd up with one Ball, three Circumvolutions being made on the side of the cut Part, the Band is to be carry'd upward with Rollers, passing obliquely above the Knee; and is brought down again along its former Turns; If it be thought fit to make this Bandage with the same Band, it must be let down to the middle of the cut Part, and carry'd up again to the Knee, many back-folds being made, which are stay'd with the Circumvolutions, till the Stump be entirely covered, and the whole Bandage wrapt up with Rollers or Bolsters.

The _Capeline_ or Head-Bandage, having two Heads, is made with a Band of the same breadth, but somewhat longer. This Band being at first apply'd to the middle of the cut Part or Wound, the Heads are carry'd up above the Knee; and one of the Ends are turn'd backward, to bring it down, and to pass it over the end of the Stump. At every back-fold which is form'd above and below the Knee, a Circumvolution is to be made with the other end of the Band, to strengthen the back-folds, continuing to bring the Band downward and upward, till the whole Stump be cover'd: Then Rollers are made round about the Stump, and the Band is stay'd above the Knee. Afterward the Part may be brought to Suppuration, cleans'd and cicatriz'd.

* * * * *

{253}

CHAP. XXII.

_Of the Operation of the _Aneurism_._

This Operation is perform'd when the Surgeon hath prickt an Artery, or when a Tumour ariseth in an Artery.

To this purpose the Patient is set in a Chair, and a Servant employ'd in holding his Arm in a Posture proper for the Operation; then a Bolster is to be laid four double, following the Progress of the Artery, to the end that the Ligature may better press the Vessel; and the Arm may be also surrounded with another single Bolster, on which is made a Ligature screw'd up with a _Gripe-Stick_, provided the Arm be not too much swell'd; for in this Case it wou'd be more expedient to deferr the Operation for fear of a Gangrene. The Artery being thus well stopt, the Surgeon lays hold on the Arm with one Hand, below the Tumour, and with the other makes an Incision with his Lancet, beginning at the bottom of the Tumour, and ending on the top along the Progress of the Artery. When the Tumour is open'd, the coagulated Blood may be discharg'd with a Finger; and if there are any Strings at the bottom, they may be cut with a crooked Pair of Sizzers, to the end that all the Clods of Blood, and other extraneous Bodies which are sometimes form'd in _Aneurisms_ when they are very inveterate may be more {254} easily remov'd. But the _Gripe-Stick_ must be loosen'd, to discover the Opening of the Artery with greater facility, and the Artery separated from the Membranes with a Fleam; for it wou'd be dangerous to cut it with a streight Incision-Knife: The Artery must also be supported with a convenient Instrument to divide it from the Nerve and Membranes; and to be assur'd of the Place of its Opening, the _Gripe-Stick_ may be somewhat loosen'd, and afterward screw'd up again. In the mean time the Surgeon gives the Instrument to a Servant to hold, whilst he passeth under the Artery a crooked Needle with a wax'd String, cuts the Thread, and takes away the Needle: Then he begins to make the Ligature beneath the Opening of the Artery, tying at first a single Knot, on which may be put (if you please) a small Bolster, that may be kept steady with two other Knots: It is also necessary that another Ligature be made in the lower part of the Artery, by reason that the little lateral Arteries might otherwise let out Blood.

The Artery ought not to be cut between the two Ligatures, lest the first Ligature shou'd be forc'd by the Impulsion of the Blood; but the Thread must be let fall, that it may rot with the Suppuration. Then the Wound may be dress'd with Pledgets, Bolsters strew'd with Astringent Powders and a Plaister; a Bolster being also laid in the Fold of the Elbow. {255}

_The Bandage_

Is made with a Band six Ells long, and an Inch broad, roll'd with one end, being at first apply'd with divers Circumvolutions under the Elbow, and moderately bound. Many turns are to be made, and a thick and streight Bolster, is to be laid upon the Tumour, (as in the Bandage for Phlebotomy) along the Artery, till it pass under the Arm-Hole: The Arm and Bolster must be surrounded with the Band, which is brought up with small Rollers, to the Arm-Pit, and stay'd with Circumvolutions round about the Breast. Afterward the Patient is to be laid in his Bed, with the Arm lying somewhat bended on the Pillow, and the Hand a little higher than the Elbow.

* * * * *

CHAP. XXIII.

_Of the Operation of _Phlebotomy_._

To perform this Operation, the Surgeon holds the Lancet between his Thumb and Fore-finger, and three other Fingers lying upon the Patient's Arm, and thrusts the Point of the lancet into the Vessel, carrying the same Point somewhat upward, to make the Orifice the greater. If a Tendon, which is known by its hardness; or an Artery, which is discover'd by Pulsation, appear beyond the Vein, and very near it, the Lancet must be only set very {256} forward in the Vein, and drawn back again streight, without turning it up, otherwise the Artery or Tendon wou'd be certainly cut with the Point. If the Artery or Tendon lies immediately under the Vein, the later must be prickt somewhat underneath, holding the Lancet inclin'd side-ways, and thrusting it very little forward; so that the Point will finish the Opening, by turning it upward.

