It is requisite to take those that have their Backs greenish, and their Bellies red; as also to seek for 'em in a clear running Stream, and to cast away those that are black and hairy.
What is Phlebotomy?
It is an evacuation of Blood procur'd by the artificial Incision of a Vein or Artery, with a design to restore Health.
Which are the Vessels that are open'd in Phlebotomy or Blood-letting?
They are in general all the Veins and Arteries of the Body, nevertheless some of 'em are more especially appropriated to this Operation; as theVena Præparatain the Forehead; theRanulæunder the Tongue; the Jugular Veins and Arteries in the Neck; the Temporal Arteries in the Temples; theCephalick,Median, andBasilickVeins in the inside of the Elbow; theSalvatellabetween the Ring-Finger and the Little-Finger; thePoplitæain the Ham; theSaphenain the internalMalleolusor Ankle; and theIschiaticain the external.
What are the Conditions requisite in the due performing of the Operation of Phlebotomy?
They are these,viz.to make choice of a proper Vessel; not to open any at all Adventures; not to let Blood without necessity, norwithout the Advice of a Physician; whose Office it is to determine the Seasons or Times convenient for that purpose; as that of Intermission in an Intermitting Fever; that of Cooling in the Summer; and that of Noon-tide in the Winter; and lastly, to take away different quantities of Blood; for in the Heat of Summer they ought to be lesser, and greater in the Winter.
What are the Accidents of Phlebotomy?
They are an Impostume, aRhombus, anEchymosis, anAneurism, Lipothymy, Swooning, and a Convulsion.
What is aRhombus?
It is a small Tumour of the Blood which happens in the place where the Operation is perform'd either by making the Orifice too small, or larger than the Capaciousness of the Vessel will admit. TheRhombusis cur'd by laying upon it a Bolster dipt in fair Water, between the Folds of which must be put a little Salt, to dissolve and prevent the Suppuration.
How may it be perceiv'd that an Artery hath been prickt or open'd in letting Blood?
The Puncture of an Artery produceth an Aneurism; and the Opening of it causeth a Flux of Vermilion Colour'd Blood, which issueth forth in abundance, and by Leaps.
Are the Leaps which the Blood makes in running, a certain Sign that it comes from an Artery?
No, because it may so happen, that theBasilickVein lies directly upon an Artery, the beating of which may cause the Blood of theBasilicato run out leaping: Therefore these three Circumstances ought to be consider'd jointly, that is to say, the Vermilion Colour, the great quantity and the Leaps, in order to be assur'd that the Blood proceeds from an Artery.
How may it be discover'd that a Tendon hath been hurt in letting Blood?
It is known when in opening theMedianVein, the end of the Lancet hath met with some Resistance; when the Patient hath felt great Pain, and afterward when the Tendon apparently begins to be puff'd up, and the Arm to swell. A Remedy may be apply'd to this Accident thus; after having finish'd the Operation, a Bolster steep'd inOxycratumis to be laid upon the Vessel, a proper Bandage is to be made, and the Arm must be wrapt up in a Scarf: If the Inflammation that ariseth in the Part be follow'd with Suppuration, it must be dress'd with a small Tent; and if the Suppuration be considerable, it is necessary to dilate the Wound, and to make use of Oil of Eggs and Brandy, orArcæus's Liniment, with a good Digestive; as also to applyEmplastrum Ceratum; to make an Embrocation on the Arm with Oil of Roses; and to dip the Bolsters inOxycratumto cover the whole Part.
Is it not to be fear'd that some Nerve may be wounded in letting Blood?
No, they lie so deep that they cannot be touch'd.
Under what Vein is the Artery of the Arm?
It is usually situated under theBasilica.
What Course is proper to be taken to avoid the Puncture of an Artery in letting Blood?
It must be felt with the Hand before the Ligature is made, observing well whether it be deep or superficial; for when it lies deep, there is nothing to be fear'd; and when it is superficial, it may be easily avoided by pricking the Vein either higher or lower.
What is to be done when an Artery is open'd?
If it be well open'd, it is requisite to let the Blood run out till the Person falls into aSyncopeor Swoon, by which means the Aneurism is prevented; and afterward the Blood will be more easily stopt: It remains only to make a good Bandage with many Bolsters, in the first of which is simply put a Counter or a Piece of Money; but a bit of Paper chew'd will serve much better, with Bolsters laid upon it in several Folds.