If the Artery stick too close to the Vein, the later is to be prickt higher or lower than it is ordinarily done; and if the Vein be superficial, and lie close upon a hard Muscle, the Lancet must not be thrust downright into the Vein, but it is requisite to carry it somewhat obliquely, and to take the Vessel above, lest the Muscle and its Membrane shou'd be prickt, which wou'd cause a great deal of Pain, and perhaps a vehement Inflammation. It is well known that the Veins of the Right Arm are usually open'd with the Right-hand, and those of the Left-Arm with the Left-hand.

_The Bandage_

Is made thus: The Surgeon having laid a Bolster upon the Orifice, keeps it close with two Fingers, and holds the Band or Fillet with the other Hand; then taking one end of the Fillet with the Middle-Finger, Fore-Finger, and Thumb, and applying it to the Bolster, he makes with the longest end of the Fillet divers Figures in form of the Letters KY in the Fold of the Arm; as also a back-fold with the shorter end of the Fillet, held between three {257} Fingers. Afterward both ends of the Fillet are ty'd beneath the Elbow.

If an Inflammation happens after the Operation, the Bolsters are to be dipt in _Oxycratum_: but if the Orifice were so small as to produce a _Rhombus_, it wou'd be requisite to press the Wound often with two Fingers, and immediately to apply a Bolster dipt in _Oxycratum_.

* * * * *

CHAP. XXIV.

_Of the Operation of _Encysted Tumours_._

If the Tumours are small and hanging, and have a narrow bottom, a Ligature may be made with Horse-Hair or Silk, dipt in _Aqua-Fortis_, which will cause 'em to fall off of themselves after some time; or else they may be cut above the Ligature.

If the Tumour or Wen be thick, and its bottom large, a Crucial Incision is to be made in the Skin, without impairing the _Cystis_ or Bagg; and when the Incision is finish'd, the Bag may be torn off with the Nails, or with the Handle of a Pen-Knife; but sometimes it is necessary to dissect it. If there be any considerable Vessels at the Root, they may be bound, or else cut; and the Blood may be stopt with Astringents. If any parts of the _Cystis_ remain, they are to be consum'd with Corrosives; and the Lips of the Wound are to be drawn together without a Stitch, making use {258} only of an agglutinative Plaister. But if the Tumour adheres very close to the _Pericranium_, it is most expedient not to meddle with it at all.

_Of _Ganglions_._

_Ganglions_ are Tumours arising upon the Tendons and Nervous Parts, which may be cur'd by thrusting 'em violently, and making a very streight Bandage, provided they be very recent; a resolvent Plaister is to be also apply'd to the Part.

* * * * *

CHAP. XXV.

_Of the Operation of the _Hydrocephalus_._

This Operation is perform'd when it is necessary to discharge watry Humours out of the Head: If these Waters lie under the Skin, a very large Opening is to be made with a Lancet, and a small Tube or Pipe left therein to let 'em run out. If the Water be situated between the Brain and the _Dura Mater_, the Membrane is to be perforated with a Lancet, after the Trepan hath been apply'd, according to the usual Method, of which we have already given some account: Cauteries and Scarifications may be also us'd to very good purpose in this Disease.

* * * * *

{259}

CHAP. XXVI.

_Of the operation of cutting the Tongue-String._

When the Ligament of the Tongue in Infants is extended to its Extremity, they cannot suck without difficulty; and when grown up, they have an impediment in their Speech.

This Ligament may be cut with a little pair of Sizzers; to which purpose the Thumb of the Left-hand being laid upon the Gum of the lower Jaw, to keep the Mouth open, the Tongue may be rais'd upward with the Fore-Finger of the same Hand, and the Sizzers may be pass'd between the two Fingers, to divide the String as near as is possible to the Root of the Tongue, avoiding the Vessels: If an Haemorrhage happens, recourse may be had to Styptick-Waters. Afterward the Nurse must take care to let a Finger be often put into the Child's Mouth, to prevent the re-uniting of the String.

* * * * *

{260}

CHAP. XXVII.

_Of the Operation of opening stopt _Ductus_'s._

If there be only one Membrane that stops the Entrance of the _Vagina_, an Incision may be made, and a Leaden Pipe put into it, having Rings to fasten it to the Waste, to hinder the re-uniting of the Wound.

If the Lips of the _Pudendum_ are conglutinated or clos'd up, the Patient must be laid upon her Back, and her Knees rais'd up, in order to make an Incision with a crooked Incision-Knife, beginning at the Top; and then a Leaden Pipe is to be put into the Opening.

If the _Vagina_ be fill'd with a Fleshy Substance, an Incision is to be made therein, till it be entirely perforated, putting at the same time a Leaden Tube into the Orifice.