If the Arteries cause so much trouble when open'd accidentally, why are those of the Temples sometimes open'd on purpose, to asswage violent Pains in the Head?
By reason that in this place the Arteries are situated upon the Bones that press 'em behind; which very much facilitates their re-union.
Are not the Arteries of Persons advanc'd in Years more difficult to be clos'd than those of Children?
Yes.
Are there not Accidents to be fear'd in letting Blood in the Foot?
Much less than in the Arm; because the Veins of theMalleolior Ankles are not accompany'd either with Arteries or Tendons; which gave occasion to the Saying,That the Arm must be given to be let Blood only to an able Surgeon, but the Foot may be afforded to a young Practitioner.
This Operation is to be perform'd, when it is inferr'd from the Signs of which we have already given a particular Account, that some Matter is diffus'd over theDura Mater. The Trepan must not be us'd in theSinus Superciliares, by reason of their Cavity; nor in the Sutures, in regard of the Vessels that pass thro' 'em; nor in the Temporal Bone without great necessity, especially in that part of it which is join'd to the Parietal-Bone, lest the end of this Bone shou'd fly out of its place, since it is only laid upon the Parietal; nor in the middle of the Coronal and Occipital-Bones, by reason of an innerProminence wherein they adhere to theDura Mater; nor in the Passage of the LateralSinus'sthat are situated on the side of the Occipital.
If the Fissure be very small, the Trepan may be apply'd upon it, altho' it is more expedient to use this Instrument on the side of the Fissure in the lower part; neither is the Trepan to be set upon the Sinkings; and if the Bones are loosen'd or separated, there needs no other trepanning than to take 'em away with the Elevatory.
The Operation must be begun with Incision, which is usually made in form of a Cross, if the Wound be remote from the Sutures, and there are no Muscles to be cut, and in the shape of the Letter T. or of the Figure 7. if it be near the Sutures, so that the Foot of the 7. or of the T. ought to be parallel to the Suture, the top of the Letter descending toward the Temples; it is also made in the middle of the Forehead. If it be sufficient to make a longitudinal Incision in the Forehead; its Wrinkles may be follow'd, and there will be less Deformity in the Scar; but it is never done Crosswise in this Part, and the Lips of the Wound are not to be cut. If an Incision be made on the MuscleCrotaphites, and on those of the back-part of the Head, it may be done in form of the Letter V. the Point of which will stand at the bottom of the Muscles; nevertheless it is more convenient to make a longitudinal Incision, by which means fewer Fibres will be cut; and it is always requisite to begin at the lower part, to avoid being hindred by the Hæmorrhage.The Incisions are to be made with the Incision-Knife, and that too boldly when there are no Sinkings; but if there be any, too much weight must not be laid upon 'em: Thus the Incision being finish'd, the Lips of the Skull are to be separated either with the Fingers, or some convenient Instrument; Then if there be no urgent Occasion to apply the Trepan, it may be deferr'd till the next Day, the Wound being dress'd in the mean time with Plaisters, Bolsters, Pledgets, and a large Kerchief or upper Dressing, the use of which we shall shew hereafter.
The Operation is begun with the Perforative, to make a little Hole for the fixing of the Pyramid or Pin which is in the Round; afterward the Round is to be apply'd, holding the Handle of the Trepan with the Left-hand, and turning with the other very fast in the beginning; but when the Round hath made its way, it is lifted up to remove the Pin, lest this Point shou'd hurt theDura Mater: Thus the Round being taken off from time to time, to be cleans'd from the Filings that stick thereto, is set on again, and the Operator begins his Work of turning anew, which must be carry'd on gently when any Blood appears, to the end that the first Table of the piece of Bone which is remov'd may not fly from the second: When it comes near theDura Mater, the Operator must proceed, in like manner, gently, searching with a Feather round about the Bone, to observe whether he still continueth his Course in the Skull. He must also often lift up the Trepan to search the Hole, to cleanse the Instrument, and to keepit from growing hot. As often as the Trepan is taken off, let him search with a Feather, to see whether the Bone be cut equally; and if it be not, he must lean more on that side which is least cut. If it be necessary to make use of theTerebella, the Hole must be made in the beginning, whilst the Bone is as yet firm; and when the Piece begins to move, theTerebellais to be put very gently into its Hole, without pressing the Bone, to draw it out; or else it may be taken away with the Myrtle-Leaf, which is an Instrument made of a firm Silver-Plate somewhat crooked. When the Piece is thus remov'd, the uneven Parts that remain at the bottom of the Hole, are to be cut with theLenticula; and if there be any Sinkings, they may be rais'd with the Elevatory. Whereupon theDura Matermay be compress'd a little with theLenticula, to facilitate the running out of the Blood, the Wounded Person being oblig'd to stoop with his Head downward, stopping his Nose and Mouth, and holding his Breath for a while, to cause the Matter to run out: Then theDura Matermay be wip'd with Lint; but if anyPusor corrupt Matter lies underneath, it must be pierc'd with a Lancet wrapt up in a Tent, that it may not be perceiv'd by the Assistants. Afterward aSindonor very fine Linnen Rag dipt in a proper Medicament, is put between theDura Materand the Skull; the Hole is fill'd with small Bolsters steept in convenient Medicinal Liquors; and the Wound is dress'd with Pledgets, a Plaister, and a Kerchief.
But the Hole ought to be well stopt with Bolsters, because theDura Materis sometimes so much inflam'd, that it bursts forth; so that if any Excrescences arise therein, and go out of the Hole, having small Roots, they may be bound and cut; but if their Roots be large, they must be press'd close with little Bolsters steept in Spirituous Medicines. Here it may not be improper to observe, that the Operation of the Trepan ought to be perform'd more gently in Children than in adult Persons, in regard that their Bones are more tender, and that Oily Medicines must not be us'd, but Spirituous. The Exfoliation is made sometimes sooner, and sometimes later; but theCallususually covers the opening of the Skull within the space of forty or fifty Days, if no ill Accident happens. In great Fractures, where there is no longer any connexion between the Bones, it is requisite to take 'em away.
The proper Bandage to be us'd after the Operation of the Trepan, is the great Kerchief, which is a large Napkin folded into two parts after such a manner that the side which toucheth the Head exceeds that which doth not touch it in the breadth of four Fingers; it is apply'd to the Head in the middle, whilst a Servant holds the Dressing with his Hand: Then the two upper ends of the Napkin being brought under Chin, the Surgeon takes the two lower, and draws 'em streight by the sides, so as that side the Napkin, which is four Fingers broaderthan the other, may be laid upon the Forehead: Afterward the two ends of the Napkin are cross'd behind the Head, and fasten'd at their Extremities with Pins, without making any Folds, that might hurt the Part; but the ends of the Napkin which fall upon the Shoulders, are rais'd up to the Head near the lesser Corner of the Eyes; and the two ends under the Chin are fasten'd with Pins, or else tied in a Knot.
This Operation is perform'd when there is a Fistulous Ulcer in the great Corner of the Eye, after this manner: The Patient being plac'd in a convenient Posture, and having his sound Eye bound up, to take away the sight of the Instruments; the Operator causeth the other Eye to be kept steady with a Bolster held with an Instrument, and makes an Incision with a Lancet in form of a Crescent upon the Tumour, taking care to avoid cutting the Eye-Lid and the little Cartilage which serves as a Pulley to the great Oblique Muscle. If the Bone be putrify'd with aCaries, an Actual Cautery may be apply'd thereto, using for that purpose a small Funnel or Tube, thro' the Canal of which the Cautery is convey'd to the Bone.But the Bone must not be pierc'd, for it is exfoliated entire by reason of its smallness; and so the Hole is made without any Perforation.
The Wound is fill'd with small dry Pledgets, and cover'd with a Plaister and Bolster: The Bandage is made with an Handkerchief folded triangular-wise, the ends of which are fasten'd behind the Head. If the Flesh grows too fast, it may be consum'd with theLapis Infernalis; and if there be occasion to dilate the Wound, to facilitate the Exfoliation, it may be done with little pieces of Spunge prepar'd, and put into it. Afterward Causticks are to be us'd, to eat away the Callous Parts, which may be mingled with Oily Medicines, to weaken their Action, taking care, nevertheless, that the Eye receive no dammage by 'em. If the Bone be corrupted, a littleEuphorbiummay be apply'd; or else the small Pledgets steept in the Tincture of Myrrh and Aloes; then the Ulcer may be handled as all others.