If the Urinary _Ductus_ as well in young Boys as in Virgins, be stopt up, an Incision is to be made therein with a very narrow Lancet; and if a small Leaden Pipe can be conveniently introduc'd, it may be done; but it is not very necessary, in regard that Children are almost always making Water, which wou'd of it self hinder the closing of the Orifice.

If the _Ductus_ of the Ear be stopt with a Membrane, it must be perforated, taking care not to go too far, for fear of piercing the Membrane of the _Tympanum_ or Drum, and {261} a small Leaden Pipe is to be put into the Opening.

If there be a carnous Excrescence on the outside of the Ear, a Ligature ought to be made therein, or else it may be cut with a pair of Sizzers, to cause it to fall off; and the rest of the Fleshy Substance that remains in the Ear must be consum'd with Causticks, convey'd to the Part by the means of a small Tube, care being had, nevertheless, to avoid cauterizing the _Tympanum_.

* * * * *

CHAP. XXVIII.

_Of the Operation of the _Phimosis_ and _Paraphimosis_._

When the _Praeputium_ is so streight that the _Glans_ can be no longer uncover'd, this Indisposition is call'd _Phimosis_; but if the _Praeputium_ be turn'd back above the _Glans_, after such a manner that it can no longer cover the same _Glans_, it is a _Paraphimosis_. If in the _Phimosis_ the _Praeputium_ cleaves very close round about the _Glans_, it is most expedient to let it alone; but if in handling the _Glans_ it be perceiv'd that it is moveable, or else that some parts of it only stick together, the Operation may be perform'd after this manner: The Patient being set in a Chair, a Servant is employ'd in pulling back the Skin to the Root of the _Penis_, to the end that the Incision may be {262} made directly at the bottom of the _Glans_: Then the Surgeon having drawn out the bottom of the _Praeputium_, introduceth a small Instrument with a very sharp Point on its flat side, at the end of which is fixt a Button of Wax, pierceth the _Praeputium_ at the bottom of the _Glans_ on the side of the Thread, and finisheth the Incision by drawing the Instrument toward himself.

The _Paraphimosis_ is cur'd by making Fomentations on the Part, to allay the Inflammation if there be any; and it is to be pull'd down with the Fingers. But if Medicinal Preparations prove ineffectual, Scarifications are to be made round about the _Praeputium_; and afterward convenient Remedies may be apply'd to remove the Inflammation, and prevent the Mortification of the Part; so that at length the _Praeputium_ may be drawn over the _Glans_.

* * * * *

CHAP. XXIX.

_Of the Operation of the _Varix_._

In order to cure this Tumour, the Surgeon having first cut the Skin to discover the dilated Vein, separates it from the Membranes, and passeth underneath a crooked Needle with a double wax'd Thread; then he makes a Ligature both above and below the dilatation of the Vein, opens the dilated Part with a Lancet, to let out the Blood, and applies a convenient Bandage: But without performing this {263} Operation, the Vein might be open'd with a Lancet, to draw out a sufficient quantity of Blood; and then the _Varix_ is to be press'd with a somewhat close Bandage.

* * * * *

CHAP. XXX.

_Of the Operation of the _Panaritium_._

The _Panaritium_ is an Abcess which ariseth at the end of the Fingers; some of these Tumours are only superficial, and others penetrate even under the _Periosteum_; nevertheless after whatsoever manner the _Panaritium_ may happen, it ought to be open'd on the side of the Finger, that the Tendons may not be hurt. If the Abcess be extended under the _Periosteum_, the opening must be made on the side, and the Lancet thrust forward to the Bone: Afterward the _Pus_ or corrupt Matter is to be discharg'd, which wou'd cause the Tendons to putrifie, if it shou'd remain too long upon 'em.

_The Dressing and Bandage_

Are made with a Plaister cut in form of a _Malta_ Cross, which is apply'd at the middle to the end of the Finger, the Heads being cross'd round about. The Bolsters must be also cut in the shape of the _Malta_ Cross, or of a plain Cross only; the Band being a Finger's breadth {264} wide, and long enough to be roll'd about the whole Dressing: It must be pierc'd at one of its ends, and cut the length of three Fingers at the other; so that the two Heads may pass thro' the Hole, to surround the Finger with small Rollers.

* * * * *

CHAP. XXXI.

_Of the Reduction of the falling of the _Anus_._

To reduce the _Anus_ to its proper place when it is fallen, the Patient being laid upon his Belly, with his Buttocks higher than his Head, the Operator gently thrusts back the Roll that forms the _Anus_ with his Fingers dipt in the Oil of Roses: Then he applies the Bolsters steept in some Astringent Liquor, and causeth 'em to be supported with a sort of Bandage, the Nature of which we shall shew in treating of the Fracture of the _Coccyx_, that is to say, the T. the double T. or else the Sling with four Heads.

* * * * *

{265}

CHAP. XXXII.

_Of the Reduction of the falling of the _Matrix_._