This Operation is perform'd when there is a small Body before the Apple of the Eye, which hinders the Sight from entring into it; but it is undertaken only in Blew, Green, and Pearl-colour'd Cataracts, or in those that are of the Colour of polish'd Steel; and not in Yellow, Black, or Lead-colour'd. To know whether the Cataract be fit to be couch'd, the Patient's Eye must be rubb'd; so that if the Cataract remains unmoveable, it is mature enough; but if it changeth its place, it is requisite to wait till it become more solid. The Spring and Autumn are the most proper Seasons for performing the Operation.
To this purpose the Patient being set down with his Eyes turn'd toward the Light, and having his sound Eye bound up, the Surgeon must likewise sit on a higher Seat, whilst the Patient's Head is held by a Servant; and his Eye being turn'd toward his Nose, is kept steady with aSpeculum Oculi, which is a little Iron-Instrument made like a Spoon, pierc'd in the middle, so that the Ball of the Eye may be let thro' this Hole: Then the Surgeon takingaSteel-Needle either round or flat, accordingly as he shall judge convenient, perforates the Conjunctive at the end of the Corneous Tunicle, on the side of the little Corner of theEye, and boldly thrusts his Needle into the middle of the Cataract, which he at first pusheth upward, to loosen it with the Point of the Needle; and then downward, holding it for some time with his Needle below the Apple of the Eye. If it ascend again after it is let go, it must be depress'd a second time; but the Operation is finish'd when it remains in the same place whereto it was thrust; neither is the Needle to be remov'd till this be done, and the Cataract entirely couch'd. In taking out the Needle, the Eye-Lid must be pull'd down, and press'd a little over the Eye.
Is to cause both the Patient's Eyes to be clos'd and bound up; then he must be oblig'd to keep his Bed during seven or eight Days, and some Defensative is to be laid upon the sore Eye, to hinder the Inflammation.
M.Dupré, Surgeon to the Hospital ofHôtel-DieuatParis, a Person well vers'd in these kinds of Operations, hath observ'd, that after the same manner as Cataracts were form'd in a very little space of time in perfect Maturity; it happen'd also very often, that the Cataracts which were suppos'd to have got up again, were not the very same with those that were couch'd, but rather a newPelliculaor little Skin, which sometimes hath its Origine in the top of theUveousTunicle, and is caus'd only by a very considerable Relaxation of the Excretory Vessels from the Sources of the Aqueous Humour which in filtrating permits the runningof many heterogeneous Parts, the Encrease of which produceth a new Cataract.
Sometimes a sort of purulent Matter is gather'd together under the Corneous Tunicle; so that to draw it out, the Eye must be fixt in a Posture with theSpeculum Oculi, and after a small Incision made therein with a fine Lancet, is to be press'd a little, to let out the Matter; but if it be too thick, it may be drawn forth by sucking gently with a small Tube or Pipe, having a little Vial in the middle, into which the Matter will fall as it is suck'd out.
Sometimes a small Tumour ariseth in the Eye, which being ty'd at its Root with a Slip-Knot, to streighten it from time to time, will at length be dissolv'd: But if the Tumour lie in the Hole of the Apple of the Eye, this Operation must not be admitted, lest the Scar shou'd hinder the Passage of the Light. Sometimes also a somewhat hard Membrane, call'dUnguis, appears in the great corner of the eye, which when it sticks thereto, may be cut off by binding it; this is done with a Needle and Thread, which is pass'd thro' the Membrane, and afterward ty'd.
If the Eye-Lids are glu'd together, a crooked Needle without a Point may be threaded, and pass'd underneath 'em; then the ends of the Thread may be drawn, to lift up the Eye-Lids, and they may be separated with a Lancet.
If the Hairs of the Eye-Lids or Eye-Brows offend the Eye, they must be pull'd out with a Pair of Tweezers or Nippers; and when any small, hard, and transparent Tumours arise in the Eye-Lids, they are to be open'd, to let out the corrupt Matter.
This Operation is necessary, when there are any Excrescences of Flesh in the Nostrils, which, nevertheless, when they are livid, stinking, hard, painful, and sticking very close, must not be tamper'd with, because they are Cancers. But if they are whitish, red, hanging, and free from Pain, the Cure may be undertaken after this manner: Take hold of thePolypuswith a Pair ofForceps, as near its Root as is possible, and turn 'em first on one side, and then on another, till it be pull'd off. If thePolypusdescends into the Throat, it may be drawn thro' the Mouth with crookedForceps; and if an Hæmorrhage shou'd happen after the Operation, it may be stopt by thrusting up into the Nostrils certain Tents soakt in some Styptick Liquor; or else by Syringing with the same Liquor.
This Operation is perform'd when the Upper-Lip is cleft; but if there be a great loss of Substance, it must not be undertaken; neither ought it to be practis'd upon old nor scorbutick Persons, nor upon young Children, by reason that their continual Crying wou'd hinder the re-union. But if any are desirous that it shou'd be done to these last, they are to be kept from taking any rest for a long time, to the end that they may fall a-sleep after the Operation, which is thus effected:
If the Lip sticks to the Gums, it is to be separated with an Incision-Knife, without hurting 'em; then the Hare-Lip must be cut a little about the edges with Sizzers, that it may more easily re-unite, the edges being held for that purpose with a Pair of Pincers, whilst the Servant who supports the Patient's Head, presseth his Cheeks before, to draw together the sides of the Hare-Lip: Whereupon the Operator passeth a Needle with wax'd Thread, into the two sides of the Wound, from the outside to the inside at a Thread's distance from each. But care must be had that the two Lips of the Hare-Lip be well adjusted, and very even; the Thread being twisted round the Needle by crossing it above.
After the Lips are wash'd with warm Wine, the Points of the Needles must be cut off, small Bolsters being laid under their ends; then the Wound is to be dress'd with a little Pledget cover'd with some proper Balsam, putting at the same time under the Gum a Linnen Rag steep'd in some desiccative Liquor, lest the Lip shou'd stick to the Gum, if it be necessary to keep 'em a-part. Lastly, upon the whole is to be laid an agglutinative Plaister, supported with the uniting Bandage, which is a small Band perforated in the middle; it is laid behind the Head, and afterward drawn forward, one of its ends being let into the Hole which lies upon the Sore: Then the two ends of the Band are turn'd behind the Head upon the same Folds where they are fasten'd, sticking therein a certain Number of Pins, proportionably to the length of the Wound.
The Patient must be dress'd three Days after; and it is requisite at the first time only to untwist half the Needle, loosening the middle Thread if there be three; to which purpose a Servant is to thrust the Cheeks somewhat forward. On the eighth Day the middle Needle may be taken off, if it be a young Infant; nevertheless the Needles must not be remov'd till it appears that the sides are well join'd; neither must they be left too long, because the Holes wou'd scarce be brought to close.
This Operation becomes necessary, when the Inflammation that happens in theLarynxhinders Respiration, and is perform'd after this manner:
The Wind-Pipe is open'd between the third and fourth Ring, above the MuscleCricoides, or else in the middle of the Wind-Pipe; but in separating the Muscles call'dSternohyodei, care must be had to avoid cutting the recurrent Nerves, lest the Voice shou'd be lost; as also the Glandules nam'dThyroides. The Space between the Rings is to be open'd with a streight Lancet, kept steady with a little Band, and a transverse Incision is to be made between 'em: Before the Lancet is taken out, a Stilet is put into the Opening, thro' which passeth a little Pipe, short, flat, and somewhat crooked at the end, which must not be thrust in too far, for fear of exciting a Cough. This Pipe hath two small Rings for the fastening of Ribbans, which are ty'd round about the Neck; and it must be left in the Wound till the Symptoms cease. Afterward it is taken away, and the Wound is dress'd, the Lips of it being drawn together again with the uniting Bandage, which hath been already describ'd.
When theUvulaor Palate of the Mouth is swell'd so as to hinder Respiration or Swallowing, or else is fallen into a Gangrene, it may be extirpated thus: The Tongue being first depress'd with an Instrument call'dSpeculum Oris, the Palate is held with aForceps, or cut with a Pair of Sizzers; or else a Ligature may be made before it is cut; and the Mouth may be afterward gargl'd with Astringent Liquors.
The Cancer at first is not so big as a Pea, being a small, hard, blackish Swelling, sometimes livid, and very troublesome by reason of its Prickings; but when it is encreas'd, the Tumour appears hard, Lead-colour'd, and livid, causing in the beginning a Pain that may be pretty well endur'd, but in the increase it grows intolerable, and the Stink is extremely noisome. When it is ready to Ulcerate, the Heat is vehement, with a pricking Pulsation; and the Veins round about are turgid, beingfill'd with black Blood, and extended as it were the Feet of a Crab or Crey-Fish, till Death happen. When this Tumour is not ulcerated, it is call'd anOccult Cancer; and anApparentone when it breaks forth into an open Ulcer.
To palliate an Occult Cancer, and prevent its Ulceration, a Cataplasm or Pultis of Hemlock very fresh may be apply'd to the Part. All the kinds of Succory, the Decoction ofSolanumor Night-shade; the Juices of these Plants, as also those of Scabious,Geraniumor Stork-Bill,Herniariaor Rupture-Wort, Plantain,&c.are very good in the beginning. River-Crabs pounded in a Leaden-Mortar, and their Juice beaten in a like Mortar, are an excellent Remedy; as also are Humane Excrements or Urine destill'd, and laid upon the Occult Cancer: Or else,
Take an Ounce of calcin'd Lead, two Ounces of Oil of Roses, and six Drams of Saffron; let the whole Composition be beaten in a Mortar with a Leaden Pestle, and apply'd. The Amalgama ofMercurywithSaturnis likewise a very efficacious Remedy.
In the mean while the Patient may be purg'd with black Hellebore andMercurius Dulcis, taking also inwardly from one Scruple to half a Dram of the Powder of Adders, given to drink, with half the quantity of Crab's-Eyes: But very great care must be taken to avoid the Application of Maturatives or Emollients, which wou'd certainly bring the Tumour to Ulceration.
When the Cancer is already ulcerated, the Spirit of Chimney-Soot may be us'd with good Success; and the Oil of Sea-Crabs pour'd scalding hot into the Ulcer, is an excellent Remedy. But if it be judg'd expedient entirely to extirpate the Cancer, it may be done thus:
The sick Patient being laid in Bed, the Surgeon takes the Arm on the side of the Cancer, and lifts it upward and backward, to give more room to the Tumour; then having pass'd a Needle with a very strong Thread thro' the bottom of the Breast, he cuts the Thread to take away the Needle, and passeth the Needle again into the Breast, to cause the Threads to cross one another. Afterward these four ends of the Threads are ty'd together, to make a kind of Handle to take off the Tumour, which is cut quite round to the Ribs with a very sharp Rasor. The Cutting is usually begun in the lower Part to end in the Vessels near the Arm-Pit, where a small Piece of Flesh is left, to stop the Blood with greater Facility: Then having laid a Piece of Vitriol upon the Vessels, or Bolsters soakt in styptick Water; the sides of the Breast are to be press'd with the Hand, to let out the Blood and Humours; and an Actual Cautery is to be lightly apply'd thereto.
The Wound is to be dress'd with Pledgets strew'd with Astringent Powders, a Plaister, a Bolster, a Napkin round the Brest, and a Scapulary to support the whole Bandage.
But instead of passing Threads cross-wise, to form a Handle, with which the Breast may be taken off, it wou'd be more expedient to make use of a sort ofForcepsturn'd at both ends in form of a Crescent, after such a manner that those ends may fall one upon another when theForcepsare shut. Thus the Surgeon may lay hold on the Breast with theseForceps, and draw it off, after having cut it at one single Stroak with a very flat, crooked, and sharp Knife. Neither is it convenient to apply the Actual Cautery to stop the Hæmorrhage, because it is apt to break forth again anew, when the Escar is fall'n off,
When the Tumour is not as yet ulcerated, a Crucial Incision may be made in the Skin, without penetrating into the Glandulous Bodies; then the four Pieces of the Glandules being separated, the Cancerous Tumour may be held with theForceps, and afterward cut off. If there be any Vessels swell'd, they may be bound before the Tumour is taken away; but if the Tumour sticks close to the Ribs, the Operation is not usually undertaken.
This Operation is perform'd when it may be reasonably concluded that some corrupt Matter is lodg'd in the Breast, which may be perceiv'd by the weight that the Patient feels in fetching his Breath; being also sensible of the floating of the Matter when he turns himself from one side to another.
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 theOmoplata; 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 thePleuron, for fear of woundingthe 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 thePleuron.
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 theMediastinum: 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 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 LinnenTent, 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 bekeptclose 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.
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,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.
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.
Is undertaken when those Parts are full of Water, after this manner: Assoon as the Patient is plac'd in a convenient Posture, eitherstanding or sitting, the Operator lays hold on theScrotumwith one Hand, presseth it a little to render the Tumour hard, and makes a Puncture, as in theParacentesisof theAbdomen. In anHydrocelethat 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 theHydrocelebe apparentlyEncysted, 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 theScrotum, because it is less painful than the lower, and less subject to Inflammation.
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. IftheOmentumor 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 ofSaccharum 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 fearcausing 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 thePeritonæum, 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 thePeritonæum, 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 otherNeedle 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 HospitalDes InvalidesatParis, who liv'd a long time in this Condition.
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 tothe 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 thePeritonæum, for fear of cutting the Intestine; and as soon as thePeritonæumappears, 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 andPeritonæum, 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 theGastroraphy. 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.
When the Intestinal Parts are fall'n into the Groin or theScrotum, the Operation of theBubonocelemay 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 theFinger, 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,tomake a good Cicatrice or Scar.
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'dSpica, which is made much after the same manner as that which is us'd in the Fracture of the Clavicle.
It happens when the Intestinal Parts fall into theScrotumin Men, or into the bottom of the Lips of theMatrixin Women. To perform this Operation, the Patient must be laid upon his Back, as in theBubonocele, and the Incision carry'd on after the same manner; which is tobe made in theScrotum, 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 BandageSpica; as in theBubonocele.
The Mortification or theSarcoceleof 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 theScrotumtaken 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 theDartoswhich 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, andto 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 is made with Pledgets and Bolsters laid upon theScrotum; and the proper Bandage is theSuspensorof theScrotum, 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 theScrotum, 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.
If the Stone be stopt at theSphincterof the Bladder, it ought to be thrust back with a Probe: If it stick at the end of theGlans, 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 theGlanson its side.
But if the Stone be remote from theGlans, it is requisite to make an Incision into theUreter; 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 anExtractor. 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 theUreter, 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.
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 theAnusnear theOs Pubis, by which means the Stone is sometimes felt, if there be any: The Finger is likewise usually put into theAnusof young Virgins, and into theVagina Uteriof 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, theGlanslying 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 thePubes, drawing out the Yard a little, to the end that the Canal of theUretermay 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 theAnus, 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 theStone 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 theAnus; 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 thePerinæumwhere 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 theRapheor 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 Woundwith 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 theForcepsis to be put, having before taken away the Probe. Some Operators make use of aGorgeretor Introductor to that purpose, conveying the end of it into the Chanelling of the Probe; which is remov'd to introduce theForcepsinto the Bladder: And as soon as they are fixt therein, the Conductors orGorgeretmust 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 Hæmorrhage 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 thatthere 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 theVagina Uteri, or into theRectumin 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 theUreter, to let in theForcepsbetween '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 theUreter.
The lesser Preparative was formerly us'd in the Lithotomy of Men, after this manner: The Finger was put into theAnus, to draw the Stone toward thePerinæum; then an Incision was made upon the Stone on the side of the Suture, and it was taken out with an Instrument.
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.
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 theFistula, 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 theFistula, having the Fore-finger of his Left-hand in theAnusor Fundament, he pulls off its Head, holding the Handle with one Hand, and the Stilet that pierceth theAnuswith the other; and at last draws out the Instrument to cut theFistulaentirely at one Stroke.
If theFistulahath 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 theAnus, 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' theAnus, and the Flesh is to be cut all at once. But if theFistulabe situated too far forward in the Fundament, theSphincterof theAnusmust not be entirely cut, otherwise the Excrements cannot be any longer retain'd. Lastly, when theFistulahath 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.
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.